- In this episode, we're revealing the best hearing aid for background noise. Welcome back to the Dr. Cliff Show. I'm Cliff Olson, Doctor of audiology and founder of Applied Hearing Solutions in Phoenix, Arizona. And I am joined once again today by my co-host, Dr. Rachael Cook and Dr. Kelsey Beck. Welcome back to the show guys. Thanks. Thanks. Alright. So today I want to dive into a topic that everybody cares about 100% of people care about this topic. So Dr. Cook, tell me what is the number one concern of people with hearing loss

- Hearing in background noise.

- You got it. Okay. And then Dr. Beck, what is the number one thing that people with hearing aids want to be able to do?

- Well, that must be hearing and background noise.

- You also have it correct. Look at that. So background noise, like is the thing, any survey that they ever do with anybody in the history of hearing loss is people wanna hear better in background noise. Always. That's the most difficult environment. It's the thing that we spend 90% of our time trying to solve for our patients when they come into our right. But here's the thing, we've been working on this problem for a very long time, and we have actually identified what the best hearing aid is, if you wanna hear better in background noise. And we're going to reveal that at the end of this particular episode. But first we have to lay the, the some context down because our recommendation will make no freaking sense to you if you don't understand these next several things that we're going to be explaining.

- Right.

- So we really need to stop, start foundationally with the audiogram. Right? So the hearing test that we do inside of the clinic, there are particular types and configurations of hearing losses that tend to struggle more in a background noise situation. So what would that particular configuration be if you had to basically explain it?

- Well, I think that some of the most common types of hearing loss that we experience in the clinic are going to be age related hearing losses and noise induced hearing losses. Both of those are very common and both of those tend to impact the same pitch regions. So when we're talking about low pitches and high pitches, when we're doing a hearing test, we're testing pitches across the board. And your response to each of those pitches will determine what types of sounds in those areas that you can or can't hear. Well, particularly when we're talking these high pitch hearing losses, the kind that we see with age and with loud noise exposure, you typically tend to miss out on those high frequency or high pitch consonant sounds. And consonants are incredibly, incredibly crucial to speech understanding, being able to tell different words apart that sound pretty similar, but vary by only like one sound. So cat sat Matt, that fat, you know, all sound pretty similar, but they all vary by that one initial consonant.

- And that's like the vast majority of people with hearing loss have this high frequency sloping hearing loss.

- Yeah, absolutely. And so the part that makes you know that type of hearing loss, especially tricky when we are talking about background noise, is that usually this individual will have good low frequency or low pitch hearing, which means that the things that you can hear are those low pitches that give us that perception of volume, right? So that someone is speaking and then the reporting is like, well, I can hear you, but I just can't understand exactly what you're saying. And so then when you go into background noise, you know, if we are all sitting in a restaurant and we have that, you know, background babble the chatter that's going on, the majority of that is actually low pitch or low frequency in nature. And then what your brain then uses to separate the thing you want to hear from that noise are those high frequency or high pitch consonance sounds that these people just don't have access to. And so we need to find a good way to not only give you good access to that, but make sure that we're not also then amplifying the background noise on top of that. Because we don't wanna give you anything more of what you can already hear. Well, we just wanna give you the things you not hearing well, so you can do well in those noisy spaces.

- Yeah. Actually, if you think about it, English is an awful language for developing.

- That's the only one I speak.

- You're like whale shoe. No, but seriously those high frequency syllabus in particular SS and S SHS and things like that, like those are the ones that always go first. And yet English has eight ton of them, uses them almost exclusively, I feel. So, yeah. Anyway.

- Yeah. And you know, it's such a gradual thing too. So a lot of people don't even realize that they're starting to decline over time. You know, people who go out and they're like, oh, well I, I hunt so that's the only time that I shoot a gun without hearing protection, but I only do it like once a year. And it's like, well that's actually causing damage to your auditory system, particularly in the high frequencies that you would use to help separate speech from background noise. Yeah.

- Right. So that's typically one of the first ways that people even notice that they have some sort of hearing loss developing is they're like, man, every time I get in that background noise I just, I can't understand anything. Yeah. Like that's one of the first symptoms that people will start to pick up on.

- I, I get a lot too, you know, I can hear, you know, my wife in this restaurant for example, but the minute that she looks down at her menu, suddenly I can't hear her anymore. And it's really because I think I'm watching her mouth move as she's speaking. Because what your brain subconsciously does is it looks for more ways to fill in the gaps of things that it is missing. One of those ways is to actually watch the mouth movements of the other person to try to figure out what the heck letter you are using in that sentence to then, you know, get the context. And sometimes you guess right? But a lot of the times you don't guess correctly. And so now you and your partner are having two completely separate conversations. Right.

