Getting direct about Direct Access

Time to spice things up a little bit with another Q&A to start this post!  Question:  What is “Direct Access” in audiology?

a) The ability to obtain hearing aids directly from an audiologist.

b) Something that is inappropriate to discuss on this blog.

c) A bill that, if passed, would allow Medicare beneficiaries to receive an audiologic examination without first obtaining a physician referral.

d) This actually doesn’t exist, and I’m just wasting your time with these stupid multiple-guess answers.

If you answered “a” – valiant effort, but this is not the definition of Direct Access.  Actually, you already can obtain hearing aids directly from an audiologist (provided that they are licensed in the state in which they practice, and/or have a hearing aid dispensing license in that state, if applicable).  If you answered “b” – perhaps another blog is better suited for you to read.  If you answered “d” – well, same thing.  Or maybe blog-reading isn’t for you.  If you answered “c” – congratulations!  You win.  If I could, I’d give you a cookie.  Probably one of these, made by my former roommate (they are still the best cookies I have ever had, to this day… and that’s saying something, because she makes some extremely yummy treats).

So, what exactly does this mean?  Here’s a scenario for you:

You are an avid Hear to Here blog reader.  You are also a Medicare recipient.  After reading the last post about audiograms, you realized perhaps you are having difficulty hearing and would like to have your hearing evaluated.  Under the current Social Security Act, you would first have to see a physician to obtain a referral to see your audiologist.  Once that physician writes you a referral, you can see an audiologist and have those diagnostic evaluations covered (at least in part) by Medicare.  If you fail to obtain a physician referral, Medicare will not cover the expense of any of these services provided by an audiologist.

Yes, it is quite a lengthy (and dare I say, bureaucratic) process.  Which is one of the many reasons why audiologists are currently working towards eliminating the need for a patient to first obtain a physician referral before seeing us to receive services.  This is where the Medicare Hearing Health Care Enhancement Act of 2007 (otherwise known as the “Direct Access” bill), introduced by Representative Mike Ross (D-AR), comes into play.  If passed, this bipartisan bill would allow Medicare beneficiaries to seek services directly from a qualified audiologist.

So why is it the current standard for Medicare beneficiaries to first obtain a physician referral, you ask?  I suppose the answer you receive will depend on whom you ask.  Before answering that question, I would like to list some of the reasons to support Direct Access:

  • There are many people who are able to directly receive services from audiologists.  These individuals include:
    • Veterans – The Department of Veterans Affairs (VA) has allowed veterans to directly access audiologists since 1992, and reports that this policy provides “high-quality, efficient, and cost-effective healthcare.”¹
    • Federal employees, including Members of Congress – these employees are able to directly access audiologic services through the Federal Employees Health Benefit Plan.¹
    • Beneficiaries of other insurances – There are many insurance companies that allow their beneficiaries to directly access audiologic services.
    • Medicare beneficiaries currently have “direct access” to a multitude of non-MD/DO providers, including:
      • Chiropractors
      • Optometrists
      • Nurse practitioners
      • Physician assistants
      • Clinical psychologists
      • Podiatrists
      • Nurse-midwifes
      • Clinical nurse specialists
      • Clinical social workers¹
  • As of 2004, an estimated 31.5 million individuals in the U.S. had some degree of hearing difficulty; this incidence of reported hearing loss is expected to grow to over 40 million individuals by the year 2050.²  That amounts to A LOT of physician referrals.  In the current model, a patient typically visits his/her primary care physician, who then refers to an ENT, who then refers to an audiologist.  It is estimated that PCPs were paid approximately $84 million from Medicare for these referrals, and ENTs were paid an additional $84 million from Medicare.  By eliminating these referral steps, Medicare would save approximately $168 million per year.³  (That is approximately 16,800,000 Chipotle dinners consisting of a burrito bowl + chips & guac).  And yet we sit and wonder why our current healthcare system is in the state of financial crisis that it is…
  • Speaking outside of monetary terms, eliminating the need for referrals also saves a patient’s time.  Simply put, it is much easier to be treated by one healthcare professional (when you really only need to see one), rather than by multiple healthcare professionals.  When you think about the average patient for audiologists (the elderly), this really comes into play.  For many of these patients, it is extremely difficult (not to mention costly) to go to multiple appointments.
  • Audiologists are licensed, masters- or doctoral-level professionals that have graduated from accredited institutions.  We are trained in the diagnosis and treatment of hearing loss and vestibular disorders.  In fact, audiologists often teach medical students, ENT residents, and physicians about hearing loss and diagnostic audiometric evaluations.  In other words, audiologists are perfectly capable of being the first line of care for the management of hearing and balance disorders in patients.

