Fitting and Modifying Hearing Instruments

Contents

The Ear The Impression The Audiogram Hearing threshold diagnosis Classifications of Hearing Loss Important Terms Trimmers Hearing Instrument Fitting The ITE Program

THE IMPRESSION
IN CANAL

IDENTIFICATION
SECOND BEND FIRST BEND
IN CANAL

OTO-BLOCK TRAGUS HELIX

ANTI-TRAGUS

CRUX
BASE BOWL

HELIX

THE EAR
ANTI-HELIX APERTURE

CRUX CONCHA TRAGUS ANTI-TRAGUS LOBULE INTERTRAGULAR NOTCH

CLASSIFICATIONS OF HEARING LOSS

The Audiogram
125 0 10 20 30 250 500 1000 2000 4000 8000 0 10

0-20 dB 21-40 dB 41-60 dB 61-80 dB 81-110 dB

NORMAL RANGE MILD LOSS MODERATE LOSS SEVERE LOSS PROFOUND LOSS

20
30 40 50 60 70 80 90 100 Frequency (Hz) 750 1500 3000 6000 110

40
Loss 50 in dB 60 70 80 90 100 110

AUDIOMETRIC SYMBOLS
AIR L R UNMASKED L BONE R

NO RESPONSE

MASKED

NO RESPONSE

The Pure Tone Audiogram

125 0 10 20 30 40 Loss 50 in dB 60 70 80 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60

Air Conduction Test

This test is performed with headphones. The sound is transmitted via the outer and middle ear and through the fluid contained inside of the cochlea.

Bone conduction test

The sound is transmitted by bone conduction (vibration) directly to the cochlea (inner ear). Important: Not via the outer and middle ear.

70
80 90 100 Frequency (Hz) 750 1500 3000 6000 110

90
100 110

Uncomfortable loudness level

This is the upper limit of the auditory sensation area. Important: The "U" level is the point where the threshold of pain begins.

Masking
In this test, the patient's good or better ear is blocked with noise, while the ear with the highest degree of hearing loss is measured. Reason: This prevents the test signal being heard by the better ear.

Hearing threshold diagnosis

Middle ear hearing impairment
125 0 10 20 30 40 Loss 50 in dB60 70 80 90 100 110 Frequency (Hz) 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 125 0 10 20 30 40 Loss 50 in dB 60 70 80 90 100 110 Frequenzcy (Hz) 750

Inner ear hearing impairment

250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 10 0 110

Combined midle earinner ear hearing impairment

125 0 10 20 30 40 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 10 0 110

750

1500

3000

6000

80 90 10 0 110

1500

3000

6000

Loss 50 in dB 60 70 80 90 100 110 Frequency (Hz)

750

1500

3000

6000

- Normal bone conduction - Air conduction impaired compared with normal

- Air and bone conduction impaired compared with normal. (Both equally strongly) Important: A hearing loss without bone
conduction - air conduction difference rules out middle ear hearing impairment

- Air and bone conduction impaired compared with normal. - Air conduction however more strongly than bone conduction

Hearing threshold diagnosis

MEDIOCOCHLEAR inner ear hearing impairment
125 0 10 20 30 40
Loss 50 in dB60 70 80 90 100 110 Frequency (Hz) 250 500 1000

Ankylosis of the middle ear

125 0 10 20 30 40 Loss 50 in dB60 70 80 90 100 110 Frequency (Hz) 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 10 0 110

Combined middle earinner ear hearing impairment

125 0 10 20 30 40 250

2000

4000

KL = LL

8000 0 10
20 30 40 50 60 70 80 90 10 0 110

500

1000

2000

4000

8000 0 10 20 30 40 50 60 70 80 90 10 0 110

750

1500

3000

6000

750

1500

3000

6000

Loss 50 in dB 60 70 80 90 100 110 Frequency (Hz)

750

1500

3000

6000

Bone conduction = air conduction Medium tone hearing impairment This hearing impairment is typical for hereditary genesis
However, the most frequent form of inner ear hearing impairment is high-tone loss

Ankylosis of the conductive system: Bone conduction still approx. 0 dB Air conduction hearing loss in the lowtone and medium-tone range Diagnosis: Commencing otosclerotic or scarred fixation of the stapes or - less pronounced - negative pressure in the middle ear

Cause: - Influenza - Chronic otitis (mucous membrane, suppuration, bone suppuration) - Otosclerosis (advanced)

Hearing Instrument Fitting

1. Behind-the-ear (BTE) Hearing Instruments
A number of different rules (e.g. NAL, POGO, Berger) exist for fitting hearing instruments, all of which yield similar results. The simplicity the half-gain rule is applied for basic fitting. A reserve gain of 5 - 10 dB should be added to avoid continuous operation of the hearing instrument with maximum volume control.

