Bone AnchoredBone Anchored Hearing Aids Hearing Aids

Dr. Amir SoltaniDr. Amir Soltani

Clinical AudiologistClinical Audiologist

UBC Resident Otology Lecture UBC Resident Otology Lecture SeriesSeries

BC Children HospitalBC Children Hospital

Sep 13, 2013Sep 13, 2013

BAHABAHAwww.dramirsoltani.com/links/www.dramirsoltani.com/links/

bahabaha What is the BAHA systemWhat is the BAHA system

A well recognized hearing treatment for A well recognized hearing treatment for conductive and mixed hearing losses conductive and mixed hearing losses since 1977 ,As well as SSDsince 1977 ,As well as SSD

The BAHA system is composed of three The BAHA system is composed of three parts: a titanium implant, an external parts: a titanium implant, an external abutment and a sound processorabutment and a sound processor

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In the early 1960s it has discovered that In the early 1960s it has discovered that titanium provides an excellent material for titanium provides an excellent material for implantable devices. Titanium is accepted implantable devices. Titanium is accepted by the human body and forms a bond with by the human body and forms a bond with surrounding bone.surrounding bone.

This is a process termed “osseointegration,” This is a process termed “osseointegration,” which takes place as the titanium implant which takes place as the titanium implant integrates and forms a permanent structure integrates and forms a permanent structure with the living bone. The process of bone with the living bone. The process of bone osseointegration is also the foundation for osseointegration is also the foundation for dental implants..dental implants..

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How does the BAHA system work for How does the BAHA system work for Mixed and Conductive Hearing Loss?Mixed and Conductive Hearing Loss?

BAHABAHA A sound processor picks up sound vibrations.A sound processor picks up sound vibrations. An abutment is attached to the sound processor and the An abutment is attached to the sound processor and the

implant. The abutment transfers the sound vibrations from implant. The abutment transfers the sound vibrations from the processor to the implant.the processor to the implant.

Titanium implant is placed in the mastoid process, where it Titanium implant is placed in the mastoid process, where it fuses with the living bone (osseointegration). The implant fuses with the living bone (osseointegration). The implant transfers the sound vibrations to the functioning cochlea.transfers the sound vibrations to the functioning cochlea.

This creates direct (percutaneous) bone conduction. In This creates direct (percutaneous) bone conduction. In contrast, traditional BC hearing aids connect indirectly to contrast, traditional BC hearing aids connect indirectly to the bone through unbroken skin (transcutaneous) and work the bone through unbroken skin (transcutaneous) and work by exerting pressure against the skull.by exerting pressure against the skull.

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Types of hearing loss Types of hearing loss the BAHA system can helpthe BAHA system can help

Mixed and Conductive hearing loss – Mixed and Conductive hearing loss – unilateral or bilateral fittingunilateral or bilateral fitting– Due to examples such as: Due to examples such as:

Chronic otitis mediaChronic otitis media Congenital atresiaCongenital atresia CholesteatomaCholesteatoma Middle ear dysfunction/diseaseMiddle ear dysfunction/disease External otitisExternal otitis

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The Baha Sound Processor snaps on The Baha Sound Processor snaps on to the abutment. The processor is to the abutment. The processor is small, discreet and is available in a small, discreet and is available in a variety of colors. The volume controls variety of colors. The volume controls are conveniently located for easy are conveniently located for easy adjustments.adjustments.

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BAHA CandidateBAHA CandidateMixed and Conductive Hearing LossMixed and Conductive Hearing Loss

> > 5 years of age5 years of age < < 45 dB HL BC PTA45 dB HL BC PTA > > or equal to 60% or equal to 60%

speech discrimination scoresspeech discrimination scores Symmetric bone conduction thresholds are Symmetric bone conduction thresholds are

defined as less than 10 dB difference in defined as less than 10 dB difference in average or less than 15 dB at individual average or less than 15 dB at individual frequencies (0.5, 1, 2, and 4Khz)frequencies (0.5, 1, 2, and 4Khz)

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Bilateral Conductive Hearing LossBilateral Conductive Hearing Loss

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Biateral mixed hearing lossBiateral mixed hearing loss

