Your Free Guide to Living Well with Hearing Loss

Your Free Guide to Living Well with Hearing Loss

Introduction

Hearing loss occurs when any part of one or both ears, the auditory nerve or the auditory part of the brain is not working normally. It is particularly prevalent in older individuals.  About a third of Americans ages 65 to 75 and half of those older than 75 have some degree of hearing loss. Hearing loss can happen at any time, from birth to during infancy, childhood, adolescence and adulthood.

According to the U.S. Centers for Disease Control & Prevention (CDC), 1.7 in every 1,000 infants and about 15% of Americans ages 6 and older have some amount of hearing loss. Hearing loss in babies and young children can lead to a range of developmental, educational and language delays, some of which can persist into adulthood if not addressed early. Disabling hearing loss is considered to be a hearing loss of 35 decibels (dB) or more in the better hearing ear. See “Loudness of Common Sounds” in this guide for a more in-depth explanation of decibels and how they relate to common sounds.

This guide will explain the different types of hearing loss, their causes and methods for prevention and treatment. There is a glossary of common hearing loss terms in this guide for your reference.

How Common Is Disabling Hearing Loss?

Disabling hearing loss is a problem that affects individuals of various ages. See the table below for a breakdown by percentage.

Age	Percent of This Age Group Experiencing Disabling Hearing Loss
45 – 54 years old	2%
55 – 64 years old	8.5%
65 – 74 years old	25%
75+	50%

Risk Factors

The following are factors that increase a person’s chance of experiencing hearing loss:

• Aging, especially being over 65 years old (see “Aging” in this guide)
• Being exposed to loud noises over time or a very loud noise (see “Loud Noises” in this guide)
• Having close family members who are deaf or hearing impaired (see “Genetics” in this guide)
• Taking ototoxic drugs (see “Ototoxic Medications” in this guide and “Ototoxic Drugs” in this guide)
• Being born with a congenital syndrome such as Down Syndrome (see “Genetics” in this guide)
• Having had certain infections or illnesses (see “Infections” in this guide and “Infections and Other Health Problems” in this guide)
• Head trauma, especially if the temporal bone is broken (see “Trauma and Injury” in this guide)
• Having a mother who had an infection or complications while pregnant (see “Other Environmental Factors” in this guide)
• Being born premature or with a low birth weight (see “Other Environmental Factors” in this guide)
• Having jaundice as a newborn (see “Other Environmental Factors” in this guide)
• Having type 2 diabetes, heart disease, stroke or neurological issues (see “Infections and Other Health Problems” in this guide)
• Exposure to certain chemicals (see “Chemical Exposure” in this guide)

How Does Hearing Work?

Our sense of hearing involves multiple steps, as sound waves travel through the various parts of the ear (outer, middle and inner) and then through the auditory nerve to the brain, where the sound is then interpreted.

Here’s how it works:

1. Outer ear – Sound waves enter the ear and are funneled through the ear canal. At the end of the ear canal is the eardrum.
2. Middle ear – The eardrum starts to vibrate, and these vibrations are amplified by three tiny bones in the middle ear called the malleus, incus and stapes.
3. Inner ear – The vibrations are then sent to the cochlea, a snail-shaped, fluid-filled structure in the inner ear. The cochlea is split into an upper and lower part by an elastic membrane called the basilar membrane. The basilar membrane is covered with tiny hair cells.
4. Auditory nerve – When the vibration causes the fluid inside the cochlea to ripple, the basilar membrane moves up and down, bumping into the top of the cochlea and bending the hair cells. When this happens, channels open up and chemicals rush into the cells, creating an electrical signal, which is carried by the auditory nerve, also called the eighth nerve.
5. Brain – Once the signal from the auditory nerve reaches the brain, the brain interprets it into a sound that we can recognize and understand. Signals from the left ear are processed in the auditory cortex on the right side of the brain, and signals from the right ear are processed in the auditory cortex on the left side of the brain. The comparison and analysis of all the signals that reach the brain allow us to detect certain sounds and suppress other sounds as background noise.

How loud are Common Sounds?

The loudness of sounds is measured in decibels (dB). A level of 70 decibels and under is considered to be a safe amount of noise. The table below includes the loudness of some common sounds to serve as a reference.

Type of Sound	Decibels (dB)
Safe range	colspan
Whisper	30
Refrigerator	40
Normal conversation	60
Dishwasher	75
Risk range	colspan
School cafeteria or heavy city traffic	85
Motorcycle	95
Snowmobile	100
Power tools, concerts	110
Ambulance siren	120
Firecrackers, gunshots	140-165

Maximum Sound Exposure Durations

The longer a person is exposed to loud noises, the more damaging it is to their hearing. The federal government’s Occupational Health and Safety Agency (OSHA) has set limits on how long employees can lawfully be exposed to loud noises without hearing protection. The table below breaks down this information.

Decibels (dB)	Hours per Day
90	8
92	6
95	4
97	3
100	2
102	1 ½
105	1
110	30 minutes
115	15 minutes or less

Degrees of Hearing Loss

Hearing loss ranges from mild to profound, which is determined by the number of decibels of hearing loss, shown below for each category. In other words, someone with 30 dB of hearing loss in the mild range would not be able to hear something of 30 dB and other sounds would have to be 30 dB louder to be heard compared to someone with normal hearing.

• Mild – May hear some speech, but not when people are talking softly (25-40 dB)
• Moderate – May hear some speech when someone is talking at a normal level (41-55 dB)
• Moderately severe – May hear a little speech when someone is talking at a normal level (56-70 dB)
• Severe – Hear no speech when someone is talking at a normal level but can hear some loud sounds (71-90 dB)
• Profound – Hear no speech but can hear very loud sounds (91 db+)

Hearing loss can also be described by how and when it manifests:

• Unilateral vs. bilateral – Hearing loss is in one ear (unilateral) or both ears (bilateral).
• Symmetrical vs. asymmetrical – Hearing loss is the same in both ears (symmetrical) or is different in each ear (asymmetrical).
• Progressive vs. sudden – Hearing loss gradually worsens over time (progressive) or happens quickly (sudden).
• Fluctuating vs. stable – Hearing loss gets either better or worse over time (fluctuating) or stays the same over time (stable).
• Pre-lingual vs. post-lingual – Hearing loss happened before a person learned to talk (pre-lingual) or after a person learned to talk (post-lingual).
• Congenital vs. acquired/delayed onset – Hearing loss is present at birth (congenital) or appears sometime later in life (acquired or delayed onset).

Types of Hearing Loss

There are different types of hearing loss, depending on which part of the auditory system is affected.

Conductive Hearing Loss

Conductive hearing loss is when sound cannot get past the outer and middle ear. It can often be corrected with medication or surgery. Conductive hearing loss can happen with:

• Fluid buildup in the middle ear from cold or allergies.
• An ear infection, also called “otitis media” or an infection of the ear canal (swimmer’s ear  also called “external otitis”) (see “Infections and Other Health Problems” in this guide).
• A perforated eardrum (see “Trauma and Injury” in this guide).
• Benign tumors in the middle or outer ear (see “Physical Blockage” in this guide).
• Excessive earwax stuck in the ear canal (see “Physical Blockage” in this guide).
• An object stuck in the outer ear (see “Physical Blockage” in this guide).
• A problem with the formation of the outer or middle ear.

Sensorineural Hearing Loss

Sensorineural hearing loss is the most common type of permanent hearing impairment and happens when there is damage to the inner ear or the auditory nerve. Medications and surgery are generally less effective in addressing this type of hearing loss. Many people with sensorineural hearing loss may benefit from using a hearing aid (see “Hearing Aids” in this guide) or a cochlear implant (see “Surgery and Implants” in this guide).

Sensorineural hearing loss can happen with:

• Certain illnesses (see “Infections” in this guide and “Infections and Other Health Problems” in this guide).
• Drugs that negatively impact hearing (see “Ototoxic Medications” in this guide for details).
• Hereditary hearing loss (see “Genetics” in this guide).
• Aging (see “Aging” in this guide).
• A blow to the head (see “Trauma and Injury” in this guide).
• Very loud noises (see “Loud Noises” in this guide).
• A malformation of the inner ear (see “Genetics” in this guide).

Mixed Hearing Loss

Mixed hearing loss is a combination of conductive and sensorineural hearing loss. In some cases, a problem causing conductive hearing loss can also affect the inner ear if left untreated. This would further deteriorate the individual’s ability to hear.

