Mild but Not Minor: Reconsidering Clinical Practice and Tinnitus-Related Aspects of Mild Hearing Loss

Article information

J Audiol Otol. 2026;30(2):83-92

Publication date (electronic) : 2026 April 20

doi : https://doi.org/10.7874/jao.2025.00633

Hantai Kim^1,2, Jong Bin Lee^,2

¹Department of Otorhinolaryngology, Head and Neck Surgery, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong SAR

²Department of Otorhinolaryngology-Head and Neck Surgery, Konyang University College of Medicine, Daejeon, Korea

Address for correspondence Jong Bin Lee, MD, PhD Department of Otorhinolaryngology-Head and Neck Surgery, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea Tel +82-42-600-9215 E-mail rogue25@kyuh.ac.kr

Received 2025 October 17; Revised 2026 January 5; Accepted 2026 January 21.

Abstract

Introduction

An individual’s level of hearing is typically determined by calculating the average pure-tone thresholds at 500, 1,000, 2,000, and 4,000 Hz in the better-hearing ear. Based on this average threshold, the World Health Organization (WHO) has traditionally categorized hearing impairment into the following classifications: no impairment, slight impairment, moderate impairment, severe impairment, and profound impairment including deafness [1]. However, this classification has been criticized for not accurately reflecting the degree of functional limitation associated with mild hearing loss, particularly the 25 dB threshold commonly used as a cut-off. In addition, the rationale behind the defined severity boundaries has been considered insufficiently evidence-based [2,3].

In response to these concerns, the Global Burden of Disease (GBD) Expert Group on Hearing Loss proposed a revised classification system. In this updated scheme, normal hearing is defined as an average threshold of less than 20 dB, and severity levels are more finely divided into mild, moderate, moderately severe, severe, profound, and complete or total hearing loss [3]. This revised categorization has been adopted by the WHO, which now defines normal hearing as thresholds of 20 dB or better in both ears, and disabling hearing loss as thresholds greater than 35 dB [4].

Mild hearing loss, defined as a pure-tone average between 20 dB and 35 dB, is often managed with no active auditory rehabilitation, typically limited to periodic hearing assessments. This conservative approach may stem from a lack of awareness regarding the degree of functional impairment—both among patients and healthcare providers. Recently, studies estimating the disability weight of hearing loss have enabled comparisons of its disease burden with other health conditions [5]. Considering this, the present review first seeks to examine the disease burden associated with mild hearing loss.

In addition, a growing number of alternative hearing devices, such as over-the-counter (OTC) hearing aids and personal sound amplification products (PSAPs), have become available in the consumer market and are considered potentially effective for individuals with mild hearing loss. As the need for auditory rehabilitation in this population gains recognition, it is essential to evaluate whether these alternative devices may serve as viable options. Furthermore, special attention is warranted in cases where tinnitus coexists with mild hearing loss. Through these discussions, this narrative review aims to provide an updated perspective on current considerations in the management of mild hearing loss.

Disease Burden of Mild Hearing Loss

Mild hearing loss is often perceived as not significantly impairing daily life. One reason for this perception may be that studies and reports define the threshold at which hearing loss begins to interfere with communication at levels higher than what is typically categorized as mild hearing loss. In 1995, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) introduced the concept of serviceable hearing, which refers to hearing levels that allow for a functional degree of verbal communication. This concept is frequently used to evaluate the value of hearing preservation in surgical settings and generally corresponds to a pure-tone threshold of ≤50 dB HL [6]. Meanwhile, the WHO uses the term disabling hearing loss, defined as a pure-tone average of ≤35 dB HL in the better-hearing ear [4]. Healthcare providers are generally more familiar with these two concepts—serviceable and disabling hearing. In addition, patients often hold negative perceptions toward hearing aids, although such attitudes have gradually improved in recent years [7]. These factors may partly explain why hearing aid adoption is lower among individuals with mild hearing loss compared to those with more severe degrees of loss [8].

