A note about hearing technology

Spouse’s tinnitus was one of several symptoms/effects of scurvy – which is what she had. I was reading the Patrick O’brian Aubrey-Maturin series at the time and put the symptoms together, suggested she return to her GP, tell him what it was and see his reaction.
“Of Course! Vitamin C Deficiency.”
The deficiency was an effect of a medication she was taking and adding more vitamin C into the mix cured the tinnitus and the other related complaints.
She had made the rounds of the usual specialists who had failed to diagnose scurvy – as one of them said, “We never see scurvy, as such.”
This is of course not to suggest that tinnitus is always a symptom of scurvy (Vitamin C deficiency) but it may give a few of you who have this problem something else to look into.

I appreciate this topic. When I was 28 I lost most of the hearing in my left ear due to infection. First thing I noticed was the loss of stereoscopic direction finding. Like dropping the soap in the shower with your head lathered up and finding the bar without opening your eyes because your hearing allows you to pinpoint its location. I don’t have a hearing aid (can’t afford one).
Anyway about 8 weeks ago I had another stroke and lost a significant degree of my hearing in the remaining ear. I have been able to get along with work as long as I can sit in a quiet room with no radio or TV on, None at all as even at low levels I can’t hear my patients speak. My problem is I need HA’s but I can’t envision taking them out 20 times a day to listen to heart, lung, and bowel sounds. Anyone have a constructive idea? I don’t qualify for disability and have no money to retire on.
Again, Thank you Anthony for this topic. I am a regular reader but rarely comment because all the smart people here would make my comments seem silly. I am an electronic engineer but now practice medicine so this has been very interesting on two levels.

Sorry Anthony, I agree with much that you say and read your blog every day, but you really CAN pay a lot less for DSP Hearing aids including CIC and RIC type – and you can adjust them yourself. I have done so. I have also had multiple poor/fraudulent service from hearing’professionals’. For example, you can chose from 6 channel units eg from http://www.audicus.com/ for $998/pr, 12 channel units from http://www.diyhearingaids.com/ for $1990/pr, 16 Channel Siemens Pure 701’s from http://www.thehearingcompany.com/ for $3295, or 32 channel units from http://www.americahears.com/ for $1798 & etc. All of these can be self-adjusted to match an audiogram, or to taste.They can also be matched up to all the latest bluetooth/telecoil etc technology. The people selling these are still no doubt making hefty profits. There really ARE multiple scams in the hearing aid supply/fit field. I am sure that the aids themselves ARE being made in China for a fraction of the sale price eg $100 per unit. The voltage differences and the germanium/silicon difference are probably just promotional stunts. This is not to say that people should purchase really cheap amplifying aidsvfrom ebay, hunting stores or elsewhere which might damage their hearing.

Don’t forget that Obamacare imposed a 10% tax on medical devices. This tax, perhaps the most bizarre, regressive, invidious, and anti-business tax n the entire world, is already driving thousands of jobs, even entire companies, overseas, as well moving the entire medical manufacturing processes to China, where they will be lost to us forever. Manufacturers must lower labor costs to afford the tax.

I think that there is a limited group of people who are going to buy hearing aids therefore dropping the price of these modern hearing aids is not going to result in a huge increase in demand.The research and development costs are high and must be paid for but we would expect the price of hearing aids to fall in the long run.I have high level hearing loss but I am reluctant to buy a hearing aid at the price they are now even if they are much better than they used to be because of modern technology.

I have been using BTE aids for a year to reduce tinnitus I got by living too close to an 8 in gun battery in Vietnam. At the beginning my tinnitus was matched by a 57dB tone at 6KHZ. After a year it matched a 32dB tone at 6KHZ. Subjectively the difference went from a steam whistle close by to an organ in a church across the street with a key stuck down. It is still annoying when I think about it but not nearly as painfully distracting as before. So far the improvement continues even if I do not wear the aids for weeks.
The BTE aids I used for tinnitus produce a continuing sound like a zylophone playing random notes. Neither the Audiologist nor my General Practitioner understand why it works. Maybe it’s placebo, but as long as the improvement persists I don’t care.
Yes they are expensive and in my case not covered by insurance. Whether the price is based on cost or other factors I do not know. But I suggest, if you are convinced that there is excessive profit involved, that you start making and selling your own brand. That’s how markets work.

