Behind the Ear vs In the Ear Hearing Aids Intro

There is an often-cited statistic in the field of audiology that people wait an average of seven years from the time they notice they have difficulty hearing to when they pursue hearing aids. Why so long? Patients have a variety of reasons for putting off the inevitable. One sign it’s time to pursue hearing aids is when you find yourself withdrawing from social gatherings or avoiding other activities where listening might be a struggle.

There is a very strong link between hearing loss and dementia, which is believed to be related, in part, to the social isolation that can occur as a result of hearing loss. Hearing aids can give you the confidence to re-engage in social situations which is a positive for your mental and physical health. Hearing aids can restore confidence in your ability to stay active and in communication with others on a daily basis.

There are several different styles of hearing aids, the choice of which can be dictated by your type and degree of hearing loss, your audiologist’s recommendation, and your personal preference, among other factors. This article will focus on some of the factors and differences between behind-the-ear (BTE) versus in-the-ear (ITE) styles.

Behind the Ear (BTE) Hearing Aids

BTE hearing aids have two main components. The first is the hearing aid itself, which includes the microphones and the electrical components as well as the battery. This portion comes in a variety of sizes depending on the power required based on the degree of hearing loss. BTE hearing aids can be rechargeable or use disposable batteries in different sizes, again depending on the power requirements. 

The second main component of a BTE hearing aid is the earmold. Your audiologist will have taken an impression of your ear for a custom earmold, which may come in a variety of materials such as silicone (soft) or acrylic (hard) and may fill your entire concha or just a portion. A soft tube will connect the earmold to the hearing aid itself, and this tubing (and possibly the earmold) will be replaced regularly. The intervals for replacement will depend on the patient’s body composition, the climate, and how much wax is present in the patient’s ears.

One advantage of BTE hearing aids is that they are appropriate for all degrees of hearing loss. For many adults, audiologists will recommend a receiver-in-canal or receiver-in-the-ear (these are synonymous) style for patients with lesser degrees of hearing loss in the low frequencies. That said, a BTE hearing aid can also be fit with varieties of earmold shapes and venting to accommodate any degree of hearing loss. 

Hearing aids that sit behind the ear, including the receiver-in-canal styles, often have superior performance in noise because of the way the microphones are positioned. The devices have a front microphone which sits on the top of the ear, and a rear microphone that is further back. The directional microphone technology is what allows patients to hear speech more clearly in the presence of background noise. The rear microphone can suppress noise from the back while the front microphone focuses on speech to the front.

BTE hearing aids are considered the most durable style of hearing aid because all of the electronics are housed behind the ear and thus are protected from cerumen (earwax) and the sweat and humid environment of the ear canal. Children are fit with BTE hearing aids for this reason, and because the earmold and tubing can be regularly, and inexpensively, changed to accommodate growth and wear and tear. While inserting hearing aids properly can be a challenge early on, BTE hearing aids are often the easiest to learn.

Some find it helpful to put the hearing aid over their ear first to orient it properly, while others prefer to insert the earmold first and then simply hang the hearing aid over their ear once the mold is in properly. To insert the earmold, you’ll pull up and back on the helix portion of your ear, as this will straighten your ear canal and make it easier to insert the tip of the earmold into your ear. You’ll then turn the earmold toward the back of your head to seat it into your concha.

You may need to wiggle it a bit to get it into the right spot, and when you do, there should be no discomfort and it shouldn’t be protruding out of your ear. The hearing aid itself can then be hung over your ear by the tubing.

One potential drawback to BTE hearing aids for some individuals is the aesthetics; they are probably the most noticeable simply due to the earmold tubing and earmold. The size and options for earmolds can be seen as an advantage for adventurous folks who like to wear their hearing aids loud and proud! Earmolds and BTE hearing aids can be ordered in a variety of bright colors and patterns.

In the Ear (ITE) Hearing Aids

ITE hearing aids are one piece, meaning that the custom shell of the hearing aid houses all of the electronics of the hearing aid. ITE hearing aids come in a full spectrum of sizes, from a device that fills the entire concha bowl to tiny completely-in-canal (CIC) and invisible-in-canal (IIC) devices. Like larger ITE hearing aids, these are custom-made using an earmold impression, but they fit all the way in your ear canal, so they are nearly invisible from the outside. These hearing aids will have markers to indicate right and left, but also top and bottom. These hearing aids also have a wire to assist in inserting and removing them.

Some patients are drawn to the ITE hearing aid style because they believe it will be the most discrete option when comparing behind-the-ear hearing aids versus in-the-ear hearing aids. Some may also feel that the ITE style will be the most comfortable, and it is potentially the least reactive because it is made from hard acrylic rather than softer materials that occasionally irritate the skin inside the ear. 

This style of hearing aid is more occluding than a RIC/RITE device simply because it is inside the ear canal, so some users may find that it inhibits natural sound quality. That said, the technology for occlusion control and noise-reduction in this style has come a long way and many users prefer this size and style.