2. In-the-ear (ITE) Hearing Instruments

The "1/3 gain rule" is normally applied when tuning these instruments. Since they are fitted closer to the wearer's ear drum, ITE instruments require a lower gain. Still, a reserve gain of 5 10 dB should be added anyway.

Note:

Reserve gain must not be added when fitting (BTE and ITE) instruments with automatic gain control. If any additional gain is required, the instrument must be reprogrammed.

Audiogram No. 1
125 0 10 20 30 Hearing 40 loss in dB 50 60 70 80 90 100 110 Frequency (Hz) 750 1500 3000 6000 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 110

SENSORINEURAL hearing loss:

Sloping hearing loss In this case, the threshold curve is identical for aerial and bone conduction.

DIAGNOSIS:
Either the inner ear or the auditory nerve is damaged.

HEARING INSTRUMENT FITTING:

For this degree of snesorineural hearing loss, a gain of: >/= 50 dB for BTE instruments >/= 45 dB for concha instruments >/= 40 dB for canal instruments >/= 35 dB for CIC instruments is required. Instruments with compression circuits (dynamic compression) are recommended.

Selection of HEARING INSTRUMENTS:

Non-programmable: Recommended: 1. BTE: PIANO 566H 2. Concha: 3. Canal: CT K-AMP113/40/06, CTAGC-I/D113/40/12 4. CIC: It is less advisable to fit linear instruments in such cases Programmable: ViVA2 Pro, MUSIC PIT S1/S1+ 113/45/03, PITV2 118/45/03, PITM118/45/03 PCT M 113/40/03, PCM 1001 110/40/12 PCIC M 110/40/00

Audiogram No. 2
125 0 10 20 30 40 Hearing loss 50 in dB 60 70 80 90 100 110 Frequency (Hz) 750 1500 3000 6000 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 110

CONDUCTIVE HEARING LOSS:

The difference between air and bone conduction is very large. The uncomfortable loudness level lies above 110 dB

DIAGNOSIS:
In this case, either the outer ear or the middle ear is damaged. E.g., the ossicular chain is interrupted

HEARING INSTRUMENT FITTING:

For conductive hearing loss, a gain is required for the difference between air and bone conduction. A gain of: >/= 50 dB for BTE instruments >/= 45 dB for concha instruments >/= 40 dB for canal instruments >/= 35 dB for CIC instruments is required. Linear hearing instruments are recommended here.

Selection of HEARING INSTRUMENTS:

Non-programmable: Recommended: 1. BTE: PIANO 566H, 568H 2. Concha: 3. Canal: CT/D113/40/03, CTAGC-I/D113/40/12 4. CIC: CIC/D 113/35/03 Less advisable are: K-AMP instruments Programmable: ViVA2 Pro, MUSIC PIT S1/S1+ 113/45/03, PITV2 118/45/03, PITV2 123/50/03 PITM 118/45/03 PCT M 113/40/03, PCM 1001 110/40/12 PCIC M 110/35/00

Audiogram No. 3
125 0 10 20 30 40 Loss 50 in dB 60 70 80 90 100 110 Frequency (Hz) 750 1500 3000 6000 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 110

Combined HEARING LOSS:

The sound perception is impaired for both air and bone conduction. Bone conduction is OK up to 500Hz.

DIAGNOSIS:
Combined conductive and sensorineural hearing loss resulting from injury to the outer, middle, inner ear and/or auditory nerve.

HEARING INSTRUMENT FITTING:

In this case: A gain of: >/= 40 dB for BTE instruments >/= 40 dB f. concha instruments >/= 35 dB f. canal instruments >/= 30 dB f. CIC instruments is required.