Back to the original question – why does this law currently exist, or why would anyone oppose Direct Access to audiologists?  Well, here’s where things get tricky.  In short, what some argue is that some patients would be improperly managed.  It is true that there are patients with certain types of hearing loss and balance disorders that require medical management.  For example, this would be the case if a patient presented with symptoms of a retrocochlear pathology (e.g. acoustic neuroma), a conductive hearing loss, additional/other otologic symptoms (dizziness, tinnitus, active drainage), etc.  However, there are current standards of care and guidelines that require referral from an audiologist back to a physician (typically an ENT) if this is the case.  As I mentioned before, audiologists are higher-level professionals that are able to make these referrals appropriately if necessary.  Further, we already do make these referrals back to physicians (when necessary and appropriate).

The opposition to Direct Access comes mainly from the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS).  As stated by the current president of the American Academy of Audiology, Dr. Therese Walden, AuD: “The leadership of the AAO-HNS contends that by allowing patients the option of going directly to an audiologist for hearing and balance problems, that somehow the safety and efficacy of the patient’s care would be compromised by not seeing a physician first.  In fact, there is significant data and research that supports audiologists as an entry point into the healthcare arena for these problems.”¹

One of the studies to which Dr. Walden refers is one completed by Dr. Dave Zapala.  Dr. Zapala and his colleagues “…examined more than 1,500 charts from Medicare-eligible recipients (in the year 2007) at the Mayo Clinic.  They evaluated the differences between assessment and treatment plans from ENT docs and audiology docs, as judged by a panel of two ENTs and two audiologists.  The bottom line is that there were no discrepancies in treatment plans for over 95 percent of the patients.”¹  The article reads: “The jury of four judges found no audiology discrepant plans in over 95 percent of cases…[and]…in no case where a judge identified a discrepancy in treatment plans did the audiologist’s plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist.”In fact, the otolaryngologists in this study reported that for 78% of patient cases reviewed, audiologic services were the only services needed. 

I know I am biased, but to me, these are considerable numbers.  This is particularly true when we think about the aging baby boomer population.  I don’t have numbers off of the top of my head, but I’m sure you can imagine that the dollar signs (spent simply on appointments for a physician referral to an audiologist) will really start to stack up.  And let’s not forget the inefficiency in care and the inconvenience for so many patients.  In fact, audiologists do not receive any monetary benefit from passing the Direct Access bill – it is really about efficiency and quality of healthcare services.

All of this being said, your next question is probably along the lines of – well, what can we do about it?  Glad you asked!  What we need is support from the general population for this bill.  If Members of Congress begin to recognize that more of their constituents are interested in and passionate about a particular bill, they start to pay attention.  Fortunately or not, audiology is a (relatively) small profession.  Our membership numbers and dollars raised are very small when compared to larger organizations such as the AAO-HNS.  We need all of the support we can get from audiologists and non-audiologists alike.

That’s where you come in!  There are many easy ways to support Direct Access.  By clicking here, you can send an email and/or letter to your representative(s) in support of Direct Access in literally a matter of minutes.  If you’re feeling particularly civic-minded, you could even organize a meeting with your respective representative(s) to discuss Direct Access and what it means to you.

If you’re looking for more information about Direct Access is, here are several very helpful/informative links:,d.dmQ,d.dmQ

As always, questions, comments, etc. are much appreciated!

1.  Beck, D. (Interviewer) & Walden, T. (Interviewee).  (2011). Direct Access: Interview with Therese C. Walden, AuD, President of the American Academy of Audiology (Interview transcript). Retrieved from the American Academy of Audiology Web site:

2. Kochkin, S. (2005). MarkeTrak VII: Hearing loss population tops 31 million people. Hearing Review, 12(7), 16-29.

3. Freeman, B.A. & Lichtman, B.S. (2005). Audiology Direct Access: A cost savings analysis. Audiology Today, 17(5), 13-14.

4. Zapala, D.A., Stamper, G.C., Shelfer, J.S., Walker, D.A., Karatayli-Ozgursoy, S., Ozgursoy, O.B., Hawkins, D.B. (2010). Safety of audiology Direct Access for Medicare patients complaining of impaired hearing. Journal of the American Academy of Audiology, 21(6), 365-379.


What you AuDda know about hearing & hearing loss (PART THREE – What’s an audiogram? I want one!)

As promised, in today’s post we will be discussing the audiogram!  Not to be confused with a Christmasgram, but equally as cool.   In the last post, we reviewed the three main types of hearing loss.  An audiogram allows us to put that newfound knowledge to use.