Auditory Neuropathy Spectrum Disorder

Auditory neuropathy spectrum disorder is a condition in which the outer, middle and inner ear detect sound, but the brain has trouble making sense of it. When people with this disorder are given hearing tests, the results range from normal to severely hearing impaired. However, they all have difficulty understanding speech clearly. They might hear sounds but not recognize words, and sometimes they report that sounds fade in and out or are out of sync.

Medical experts are not sure how many people are affected by auditory neuropathy spectrum disorder, but they think that it is quite common among people who are hearing impaired and deaf. Depending on the cause, this kind of hearing impairment may get better, remain stable or get worse with time.

There are multiple causes, including damage to the hair cells, auditory neurons that connect the hair cells to the auditory nerve, the auditory nerve, or genetic factors (some of which may occur at the same time). This type of hearing loss may be congenital or develop later with age. In some cases, people with auditory neuropathy spectrum disorder also have other neurological problems including Charcot-Marie-Tooth syndrome and Friedreich’s ataxia.

There is no agreed-upon treatment for auditory neuropathy spectrum disorder. Some doctors say that hearing aids and cochlear implants have helped, while others advise that pre-lingual children with this disorder learn American Sign Language as their first language and post-lingual children learn to lip read.

What Causes Hearing Loss?

The causes of hearing loss are different, depending on whether it is congenital or acquired hearing loss.

Causes of Congenital Hearing Loss

Congenital hearing loss includes any hearing loss that is discovered between birth and age 5. Although most infants (93%) in the United States are screened for hearing impairment in the first month of life, sometimes the hearing loss does not become apparent until later.

Genetics

Genetic factors account for between 50% and 70% of congenital hearing loss, with about 20% of babies with hearing loss also having Down Syndrome, Pendred’s or Usher Syndrome. When a person has one of these genetic syndromes, associated hearing loss is called syndromic and the genetic mutations of the syndrome cause a malformation of part of the ear.

Other mutations that are not associated with a syndrome (nonsyndromic), can also cause hearing loss. A mutation in a single gene, GJB2, is responsible for 30% to 50% of nonsyndromic hearing loss, by causing a defect in the formation of the cochlea. Parents who are congenitally deaf have a higher chance of having a baby who will have hearing loss. However, 90% of babies with hearing loss are born to hearing parents.

Infections

Infections (prenatal or postnatal) cause about 20% of the cases of congenital hearing loss. Infections that can cause hearing loss in infants include AIDS, meningitis and “TORCH” organisms (toxoplasmosis, rubella, cytomegalovirus, and herpes).

In the United States, 10% of infants with congenital hearing loss and 35% of those with moderate to severe late onset hearing loss had cytomegalovirus (CMV) at birth. CMV is a member of the herpes family of viruses. It is a common virus that is present in over half of American adults by age 40 and in one-third of children ages 5 and younger. In healthy people, CMV has no symptoms and those infected may be unaware. Hearing loss is the most common symptom of CMV, but it can also cause brain, liver, spleen, lung, and growth problems in babies born with it.

CMV may be transmitted to infants in utero through the placenta or after the birth in breast milk, and from children to adults via saliva or urine. Although there is no cure for CMV, if a baby is found to have CMV, doctors may prescribe an antiviral medication called valganciclovir to improve hearing and developmental outcomes.

Some babies with congenital CMV have one or more of the following symptoms:

• Rash
• Jaundice (yellowing of the skin or whites of the eyes)
• Microcephaly (small head)
• Low birth weight
• Hepatosplenomegaly (enlarged liver and spleen)
• Seizures
• Retinitis (damaged eye retina)

CMV can be diagnosed in infants through a test of the baby’s saliva or urine in the first three weeks of life.

People with a mutation in the gene MTTL1 who develop type 2 diabetes are at a very high risk (61%) for hearing loss. The hearing loss does not manifest itself until diabetes is present, and since type 2 diabetes can be prevented, those with this gene mutation should follow recommendations for eating a healthy diet and getting plenty of physical activity.

Ototoxic Medications

Taking certain kinds of medication while pregnant can result in hearing loss in the baby. Medications that cause hearing loss are called ototoxic drugs. Ototoxic drugs include:

• Streptomycin – Causes damage to the vestibular portion of the inner ear, which can result in vertigo and difficulty maintaining balance. In addition, between 4% and 15% of patients who receive 1 g/day for more than a week develop measurable hearing loss, beginning after 7 to 10 days and slowly worsening if treatment is continued. Permanent deafness may result.
• Neomycin – Has the greatest cochleotoxic (damaging to the cochlea) effect of all antibiotics. Used for intestinal sterilization, large doses can affect hearing, potentially resulting in complete deafness.
• Gentamicin and tobramycin – Have vestibular (balance) and cochlear toxicity, causing impairment in both balance and hearing.
• Vancomycin – Can cause hearing loss, especially in the presence of kidney problems.
• Azithromycin (Z pak) – Has also been shown in rare cases to cause both reversible and irreversible hearing loss.
• Viomycin – A medication for tuberculous, has both cochlear and vestibular toxicity.

Other Environmental Factors

In addition to genetic factors and infection, other environmental factors can cause congenital hearing loss. These include:

• Infant head trauma.
• Pregnancy complications such as asphyxiation/anoxia
• Sepsis.
• Craniofacial abnormalities where parts of the ear are differently shaped.
• Rh incompatibilities.
• Neonatal jaundice.
• Being born premature/low birth weight.

Causes of Non-Congenital Hearing Loss

Non-congenital hearing loss is caused by aging, environmental factors or a combination of factors. Although hearing loss that develops after early childhood is considered to be non-congenital, some people are genetically predisposed to develop hearing impairment later in life, so there may still be a genetic component.

Aging

The most common cause of non-congenital hearing impairment is aging. This is called presbycusis. Over time, the structures in the inner ear may deteriorate. Among those aged 65 to 75, one-third have some amount of hearing loss and this increases to one-half after age 75.

While some older Americans may not want to admit that they cannot hear as well as they used to, hearing loss can cause a variety of problems. These include social isolation, depression, inability to hear and communicate, and inattentiveness to alarms, car horns and doorbells. Further, seniors with hearing loss may be mistaken for those with dementia when they are unresponsive to questions or uncooperative regarding directions from others.

Loud Noises

Being exposed to loud noises often or for long periods of time (see “Maximum Sound Exposure Durations” on page X of this guide) can damage the tiny hair cells in the inner ear, the membrane in the cochlea or the auditory nerve, leading to partial hearing loss or complete deafness. In addition to loud noise exposure over time, a single extremely loud sound can cause hearing loss by rupturing your eardrum.

Military veterans who experienced active combat are prone to hearing loss because they have frequently been exposed to loud noises from airplanes and other military vehicles as well as gunfire and blasts. A report from the U.S. Department of Veterans Affairs estimated that more than 60,000 military service members are on disability for hearing loss from Operation Iraqi Freedom and Operation Enduring Freedom alone.

Loud workplaces can cause hearing loss (see “Maximum Sound Exposure Durations” on page X of this guide for federal safety guidelines in the workplace). In fact, among adults aged 20-69 who report 5 or more years of exposure to very loud noise at work, 18% have speech-frequency hearing loss in both ears, compared to the 5.5% of adults with speech-frequency hearing loss in both ears who report no noise exposure at work.

How Do You Know If It Is Too Noisy?

If you need to raise your voice to be heard by someone who is only an arm’s length away, the noise level in the environment is probably more than 85 dB and could damage your hearing over time. Some places such as construction sites may have signs or posters warning of loud noise.

Infections and Other Health Problems

Infections and other serious health problems that occur after birth can negatively impact hearing later in life. Infectious diseases account for a quarter of profound hearing loss. Below are the most common diseases that can cause hearing loss:

• Mumps – When deafness associated with mumps happens, it is usually sudden and profound and may be accompanied by nausea, dizziness, vomiting and tinnitus (ringing in the ears). Hearing loss from mumps occurs only in one ear 80% of the time and may only affect one’s ability to hear high frequency sounds.
• Cytomegalovirus (CMV) – Other than early childhood, the most common time for people to catch CMV is during adolescence when it is spread through kissing or sexual contact. Even when the infected individual has no other apparent symptoms, 7%-13% develop hearing loss.
• Measles – This highly contagious virus can lead to hearing loss, which is typically bilateral (both ears), asymmetrical and severe.
• Viral meningitis – Occurring most frequently in children over two years old, meningitis can cause hearing loss.
• Herpes simplex – There are two types of herpes simplex, type 1 (oral, usually found in and around the mouth) and type 2 (genital). Type 1 is extremely common and can be acquired at any time. Type 2 is generally contracted in the teenage years and adulthood.  Both types can cause hearing loss.
• Infectious mononucleosis and other viral agents – Infectious mononucleosis (mono) and other viruses including adenovirus, enterovirus, influenza (the flu), and parainfluenza can result in hearing loss.
• Bacterial meningitis – This serious disease has a high mortality rate and is one of the major culprits of infection-induced hearing loss, both from the disease itself and the ototoxic antibiotics used to treat it (see “Other Environmental Factors” on page X of this guide). More than two-thirds of infected people who experience hearing loss from this cause become deaf, with the remainder experiencing anywhere from mild to severe hearing impairment. Sometimes, when caught early, the hearing loss may be reversed.
• Syphilis – While rare, hearing loss can occur with syphilis infections when left untreated. Hearing loss may be sudden and fluctuating, involve vertigo and may occur in one or both ears.
• Chronic ear infections – Middle ear infections (otitis media) are extremely common among young children. When an individual gets multiple infections, fluid can remain in the ear even when no active infection is present, leading to hearing loss.