- And this is exactly why we do word recognition testing where you can't see anybody's face. That's right. Exactly.

- You can't see your face, you have no context. It's say the word cat, say the word dog, and you have no context of what that word's gonna be.

- Right.

- What's interesting is that that point that you just brought up is individuals with completely normal hearing, in order for them to even hear well in background noise, they often require visual cues as well.

- Absolutely. Because your brain is, you know, it's a big computer, right? And the more information you can give to a said computer, the better outcome you're going to have. Right. And so if we're, you know, if even with normal hearing and we're getting all of the information, your brain is still going to look for things to even support itself even more to really round out that experience. But then if you start deleting information, suddenly you don't have half of the code to decipher what the heck is going on.

- Yep. And so there was a, and you had brought up Dr. Cook, the being able to identify what their word understanding is or, or word recognition is in a quiet situation. And there was some data that had come out here fairly recently showing that we cannot predict someone's ability to hear and understand speech and background noise with a words in quiet text. No way.

- And do you know how much cognitive processing it takes to separate out speech from background noise, even with normal hearing?

- Like - So many things have to be firing on all cylinders and just perfectly so someone could perform incredibly well on a word recognition task in quiet. And again, like you said, that is not indicative at all of what's gonna happen when you throw that individual into a, on a surrounding background

- Noise. Absolutely. And so the way that we would actually handle that is we would do a speech and noise test. So this is the second thing that we need to make sure that we understand when we're testing somebody's hearing, is we need to know what their innate ability is to separate speech from noise when their brain has access to all of these missing speech components due to their hearing loss. Right. So let's just give a high level of, of what that test would actually look like, right?

- Yeah. So what this test looks like for those of you at home is that we will put you into the sound booth. We will start to play, or at least the one that we use in the clinic, right? We use the a test called the QuickSIN. There are various numbers of different speech and noise tests, but the one that I'll go into is just the one that we use in the clinic. So we'll put you in the booth, you'll, we'll have you repeat some sentences back to us, right? Not terribly long sentences, but you do get a little bit more context with that, with that kind of setup as well. And then what we'll have, what will also be happening is that at the same time, with every single sentence, the background noise, kind of like that chatter you have in a restaurant gets a little bit louder with every single sentence, right? And so it's designed to be difficult, it's designed to test how much separation from the background noise do you need speech to be in order for you to be able to understand it when you have access to all of the missing speech information when we compensate or replace them due to your hearing loss. Right.

- And I think that that concept can get a little bit tricky. What we're really trying to see is if you have a hearing loss in that hearing loss is treated appropriately in theory, how should you perform in these environments?

- Exactly.

- So sometimes people think that when they're doing this test and they hear that they got perhaps like a low score on their QuickSIN test, they're like, oh, I'm doing good, I'm fine. It's like, oh, no, no, no, no. This is, this is if treated appropriately. So just wanna make sure that's

- Correct. Yeah, absolutely. And and to your point as well, you mentioned low score versus high score, right? So in this particular test, the lower the score, the better. So if you score at like a zero on this test, that means that with your hearing loss treated, you will understand, you know, speech and background noise better than someone with normal hearing. You score a 26, which is the highest end on this scale, you score a 26 on this test. And that means even with your hearing loss treated appropriately, we could turn the air conditioning on and it could create so much noise that you actually would have no idea what another person is saying

- To you. And that's with your hearing loss treated perfectly,

- Right? Yeah, exactly.

- And so here's the, an interesting way of explaining it is that let's say you score a 10, which isn't an uncommon score that we would see inside of the clinic. What that technically means is you need 10 decibels of speech above the background noise. So if the background noise is 70 decibels, you would need the person's speech when amplified to be 10 decibels louder than the background noise for you to understand 50%

- Yeah.

- Of what they actually say, which, which is usually enough for you to fill in the missing gaps with visual cues and things like that. Right? So it really, for us to understand how much separation you really need and to be able to identify a, a potential hearing aid to solve for your problem, we would need to know what that score is. So if that score is not being tested inside of the clinic, we really have no clue. Yeah. Right. We have no clue if the way that we're treating you is going to be enough to overcome whatever your speech and noise score is.

- Yeah. I think that a lot of times I see patients that are consistently disappointed by their performance with hearing aids. And so they do think like, well, what's the next best thing? What's the next best thing? Background noise. Background noise. I'm like, what's your, what's your speech and noise score? And they're like, what are you even talking about? Speech and noise score,

- Huh?