Although often underestimated, mild hearing loss can still interfere with communication and daily functioning. In the GBD study, each level of hearing impairment is accompanied by a corresponding lay description that reflects the degree of functional difficulty. Mild hearing loss, defined as a hearing threshold between 20 and 34 dB, is described as “has great difficulty hearing and understanding another person talking in a noisy place (e.g., on an urban street).” When accompanied by tinnitus (ringing), the added burden is described as “sometimes has annoying ringing in the ears”. These descriptions are quantified through disability weights (DWs), with mild hearing loss assigned a DW of 0.010 (95% uncertainty interval: 0.004–0.019), and mild hearing loss with tinnitus having a higher DW of 0.021 (0.012–0.036) (Table 1) [9]. In a study conducted in China by Liu, et al. [10], the DWs were estimated to be slightly higher: 0.021 (0.002–0.079) for mild hearing loss and 0.032 (0.004–0.107) for mild hearing loss with ringing. As a reference, DW is calculated as 0 for a state of perfect health and 1 for a state equivalent to death.

Table 1.

Grades of hearing impairment and their disability weights

Table 2 summarizes health states with DWs comparable to that of mild hearing loss. In the GBD study, mild hearing loss has a DW similar to that of mild Parkinson’s disease. When tinnitus is present, the DW aligns more closely with that of stress incontinence or mild musculoskeletal problems of the lower limbs [11]. In the study by Liu, et al. [10], mild hearing loss was positioned between hypothyroidism and controlled asthma, while mild hearing loss with ringing fell between mild musculoskeletal problems of the lower limbs and mild angina pectoris (Table 2). Notably, most health conditions with comparable DWs to mild hearing loss are typically managed with some form of intervention, indicating that mild hearing loss—specially when accompanied by tinnitus—should not be regarded as negligible in terms of disease burden.

Table 2.

Disability weights of selected conditions

Still, one might argue that the absolute DW of mild hearing loss is quite low, and therefore its overall burden might also be minimal. Indeed, when compared to the DW of profound hearing loss, which reaches 0.204 (0.130–0.288), the value for mild hearing loss, 0.010 (0.004–0.019), appears relatively small. However, it is important to adopt a more macroscopic perspective. Mild hearing loss is highly prevalent and tends to persist or even worsen over time. When considering disease burden using years lived with disability (YLD), which is calculated by multiplying DW by prevalence and duration, the results tell a different story. Among all grades of hearing loss, moderate hearing loss yields the highest YLD at 622,400, followed closely by mild hearing loss at 597,200. In contrast, profound hearing loss contributes a much lower YLD of 173,500 (Table 1) [5]. Given the global trend of increasing life expectancy, these YLDs are likely to rise further in the future.

In addition to the aforementioned issues, hearing loss must also be considered in the context of its association with another major public health concern: dementia. In particular, midlife hearing loss has been widely recognized as a potentially modifiable risk factor for dementia [12]. Taken together, these findings suggest that the burden of mild hearing loss has been relatively underrated, and that it is now time to reconsider a more proactive approach to intervention. Especially given the increasing availability of alternative options that may address the limitations of conventional management strategies, the approach to managing mild hearing loss warrants renewed attention.

Management of Mild Hearing Loss: Hearing Aids

Hearing aids may be used to alleviate “the great difficulty hearing and understanding another person talking in a noisy place” caused by mild hearing loss, and they can be effective [13,14]. However, some studies have reported limited benefits in individuals with mild hearing loss. In fact, one study found that hearing aid use resulted in worse outcomes in the aversiveness subscale of the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, indicating that amplified sounds may be perceived as more unpleasant in some cases [15]. A systematic review on the use of hearing aids in individuals with mild hearing loss concluded that, although hearing aids offer measurable benefits, users may occasionally experience discomfort with amplified sounds. The authors emphasized that prescribing hearing aids to patients with mild hearing loss can be supported when the patient expresses interest in using them [16]. A Delphi review on hearing aid prescription in mild hearing loss similarly highlighted that the key factors influencing the recommendation for hearing aids are whether the patient reports hearing-related difficulties and whether they are motivated to solve those difficulties through amplification [17].

In cases of mild hearing loss, the decision to use hearing aids is generally patient-driven rather than initiated by the clinician. That is, hearing aid use tends to depend on the patient’s motivation and perceived need, rather than being routinely recommended by healthcare providers. However, when tinnitus is present alongside mild hearing loss, clinicians are more likely to proactively recommend hearing aids [17]. This is largely due to the well-established evidence that hearing aids can provide relief from tinnitus symptoms [18-20]. Accordingly, most tinnitus guidelines and consensus statements recommend the use of hearing aids when tinnitus is accompanied by hearing loss [21-26].

