1. Clinic Hearing Aid Comparisons: CROS Technology
Scot Frink, AuD
Salem Audiology Clinic
California Academy of Audiology
September, 2018

2. Disclaimers
Independent practitioner; do not work for or have any vested interest in any hearing aid manufacturer.
AmpCROS is not my original idea (I will elaborate shortly)

3. Overview
Brief review of available CROS / BiCROS Solutions for Single-Sided Deafness
Review of the previous comparison studies by Salem Audiology Clinic
Discussion of AmpCROS as a solution

4. Salem Audiology Clinical Comparison Studies
2000: Phonak (Adult utilization of FM technology)
2005: Phonak, Unitron, Interton (CROS)
2007: Phonak, Starkey (Feedback control)
2010: Phonak, Unitron (CROS)
2014: Phonak, Widex (CROS)
2015: Superpower BTE vs. RIC
: Phonak, Widex, Starkey, Signia (CROS)
: AmpCROS Case studies
2017 (in progress): Unitron, Widex, Signia (Tinnitus)
2018 (in development): OTC vs. Prescribed comparison

5. Salem Audiology Clinical Comparison Studies
2000: Phonak (Adult utilization of FM technology)
2005: Phonak, Unitron, Interton (CROS)
2007: Phonak, Starkey (Feedback control)
2010: Phonak, Unitron (CROS)
2014: Phonak, Widex (CROS)
2015: Superpower BTE vs. RIC
: Phonak, Widex, Starkey, Signia (CROS)
: AmpCROS Case studies
2017 (in progress): Unitron, Widex, Signia (Tinnitus)
2018 (in development): OTC vs. Prescribed comparison

6. Salem Audiology Clinical Comparison Studies
2000: Phonak (Adult utilization of FM technology)
2005: Phonak, Unitron, Interton (CROS)
2007: Phonak, Starkey (Feedback control)
2010: Phonak, Unitron (CROS)
2014: Phonak, Widex (CROS)
2015: Superpower BTE vs. RIC
: Phonak, Widex, Starkey, Signia (CROS)
: AmpCROS Case studies
2017 (in progress): Unitron, Widex, Signia (Tinnitus)
2018 (in development): OTC vs. Prescribed comparison

7. Salem Audiology Clinical Comparison Studies
2000: Phonak (Adult utilization of FM technology)
2005: Phonak, Unitron, Interton (CROS)
2007: Phonak, Starkey (Feedback control)
2010: Phonak, Unitron (CROS)
2014: Phonak, Widex (CROS)
2015: Superpower BTE vs. RIC
: Phonak, Widex, Starkey, Signia (CROS)
: AmpCROS Case studies
2017 (in progress): Unitron, Widex, Signia (Tinnitus)
2018 (in development): OTC vs. Prescribed comparison

8. Salem Audiology Clinical Comparison Studies
2000: Phonak (Adult utilization of FM technology)
2005: Phonak, Unitron, Interton (CROS)
2007: Phonak, Starkey (Feedback control)
2010: Phonak, Unitron (CROS)
2014: Phonak, Widex (CROS)
2015: Superpower BTE vs. RIC
: Phonak, Widex, Starkey, Signia (CROS)
: AmpCROS Case studies
2017 (in progress): Unitron, Widex, Signia (Tinnitus)
2018 (in development): OTC vs. Prescribed comparison

9. Summary Each manufacturer have their strengths and weaknesses.
Widex: Speech clarity, music, tinnitus
Phonak: Background noise, cosmetics, form factors.
New product introductions may change this
Rechargeable options (All)
Own speech quality (Signia)
Direct Connectivity (Signia)

10. Menti Question 2A!

13. What about the Unitron AmpCROS?

14. What about Unitron?
The “AmpCROS” is not a specific product, but more of a method to jury-rig a hearing aid system to function in the same capacity as a CROS / BiCROS system.
I take no credit for the creation of the concept, only it’s perpetuation.
How is it done?

15. Explaining AmpCROS
Any Unitron product that has the “Binaural Phone” feature can be set up this way (or, for that matter, any manufacturer that has a binaural phone feature).
For Unitron, currently, the “600” level or higher.
NOT limited to Unitron; any company with a binaural acoustic telephone feature can do this (Unitron, Phonak, Signia, Starkey, Widex)
Currently, not available for ReSound or Oticon.

