Introduction Bone Anchored Implants (BAI), Candidacy and Pre-Operative Testing for Adult Patients

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1 Introduction Bone Anchored Implants (BAI), Candidacy and Pre-Operative Testing for Adult Patients Developed by Hakanssonand his colleagues in Sweden in the late 1970s 3 Components Sound Processor (#1) External Abutment (#2) Implant (#3) Elina Mindlina, Au.D, CCC-A FDA Approval Conductive and Mixed HL 1996 Single-sided Deafness 2002 Picture taken from Cochlear Corporation BAI Processors Cochlear Americas Oticon Medical Baha 4 BP110 Ponto Plus Ponto Plus Power Cordelle II Pictures taken from Google Images FDA Indication Criteria for Implantation (Mixed and Conductive Hearing Loss) BC better than or equal to 45 db HL (PTA at.5, 1, 2 & 3 khz) Cochlear Americas =Baha 4 OticonMedical = Ponto Plus BC better than or equal to 55 db HL (PTA at.5, 1, 2 & 3 khz) Cochlear Americas = BP110 OticonMedical = Ponto Plus Power BC better than or equal to 65 db HL (PTA at.5, 1, 2 & 3 khz) Cochlear Americas = Cordelle II 60% monosyllabic word score Bilateral Fitting: Symmetric bone conduction thresholds Less than a 10 db difference on average (.5, 1, 2 & 3 khz) or less than 15 db at individual frequencies FDA Indication Criteria for Implantation (Single Sided Deafness) Profound sensorineural hearing loss on the poorer hearing side Normal hearing in the opposite ear Air conduction thresholds of 20 db HL or better (measured at.5, 1, 2 & 3 khz) Baha 4 or Ponto Plus Rehabilitative Considerations Is a BAI the best option? Very limited rehab device options Chronic otitis media/externa Congenital atresia/microtia/stenosis Middle ear disease Is a BAI a reasonable option? Medically stable conductive/mixed hearing loss SSD Is a BAI a limited option? Strong HA candidate/other assistive devices Patient not interested in surgery High surgical risk 1

2 BAI Testing Protocol: Part #1 Case History Communication Analysis Listening difficulties Individual goals/expectations Previous experience with hearing assistive devices Comprehensive Audiogram Otoscopy and Immittance Testing SRTs Air and Bone conduction thresholds Word Recognition Testing BAI Testing Protocol: Part #2 Programming of Devices to be used for Testing Hearing Aid/s and CROS/BiCROS NAL-NL2 targets (real ear or simulated) Perform a Listening Check BP110/Ponto Plus Power Speech Processors Settings Full on gain (volume control adjusted to a comfortable level by patient) or program using In-Situ BC or Bone Conduction Direct portion of the software Perform a Listening Check BAI Testing Protocol: Part #3 Select Speech Materials for Testing in Quiet AzBio Sentences Northwestern University Auditory Test No.6 (NU-6) Testing in Noise Quick Speech-in-Noise Test (QuickSin) *preferred test* AzBio Sentences in Noise Bamford-Kowal-Bench Speech-in-Noise (BKB-SIN) test Special Needs Population Word Intelligibility by Picture Identification (WIPI) test Northwestern University-Children's Perception of Speech (NU-CHIPS) test Unilateral Conductive/Mixed Loss» Speech and Noise from 0 azimuth BAI on a test band Personal/stock hearing aid 50 year old female Meet Patient V.B. Right auriculectomy for basal cell carcinoma Communication Difficulties Hearing and understanding speech from the right side Hearing her TV (not enough volume) NU-6 Speech on right ear/noise on left ear 6%Unaided 62% BAI simulator Speech and Noise from 0 azimuth 60% (Unaided and BAI simulator) BAI device right side Placement of a prosthetic ear on the right side 2

