1. Bone Anchored Hearing Aids Dr. Amir Soltani Clinical Audiologist UBC Resident Otology Lecture Series BC Children Hospital Sep 13, 2013

2. BAHA www.dramirsoltani.com/links/baha What is the BAHA system What is the BAHA system A well recognized hearing treatment for conductive and mixed hearing losses since 1977,As well as SSD A well recognized hearing treatment for conductive and mixed hearing losses since 1977,As well as SSD The BAHA system is composed of three parts: a titanium implant, an external abutment and a sound processor The BAHA system is composed of three parts: a titanium implant, an external abutment and a sound processor

3. BAHA

4. BAHA In the early 1960s it has discovered that titanium provides an excellent material for implantable devices. Titanium is accepted by the human body and forms a bond with surrounding bone. In the early 1960s it has discovered that titanium provides an excellent material for implantable devices. Titanium is accepted by the human body and forms a bond with surrounding bone. This is a process termed “osseointegration,” which takes place as the titanium implant integrates and forms a permanent structure with the living bone. The process of bone osseointegration is also the foundation for dental implants.. This is a process termed “osseointegration,” which takes place as the titanium implant integrates and forms a permanent structure with the living bone. The process of bone osseointegration is also the foundation for dental implants..

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

6. BAHA A sound processor picks up sound vibrations. A sound processor picks up sound vibrations. An abutment is attached to the sound processor and the implant. The abutment transfers the sound vibrations from the processor to the implant. An abutment is attached to the sound processor and the implant. The abutment transfers the sound vibrations from the processor to the implant. Titanium implant is placed in the mastoid process, where it fuses with the living bone (osseointegration). The implant transfers the sound vibrations to the functioning cochlea. Titanium implant is placed in the mastoid process, where it fuses with the living bone (osseointegration). The implant transfers the sound vibrations to the functioning cochlea. This creates direct (percutaneous) bone conduction. In contrast, traditional BC hearing aids connect indirectly to the bone through unbroken skin (transcutaneous) and work by exerting pressure against the skull. This creates direct (percutaneous) bone conduction. In contrast, traditional BC hearing aids connect indirectly to the bone through unbroken skin (transcutaneous) and work by exerting pressure against the skull.

7. BAHA Types of hearing loss the BAHA system can help Types of hearing loss the BAHA system can help Mixed and Conductive hearing loss – unilateral or bilateral fitting Mixed and Conductive hearing loss – unilateral or bilateral fitting –Due to examples such as:  Chronic otitis media  Congenital atresia  Cholesteatoma  Middle ear dysfunction/disease  External otitis

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

9. BAHA BAHA Candidate Mixed and Conductive Hearing Loss BAHA Candidate Mixed and Conductive Hearing Loss > 5 years of age > 5 years of age or equal to 60% speech discrimination scores or equal to 60% speech discrimination scores Symmetric bone conduction thresholds are defined as less than 10 dB difference in average or less than 15 dB at individual frequencies (0.5, 1, 2, and 4Khz) Symmetric bone conduction thresholds are defined as less than 10 dB difference in average or less than 15 dB at individual frequencies (0.5, 1, 2, and 4Khz)

10. BAHA Bilateral Conductive Hearing Loss Bilateral Conductive Hearing Loss

11. BAHA Biateral mixed hearing loss Biateral mixed hearing loss

12. BAHA Severe Mixed or Sensorineural Hearing Loss

13. BAHA Unilateral Conductive Hearing Loss Canal Atresea

14. BAHA Audiological Assessments: Audiological Assessments: 1: Pure tone Audiometry, including AC&BC testing 1: Pure tone Audiometry, including AC&BC testing 2: Speech tests through insert receiver or headphones + Bone vibrator testing 2: Speech tests through insert receiver or headphones + Bone vibrator testing A: SRT B: SDS C: Quick SIN A: SRT B: SDS C: Quick SIN

15. BAHA Impedance testing includling: (If possible) Impedance testing includling: (If possible) Conventional (low probe tone) tympanometry and high probe tone if necessary Conventional (low probe tone) tympanometry and high probe tone if necessary Acoustic reflex thresholds, Ipsi & Contra Lateral stimuli Acoustic reflex thresholds, Ipsi & Contra Lateral stimuli OAE OAE

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

17. BAHA Counseling Counseling 1: Introduction ( How it works) 1: Introduction ( How it works) 2: Benefit – Limitation 2: Benefit – Limitation 3: Documentation & Pre-post fitting assessments Questionnaire (Cosi-Aphab) 3: Documentation & Pre-post fitting assessments Questionnaire (Cosi-Aphab) 4: Realistic expectation 4: Realistic expectation

18. BAHA Sound processors from Cochlear Sound processors from Cochlear 1: BAHA 3 1: BAHA 3 2: BP 100 & BP 110 2: BP 100 & BP 110 3: BAHA Intenseo 3: BAHA Intenseo 4: BAHA Davino 4: BAHA Davino 5: BAHA Compact 5: BAHA Compact 6: Classic 300 6: Classic 300 7: Cordell 7: Cordell

19. BAHA Oticon product Oticon product 1: Ponto 1: Ponto 2:Ponto pro 2:Ponto pro **Programmable, under Noah, 4 memory, 10 band frequency shaping, adaptive multi directional mic, data logging **Programmable, under Noah, 4 memory, 10 band frequency shaping, adaptive multi directional mic, data logging

