Stage Monitoring with Hearing Loss

This article provides practical guidance for performers with hearing loss, as well as supporting knowledgeable audio engineers who are mixing monitors for an artist with hearing loss. For further discussion on the topic, please listen to the Talking Ears episode

Performing music in front of an audience has to be one of life’s greatest joys. For musicians, it is often also necessary for their living and to express themselves artistically. While stage monitoring is a notoriously difficult technical problem with many confounding factors, one significant barrier which is underdiscussed is the performer’s own hearing loss.

In clinical visits, the question often comes up: How can we sustain an active music performance schedule when your ears don’t hear the way others do, or the way they used to?

Adjusting stage monitoring for hearing loss is a highly individualized process that depends on the musical setting, the specific genre of music, the composition of the ensemble, and of course your specific hearing loss. Each poses different challenges and also opportunities to take advantage of various solutions, which may include:

• Audiogram-informed EQ and compression processing

• Spatial processing

• Ambient miking and talkback systems

• Purpose-built monitoring systems such as Sensaphonics’ 3DME and AVIOM’ Audiogram EQ

• Instrument-specific pickup and monitoring solutions

The goal with all of these methods is the same: to arrive at a clear and functional mix that delivers what you need to hear to perform.

Image credit: Eno, B., & Adriaanse, B. (2025). What art does: An unfinished theory.

This is a good time to mention that our hearing and monitoring also supports connection with the other important people in the room. Of course this includes the ensemble and anyone else who is on stage with you, but less obviously it includes the audience. A performance becomes a glorified rehearsal if we do not consider the audience. Working with musicians - and being performers ourselves - we know that the feedback from the audience is one of the main draws to the stage.

Another important goal is conserving the hearing that you have. Just because you already have hearing loss does not mean it is too late to practice safe listening and hearing-loss prevention techniques. Instead of preventing hearing loss, we shift focus to conserving residual hearing. This becomes increasingly important as hearing loss becomes more severe, since there is less hearing left to conserve and the impact of losing what remains can be profound.

Finally and possibly most importantly, the goal is to arrive at a musically pleasing monitoring solution. When barriers compound, the joy can quickly escape the live performances.

The Floor and the Ceiling of Sensorineural Hearing Loss

Hearing loss comes in several different types, with sensorineural hearing loss being the most common experienced in adults with sound exposure. For this reason, this discussion will focus on sensorineural hearing loss; however, if you or the artist you are working with has a conductive type of hearing loss, there may be a different set of recommendations beyond the scope of this article.

Reduced dynamic range is a hallmark of a sensorineural hearing loss. Dynamic range can be defined as the distance between the quietest audible sound and the loudest tolerated sound.

Analogy Time! You can think of a typical monitor mix like a tunnel that is wide enough to accommodate most, if not all, of the sound sources in a musical setting. The loudest to the quietest - the tallest to the shortest - fit comfortably through the tunnel when one’s dynamic range is in the normal swing of 90 to 120 dB.

Hearing loss, has two major effects on this dynamic range tunnel:

1. Loss of sensitivity to hearing thresholds. In our analogy, the floor of the tunnel is raised while the ceiling remains where it is. This means the loudest and tallest elements must be squeezed together with the quieter elements just to fit through the newly confined space.

2. On the other end of the spectrum, loudness intolerance (also known as recruitment or hyperacusis) is also common with most sensorineural hearing losses. These effectively lower the ceiling of the tunnel in the same places where the floor has been raised the most, creating a bottleneck that further complicates monitoring options.

Another barrier is that reliable performance requires control and consistency in environments where stage acoustics and setup can vary widely from venue to venue and night to night. These considerations tend to affect traditional wedge monitors more than in-ear monitors, though both systems have limitations in challenging circumstances.

In an ideal situation there would be a dedicated monitor engineer who understands your hearing loss, knows how to adjust for it in the mix, and is attentive enough to resolve issues that may arise during a performance. If this describes your situation, then share this article with them and reach out if we can support your team further.

Self-mixing, however, requires technical skills to understand the processing involved and access these controls from the stage during rehearsals and performances. Satellite units, standalone monitor mixers, touch screen remote control of wireless mixing boards, and app-based sound controls can reduce this barrier, but they require basic technical skills and - more importantly - a willingness to split attention between performance and technical production tasks.

It’s Not Just About Flipping the Audiogram

The first step in adjusting monitoring to accommodate hearing loss is understanding the audiogram, the term used to describe the hearing test results from diagnostic hearing testing.