16. Explaining AmpCROS First, add the binaural phone product as program #2
Set it as the “Start-up” program (if possible)
Configure it so that the telephone ear is the same as the bad side (counter-intuitive)
This effectively then works by transferring sound from that side to the other side.
New concept!

17. Explaining AmpCROS New concept: “Trinaural hearing”
#1: Direct stimulation to the better ear.
#2: Wireless transmission from bad side to better side.
#3: Direct stimulation to the bad side
Possible maintenance of summation effect plus the benefit of CROS transference

18. Explaining AmpCROS
It is paramount to complete Real Ear testing when doing an AmpCROS since the default algorithm is for a telephone setting, not one developed for face-to-face speech.

19. Explaining AmpCROS Downsides
Cost: you’re paying for two hearing aids, not an aid and a transmitter.
Performance: Since you’re using the binaural phone setting, many of the other features that would normally benefit the patient in the standard automatic feature (Directionality, Automatic Navigation between environments, etc.) are turned off.

20. Explaining AmpCROS When to consider an AmpCROS?
If auditory deprivation is a concern (i.e. some remaining residual hearing in the bad ear).
Preserving the nerve for future use (CI).
If the patient was fit with a system and then suffers from SSD.
If hearing loss fluctuates (i.e. Meniere’s Disease).
Rechargeability*

21. Explaining AmpCROS Myths about AmpCROS
“Giving the patient a limited amount of amplification on the bad side helps to avoid auditory deprivation”
This depends on if there is any residual hearing remaining. If there isn’t, stimulation there won’t matter.

22. Explaining AmpCROS Myths about AmpCROS
“Utilizing a tinnitus management strategy for the poorer side can help if that is where the tinnitus is percieved.”
Again, if it’s a dead ear, it’s a dead ear. If there is residual hearing left, that side may pick up the tinnitus noise generator, but the distortion involved minimizes its benefit. Better to stimulate the better ear since tinnitus is perceived in the brain, not an impaired cochlea

23. Explaining AmpCROS Myths about AmpCROS
“Unitron is the only company that can do AmpCROS”
Truth: Any product capable of binaural acoustic telephone is capable of AmpCROS
Includes: Unitron, Phonak, Signia, Widex, Starkey
Not available: ReSound, Oticon --yet

24. Explaining AmpCROS
Need an IIC CROS? Check with Starkey…

25. Verifying Candidacy
If absolutely no residual hearing, go with traditional CROS / BiCROS.
If there is some residual hearing, base candidacy on WRS scores

26. Verifying Candidacy Better ear: 80% Worse ear: 20% Binaural:
Improves to 96%, go with binaural fit
Degrades to 64%, go with BiCROS
Doesn’t change? Consider AmpCROS

27. Patient Zero
Case Study: Irma, age 56

28. Patient Zero Case Study: Irma, age 56
Initially presented with a mild binaural loss with slight symmetry (September 2016)
Left WRS: 45dbHL
Right WRS: 45dbHL
Binaural WRS: 45dBHL
Previou user (fit elsewhere) of both CICs and RICs
Fit with Unitron Stride Pro CICs

29. Patient Zero Case Study: Irma, age 56
Many issues with performance and fluctuation in volume
Many complaints about the loudness of her own voice (occlusion?)
Despite good REM results, generally preferred gain set higher than recommended.
Patient had many problems, nearly cancelled purchase

30. Patient Zero Case Study: Irma, age 56
October, 2016: Problems with perception of loudness continued along with increasing perception of tinnitus, particularly in the left ear.
Re-tested, and demonstrated significant asymmetrical low-frequency decrease in her left ear. Referred to ENT.

31. Patient Zero Case Study: Irma, age 56
Aided WRS: Right 100%, Left 24%, Binaural 100%

32. Patient Zero Case Study: Irma, age 56
December, 2016: Diagnosed with Meniere’s Disease
What do we do now?

33. Patient Zero Case Study: Irma, age 56 AmpCROS time!
Re-set start-up program to Acoustic program
Took appropriate measures for matching to Right ear REM target.
Reprogrammed automatic program for traditional settings when Meniere’s isn’t an issue.