- Yeah. And then we test them and their speech and noise score is so high and it's like, oh, well that explains it right there. Even with your hearing aids programmed perfectly, hearing aids alone may not be enough here.

- Well, and and even more to that point, as well as sometimes you'll even test that same individual who has had two, three sets of hearing aids with no success in that background noise. And then you test their word rec or their, you know, QuickSIN their speech and noise test, and they score really, really well on that test, Which really gives into this clue of, huh, how have these hearing aids been set up in the past where someone who should be doing really, really well in noise is reporting that they can't even go to restaurants with their family anymore. Yeah. Right. And so it leads to, you know, even just the next topic of how you set up the hearing aid matters so much when we're talking about background noise, you cannot just, you know, do like what's called like a first fit. Right? So a first fit is when we place your hearing test into the software of the hearing aid, and the software spits out its best guess as to how much sound you might need in order to be hearing very well. We know that that often is absolutely an incorrect prescription, essentially. Because if you do in fact measure someone's prescription against what that first fit is, it's oftentimes really below where they need to be. Or maybe you'll have a very high peak or something like that. Yeah,

- Yeah. That's because most of these hearing aid software are designed to make sound comfortable

- Yes.

- For a patient which they know leads to the patient being more accepting of the devices, even if it's sacrificing speech eligibility.

- Yeah.

- And ability to understand speech and background noise. Yeah. So the way that we solve for this inside of the clinic is to perform real ear measurement or real ear verification. It's basically our way of verifying that the hearing aid is being programmed to your prescription that is necessary to optimize speech understanding and noise. There was a very good study done back in 2012 by Doctors Leavitt and Flexor who combined their efforts to identify, okay, if we have a bunch of modern high tech hearing aids programmed to just the first that guesstimate by the software, how do those perform in relation to the same hearing aids programmed using Real Ear Measurement and verifying that you're actually meeting your prescription. But the thing that they also threw, and there was a little bit of a curve ball, they're like, you know what, I wonder if we pulled an old crappy analog hearing aid to a verified prescriptive target, which is the NLNL one, would that perform as well as these modern hearing aids? And so what they actually found is that the modern hearing aids that were not programmed using Real Ear Measurements had significant worse performance than when those same hearing aids were programmed with Real Ear Measurement. But the crazy thing is, is they identified that the old analog hearing aid programmed with real ear measurement

- Outperformed Yep.

- The modern digital, most advanced technology on the planet that was just set the first fit settings. Yep. So you literally cannot even take the most amazing hearing aid in the world and make it perform as good as an old analog hearing aid from back in the eighties. Which blows your freaking mind when you think about it. I

- It does. And then it also doesn't. Right. Because if we can just kind of think, you know, even for the lay person, right, who does not do what we do, if you are trying to build a house, right. But you don't measure every, you know, two by four that you're using to frame the house, You're gonna end up with some wonky walls. Yeah. Right? Same thing with your prescription. If we don't actually measure what is going on inside of your ear as opposed to, I don't know, Joe Schmo down the street, how do I actually know that I've done my job? That I've given you what you need to be successful? So what blows my mind more is that how infrequently across the board people are doing real air measurement. That's what blows my mind even more. Because logically you should measure things like if you want it done right, you should measure. And we've had the technology for decades at this point to do these measurements. Yeah,

- Yeah. Some of the estimates are right around 30% of hearing care professionals will actually do real air measurement. I tend to think that these numbers are a little bit high based off of interviews that I do with providers and all that. Yeah. But regardless, we'll, we'll, we'll err on the side of, of caution and say, okay, it's 30%, that means that 70% of people who are being fit with hearing aids, they do not know if they're meeting their prescription. In fact, I've never measured a hearing aid on first fit settings that ever actually perfectly matched someone's prescription.

- Only one time. One time. Really? Only once. Okay.

- And it was just a couple months ago, Hey, that's perfect, just leave

- It alone. But I took several screenshots because I was like, this will never happen again. Doesn't exist. This is a unicorn. I told, I told my patient, I was like, who are you?

- What? Well, you have the perfect average ear.

- You literally have the perfect average ear. And I've never seen this happen before. And I was telling you like, this never happens. Never. Like I took pictures and I sent them to the company immediately and I was like, look,

- Wow, this

- Is amazing.

