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Earmolds:PracticalConsiderationstoImprovePerformanceinHearingAids|HearingReview

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Earmolds:PracticalConsiderationsto
ImprovePerformanceinHearingAids
PUBLISHEDONSEPTEMBER1,2009

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BrianTaylor,AuD,istheprofessionaldevelopmentmanagerat
UnitroninPlymouth,Minn.DarrelTeter,PhD,ownsaprivate
practiceinHighlandsRanch,Colo,wasamemberoftheoriginal
IHAFFprotocolcommittee,andhasservedasaconsultantfor
Phonakformorethan35years.

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Itisapopularbeliefamongsomehearingcareprofessionalsthatdigital
electronicshasrenderedknowledgeofbasicearmoldmodifications
unnecessary.Thisstatementissupportedbythefollowingobservations:

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1)Mostcliniciansrelyonsoftwaretoelectronicallyadjustthegainand
frequencyresponseofthehearingaid.Althoughthisiscertainlyan
effectivewaytomodifytheacousticparametersofamodernhearingaid,
theremaybetimeswhenadjustmentstotheacousticalplumbingofthe
deviceareuseful.

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2)Manygraduatelevelaudiologyprogramsofferlittlehandsonor
academictrainingonearmoldmodificationsandhowtheyaffectthe
acousticalcharacteristicsofthefitting.Forexample,theHandbookof
ClinicalAudiology,longastaplereadingforaudiologygraduatestudents,
eliminateditschapterdevotedtoearmoldsafterthethirdedition,which
waspublishedin1985.
3)Publishedreportsinthepertinentjournalsarescarce,asarecent
searchuncoveredlessthanadozenarticlesrelatedtoearmoldacoustics
andearmoldmodifications.
Thepurposeofthisarticleistorevisitsomeofthemorepractical
considerationssurroundingtheselectionandmodificationofearmolds
andhowthosefactorscontributetoamoresuccessfulhearingaidfitting.

DeathofMechanicalAlterations?
Thebeliefthatdigitalelectronicssupplantstheneedformodificationsto
earmoldsisnotwithoutmerit.Itisindeedtruethatmanychangestothe
acousticparametersofamodernhearingaidcanbereadilyadjustedwith
afewclicksofamouseorcomputerkeyboard,usingthemanufacturers
fittingsoftware.Manytraditionalearmoldmodificationtechniquesthatlost
favorinthe80sand90sduetothesurgeincustomproductpopularity

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needtobereexaminedwiththesurgeinbehindtheear(BTE)product
usesince2005.
Oneofthelikelyfactorscontributingtothedisregardofearmoldacoustics
andhowtheycontributetoasuccessfulfitcanbeattributedtothe
popularityofopencanal(OC)technology.MiniBTEdevices,whichare
usuallycoupledtotheearwithanoncustomizedthintubeanddomeear
tip,compriseasignificantpartoftotalOCsales.Asothershave
demonstrated,13thefittingrangeofminiBTEOCproductscanbe
extendedwiththeuseofacustomearmold.Althoughnolonger
consideredanopencanalfitting,miniBTEswhencoupledtoacustom
madeearmoldusingeitherathintubeorathinwiremaintaintheir
cosmeticappeal.
WhensalesofOCproductsarecombinedwithconventionalBTEhearing
aids,welloverhalfofallhearingaidssoldintheUnitedStateshavethe
potentialtobecoupledtotheearwithacustomearmold.Thus,itis
prudenttorevisitsomeofthebasicsciencesurroundingearmoldsand
earmoldacoustics,especiallyasitrelatestothintube/thinwireminiBTE
technology.

EarmoldMaterialsandStyles
Beforegoingintosomeofthedetailssurroundingtheuseofcustom
earmoldsforthintube/wireminiBTEs,itisimportantforthedispensing
professionaltohaveknowledgeofthebasisofearmoldselectionand
modifications.Thefirstconsiderationiswhentousevariousearmold
materialsandstyles.
Beforethis
discussion,
however,
the
assumption
mustbe
FIGURE1.Anexampleofaproperlyinsertedotoblock.
madethat
theear
impressionistakencorrectly.Theearimpression,usingthecorrectsize
otoblock,mustmakecontactwiththeentirecanalwall,asshownin
Figure1.Inaddition,theotoblockshouldextendbeyondthesecondbend
oftheearcanal,andregardlessoftheearmoldstylebeingordered,the
earimpressionmaterialshouldcompletelyfilltheentireconcha.Before
sendingthefinishedearimpressiontothemanufacturer,thepractitioner
shouldcarefullyinspecttheimpressionandensureallthemajor
landmarksoftheearhavebeenaccuratelycast.
Asconventionalwisdomwoulddictate,thechoiceofearmoldmaterialand
styledependsagreatdealontheextentofthehearinglossandthe
professionalsneedtomeetspecificgainandoutputrequirements.Kuk4
determinedthatthecanalportionoftheearmoldcontributesthemostto
maximumgainrequirementsoftheBTE.Thiswouldsuggestthatskeleton
andcanalstyleearmoldsareappropriateforhearinglossesuptoabout
75dBHL.
Anotherimportantconsiderationisthetypeofmaterialusedtomakethe
earmold.Ingeneral,softermaterials,suchassiliconandvinyl,areused
forhearinglossesgreaterthan75dBHL.Table1outlinesthethreemajor
earmoldmaterials,alongwiththeirperformanceadvantages.