Ototoxic Drugs

Just as ototoxic medications can cause a baby to be born with hearing loss or deafness, taking ototoxic drugs later in life can lead to hearing impairment. Ototoxic medications are most often prescribed for life-threatening infections (see “Ototoxic Medications” on page X of this guide for a detailed list of examples), erectile dysfunction (Viagra) and cancer (chemotherapy drugs including cisplatin and carboplatin). In addition to causing new hearing problems, they can make hearing problems worse for older individuals and those already experiencing some hearing loss.

Trauma and Injury

Head injury from falls, blunt trauma or a concussion can prevent the brain from making sense of incoming sounds, even if all of the parts of the ears are working properly. Deafness is most common when the temporal bone in the skull is fractured. This damages the 8th cranial nerve (auditory nerve), which is normally protected by the temporal bone.

In cases of head injury, the hearing loss happens right away. Conductive deafness usually disappears within two months. Sensorineural hearing loss experienced after a head injury takes longer to heal, usually within nine months, but hearing loss is permanent in 10%-15% of cases.

Severe injuries can result in post-traumatic Meniere’s syndrome, characterized by periods of dizziness that are accompanied by noises in the ear, a feeling of fullness in the ears or hearing changes. This can take place immediately after injury or up to one year afterward.

Hearing loss usually does not happen with brain damage such as that caused by stroke because hearing is processed in multiple parts of the brain. Also, people can experience hearing impairment after an automobile’s airbag deploys, but it is not clear if this is because of the trauma of impact or the loud noise of deployment.

In addition to head injury, it is possible to damage hearing by puncturing the eardrum. Eardrums can get punctured or perforated by putting objects in the ear (like cotton swabs), experiencing an infection or being around a very loud noise. Most punctured eardrums will heal on their own within a few weeks, but if this does not happen, they can be patched or surgically corrected.

Physical Blockage

If the outer ear or middle ear is blocked by an object or tissue, it can cause hearing problems that are usually temporary. For example, sometimes very young children put small objects like pebbles or buttons in their ears. Earwax buildup can also muffle hearing. In both of these cases, a visit to a pediatrician, primary care doctor or ear, nose and throat doctor (EMT) may quickly correct the issue.

Some people may have a benign (non-cancerous) tumor blocking the outer or inner ear. In most cases, this will require minor surgery to fix.

Chemical Exposure

Just as some medications can cause hearing loss, some chemical substances can do the same. These are called ototoxicants. For some of them, just exposure to the substance is enough to cause hearing impairment, while others only cause hearing loss when paired with loud noises. They include:

• Organic solvents – For example, toluene, styrene, xylene, ethylbenzene and trichloroethylene
• Heavy metals – For example, mercury, lead and trimethyltin
• Asphyxiants – For example, carbon monoxide and hydrogen cyanide
• Pesticides – For example, organophosphates (OPs), pyrethroids, dipyridyl compounds and hexachlorobenzene (HCB)

The OSHA has more information about hearing loss and ototoxicants here: https://www.cdc.gov/niosh/docs/2018-124/pdfs/2018-124.pdf?id=10.26616/NIOSHPUB2018124

Prevention, Screening and Diagnosis

Whether for yourself or your children, it is important to take steps to protect hearing. This involves avoiding certain activities and substances, making sure infants and children are screened for hearing loss and going to the doctor for a diagnosis if you or your child is experiencing any problems hearing or understanding speech.

Babies and Children

Babies and children are vulnerable to hearing loss, even before they are born. Since hearing has a huge effect on language development and education, prevention, early diagnosis and early treatment are critical to giving your child the tools for success.

Hearing Loss Prevention for Babies and Children

While not all hearing loss is preventable, there are some things you can do to potentially reduce the risk that your child may be hearing impaired or deaf:

• Staying away from ototoxic medications while pregnant – It is recommended to tell any doctors you visit that you are pregnant, especially if you have a family history of hearing loss.
• Breastfeeding your baby – Babies who are breastfed get protective antibodies in breast milk.
• Getting tested for CMV when pregnant – If you are positive for CMV (see “Infections” on page X of this guide), your obstetrician can be on the lookout for signs of congenital CMV when your baby is born and can administer antiviral medication.
• Being as healthy as possible during pregnancy – It is recommended to get good prenatal care, take prenatal vitamins and follow your obstetrician’s advice to reduce the risk of premature birth and low birth weight.
• Making sure your child gets all regular vaccines and boosters – Several of the infections most likely to cause hearing loss (measles, mumps and rubella) are preventable by getting the recommended vaccines for children. Those three diseases are covered in the MMR shot. Getting the flu vaccine and the 13-valent pneumococcal conjugate vaccine (PCV13) also help prevent many ear infections.
• Cutting the noise – It is recommended to keep babies and children away from loud noises including noisy toys, fireworks and loud music. Music played at top volume through earbuds is between 94 and 110 dB, well within the damaging range. Fireworks displays are between 150 and 170 dB, and sporting events can be between 94 and 110 dB.
  • If your child must be around noise, consider using hearing protection.

• Preventing and treating ear infections – Since ear infections can lead to hearing loss, in addition to being very painful and sometimes resulting in a fever, it is best to prevent them as much as possible and treat them quickly when they arise. Here are some tips:
  • Not giving your baby a bottle to go to sleep with
  • Keeping children and babies away from cigarette smoke
  • Separating well children from sick ones as much as possible
  • If your baby or young child has a fever, is crying in pain or says their ear hurts, taking them to the pediatrician
  • If your child has gotten more than five ear infections in a year, talking to your pediatrician about inserting tubes into the ear to assist with air flow

Warning Signs for Babies

If your baby is showing the following signs, they may be experiencing hearing loss:

• Does not startle at loud noises
• Does not turn toward the source of sound by age 6 months
• Does not say single words by age 1 year
• Turns head when they have visual contact with a parent, but not when just their name is called
• Seems to hear some sounds but not others

Warning Signs for Children

The signs of hearing loss in children are slightly different from those of babies. See below:

• Speech is delayed
• Speech is garbled and unclear
• Does not follow verbal directions
• Often says “huh?” or “what?”
• Listens to the TV at a very high volume

Since hearing loss can cause developmental delays in language, social interaction and emotion, not reaching developmental milestones is potentially a sign of hearing loss. You can check here https://www.cdc.gov/ncbddd/actearly/milestones/index.html to see when your baby or child up to age 5 should be reaching developmental milestones.

Hearing Loss Screening for Babies and Children

Standard practice in the United States is to screen newborns for hearing loss soon after birth before they leave the hospital. This is mandated by law in 39 states. If, for some reason, your newborn does not receive this screening test in the couple of days after birth, it is recommended to have the pediatrician do the screening within the first month. See “Individuals with Disabilities in Education Act, Part C” in this guide for more information on infant and toddler screening and services.

If the screening shows abnormal results, the pediatrician or neonatologist will refer your baby for a full hearing test, which should be done as soon as possible. Statistically, about one-half of infants with abnormal hearing screening results are determined to have normal hearing.

When hearing loss is detected and remediated within the first six months, these babies are typically able to develop linguistically, socially and emotionally at the same pace as their hearing peers, regardless of whether speech, sign language or a combination are used to communicate. When diagnosis and remediation take place after six months of age, babies show developmental delays.

Older children should also have a hearing test before entering school and any time that their hearing becomes a concern. An audiologist, an expert on testing for hearing, will conduct the hearing test. The hearing test may be one or more of the following:

• Auditory Brainstem Response (ABR) or Brainstem Auditory Evoked Response (BAER) – This test checks the brain’s response to sound. Since this test does not rely on a person’s response behavior, the person being tested can be an infant and can even be sound asleep during the test.
• Otoacoustic Emissions (OAE) -This is a test that checks the inner ear’s response to sound. Like the ABR, it does not rely on a person’s response behavior, and the person being tested can be a baby and even sleep through the test.
• Behavioral Audiometry Evaluation – This tests how a person responds to sound by playing tones of different pitches and volumes in one ear at a time and then both ears, asking subjects to indicate when they hear a sound. The person being tested must be awake, able to follow directions and actively respond to sounds heard during the test.

