10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum?

- Hearing Review

TRENDING: Oticon’s New Hearing Aid Takes ‘Open Sound&...     SEARCH 

Hearing Loss  Products  Practice Building  Inside Hearing  Resources  Magazine

RECENT POSTS

Challenges of Instant-Fit Ear Tips: Ear Science Institute Australia Rece

Grant for ClearDrum Ear Implant
What Happens at the Eardrum?
Dec 18, 2019 | Behind the Ear, Patient Fittings, Research |  ASHA Offers Tips for Students with
Upcoming School Year

Neural Encoding of the Stimulus En

Facilitated by Widex ZeroDelay Tec

Competing in the New Era of Heari

How to Use Teleaudiology Technolo

Setup or in an Existing Of ce

New Circuit Design Could Help Ma

Sensors Lighter and More Flexible

Hearing Aid Fitting | December 2019 Hearing FOLLOW US

Review
The acoustic effects of various ear tips, and how they can in uence RIC  Facebook
hearing aid ttings.
 Twitter
By Laura Winther Balling, PhD; Niels Søgaard Jensen, MSc; Sueli
Caporali, PhD; Jens Cubick, PhD, and Wendy Switalski, MBA, AuD  LinkedIn

A variety of ear tips are now available for receiver-in-the-canal (RIC)  YouTube

hearing aids. But how might they in uence a hearing aid tting?
Analyzing real-ear measurements and vent effects, this study looks at
ve different kinds of RIC ear tips and their effects on the sound reaching
the eardrum and resulting sound quality. The bottom line: Dispensing
professionals need to understand the effects of the speci c ear tip in the
actual ear and recognize that using an “instant- t tip” cannot simply be
an “instant tting,” but instead requires individualization with the same
care that is given to prescribing gain.

Receiver-in-canal (RIC) hearing aids (HAs) with instant- t ear tips

have become increasingly popular over the last decade. For example,
around 82% of HAs dispensed in the United States in the rst half of
2019 were RIC devices.1 These are generally t with instant ear tips,
which have several advantages for both the hearing care
https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 1/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

professional (HCP) and the end user, primarily time ef ciency and
physical comfort. However, this type of tting also raises some
challenges, which need to be dealt with in order to ensure
appropriate gain and output, and optimal sound quality for the end
user.

In this article, we address the challenges that arise from variations in

the direct sound and vent effect for instant- t ear tips. When the
effective vent size—including the vents in the ear tip and the leakage
around it—is large, only a small amount of low-frequency sound from
the hearing aid (HA) reaches the eardrum; this is what is referred to
as the vent effect (VE).2 At the same time, the insertion loss (IL)—the
attenuation of the direct sound reaching the ear drum caused by the
presence of the hearing aid in the ear—is smaller for larger effective
vent sizes.

This makes it important to understand the effective vent size of

instant ear tips—something which, with only a few exceptions (eg,
Mueller and Ricketts3), has not been extensively addressed in the
scienti c literature. In the present article, we describe and discuss a
recent study4 that used extensive real-ear measurements to show
how IL and VE vary substantially between users, and we outline how
this variation may be accommodated in the tting. The
measurements we report are for ve different Widex ear tips, but
the results may be generalized to ear tips provided by other
manufacturers.

A further aspect to consider—particularly for those ear tips that are

open by design, but in practice for all types—is the mixing of the
direct sound through the vent and/or any leakage around the ear tip
with the ampli ed sound from the HA, which is delayed by the digital
signal processing. When the two sound contributions are of
approximately equal amplitude, differences in phase will lead to
cancellations, which can be seen as ripples in the spectra of the
resulting sound. This artifact, called the comb- lter effect, has
negative effects on sound quality.

Insertion Loss and Vent Effects

Subjects. A total of 30 normal-hearing individuals (10 female, 20
male) participated in the experiment. The mean age was 45 years
(range: 19 to 67 years). Measurements from one participant were
excluded due to issues with cerumen occluding the probe tube, so
measurements are reported for 58 ears.

Methods. The experiment consisted of a series of real-ear

measurements with ve different ear tips. Participants were tted
with a pair of Widex EVOKE 440 Passion RIC HAs with S-receivers
and the following instant ear tips: Widex Open, Tulip, Round (2-
vent), Round (1-vent), and Double domes (Figure 1). Measurements
were made for all ear tips for all participants, but in different orders.
During the measurements, the microphone in the HA was not used.
Instead, the only active processing task of the HA was to present a
sound signal streamed to the HA via the receiver into the ear canal.

https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 2/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

Figure 1. The ve different instant ear tips used in this study: a) Open; b)
Tulip; c) Round 2-vent; d) Round, 1-vent; e) Double domes.