ITE hearing aids are only one piece and therefore could be simpler for some patients to insert it properly, provided they have it oriented correctly. The onboard controls to change program and volume may also be easier to access at the level of the ear canal than on a device sitting behind the ear. Many modern devices today are able to be adjusted using a remote control and/or an application on your smartphone, which would allow for changes without touching the devices.

When all of the electronics are inside the ear, the devices are more vulnerable to damage as a result of interacting with cerumen and sweat. Patients may find this style of device challenging to clean and maintain. For the small devices that sit completely in the ear canal, dexterity is a significant consideration to be able to use the small wire to remove the hearing aids at the end of the day. 

Comparison: Behind the Ear vs In the Ear Hearing Aids

In considering the decision between behind the ear versus in the ear hearing aids, it is important to determine what your motivating factors are. Are you most concerned with… 

  • Aesthetics: For more severe hearing losses that would require a full-shell ITE hearing aid, the visibility of the device is probably going to be equal to that of a BTE hearing aid. If your hearing loss is in the mild to moderate range and can be adequately accommodated using a CIC or IIC device, you might also consider a RIC or RITE hearing aid. Both will be nearly invisible, and the RIC device will probably have better noise-reduction technology due to the placement of the microphones.

    ITE hearing aids generally come in “skin” tones, though occasionally the small devices are red and blue to indicate right and left ears, respectively. BTE hearing aids often come in the skin tones, as well, though they are more likely than ITE hearing aids to be available in alternative colors, particularly the pediatric lines.
  • Durability: BTE hearing aids are more durable than ITE hearing aids, so if you are rough on your devices or particularly concerned about wax or debris, a BTE device is going to be recommended over an ITE. The earmold is much more easily and cheaply replaced if damaged than an entire hearing aid.
  • Size: In general, greater degrees of hearing loss require larger hearing aids, regardless of style. The power required to provide adequate gain for severe to profound hearing losses necessitates a device that takes a larger battery.
  • Performance: You may find the performance to be generally equal between behind the ear hearing aids versus in the ear hearing aids, should you have the opportunity to try both styles. If performance is your main motivator for getting hearing aids (hint: it should be!) you may want to trial behind-the-ear hearing aids first to see what type of benefit you notice. It would be harder to trial ITE devices as they are made specifically for your ear, though a change in style would fall within the mandatory trial period for prescription hearing aids. 

Choosing the right hearing aid for you

Whether you are opting for a behind the ear hearing aid or an in the ear hearing aid, an impression will be taken of each ear for either the custom earmold or for the ITE hearing aid. This involves the audiologist or hearing aid dispenser putting a small cotton or foam block in your ear canal, followed by soft impression material. It takes a few minutes to cure, and then it is removed and sent to the manufacturer for the custom devices to be made.

If you are opting for a BTE hearing aid with an earmold, you will be able to choose the color of your earmolds. The audiologist will make a recommendation regarding material (hard or soft) as well as venting (small hole to allow for air flow).

You can discuss your type and degree of hearing loss with your provider and ask for their recommendation on the most appropriate style to accommodate your hearing loss and lifestyle. Most audiologists and hearing aid dispensers have sample devices that you can try on to see how they look in the mirror and how comfortable they are. Understandably, this is trickier with an ITE or earmold because they are custom-made for your ear. Be sure to let your provider know if you have any allergies or sensitivities to certain materials such as silicone or acrylic because this will help guide their selections.

Care and maintenance

With an earmold, always check to see if there is wax or other debris in the opening or anywhere along the tubing. You should also check to ensure your tubing is soft and supple- if it becomes hard or discolored, it’s time to have it changed by your audiologist. Some earmolds also include a vent, or a small hole through the mold, which should remain clear for comfort and ventilation. Your earmold should be wiped with a soft cloth or tissue when you remove your hearing aids. Try to avoid using alcohol or other chemicals which may break down the material.

Your audiologist may provide you with a drying kit for your hearing aids, which can help to remove moisture and is a safe place to store the hearing aids when they are not being worn. These can be particularly useful in warm and humid climates, or for individuals who frequently sweat. If your hearing aids use disposable batteries, remove the batteries prior to putting your hearing aids into the drying kit.

We live in an increasingly noisy world where communication is power. Hearing aids can offer significant benefit in all situations, but particularly listening in background noise. No technology is ever going to be perfect, but if you are noticing significant listening challenges, it is wise to see an audiologist or hearing aid dispenser for a full diagnostic evaluation and hearing aid discussion. It is best not to feel overwhelmed by the decision over hearing aid styles (behind the ear vs in the ear) or manufacturers, as that is the expertise of your provider to help guide you through the decision making process.

erin edwards aud
Clinical Audiologist at Towson University | + posts

Erin Edwards received her Doctor of Audiology degree from Towson University in 2015 and her Ph.D. in Education and Leadership from Pacific University in 2022. She has worked with patients of all ages in a variety of settings and has a specific interest in cochlear implants, the relationship of hearing loss and dementia, and interdisciplinary healthcare.

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