In addition to the hearing tests that the audiologist administers, he or she will take a detailed family history and will talk to the parents about warning signs that might indicate hearing loss.

Adults

Since hearing loss can happen at any time, adults should take steps to protect their hearing and, if there is hearing loss, address it. Note that adult men are twice as likely as women to experience hearing loss.

Hearing Loss Prevention for Adults

It is recommended that all adults, but particularly those with a genetic predisposition, take extra care to protect their hearing. Additionally, people who have already experienced some hearing loss may prevent further hearing impairment by taking these steps.

Not taking ototoxic medications when at all possible – If you must take them, consider asking your doctor about mitigating potential hearing loss.

• Protecting your ears – If you are around loud noises frequently for work (aviation, military, construction, manufacturing, musical performance, etc.) or recreation, it is recommended to wear earplugs or noise-cancelling ear muffs. If you live in a city or near an expressway or train tracks, you may keep your windows closed and get drapes and rugs or carpets to absorb sound. Try not to listen to loud music on earphones or earbuds. When buying home appliances, look for those with a low noise rating.
• Stopping tobacco use – Tobacco products contain nicotine, which has been proven to damage inner ear hair cells. This applies to nicotine vaping and secondhand smoke as well.
• Not using cotton swabs to remove earwax – This can push earwax further in, compacting it, and the swab can puncture your eardrum. Instead, consider using an in-home irrigation kit to soften and gently remove the earwax.
• Eating right and being active – These healthy habits may be able to help you prevent diabetes, heart disease and stroke, all risk factors for hearing loss.
• Protecting your skin – If you come into contact with ototoxicants like pesticides, heavy metals or organic solvents (see “Chemical Exposure” on page X of this guide), it is recommended to wear protective gear such as gloves, face masks and coveralls to prevent absorbing these chemicals through the skin or respiratory system.

Warning Signs for Adults

The following symptoms may be indicative of hearing loss in adults:

• Speech and other noises sound muffled
• Difficulty understanding words, especially with background noise
• Difficulty hearing consonants
• Needing to frequently ask people to talk louder, more clearly and more slowly
• Needing to turn up the volume on the TV or radio
• Withdrawing from conversations
• Avoiding social settings like parties
• Experiencing a ringing in the ears (tinnitus)
• Sudden loss of hearing in one ear

In this case, it is recommended to seek immediate medical attention.

Hearing Loss Diagnosis for Adults

If you have one or more of the warning signs above, it is recommended to visit your doctor and ask for a hearing screening. This may include one or more of the following:

• Physical exam – The doctor will look in your ears to see if you have excess earwax, signs of infection or structural/physical blockages.
• Whisper test – The doctor may ask you to cover one ear at a time and determine how well you hear words spoken at different volumes.
• Tuning fork test – Tuning forks are two-pronged metal objects that make sounds at different pitches when struck. The doctor will strike various pitches to see which you respond to. This can help identify if there is hearing loss, and if so, what part of the ear is affected.

If a screening test indicates a potential problem, your doctor will refer you to an audiologist for an audiometry test, which is the same as the behavioral audiometry evaluation discussed in “Hearing Loss Screening for Babies and Children” on page X of this guide.

You may also choose to perform your own hearing screening at home with a smartphone app. But note that apps tend to be less accurate than a test given by an audiologist. Below are some of the top apps in this category:

• Mimi
  • Apple App Store: https://apps.apple.com/us/app/mimi-hearing-test/id932496645

• Easy Hearing Test
  • Apple App Store: https://apps.apple.com/us/app/easy-hearing-test/id1433904646

• Hearing Test
  • Google Play Store: https://play.google.com/store/apps/details?id=mobile.eaudiologia&hl=en_US&gl=US

• Sound Scouts Hearing Test
  • Google Play Store: https://play.google.com/store/apps/details?id=com.cmee4.soundscouts&hl=en_US&gl=US

Treatment for Hearing Loss

In children, hearing loss can cause developmental delays as well as social, emotional and educational problems. Even mild untreated hearing loss may have a large effect on children, who are not able to hear 25%-50% of speech in the classroom and are sometimes falsely labeled as behavior problems or learning disabled. This explains why children with unilateral hearing loss (only in one ear) are 10 times as likely to be held back a grade in school as children with normal hearing.

In some cases, rapid treatment may reverse, slow or halt the hearing loss and improve hearing, and in all cases, treatment is known to improve comprehension and communication.

As for adults, hearing loss puts them at risk for social isolation, depression, cognitive decline and even dementia. It is a safety concern, since those with hearing loss may not adequately hear things like doctor’s instructions, alarms and car horns. It also has an income effect; people with untreated hearing loss earn, on average, $20,000 less per year when compared to hearing-impaired people with hearing aids or cochlear implants.

Treatment Statistics

The majority of hearing impairment in babies and young children in the U.S. is treated. In a survey done by the CDC, over 65% of infants who were identified as having hearing loss got early intervention services. The vast majority of babies identified with hearing impairment (nearly 90%) are referred to the Program for Infants and Toddlers, also called Part C of the Individuals with Disabilities Education Act (IDEA). This program then channels these babies and their families to the Early Hearing Detection and Intervention (EHDI) program in their state. See “Part C” in this guide for more information.

Unfortunately, the numbers are not as good for adults. According to the Hearing Loss Association of America, those with hearing loss wait an average of seven years before seeking treatment. Among adults ages 20 to 69 with hearing loss who could benefit from a hearing aid, only 16% had one. For adults 70 and older with hearing loss who could benefit from a hearing aid, fewer than one-third (30%) had one. The major reasons given for not seeking treatment are stigma and cost.

Medical Treatment

Once a person has been diagnosed with hearing loss, the next steps are to identify whether it is a conductive, sensorineural, mixed or auditory neuropathy spectrum disorder (see “Types of Hearing Loss” in this guide) and to identify the specific cause(s) of the hearing loss. This will indicate which treatment options may be effective. Depending on the type and complexity of the hearing loss, this may be done by a primary care physician, otolaryngologist (also called an ear, nose and throat doctor or ENT) or an audiologist.

Medical Professionals

See below for an explanation of the different types of medical professionals that may be seen for hearing loss and how they may be able to help.

Primary Care Provider

This is a doctor (such as a pediatrician, family doctor, internist or geriatrician), nurse practitioner or physician assistant who treats a wide range of health issues. In situations where the hearing loss is conductive, primary care providers are often able to treat and resolve the issue. They may be able to treat and usually reverse the following causes of hearing loss via the following methods:

• The ear infections otitis media and external otitis, by prescribing antibiotics (see “Medication” in of this guide)
• Objects in the ear, by removing the objects

For other causes of hearing loss, your primary care provider is likely to refer you to either an ENT or an audiologist.

Audiologist

An audiologist is a healthcare professional specializing in hearing. While they are not medical doctors (M.D.), they do have a doctorate degree in audiology (Au.D.). Audiologists do full hearing tests (see “Prevention, Screening and Diagnosis” in this guide) and also treat the following:

• Mild to profound sensorineural hearing loss, by fitting and adjusting hearing aids (see “Hearing Aids” in this guide)
  • They may monitor hearing and make adjustments to hearing aids as needed.
• Various kinds of hearing loss, by advising patients on assistive devices (see “Assistive Listening Devices” in this guide) and teaching patient’s behaviors to protect their hearing
• Tinnitus, by counseling on how to deal with it
• Balance issues, via a type of physical therapy called vestibular rehabilitation
• Referring patients to an ENT or  when needed

Otolaryngologist or Ear, Nose and Throat Doctor (ENT)

An ENT is a physician who provides diagnosis and treatment including surgical services to patients having health problems in the ear, nose, throat or neck area. They may be able to treat the following causes of hearing loss:

• The ear infections otitis media and external otitis, by prescribing antibiotics (see “Medication” in this guide)
• Objects in the ear, by removing the objects
• Otosclerosis, an abnormal growth in a bone in the middle ear, via surgery (see “Surgery and Implants” in this guide)
• Recurrent ear infections, by surgically inserting a tube in the ear(s) to facilitate air flow  (see “Surgery and Implants” in this guide)
• Tumors and other tissue blockages of the ear canal, by surgically removing them
• Excessive earwax, by softening and gently removing it

Medication

Generally speaking, medication is not typically the main way that hearing loss is treated. However, there are some medications that are used to address some causes of hearing loss. Here are some of the most commonly prescribed medications and how they are used.