The real-ear measurements were conducted using an Interacoustics

Af nity 2.0 system. The participants were seated 1 meter from the
system’s loudspeaker in a standard audiometric test suite. To
measure the real-ear unaided response (REUR), probe tubes were
placed in the ear canal within 5 mm of the eardrum, as veri ed by
otoscopy. Pink noise was then presented from the Af nity system at
0° azimuth at a level of 65 dB SPL. Next, without changing the
position of the probe tube, the hearing aids were placed on the ears
and real-ear occluded responses (REOR) were measured with the HAs
switched off using the same pink noise signal. The IL was calculated
as the difference between the REOR and the REUR. The IL
measurement setup is shown in Figure 2, together with an example
of individual results.

Figure 2. Real-ear measurement con gurations used for insertion loss (IL)
estimation, with pink noise presented from a loudspeaker in front of the
participant. IL was calculated as the difference between REOR and REUR,
as shown in the example on the right.

After conducting the measurements for the IL, and without

removing the hearing aids and probe tube, another set of real-ear
measurements were conducted to estimate the VE based on
streaming of brown noise to the HAs via a TV-DEX accessory. The
rst measurement was conducted with the hearing aid streaming in
the ear. Before the second measurement, and with the hearing aids
still in place, the ear canal and concha were lled with impression
material in order to measure the response from the hearing aids
with a fully occluded ear, thereby making sure that no sound could
“escape” from the ear canal. The difference between these two
measurements shows the VE—de ned as how much the HA sound is
reduced at the eardrum when the HAs are tted with the given ear
tip. The VE measurement setup is shown in Figure 3, together with
an example of individual results.

https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 3/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

Figure 3. Real-ear measurement con gurations used for VE estimation,

with brown noise being streamed to the HA and presented via the
receiver. VE was calculated as the difference between the ‘normal’
response and the ‘occluded’ response, as shown in the example on the
right.

Results

Figure 4. Average IL in 1/3-octave bands across 58 ears for the ve ear

tips (top left). The other panels show the average IL per tip (thick colored
line) ±1 standard deviation (color-shaded area). The grey-shaded area
represents the observed range of individual measurements.

IL comparisons. Figure 4 above shows the average IL in 1/3-octave

bands for each of the different ear tips in the top left panel (“All
tips”), and the variation across ears for each of the ve ear tips in the
remaining panels. The IL can be thought of as the attenuation that
the ear tip imposes on sounds from the environment, taking into
account its effect on the ear-canal resonance. Two things are
important in the results shown here:

1. We see in the average IL that the ear tips fall into three distinct
groups, as expected:

The Open ear tips are mostly transparent (ie, 0 dB IL) for sound
generated outside the ear canal, apart from a slight attenuation of
approximately 2 dB at frequencies above 2 kHz.

The Tulip and the two Round ear tips form a second group, with a
transparent response up to 1 kHz and a maximum attenuation of
approximately 9 dB (Tulip, Round 2-vent) to 12 dB (Round, 1-vent)
at a frequency of about 2.6-2.8 kHz;

The Double domes are on average only transparent up to 600 Hz,

and they show the highest average attenuation of 16 dB at 3 kHz.

https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 4/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

2) We see substantial variability in IL among individual ears. The

variability, illustrated by the color-shaded areas (standard deviation)
and grey-shaded areas (range from minimum to maximum), is largest
for the Double domes, but also considerable for the other types of
ear tips.

VE comparisons. Figure 5 shows the VE data plotted in the same

way as the IL data in Figure 4. Again, we see the same pattern of
three groups of ear tips, and substantial variation between ears for
each ear tip:

1) On average, the largest VE was found for Open tips. Here, the
largest average vent loss is about 40 dB around 125 Hz, and a vent
loss is observed up to just below 2 kHz.

2) The measurements for Tulip, Round (2-vent) and Round (1-vent)

are again quite similar, with a vent loss going up to between 1 and
1.5 kHz, and a maximum attenuation of about 30 dB at the lowest
frequencies.