Selection of HEARING INSTRUMENTS:

Non-programmable: Recommended: 1. BTE: PIANO 562A,566H,568H, 2. Concha: IT 110/40/06, 3. Canal: CT/D113/40/03, CTAGC-I/D113/40/12 4. CIC: CIC/D 113/35/03 Programmable: ViVA2 Pro, MUSIC, SWING S1/S1+, 1001, 3004 PIT S1/S1+ 113/45/03, PITV2 118/45/03, PITM 118/45/03 PCT M 113/40/03, PCS M 115/40/03, PCM 1001 110/40/06, VIVA Pro 110/40/03 PCIC M 110/35/00, VIVETTE Pro 105/35/06

Audiogram No. 4
125 0 10 20 30 40 Hearing loss 50 in dB 60 70 80 90 100 110 Frequency (Hz) 750 1500 3000 6000 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 110

FLAT-CURVE SENSORINEURAL HEARING LOSS:

The hearing loss is roughly the same at all frequencies.

DIAGNOSIS:
Bone conduction = air conduction. Damage has occurred to the inner ear or auditory nerve.

HEARING INSTRUMENT FITTING:

With this degree of sensorineural hearing loss, a hearing instrument that also offers power in the low frequency range is required. A gain of: >/= 50 dB for BTE instruments >/= 45 dB for concha instruments >/= 40 dB for canal instruments >/= 40 dB for CIC instruments is required. Often PP instruments are required.

Selection of HEARING INSTRUMENTS:

Recommended: 1. BTE: Non-programmable: PIANO 568H, 564P Programmable: ViVA2 Pro, MUSIC, SWING S1/S1+, S2/S2+, PIT S1/S1+ 113/45/03, PITV2 118/45/03, PITM 118/45/03 PCT M 113/40/03, PCS M 115/40/03, PCM 1001 110/40/06, PCIC M 115/40/00,

2. Concha: IT 110/40/06, 3. Canal: CT/D113/40/03, CTAGC-I/D113/40/06 4. CIC: Not recommended: K-AMP instruments

Audiogram No. 5
125 0 10 20 30 250 500 1000 2000 4000 8000 0 10

Ski slope hearing loss:

Hearing loss begins at approx. 1000 Hz.

20
30 40 50 60 70 80 90 100 Frequency (Hz) 750 1500 3000 6000 110

DIAGNOSIS:
This hearing loss may be caused by noise or due to age.

40
Loss 50 in dB 60 70 80 90 100 110

HEARING INSTRUMENT FITTING:

An "open" fitting (BTE) should be supplied in such cases. A gain of: >/= 50 dB for BTE instruments >/= 45 dB for concha instruments >/= 40 dB for canal instruments and >/= 40 dB for CIC instruments is required. A hearing instrument with a large vent (IROS) is required here. The TILL function is also advantageous.

Selection of HEARING INSTRUMENTS:

Recommended: Non-programmable: PIANO, HI with open fitting 566H, 568W 2. Concha: IT 110/40/06, 3. Canal: CT/D113/40/03, CTAGC-I/D113/40/12 1. BTE: Programmable: ViVA2 Pro, MUSIC, SWING S1/S1+, S2/S2+, PIT S1/S1+ 113/45/03, PITV2 118/45/03, PITM 118/45/03 PCT M 113/40/03, PCS M 115/40/03, PCM 1001 110/40/06,

4. CIC: Not recommended:

PCIC M 115/40/00, Custom CS and CIC instruments without enough space for a large VENT.

Audiogram No. 6
125 0 10 20 30 40 Hearing loss 50 in dB 60 70 80 90 100 110 Frequency (Hz) 750 1500 3000 6000 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 110

Reverse slope hearing loss:

The hearing loss is less pronounced at higher frequencies (5-10 dB per octave).

DIAGNOSIS:
e.g. M?i?e's disease (accompanied by dizziness)

HEARING INSTRUMENT FITTING:

For this hearing impairment, a PP (BTE or ITE) instrument should be recommended.. A gain of: >/= 45 dB for BTE instruments >/= 40 dB for concha instruments >/= 35 dB for canal instruments >/= 30 dB for CIC instruments is required. Reason: Power required in low-freq. range.