34. AmpCROS Mini-Study
Repeated study methodology from 4-manufacturer CROS study
Subjective survey
Objective sound field testing

35. AmpCROS Mini-Study Eight individuals, all previous CROS / BiCROS users
Some degree of residual hearing in the worse ear

36. AmpCROS Mini-Study Aid Aided CROS Overall Unaided Company Only w/CROS
Aid
Aided
CROS
Overall
Unaided
Company
Only
w/CROS
Improvement
51%
BiCROS
71%
87%
20%
16%
36%
43%
AmpCROS#1—Unitron
93%
22%
42%
AmpCROS#2—Original
92%
21%
41%

37. Case Studies Case Study: Lynise, age ??? Previous CROS user
Complete VIII nerve removal
WRS 0% Left, 100% Right, 100% binaural
Severe tinnitus in the Left ear

38. Case Studies Case Study: Lynise, age ??? NOT an AmpCROS candidate.
Uses Widex Dream Fashion CROS system
Zen Sounds do help with the tinnitus

39. Case Studies Case Study: Steel, age 52 Previous CROS user
WRS 88% Right, 20% Left, 92% binaural
Severe tinnitus Left

40. Case Studies Case Study: Steel, age 52
Fit with Unitron Moxi Fit 800 Rechargeable
Right ear standard receiver, closed dome
Left ear cShell with Super Power receiver
Program
P1: Automatic (SoundNav)
P2: AmpCROS (Binaural Phone)
P3: Conversation in Crowd
P4: AmpCROS with Tinnitus Management
Prefers AmpCROS setting most of the time, mainly to assist with tinnitus (but not the tinnitus management setting)

41. Case Studies Case Study: Kirk, age 61 New user
WRS 0% Right, 92% Left, 92% binaural
Ordered the new Phonak Audeo BR90 with CROS BR

42. Case Studies Case Study: Kirk, age 61 New user
WRS 0% Right, 92% Left, 92% binaural
Ordered the new Phonak Audeo BR90 with CROS BR

43. Case Studies Case Study: Kirk, age 61
“Not available until Spring, 2018” (Defined as March 22 to June 21)
Stop-Gap fitting: Phonak Audeo V90 demo units configured in an AmpCROS format

44. Case Studies Case Study: Kirk, age 61
“Just wanted to let you know I love the Hearing Aids. I have already heard so many sounds around me that I have never been able to hear! I am so impressed. The sound quality is exceptional. Just want to thank you for all you have done for me. It is totally amazing what I have missed for the past 55 years. I will see you next week for my next appointment.”

45. Case Studies
Lloyd, age 72
Long-term user, currently with Phonak Naida “S” IX UP BTEs from 2012
WRS 40% Right, 12% Left, 56% binaural

46. Case Studies
Lloyd, age 72
Could not give him enough gain in the Left ear to achieve any perception of benefit when fit binaural—without feedback (SoundRecover turned on)

47. Case Studies
Lloyd, age 72
Added an “AmpCROS” program so that he could try it out and see if it helped. Did not take away his regular programs or change AmpCROS to Start-up.

48. Case Studies
Lloyd, age 72
Used about 12dB less gain on the Left side, 4dB less on the Right side.
WRS improved from 56% binaural to 68%

49. Menti Question 2B!

50. Individual Manufacturer Set-ups
Unitron
Select a 600-level instrument or higher
Go to “Programs”
Acoustic telephone defaults; turn off Easy-t
Rename it “AmpCROS”
Go to “Configure Features”
Go to “Specific Features”  “Binaural Phone”
“Enable Binaural Phone” should be checked
Set the bad ear as the “Preferred Ear” (Counter-intuitive)

51. Individual Manufacturer Set-ups
Unitron
Go to “End Fitting”
Select “Start-up Settings”
Set Start-up to “Acoustic Telephone”
Select “Program Toggle Exceptions”
Disable “SoundNav”

52. Individual Manufacturer Set-ups
Unitron
Go to “Fitting”  “Tuning” and reduce Bad Ear Gain by 50% to start from it’s default
If patient perceives distortion when that side is active, reduce gain further until distortion is no longer perceived.
If patient perceives no sound from that side, increase gain in 2dB increments until it is or distortion is perceived.
If feedback is present in either case, use normal measures to correct it (FB manager, dome size, reduce gain / HFs).