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Severe Mixed or Sensorineural Hearing Loss

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Unilateral Conductive Hearing Loss Canal Atresea

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Audiological Assessments:Audiological Assessments:

1: Pure tone Audiometry, including 1: Pure tone Audiometry, including AC&BC testingAC&BC testing

2: Speech tests through insert 2: Speech tests through insert receiver or headphones + Bone receiver or headphones + Bone vibrator testingvibrator testing

A: SRT B: SDS C: Quick SIN A: SRT B: SDS C: Quick SIN

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Impedance testing includling: (If possible)Impedance testing includling: (If possible)

Conventional (low probe tone) Conventional (low probe tone) tympanometry and high probe tone if tympanometry and high probe tone if necessarynecessary

Acoustic reflex thresholds, Ipsi & Contra Acoustic reflex thresholds, Ipsi & Contra Lateral stimuliLateral stimuli

OAEOAE

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Test RodTest Rod The test rod is used as a pre-The test rod is used as a pre-

operative device. It is particularly operative device. It is particularly useful for potential candidates who useful for potential candidates who are on the limits of the audiological are on the limits of the audiological criteria or if there is uncertainty as to criteria or if there is uncertainty as to which side to place the implant. The which side to place the implant. The test rod can also be used to test rod can also be used to demonstrate the abutment, snap demonstrate the abutment, snap coupling and sound processor.coupling and sound processor.

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CounselingCounseling 1: Introduction ( How it works)1: Introduction ( How it works) 2: Benefit – Limitation2: Benefit – Limitation 3: Documentation & Pre-post fitting 3: Documentation & Pre-post fitting

assessments Questionnaire (Cosi-assessments Questionnaire (Cosi-Aphab)Aphab)

4: Realistic expectation4: Realistic expectation

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Sound processors from CochlearSound processors from Cochlear 1: BAHA 3 1: BAHA 3 2: BP 100 & BP 1102: BP 100 & BP 110 3: BAHA Intenseo3: BAHA Intenseo 4: BAHA Davino4: BAHA Davino 5: BAHA Compact5: BAHA Compact 6: Classic 3006: Classic 300 7: Cordell 7: Cordell

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Oticon productOticon product 1: Ponto1: Ponto 2:Ponto pro2:Ponto pro **Programmable, under Noah, 4 **Programmable, under Noah, 4

memory, 10 band frequency shaping, memory, 10 band frequency shaping, adaptive multi directional mic, data adaptive multi directional mic, data logginglogging

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Direct bone conductionDirect bone conduction

Summary:Summary: Works independently of ear canal and Works independently of ear canal and

middle earmiddle ear Direct transmission gives clear soundDirect transmission gives clear sound Preoperative testing possiblePreoperative testing possible High wearing comfortHigh wearing comfort Safe and simple surgerySafe and simple surgery

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Advantages of the BAHA systemAdvantages of the BAHA systemin comparison to other alternativesin comparison to other alternativesMixed and Conductive Hearing LossMixed and Conductive Hearing Loss

Over bone conduction devicesOver bone conduction devices More comfortable Better sound quality Aesthetic appearance

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Over air conduction devicesOver air conduction devices

No occlusion of the ear canal No feedback problems Sound bypasses the middle ear

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Over reconstructive surgeryOver reconstructive surgery

Predictable results Low risk for the patient Reversible surgery

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Disadvantages of other devicesMixed and Conductive Hearing Loss

Bone conduction devicesBone conduction devices Discomfort Poor sound quality Cumbersome

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Air conduction devicesAir conduction devices

Presence of ear mould aggravates infection

Acoustic feedback Dependent on middle ear function

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Reconstructive surgeryReconstructive surgery

Potential risk of hearing damage Less predictable outcome

BAHABAHA FDA Clearances

1996 – 2002

1996 – the BAHA system was cleared to treat mixed and conductive

hearing loss. 1999

– the BAHA system was cleared for pediatric use in children age five and older.

2001– the BAHA system was cleared for bilateral fittings.

2002 – the BAHA system was cleared for use in patients with

unilateral sensorineural hearing loss also known as Single Sided Deafness (SSD).