Selection of HEARING INSTRUMENTS:

Recomm.:

Non-programmable: PIANO 566H, 562A, VIVA 703 584P, 584 P-2 2. Concha: IT KAMP113/40/06 3. Canal: CTAGC-I108/35/06
1. BTE: CIC/D 113/35/03 Linear ITEs

Programmable: ViVA2 Pro, MUSIC, SWING S1/S1+,

PIT S1/S1+ 113/45/03, PITV2 118/45/03, PITM 118/45/03 PCT M 113/40/03, PCS M 110/35/00, VIVA Pro CT 105/35/03 PCS V 105/35/03 PCIC M 110/35/00, VIVETTE Pro 100/30/03 and 105/35/03

4. CIC: Not recommended:

Audiogram No. 7
"COOKIE BITE" MID-FREQ. HOLLOW:
125 0 10 250 500 1000 2000 4000

Little loss at high and low frequencies.

DIAGNOSIS:
Probably due to an hereditary hearing impairment

20
30 40 Hearing loss in dB 50 60 70 80 90 100 110

HEARING INSTRUMENT FITTING:

Persons exhibiting this hearing impairment should be supplied with multi-channel hearing instruments. Reason: Different ampification for different frequency areas. A gain of: >/= 45 dB for BTE instruments >/= 45 dB for concha instruments >/= 40 dB for canal instruments >/= 40 dB for CIC instruments is required.

Frequency (Hz)

500

1000

2000

4000

8000

Selection of HEARING INSTRUMENTS:

Recomm.: Non-programmable: 1. BTE: PIANO 568W, 2. Concha: IT KAMP113/40/06 3. Canal: CTAGC-I/D113/40/06 4. CIC: CIC/D 113/35/03 Programmable: MUSIC, Triton, S1/ S1+, S2/S2+ PITM 118/45/03, PIT 3004, S2/S2+ 118/50/03, PCT M 113/40/03, PCS M 115/40/00, PCM2131 107/40/12 PCIC M 115/40/00, VIVETTE Pro 110/40/03

Audiogram No. 8
125 0 10 20 30 40 Hearin50 l oss in dB 60 70 80 90 100 110 Frequency (Hz) 750 1500 3000 6000 250 500 1000 2000 4000 8000 0 10 20 30 40 50 60 70 80 90 100 110

PROFOUND HEARING LOSS:

Only minimal residual hearing ability can be found between 500 Hz and 4000 Hz. (almost total deafness)

DIAGNOSIS:
e.g. caused by interruption of the blood supply to the inner ear.

HEARING INSTRUMENT FITTING:

Only the most powerful PP instruments can be used for such hearing impairments. Pocket-size or maximum-power BTE instruments should be recommended here.

Selection of HEARING INSTRUMENTS:

Recommended: 1. BTE: 2. Concha: Also recommended: Note recommended: Non-programmable: 684 P-AO IT PP 125/60/03 Programmable: PIT -S3/S3+ 125/60/03

High-power BTE or pocket hearing instruments Cosmea-Top, Cosmea-small, and CIC ITE instruments

LINEAR CIRCUIT TEST DATA

PEAK GAIN HFA GAIN PEAK SSPL90 HFA SSPL90

HARMONIC DISTORTION

RESP dBSPL 90 80 70 60 .25 .5 1 2

SSPL90 dBSPL 100 90 80 70 4KHz SSPL90 CURVE

MAX SSPL90: 107.3 dB AT 1700Hz HF AVG SSPL90: 106.5

RESP LIMIT: 72.0 dB F1=272 Hz F2=6500 Hz

HF AVG FULL ON GAIN 37.6 dB AT 60 dB IN

HFAVG RESP CURVE GAIN 29.8 dB REF TEST GAIN=29.6 dB

% TOT HARM DIST AT dB 4.6 AT 500Hz 70 AT 800Hz 70 2.8 AT 1600Hz 65

EQ IN NOISE: 26.5 dB BATT. MA.: 1.0 AT 1.30 VOLTS (ZINC AIR)

60 dB IN FULL ON GAIN

BATTERY CURRENT DRAIN

EQUIVALENT INPUT NOISE

AGC CIRCUIT TEST DATA

RESPONSE PEAK

HFA GAIN

PEAK SSPL90

HFA SSPL90

HARMONIC DISTORTION

RESP dBSPL 90 80 70 60 .25 .5 1 2

SSPL90 dBSPL 100 90 80 70 4KHz SSPL90 CURVE 50 60 70

MAX SSPL90: 106.0 dB AT 1700Hz HF AVG SSPL90: 100.9 HF AVG FULL ON GAIN 33.9 dB AT 50 dB IN

RESP LIMIT: 64.0 dB F1=294 Hz F2=6700 Hz

% TOT HARM DIST AT dB 2.6 AT 500Hz 70 3.1 AT 800Hz 70 HFAVG RESP CURVE GAIN 1.0 AT 1600Hz 65 33.9 dB REF TEST GAIN=33.9 dB EQ IN NOISE: 22.3 dB BATT. MA.: 0.6 ATTACK 2MS AT 1.30 VOLTS (ZINC AIR) RELEASE 45MS MEASURED AT 2 KHZ

