1. Audiology Now 64 42 www.audiology.asn.au
KEITH CHITTLEBOROUGH
Connect Hearing,
Melbourne, Victoria
THE CLIENT
In 2011 CM, a 39 year old female,
attended the practice in response to
advertising for Lyric™, a hearing device
manufactured by Phonak and then
available in Australia for only a few
months. CM presented with a
progressive sensorineural hearing loss
of unknown aetiology, of a moderate
flat severity. She first noticed her
hearing deteriorating around age 22,
but was only fitted 3 years prior with
CICs by another provider. She reported
that the perceived cosmetic and social
stigma of hearing aids had prevented
her from seeking amplification, despite
working in a heavily communicative
occupation, but the needs of her office
job finally forced her to take action.
Lyric offered her an invisible hearing
solution, which was her primary driver,
but she was also dissatisfied with the
sound quality of her CICs in noise,
opting to remove them in noisy
environments like restaurants. This
part time use would often extend to
the home environment where it had
impact on her relationship with her
partner.
SIZE AND FITTING OF LYRIC 1
CM's ear canal suitability was assessed
using medical microscopy (Kaps SDM
60); this provides significantly improved
visualization due to greater
magnification and illumination
compared to standard otoscopes, but
also far better depth perception as it
utilizes binocular vision. I look for
factors that affect fitting, such as the
curvature of the canal, bends and
narrowing, the slope of the tympanic
membrane (many have up to a 45
degree slope which effects insertion
depth) and exostoses. I also look for
the presence of any medical contra-
indicators, such as ear pathology
(perforation, fungal spores,
cholesteatoma etc.), self-induced canal
abrasion and cerumen.
In CM's case one ear canal was wax
occluded from CIC and cotton bud
usage, for which we referred her to her
GP to be removed. It would later
become standard practice to remove
cerumen in clinic, by a combination of
curette and vacuum suction, the latter
is best as it causes the least skin
irritation and can be used deep within
bony portion of the ear canal. With the
magnification power, illumination and
binocular depth perception of the
medical microscope, it is possible to
safely remove cerumen directly off the
tympanic membrane. This has
improved our Lyric fitting proficiency,
but has also benefitted other patients
in need of cerumen and foreign object
removal, mastoid cleaning or discharge
maintenance.
Post CM's wax removal, I measured
canal length with a soft depth probe
that touches the tympanic membrane
(as superior as possible as slopes
increase proximity). In CM's case her
ear canals were oval, with a moderate
curvature, and she had a depth of
24mm from tympanic membrane to
opening of the auditory meatus (a
4mm insertion depth, Lyric 1 being
16mm long). Dummy devices were
inserted to test size and, due to the
narrowness of her canals, the smallest
Lyric size (S-S) was selected.
Insertion was completed to the
measured depth, using glycerine
lubricant and Lyric forceps (a tool with
depth gauge that, by measuring off the
opening of the meatus, allows us to
place a Lyric 4mm from the tympanic
membrane). There was initial mild pain
on insertion which quickly subsided, at
the time this was considered
acceptable. It is not. Pain was a side-
effect of our early insistence on depth
placement and poor fitting technique.
Case Study:
A Five Year Patient
Journey with an Extended-
Wear Hearing Aid
Above/ Audiogram
Above/ Keith Chittleborough

2. info@audiology.asn.au 43 Audiology Now 64
It takes approximately 30 + insertions
before a Lyric clinician develops full
technical proficiency. With experienced
clinicians, in most cases clients barely
feel Lyric being inserted, even the first
time.
Lyric was now in her canal and
amplifying. No modification of the first
fit parameters were necessary. She
reported a very 'natural' sound quality
compared to her CICs, good volume
and less abrasive. Appearance: a truly
invisible device. She was extremely
pleased-this, however, was to change.
MIGRATION AND SUPPURATION
CM contacted us several days later
reporting her devices had migrated
from her ear canals until the lateral
portion of the device was visible.
Devices were removed, canals checked
for any sign of trauma, and then Lyric
was reinserted to previous depth, using
no glycerine in an attempt to allow
more grip. Greater insertion force was
used.
CM reported a week later that one ear
was mildly sore, that the device felt
'squishy' and had stopped amplifying.
