aids). When he bought his last hearing aid, however, I insisted that he get a telecoil (even though he hears quite well on the phone). Because I also wanted him to have an open canal fitting (which he loves), and I hoped that he’d be able to use a mini-BTE, I asked his audiologist to choose a mini-BTE that could accommodate a telecoil.

As a first step (toward using HAT), I bought him a personal communicator and a neckloop. Although this doesn’t offer the freedom and convenience of wireless technology, it’s a start. At home, he detaches the microphone and mounts it on the TV (a little plastic mount came as part of the package). The microphone plugs into the unit (which

looks something like a remote control) with a long cord. He plugs his neckloop into the unit and switches his hearing aid to the telecoil setting. He hears better and watching TV is more relaxing. In the car, he plugs the neckloop into the unit, and my mother attaches the microphone to her lapel. At church, he can plug the neckloop into the receiver for the assistive listening system. If he needs to, he can plug his neckloop into the phone. My next goal is to convince him to try an induction loop in the room where he and my mother watch television. With that, he could just walk into the room and switch his hearing aid to the telecoil setting.

Cochlear Implants and the Use of Hearing

Assistance Technology

Virtually all of the information in this chapter applies to cochlear implants as well as to hearing aids. All implants have DAI capability, meaning that they can be plugged into televisions, personal music players, computers, telephones, and other audio sources with special cables. All implants offer telecoil options that allow them to be used with hearing aid–compatible telephones and induction loops. Implants can be connected to FM and IR receivers with special cables; in some cases, FM receivers are built into the speech processor or connect to it with an adapter.

TELEPHONES AND TELEPHONE ACCESSORIES

The ability to communicate by telephone continues to be vitally important in our society. Unfortunately, it can be a formidable challenge for people with hearing loss (visual cues are unavailable, important frequencies are filtered out, volume may be inadequate). Fortunately, dozens of products are available to improve telephone communication. Some are meant to work with hearing aids, some are meant to work without them, and some can be used either way (which can be helpful when the phone rings in the

middle of the night or you’re just getting out of the shower). Others use a text format that makes the issue of hearing aids irrelevant.

Hearing Aid Compatibility

Holding a telephone handset over a hearing aid usually causes feedback. Telecoils were originally designed to improve telephone communication by minimizing feedback and room noise (the hearing aid microphone is turned off when a telecoil is used with a telephone). Telecoils were developed to take advantage of telephone technology that’s now obsolete. Years ago, magnets drove the speakers in telephone handsets, and some of the electromagnetic signal leaked out. The leaking signal could be picked up and amplified by a telecoil. As telephone technology improved, however, magnets were no longer used, and the electromagnetic signal disappeared. Eventually, telephones were no longer compatible with telecoils. The Hearing Aid Compatibility Act of 1988 required manufacturers to begin making landline phones (corded and cordless) that were compatible with hearing aids. As a result, virtually all modern landline telephones are now hearing aid compatible (HAC). Landline phones that are HAC contain electronics that generate an electromagnetic signal for telecoil use. Unfortunately, standards don’t regulate electromagnetic signal strength; therefore users must be careful to choose a phone that meets their particular needs (portable devices that amplify the electromagnetic signal are also available).

Landline Telephones

Listeners with telecoils achieve a direct connection with HAC telephones by switching their hearing aids to the telecoil setting and placing the handset over the hearing aid. It can take some experimenting to find the right spot for the handset relative to the hearing aid. Without a telecoil, using the telephone with a hearing aid is likely to cause feedback, although this is less likely with CIC hearing aids. It may be easier to remove the hearing aid and use a telephone with amplification. Hard-of-hearing listeners without hearing aids can also benefit from telephone amplification. There are several types from which to choose, with many models in each category.

In-Line Amplifiers

In-line amplifiers can be used with virtually all modular, corded telephones. Most telephones today are modular, meaning that the handset can be unplugged from the base. The curled cord attached to the handset plugs into the amplifier, and the amplifier plugs into the telephone’s base

Figure 9.10. Example of a Portable (Strap-on)

Telephone Amplifier. (Courtesy of Global

Assistive Devices, Inc. and Harris

Communications.)

the telephone to be used by people without hearing loss. Replacement handsets work with most modular corded telephones; however, they’re not compatible with trimline models in which the dialing mechanism is in the handset.