Let’s back up for just a minute, though.  What is an audiogram?  The audiogram can be defined as “…the accepted clinical representation of puretone thresholds as a function of frequency.”¹  Basically, a puretone evaluation looks to find the lowest (softest) level at which you can hear a tone across a range of different frequencies, or pitches – from low pitched tones to high pitched tones.  The audiogram, then, is a visual representation of this.  The audiogram is what most people refer to as a hearing test or hearing evaluation.  A full audiologic evaluation should include other tests in addition to puretone audiometry – but that’s another subject we’ll save for just a bit.

I am a visual learner myself, so now seems like the perfect opportunity to introduce a picture of an audiogram.


As you can see, frequency, or pitch, is represented on the X (horizontal) axis of the audiogram;  volume, or loudness level, is represented on the Y (vertical) axis.  This ‘volume’ level is presented on a dB HL scale (hearing level).  This is in contrast to a dB SPL scale (sound pressure level).  A “normal” audiogram represented with the dB SPL scale would look quite a bit different than a “normal” audiogram represented with the dB HL scale.  If there is interest, we can discuss why this is at a later date (this is me shamelessly trying to solicit comments on my blog).

Anyways, back to that pesky audiogram.  As mentioned earlier, the audiogram is a representation of the lowest (softest) level at which an individual can hear across a range of pitches.  We also refer to this as an individual’s threshold for hearing across those frequencies.  A typical puretone audiometric evaluation tests from 250 Hz (low pitch) to 8,000 Hz (high pitch).  Does anyone know the actual range of frequency audibility in humans (soliciting again)?  Hint: our current clinical tests do not span the full range.  Bonus points/a special shout-out to the first person with the correct answer!  There is increasing evidence that puretone behavioral testing above 8,000 Hz may be clinically useful in certain situations – for instance, in cases of ototoxic monitoring.  However, our current clinical standards call for testing through 8,000 Hz in most instances.
That brings us back to the volume/loudness level (in dB).  On the audiogram, as we go down the graph, the volume gets ‘louder’ (remember that loudness [and loudness judgments such as ‘soft’, ‘loud’, etc.] in the true sense of the word is a perception, so this term is held loosely for the moment).  Sounds at the top of the graph, then, are soft; sounds at the bottom of the graph are loud.  To give you an idea – for any readers with normal hearing, a 1,000 Hz pure tone presented at 110 dB HL would likely be quite offensive to you.  For a better representation of different sounds across an audiogram, I’ve attached another picture:Image
This audiogram has nicely plotted various environmental (and speech) sounds as they typically occur at a given volume and frequency.  For instance, a watch ticking would typically be around 2,000 Hz (keep in mind that these environmental/speech sounds are not pure tones, so this is just to give you some reference) at 30 dB HL.  A dog barking would be in a lower frequency range (below 250 Hz), and also much louder (70 dB HL).  Typical conversational speech sounds occur in the volume range of 40-55 dB.  This, however, varies as a function of distance, environment, etc.
Back to our original audiogram (I’m easily distracted) – there is one more piece of important information to share: X’s represent the left ear; O’s represent the right ear.  These can both be seen on the first posted audiogram picture.  An X symbol indicates the air-conduction threshold of hearing found at the particular frequency tested.  Referring back to a previous post, air conduction testing tests the entire peripheral auditory system – the outer, middle, and inner ear.  Air conduction testing is done either through supra-aural headphones or insert earphones.  There are reasons to use headphones vs. inserts that we won’t get into today; however, both are clinically valid measurements if used correctly.  One symbol that you haven’t yet seen would be the caret ^.  That caret represents the bone conduction threshold at the frequency tested.  Audiologists obtain this threshold by placing a bone oscillator on an individual’s head – it typically rests on the mastoid of the temporal bone, and thus, stimulates the cochlea directly.  And yes, we KNOW that it is not on your ears, thank you :).  In this scenario, we can bypass the outer and middle ear to test the inner ear directly.  Thinking in terms of differential diagnosis, this helps us to determine where the site of lesion (if any) is occurring.  If we obtain bone conduction thresholds that are much better (lower) than air conduction thresholds, this indicates that the individual has a conductive hearing loss or a mixed hearing loss (buzz words all over this blog!).  Rather than using the ^, this is also sometimes written on the audiogram is < or > (depending on which mastoid the bone oscillator is placed).  There are other symbols that pop up on the audiogram, but for our interests here, we now have enough information to look at the first audiogram posted above.
As the graphic nicely points out, the blue shaded region in the audiogram is what is clinically considered to be ‘hearing within normal limits’ across any frequency.  Though the picture above shows 20 dB HL as the upper limit for normal, most clinics actually use 25 dB HL.  Hearing ‘loss’, then, is classified by the degree of loss, or where one’s threshold lays within a range at different frequencies.  The American Speech-Language Hearing Association (ASHA) establishes degree of hearing loss based on the following classification system:
26 – 40 dB HL: Mild hearing loss
41 – 55 dB HL: Moderate hearing loss
56-70 dB HL: Moderately-severe hearing loss
71-90 dB HL: Severe hearing loss
91+ dB HL: Profound hearing loss
Thinking in these terms, an individual can have normal hearing in one frequency region and hearing loss in a different frequency region (they can even have different degrees of hearing loss in various frequency regions).  That actually is the case in the first audiogram posted.  That person has normal hearing sensitivity to pure tones through 1,500 Hz, which then slopes to a severe hearing loss from 4,000-8,000 bilaterally.  In the case of this audiogram, we can’t classify which type of hearing loss it is because we do not know the bone conduction scores. 
Here’s another one:
In this case, we do have the bone conduction scores (I have beef with this audiogram in other regards, but those should remained unnamed for now).  In this instance, this individual has mild sensorineural hearing loss through 2,000 Hz, sloping to severe sensorineural hearing loss bilaterally. 
Here’s an example of a conductive hearing loss, where all of the bone conduction thresholds obtained (indicated by the brackets [ , ]) are within normal limits, but air conduction thresholds are outside of normal range:
Again, this would suggest some sort of pathology or problem in the outer or middle ear that is preventing the proper transfer of sound to the inner ear.  Cool, huh?
As I mentioned earlier, a full audiologic evaluation should (in most instances) contain more than just puretone audiometry.  Speech audiometry is also a very important part of what we test.  One component of speech audiometry is word recognition.  This test presents phonetically-balanced lists of words to an individual (via air conduction) at an appropriate loudness level.  That is key here: the words are presented at a level that should be loud enough based on the individual’s pure tone thresholds.  The percentage of words that the person is able to correctly repeat back to the tester/audiologist is considered to be that individual’s word recognition score.  In simple terms, this test investigates a person’s clarity of words (whereas puretone audiometry assesses audibility).  Interestingly, in cases of hearing loss (particularly sensorineural), words may be loud enough, but that does not necessarily mean they are clear enough to understand (I told you I’d tie that audibility vs. clarity thing in here somewhere).  This score becomes important to know when thinking about pursuing hearing aids (particularly in terms of realistic expectations for hearing aids), which is something we will definitely be discussing in this blog.
To wrap up today, please let me know if you have any lingering questions about the audiogram.  Or if you’re Bennett Kuhar, please continue to ask me every day when my next post is coming (#1 Here to Hear fan!!!!!).  Thank you all for reading.  In light of recent tragic events, please take a moment now to feel thankful for anything/everything you have.  I know that I am.
Until next time, happy holidays!:

1.  Schlauch, R.S., & Nelson, P. (2009). Puretone Evaluation. In J. Katz, L. Medwetsky, R. Burkard & L. Hood (Eds.), Handbook of Clinical Audiology (31-49). Baltimore, MD: Lippincott Williams & Wilkins.


What you AuDda know about hearing & hearing loss (PART TWO)

And.. (drumroll, please).. we’re back, yet again!  I’ve had so many people ask when the next post was coming (errmm, okay, maybe 2 people).  Sorry to keep everyone waiting.  I don’t really have an excuse other than that life seems to sometimes get in the way of all of the big things I have planned, as I’m sure you all have experienced.
Anyways, last time we discussed how we hear.  As I mentioned before, given the fact that the auditory system is so complicated, there are many things that can go wrong.  As audiologists, we classify hearing loss into 3 main types.  I will also briefly mention a fourth “disruption of the system” that can and does occur.  What I’m referring to there is something that happens centrally, and may cause central “hearing loss” (term held loosely).  However, I will devote an entire post later on to central anatomy and the like (as per a request from a reader), so I don’t want to touch too heavily on it today.
To refresh your memory, in the last post we talked about the outer ear, the middle ear, the inner ear, and the central pathways.  Just to repeat myself once again, damage to any one part of the system can affect one’s ability to hear properly.  Type of hearing loss is classified by where the damage occurs in the auditory system.  Thus, we have 1) Conductive hearing loss 2) Sensorineural hearing loss and 3) Mixed hearing loss.
Again tying this back to Part One, conductive hearing loss occurs when there is some disruption to the transmission of sound in the outer or middle ear.  That is to say, with this type of hearing loss, sound can never reach the inner ear (or reaches it at a lower ‘loudness’ level) to be processed/encoded into a signal that can be sent to the brain.  Examples of the cause of this sort of hearing loss include:
  • Anotia – absent pinna/pinnae  (yes, I know you know that really cool(?) vocabulary word)
  • Atresia – absent ear canal
  • Cerumen impaction – otherwise known as earwax!  This seems like the perfect opportunity to insert a Q&A!  Question: Should I use Q-Tips? Answer: No, you should NOT use Q-Tips!  Wax is produced in the outer third of your ear canal.  Naturally, it migrates out of the ear canal.  When you use Q-tips, what you are likely doing is pushing the wax back into your ear canal, which can eventually cause the wax to become impacted.  Tell your friends.
  • Tympanic Membrane (Eardrum) Perforation – a hole in the eardrum can cause a conductive hearing loss if the hole is big enough.  A perforation can result from trauma to the ear/head, exposure to an impulse noise (a very, very loud sound), digging too far with a Q-Tip (OK, maybe I’m just trying to scare you a little… but seriously!  Stop sticking those swabs down into your ears.)  
  • Otitis media – commonly known as an “ear infection.”  Children are especially prone to this, though it can occur at any age.  If there is fluid build-up behind the eardrum, it can cause hearing loss. 
I don’t want to oversimplify things, because there are many pathologies/disorders that can cause a conductive hearing loss.  Thus, the list above is just to give you an idea of things that may cause this sort of hearing loss.  There are two important things to note about conductive hearing loss.  First, as I mentioned before (and as is implied in the word conductive), a conductive hearing loss is limiting or preventing the transmission of sound into the inner ear, essentially.  However, there isn’t (for simplicity’s sake) any distortion to the signal itself; it is merely attenuated because it cannot be transferred properly by the outer/middle ear system.  Thus, in a person with conductive hearing loss, the incoming signal enters the inner ear to be processed at a ‘softer’ level than it would in a normal-hearing individual.  Another important thing to note is that many of these pathologies may (emphasis on may) be fixed/managed medically or surgically.  For instance, otitis media is often medically managed through the use of antibiotics and/or the placement of a tympanostomy (PE) tube.  Cerumen can also be managed.  If you are a wax-builder, you should see your physician and/or audiologist regularly for wax removal.  One more caveat here: We see many patients that seem “relieved” when we tell them that they have some wax in their ear(s) – “Oh! I knew that was the problem.”  Though you may have wax in your ears, and it could be affecting your hearing, it is still possible that you have sensorineural hearing loss as well.  Keep that in mind.