Both devices had migrated again, but
not as severely. Removal showed her
ear canal with the dead device to be
wet with white viscous material and
bloody on the inferior canal. The
medial foam seal on the Lyric was
blanched. Moisture had apparently
caused the device failure and the
swelling of the medial seal had caused
the pain. The bleed may have been
caused by CM who admitted to
manipulating the devices, but it was
also likely to be result of removal of a
device under moderate suction bound
to a wet, weak canal.
At the time we thought the wetness
was due to water passing into the ear
from showering. We were later to
determine it was instead a by-product
of a reduced 'moisture vapour transfer
rate.' The ability of internal humidity to
pass out through the foams seals can
be compromised in tight fittings, deep
fittings, in humid environments and
with certain clients. The resultant white
porridge-like substance is what we call
'non-infectious otitis externa.' To an
untrained eye it could be diagnosed as
an infection, but there is no intrinsic
pain (unless skin is damaged) and is
mainly water mixed with skin cells,
reactive secretions and intrinsic
microbiota (which can give it a pungent
scent, but not foul), and will disappear
naturally in a matter of days without
intervention (quicker if removed by
vacuum suction).
CM was not concerned about the ear
injury or device failure, but was instead
upset that we had to remove the
device. Given the migration issues and
canal trauma, CM was advised that
Lyric 1 was simply too big for her
anatomy. Alternative cosmetic hearing
solutions were offered, such as IIC/
micro-CICs, that were smaller than her
current CICs, but this was rejected-she
wanted Lyric. However, it was not
thought a viable or clinically safe
option. CM was upset to the point of
tears, something I had never seen
before-a patient crying when I said they
couldn't have a hearing aid.
Fortunately, Lyric version 2.0's launch
was on the horizon and I was able to
console her with the possibility of a
future fitting of a reportedly smaller
device. The client opted to continue
using her older CICs and wait. 8
months later, she returned.
SIZE AND FITTING OF LYRIC 2
2012 brought Lyric 2 which, compared
to 1, was 4mm shorter and significantly
reduced in both the diameter of the
core and thickness of the foam seals.
Client measured at 8mm insertion
depth and the smallest size device (XS)
was inserted to 6mm only due to
narrowing of canals. There was minor
migration of 1mm after one week, the
Lyric finding its 'sweet spot.' There
were no further complications. CM was
wearing the devices full-time, enjoying
the freedom of not worrying about her
aids, and, after minor subjective adjusts
to her amplification she was very
positive in regards to the Lyric sound,
even in background noise. The depth
of placement of Lyric theoretically
allows the Lyric to capture spectral
transformations of the pinnae and
canal, and, with its simple analogue
processor, deliver a sound quality that,
to many clients, is preferable to
standard digital devices.
CM signed and paid for a one year
contract, which entitled her to 7
devices per ear and all the audiological
services. We planned to see her every
3 months for device replacement, but
this was not to be.
DEVICE LIFE EXPECTATIONS
We had the expectation that devices
would last up to 4 months of reported
battery life. However, CM would
invariably contact us much earlier
reporting her devices were dead.
Devices generally lasted less than 2
months. Sometimes they appeared
slightly wet but often with no sign of
damage to the devices. CM was
frustrated, as were we. All measures
for care in shower were undertaken.
Ultimately, we concluded this reduced
device life is caused in part by reduced
moisture vapour transfer rate in a tight
fitting (coupled with normal
manufacturing variance).
What we learnt from this is to expect
the unexpected with Lyric and to
compensate clients with a same day
VIP service for replacement devices, as
we could not predict device longevity.
This customer service delivery would
become paramount in 2013-14 as the
latter versions of 2.3 (last of Lyric 2)
became increasingly unstable. A core
component, the 'reed switch' (a
magnetic pick-up for programming and
client adjustment), planned to be
phased out in 3.0, was no longer being
produced. The old stock being utilized
meant device life expectation dropped
dramatically due to intrinsic early
device failure, sometimes in a matter of
hours after fitting.
This was managed in CM's case with
honesty about the device. While she
became frustrated at times when what
she had taken to calling 'my ears' failed
her, on our part understanding,
explanations and flexible service
delivery did a lot to alleviate her
distress and she continued to renew
her subscription each year.
LYRIC 3.0 AND THE NEW ANALOGUE
PROCESSOR
In 2014 Lyric 3.0 arrived with a newly
designed analogue microchip and the
reed switch replaced with Phonak's
more reliable GMR. This reduced the
rate of early device failures. 3.0's new
amplification programming was based
off NL2 with a greater high frequency
Above/ Lyric

3. emphasis than before, the aim to have
more high frequency clarity. However,
as with any long term user of a
product, adaptation to a new sound is
often difficult. Many clients reported
Lyric 3.0 to be a sharper, clearer
device, but CM did not.