Portable Amplifiers

A portable amplifier is a small device with a volume control that fastens to the handset of a corded or cordless telephone with a strap. Most have volume controls so that they can be left on telephones used by people without hearing loss. In addition to amplifiers that boost the acoustic signal, there are also portable “induction amplifiers” that boost the electromagnetic signal.

Amplified Ringers

Special ringers are available for use with corded and cordless landline telephones. Most models offer some combination of a very loud ringer (with a volume control); ringer frequency options (the user chooses the frequency that’s easiest for her to hear); ringer pattern options (horn, siren, warble); and a flashing light, strobe, or vibrator that can be activated along with the ringer. The device plugs into a telephone outlet on the wall; at the other end, it plugs into a jack on the base of the telephone.

Amplified Telephones

Stand-alone telephones have been designed especially for people with hearing loss. Both corded and cordless models are available, and they’re all HAC. These telephones increase the voice signal by as much as 55 dB and provide a strong electromagnetic signal for telecoil users. They come with any combination of standard telephone features that a user might want. In addition, most offer options such as a very loud ringer; ringer frequency choices; and a flashing light, strobe, and/or vibrator to announce incoming calls. Some have oversized, easy-to-read, easy-to-push buttons. Many have volume controls, some have tone controls, and a few have controls that mute the handset microphone while the user is listening. Some have a built-in speakerphone, which eliminates feedback from the hearing aid. Some have an emergency call button.

Almost all specialty telephones have one or two headset jacks into which the user can plug a headset, neckloop, silhouette, DAI patch cord, personal communicator, or cochlear implant. Using one of these accessories gives the listener a direct, hard-wired connection to the telephone that eliminates feedback and reduces room noise. Some accessories (for example, headsets and neckloops) allow input to both ears, which can be especially helpful to listeners with hearing loss. Many models also include answering machines. Plugging an accessory device into the telephone’s headset jack also allows the listener to hear messages through a direct connection, perhaps with both ears.

Specialty telephones generally accommodate Caller ID, a service offered by telephone service providers for a monthly charge. Although this service may be nothing more than a convenience for people with normal hearing, it can be critically important for people with hearing loss. People who are hard of hearing often have difficulty recognizing voices over the phone. Knowing who’s calling can eliminate the initial confusion and provide enough context to make understanding the conversation easier.

Digital Cell Phones

A cell phone offers advantages to people with hearing loss. First, it has a headset jack that allows the user to connect an accessory device (for example, a hearing aid with DAI, a cochlear implant processor, a neckloop, a silhouette, or a personal communicator) to create a direct, hard-wired connection. This allows the phone to be separated from the hearing aid, minimizing feedback and interference. Some cell phones offer Bluetooth capability (see later discussion), which goes a step further and creates a direct, wireless connection between a cell phone and hearing aids that are Bluetooth enabled. Most cell phones have volume controls, ringer options, and adjustable ringer volume. In addition, most offer a vibrating signal or flashing screen to announce incoming calls. Some offer email, instant

messaging, and text messaging—visual communication options that can be especially helpful to users with hearing loss. Most can accommodate Caller ID (for an extra charge from the service provider). Some have speakerphone capability (again, increasing the distance between the phone and the hearing aid, thereby minimizing feedback and interference).

Cell phones originally were exempt from the Hearing Aid Compatibility Act of 1988. As they became ever more popular, however, people with hearing loss complained of interference when they tried using them with hearing aids. As it turns out, a transmission technology used by digital cell phones produces radio frequency (RF) emissions that can be picked up by a hearing aid as buzzing. In 2003, the Federal Communications Commission (FCC) ordered cell phone manufacturers and service providers to begin addressing hearing aid compatibility for cell phones. For cell phones, HAC was defined in terms of RF emissions as well as telecoil compatibility. Today, all major cell phone manufacturers are required to make some models that are HAC.

The FCC requires cell phone manufacturers to rate (1) how well a cell phone works with hearing aids in the microphone (nontelecoil) mode, and

(2) how well a cell phone works with telecoils. The rating scale ranges from M1 to M4 for compatibility in the microphone mode and T1 to T4 for compatibility in the telecoil mode. A rating of 1 (M1 or T1) is poor, 2 is fair, 3 is good, and 4 is excellent. Only phones rated 3 or 4 can be labeled HAC.

Newer hearing aids are rated on the same M1 to M4 and T1 to T4 scales. Unfortunately, labeling hearing aids with M and T ratings is not mandated by law. If the hearing aid that you’re considering buying doesn’t carry a rating, your audiologist may be able to obtain it from the manufacturer.

