Starkey Research & Clinical Blog

True or False? Two hearing aids are better than one.

McArdle, R., Killion, M., Mennite, M. & Chisolm, T. (2012).  Are Two Ears Not Better Than One? Journal of the American Academy of Audiology 23, 171-181.

This editorial discusses the clinical implications of an independent research study. This editorial does not represent the opinions of the original authors.

Audiologists are accustomed to recommending two hearing aids for individuals with bilateral hearing loss, based on the known benefits of binaural listening (Carhart, 1946; Keys, 1947; Hirsh, 1948; Koenig, 1950), though the potential advantages of binaural versus monaural amplification have been debated for many years.

One benefit of binaural listening, binaural squelch, occurs when the signal and competing noise come from different directions (Kock, 1950; Carhart, 1965). When the noise and signal come from different directions, time and intensity differences cause the waveforms arriving at each ear to be different, resulting in a dichotic listening situation. The central auditory system is thought to combine these two disparate waveforms and essentially subtract the waveform arriving at one side from that of the other, resulting in an effective SNR improvement of about 2-3dB (Dillon, 2001).

Binaural redundancy, another potential benefit of listening with two ears, is an advantage created simply by receiving similar information in both ears. Dillon (2001) describes binaural redundancy as allowing the brain to get two “looks” at the same sound, resulting in SNR improvement of another 1-2 dB (MacKeith & Coles, 1971; Bronkhorst & Plomp, 1988).

Though the benefits of binaural listening would imply benefits of binaural amplification as well, there has been a lack of consensus among researchers. Some studies have reported clear advantages to binaural amplification over monaural fittings, but others have not. Decades ago a number of studies were published on both sides of the argument, but differences in outcomes may have been related to speaker location and the presentation angles of the speech and noise signals (Ross, 1980) so the potential advantages of binaural amplification were still unclear.

Some recent reports have supported the use of monaural amplification over binaural for some individuals, in objective and subjective studies. Henkin et al. (2007) reported that 71% of their subjects performed better on a speech-in-noise task when fitted with one hearing aid on the “better” ear than when fitted with two hearing aids. Cox et al. (2011) reported that 46% of their subjects preferred to use one hearing aid rather than two.

In contrast, a report by Mencher & Davis (2006) concluded that 90% of adults perform better with two hearing aids. They explained that 10% of adults may have experienced negative binaural interaction or binaural interference, which is described as the inappropriate fusion of signals received at the two ears (Jerger et al., 1993; Chmiel et al., 1997).

The phenomenon of binaural interference and the potential advantage of monaural amplification was investigated by Walden & Walden (2005). In a speech recognition in noise task in which speech and the competing babble were presented through a single loudspeaker at 0-degrees azimuth, they found that performance with one hearing aid was better than binaural for 82% of their participants. This is in contrast to Jerger’s (1993) report of an incidence of 8-10% for subjects that might have experienced binaural interference. One criticism of Walden & Walden’s study is that their “monaural” condition left the unaided ear open. Their presentation level of 70dB HL and the use of subjects with mild to moderate hearing loss indicates that subjects were still receiving speech and noise cues in the unaided ear, resulting in an albeit modified, binaural listening situation. Furthermore, their choice of one single loudspeaker for presentation of noise and speech directly in front of the listener created a diotic listening condition, which eliminated the use of binaural head shadow cues. This methodology may have limited their study’s relevance to typical everyday situations in which listeners are engaged in face to face conversation with competing noise all around.

Because the potential advantages or disadvantages of binaural amplification have such important clinical implications, Rachel McArdle and her colleagues sought to clarify the issue with a two-part study of monaural and binaural listening. The first experiment was an effort to replicate Walden and Walden’s 2005 sound field study, this time adding a true monaural condition and an unaided condition. The second experiment examined monaural versus diotic and dichotic listening conditions, using real-world recordings from a busy restaurant.

Twenty male subjects were recruited from the Bay Pines Veteran’s Affairs Medical Facility. Subjects ranged in age from 59 to 85 years old and had bilateral, symmetrical hearing losses. All were experienced users of binaural hearing aids.

For the first experiment, subjects wore their own hearing aids, so a variety of models from different manufacturers were represented. Hearing aids were fitted according to NAL-NL1 prescriptive targets and were verified with real-ear measurements. All of the hearing aids were multi-channel instruments with directional microphones, noise reduction and feedback management. None of the special features were disabled during the study.