- Wow. Well, and even too, earlier this week I did a fitting, it might've, it might've been Tuesday, right? I did a fitting and one ear was actually pretty close, not dead on, but I was not upset at it, honestly. Like if you had gone through a fitting sequence and we had made some adjustments, and that's what we turned out with, I'd actually say like 85 to 90% was dead on prescription. The other ear was absolutely not, was nowhere near where it needed to be. So even two ears on the exact same person, because size and shape differences ev and the way that it impacts acoustics. One ear was actually, I was okay with the other one, was like, that is one of the more atrocious ones that I have ever seen. So again, if you don't measure, how do you know?

- Yeah. And you don't, it's a very important thing because you could accidentally get one of the hearing aids program correctly. If you don't get the other one programmed correctly, you lose out, you lose out on a lot of binaural benefits. Right. So, binaural, squelch, binaural summation, which are both very important things when it comes to hearing and background noise. So, you know, two is one, one is none, is basically what that comes down to. Now for individuals who are like, you know what, I'm not sure if I'm part of the 30% who's had this test done and part of, or part of the 70% that has not had it done, what does real measurement even look like to them as a patient going into a provider?

- So there's several different systems that are used to complete real ear verification. But the general gist is that the individual will be seated in a chair and in front of them there's gonna be some sort of speaker unit. This speaker is going to play speech signals. And while it's playing these speech signals, the individual's wearing these loops over their ears with probe microphone tubes that go deep in their ear canals with their hearing aids on top. And so what that's doing, these probe microphone tubes are measuring and recording exactly what is coming out of the hearing aids in real time in response to these speech signals. Now on the provider side of things, which, you know, really, you should be able to see that at some point and and see that things have been matched up. So hopefully your providers showing you at some part of this process. But on the provider side of things, your, your hearing loss is entered in. So your, your thresholds from your audiogram or your hearing evaluation are entered in and then a prescription is generated. And there's several different prescriptions out there. But for the most part, most providers tend to kind of pick one prescription and stick with it. And it generates these targets, which basically means, alright, based on this person's age, their gender, if they've worn hearing aids before or not, what type of hearing aids are they wearing? It takes all these characteristics into account and says, here's how the hearing aids should be set up then as that speech signal is playing from in front of the patient. And this speech signal could be a variety of different things. It can be English speech passages or like what we use in the clinic. The ISTS signals actually a blend of six different languages at the same time, regardless as that speech is being played, those probe microphone tubes are measuring if the hearing aid is actually delivering the appropriate amount of amplification at each pitch to match the, the prescription there. And then if they're really, really good, they play it at multiple levels. So not just for an average speech presentation, but also for a very loud speech presentation and a very soft speech presentation as well.

- Very well said. So, and when it comes to understanding speech and background noise, I wanna be very clear here. We need to make sure that the loud prescription is being matched well. Yeah. Because what do people tend to do when they go into background noise situations? They tend to speak louder to overcome the noise. But if you don't have enough amplification being added to the loud speech of your friend or family member, you never actually get enough separation from the background noise with that person's speech.

- Right. - On top of that, you also have to make sure that the maximum power output of the hearing aid, that's a big one, is verified well as well with Real Ear Measurements. So you have to make sure that the ceiling of amplification can go up high enough to capture these louder speech fluctuations from the person that you're talking to.

- Right, exactly. And you also wanna make sure that they're not too high either to where you're going to end up amplifying to a dangerously loud level for this individual as well. So there, it kind of has two functions in that respect.

- Yeah. You want things to be loud enough for you to hear, but not so loud that they're uncomfortable. Exactly. Right. Right. Now we also have to talk about this next part, which is part number four really, which is, okay, let's say that we've done all of this stuff, we've accommodated for all of it, but your speech and noise score is just really too high to be handled with, with any particular hearing aid we might have to consider different accessories. So the, the best hearing aid in the world would have to have at least some kind of accessories, like an assistive listening device to help cut through background noise. Yeah. Let's give them a really high level understanding of what a, an accessory like this would be like.

- So an accessory like this could be a, a couple of things. So of course you have to have the hearing aids and you have to help them well programmed. But then an accessory could be something like a remote microphone where someone could clip a microphone onto their shirt, right? So whoever you're speaking with, and then their voice only has to travel this far right to the bottom, to the, to the collar of their shirt. And then from there, your, that person's voice is actually sent directly into the hearing aids via Bluetooth. That way you can actually hear what they're trying to say without having to have their voice cut through the background noise or, you know, get softer as it's traveling across the table before it even hits your hearing aids. Right. So it gives you more benefit in that respect. So for example, let's just say if you had that, you know, same hearing speech and noise score like the 10 that we were talking about, right? Or you need 10 decibels louder than the background noise to hear that person's well person's voice. Well, clipping a microphone onto that other person's shirt will actually decrease that score by nine points. Which means that you only need them to talk now one decibel louder than the background noise for you to get good clarity out of their voices when you go to those noisy spaces. So they really do provide a lot of benefit in that respect to make sure that you can actually get good clarity of the person you wanna hear.