Overall, the use of hearing aids in individuals with mild hearing loss has been associated with benefits, and positive long-term outcomes can be expected. Nevertheless, the adoption rate remains remarkably low, suggesting the presence of additional barriers that influence hearing aid usage. Among these, cost appears to be a major factor. One study comparing the characteristics of hearing aid adopters and non-adopters found that economic indicators such as monthly income and employment status were significantly associated with hearing aid adoption [8]. In addition, conventional hearing aids typically require in-person visits to a hearing aid provider or center for fitting, which may pose a burden for many individuals. While such barriers may be the same across different levels of hearing loss, individuals with mild hearing loss—who generally experience less functional impairment—may be less motivated to overcome these obstacles than those with more severe hearing loss.

Alternative Amplification Options for Mild Hearing Loss: PSAPs and OTC Hearing Aids

While the use of hearing aids is sufficiently justifiable in cases of mild hearing loss, factors such as the financial burden and the inconvenience of in-person fitting often serve as barriers to their adoption. If these obstacles were mitigated, it is reasonable to anticipate that hearing aid usage would increase among individuals with mild hearing loss. In particular, the recent introduction and growing availability of OTC hearing aids and PSAPs hold promise in addressing two of the major limitations of conventional hearing aids: high cost and the need for professional fitting.

PSAPs cannot be classified as hearing aids; they are acoustic amplification devices intended to enhance audibility of soft sounds in individuals with normal hearing. Because they are required to neither provide high levels of amplification nor incorporate the range of features typically included in conventional hearing aids, PSAPs are generally more affordable and not necessary for a professional prescription. Their ease of acquisition and use has generated increasing interest, and several studies have been conducted to evaluate their effectiveness in individuals with hearing loss. Table 3 summarizes key findings from studies investigating the performance of PSAPs as alternative amplification options for individuals with mild to moderate hearing loss [27-30]. In addition, recent studies examining the effects of consumer audio devices (e.g., Apple AirPods Pro) and hearing aid application software are also included in Table 3 [31-33].

Table 3.

Selected studies on alternative hearing devices for individuals with mild hearing loss

Most studies have evaluated the use of PSAPs positively in individuals with mild-to-moderate hearing loss. In the study conducted by Brody, et al. [27], hearing aids outperformed PSAPs across all domains. However, PSAPs still demonstrated significant improvement compared to the unaided condition, leading the authors to conclude that PSAPs could serve as a budget-friendly option for hearing support. Cho, et al. [28] reported that while premium hearing aids provided superior performance in individuals with moderately severe hearing loss, there were no significant differences among PSAPs, basic hearing aids, and premium hearing aids in individuals with mild hearing loss. Taken together, even with a conservative interpretation of these findings, it is reasonable to expect that PSAPs can provide adequate benefit in cases of mild hearing loss. On the other hand, although Apple AirPods Pro and smartphone-based hearing aid applications show potential as assistive devices for individuals with mild hearing loss, their effectiveness appears less consistent compared to that of PSAPs [31-33]. Based on such evidence, the Korean Otological Society Hearing Aid Study Group has published a position statement reaffirming conventional hearing aids are the gold standard; however, the statement acknowledges that PSAPs may offer benefit in particular contexts such as mild hearing loss [34]. If effective usage protocols for PSAPs in mild hearing loss become more established, they may substantially reduce the cost barrier that currently limits hearing aid adoption in this population.

OTC hearing aids, as their name implies, are hearing aids that have received FDA approval as medical devices and therefore meet the regulatory requirements for hearing aids [35]. In terms of function and performance, they are naturally superior to PSAPs. The key distinction, as suggested by the term “over-the-counter,” lies in the point of purchase and, ultimately, in the fact that these devices are designed to be fitted directly by consumers without professional involvement. Thus, while there is little doubt regarding their ability to provide adequate amplification as conventional hearing aids, concerns remain regarding potential safety issues and the effectiveness of self-fitting in the absence of professional guidance.

Fortunately, safety is generally not considered a major concern. A study comparing OTC and conventional hearing aids in terms of safety and efficacy reported that, although OTC devices were slightly less efficacious, they were comparably safe [36]. However, there are concerns that patients with hearing loss caused by conditions such as sudden hearing loss or middle ear infections—conditions that require medical or surgical treatment rather than hearing aids—may attempt to address the problem on their own by purchasing OTC devices. This could ultimately delay appropriate treatment [37]. To reduce this risk, it has been suggested that OTC hearing aid packaging should include clear descriptions of appropriate indications, or that verification dialogs should be incorporated during device setup via supporting applications to ensure that the device is being used in suitable cases [38].