Subjects were tested in sound field, with a single loudspeaker positioned 3 feet in front of them. They were tested under five conditions: 1) right ear aided, left ear open, 2) left ear aided, right ear open, 3) binaurally aided, 4) right ear aided, left ear plugged (true monaural) and 5) unaided. The QuickSIN test (Killion et al, 2004) was used to evaluate sentence recognition in noise in all of these conditions. The QuickSIN test yields a value for “SNR loss”, which represents the SNR required to obtain a score of 50% correct for key words in the sentences.

The primary question of interest for the first experiment asked whether two aided ears would achieve better performance than one aided ear. The results showed that only 20% of the participants performed better with one aid, whereas 80% performed better with binaural aids. The lowest SNR loss values were for the binaural condition, followed by right ear aided, left ear aided, true monaural (with left ear plugged) and unaided. Analysis of variance revealed that the binaural condition was significantly better than all other conditions. The right-ear only condition was significantly better than unaided, but all other comparisons failed to reach significance.

The results of Experiment 1 are comparable to results reported by Jerger (1993) but contrast sharply with Walden and Walden’s 2005 study, in which 82% of respondents performed better monaurally aided.  To compare their results further to Walden and Walden’s, McArdle and her colleagues compiled scores for the subjects’ better ears and found that there was no significant difference between binaural and better ear performance, but both of these conditions were significantly better than the other conditions. They also examined the effect of degree of hearing loss and found that individuals with hearing thresholds poorer than 70dB HL were able to achieve about twice as much improvement from binaural amplification as those subjects with better hearing. Still, the results of Experiment 1 support the benefit of binaural hearing aids for most participants, especially those with poorer hearing.

The purpose of Experiment 2 was to further examine the potential benefit of hearing with two ears, using diotic and dichotic listening conditions. Diotic listening refers to a condition in which the listener receives the same stimulus in both ears, whereas dichotic listening refers to more typical real-world conditions in which each ear receives slightly different information, subject to head shadow and time and intensity differences.

Speech recognition was evaluated in four conditions: 1) monaural right, 2) monaural left, 3) diotic and 4) binaural or dichotic. Materials for the R-SPACE QSIN test (Revit, et al., 2007) were recorded through a KEMAR manikin with competing restaurant noise presented through eight loudspeakers. Recordings were taken from eardrum-position microphones on each side of KEMAR, thus preserving binaural cues that would be typical for a listener in a real-world setting.

In Experiment 2, subjects were not tested wearing hearing aids; the stimuli were presented via insert earphones. The use of recorded stimuli presented under earphones eliminated the potentially confounding factor of hearing aid technology on performance and allowed the presentation of real-world recordings in truly monaural, diotic and dichotic conditions.

The best performance was demonstrated in the binaural condition, followed by the diotic condition, then the monaural conditions. The binaural condition was significantly better than diotic and both the diotic and dichotic conditions were significantly better than the monaural conditions. Again in contrast to Walden and Walden’s study, 80% of the subjects scored better in the binaural condition than either of the monaural conditions and 65% of the subjects scored better in the diotic condition than either monaural condition. These results support the findings of the first experiment and indicate that for the majority of listeners, speech recognition in noise improves when two ears are listening instead of one. Furthermore, the finding that the binaural condition was significantly better than the diotic condition indicates that it is not only the use of two ears, but also the availability of binaural cues that have a positive impact on speech recognition in competing noise.

McArdle and her colleagues point out that their study, as well as other recent reports (Walden & Walden, 2005; Henkin, 2007), suggests that the majority of listeners perform better on speech-in-noise tasks when they are listening with two ears. When binaural time and intensity cues are available, performance is even better than with the same stimulus reaching each ear.  They also found that the potential benefit of binaural hearing was even more pronounced for individuals with more severe hearing loss. This supports the recommendation of binaural hearing aids for individuals with bilateral hearing loss, especially those with severe loss.

Cox et al (2011) reported that listeners who experienced better performance in everyday situations tended to prefer binaural hearing aid use, but also found that 43 out of 94 participants generally preferred monaural to binaural use over a 12-week trial. For new hearing aid users or prior monaural users, this is not surprising, as it can take time to adjust to binaural hearing aid use. Clinical observation suggests that individuals who have prior monaural hearing aid experience may have more difficulty adjusting to binaural use than individuals who are new to hearing aids altogether.  However, with consistent daily use, reasonable expectations and appropriate counseling, most users can successfully adapt to binaural use. It is possible that the subjects in Cox et al’s study who preferred monaural use were responding to factors other than performance in noise. If they were switching between monaural and binaural use, perhaps they did not wear the two instruments together consistently enough to fully acclimate to binaural use in the time allotted.