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TABLE1.Threecommonearmoldmaterials,alongwith
advantagesofeachmaterial.

EarmoldMaterialCharacteristics
Regardlessoftheearmoldstyleormaterial,Lybarger5notedthree
requirementsofaproperlyfittedearmold:
1)Acousticseal.Theearmoldneedstodirectsoundtowardthe
eardrumwithoutacousticfeedback.
2)Comfort.Theearmoldshouldfitascomfortablyaspossiblewithout
causingirritationtotheexternalear.
3)Aestheticappearance.Theearmoldneedstobeasinconspicuousas
possiblewithinthelimitssetbytheacousticrequirementsofthepatient.
Morethan44yearssinceLybargermadetheseobservationsandeven
thoughelectronicfeedbackcancellationalgorithmsexistinmanymodern
hearingaidsthesethreebasicrequirementsstillholdtrue.Infact,given
theproliferationofminiBTEproducts,thesethreeconsiderationstakeon
arenewedimportanceaddressedinthefinalsectionofthisarticle.First,
however,thebasicacousticfactorsaffectingearmoldperformancewillbe
reviewed.

Venting
Therearethreemajortypesofventsfoundinahearingaidshellor
earmold:parallel,diagonal,andtrench.Allthreeventsaredesignedto
accomplishthesamething,whichistoprovidesomereductionof
amplifiedlowfrequencysoundthatis,allowlowfrequencysoundsto
leakoutoftheear.Ventingalsoallowsforsomepressurerelief,which
resultsfromboneconductedsoundgettingtrappedintheclosedoffear
canalwhenatightfittinghearingaidisinsertedintotheearcanal(the
soundisgeneratedfromthecondyleareaofthemandible,whichis
locatedclosetotheearcanal).Thisproblemisespeciallyapparentwhen
patientstalkorchew.
Themostcommonlyusedventistheparalleltypehowever,thereare
instanceswhenaprofessionalmayhavetosubstituteadifferentstyle
vent.Itiseasytoforgetthattheventtypecanhaveasignificanteffecton
thereductioninlowfrequencyenergy,asdiagonalventsreducelow
frequencyenergymorethanparallelventswiththesameinternal
diameter.ThisisillustratedinFigure2,whichcomparesthesamehearing
aidwithidenticalacousticalsettings.Theonlychangeisthestyleofvent.
Noticeinthisparticularexamplehowgainisreducedthrough3000Hz
withtheuseofadiagonalorsidebranchvent.

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FIGURE2.Theeffectsofventstyleongainandfrequency
response.Thehearingaid,earmoldstyle,andventdiameterwere
heldconstantandtheventtypewaschanged.Thegreencurves
showaidedgainforaparallelventandthepurplecurvesshow
theaidedgainforthesameproductandearmoldstyleusinga
diagonalvent.TheorangecurveistheREUR.

Tubing
TubingSize Inside/OutsideDiam
#12
#13standard
#13medium
#13thick
#14
#15

2.16/3.18mm
1.93/2.95mm
1.93/3.10mm
1.93/3.30mm
1.68/2.95mm
1.50/2.95mm

Thintube

0.90/1.40mm

Tubinglengthandinternaldiametercanhaveapronouncedeffectonthe
frequencyresponseofthehearingaid.Tubingdiametersare
standardizedaccordingtotheinternaldiameter.Themostcommon
tubingissize13.Hereisasummaryofcommontubingoptionswiththe
correspondinginside/outsidetubediameters(inmm):

FIGURE3.Theeffectonhearingaidresponseforvarioustubing
diametersmeasuredonanearsimulator.Theinternaldiameters
forsize13and14tubingarelistedabove.The.031inchdiameter
issimilartotodaysthintubeinternaldiameter.5
Figure3providesagoodexampleofhowthegainabove1000Hzis
affectedbytheinternaldiameterofthetubing.Inthisexample,five
differentinternaldiametersarecomparedinaZwislockicoupler.The
.031inch(0.80mm)internaldiametercurveinFigure3closely
approximatestheinternaldiameterofamodernthintube.Eventhough
thereductioningainresultingfromtubingresonancescanbe
compensatedthroughsoftwareadjustments,ifthepropercorrectfactoris
notproperlyverified,thintubefittingscanresultininadequatemidand
highfrequencygain.