Over-the-Counter Pain Relievers

These include ibuprofen and acetaminophen and are used to relieve the pain of middle ear infections (otitis media) and ear canal infections (external otitis), which can be quite intense. Aspirin is not recommended for children because of a rare but potentially dangerous condition called Reye’s syndrome.

Antibiotics

These medications including amoxicillin, which is the most commonly prescribed antibiotic for ear infections, kill the bacteria causing an infection. Doctors may wait to see if the ear infection clears up on its own and only prescribe an antibiotic if the infection is severe or has lasted more than a few days. Once the infection is cleared up, hearing is usually restored.

Corticosteroids

A sudden loss of hearing (sudden sensorineural hearing loss or SSHL) is considered an emergency and may be treated with corticosteroids. Bilateral progressive hearing loss, or autoimmune inner ear disease, and fluctuating sensorineural hearing loss including Meniere’s disease may also be treated with corticosteroid medication.

Medications for Underlying Causes of Hearing Loss

When a disease such as multiple sclerosis includes hearing loss as a symptom, medication for the underlying disease can improve hearing.

Experimental Drug

An experimental drug is one that is in clinical trials. These drugs, when injected into the eardrum, are expected to convert stem cells into new hair cells in the inner ear. If approved, such a drug may be used to treat noise-induced hearing loss and SSHL.

Surgery and Implants

In some cases, surgery may significantly improve hearing and comprehension. If there is a malformation of the outer ear, eardrum or hearing bones in the inner ear, this may often be corrected surgically. Surgery may also remove any benign tumors blocking the outer ear or ear canal.

Ear Tubes

When young children have fluid buildup behind the eardrum with hearing loss that affects speech development or have recurring and frequent ear infections, a pediatrician may recommend inserting tiny tubes into the ear. The tubes, also called tympanostomy tubes, ventilation tubes, myringotomy tubes or pressure equalization tubes, are made from metal or plastic and are surgically inserted into the eardrum, facilitating airflow and reducing fluid buildup.

Ears drain excess fluid into the throat as needed through structures called eustachian tubes. Eustachian tubes are not used in hearing but can sometimes cause a problem if they are not working well to drain the fluid out of the ear. In small children, eustachian tubes may be too small to effectively drain, causing fluid backup and frequent ear infections. As the eustachian tubes grow along with the child and enable the ear to drain itself, the ear tubes usually fall out on their own within six to nine months, and the hole in the eardrum closes. In rare cases, the tubes will need to be surgically removed and/or the hole surgically closed.

Cochlear Implants

Cochlear implants are electronic devices that are used for people with irreversible sensorineural hearing loss for whom hearing aids do not work. A surgeon inserts an electrode into the patient’s cochlea and then implants a disk-shaped receiver under the skin behind the ear, attaching it to the skull. The implant bypasses the parts of the inner ear that are not working and sends sound signals directly to the auditory nerve.

Although the sounds will not sound like normal hearing, with time, those with cochlear implants can learn to interpret the sounds and understand speech. Surgery to implant the devices has improved so that those with some existing level of hearing can now keep the hearing they have while also benefiting from the device.

Language outcomes for children who receive cochlear implants before age two are developmentally comparable to their hearing peers by age six.

Bone-Anchored Hearing Systems

Like cochlear implants, these are devices that are surgically inserted into a patient’s head. However, they are suitable for people with severe outer and/or middle ear malformations or unilateral hearing loss. They must have at least one functioning inner ear for the device to work because it uses the skull bone to conduct sound signals to the inner ear for processing.

A titanium bone implant is inserted into the skull near the ear with the functioning inner ear. This is attached to an external microphone and sound processor that sits behind the ear. The external device picks up sound and it is transmitted through the bone of the skull to the inner ear, stimulating the hair cells to vibrate and send the signal to the auditory nerve.

The type of surgery needed will depend on the device’s manufacturer, so when discussing bone-anchored hearing systems with your audiologist, you may want to ask about the surgery needed for each type.

Hearing Devices

In addition to hearing devices that are surgically inserted into the body, people who are hearing impaired may also use external devices. In fact, external hearing aids are the most common treatment for long-term hearing loss.

Hearing Aids

Hearing aids are small electronic devices that sit behind the ear or are inserted into the ear or ear canal. They work by amplifying sounds through a tiny microphone that funnels sound to an amplifier and then a speaker. They are used primarily with those with sensorineural hearing loss where the damage to the hair cells in the inner ear is not extensive. By making sounds louder, the hearing aid makes the remaining hair cells vibrate more, thereby sending the signal through the auditory nerve to the brain. There are several types of hearing aids:

• Behind-the-ear (BTE) – These have a hard plastic case with electronic components that go behind the ear and are connected to a plastic ear mold that goes in the ear. They can be used for people of all ages with mild to profound hearing loss.
• In-the-ear (ITE) – These devices have a hard plastic case that is inserted in the outer ear, blocking it completely. Some ITE aids have a feature called a telecoil that makes it easier to hear telephone conversations and some kinds of public address systems. Some cochlear implants also have tele-coils. ITE aids are not used for children because their ears are still growing, and the aid would need to be refitted too frequently.
• Canal aids – These are the most discrete because there is little visible of the device. Some are in the canal (ITC) and are custom made to fit the individual’s ear canal. Others are completely in the canal (CIC) and are nearly invisible from outside. They are too small to contain a tele-coil and are used for people with mild to moderately severe hearing loss. They are not recommended for small children or people with profound hearing loss because they are not powerful enough.

Assistive Listening Devices

Assistive listening devices improve sound transmission for people with hearing loss and can be used to augment cochlear implants, bone-anchored hearing systems or hearing aids. Some are personal devices while others are meant to be used in large public spaces such as classrooms, theatres, airports and places of worship.

Hearing Loop System

With a hearing loop system, the sound source (a microphone, public address system, home television or telephone) is connected to an amplifier, which sends the amplified sound through a thin wire loop that is installed around the perimeter of the room or area or under the carpeting. The loop creates an electromagnetic signal that is picked up by a receiver worn in the ears or in a headset. Some hearing loop systems are portable.

FM Systems

FM systems use radio waves to transmit amplified sound to a personal receiver. They are frequently used in classrooms, with the teacher wearing a microphone hooked up to an amplifier. People using this system need to tune to a specific channel to receive the correct signal, just like with a radio.

Infrared Systems

These systems convert sound into light and beam it to a personal receiver where it is turned back into sound. Since light cannot go through walls like radio waves, it is suitable for use where confidentiality is an issue, such as in a courtroom or places where there are many different signals like a multiplex movie theatre. Strong light interferes with the signal, so they cannot be used outdoors or in brightly lit environments.

Personal Amplifiers

As the name suggests, these are portable personal devices that the user can take and use as needed. They are about the size of a mobile phone and often have microphones that can be pointed in the right direction to pick up the sound.

Each of these types of assistive listening devices can also be compatible with telecoil technology. When this is the case, a sign may be posted, and users will make a minor setting change to telecoil to receive the signal.

Augmentative and Alternative Communication Devices

Since people with severe to profound hearing loss and the Deaf sometimes have speech issues, they can get an augmentative and alternative communication device (AAC) to help them communicate with others face-to-face.

Touch Screen or Picture Board

A picture board or its digital equivalent, a touch screen, will have images of common tasks and objects. The user will touch or point to a picture to communicate. For example, someone might point to a glass to ask for a glass of water. Some devices also include text, and some touch screens can be personalized based on the user’s interests, occupation or age. Boards are double-sided for two-way communication.

Speech Generating Devices

These devices translate written words into speech. They can be customized with different voices and accents. Some of these are free-standing devices, while others are software-based and use a computer’s audio output to generate the sound.

Assistive Devices for Telephone

People who are hearing impaired can buy text telephones (TTY) that use both sound and text.

To assist hearing-impaired people, communicate by phone, there is a National Telecommunications Relay System that users can access by calling 711. A communications assistant will type speech to display on a computer or phone and then read the typed words of the hearing-impaired person to the hearing person on the other end.

There is also a free, subscriber-based system called the Video Relay Service for people with smartphones, computers or video phones. Rather than typing the hearing person’s words, the interpreter would use American Sign Language (see “American Sign Language” on page X of this guide) to sign them.

Alerting Devices

Alerting devices use lights, loud sounds or vibrations to alert hearing-impaired people that something is going on that needs their attention. They can be attached to alarm clocks, doorbells, telephones and baby monitors.