Research on self-fitting has also been largely positive. Some studies have reported that the subjective benefits of OTC hearing aids are comparable to those of conventional hearing aids [39]. In addition, when comparing self-adjustment with fitting by professionals, the outcomes were similar, but the self-adjustment group demonstrated higher satisfaction and longer daily use [40]. Furthermore, in cases of mild to moderate hearing loss, the long-term outcomes of self-fitting with OTC hearing aids were found to be comparable to those of audiologist-fitted devices [41]. Taken together, their findings suggest that purchasing and adjusting OTC hearing aids independently can indeed provide meaningful improvements in hearing.

Considering that most studies demonstrating the effectiveness of PSAPs and OTC hearing aids have focused on patients with mild to moderate hearing loss, we may infer that these alternative devices could be sufficiently effective, at least in cases of mild hearing loss. If the greatest barriers to using conventional hearing aids in mild hearing loss have been their high cost and the need for professional fitting, these barriers could be substantially reduced with PSAPs or OTC hearing aids. Therefore, it may be worth more actively considering and recommending the use of PSAPs or OTC devices for auditory rehabilitation in individuals with mild hearing loss.

Tinnitus-Related Considerations

Patients with mild hearing loss who experience tinnitus are more likely to consider using hearing aids, as evidence has shown that hearing aids are effective for tinnitus when hearing loss is present [20-26]. While some tinnitus patients may benefit from medication [42], in cases of chronic subjective tinnitus accompanied by hearing loss, hearing aid use is generally recommended—even in cases of mild hearing loss [17]. Given the factors discussed above, the wider adoption of hearing aids, particularly through PSAPs or OTC devices, could be expected to benefit many patients with chronic tinnitus.

However, a critical concern must be emphasized here. Although hearing aids are frequently mentioned as a treatment option for tinnitus with coexisting hearing loss, they represent only one component of a comprehensive management strategy. When tinnitus patients receive care from otolaryngologists or other professionals, hearing aids are typically provided in conjunction with counselling and cognitive behavioral therapy, rather than as a standalone intervention. If patients with mild hearing loss and tinnitus begin to adopt PSAPs or OTC hearing aids without professional involvement—based solely on the commonly known notion that “hearing aids help tinnitus”—there is a significant risk that essential elements of tinnitus treatment, such as counselling-based interventions, may be omitted (Fig. 1).

Fig. 1.

Potential concerns of over-the-counter (OTC) hearing aids and personal sound amplification products (PSAPs) for tinnitus management in mild hearing loss. Conventional hearing aid use through hearing professionals is usually accompanied by counselling, as a component of tinnitus retraining therapy and cognitive behavioral therapy, forming a comprehensive management approach. In contrast, direct-to-consumer use of OTC hearing aids or PSAPs may omit those counselling-based interventions.

Indeed, studies highlighting the effectiveness of hearing aids for tinnitus have consistently noted that informational counselling must accompany device use to achieve optimal outcomes [19]. Furthermore, some authors have argued that, for this reason, OTC hearing aids cannot be considered an ideal treatment option for patients with clinically significant tinnitus [20]. Thus, in patients with mild hearing loss and comorbid tinnitus, if the ultimate therapeutic target is tinnitus, hearing aids, whether conventional, PSAPs, or OTC hearing aids, should be integrated into a comprehensive treatment plan that includes professional counselling-based interventions. It is essential to emphasize and promote this approach.

Discussion

This narrative review was based on a focused literature search conducted using PubMed. The review process was guided by key clinical questions related to the disease burden of mild hearing loss, alternative amplification options, and tinnitus-related considerations. To contextualize the burden of hearing loss, we first reviewed studies from the GBD framework that addressed hearing loss related disability [2,5,9,11]. And we supplemented these with another region-specific study using similar methodologies [10].

For studies on mild hearing loss, pediatric populations and unilateral mild hearing loss were excluded to focus on adult bilateral mild hearing loss. We included studies addressing hearing aid use in mild hearing loss, as well as those evaluating alternative amplification devices such as PSAPs and OTC hearing aids. Studies limited to moderate or more severe hearing loss were excluded. Although an exclusive focus on populations with mild hearing loss would have been ideal, most studies evaluating those devices have been conducted in individuals with mild-to-moderate hearing loss. This was considered acceptable as the objective was to assess whether these devices can provide functionally adequate acoustic amplification. If such devices demonstrate favorable outcomes even in moderate hearing loss, it is reasonable to infer that their amplification capacity, from a technical perspective, would be sufficient for individuals with mild hearing loss.