- Yeah. In most cases, someone with hearing loss using a remote microphone like you just explained, would tend to outperform someone with normal hearing in that same environment because they're getting a direct audio feed. Like if we were in a noisy place right now and I had the hearing aids on and I couldn't hear you, then we could clip the microphone on your shirt. It would stream your voice directly into my ears and I hear everything completely fine.

- And you can even on top of that change how the hearing aids function when it is connected to a, a microphone like that where you can actually shut the microphones of the hearing aid off completely if you wanted to. And now really the only thing that you're getting is anything that's being picked up by that microphone.

- Yep. - Right. And so you can augment that in a lot of different and creative ways to give someone even more benefit using that kind of a device.

- But what happens if you are at a table with several people and one microphone won't help.

- I love this question. They also do have other types of devices. So one of those devices is actually a table microphone where you can quite literally place this in the middle of the table. You can even select which microphones on that device you want active to pull in more voices than just that one.

- Yeah. I think about this too for like, not even just like restaurant settings, but if you're working and you're in, in, you know, business meetings at these long conference tables where someone could be eight or nine people away from you down at the end of a table, you know, the two things that really can make speech very difficult to understand, especially in noise, distance and reverberation distance is gonna mean that that sound energy just really loses energy as it travels. And reverberation is gonna be, the echo kind of comes from sound waves bouncing off of surrounding walls. So they even have table microphone systems that can link in with one another and you could have multiple of them set along at different points of this table to really pick up voices from all around this table as well. So table microphones for restaurant settings, what do they call those other ones? They're, they don't call 'em table mics. The, the square ones for phone act that are for the conference

- Tables. Oh, so it's, well it's a table, it's a Roger table.

- Mic two is one, table one, mic two. Yeah, yeah, yeah. Okay. Oh yes. 'cause the other ones called the select

- The select two. Yeah.

- Okay.

- Okay. Which is multipurpose, right? Yes. You can do a variety of different things. You have ones that like, you can point to people set on a table, clip onto a shirt plugin so you can stream TV into your ears if you've got, you know, like we've talked about a spouse who's really noisy in the kitchen while you're trying to watch tv. Sure. How disrespectful that is.

- Right. How dare they put the dishes back? Gosh darn it. I hate when they're cooking me dinner. Right?

- Exactly. Exactly. So using accessories like these, like you said, Dr. Beck, you can significantly reduce that speech and noise score down to a level where background noise is not a problem at all if you're willing to use one of them.

- Yeah. Well if you're, that's, that's it. And that's the thing, right? Is that we can tell you all of the things that will make it the best it possibly can be made. Right. Your job is then to tell us what you are and aren't willing to do. Right. So if you're not willing to ask the other person to clip that microphone to their shirt, well that is, that is what I can do. That is your, that is the limitation then you're setting for yourself. What I will say to those people though, 'cause every time, every, I feel like a lot of the time I get kind of that pushback is that other people want to be understood. Right? There is not a single person who's going to sit down to have a conversation with you that would be okay with you not understanding them. And so if you say, Hey, I have a hearing loss, if you wore this on your shirt, this would really, really help me out. I not, I have yet to meet a person who will say no to that.

- No. I actually like repeating myself 10 times. Yeah. Yeah. I actually, that's better for me. Like, no one's gonna say that. Everyone's like, oh yeah, I, that makes sense.

- So let's, let's humor this for a second though. Let's say that someone's like, Nope, absolutely not. We have to start talking about what features inside of hearing aids actually can provide some assistance for people who are not willing to use those assistive listening devices. One of those is noise reduction. Sure. Right. So noise reduction, there's a couple different ways that it works depending on the manufacturer, but the, the main way that it's worked for years is that hearing aids can identify steady state noise versus speech fluctuations. And a lot of this information when it comes into a hearing aid, they can kind of categorize it like, is this more likely than not noise or is it speech information? And if they've identified that it falls into a channel of the hearing aid that's like, hey, that's pretty much just noise. They can lower the amplification given to the noise without dropping the amplification level for the person speaking to you.

- Sure.

- So noise reduction and you can set it up to varying degrees of strength. Sometimes you can set it too high and it starts bringing down speech too, which is what you wanna be careful of. That's why you don't wanna just throw in a ton of noise reduction to everyone's programming. But then you can also have it too low where even these lower level hums of like the air conditioner can be so noisy that it interferes with speech. So you need to really make sure that you find the right setting for that. But this is different than noise cancellation. Like I think a lot of people are like, why can't you just do what B'S headphones do? So like why is that not possible?