Hi Anthony,
Some healthy skepticism may be required.
This post caught my attention as I wear BTE hearing aids, and I have a good friend who is our city’s ear nose and throat specialist, and before I got my hearing aids (about 2 years ago) he told me what I should expect to pay. It was along the lines of $5000 (NZ), which is about $4,000 (US). He commented then that the price was way too high and could be lower. I forwarded him your post. Here is Wayne’s comment:
“Thanks for that. However the justification for the high price in totally unconvincing. When the NHS in the UK put out a tender for hearing aids the price dropped from 900 pounds to 90 pounds for the same item. They can still make money on 90. It doesn’t include fitting fee, but that is usually quite reasonable. No – there is definitely strategic price control going on somewhere in the process.”
Robin (New Zealand)

My mother had a hearing aid from the UK National Health Service in the 1960’s that was around the size of an old Sony Walkman with a not dissimilar ear cord to an ear mold. I have been wearing hearing aids for the last 30 years – due to inheriting my mother’s problem greatly assisted by too many hours working alongside fighter aircraft in reheat.
The first aids I had were from the UK National Health system and were simple Behind the Ear (BTE) analogue amplifiers with clipping of the highest output. The NHS only started supplying digital hearing aids around ten years ago. I moved to a commercial In the ear (ITE) aid in UK at the cost of £2,400 in the early 90’s this was digital with adaptive volume control and a simple graphic equalizer. I replaced that in the US for $2000 with a more updated aid 6 years later. As my hearing got a little worse I updated to a digital BTE with several different settings and ‘bluetooth’ at a cost of $3000 – around the same price as the early digital aid that I got in UK 15 years previously.
When I got my first hearing aid I was very self-conscious as being deaf and failing to hear people seems to be treated in a less friendly way by society. People seem to think someone who does not hear them is stupid or rude; hiding the hearing aid only reinforces their assumption. I am now beyond being embarrassed and would rather have a hearing aid that works and allows me to do my job even to carrying around a Walkman sized device similar to what my mother used.. My current Oticon hearing aid has a neck pendant called a streamer that provides Bluetooth connectivity and with its own microphone allows me to answer my cellphone even if it’s in my pocket or somewhere within 30 feet. The people I work with have got used to me apparently talking to myself.
As to your points Anthony. I can understand that hand tailoring a set of hearing aid circuits to fit inside the ear canal is extremely manpower intensive and skilled. But I have to wonder if that is due to the wish for the recipients to have a contact lens equivalent in hearing aids. A standard small electronics container could be fitted to any earpiece and if it cannot be buried right in the canal then it is just an In The Ear aid alternatively the microphone and speaker could be in the canal but all the electronics in a standard ‘pack’ behind the ear. Both these methods would standardize the electronics for the aids and make them more mass-producible reducing their price.
Feedback is an area that you did not mention. Although electronics can be used to limit feedback it is difficult when the speaker and the microphone are both in the ear canal. With my hearing loss the power output is such that feedback can only really be avoided with a BTE aid. This means the microphones are also BTE but there are 3 on my aid which allows noise cancelling and user choice of which ones to be active.
Finally, thanks to the way people use Walkman, the iPod and other digital music systems the number of people with deafness is about to increase dramatically. This will change the market from specialist providers to a mass market. As soon as that happens (and posts here suggest it is happening) it will be seen as a business opportunity and the current trio of major hearing aid manufacturers will suddenly have to defend their market share. If as some posters here are surmising the germanium issue is just a marketing ploy, then the mass-market will soon bring in changes. In real terms the price of hearing aids is already dropping, I think that this will continue.
For those with tinnitus – I have occasional very severe tinnitus (up to the level of sitting close to the engines in an aircraft at takeoff) but have found that a cocktail of vitamins and protein supplements appears to greatly assist. There is a fair amount of research on this area to be found on the internet and everyone is different in their vitamin balance it may be an idea to have some tests done to see if you are not absorbing enough of a vitamin or protein.