80 dBIN

50 dB IN FULL ON GAIN

2 kHz I/O CURVE

AGC KNEEPOINT

ATTACK & RELEASE TIME

BATTERY CURRENT DRAIN

EQUIVALENT INPUT NOISE

GAIN

10 dB 40 dB IN OUT PEAK GAIN vs. AVERAGE GAIN

50

G A I N

40

30
20 10 .25 .5 1 2 4KHz

FREQUENCY PEAK = 45dB AVG = 35 + 42 + 38 / 3 = 38.3dB

MAXIMUM OUTPUT (MPO)

PHYSICAL LIMIT

PEAK SSPL90 vs. AVG SSPL90

110 100 90 80 70 .25 .5 1 2 4KHz

S S P L 9 0

FREQUENCY PEAK = 109dB AVG = 106 + 108 + 101 / 3 = 105dB

FREQUENCY
TIME 1 SECOND

1V

= 2 Hz
1 CYCLE 1 CYCLE

TIME 1 SECOND

1V

= 4 Hz
2 CYCLES 2 CYCLES

Peak to Peak
1 SEC 1 SEC
Amplitude

0.5 V

1V

2 CYCLES

2 CYCLES

= 0.5V PP(Peak to Peak)

= 1.0V PP (Peak to Peak)

HARMONIC DISTORTION

FUNDAMENTAL FREQUENCY = 100Hz

SECOND HARMONIC = 200 Hz

EQUIVALENT INPUT NOISE

CIRCUIT NOISE

CIRCUIT NOISE

SIGNAL IN TO AMP

SIGNAL OUT OF AMP

TRIMMER OPTIONS
TONE / NH RPC

G A I N
BLUE ARROW FREQUENCY

G A I N
FREQUENCY

GREEN ARROW
OUTPUT /PC

HIGH CUT / NL G A I N YELLOW ARROW

S S P L 9 0 FREQUENCY GRAY ARROW FREQUENCY

TRIMMER OPTIONS
AGC O U T GAIN

G A I N
WHITE ARROW SSVC

RED ARROW

INPUT

FREQUENCY

ASP O U T

G A I N WHITE ARROW INPUT

ORANGE ARROW

FREQUENCY

TRIMMER OPTIONS for K-AMP Instruments

LB = G90 G A I N ORANGE ARROW G90 amplifies loud, high-frequency sounds up to 12dB Note: This is available only as a programmable function. LFC G A I N FREQUENCY

LFC= Gain-dependent low-frequency control

GC = G65 G A I N

TK = G40 O U T

RED ARROW WHITE ARROW

FREQUENCY

WHY PROGRAMMABLE HEARING AIDS? NO WAY!

FACTORY

HEARING AID DISPENSER

PATIENT

vs.
FACTORY

HEARING AID DISPENSER

PATIENT

Hearing Instrument Fitting

Diagram of a pure tone audiogram and the required target gain of the hearing instrument

Fitting Hearing Instruments

Display: Basic setting and target gain of hearing instrument

Basic setting of hearing instrument Target gain of hearing instrument It is the hearing instrument dispenser's job is to bring the hearing instrument (black curve) as closely into line as possible with the red target gain.

Hearing Instrument Fitting

Display: Fitted hearing instrument

Size Classes
Custom instruments are available in four size classes, and modular instruments come in two classes.

Comparison of size classes by their fitting position in the ear

Among custom instruments, a distinction is made between: Concha instruments Battery type 13
(INSITA TOP)

Canal instruments
(COSMEA TOP)

Battery type 312

Canal instruments
small (COSMEA SMALL)

Battery type A 10/230

CIC instruments
(completely in the canal)

Battery type A 10/230

Modular instruments come in the following structural shapes:

Canal instruments
Canal instruments
small

Battery type 312

Battery type A 10/230

1 Concha instruments 2 Canal instruments 3 Canal instruments, small 4 CIC instruments