- Oh man B'S headphones have the easiest job in the world. They're probably gonna come for me for saying that. But really when you think about it, when someone is using headphones, the, the first advantage that they get is really that they're doing direct audio input. So typically this is not a live type of a setup. This is you're listening to music or you're taking a, you know, a phone call or whatever it may be, through headphones, which means that you're getting a really strong, really clear, really crisp signal already from the jump then noise cancellation, really the, the headphones themselves are just using tech normally phase cancellation. Right. Where, you know, sound waves come in at one way, they send in a pattern to go the other way, boom, cancel each other out. That's great. But you're not doing that with people who are sitting right across from you in a loud or noisy setting. You're doing that to stream in that really nice, clean, clear audio

- So you can basically kill everything Yeah.

- On - The outside. Yeah. And you get directly what's being fed in, but when the signal is already mixed with the noise and you have to try to separate them out, it creates a impossible task.

- Sure. And most people when they're using those headphones are having completely blocked off ear canals. So they're fine to have their ears blocked off because they're probably not talking, they're probably just listening to something. And if they are talking, well, you know, it's on a phone call or something like that and their voice is gonna be a bit louder to them when they're doing that. But it's temporary. Versus with hearing aids where you're having back and forth conversation all the time, if your own voice was trapped in like that all of the time, we get complaints about that too, of I sound too loud or my own voice is too strong, or Oh my gosh, I cannot eat potato chips anymore because that chewing noise is way

- Too much. Right. Well and if you think about it this way too, so, you know, restaurants are the most, you know, complained about spaces, right? And that background noise in a restaurant is speech information.

- Yeah.

- Right. And hearing aids are designed to give you more speech information, which makes it a really challenging type of noise. Right. So like air conditioning noise, there is a very big difference between that hum of the air conditioning.

- Oh yeah.

- Versus you know, the chatter that you get in a restaurant. Right.

- I feel like hearing aids have got that down now. Like if your AC kick kicks on and your AC

- Bugs you, we can manage that. Yep. Really easy. And there's no con and there's not really a lot to confuse speech with that type of noise. But then when you go into those restaurant settings where the noise is speech and the thing you're trying to listen to is speech, that is a very hard thing to program out. And now hearing aids using, you know, AI and you know, with technological advances are getting a lot better at it. It is still a really, really tall order. Whereas with Bose, again, or any other noise canceling headphone, right. You are not trying to get anything from your environment. But with hearing aids, we are trying to bring in your environment and get rid of your environment. Yeah. I mean it's a really tall order. Yeah.

- Yeah. I think also we just need to change the, the wording because speech and noise is misleading. It's speech and speech. Yeah. Yeah. It is literally speech and speech.

- Speech that you wanna hear and speech that you don't want to hear.

- Exactly.

- Yeah.

- Yeah.

- And so there's another trick that hearing aid manufacturers will use, which is called directionality,

- Which - Is where they'll take multiple microphones on a hearing aid and through that they can identify which direction sound is actually coming from based on a timing difference between when that sound hits the front microphone and the rear microphone and vice versa. And you can really narrow in the range that you want the hearing aid to, to be picking up speech in. And so oftentimes they'll of course orient the microphone pickup range in front of you. 'cause that's typically where you want to hear the people talking to you. And you can essentially turn down or reduce the sounds that are coming from behind you. So if you're in a noisy restaurant, you don't want to hear the table behind you. It's very helpful, helpful to use a directional microphone setup to primarily focus on the people that you're facing.

- Sure. Until you go to a birthday party dinner and you're at a table with 12 people and you've got one person on your right, one person on your left, maybe two people on your right, two people on your left, and you're hearing, you know, the two or three people right here. But then as soon as someone to your right says something, those hearing aids are using that directionality to give you that frontal focus. Because chances are, you're probably gonna wanna hear what's happening from in front of you. But in those types of settings now you do wanna hear what's to the right. You do wanna hear what's to the left hearing aids. It's a tall order, it is the tallest of orders.

- And you also have to consider that, that a lot of people with a high frequency sloping hearing loss, they would be open fit with their domes inside of their ear canals. Yeah. Which reduces the effectiveness of directionality because what's all the background noise doing anyway? It's finding its way right inside your ear canal. Yeah. And it's not being 100% processed by the hearing aids. So, so that limits the, the functionality of that. But it is also a very important feature. Like you can get a significant improvement with directionality, you can get a significant improvement with noise reduction with different compression settings and all that. Making sure loud level speech is boosted loud enough

- In

- Those environments.