I’m an analog IC designer (Ph.D. EE with 25+ years experience, if you care) who works on nanometer scale chips. I also work in the Minneapolis area so I have friends who work in the medical electronics business. So I can make a few observations on the technology involved, and in short, much of what makes the iPhone cheap doesn’t apply to hearing aids.
The newest technologies in say 45nm would certainly be feasible for these projects in theory, since the digital voltage is around 1V max. I’d hate to do the analog design, though. The transistor gates in a 45nm process are around 14-15 atoms so you get significant quantum mechanical tunneling through the gate, and the drain to source leakage is very, very high. That is a factor even in what I call low-speed analog design in these technologies of 100 MHz or so. But at audio frequencies the leakage would be exceptionally difficult to deal with for the analog part of the chip. The digital would be straightforward, but since there’s relatively little digital processing, the chip for a hearing aid would be what we call “pad limited”, meaning that the chip size would be dictated by necessary communication paths off the chip, which would significantly drive up the chip cost since silicon is expensive for these processes.
But you could never, ever make a hearing aid design work economically at 45nm. What we in the business call NRE (non-recoverable expenses) in this technology start at around $20M per project, so you can really only contemplate these technologies for things that are going to be selling hundreds of millions per year, while hearing aids don’t even hit the 2M/year level. Doing the math on the back of my napkin, the entire hearing aid industry would have to submit the minimum order for wafers every other year to supply itself (details later if there’s demand). At such low volumes your NRE is easily going to be $40M+ since the foundry isn’t going to be cutting you a break, if you can even get in, since they don’t like low volume customers.
To give you a feel for what it takes to really make use of one of the modern, cheap-in-volume processes, we order twice as many wafers a day as the entire hearing aid industry would use in a year and it’s still hard to justify the various expenses.
Overall, you’re far better off using an older, lower speed (and lower leakage) CMOS process. The expenses of designing a single mask set in something like a 180nm process are around $20K vs. $2.5M+ for a 45nm process. You get a similar break in the software needed to design the chips, too.
The germanium issue is also a bit oversold. In the last 20 years there’s been a huge increase in what we call subthreshold design techniques that would allow replacing the germanium power amplifier with an integrated solution in CMOS at nearly the same efficiency. The design techniques aren’t as well known as what I assume the germanium users are doing, but they’re out there and used in many areas such as watches and the like. They’re useful for slow designs like these audio frequencies, but they’re not what I’d call mainstream.
Most frustrating to me would be the overall design cycle, though. From talking to my Medtronic neighbor the FDA is a pain to deal with. His example was a medical chip, where he finished the design in about 12 months. Then it went out to trials and those trials are expensive in terms of insurance, medical doctor’s time, result analysis, lawyers to look over paperwork, paperwork required for engineers to submit, etc. All the while the FDA was in the loop to slow things down, sending things back to make a few tweaks, etc. Overall it took 5 years for approval, which is better than the typical 7 for a pacemaker. But in that 5 year span the original foundry nearly went out of business and if it had he’d have had to start over. Compare that with the overhead of the FCC, where approval of a wireless chip usually is done in less than a month at a relatively low cost, and from design start to volume production can be less than 18 months. I understand the need to be safe, but those “hunter’s ears” you’re talking about don’t go through the FDA and that’s one of the bigger reasons they’re much cheaper. When you get the FDA into the loop you automatically delay the process and drive up the cost immensely.

Jim,
Thank you
Azygos

There has also been consolidation in the industry. Many smaller companies doing the most advance technology (I actually worked at one) in the 90s have been bought out by larger firms.