Actually, the first step is obtaining an updated audiogram. When you meet with an audiologist, here are several things musicians should ask for based on the Clinical Consensus Document: Audiological Services for Musicians and Music Industry Personnel, published by the American Academy of Audiology (AAA) in January 2020.

Standard Audiograms test the octaves between 250 - 8000 Hz. Expanded Audiograms, as recommended by the AAA 2020 consensus document, test additional interoctaves and can cover 125 - 16000 Hz.

All available “Interoctaves” Standard audiometric testing is typically performed at octave intervals between 250 and 8000 Hz. In certain circumstances, additional frequencies are added at the half-octaves, including 750, 1500, 3000, and 6000 Hz. These are referred to as interoctaves in audiometric nomenclature. In musical terms they would be considered fifths. The purpose here is to obtain the highest possible resolution for test of a musician’s hearing status.

Extended High Frequencies 8000 Hz is not considered a particularly high frequency in audio engineering terms, but it is the highest frequency tested in standard audiometric exams. Extended high frequencies are available in many audiometers but are not always included in a standard hearing test unless medically indicated or specifically requested. According to the 2020 clinical consensus document, extended high frequency testing up to at least 16,000 Hz is important for musicians and audio engineers who want to understand the upper octave of their hearing.

There is also evidence that this frequency range is more sensitive to damage from sound exposure and may act as an early indicator of hearing injury that does not yet present in the standard audiometric frequencies.

Extended Low Frequency (125 Hz) Most audiometers are capable of testing 125 Hz, a full octave below the lowest standard audiometric frequency of 250 Hz, though it is not routinely tested. For audio engineers, stopping at 250 Hz can feel like being short-changed since that is barely outside the range of low mids. Still, accurate testing below 125 Hz may not be possible in certain clinical settings due to technical limitations of transducers and variability between test environments.

Speech In Noise Testing (QuickSIN) Our ability to parse complex sound settings is based on interplay between what our ears can take in (our hearing sensitivity) and how well our auditory brain can process the signals. Clinical we test this using speech in noise testing, which does exactly what it says on the tin: the patient is instructed to repeat numbers, words, or sentences with progressively more interfering background noise. Musical training tends to improve one’s score in these tests, but significant sensorineural hearing loss can quickly degrade these results.

Uncomfortable Loudness Levels (UCL) Uncomfortable Loudness Levels may help document loudness growth and perceived levels at suprathreshold intensities. Decreased UCLs may indicate decreased loudness tolerance or hyperacusis and may suggest the need for more aggressive compression (more on this shortly) in those ranges. In the authors’ experience, however, these test values are rarely directly translatable into monitoring processing and should be used with caution.

Demystifying the Audiogram

It is important to understand that your audiogram only shows your thresholds of hearing, indicated by a blue X for the left ear and red O for the right ear. These are the softest levels you are able to hear at each test frequency, with a normal range of -10 to 20 dB HL. However, practically all musical monitoring situations occur far above these thresholds. Music performance settings - from solo acoustic rehearsal to a full live band - occur in the range of 70 to 115 dB SPL with very few outliers on either end.

Because of this, the threshold of hearing is only a partial indicator of how to assist someone with hearing loss who wants to monitor music accurately at these higher levels. As discussed, dynamic range often reduces with sensorineural hearing loss so applying one-to-one gain using EQ may “flatten” an individual’s audiometric thresholds, the signal would quickly become harsh, painful, and potential damaging as inputting sounds exceed the quietest audible level.

Next, we need to address the upside-down elephant in the room: the audiogram’s Y axis is inverted and displays low intensities at the top and high intensities at the bottom. In this way, a hearing loss is shown as a lowering of the threshold. This is, in a word, confusing. So when we “flip” the audiogram (us the audiometric thresholds to inform EQ and dynamic processing decisions) we are normalizing the orientation to the rest of our audio processing displays.

How Can Hearing Aids Teach Us To Mix Monitors for Performers with Hearing loss??

Here we can take some lessons from hearing aid design. Modern hearing aids use complex prescriptive target levels based on decades of research, feedback, and technological advances. While these exceed the scope of this article, we can start with a simple 1/2 or 1/3 gain rule which was historically used as a starting point for amplification fittings.

For example, if a person has a 60 dB hearing threshold, a third-gain rule would apply 20 dB of gain at that frequency, while a half-gain rule would apply 30 dB of gain. The goal was audibility without discomfort.

Modern digital hearing aids instead rely on wide dynamic range compression (WDRC). Compression ratios as low as 1.2:1 or 1.5:1 may be applied across most or all of the signal range.