- Well, and even just basic communication strategies, like knowing where to sit, knowing where to position yourself so that you're, the features that are gonna kick on in your hearing aids have the best opportunity of giving you that benefit that you're looking for.

- And when I'm talking to patients about noise reduction and about hearing aid directionality, I actually quite literally draw them, you know, a picture of, you know, kind of what a restaurant might look like. Yeah. And I will actually have them. Okay. If you are trying to hear your best, which of these tables would you sit at? You know, what, do you sit near the bar? Would you sit, you know, near the front door? Would you sit kind of off to the side? And I'll let them pick, and then I'll let them pick which seat at that table they would want to sit at in order to hear their best. And 90% of the time people get this question wrong.

- Yeah. - Because the tendency is to sit, you know, all the way to the back of the restaurant with your back to the wall and looking out at the rest of the restaurant. Well, let us just say that I'm wearing these hearing aids and I'm trying to talk to Dr. Cliff over here. And not only am I looking at you, but I'm also looking at the rest of the restaurant. Well, guess what with that directionality, yes, you are in my pickup range, but so is everybody else behind you. Yeah. Right. And so we have this conversation of where you sit at the table, even if you don't get to select your table, can often have a really large impact on how well you're hearing people when you go to those spaces. Definitely.

- So all of this information is very pertinent to understand if you have hearing loss, and I understand that people are probably getting a little antsy. They're like, guys, why are you dancing around this question of what the best hearing aid is? Well, let's give them some ideas of what some of the best hearing aids are, and then we'll tell you which one we believe truly is the best. So you've gotta, you've gotta really start talking about the major brands here, which have put in the most research and development into solving this problem. So you've got companies like Phac, right? So the, the Phac devices right now, they have great accessories. We already talked about, you know, some of the table microphones that they have, the, the Roger devices, the clip on microphones, they have, they have great noise reduction strategies. They've even tried to solve the open versus closed vent thing with the active vent receivers. So like they've done a lot of work with their ability to reduce background noise and help people understand speech and background noise the best that they can. What are some of the other brands that we work with that we see do a pretty good job?

- Yeah. Oticon jumps out to me just because they've got their initial deep neural network and now they're on their deep neural network 2.0, which is really deep neural network is a form of artificial intelligence that's really trained on real life sound samples to be able to try to separate out speech from background noise. And so the original deep neural network was trained on about 12 million sound samples, the Deep Neural Network 2.0. What they did was actually separate that into further channels to separate out that speech from noise. So I don't think they trained it on any

- More. They added some more, but Yeah.

- Yeah. But it was more getting more specific even

- There. Yeah. Refining more

- And the addition of some 40 motion sensors. So actually playing with this idea of, you know, we were talking about directionality in those noisy environments, but sometimes you're walking or you're moving, and if you're walking, chances are the person that you're trying to hear is not gonna be standing backwards, walking right in front of you. They're gonna be to either side. So they really took in this idea of motion and how motion can relay what types of noise reduction and directionality strategy should be utilized in that setting. So I think that's pretty cool.

- And then some of the other brands as well, you know, Starkey, Signia IX, Resound, they're all doing very similar things as well where really trying to, you know, hone in on what kinds of noises do we need to reduce, how do we refine these systems even further?

- Yeah. - You know, resound does something really cool too, where you can have different types of noise reduction applied differently to certain types of environments. You know, for mildly noisy. Moderately noisy, are we just trying to get rid of air conditioning? They do let you go through in the software and identify different types and volumes of that noise as well to apply noise reduction differently. So all of the hearing aid manufacturers are putting a lot of research and time Oh yeah. Into these types of systems because it is the number one complaint,

- Right? Yeah. I think people see like all these other cool features coming out in hearing aids like Bluetooth and Ellie Audio, all that stuff, right? But at the core, where they spend most of their time and money is solving that singular problem, which is understanding speech and background noise. So when you look at companies like Resound, if you looked at how much money they put into r and d, you would see that it is vastly weighted over towards solving the problem of speech understanding and noise. Right? Like the small rechargeable hearing aids are great, right. But that requires much less ingenuity, in my opinion. Don't, you know, there's probably engineers out there who are upset with me who work on battery life and all that, but still like solving this number one problem is where the money goes.