To select the best cell phone–hearing aid combination, add the M ratings for microphone mode or T ratings for telecoil mode. Look for a combined rating (cell phone + hearing aid) of M5 or M6, or T5 or T6. A rating of 5 should provide good performance; a rating of 6 should provide excellent performance. Despite the best intentions of the FCC and cell phone manufacturers, however, ratings do not guarantee performance. It’s still necessary to try a cell phone with your hearing aid before purchasing it.

Specialty cell phones designed for people with hearing loss are also becoming available. These HAC phones offer up to 50 dB of amplification.

Things to Look for When Shopping for a Digital Cell Phone

A full-service store owned and operated by a wireless service provider; these stores must allow you to try different cell phones with your hearing aids. Regulations do not require general retailers like Radio Shack, Best Buy, and Wal-Mart to do so.

A store with a clear return or exchange policy that is provided in writing

A knowledgeable sales person who can answer your questions about HAC

Packaging that identifies the cell phone as HAC

A rating of M3 or M4 if you use hearing aids without telecoils, or T3 or T4 if you use hearing aids with telecoils

Literature on the cell phone and its HAC

A cell phone with output jacks and accessories that allow you to listen with both ears

A cell phone with a volume control

A cell phone with a vibrating alert or flashing screen in addition to a ringer

A cell phone with a variety of ringer or tone pattern options

A cell phone with adjustable ringer volume

A cell phone with text messaging, instant messaging, and email

A cell phone with speakerphone capability (increased distance between the hearing aid and telephone reduces feedback and interference)

A cell phone that can be connected to a teletypewriter (TTY) if the user uses a TTY to make or receive calls (see later discussion)

A cell phone with video streaming (if needed to communicate with sign language)

A cell phone with the ability to control backlighting (telecoil users can get interference from things like a phone’s backlighting, antenna, keypad display, battery, or circuit board)

A “flip” or “clam shell” cell phone; this style sometimes works better because the hearing aid is farther from internal sources of interference

A cell phone with good reception; HAC cannot improve the reception of the phone itself

Bluetooth Solutions

Bluetooth is networking technology that allows electronic devices to find and communicate with one another, without wires, cables, or line-of- sight requirements. Bluetooth technology is inexpensive, power efficient, portable, and highly resistant to most forms of interference. It’s a feature that’s increasingly found in cell phones and a growing number of other devices, such as fax machines, personal data assistants (PDAs), digital cameras, music players, computers, and computer peripherals (for example, keyboards, mice, and printers). In early 2007, there were more than 1,000 Bluetooth-certified devices on the market.

A Bluetooth-enabled device contains a microchip that makes wireless communication with other Bluetooth-enabled devices possible. The Bluetooth protocol was developed collaboratively by a group of electronics manufacturers in the late 1990s. The working group needed a code name for the technology that was under development. A comparison was made to Viking King Harald Blatand—in English, King Harold Bluetooth. King Bluetooth is remembered for uniting warring factions in what is now Denmark, Norway, and Sweden during the tenth century. The King’s ability to connect many different tribes to form his kingdom parallels Bluetooth’s

settings programmed by the audiologist. A microphone on the device picks up the user’s voice and sends it back to the cell phone. When the call is finished, the Bluetooth connection ends, and the hearing aid microphone is reactivated. The only time that the user needs to touch the phone is to dial. Feedback and interference are eliminated because the phone is separated from the hearing aid. The same device is also designed to receive signals from a wireless microphone/transmitter that can be worn by a companion in a noisy place. This option makes it similar to a personal FM system, but smaller and less expensive. If the user doesn’t have a Bluetooth-enabled phone, a Bluetooth adapter can be attached; the same is also true for other audio devices.

If the user’s hearing aid doesn’t have DAI capability but it has a telecoil, a neckloop with a Bluetooth device allows the cell phone’s output to be picked up by the telecoil. The connection between hearing aid and cell phone is still hands free and wireless (Figure 9.12, upper left). This option also allows custom (non-BTE) hearing aids with telecoils to be compatible with Bluetooth-enabled devices.

Alternatively, a hand-held FM transmitter with Bluetooth capability can receive a signal from a Bluetooth-enabled phone and transmit it (using FM radio waves) to BTE hearing aids that are equipped with integrated FM receivers or FM boots (see Figure 9.12, upper right). Again, the problems of feedback and electromagnetic interference are eliminated because the hearing aid is separated from the cell phone. The user speaks directly into the hand-held FM microphone/transmitter, and the caller’s voice is heard through the hearing aids. The cell phone is needed only to initiate and terminate calls. The FM microphone/transmitter can also be used as part of a personal FM assistive listening device.