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Clinical AspectsClinical AspectsSingle Sided DeafnessSingle Sided Deafness

For adults:– Difficulties to understand in group

conversations, or with noise.– Difficulties to localize sounds,– Difficulties to understand a person situated on

the deaf side. For children:

– - School handicap.

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Unilateral sensori-neural hearing lossSingle Sided DeafnessSSD

Acoustic neuroma tumors Sudden deafness Neurological degenerative disease Genetics

Ototoxic treatments Inner ear malformation Trauma

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Options availableOptions available 1: BAHA, Implanted in the mastoid of 1: BAHA, Implanted in the mastoid of

poorer ear, transcranial routine of signalpoorer ear, transcranial routine of signal 2: Transcranial CROS, BTE or ITE power aid 2: Transcranial CROS, BTE or ITE power aid

fitted to the poorer earfitted to the poorer ear 3: Trans Ear, Quasi BC fitted to the poorer 3: Trans Ear, Quasi BC fitted to the poorer

earear 4: Wireless CROS(Phonak, Unitron)4: Wireless CROS(Phonak, Unitron) 5: Wired CROS5: Wired CROS

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BAHA CandidateBAHA CandidateSingle Sided DeafnessSingle Sided Deafness

>> 5years of age 5years of age Intended to improve speech recognitionIntended to improve speech recognition Intended for patients with SSD or unilateral sensori-Intended for patients with SSD or unilateral sensori-

neural hearing loss when the other ear is normalneural hearing loss when the other ear is normal Normal hearing is defined as PTA AC threshold equal to Normal hearing is defined as PTA AC threshold equal to

or better than 20 dB at .5, 1, 2 and 3kHzor better than 20 dB at .5, 1, 2 and 3kHz For patients who cannot or will not use AC CROS HAFor patients who cannot or will not use AC CROS HA Functions by transcranial routing of the signalFunctions by transcranial routing of the signal

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How does the BAHA system How does the BAHA system work for SSD?work for SSD?

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Advantages of the BAHA systemAdvantages of the BAHA systemin comparison to other alternativesin comparison to other alternativesSingle Sided DeafnessSingle Sided Deafness

Effective approach in patients with unilateral deafnessEffective approach in patients with unilateral deafness Alleviates the degree of hearing handicap resulting from Alleviates the degree of hearing handicap resulting from

the head shadow effectthe head shadow effect Improves speech intelligibility in noiseImproves speech intelligibility in noise Improves the patient’s quality of lifeImproves the patient’s quality of life Provided a greater perceived benefit compared to CROS Provided a greater perceived benefit compared to CROS

systemsystem

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Head-shadow EffectHead-shadow EffectReviewReview

Minimal effect at 1500Hz, but continues upward to Minimal effect at 1500Hz, but continues upward to approximately 15 dB at 5000 Hz (Staab 1988b)approximately 15 dB at 5000 Hz (Staab 1988b)

For speech the overall reduction of effective intensity is For speech the overall reduction of effective intensity is approximately 6 dB (Tillman et.al., 1963)approximately 6 dB (Tillman et.al., 1963)

Its effect on speech intelligibility is approximately a Its effect on speech intelligibility is approximately a reduction of 23% when sound is coming directly from the reduction of 23% when sound is coming directly from the ‘bad’ ear side.‘bad’ ear side.

Binaural amplification in eliminating the head shadow Binaural amplification in eliminating the head shadow effect can be about 25% or 6 dB improvement in the S/N effect can be about 25% or 6 dB improvement in the S/N ratio (from the Handbook of Clinical Audiology, Katz)ratio (from the Handbook of Clinical Audiology, Katz)

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Conclusion Conclusion Why BAHA for Single Sided DeafnessWhy BAHA for Single Sided Deafness

Effective approach in patients with unilateral Effective approach in patients with unilateral deafnessdeafness

Alleviates the degree of hearing handicap Alleviates the degree of hearing handicap resulting from the head shadow effectresulting from the head shadow effect

Improves speech intelligibility in noiseImproves speech intelligibility in noise Improves the patient’s quality of lifeImproves the patient’s quality of life Provided a greater perceived benefit compared Provided a greater perceived benefit compared

to CROS systemto CROS system