- A lot of those other features, like you're talking about, like rechargeability, it's a, it's a feature that is appreciated very quickly and then never again. It's like it's, it's taken for granted almost of like, you know, this incredible supercomputer that needs to operate for 16 to 20 hours a day on a single charge and do all of this processing power and live through all of these environments. And you're like, yeah, it gets me through the day anyway. Still can't hear background noise. Yeah. Like it's just, you don't, you know, it's a given at that point. Alright, great. It gets me through the day. Now I need it to do what I need it to do throughout the course of the day. Exactly.

- Right. Right. So, okay. So I think we're at the point right now where we can safely say that we know what the best hearing aid is in background noise. We have experience with all of these different brands. We know exactly everything that they do when it comes to their strategies to eliminate background noise and enhance speech. So Dr. Cook, what is the best hearing aid? If you want to hear better in background noise,

- I think the best hearing aid, if you wanna hear better in background noise is your hearing healthcare provider.

- What do you mean by this?

- Because it doesn't matter. It doesn't matter what hearing aid you have, it really doesn't, you could spend $20,000 on top of the line, most premium hearing aids ever. And if the hearing care provider that you are working with does not follow all of the steps, all of the testing protocols and all of the verification in order to make sure that that hearing aid is optimized for your ability to hear and background noise, it's not gonna do it.

- It's not gonna do it. But, but, but if someone was trying to pin you, Dr. Beck, I'm like, well for me though, what is the best hearing aid for me in background noise?

- Well, that's the thing though. You and Joe Schmo down the street are not the same person. Right. Because Joe Schmo down the street might do, for example, really well on that speech and noise test, whereas you might not. Right? And so the best hearing aid for you and background noise is not going to be the same one as Joe Schmoe down the street who did really well on that test. Right. And so every hearing aid does something a little bit differently. Yep. It kind of operate almost on a spectrum where we've got some, all the way on one side where they, you know, employ a lot of noise reduction, a lot of this, a lot of that, and some that don't really employ very much of anything at all because they rely on your brain's ability to do a lot of that for you. Right. And so for me to be pinned down to say, this one is the best, it all just kind of depends. And I know that that's really not, you know, the answer everybody wants, but again, it goes to Dr. Cook's point here is that if we don't do everything precisely the right way from testing to device selection, to counseling about what this device's capabilities are going to do, you are going to be disappointed. Yep.

- Yeah. And I really think it comes down to that, which is we can definitely identify the worst hearing aid for someone for hearing and background noise, and that's the one that has not been selected based on the wants, needs and values of an individual. Yep. None of the proper testing protocols have been followed. None of the proper verification protocols have been followed. The concept of assistive listening devices is never discussed or given as an option. Like there's, there's all these things that, that would have a significantly heavier weight on your success in background noise than the actual device that you

- Pick. Yeah.

- You could argue that someone could go, like you just said, and spend a ton of money on a certain brand of hearing aid and with a particular provider that hearing aid sucks in background

- Noise. Yep.

- And then you take it to a provider who goes and does all the proper testing, all the proper verification and setup of that, that same exact hearing aid and that person does well in background noise.

- Yep.

- Right. So like it's, it's literally an impossible question to answer in terms of if you want an actual device for me, which one's the best one? It just can't be done.

- It would be doing you a disservice to say that this blanket statement of this device is, is the best for everybody. It's not true because again, if it's not optimized, then there you will not perform well. You will not the end period.

- Yep. Moral of the story here is that the hearing care professional matters significantly more than the devices that you end up going with. So if you were going to be spending a lot of time, now, listen, I want you guys to watch my video content talking about the best hearing aids and out there, Dr. Cook wants that

- As well. Yes, of course.

- Right? Like we want the video views on that and we like getting people excited for the newest tech and all that. But if you spend enough time watching the content, everything is hedged with the statement of, none of this matters unless you're hearing care professionals following comprehensive best practices.

- And it's true. And I know that it's not the fun answer, and I know that it's not the most direct answer in the world, but it's the truthful answer. It's the honest, realistic, true answer, which is you have to find a provider that is going to do what you need them to do in order to hear your best.

- So there's probably people watching this right now who are like, yeah, makes sense. I get it now. Yeah. And then there's people who are still out there who will comment on this video and say, wait, okay, so hold on. Can you just tell me what the best hearing aid is for hearing and background noise? Right. And, and if, and, and listen, we love the comment. So if you wanna leave that comment down on the comment section, we will go into our broken record track where we're saying, well, sure all of them can be really good, or all of them can be really bad depending on the provider that you go to. Yep. So very good discussion guys. Thank you so much for that this morning, guys, if you enjoyed this video, hit that thumbs up button. If you hated this video, make sure that you hit the thumbs down button as well. And if you wanna take more episodes, just like this one, make sure that you hit that subscribe button with notification bell and we will see you next time.