Financial Assistance Resources

• Hearing aids and other devices can be expensive. Below are some resources that may be able to provide financial assistance.
  • The following states mandate coverage for hearing aids for children:
    • Colorado, Connecticut, Delaware, Kentucky, Louisiana, Maine, Maryland, Minnesota, Missouri, New Jersey, New Mexico, North Carolina, Oklahoma, and Oregon
  • These states mandate health insurance coverage for both children and adults:
    • Arkansas, New Hampshire and Rhode Island
  • Children may be covered by their state’s early intervention program or State Children’s Health Insurance Program.
• Medicaid – Medicaid will pay for the diagnosis and treatment of hearing loss, including hearing aids, under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service for eligible children and young adults ages 21 and under.
• School district – If a child’s IEP (individual education plan, see “The IEP” section of this guide for more information) specifies a need for a hearing aid or other hearing device under Supplementary Aids and Services, you may be able to get it at no cost.
• State vocational rehabilitation agencies – College students and other adults may be able to get financial assistance to pay for hearing devices if they can prove that their hearing loss endangers their job.
• State telephone programs – Go to https://tedpa.org/resources/ to see if you qualify for free or low-cost telephone equipment from your state program.
• State health departments – Many states have a hearing aid assistance program. They accept donations of used hearing aids, restore them and distribute them to those in need.
• Department of Veterans Affairs (VA) – Military veterans and service members may qualify for assistance with hearing aid cost or other rehabilitative services. Also see https://www.militaryaudiology.org/
• Employers – Employers with 15 or more employees, hotels, hospitals, senior centers and residential facilities are required to provide auxiliary aids and services for communication access (but not hearing aids, see “Americans with Disabilities Act, ADA” in this guide to learn more). To find out more, call the Disability and Business Technical Assistance Center at 800-949-4232 (V/TTY) for more information or visit their website at ADATA at https://www.adata.org/
• Non-profits – The following non-profit organizations provide help with hearing aids and other devices:
  • Miracle Ear Foundation – https://www.miracle-ear.com/miracle-ear-foundation
  • The Starkey Hearing Foundation, Hear Now Program – https://www.starkeyhearingfoundation.org/Hearing-Assistance
  • Lions Affordable Hearing Aid Project – Contact your local Lions Club here https://www.lionsclubs.org/en/start-our-approach/club-locator to ask if they have hearing aids available
  • Easter Seals – https://www.easterseals.com/our-programs/medical-rehabilitation/hard-of-hearing-deaf-services.html

Supplements and Alternative Therapies

In addition to a medical approach and the use of hearing aids and other devices, you may want to try these supplements and alternative therapies. If you want to try one or more of these, remember to first discuss it with your doctor.

Supplements

While no vitamin, mineral or herbal supplements have been shown to improve hearing, some have been identified that may support and preserve hearing.

• Vitamin C – This supplement has been shown to protect hearing from noise-induced hearing loss in animals but has not yet been proven to have the same effect in people.
• Carotenoids, and specifically beta-carotene and beta-cryptoxanthin – A large study showed that women with a high intake of these nutrients were at a lower risk for hearing loss.
• Folate – A Dutch study found that higher folate intake led to a lower incidence of hearing loss over three years. In the U.S. foods are fortified with folate, which is not the case in the Netherlands.
• Ginger tea – Ginger is a natural anti-inflammatory and antibiotic.
• Turmeric – This spice contains a lot of potassium, a nutrient that is important for ear health.
• Ginkgo biloba – This herb may help with symptoms of tinnitus.

Holistic Therapies

• Acupuncture – This ancient Chinese healing modality has been used to treat hearing loss for hundreds of years. One study found that it can help with some sensorineural hearing loss. Another study on acupuncture for sudden hearing loss showed that it helped two-thirds of participants, particularly those with milder symptoms.
• Sound therapy – This is a desensitizing treatment for people with tinnitus that trains the brain to ignore the ringing.
• Laser therapy – This has been used for SSHL, and health professionals believe that the laser triggers biochemical reactions that stimulate cell repair. It is still being investigated to determine which frequencies of light are most effective.

Ways to Improve Communication and Safety If You Experience Hearing Loss

Regardless of your level of hearing loss, there are steps you can take that may make life easier.

Because hearing loss can cause people to miss safety alerts and limits communication, using safety measures and improving communication can significantly improve quality of life.

American Sign Language

When a child is born with hearing impairment, parents may choose to communicate with American Sign Language (ASL). American Sign Language is a distinct language from English, with its own grammar, word order and even regional accents. Words and sounds are communicated with the hands and face. When necessary, as in spelling a name, English words can be spelled out with fingerspelling.

Children can learn ASL in different ways. When a child is born deaf or hearing impaired to deaf or hearing-impaired parents who already know ASL, he or she will learn it as naturally as any child learns the language of their parents. However, most hearing-impaired children (90%) are born to hearing parents who may not know ASL. In this case, the parents and the child may learn ASL at the same time or the child may learn it from deaf or hearing-impaired peers. People who know ASL may not be able to use it to communicate with deaf or hearing-impaired people from other countries, as there is no universal sign language.

Studies show that the most effective way for children to acquire language skills is auditory, so treatment, particularly cochlear implants, bone-anchored hearing systems and hearing aids, (see “Treatment” in this guide) is recommended if medically indicated early in life, in addition to using ASL and other forms of communication.

As with learning any language, learning ASL is much easier for babies and very young children than it is for older children, teens and adults. That being said, it is still possible to learn ASL at any age.

Reading Lips (Speech Reading)

Speech reading or lip reading consists of looking at a speaker’s mouth and face to determine the sounds or spoken words. According to the CDC, about 40% of the words in English can be seen on the lips of the person speaking. This assumes good conditions, where the person who is speaking is well lit and fully facing the person doing the speech reading. Some words, however, look identical to each other although they sound different. This is why speech reading is used as a supplementary communication means, along with auditory training or cued speech.

Auditory Training

Most children who are deaf or hearing impaired have at least a small ability to hear, called residual hearing. A speech language pathologist can work with babies and young children to teach them how to make the most of whatever hearing they have.

Cued Speech

Cued speech uses speech reading but adds more information to help distinguish between words that look the same when spoken. It uses eight hand shapes and four places near the mouth to help the person looking tell the difference between speech sounds. These hand shapes and mouth positioning can be found here: https://www.cdc.gov/ncbddd/hearingloss/parentsguide/download/cued_signs.pdf.

Service Animals

Service dogs assist deaf and hearing-impaired individuals by alerting them to a variety of sounds including a doorbell or knock on the door, alarm clock, oven timer, fire or smoke alarm, telephone ring, baby cry or someone calling their name. The service dog is trained to physically touch the person and lead him or her to the source of the sound. The hearing-impaired person can also get a good idea of surrounding sounds by watching the reaction of the hearing dog.

Hearing dogs wear special vests or leashes to show that they are service animals. When other people see this indication of a hearing dog, they are more likely to know that they are dealing with someone who is hearing impaired and can make appropriate adjustments like fully facing the person when talking.

In order to qualify for a service animal, you will need a note from your physician that shows that your hearing loss is severe enough to negatively impact wellbeing. Hearing dogs require special training, but not as much as other classifications of service dogs. Even so, they can be expensive.

Smartphones and Apps

Smartphones that are relatively late models have a number of built-in features that may help those who are hearing impaired. These features can be activated and adjusted in Settings.

iPhone Settings (iPhone 5 and Later)

• Volume control – Use the button on the side of the phone
• Live Listen (needs iOS 14.3 or later) – This turns the iPhone into a microphone that can pick up sounds even from across a room and send it to compatible Made for iPhone hearing aids, AirPods or Powerbeats. Learn how to set it up here: https://support.apple.com/en-us/HT209082.
• Mono audio – This is for people with hearing loss in one ear. Stereo recordings have separate audio information in each ear, but you can adjust your phone so that all of the audio is combined and you do not miss some of the sound. This is called “mono” audio. Go to Settings > Accessibility > Audio/Visual
  • Mono Audio: Combine the left and right channels into a mono signal played on both channels
  • Balance: Drag the Left Right Stereo Balance slider
• Noise cancelling – The phone automatically reduces background noise so you can hear the phone conversation, but you can turn this on or off in Settings > Accessibility > Audio/Visual.
• RTT and TTY for phone calls – You can configure your iPhone to use RTT and TTY protocols to make calls appear as live text on your iPhone or an external TTY device.
• Flash LED for alerts – Visible and vibration alerts help you avoid missing calls, messages and notifications
• Siri – Use the Siri digital assistant by typing the desired question.
• Fine tune audio in headphones – If you have certain Apple or Beats headphones, you can adjust the tone, vocal range, brightness and amplification for both phone and media. This is also done in Settings > Accessibility > Audio/Visual. Choose Headphone Accommodations.

