Changing mindsets on hidden hearing loss: The case for early intervention

As audiologists, one of the most challenging conversations we have is with patients who struggle to hear in background noise but present with normal or mild audiometric thresholds. For many years, we lacked clear answers for these patients. How do we tell someone, “I believe you, but your tests are normal”? More importantly, how can we help them?

Understanding hidden hearing loss (HHL)

A relatively new term in audiology, hidden hearing loss (HHL) describes individuals who experience significant difficulty understanding speech in noisy environments, following conversations with multiple speakers, or managing listening fatigue—despite having normal or mild audiometric thresholds.

Simply put, these patients struggle more than would be expected based on their audiogram results.

HHL is distinct from central auditory processing disorders, as it originates from defects in the cochlea and other peripheral auditory pathways. While the mechanisms underlying HHL are not yet fully understood, research suggests multiple contributing factors.

Early studies pointed to the loss of inner hair cell (IHC) synapses as a primary cause. More recent research, such as that by Kohrman et al., has expanded this understanding by identifying transient loss of cochlear Schwann cells and demyelination processes as additional contributors.^1-2

What can we do for patients with HHL?

When a patient sits in front of us, seeking help for their struggles, the crucial question becomes: Is there evidence supporting any particular treatment approach for HHL?

Fortunately, yes.

Timmer and colleagues explored whether individuals with mild hearing loss use hearing aids differently than those with moderate loss.³ Their study analyzed data from 16,766 fittings across 159 clinics in four countries, focusing on 8,489 bilateral fittings. They utilized objective hearing aid data logging to track daily use.

Key findings:

• Individuals with mild or moderate hearing loss used their hearing aids an average of 8.5 hours per day.
• Those with moderately severe hearing loss used them 9.0 hours per day.
• The study found no significant difference in hearing aid use between individuals with mild and moderate hearing loss.

The takeaway for clinicians

This research provides compelling evidence that clinicians should not hesitate to recommend hearing aids to motivated individuals experiencing difficulty, even if their audiogram appears normal or only mildly affected. Patients with HHL may benefit just as much as those with more traditional hearing loss.

By recognizing and addressing HHL, we can move beyond telling patients, “Your hearing is fine,” and instead provide them with real solutions that improve their quality of life.

Clinical strategies for managing HHL

Recognizing HHL is the first step, but how can you actively support these patients? Here are some evidence-based strategies:

1. Comprehensive case history and counseling

• Ask detailed questions about real-world listening challenges, particularly in noise.
  
• Validate patient concerns—acknowledging their struggles can help build trust and engagement.
  
• Educate patients about hidden hearing loss, explaining that hearing difficulties aren’t always reflected in an audiogram.

2. Early intervention with hearing technology

• Hearing aids and assistive devices: Amplification and directional microphones may help patients struggling in noise, even with normal thresholds.
  
• Remote microphone systems: Wireless microphone technology, like Roger™ technology, can enhance speech clarity in difficult listening environments.

4. Monitor & follow-up

• Set up regular progress evaluations to track changes in hearing and listening ability.
  
• Adjust treatment plans as needed, ensuring patients receive continuous support rather than a “wait and see” approach.

By shifting our approach and acting early, we can make a meaningful difference in the lives of patients with hidden hearing loss.

Discover how Phonak hearing solutions, including advanced hearing aids and Roger™ technology, can help individuals struggling with hidden hearing loss. Click here to learn more.

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References:

1. Kohrman, D. C., Wan, G., Cassinotti, L., & Corfas, G. (2020). Hidden hearing loss: A disorder with multiple etiologies and mechanisms. Cold Spring Harbor Perspectives in Medicine, 10(1), a035493. https://doi.org/10.1101/cshperspect.a035493
   
2. Budak, M., Grosh, K., Sasmal, A., Corfas, G., Zochowski, M., & Booth, V. (2021). Contrasting mechanisms for hidden hearing loss: Synaptopathy vs myelin defects. PLoS Computational Biology, 17(1), e1008499. https://doi.org/10.1371/journal.pcbi.1008499
   
3. Timmer, B. H. B., Hickson, L., & Launer, S. (2016). Hearing aid use and mild hearing impairment: Learnings from big data. Journal of the American Academy of Audiology.