Also available are streamers that receive Bluetooth signals from external devices (including cell phones) and wirelessly stream them to the hearing aids that go with them (see Figure 9.12, bottom). The streamer hangs around the user’s neck. Some devices offer one channel of sound that goes to both ears; others offer stereo sound.

The future will undoubtedly bring other ways to create wireless connections between hearing aids and Bluetooth-enabled devices. It’s even possible that Bluetooth technology may someday be integrated inside hearing aids, eliminating the need for a DAI connector or other accessories. In the shorter term, we’re likely to see Bluetooth transmission incorporated into the assistive listening systems found in public facilities.

Devices like the Bluetooth boot adapter, the Bluetooth neckloop, the Bluetooth-enabled FM microphone/transmitter, and the Bluetoothenabled streamer are innovations designed to allow hearing aids to function as wireless headsets for audio devices (like cell phones). And there are already wireless headsets that function as hearing aids! These headsets have been designed to provide amplification (which can be customized to some extent) when the listener isn’t talking on the phone or using another electronic device. What’s more, high-tech hearing aids

Figure 9.12. Upper left, Bluetooth device attached to a special neckloop that makes all hearing aids with telecoils Bluetooth compatible. Upper right, Bluetooth-enabled FM microphone/transmitter shown with compatible BTE hearing aids that have FM receivers attached. The Bluetooth signal is picked up from an external source by the microphone/transmitter and sent to the hearing aids via FM. Bottom, Bluetooth-enabled “streamer” that transmits the signal from an external source to compatible BTE hearing aids. (Courtesy of Starkey Laboratories, Inc. [upper left], Phonak [upper right], and Oticon, Inc. [bottom].)

and wireless headsets are looking more and more alike—in some cases, even audiologists can’t tell them apart.5 As more people without hearing problems wear devices in their ears to communicate with their audio equipment, the distinction between hearing aids and other types of hearing technology is becoming blurred.6 In fact, we could be seeing the beginning of a convergence between high-tech wireless systems and hearing aids.7

Figure 9.13. Can You Tell Which Are Hearing Aids and Which Are (Wireless) Bluetooth Headsets? (Answer: Upper and lower right are hearing aids; upper and lower left are headsets.) (Courtesy of Plantronics, Inc. [upper left], Bernafon, LLC [upper right], GN Netcom [lower left] and Phonak [lower right]).

Listeners with severe and profound hearing loss might need something more, but those with mild or moderate hearing loss might be able to use wireless headsets for the telephone, watching TV, and listening to music, and for customized (hearing aid) amplification. Just as some people wear sunglasses that are prescriptive, some people might wear wireless headsets that are prescriptive.8 Hearing aids will be “hiding in plain sight,” and the stigma attached to wearing them should disappear.9 Perhaps wearing hearing technology is finally becoming fashionable!

Text Telephones

Text telephones are commonly known as TTYs (TeleTYpewriters). An older term is Telecommunication Device for the Deaf (TTD). This term has been replaced because text telephones are actually used by people with varying degrees of hearing loss. A TTY functions as a typewriter that can send and receive messages over telephone lines. A user types the message to be sent on a TTY keyboard; when a message is received, words print out across a screen or on paper (depending on the model). When both parties are

Figure 9.14. Example of a TTY with an Acoustic Connection and Printer (located under the handset). (Courtesy of Ultratec, Inc. and Harris Communications.)

using TTYs, conversations occur in text rather than voice. Many businesses and most government agencies have TTYs for communicating with their patrons who use them; look for a TTY number where the voice telephone number is listed.

There are two types of TTY connections: acoustic and direct. Some TTYs have rubber cups into which the handset of a landline telephone is placed to form an acoustic connection. In other cases, a TTY plugs into a phone jack to achieve a direct connection. A direct connection eliminates room noise and offers more features, but occasionally there are digital–analog compatibility issues that don’t exist with an acoustic connection. Some models accommodate connections of both types.

Dozens of TTY models and feature combinations are available. Some models are designed to work with traditional, corded telephones; some can also be used with cordless phones and TTY-compatible cell phones. Other TTY models are stand-alone units meant to be used in place of a voice telephone.