What a perfect segue!  Couldn’t have done it better myself.  Oh, wait…
The second type of hearing loss is sensorineural hearing loss.  The cause of this hearing loss occurs within the inner ear (or beyond).  This becomes slightly more apparent when we break up the word – sensory/neural.  Doing that always reminds me of one of my favorite Jack Handey quotes:
“Maybe in order to understand mankind, we have to look at the word itself.  Basically, it’s made up of two separate words – “mank” and “ind.”  What do these words mean?  It’s a mystery, and that’s why so is mankind.”
But anyways, there is some disruption within the inner ear (sensory), the VIIIth (vestibulocochlear) nerve, or beyond.  In case you’re wondering about this, yes, that is quite vague.  Truth be told, our tests today cannot necessarily pinpoint an exact region or place of an individual’s sensorineural hearing loss (but again, this is not always true).  There are many theories about what causes sensorineural hearing loss.  It is widely thought that many cases of sensorineural hearing loss are caused by disruption of/damage to outer and/or inner hair cells.  However, this is certainly not the only site of possible lesion when an individual has this sort of hearing loss.  Possible contributing factors to/causes of sensorineural hearing loss include:
  • Genetics
  • Noise exposure
  • Aging (presbycusis)
  • Trauma (either physical head trauma or noise exposure)
  • Certain diseases/illnesses, such as meningitis
  • Certain medications (these are called ototoxic medications)
  • Retrocochlear pathologies (acoustic neuroma, for instance)
  • Anatomic abnormalities (this is typically congenital)
Again, this is not an extensive list.  Furthermore, the exact etiology of the hearing loss in each of these instances may be slightly different.  However, there are some commonalities between most types of sensorineural hearing loss that should be noted.  Unlike in conductive hearing loss, sensorineural hearing loss often means that there may be some distortion to the signal.  By definition, the mechanism by which the inner ear sends a signal to the brain is not working the way that it should be.  This influences both audibility and clarity (unlike conductive hearing loss, which influences only audibility).  This will be very important to remember as we continue to discuss hearing loss and hearing aids in this blog (it will surely come up in Part Three of this three post-series, as we talk about how hearing loss is diagnosed and classified). 
If you are one smart cookie (or even if you’re not…), you probably already have a pretty good idea about what Mixed hearing loss might be.  Conductive hearing loss and sensorineural hearing loss are not necessarily mutually exclusive – someone may have both.  For instance, if you have presbycusis (hearing loss due to aging), and you compulsively use Q-tips and give yourself a wax impaction… you could have mixed hearing loss.  However, the wax problem can be remedied by proper wax removal.  There is no ‘cure’ for presbycusis, on the other hand (and I hope to discuss the current research at some point in this blog).  That is where hearing aids come into the picture.  At the moment, hearing aids are often the best ‘tool’ we have to manage hearing loss (*cue everyone grumbling about how expensive hearing aids are, how insurance doesn’t cover them, and how they aren’t as helpful as you’d like for them to be* — trust me, we’ll get to this!).   
As promised, there is also the possibility of central “hearing loss”, where some sort of disruption to the system occurs at a higher level of processing.  This is not necessarily tested in a traditional hearing test, and many factors can play into this (including age).   Essentially, this topic is a whole ‘nother beast, and is worthy of its own, separate, post.  It will thus be addressed accordingly. 
Now that we (hopefully) have at least a basic understanding of how we hear and the types of hearing loss, we can get into the fun stuff!  In the next post, we’ll finally start talking about the diagnosis of hearing loss.  That means we can start talking about audiograms! (What’s an audiogram?  I want one! – 100 points to Gryffindor for anybody that gets that reference)‘Til then, keep your britches on, everybody. 
Also, I would like to take the opportunity to ask all of you what you would like to learn about (within the scope of this blog, that is).  Several readers have already sent in topic requests — please feel free to do the same!  I thank you for them, and promise that they will be addressed!