Though their study presented strong support for binaural hearing aid use, McArdle and her colleagues suggest that listeners may benefit from “self-experimentation” to determine the optimal configuration with their hearing aids. This suggestion is an excellent one, but it may be most helpful within the context of binaural use. Even patients with adaptive and automatic programs can be fitted with manually accessible programs designed for particularly challenging situations and should be encouraged to experiment with these programs to determine the optimal settings for their various listening needs.

Clinicians who have been practicing for several years may recall the days when hearing aid users often lost their hearing aids in restaurants because they had removed one aid in order to more easily ignore background noise. That is less likely to occur now, as current technology can help most hearing aid users function quite well in noisy situations. With directional microphones and multiple programs, along with the likelihood that speech and background noise are often spatially separated, binaural hearing aids are likely to offer advantageous performance for speech recognition in most acoustic environments. Bilateral data exchange and wireless communication offer additional binaural benefits, as two hearing instruments can work together to improve performance in noise and provide binaural listening for telephone or television use.

References

Bronkhorst, A.W. & Plomp, R. (1988). The effect of head induced interaural time and level differences on speech intelligibility in noise. Journal of the Acoustical Society of America 83, 1508-1516.

Carhart, R. (1965). Problems in the measurement of speech discrimination. Archives of Otolaryngology 82, 253-260.

Carhart, R. (1946). Selection of hearing aids. Archives of Otolaryngology 44, 1-18.

Chmiel, R., Jerger, J., Murphy, E., Pirozzolo, R. & Tooley, Y.C. (1997). Unsuccessful use of binaural amplification by an elderly person. Journal of the American Academy of Audiology 8, 1-10.

Cox, R.M., Schwartz, K.S., Noe, C.M. & Alexander, G.C. (2011). Preference for one or two hearing aids among adult patients. Ear and Hearing 32 (2), 181-197.

Dillon, H. (2001). Monaural and binaural considerations in hearing aid fitting. In: Dillon, H., ed. Hearing Aids. Turramurra, Australia: Boomerang Press, 370-403.

Henkin, Y., Waldman, A. & Kishon-Rabin, L. (2007). The benefits of bilateral versus unilateral amplification for the elderly: are two always better than one? Journal of Basic and Clinical Physiology and Pharmacology 18(3), 201-216.

Hirsh, I.J. (1948). Binaural summation and interaural inhibition as a function of the level of masking noise. American Journal of Psychology 61, 205-213.

Jerger, J., Silman, S., Lew, J. & Chmiel, R. (1993). Case studies in binaural interference: converging evidence from behavioral and electrophysiologic measures. Journal of the American Academy of Audiology 4, 122-131.

Keys, J.W. (1947). Binaural versus monaural hearing. Journal of the Acoustical Society of America 19, 629-631.

Killion, M.C., Niquette, P.A., Gudmundsen, G.I., Revit, L.J. & Banerjee, S. (2004). Development of a quick speech-in-noise test for measuring signal-to-noise ratio loss in normal hearing and hearing-impaired listeners. Journal of the Acoustical Society of America 116, 2395-2405.

Kock, W.E. (1950). Binaural localization and masking. Journal of the Acoustical Society of America 22, 801-804.

Koenig, W. (1950). Subjective effects in binaural hearing. [Letter to the Editor] Journal of the Acoustical Society of America 22, 61-62.

MacKeith, N.W. & Coles, R.A. (1971). Binaural advantages in hearing speech. Journal of Laryngology and Otology 85, 213-232.

McArdle, R., Killion, M., Mennite, M. & Chisolm, T. (2012).  Are Two Ears Not Better Than One? Journal of the American Academy of Audiology 23, 171-181.

Mencher, G.T. & Davis, A. (2006) Binaural or monaural amplification: is there a difference? A brief tutorial. International Journal of Audiology 45, S3-S11.

Revit, L., Killion, M. & Compton-Conley, C. (2007). Developing and testing a laboratory sound system that yields accurate real-world results. Hearing Review online edition, www.hearingreview.com, October 2007.

Ross, M. (1980). Binaural versus monaural hearing aid amplification for hearing impaired individuals. In: Libby, E.R., Ed. Binaural Hearing and Amplification. Chicago: Zenetron, 1-21.

Walden, T.C. & Walden, B.E. (2005). Monaural versus binaural amplification for adults with impaired hearing. Journal of the American Academy of Audiology 16: 574-584.