53. Individual Manufacturer Set-ups
Phonak
Select a 50-level instrument or higher
Go to “Programs”
Acoustic telephone defaults; turn off EasyPhone
Rename it “AmpCROS”
Change it to be Program 1 via pull-down menu for position
Mark it as “Start-up”
Change “AutoSense” position pull-down to not be accessible (or keep it?)

54. Individual Manufacturer Set-ups
Phonak
Go to “Program Options”
Make sure “DuoPhone” is enabled (default)
Disable “DirectTouch
Set the bad ear as the “Preferred Ear” (Counter-intuitive)

55. Individual Manufacturer Set-ups
Phonak
Go to “Gain & MPO” and reduce Bad Ear Gain by 50% to start from its default
If patient perceives distortion when that side is active, reduce gain further until distortion is no longer perceived.
If patient perceives no sound from that side, increase gain in 2dB increments until it is or distortion is perceived.
If feedback is present in either case, use normal measures to correct it (FB manager, dome size, reduce gain / HFs).

56. Individual Manufacturer Set-ups
Starkey
Select a i1600 or higher product
On the “Quick Fit” Screen
Select Program 2 to be “Telephone” (not “AutoPhone”, “Telecoil”, or Autocoil”)
Can’t re-name
Can’t set “Start-up” Differently; have to manually go to Program 2 every day

57. Individual Manufacturer Set-ups
Starkey
Go to “Fine-Tuning” and reduce Bad Ear Gain by 50% to start from its default
If patient perceives distortion when that side is active, reduce gain further until distortion is no longer perceived.
If patient perceives no sound from that side, increase gain in 2dB increments until it is or distortion is perceived.
If feedback is present in either case, use normal measures to correct it (FB manager, dome size, reduce gain / HFs).

58. Individual Manufacturer Set-ups
Widex
Select a 330-level instrument or higher
Go to “Fine Tuning”  “Program Manager”
Add “Phone +”
Regarding “preferred ear” and “Start-up”, there is no wait to set up the defaults for this in the Compass software.
The patient must manually activate Phone+ by a long press of the button each day after they’ve put them on.
No way to rename

59. Individual Manufacturer Set-ups
Widex
Go to “Fine Tuning” and reduce Bad Ear Gain by 50% to start from its default
If patient perceives distortion when that side is active, reduce gain further until distortion is no longer perceived.
If patient perceives no sound from that side, increase gain in 2dB increments until it is or distortion is perceived.
If feedback is present in either case, use normal measures to correct it (FB manager, dome size, reduce gain / HFs).

60. Individual Manufacturer Set-ups
Signia
Select a “3” level instrument or higher
Go to “Program Handling”
Select “Phone”  “Twin Phone”
You will get a pop-up, asking you which ear is the Phone / Bad Ear. Proceed accordingly.
Rename it “AmpCROS”

61. Individual Manufacturer Set-ups
Signia
Go to “Fine Tuning”  “Microphone / Audio”
Set “Input Configuration” with Contra-Lateral Microphone level at “Max” (0dB attentuation)
No way to change it to be start-up, so patient will have to manually change to Program 2 every day.

62. Individual Manufacturer Set-ups
Signia
Go to “Fine Tuning”  Frequency Shaping and reduce Bad Ear Gain by 50% to start fro its default
If patient perceives distortion when that side is active, reduce gain further until distortion is no longer perceived.
If patient perceives no sound from that side, increase gain in 2dB increments until it is or distortion is perceived.
If feedback is present in either case, use normal measures to correct it (FB manager, dome size, reduce gain / HFs).

63. Individual Manufacturer Set-ups
ALL Manufacturers…
Perform Real Ear Measurements on the Good Ear as you normally would; Keep the Bad Ear instrument muted during this.
Once completed, rotate the patient 90 degrees, as if you are going to present to the bad ear but still measure REMs in the good ear.
Reduce presentation level from 65dBSPL to 60dBSPL (head shadow)
REM results should be in the target, may be slightly high.

64. Summary
AmpCROS is a back-up alternative to traditional CROS amplification.
Should only be used in certain situations
Fluctuating hearing loss
Post-fitting SSD
Maintaining residual hearing
…to preserve nerve function (CI)
…for tinnitus situations