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Dampers
Assoundtravelsthroughthetubing,standingwaveresonancesoccur.
Thesecreatepeaksinthefrequencyresponseofthehearingaid,
resultinginacousticfeedbackorpoorsoundquality.Tosomeextent,
thesepeaksandvalleyscanbesmoothedoutelectronicallyusingthe
fittingsoftware.
However,manymanufacturersstillrelyonplasticormetaldampers
placedintheearhooktosmoothouttheresponse.Forexample,inmany
highgainBTEs,a680or1000ohmdamperisusedtosmoothoutthe
frequencyresponseofthehearingaid.Thelocationofthedamperalso
hasasignificanteffectonthefrequencyresponse.Fortheclinician,
knowingthetypeandlocationofadamperisessentialwhenreplacingit,
asthedamperimpactssoundquality.

SoundBoresandHorns
Changesinsoundborediameteraffectthehighfrequencyresponseof
thehearingaid.Increasesinborediameteralone,however,yieldlittleor
nochangeinthehighfrequencyresponse.Figure4showstheaidedand
insertiongaindifferencesforastandard,bell,andopensoundbore,
respectively.Noticehowlowfrequencygainisaffectedduetochangesin
theventingcharacteristicsrelativetothesoundbore,buthighfrequency
gainisunaffected.Thisisduetothefactthatchangesinthehigh
frequencyresponsecanonlybeaccomplishedmechanicallywithahorn,
andnotwithalargersoundborewithintheearmold.Simplyincreasing
thesizeofasoundborehasnoappreciableeffectonthehearingaids
responseinthehighfrequencies.

FIGURE4.Theresponsecurvesforthesamehearingaidusing
earmoldswiththreedifferentsoundbores.Notethereisnota
significantdifferenceinthehighfrequencies.Thedifferences
seeninlowfrequencygainareduetochangesinventtypefor
eachoftheearmolds.

Foranacoustichorntoworkeffectively,agradualincreaseininternal
diameteroveraspecificlengthisrequired.Ifthelengthistoolongortoo
short,theincreaseinhighfrequencygainwillnotbeattained.Witha
properlyconstructedhorn,anincreaseinhighfrequencygaincanbe
readilyachievedwithoutincreasingthehearingaidsoutput.The3mmor
4mmLibbyhorn,alongwithwelldesignedContinuousFlowAdaptors
(CFA),areprovenmethodsforobtainingmorehighfrequencygain
mechanicallyratherthanelectronically.WhenusingaLibbyhorntube,it
isimportantnottomodifythelengthofthetubing,asshorteningthe
lengthcanrenderthehornineffective.Themechanicalactionofahornis
governedbythelengthandtaperofthehorn.Insimpleterms,forany
horntobeeffective,thelengthofthehornmustbeatleast17mm.With
theproperlengthmaintained,upto12dBofgainbetween2kHzand5
kHzcanbeobtained(Figure5).

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FIGURE5.Thedifferenceinhighfrequencygainbetweenan
earmoldwithstandardtubingandsoundbore(purplecurve)
comparedto4mmLibbyhorn(bluecurve).TheREURisthe
orangecurve.

CustomMoldsandThintube/wireMiniBTEs
Rose1outlinedseveralbenefitsassociatedwithcouplingathintube/wire
miniBTEproducttoasmallcustomearmold.Theseincludegreater
patientcomfort,improvedretention,andanextendedfittingrange.
Regardlessoftheadvantagesofcouplingacustomearmoldtoathin
tube/wireproduct,thereareseveralacousticalchangesthatshouldbe
consideredwhenclosingofftheearcanal.
Ithasbeendocumentedthatopencanalproductsdonotprovide
adequategaininthelowfrequenciesforlossesgreaterthanabout40
dBHL.Overthepastseveralyears,manufacturershaveofferedclosed
anddoubledomesdesignedtocloseofftheearcanal,increaselow
frequencygain,andthusextendthefittingrangeoftheseproducts.
Figure6fromTeie6showsmeandataforninepatientsusingfivedifferent
couplingoptionsforathintubeminiBTE.Thehearingaidwas
programmedforaflat50dBHLhearinglossandtheprescribedtarget
gainisshowninred.Forthenoncustomcouplingsystems,gainthrough
1500Hzissignificantlycompromised.Therearetwoimportantclinical
considerationsthatcanbetakenfromthisstudy,whichbothunderscore
theimportanceofbeingknowledgeableaboutthemechanicalproperties
ofearmoldsandtubing:

FIGURE6.Themeanaidedoutputforfivedifferentcoupling
optionsusingthesameminiBTEinrelationtoaprescriptive
fittingtargetforaflat50dBhearingloss.FromTeie.6
1)Onaverage,gainat500to1500Hzisinadequatewhenanoncustom
couplingsystemsuchasacloseddomeordoubledomeisused.In
practicalterms,thissuggeststhat,forlossesgreaterthan30to35dBHL
inthelowandmidfrequencies,audibilityiscompromisedwhena
noncustomdomeoreartipisusedwithathintube/wirefitting.