Some models contain printers, text answering machines with personalized text greetings, and alerting devices to signal incoming calls. Some include a screening system that addresses incoming voice calls. The screener responds to a voice call with a voice message telling the caller that he has reached a TTY and explaining how to contact a Telecommunications Relay Service (see later discussion). Some models offer a 911 emergency dialer that sends a prerecorded voice message informing the operator that the caller has a hearing loss. Some models can accommodate Caller ID. Some are small, lightweight, and designed to be portable.

Figure 9.15. Example of TTY with a Direct Connection and Printer. (Courtesy of Ultratec, Inc. and Harris Communications.)

TTY–Computer Communication

Some TTYs (ASCII-equipped) can communicate with any computer; the computer needs no special hardware or software. Alternatively, by adding special software and a special modem, a computer can be modified to function as a TTY (and receive calls from other TTYs).

Telecommunications Relay Services

When both parties have text telephones, messages can be typed and read back and forth. When one party uses a TTY and the other uses a voice telephone, however, a Telecommunications Relay Service (TRS) is needed. Let’s say that you’re a TTY user and you want to order a pizza (or chat with a friend or call your babysitter). You contact a relay service by dialing 711 (nationwide) and type your message. The message is received by a Communication Assistant (CA) with access to both a voice telephone and a TTY. The CA dials your favorite pizza place and reads your message to the person who answers the phone (converting it from text to voice). The CA then types the pizza person’s voice response (converting it from voice to text) and sends it to your TTY. The conversation continues with the CA converting text to voice and voice to text. The CA is required to repeat exactly what has been said or typed and must keep all conversations strictly confidential. Calls can be initiated by either the TTY or voice telephone user.

Title IV of the ADA requires all telephone companies to provide local and long-distance relay services (see Chapter 10). Service providers must make

information about their relay services available to the public. The service must allow text telephone users to communicate with people anywhere in the United States at any time (24/7). There can be no restrictions on the number of calls made, the length of calls, or the nature of conversations. Services are free, although typical long-distance charges apply. If you need special equipment or computer modifications (discussed later), they may be free as well; check with your state’s agency or commission for deaf and hard of hearing people.

Internet Protocol Relay Service

Internet protocol (IP) relay users connect to a CA using the Internet rather than a telephone. To initiate a call, the user goes to an IP relay center’s website and types the number she wishes to reach. A CA dials the number and converts text to voice and voice to text. Because calls are made over the Internet (rather than telephone lines) all calls, even long-distance calls, are free. IP relay is available to anyone with Internet access from a computer or another Internet-enabled device. This eliminates the need to buy or access a TTY. For some, using a computer screen and keyboard is faster, easier, and more familiar than using a TTY.

Video Relay Service

Sign language users can use the Internet to connect to a video relay service. Users typically use a personal computer equipped with a web camera and video conferencing software. The relay center is staffed with sign language interpreters who translate sign language to voice and voice to sign language.

Voice Carry Over Relay Service

Voice carry over (VCO) is a relay option that allows callers to use their own voices to send messages, but to receive messages in writing from a relay service. This makes relay calls quicker and more natural, especially for users who’ve lost their hearing later in life and have speech that’s easy to understand. A VCO call can be made to a person who’s using a traditional voice telephone. In this case, the user speaks and the CA converts the other party’s voice response to text that’s displayed on the screen of the user’s VCO phone. A call can also be made to a TTY user, in which case the VCO user speaks and the CA types the conversation for the TTY user. The TTY user types her response directly to the VCO user. A VCO user can also call another VCO user; in this instance, both parties speak and the CA types both sides of the conversation. Special types of VCO arrangements (requiring the user to have two telephone lines) allow the user to hear voice messages as well as read them, although the written message is delayed slightly relative to the voice message.

Figure 9.16. A VCO Telephone Allows the User to Communicate by Speaking and Reading. (Courtesy of Clarity, a Division of Plantronics, Inc).

Captioned Telephone Service

This service allows the user to both hear and read the other party’s words on a special phone. Speech recognition software is used to create captions in real time. A captioner (at the captioning relay center) repeats what the other party says into a microphone, and speech recognition software converts it into text. Users can listen and read the captions simultaneously or refer to the captions only when clarification is needed.

Internet-based Captioned Telephone Service

More recently, Internet-based captioned telephone services have become available. In this case, a user can read captions on a web browser while listening to the caller’s words on a telephone. No special equipment is needed, just a computer with Internet access and a phone (which may be a cell phone).

Telephones in Public Places

Pay telephones and emergency telephones are required to be HAC, which means they must work with telecoils. For people without telecoils,