Android Phone Settings 

• Live transcribe – See text of live conversations in over 70 languages ​​and participate in the conversation quickly thanks to speech synthesis.
• Live caption – Create or enjoy movies, videos and audio media with captioning with the ability to choose the preferences of the subtitles (language, text and style)
• Sound amplifier – This is done via a third-party app but works similarly to the setting to fine tune audio in headphones on the iPhone. Download here: https://play.google.com/store/apps/details?id=com.google.android.accessibility.soundamplifier&hl=en
• Hearing aid compatibility – Lets you pair hearing aids with your Android device to hear more clearly.
• Real-time text during calls (RTT) – This works with TTY. Like with the iPhone, this option offers the possibility of typing text to communicate during a live phone call.     

Apps

This is a sampling of the smartphone apps that are available for the hearing impaired. You can find more on the Apple App Store and Google Play Store.

• Ava – This is an instant transcription app that allows the hearing impaired to participate in a group conversation. Each person in the group downloads the app and their microphones transcribe their words into text. Available for iPhone and Android. Download here: https://www.ava.me/
• RogerVoice – This app not only gives users a transcript of vocal phone conversations, it also translates the deaf or hearing-impaired person’s text into synthesized speech.  Available for iPhone and Android. Download here: https://rogervoice.com/en/
• TapSOS – This app allows those who are deaf or hard of hearing to communicate with emergency services. In addition to pinpointing the caller’s location, it also transmits the caller’s personal medical history so emergency responders can be prepared. Available for iPhone and Android. Download here: https://www.tapsos.com/
• Subtitle Viewer – This app creates real-time subtitles for movies viewed on TV or in the movie theatre. Available for iPhone and Android. Download here: https://www.subtitleviewer.com/

Everyday Tips

Living with hearing loss is different and may be difficult and frustrating at times both for you and the people around you. However, there are some ways you may be able to improve communication and avoid obstacles. Here are some tips:

• Letting people know you have hearing loss – When others are unaware, they may get frustrated when you ask them to repeat themselves or think you are being inattentive or difficult. Once they know, they may tend to be more patient, understanding and accommodating.
• Checking out body language – When engaging in conversation, it is recommended to pay attention to the other person’s body language and expressions. This can help fill in any gaps in speech that you may have missed.
• Being honest – When talking to others, you may let them know which parts of what they said you understood and which parts you missed.
• Picking the location – If you are in a large group of people like at a party or convention, it is recommended to ask people you are talking to if they mind moving to a quieter, less crowded part of the room. When going out to dinner, you may choose a restaurant that is quieter so you can participate more in the conversation. Once you are in a restaurant, you may ask to be seated in the quietest area.
• Asking your spouse or partner for help – Since you will be communicating often with your spouse or partner, it is recommended to talk about how to make communication easier between you. For example, asking for the hearing partner to lightly touch your arm before talking so you are aware or always facing each other when talking. Some spouses act as proxies for the one with hearing loss at social events by listening and repeating the conversation later.
• Joining a group – By talking with other people who have hearing loss, you can get valuable insights about speaking up for yourself, using hearing technology, dealing with social isolation and other questions and challenges.
• Turning off background noise – Before talking, consider turning off the radio or television so you can hear better.
• Finding an alternative to “what?” – When you need to ask people to repeat something, saying “what?” repeatedly can be frustrating for you and them. You may try alternatives like “I’m sorry?” “Pardon me?” “I didn’t get that” or “Once again?”
• Giving others direction – When a friend asks how to communicate with you better, let them know. Many deaf and hearing-impaired people ask others to speak a bit louder and more clearly than they normally do, but not to shout. Shouting can actually sound too loud to someone with hearing loss and it makes it more difficult to lip read.
• Seeking the light – Being in a room that is well lit makes it easier to see other people’s lips, expressions and body language. That said, it is recommended to avoid areas that are backlit, as this may cause issues with shadows and glare.
• One at a time – In group settings, it is recommended to ask people to talk one at a time, so it is easier for you to understand.

Knowing Your Rights

Being deaf or hearing impaired is a disability that is covered by the Americans with Disabilities Act (ADA). The ADA makes it illegal to discriminate against you because of your disability and requires employers, government agencies and private businesses to provide accommodations to you.

Americans With Disabilities Act (ADA)

The ADA applies to:

• Employers (federal, state and local government employers and private companies with 15 or more employees)
  • They cannot ask about deafness or hearing impairment in a job interview.
  • They may not rescind a job offer once they find out the hiree has hearing loss or deafness.
  • They are allowed to ask employees about medical conditions like hearing loss if they suspect that it is negatively impacting job performance or causing a safety issue.
  • They are required to provide “reasonable accommodations” to deaf or hearing-impaired employees when requested as long as they do not cause “undue hardship.” These may include:
    • A sign language interpreter
    • Assistive technology, such as a TTY telephone, telephone headset and computer software
    • Emergency notification systems
    • Assistive listening devices like communication access real-time translation (CART), which translates voice into text at real-time speeds
    • Appropriate written memos and notes
    • A desk in a quiet area
    • Changing an employee’s nonessential duties
  • The ADA prohibits them from refusing to promote you as a result of your hearing impairment unless your hearing impairment is a safety concern or a federal law requires good hearing to do a specific job.
  • The ADA prohibits harassment or offensive conduct based on the disability.
  • The ADA prohibits retaliation against an employee who files a complaint or makes a claim of discrimination based on disability.
• Businesses, government agencies (police, election workers, courts, motor vehicle division, IRS, etc.) and not-for-profit organizations
  • These organizations are required to provide accommodations to effectively communicate with deaf and hard of hearing individuals, giving priority to the accommodation requested by the deaf or hearing-impaired person. This includes providing:
    • A qualified notetaker
    • A qualified sign language interpreter
    • Oral interpreter
    • Cued-speech interpreter
    • Tactile interpreter
    • Real-time captioning
    • Written materials
    • Printed script of a stock speech
  • They are required to have these policies in place and to train their employees in their implementation.

If an employer breaks any of these rules, you can file a complaint with the Equal Employment Opportunity Commission (EEOC). If the EEOC agrees with you, they will issue a “right to sue” letter, which allows you to sue the employer. Learn more about the provisions of the ADA online at https://www.ada.gov/ or by calling 800-514-0301 (Voice) and 800-514-0383 (TTY).

Individuals With Disabilities Education Act (IDEA)

The Individuals with Disabilities Education Act (IDEA) provides early intervention services for babies from birth to age 2 in Part C and ensures that individuals ages 3-21 receive special education and other services in Part B.

Part C (Ages Birth to 2)

Part C is also called the Program for Infants and Toddlers with Disabilities and is a federal grant program that provides funds to states to pay for early screening, diagnosis, treatment and counseling for babies with disabilities including hearing loss and their families. Each state that receives funding under IDEA (which is currently all 50 states and eligible territories) must ensure that these services are available to all qualifying babies and their families and must appoint a lead agency to administer the services. The lead agency is subject to oversight by an Interagency Coordinating Council (ICC), which is made up of representatives of relevant government agencies, providers of early intervention services and parents of young children with disabilities. You can find the lead agency in your state or territory here: https://ectacenter.org/partc/ptclead.asp.

The services provided by the lead agency include:

• Outreach and referral to locate and identify babies in need of services as early as possible
• Assessment (screening and diagnosis)
• Plan for the services needed
  • Audiology
  • Assistive technology
  • Health and medical services
  • Occupational therapy
  • Psychological services
  • Sign and cued language services
  • Social work
  • Special instruction
  • Speech-language pathology services
  • Transportation
  • Family training, counseling and home visits
• Case management to assist families in accessing services and resources

Part B (Ages 3-21)

Part B of the IDEA covers over 6 million children with disabilities who receive special education and related services every year.

Babies who received diagnosis and services under Part C will be automatically transitioned to Part B once they turn 3. Other children may be referred by their pediatrician, babysitter, teacher or parent. When there is a concern about a child’s development or disability, you may contact the local public school (even if the child is not yet of school age). Each state is required to have a Child Find office to identify children with disabilities and these offices can be reached through the local public school. With parental consent, the Child Find office will arrange appropriate screenings, which are free to families.