What you AuDda know about hearing & hearing loss (PART ONE)

After a brief hiatus (you can blame the Praxis for that), we’re back!  As I previously mentioned, this post will focus on how we hear, types of hearing loss, as well as how hearing loss is diagnosed.  First things first, though – credit goes to Mr. John E. Glavin for the punny title (I may be semi-regretting not thinking of it myself/using it as the blog title).  Unfortunately (?), I think I outdid myself on the puns in Post #2, so you may not see many of those for awhile (you can all breathe a sigh of relief).  Also, I have realized that I was being slightly ambitious last time when telling you that I would cover all of the above-listed topics in one post.  That being said, this will be a multiple-part series of posts.  But anyways, I’m sure you’re all on the edge of your seats right now, so let’s get started…

Generally speaking, I find that many patients have little (if any) understanding of their hearing loss.  Ultimately, I believe that this lack of understanding of the root of their problem(s) often leads to lack of success/satisfaction with hearing aids and aural rehabilitation.  Hearing is a very complex process; admittedly, a great deal of research still needs to be done, as there are many parts of the auditory system that are still not fully understood by scientists/researchers/professionals, etc.

When I discuss hearing with patients, I like to emphasize the idea that there are two primary factors that contribute to “hearing”: audibility and clarity.  Ultimately, you need both in order to understand an auditory signal.  Unfortunately (and as I will discuss), hearing loss oftentimes means more than just reduced signal audibility.  Depending on the type of hearing loss, clarity can be reduced as well, which is something that is more difficult for patients to understand and for professionals to treat.  Depending on where the “damage” has occurred in a person’s auditory system, audibility and clarity may be affected.

In order to understand a disrupted/damaged system, I think its necessary to first understand how the system is supposed to function.  I like to think of the auditory system in terms of four main components: 1) The outer ear 2) The middle ear 3) The inner ear (wait, I thought we had just one ear?), and 4) The central pathways/brain.  As I give you a bit of detail about each component, I’d like you to keep in mind that a disruption at any point in the system can ultimately compromise an individual’s ability to hear properly.  With such a complex system, it becomes apparent that there are many points at which a breakdown can occur.

Starting with component #1, the outer ear is the part of the peripheral auditory system that people typically use the term “ear” to describe.  Yep, that thing that sits on the side of your head (well, barring any trauma or congenital defect, on both sides of your head) is actually called the pinna.  For any guys that were discouraged by my last post making fun of their pick-up line, perhaps you can use this newfound knowledge next time you’re at the bar and impress some lucky lady by using this new, somewhat important-sounding vocabulary word.  I mean, what girl wouldn’t love to be told she has great pinnae?…

On second thought, don’t do that.


The purpose of the pinna is to collect any sound signal and direct it down into your ear canal, which is also part of trhe outer ear.  Once the sound is in the ear canal, it eventually reaches the eardrum, also known as the tympanic membrane (TM)™ (I really just wanted to TM my TM acronym).  The tympanic membrane transmits that sound through to…

Component #2, the middle ear.  Without going into too much detail, the middle ear is a hollow cavity that contains three tiny bones — the malleus, the incus, and the stapes (fun fact: the stapes is my favorite bone in the human body!).  Together, these three bones are called the ossicles.  Essentially, the middle ear acts to transduce the sound collected by the outer ear and transfer that sound energy to the inner ear (for you nerds out there, the auditory system takes an acoustic signal, transduces it into a mechanical signal, which is eventually transduced into an electrical signal within the inner ear).