3 Bilateral Conductive/Mixed Loss Speech from 0 azimuth in quiet BAI on test band Personal or stock hearing aid/s BAI on test band + HA (if time allows) Meet Patient D.C. 46 year old female with Down Syndrome Longstanding history of bilateral hearing loss PE tubes many years ago No history of significant discharge or drainage Cerumen management every 3 months Referred to Vanderbilt by ENT in Chattanooga Accompanied by mother and sister Audiogram Left Ear Flat type B tymp Ear canal volume 0.3 ml Right Ear Small anterosuperior TM perforation No evidence of a cholesteatoma Ear canal volume 0.3 ml Communication Analysis Doesn t hear unless you raise your voice Unable to fully participate in conversations Struggles on the telephone Turns up volume on TV Previous Hearing Aid Use Has never tried amplification ears are too small for custom hearing aids Daily Activities Works 2 times per week Volunteers (travels by bus) Lives with mom Goals Family Improve hearing and quality of life Better safety awareness DC Hear her friends on the phone WIPI Speech 0 azimuth in quiet Unaided 12% Bilateral HAs 80% BAI simulator right ear 80% HA left ear/bai simulator right ear 76% Trial period with Oticon Power BTE aids and skeleton earmolds 3 week follow-up visit Full time use of HAs DC can speak on the phone Family reports significant improvement in hearing Very happy with her performance Single Sided Deafness» Transcranial Attenuation (TA), Hz Low TA (0-5 db), Medium TA (6-14 db), High TA (15-21 db) Patients with Low/Medium TA are better BAI candidates BAI on test band CROS system 3

4 Meet Patient A.D. 37 year old female Hearing loss following vestibular schwannoma surgery in 2012 Communication Difficulties/Concerns Hearing speech from left side (needing repetition at work) Difficulty with sound localization *No hearing in the left ear* Quick-Sin Speech on left ear/noise on right ear 28% improvement with a Ponto Plus Power device 26% improvement with a BP110 device 18% improvement with a CROS system Patient is currently considering all options Asymmetric/Unilateral Hearing Loss Testing Set Up Unaided or with a personal HA for the better hearing ear (if pt. has one) --serves as baseline BAI on a test band (by itself or in combination with a personal HA for the better hearing ear) BiCROS system» If the poorer ear is aidable, can also test with a stock HA Meet Patient L.O. 64 year old female Right ear hearing loss since childhood Gradual progressive loss in left ear Word recognition 88% Left hearing aid not used consistently (not available for testing) Understanding around the dinner table Large group settings (conferences and social activities) Hearing in the car Quick-Sin Speech on right ear/noise on left ear 19% improvement with a BAI simulator New PhonakRITE hearing aid for the left ear BP110 right side 46 year old female Sudden hearing loss right ear following a stroke in June % word recognition Meet Patient T.W. Understanding in noisy environments, car and church Hearing the radio (not enough volume) 4

5 Quick-Sin Speech on right ear/ Noise on left ear 3% improvement with a Right hearing aid 7% improvement with a CROS system 36% improvement with a BAI simulator Transcranial Attenuation Right Left 500 Hz -20 db 500 Hz -20 db 1000 Hz -5 db 1000 Hz -5 db 2000 Hz -15 db 2000 Hz -5 db 4000 Hz -10 db 4000 Hz -0 db Low to Medium TA Fit with a loaner BAI on a soft band BAI Testing Protocol: Part #4 Device Consultation Good BAI Candidates Demonstrate devices for Cochlear Americas and Oticon Medical Determine color/power of the appropriate device for both companies Provide written literature for both companies Poor BAI Candidates or Interested in Non-Surgical Options Select product if time allows, otherwise, schedule the patient for a Hearing Aid Selection appointment References McArdle, R.A., & Wilson, R.H. (2006). Homogeneity of the 18 QuickSIN lists [Electronic Version]. Journal of the American Academy of Audiology, 17(3): Valente, M. (2012). Single Sided Deafness: Tunnel of Care, Presented in partnership with Oticon Medical.Retrieved May 22, 2012, from AudiologyOnline Web site: recordedcoursedetails.asp?class_id=