The cost of the Part B and Part C services may be paid out of pocket by a combination of the following, as applicable:

• Medicaid
• CHIP (Children’s Health Insurance Program, a federal and state collaboration to provide low-cost health insurance to children whose families do not qualify for Medicaid)
• TRICARE (the U.S. health care program for uniformed service members, retirees, and their families around the world)
• Private health insurance
• Families (post-insurance balance using a sliding scale based on income)

The Individualized Education Plan (IEP)

Under the IDEA, if the child is found to have deafness or hearing impairment to an extent that it interferes with daily functioning, comprehension, speech development and other essential skills, a plan will be created within 30 days. This individualized education plan, or IEP, will outline the extent of the deafness or hearing loss, what devices or accommodations are required and reasonable goals for the child.

The IEP is put together by a team of educators and the child’s parents. The IEP team includes:

• Child’s parents
• At least one of the child’s teachers
• At least one special education teacher or provider
• A representative of the public agency who is qualified to provide or supervise the production of specially designed instruction to meet the unique needs of children with disabilities
• A person who can interpret the instructional implications of evaluation results
• Anyone else with knowledge or special expertise regarding the child
• The child with a disability, when appropriate

Another issue considered during the IEP process is placement, or where the child will be educated. IDEA specifies that kids should be educated in the “least restrictive environment” or LRE. This means that they should be educated alongside non-disabled peers unless the nature of the disability is so severe that this is not possible, in which case they would be educated in special schools that are able to more appropriately deal with their disability. Even when the child will go to the local public school, there may be parts of the school day when he or she will be educated outside the general classroom. This will all be outlined in the IEP.

If there is a dispute between the parents and the school as to whether the school is fully complying with IDEA and ADA requirements, there is a dispute process. The first step is to request an IEP meeting. By law, this must take place every school year, but can also happen upon request. At this meeting, the IEP will be reviewed and parents can share their concerns with the IEP team. If this does not satisfactorily resolve the problem, parents can ask for a facilitated IEP meeting with an impartial facilitator, go through mediation or file a state complaint. State complaints must be resolved within 60 calendar days.

Glossary of Hearing Loss Terms

Alerting Device – These are visual or tactile devices to alert a person with severe to profound hearing loss to door knocks, telephone rings, fire alarms and other sounds that require attention.

Americans with Disabilities Act (ADA) – The Americans with Disabilities Act of 1990 Public Law 101-336 is a federal law that prohibits discrimination on the basis of disability by public entities (employers with 15 or more employees, federal, state and local government agencies, non-profit organizations and private businesses that serve the public).

Amplified Phone – This is a telephone equipped with volume control on the handset.

Assistive Listening Device (ALD) – This is a technical tool to assist people with hearing loss, with or without a hearing aid or cochlear implant. It brings the speaker’s voice directly to the ear and helps to overcome the problems of background noise.

Audio Loop (Induction Loop or Hearing Loop) – This is a system that uses electromagnetic waves to transmit sound. The sound from an amplifier is fed into a wire loop surrounding the seating area or worn on the listener’s neck. The sound is then broadcast to either a telecoil in a hearing aid or a special induction receiver.

Auditory Brainstem Response (ABR) Test – This is a test for brain functioning in comatose, sleeping or unresponsive patients, often used to test hearing in infants and young children. It involves attaching electrodes to the head to record electrical activity from the hearing nerve and other parts of the brain.

Auditory Nerve – This is the eighth cranial nerve that connects the inner ear to the brainstem and is responsible for hearing and balance.

Auditory Neuropathy – This is a hearing disorder in which sound enters the inner ear normally but is impaired when signals move from the inner ear to the brain.

Auxiliary Aids and Services – These are devices and services that may be required under the ADA to help overcome communication barriers. Examples of auxiliary aids and services include assistive listening devices, interpreters, notetakers, captioning, and TTY.

Captioned Telephone – This is a special phone for people with hearing impairment. Text of a telephone conversation is displayed on a monitor built into the phone so the person with hearing loss can follow the call. 

Communication Access Real-Time Translation (CART) – This is the verbatim, near instantaneous conversion of spoken language into text. A stenotype machine, laptop computer and real-time software are used to produce the text. The text is usually projected on a screen or displayed on a laptop or computer monitor.

Closed Captions – This is text display of spoken dialogue and sounds on TV and videos visible only to those using a caption decoder or TV with built-in captioning chip. They can be toggled on and off.

Cochlear Implant (CI) – A cochlear implant is an electronic device that is surgically implanted and works by bypassing the outer and middle ear and sending sound waves via electrical impulses directly to the inner ear. This enables people with severe to profound hearing loss to hear sounds and potentially better understand speech.

Communication Access – These are accommodations mandated by the ADA that create an environment where people with hearing loss can communicate.

Compatible Telephone – This is a telephone that is compatible with hearing aids with tele-coils. It generates a magnetic field that can be picked up by turning on a “T-switch” to activate the telecoil in a hearing aid. The Hearing Aid Compatibility Act of 1988 mandates that all telephones manufactured in the United States from 1989 on should be hearing-aid compatible.

Computer-Assisted Note Taking – A notetaker listens to a speaker and then types a summary of what is being said. The notes are displayed on a projection screen or monitor.

Cued Speech – This is a sound-based visual communication system, which, in English, uses eight hand shapes in four different locations (“cues”) in combination with the natural mouth movements of speech to distinguish between the sounds of spoken language that look the same to a person reading lips.

Decibel (dB) – This is a unit used to express the loudness of sounds. Sounds of different frequencies need to be from 0-20 dB in intensity to be heard by normal ears.

deaf (Lowercase “d”) – This is a colloquial term that implies hearing thresholds in the severe-to-profound range by audiometry.

Deaf Culture (Always a Capital “D”) – These are members of the Deaf community in the United States who are deaf (see above) and use American Sign Language. They do not consider themselves to be hearing “impaired,” nor do they feel that they have a hearing “loss,” but consider themselves deaf. They do not view their deafness as a pathology or disease to be treated or cured.

Effective Communication – This is a term used in the ADA as a standard for access for people with hearing loss. A public company, employer, organization or government entity must provide an auxiliary aid or service where necessary to ensure effective communication with individuals with disabilities. Entities are encouraged to ask people who are deaf or hearing-impaired what kind of communication aid or service they prefer.

Hard of Hearing – This is a term used by the Deaf to signify that a person has some usable hearing encompassing anything from mild to severe hearing loss. In the Deaf community, persons who are deaf do not use oral language, whereas those who are hard of hearing usually have some oral language.

Hearing Loss (Used Interchangeably With “Hearing Impairment”) – This is hearing below normal threshold levels for hearing determined by audiometry.

Hearing Aid – This is an electronic amplification device to assist persons with hearing loss. Hearing aids only assist; they do not restore normal hearing.

Hearing Dog – This is a service dog that has completed extensive training to alert its owner to a variety of sounds in different environments. These dogs are usually identified by a bright orange leash with black lettering or a vest.

International Symbol of Accessibility for Hearing Loss – This is a symbol used to denote communication access for those who are deaf or hearing impaired. It consists of an outline of an ear with a slash through it to identify that a room or venue is hearing-accessible. There is also another similar one with a “T” in the lower right-hand corner to inform people that the room or venue has a hearing loop installation that can interface with hearing aids equipped with telecoils.

Interpreter-Sign Language – This is a person who translates spoken English into American Sign Language’s visible movements of hands, body and face. In other countries, the sign language interpreter would use the local sign language.

Lipreading (Speechreading) – This is a skill used by a person with hearing loss to try to understand speech by watching the lips, facial expressions and body language of the person talking.

Otologist/Neurotologist – This is a physician who provides medical and surgical care to patients with diseases that affect the ears, balance system, temporal bone, skull base, and related structures of the head and neck. The neurotologist is knowledgeable about and can diagnose and treat problems with hearing, balance, nerve function, and infectious disease and malformations of the head and neck.

Presbycusis – This is the slow, progressive type of hearing loss that is associated with aging.

Real-Time Captioning – This is the process of producing either open or closed captions simultaneously with a live event. Real-time captioning incorporates a specialized computer system and stenographic keyboard much like those used in courtrooms.

Telecommunications Relay Service – This is a free telecommunication service that enables text telephone users to communicate with a non-text telephone user by way of a relay service communications assistant.

T-switch – This is a setting on telecoil-enabled hearing aids that can be used with a hearing aid compatible telephone, assistive listening device, and audio loop system. When the hearing aid is switched to “T,” it causes the hearing aid to pick up sounds coming from the compatible device being used.

Text Telephone (TT or TTY) – This is a telecommunications device used by those who cannot adequately hear speech on the phone. A typewriter-like unit shows the conversation on a screen so that it can be read.

Vestibular – This term relates to a person’s sense of balance.

Visual Alarm Signal – This is a visual signal (flashing light) giving notice that an audible event, such as a doorbell ring, has taken place.