3) Double domes show the least pronounced vent loss, with a cut-off
frequency of about 1.2 kHz and an average VE of 24 dB around 125
Hz.

Figure 5. Average VE in 1/3 octave bands across 58 ears for the ve ear
tips (top left). The other panels show the average VE per tip (thick colored
line) ±1 standard deviation (color-shaded area). The grey-shaded area
represents the observed range of individual measurements.

However, while these numbers represent averages, measurements

again show high individual variability in the VE across ear tips. Open
shows the lowest variability, and Double domes show the greatest
variability, as was also the case for the IL. At the lowest frequencies,
the VE with Double domes can be as low as 6 dB (nearly fully closed)
or as high as 38 dB (nearly completely open).

Implications for Fitting Hearing Aids

Both the IL and VE measurements showed differences between ear
tips, and large inter-participant variability. Both these overall results
have important implications for tting with instant- t ear tips.

First, it is clear (and not surprising) that the choice of ear tip has big
implications for HA acoustics, both in terms of how much direct
https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 5/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

sound is transmitted (IL) and in terms of how much low-frequency

sound escapes through the ear tip (VE). This means that to achieve
the desired gain and output targets, and to provide optimal sound
quality for the individual user, the tting software should take the
acoustics of the actual ear-tip style into account during tting, as is
done in the Widex Compass GPS tting software.

Second, the high variability in the measurements between ears

shows how crucial it is to take the individual effective vent size into
account. This applies for all ear tips where both the average IL and
VE may vary signi cantly from the actual IL and VE for the individual
HA tting (as shown in Figures 4 and 5). For example, the highest
average VE for the Tulip ear tips is just over 30 dB, but in the
individual measurements, the largest VE varies from below 20 dB to
above 40 dB. This highlights the importance of evaluating the
effective vent size for each individual tting instead of relying on
averages. In Compass GPS, this is done through the feedback test,
where the effective vent size is estimated and subsequently factored
into the prescription of gain by compensating for the individual’s VE.
This ensures that an individual with a larger-than-average effective
vent does not get too little gain in the low frequencies and a tinny
sound quality, while an individual with a smaller-than-average
effective vent does not get too much gain and a boomy effect.

In addition to these more general consequences, the observed VE—

even for the supposedly closed Double domes—may in many cases
be so large that listeners with relatively large low-frequency hearing
loss do not get the prescribed gain in the low frequencies. This
points to the advantage of using custom molds for such hearing
losses. This unintended venting will also have negative
consequences for low-frequency directional and noise-reduction
processing.

Implications for Sound Quality

A further crucial challenge for sound quality in open ts is the comb-
lter effect. As described above, this effect arises when the direct
sound that comes through any venting and leakage mixes with the
signal from the hearing aid, which is typically delayed between 2-8
ms due to the signal processing. Delays in the lower end of this
range, as is seen in the Widex EVOKE hearing aids, generally give
better sound quality, especially for own voice.5 However, even a
delay of a few milliseconds means that the direct and HA sounds
may be out of phase at certain frequencies, resulting in peaks and
troughs in the signal that resemble the teeth of a comb when plotted
as a gain-frequency curve. These distortions are most pronounced
when the two sound sources are of approximately equal amplitude,
which, depending on the ampli cation and the individual effects of
the HA ear tips, will typically be in the range from 500 Hz to 2 kHz.
Research on delays in hearing aids has focused primarily on
determining the upper delay limit within which HA sound quality is
tolerable,6-8 but even within this limit the artifact remains.

https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 6/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

The mixing of sounds will be most apparent with open ts, but as the
results reported above show, all the different ear tips may be
effectively open for the individual ear, so the risk of comb- ltering
compromising sound quality is quite substantial. A precise
estimation of the vent size will allow gain to be turned down in those
frequency bands that give the most pronounced comb- lter effects,
while leaving non-affected frequency bands unaltered; however, this
does of course need to be balanced with the aim of providing the
best possible audibility for the individual user.

Conclusion
In this article, we have demonstrated some of the challenges of
tting with instant- t ear tips, with a focus on the variation in direct
sound reaching the eardrum and in vent effects, both between ear
tips and between individual users. It is crucial that these acoustic
variations are considered during tting, both generally for the
different types of ear tips and speci cally for the individual HA
user’s effective vent size. This is important in order to be able to
provide the prescribed gain, but it also has great implications for
sound quality—both for the tonal balance (perceptions of tinny or
boomy sound quality) and for preventing the distortions that are due
to the comb- lter effect. This requires understanding the effects of
the speci c ear tip in the actual ear and recognizing that using an
“instant- t tip” cannot simply be an “instant tting,” but instead
requires individualization with the same care that is given to
prescribing gain.