Her initial reports were that the sound
was 'off.' Not as clear. Gain
adjustments were completed. She
came back early several times, a few
days apart, to try different parameters.
The compression characteristics were
altered and, after an adaptation period,
she became used to the sound
(although, it was still 'not as good' as
Lyric 2). At this time CM was also the
first client to discover that the GMR
was too sensitive and the t-coil in her
work phone was adjusting her device
(essentially turning it off). Unable to be
fixed, she replaced her work phone.
The learning derived from CM's
experiences was disseminated back to
the manufacturer's reps and through
the Lyric fitting network in order to
facilitate better practice. While CM was
annoyed by the sound and phone
issues, we made sure her opinion was
valued, communicated, and this made
her feel a part of the pioneering
process of Lyric.
LYRIC 3.1 AND THE IMPROVED
PROCESSOR
2015: It was a long wait for Lyric 3.1
due to intensive testing by the
manufacturer to determine why 3.0's
new chip had not worked as well as
expected. Ultimately, it came down to
the compression characteristics-3.0
was too aggressive and the MPO too
low. Fixing this resulted in immediately
improved subjective client responses
from those finding 3.0 'off,' as it did for
CM. The GMR over-sensitivity was also
corrected.
Device longevity by this point had also
increased for CM. We were often
seeing 3+ month durations between
visits. This may be due to dual factors
of improved device reliability (newer
technology, ever-tightening
manufacturing controls) and perhaps
an improved homeostatic balance
within the ear itself, the ear had 'gotten
used to' a foreign object.
LYRIC VERIFICATION
It is often asked how we verify.
I program the device based off
subjective preferences for practical
reasons. However, certain verifications
can be completed and are of interest.
REIG
The benefit of REIG testing for an
extended wear device is questionable,
as the targets are based on WDRC
digital devices and not deep fit
analogue devices, so there is no truly
valid scientific target. However, as can
be seen, the frequency response of
Lyric is not unexpected and follows
NAL NL2 closely. I personally do not
use this in standard practice because
in my opinion it is both uncomfortable
and time consuming, without providing
sufficient benefit.
SPEECH TESTING
A speech evaluation is not used
regularly, although it can be useful for
client demonstration purposes and for
trouble shooting. AB words significantly
improve and BKB shows acceptable
understanding in challenging (+10)
signal to noise ratios.
CONCLUSION: WHY EXTENDED-
WEAR HEARING AIDS MATTER
CM's patient journey reflects the
pioneering of Lyric, not only has the
device changed, but the way we
delivered patient care as well. There
have been numerous setbacks and
challenges with the device, times when
as a clinician I felt out of my depth,
questioned whether Lyric as a product
was all too hard, whether even the
cost-benefit of the time involved was
justified. In the end, personal
inclinations pale into comparison of
what really mattered: making it work
for the client.
Our patient, CM, continues to wear
Lyric 3.1 and in 2016 is on her fourth
consecutive year of subscription
contracts. She tells us she would never
go back to daily-wear devices. Her story
is not an isolated one; CM is now just
one of hundreds of Australian clients
wearing Lyric who wouldn't otherwise
be benefitting from amplification.
A final thought: I think we as clinicians
can often downplay the desire of many
patients for a more 'invisible' hearing
solution, superimposing our own
audiological opinions on a pervasive
stigma - we see cosmetic fear as
irrational, as 'vanity,' as something
where the patient should change,
rather than ourselves as healthcare
providers. The social fear of wearing
hearing aids, while especially strong in
our younger patients, is present in
almost all of our clients, regardless of
age, gender or ethnicity, and perhaps
these fears deserve greater
acknowledgement.
The long latencies between patients
noticing a hearing problem to seeking
treatment (in CM's case 17 years), and
often low wearing compliance, are due
in part to the stigma and practical
drawbacks of the standard hearing
devices we're offering. Given the
recognised links between amplification
and cognition over the lifespan, I think
Lyric, and perhaps other extended-
wear hearing aids yet to be developed,
fill an essential audiological and patient
need both now and into the future.
I'd like to acknowledge Brooke Hanby,
Phonak's Audiology & Business
Development Manager - Lyric, for her
assistance and unwavering support.
Above/ REIG Lyric
info@audiology.asn.au 45 Audiology Now 64