20. BAHA Direct bone conduction Direct bone conductionSummary: Works independently of ear canal and middle ear Works independently of ear canal and middle ear Direct transmission gives clear sound Direct transmission gives clear sound Preoperative testing possible Preoperative testing possible High wearing comfort High wearing comfort Safe and simple surgery Safe and simple surgery

21. BAHA Advantages of the BAHA system in comparison to other alternatives Mixed and Conductive Hearing Loss Advantages of the BAHA system in comparison to other alternatives Mixed and Conductive Hearing Loss Over bone conduction devices Over bone conduction devices More comfortable Better sound quality Aesthetic appearance

22. BAHA Over air conduction devices Over air conduction devices No occlusion of the ear canal No feedback problems Sound bypasses the middle ear

23. BAHA Over reconstructive surgery Over reconstructive surgery Predictable results Low risk for the patient Reversible surgery

24. BAHA Disadvantages of other devices Mixed and Conductive Hearing Loss Bone conduction devices Bone conduction devices Discomfort Poor sound quality Cumbersome

25. BAHA Air conduction devices Air conduction devices Presence of ear mould aggravates infection Acoustic feedback Dependent on middle ear function

26. BAHA Reconstructive surgery Reconstructive surgery Potential risk of hearing damage Less predictable outcome

27. BAHA 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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29. BAHA Clinical Aspects Single Sided Deafness Clinical Aspects Single 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.

30. BAHA Unilateral sensori-neural hearing loss Single Sided Deafness SSD   Acoustic neuroma tumors   Sudden deafness   Neurological degenerative disease   Genetics   Ototoxic treatments   Inner ear malformation   Trauma

31. BAHA Options available Options available 1: BAHA, Implanted in the mastoid of poorer ear, transcranial routine of signal 1: BAHA, Implanted in the mastoid of poorer ear, transcranial routine of signal 2: Transcranial CROS, BTE or ITE power aid fitted to the poorer ear 2: Transcranial CROS, BTE or ITE power aid fitted to the poorer ear 3: Trans Ear, Quasi BC fitted to the poorer ear 3: Trans Ear, Quasi BC fitted to the poorer ear 4: Wireless CROS(Phonak, Unitron) 4: Wireless CROS(Phonak, Unitron) 5: Wired CROS 5: Wired CROS

32. BAHA BAHA Candidate Single Sided Deafness BAHA Candidate Single Sided Deafness > 5years of age > 5years of age Intended to improve speech recognition Intended to improve speech recognition Intended for patients with SSD or unilateral sensori- neural hearing loss when the other ear is normal Intended for patients with SSD or unilateral sensori- neural hearing loss when the other ear is normal Normal hearing is defined as PTA AC threshold equal to or better than 20 dB at.5, 1, 2 and 3kHz Normal hearing is defined as PTA AC threshold equal to or better than 20 dB at.5, 1, 2 and 3kHz For patients who cannot or will not use AC CROS HA For patients who cannot or will not use AC CROS HA Functions by transcranial routing of the signal Functions by transcranial routing of the signal

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

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35. BAHA Advantages of the BAHA system in comparison to other alternatives Single Sided Deafness Advantages of the BAHA system in comparison to other alternatives Single Sided Deafness Effective approach in patients with unilateral deafness Effective approach in patients with unilateral deafness Alleviates the degree of hearing handicap resulting from the head shadow effect Alleviates the degree of hearing handicap resulting from the head shadow effect Improves speech intelligibility in noise Improves speech intelligibility in noise Improves the patient’s quality of life Improves the patient’s quality of life Provided a greater perceived benefit compared to CROS system Provided a greater perceived benefit compared to CROS system

36. BAHA Head-shadow Effect Review Head-shadow Effect Review Minimal effect at 1500Hz, but continues upward to approximately 15 dB at 5000 Hz (Staab 1988b) Minimal effect at 1500Hz, but continues upward to approximately 15 dB at 5000 Hz (Staab 1988b) For speech the overall reduction of effective intensity is approximately 6 dB (Tillman et.al., 1963) For speech the overall reduction of effective intensity is approximately 6 dB (Tillman et.al., 1963) Its effect on speech intelligibility is approximately a reduction of 23% when sound is coming directly from the ‘bad’ ear side. Its effect on speech intelligibility is approximately a reduction of 23% when sound is coming directly from the ‘bad’ ear side. Binaural amplification in eliminating the head shadow effect can be about 25% or 6 dB improvement in the S/N ratio (from the Handbook of Clinical Audiology, Katz) Binaural amplification in eliminating the head shadow effect can be about 25% or 6 dB improvement in the S/N ratio (from the Handbook of Clinical Audiology, Katz)

37. BAHA BAHA Conclusion Why BAHA for Single Sided Deafness Conclusion Why BAHA for Single Sided Deafness Effective approach in patients with unilateral deafness Effective approach in patients with unilateral deafness Alleviates the degree of hearing handicap resulting from the head shadow effect Alleviates the degree of hearing handicap resulting from the head shadow effect Improves speech intelligibility in noise Improves speech intelligibility in noise Improves the patient’s quality of life Improves the patient’s quality of life Provided a greater perceived benefit compared to CROS system Provided a greater perceived benefit compared to CROS system