Even in cases of mild hearing loss, individuals experience “great,” not mild, difficulty in understanding speech in noisy environments [5]. This challenge becomes even more pronounced when tinnitus is present, with DW ranging from approximately 0.012 to 0.036, which corresponds to the level of discomfort reported in conditions such as insomnia, controlled asthma, mild anxiety, mild low back pain, or mild dementia [10]. Furthermore, considering the rapid increase in the number of people with mild hearing loss due to the extension of life expectancy, the YLD associated with mild hearing loss has been estimated at 597,200—substantially greater than that of severe hearing loss (161,600) or profound hearing loss (173,500) [5].

Nevertheless, because there has been no established treatment for mild hearing loss other than hearing aid use, the high cost of devices and limited access to professional fitting have long hindered the widespread adoption of hearing aids. In recent years, however, alternative devices such as PSAPs and OTC hearing aids have emerged, and numerous studies have demonstrated that these devices can be sufficiently effective for individuals with mild to moderate hearing loss [28,39-41]. Given their lower cost and the feasibility of selffitting with comparable outcomes, these alternatives may overcome the major drawbacks of conventional hearing aids. Accordingly, for mild hearing loss, in particular, more proactive use could be a reasonable and practical consideration.

The authors believe that current guidance—suggesting that hearing aids may be used if patients desire—should be reconsidered. Let us take, for example, two highly familiar conditions: hypertension and diabetes. It is not unusual for patients with hypertension to take antihypertensive medication, or for patients with diabetes to take glucose-lowering drugs. Yet, in most cases, it is not the patient who independently initiates pharmacologic treatment; rather, physicians first explain the potential benefits of consistent medication use and recommend treatment. Importantly, the cost of such medication is generally not prohibitive, which further facilitates their acceptance. In the context of mild hearing loss, it may now be time to consider a shift toward more proactive physician-driven recommendations. Whereas the high financial burden of conventional hearing aids has long restricted their use to a “patient-driven” choice, the advent of more affordable options such as PSAPs and OTC hearing aids lowers this barrier. Accord-ingly, clinicians may begin to encourage their use more actively. Of course, before such a shift can be implemented, clear and detailed guidelines for the use of PSAPs and OTC hearing aids must be established. The authors believe this is an issue that warrants serious attention from experts in the field.

While it is reasonable to expect that mild hearing loss can be effectively managed with PSAPs or OTC hearing aids, one critical issue must not be overlooked. These devices are basically designed and marketed on the assumption that individuals will purchase and fit them independently. In contrast to conventional hearing aids, their use does not necessarily involve consultation with physicians or other hearing professionals. This lack of professional involvement carries the risk of suboptimal, or in some cases even harmful, outcomes. For example, when mild hearing loss is caused by potentially reversible conditions, such as conductive hearing loss due to a small tympanic membrane perforation, surgical treatment may represent a more appropriate intervention than amplification alone [34].

This concern becomes particularly relevant when patients with tinnitus independently decide to use amplification and directly purchase PSAPs or OTC hearing aids. Counseling is repeatedly emphasized as a core component of tinnitus management across multiple clinical guidelines; bypassing this step in favor of amplification alone cannot be considered comprehensive treatment [21-24]. In such contexts, the use of PSAPs or OTC hearing aids without professional guidance may, in some cases, result in greater harm than benefit.

This review highlights two key messages. First, the disease burden of mild hearing loss should not be underestimated, and alternative amplification devices offer promising opportunities to overcome longstanding barriers associated with conventional hearing aids, warranting a reappraisal of amplification strategies in mild hearing loss. Second, because these alternative devices can be accessed without the involvement of otolaryngologists or other hearing professionals, their use requires careful consideration, which necessitates cautions. The use of alternative amplification devices, such as PSAPs or OTC hearing aids, may be approached more flexibly in individuals with mild hearing loss without tinnitus. In contrast, in patients with mild hearing loss accompanied by tinnitus, particularly when amplification is considered primarily for tinnitus relief, greater caution is warranted. Tinnitus management extends beyond amplification alone and depends heavily on counselling-based interventions delivered within a professional framework. Therefore, although PSAPs or OTC hearing aids may have a role, the self-directed use of these devices without professional involvement may be suboptimal and should generally be discouraged when tinnitus treatment is a primary therapeutic goal.

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