In other words - and this may make some audio engineers cringe - the compression threshold may be set very low, perhaps at the point of audibility, with the understanding that the compressor will be providing gain reduction nearly continuously. If you find yourself wondering about attack and release times, how the dynamics of music are affected, or how pumping and harmonic distortion are minimized, then you are beginning to understand why music often sounds unsatisfying to musicians through modern hearing aids.

Another reason hearing aids often fall short for music listening is the additional processing designed to improve speech understanding. These systems often include:

• Digital noise reduction

• Feedback suppression

• Speech-focus processing

• Adaptive directional microphones

These algorithms attempt to emphasize speech while reducing noise. However, it does not take much imagination to see how this can be counterproductive for musical sources. For instance, an active noise reduction algorithm may hear the sizzle of a jazz drummer’s ride cymbal as unwanted noise and reduce it unnecessarily.

Speech-focus algorithms are actively seeking spoken language and reducing everything else. For instance, the long sustained tone of a flute, woodwind, or operatic singer may be mislabeled as unwanted feedback and the hearing aid may actively suppress them using phase- or pitch-shift algorithms, which can create unpleasant and unmusical effects.

To summarize, traditional hearing aid gain staging is a helpful analogy for mixing monitors for hearing loss, but the advanced processing inherent in modern hearing aids can be counterproductive when the primary source is music.

Solutions: Traditional Mix Management

The primary solution—and something consistent across all options—is traditional mix management. We are taught early on that if something is buried, it is wise to reduce the interference and turn down the overpowering elements instead of turning up the target source. In other words, focus and simplify the mix.

It can be helpful to divide signals into three categories: (1) Focal Sources, such as your own voice and instruments; (2) Rhythm and Pitch References, such as drums, bass, and click track; and (3) Color/Optional Sources, such as horns, strings, and aux percussion. While these color elements add genre-defining favor to the overall musical setting, they are often not mission-critical to a performer’s ability to execute their part. For performers with hearing loss, optional sources can often be muted or significantly reduced.

To Be Continued…

In the next part of this series, we’ll dive into additional audiogram-informed EQ and dynamics processing, spatial processing, ambient miking, and purpose-built monitoring systems.

If you have any questions before the next section is released, feel free to contact us. Each case is unique and needs individualized attention, and since we’ve seen thousands of cases we can likely help get you on the right track.

2022 recap and Talking Ears featured in the NHCA "Spectrum" publication

2022 brought about many changes for Earmark Hearing Conservation, including the launch of my music audiology interview podcast, “Talking Ears”. The show provides space for guests to share their stories and views on what is arguably the most important issue in the music industry: hearing health. The formula is rather simple - long-form interviews provide nuance and breadth, while the artist’s own music provides context.

As the host, I try to stay out of the way as much as possible and let the guests’ words and music do the talking. However, this show has marked a significant shift in the way I share my own personal story as an individual who experienced hearing damage and tinnitus due to music exposures from a young age. Though it is a vulnerable feeling and not always comfortable to do so, this relates directly to the philosophy that sparked the show in the first place: dialog and transparency are the bricks that pave the path to better hearing health awareness.

View Article

Click here to download the full NHCA Spectrum article.

One of those instances where I spoke about myself was when past National Hearing Conservation Association president Merlyn Lubiens interviewed me for the recent issue of “Spectrum”, the official NHCA publication. Feel free to read the article through the above link, admire the masterwork writing, and chuckle at the endearing use of a dad-joke to wrap up an otherwise buttoned-up piece. If you listen close, you’ll likely hear me blushing through the pages.

But this isn’t about me. Along with producers Juan Vasquez, AuD, and Mary Kim, AuD, we’ve interviewed Grammy winners, touring musicians, audio engineers, researchers, psychologists, educators, and some of the most renown music audiologists in the world. Their words and music is what we are collecting. And the more personal stories we share, the greater the chance a listener will see their own experiences and attitudes reflected back. The subject remains loosely the same (it is called “Talking Ears” after all) but the views and connections are always refreshing and inspiring to our team.

This is a labor of love, and boy howdy is a labor. From top to tail, each episode takes between 10 to 16 hours for our team to produce. Luckily, the overwhelming response shows that this is a worthwhile endeavor and one we will continue with gusto into the new year.

None of this would be possible without the support of Juan and Mary. The show would be nothing without countless hours spent planning and scheduling guests, listening to interviews, and providing edit suggestions and feedback.

We have incredible things planned in 2023, exciting upcoming announcements, and sincere hopes the future of the show. Your continued listenership means the world to us, and we welcome your thoughts, feedback, criticism, and suggestions. Some would say… we’re all ears.

Best, Frank