References

1. Strom KE. Hearing aid sales increase by 3.8% in rst half of 2019.
July 17, 2019. Available at:
http://www.hearingreview.com/2019/07/hearing-aid-sales-
increase-3-8- rst-half-2019/

2. Kuk F, Nordahn M. Where an accurate tting begins: Assessment

of in-situ acoustics (AISA). Hearing Review. 2006;13(7):34-42.

3. Mueller HG, Ricketts TA. Open-canal ttings: Ten take-home tips.

Hear Jour. 2006;59(11):24-39.

4. Caporali S, Cubick J, Catic J, Damsgaard A, Schmidt E. The vent

effect in instant ear tips and its impact on the tting of modern
hearing aids. Poster presented at: International Symposium on
Auditory and Audiological Research (ISAAR), Nyborg, Denmark,
August 2019.

5. Groth J, Søndergaard MB. Disturbance caused by varying

propagation delay in non-occluding hearing aid ttings. Int J
Audiol. 2004;43(10):594-599.

6. Stone MA, Moore BCJ. Tolerable hearing aid delays. II. Estimation
of limits imposed during speech production. Ear Hear.
2002;23(4):325-338.

7. Stone MA, Moore BCJ. Tolerable hearing aid delays. IV. Effects on
subjective disturbance during speech production by hearing-
impaired subjects. Ear Hear. 2005; 6(2):225-235.

https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 7/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

8. Goehring T, Chapman JL, Bleeck S, Monaghan JM. Tolerable delay

for speech production and perception: Effects of hearing ability
and experience with hearing aids. Int J Audiol. 2017;57(1):61-68.

ABOUT THE AUTHORS: Laura Winther Balling, PhD, is an Evidence

and Research Specialist, Niels Søgaard Jensen, MSc, is a Senior
Evidence and Research Specialist, and Sueli Caporali, PhD, and Jens
Cubick, PhD, are Audiological Performance Specialists at Widex.
Wendy Switalski, MBA, AuD, is Director of Professional
Development at Widex USA.          

CORRESPONDENCE can be addressed to Dr Balling at:

laba@widex.com

CITATION FOR THIS ARTICLE: Balling LW, Jensen NS, Caporali S,

Cubick J, Switalski W. Challenges of instant- t ear tips: What
happens at the eardrum? Hearing Review. 2019;26(12)[Dec]:12-15.

SHARE:      

RATE:

 PREVIOUS NEXT 

Ida Institute Accepting Proposals for Diplomats Experiencing ‘Havana

2020 Research Grants Syndrome’ to Receive Bene ts

RELATED POSTS
https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 8/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review

INSERM Having Both NIDCD

Researchers Hearing and Campaign
Find Visual Aims to
Premature Impairments Protect
Directional Babies May May Lead to Tweens'
Hearing Have Elevated Hearing
Instrument Increased Dementia October 2, 2008
Buyer’s Risk of Risk
Guide Developmen July 10, 2020
tal Delay
October 4, 2001
September 2, 2017

Leave a reply
Your email address will not be published. Required elds are marked *

COMMENT

NAME * EMAIL * WEBSITE

POST COMMENT

SEARCH … MEDQOR MEDIA NETWORK RESOURCE CENTER

24×7 Webinars

Axis Imaging News White Papers

FOLLOW US
Clinical Lab Products Videos

Orthodontic Products

Physical Therapy Products

Plastic Surgery Practice HELPFUL LINKS

Rehab Management
Media Kit
RT: For Decision Makers in Respiratory Care
Subscribe
https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 9/10
10/08/2020 Challenges of Instant-Fit Ear Tips: What Happens at the Eardrum? - Hearing Review
Subscribe
Sleep Review
Contact Us

© 2020 Medqor | Advanced Healthcare & Technology Tools Privacy Policy Terms of Service Copyright

https://www.hearingreview.com/hearing-loss/patient-care/hearing-fittings/challenges-of-instant-fit-ear-tips-what-happens-at-the-eardrum 10/10