The stapes is attached to the oval window (part of the cochlea), which brings us to component #3, the inner ear.  The inner ear has two main functions: 1) Vestibular (balance) and 2) Hearing.  For our purposes in this post, we are concerned with the second function of the inner ear — hearing.  An important part of the inner ear is the cochlea.  The cochlea is actually a bony, fluid-filled labyrinth.  However, it is sometimes deemed as the “hearing organ” because it houses the Organ of Corti, a complex organ in the inner ear that contains inner and outer hair cells.  These hair cells are the sensory receptors of the auditory system, and are (as far as we know) crucial for our hearing.

Last but not least, we have component #4, the central auditory pathway.  Once the signal has reached the auditory nerve, it then must travel all the way up the brainstem to the brain.  At this point in the process of hearing, the brain must take the signal that was transduced/transferred by the peripheral hearing mechanism and then apply meaning to it.  Central processing is a key component in understanding an incoming auditory signal.  It is also (arguably), the most complex part of hearing.  That being said, I plan to focus on the central auditory pathways/central processes more thoroughly in another post.  There is no way I could do it justice here.

Now that we’ve at least introduced key components of the auditory system (both peripheral + central), we can start talking about more complex, exciting (depending on who you ask…) things.  However, this is where we will end PART ONE of the series (just as it’s getting good, right?  I’m likening this to an episode of LOST).  In the next part of the series, I’ll discuss where these supposed breakdowns in the system can (and do) occur.

To officially end with two of my favorite things I really like, here’s a little audiology humor for you:


Happy Monday!

May the AuDs be ever in your favor…

Since this blog is meant to cater to any/everyone, even those who may have little to no knowledge of hearing and hearing-related professions, I’d like to start with the basics.  Also, October is National Audiology Awareness month!  (I am pretty sure some of my friends thought I made that up).  What better time to spread the word about what audiology is and does?  Question time!

Question #1: What is an audiologist?

Your answer is…

a) A sound specialist

b) The primary health-care professionals who evaluate, diagnose, treat, and manage hearing loss and balance disorders in adults and children¹

c) “Is that like… a speech-language… pathologist person?”

d) pretending that you can’t hear… “WHAT?!”

If your answer is b, you can give yourself a big pat on the back!  If your answer is d, you are probably like every other awkward guy that thinks he just came up with the best pick-up line EVER! (Hint: we’ve all heard it a million times before). 

But anyways, as I quoted before, an audiologist is the primary health-care professional who evaluates, diagnoses, treats, and manages hearing loss and balance disorders in adults and children¹.  Let’s break that down a little bit, shall we?

Question #2: What qualifications must one have to be an audiologist? (Ok, here’s where I just start answering my own questions without creating [arguably] funny multiple choice answers)

An audiologist holds either a masters or doctoral degree in audiology/related health & science field.  Wait – masters or doctorate?  Huh?  Yes, you read correctly.  We make even the “basics” confusing.  For a long time, an individual needed at least masters degree in order to become a licensed audiologist.  However, most states now require that anyone graduating after January 1, 2008 hold a doctoral-level degree in order to become a licensed audiologist in that state.  Thus, audiology is currently in a transition period.  Audiologists who earned their masters prior to this date can, but are not required to, finish a doctoral degree.  Those of us who entered graduate school after 2008 must pursue a doctorate (if we ever want to be licensed).  The degree that most audiology students are now pursuing is termed the ‘Au.D.’, or Doctor of Audiology degreeHowever, an individual could alternatively pursue a Sc.D. or Ph.D. and still become a licensed audiologist, provided that he/she take the appropriate coursework and pass the necessary examinations, etc.  Make sense?

Question #3: What does an audiologist actually do…?

Audiologists can work in a wide range of settings.  These include:
-Private Practice
-ENT Office/Clinic
-Veterans’ Administration (VA) Hospitals

Ok, but what do they actually do?
I think the classic thought about what audiology is is a little something like this…

However, there is a lot more to audiology than sticking headphones on a person and asking them to raise their hand for the beep.  What else, you ask?  Well… audiologists also:

  • Perform comprehensive audiologic assessments to diagnose hearing loss, using behavioral (seen above) and objective measures – don’t worry, we’ll talk about these later
  • Perform evaluations to diagnose vestibular (balance) disorders
  • Treat & manage hearing loss through education, amplification, and/or counseling
  • Assess, diagnose, and treat/manage central auditory processing disorders
  • Assess, diagnose, and treat/manage tinnitus (noise/ringing in the ears)
  • Design and implement newborn hearing screening programs
  • Design and implement hearing conservation programs
  • Work with cochlear implant patients
  • Implement auditory training/aural (re)habilitation programs
  • Perform surgical monitoring, particularly for ear-related surgeries¹ ²