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2)Thereisadecreaseingainat1500Hzforthethintubefitting,as
describedbyTeie.6Thisreductioningainat1500Hzwiththethintube
fittingisespeciallyprominentwhentheearmoldwiththintubeis
comparedtotheearmoldwithstandard#13tubing.Thisfindingis
consistentwithtubingresonancesassociatedwiththesmallinternal
diameterofthethintube,whichneedstobeaccountedforduringthe
fittingprocessbypossiblyincreasinggaininthatfrequencyregion
throughadjustmentsusingthefittingsoftware.
Extendingthefittingrange.Customearmoldscanextendthefitting
rangeofminiBTEdevices.Figure7showstherealearaidedresponse
(REAR)ofareceiverinthecanal(RIC)productforapatientwithaflat50
dBhearingloss.Asexpected,theearmoldwiththesmallestventorthe
1.5mmSelectaVent(SAV)shownasthepurpleREARcurveprovides
theleastamountoflowfrequencygainreduction.

FIGURE7.CustommadeearmoldcoupledtothinwireminiBTE
devicefora50dBHLloss(Purple:1.5SAVGreen:largecavity
vent).Thebottompurpleandgreencurvesaretheinsertiongain
curves.ThetoppurpleandgreencurvesaretheREAG
responsesinrelationtotheREUR(inorange).
Anaddedadvantageofusingcustomearmoldswiththintube/wire
productsisthatthelowfrequencyresponsecanbetailoredbymodifying
thesizeofthevent.Thisisespeciallyimportantwhentryingtoreduce
occlusionrelatedissuescommonlyassociatedwithclosingofftheear
canaltoobtainmoregaininthelowfrequencies.AsshowninFigure7,a
significantamountoflowfrequencygaincanbemodifiedbychangingthe
ventsize.Asexpected,thegreencurveinFigure7,whichrepresentsthe
largerventdiameterandshorterventlength,hassignificantlylesslow
frequencygaincomparedtotheearmoldusinga1.5mmparallelvent
(purplecurve).Customearmoldscoupledtothintube/wiredeviceshave
beenshowntoextendtheirfittingrangetoflatmoderatetosevere
hearinglosses.

Summary

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Thebasictenetsofawellfittedhearingaidareasmoothbroadband
News
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responsewithsufficientaudibility,comfort,andsoundquality.AsFigure8
illustrates,theperceptionofamplifiedsoundcanbemodifiedthrough
mechanicalchangestothecouplingsystem.Inordertoaccomplishthese

HearingReview

things,whileminimizingcommonproblemslikefeedbackandocclusion,
considerableattentionmustbegiventohowventing,tubing,andother
mechanicalaspectsofthecouplingsystemaremade.Allcanmakea
significantimpactonthequalityofthefinalfitting.

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FIGURE8.Thegeneraleffectsofventing,damping,andacoustic
hornsonthefrequencyofahearingaid.Noteonthebottom
schematicatypicalfrequencyresponseissuperimposedonthe
figure.AdaptedfromBerger,1970.7

References
1. RoseD.Thereturnoftheearmold.HearingReview.
200613(9):1419.AccessedAugust5,2009.
2. RoseD,GhentR,WrightN.Extendingcandidacyforthintube
fittingsbymodifyingtheearmold.HearingReview.
200815(10):1215,48.AccessedAugust5,2009.
3. TaylorB.Optimizingopencanalfittingswithcustomearmolds.
AdvanceforAudiologists.200911(3):3034.
4. KukF.Maximumuserrealearinsertiongainwithtenearmold
designs.JAmAcadAudiol.199424(4):299312.
5. LybargerS.Earmolds.In:KatzJ,ed.HandbookofClinical
Audiology.3rded.Baltimore:Williams&Wilkins1985.
6. TeieP.Earcoupleracousticsinreceiverintheaidfittings.In
press,2009.
7. BergerK.TheHearingAid:ItsOperationandDevelopment.
Livonia,Mich:NationalHearingAidSociety1970.

CorrespondencecanbeaddressedtoHRat
hearingreview@allied360.comorBrianTaylor,AuD,at.
Citationforthisarticle:
TaylorB,TeterD.Earmolds:Practicalconsiderationstoimprove
performanceinhearingaids.HearingReview.200916(10):1014.

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