The scope of practice of an audiologist is quite broad.  Thus, there is a difference between an audiologist and a hearing aid dispenser/hearing instrument specialist.  Provided they have the necessary licensing, both an audiologist and a hearing aid dispenser are qualified to dispense and fit hearing aids.  However, audiologists go through a different amount of schooling and training.  Thus, it pains me to see audiologists lumped into the category of “sleazy salespeople” because we work with hearing aids.  That is NOT to say that there aren’t excellent hearing aid dispensers out there – because there are.  But, as a person with hearing loss, it is up to you to be an informed consumer and to research the provider/professional that you are going to see.  What are his/her qualifications?  How long has he/she been practicing?  Where did you hear about this person, and what sort of reputation does he/she have?  Does this person make commission off of selling you hearing aids?  Whether the professional you ultimately end up turning to is an audiologist or a hearing aid dispenser, these are some of the many questions that you should ask yourself beforehand.  Think carefully before seeing someone about your hearing loss and before making a decision about whether or not to pursue amplification for/management of your hearing loss.

In my next post, I plan to discuss what hearing loss is and how it is diagnosed.  Stay tuned!  And in the mean time, may the AuDs be ever in your favor (I’m already abusing my ability to link to websites so easily).

For more information about audiology, you can visit the references listed below–


  1. American Academy of Audiology (n.d.). What is an audiologist? Retrieved from
  2. American Speech-Language Hearing Association (n.d.). Fact Sheet for Audiology. Retrieved from

Hearing Loss: Who’s Listening?

I was inspired to begin this blog (I have always said I would never have a blog – never say never, I suppose) after reading two articles published in the popular media.  These articles documented the experiences of two different individuals seeking out amplification options to help manage their hearing loss(es).

Unfortunately, these two individuals did not have positive experiences with their hearing healthcare professional(s) and/or their amplification devices.  Furthermore, many of the “facts” published in these articles were not necessarily factual.  It saddens me to think that 1) there are individuals out there with similar negative experiences and that 2) there are other individuals who are dissuaded from pursuing help for their hearing loss because of a lack of understanding regarding hearing healthcare.  As a (future) audiologist, I take personal responsibility for the fact that hearing health seems to be shrouded in so much mystery to so many.  In short, I would like to shed some light (or, to insert a cheesy audiology joke, to make things loud & clear) on the (admittedly) confusing auditory system and hearing healthcare industry.

Hearing loss is a pervasive problem.  In fact, it was estimated that 31.5 million individuals in the United States had some degree of hearing loss in 2004; that number is expected to grow to over 40 million individuals with hearing loss by the year 2050 (Kochkin, 2005).  Despite its prevalence, hearing loss is often ignored, brushed aside, or overlooked – by those affected, by their family members, and by physicians alike.  Approximately 24.1 million individuals with this reported hearing difficulty do not pursue management or treatment through the use of amplification (Kochkin, 2005).  There are a number of suggested reasons for individuals ultimately deciding not to pursue amplification, many of which I hope to  discuss in this blog.  My hope is to break down some of those barriers through education of both the consumer and the healthcare professional.

As for the patient/consumer, I hope that this blog can provide some answers to the many questions that someone with hearing loss may have.  Despite the vastness of the internet, there seem to be few (if any) places that a patient/consumer can turn to to educate him or herself about hearing loss and treatment options.  As someone who considers herself an informed consumer, this appalls me, and I hope to remedy that as a (mostly neutral) third party.

As for the hearing healthcare professional, particularly the audiologist – I hope to foster discussion, debate, and ultimately, education.  I do not claim to know it all (in fact, I am acutely aware of how much I do NOT know), but first and foremost, I aim for all of us to provide the best quality of care to our patients as possible.

Today, amidst the hearing aid fitting of a first-time user, a skeptical patient asked me why I entered this field.  Though he was a very nice man, I had the feeling that his underlying question was more along the lines of… what do you get out of selling me these hearing aids that I don’t want?  Without hesitation, I answered that I wanted to help people.  I told him that my goal was to help him to hear better, and that I wasn’t doing my job if that didn’t happen.  I meant every word of it.

And so, we’re here to hear*.  Are you listening?

*I feel as though this is the point where I have to apologize for my complete inability to come up with creative or catchy titles/taglines.  So, I’m sorry, and please bear with me as you read what is likely to become a series of extremely un-witty audiology lines.




Kochkin, S. (2005). MarkeTrak VII: Hearing loss population tops 31 million people. Hearing Review, 12(7), 16-29.