Martijn J. H. Agterberg

Comparison between a new implantable transcutaneous bone conductor and percutaneous bone-conduction hearing implant

Objectives Despite good results on osseointegration and limited skin reactions with percutaneous bone conductors, there remains room for improvement. Especially in children, adverse events with percutaneous bone conductors might occur more frequently. Transcutaneous bone conductors, if powerful enough, can provide a solution that minimizes adverse events and implant loss. This study compares a new transcutaneous bone conduction hearing aid, the Sophono Alpha 1 (Sophono), with the percutaneous BAHA system (BAHA). Methods In our tertiary referral center, 12 patients (age 5–12 yr) with congenital unilateral conductive hearing loss were enrolled in the study as follows: 6 patients with the Sophono and 6 with the BAHA. Both clinical results and audiologic data were gathered. For an objective audiologic comparison between both systems, we used a skull simulator. Results The skin reactions were comparable between both groups, in 1 implant was lost 1 month after second phase surgery (BAHA). The users received audiologic benefits from both systems. The BAHA-based outcome was slightly better compared with Sophono-based results in sound field thresholds, speech recognition threshold, and speech comprehension at 65 dB. The skull simulator demonstrated that the BAHA device has an output that is 10 to 15 dB higher compared with the Sophono device. Conclusion The Sophono offers appealing clinical benefits of transcutaneous bone conduction hearing; however, the audiologic challenges of transcutaneous application remain, as the Sophono does not exceed percutaneous application regarding audiologic output.

Improved horizontal directional hearing in bone conduction device users with acquired unilateral conductive hearing loss

We examined horizontal directional hearing in patients with acquired severe unilateral conductive hearing loss (UCHL). All patients (n = 12) had been fitted with a bone conduction device (BCD) to restore bilateral hearing. The patients were tested in the unaided (monaural) and aided (binaural) hearing condition. Five listeners without hearing loss were tested as a control group while listening with a monaural plug and earmuff, or with both ears (binaural). We randomly varied stimulus presentation levels to assess whether listeners relied on the acoustic head-shadow effect (HSE) for horizontal (azimuth) localization. Moreover, to prevent sound localization on the basis of monaural spectral shape cues from head and pinna, subjects were exposed to narrow band (1/3 octave) noises. We demonstrate that the BCD significantly improved sound localization in 8/12 of the UCHL patients. Interestingly, under monaural hearing (BCD off), we observed fairly good unaided azimuth localization performance in 4/12 of the patients. Our multiple regression analysis shows that all patients relied on the ambiguous HSE for localization. In contrast, acutely plugged control listeners did not employ the HSE. Our data confirm and further extend results of recent studies on the use of sound localization cues in chronic and acute monaural listening.

Contribution of monaural and binaural cues to sound localization in listeners with acquired unilateral conductive hearing loss: improved directional hearing with a bone-conduction device.

Sound localization in the horizontal (azimuth) plane relies mainly on interaural time differences (ITDs) and interaural level differences (ILDs). Both are distorted in listeners with acquired unilateral conductive hearing loss (UCHL), reducing their ability to localize sound. Several studies demonstrated that UCHL listeners had some ability to localize sound in azimuth. To test whether listeners with acquired UCHL use strongly perturbed binaural difference cues, we measured localization while they listened with a sound-attenuating earmuff over their impaired ear. We also tested the potential use of monaural pinna-induced spectral-shape cues for localization in azimuth and elevation, by filling the cavities of the pinna of their better-hearing ear with a mould. These conditions were tested while a bone-conduction device (BCD), fitted to all UCHL listeners in order to provide hearing from the impaired side, was turned off. We varied stimulus presentation levels to investigate whether UCHL listeners were using sound level as an azimuth cue. Furthermore, we examined whether horizontal sound-localization abilities improved when listeners used their BCD. Ten control listeners without hearing loss demonstrated a significant decrease in their localization abilities when they listened with a monaural plug and muff. In 4/13 UCHL listeners we observed good horizontal localization of 65 dB SPL broadband noises with their BCD turned off. Localization was strongly impaired when the impaired ear was covered with the muff. The mould in the good ear of listeners with UCHL deteriorated the localization of broadband sounds presented at 45 dB SPL. This demonstrates that they used pinna cues to localize sounds presented at low levels. Our data demonstrate that UCHL listeners have learned to adapt their localization strategies under a wide variety of hearing conditions and that sound-localization abilities improved with their BCD turned on.

Single-sided deafness and directional hearing: contribution of spectral cues and high-frequency hearing loss in the hearing ear

Direction-specific interactions of sound waves with the head, torso, and pinna provide unique spectral-shape cues that are used for the localization of sounds in the vertical plane, whereas horizontal sound localization is based primarily on the processing of binaural acoustic differences in arrival time (interaural time differences, or ITDs) and sound level (interaural level differences, or ILDs). Because the binaural sound-localization cues are absent in listeners with total single-sided deafness (SSD), their ability to localize sound is heavily impaired. However, some studies have reported that SSD listeners are able, to some extent, to localize sound sources in azimuth, although the underlying mechanisms used for localization are unclear. To investigate whether SSD listeners rely on monaural pinna-induced spectral-shape cues of their hearing ear for directional hearing, we investigated localization performance for low-pass filtered (LP, <1.5 kHz), high-pass filtered (HP, >3kHz), and broadband (BB, 0.5–20 kHz) noises in the two-dimensional frontal hemifield. We tested whether localization performance of SSD listeners further deteriorated when the pinna cavities of their hearing ear were filled with a mold that disrupted their spectral-shape cues. To remove the potential use of perceived sound level as an invalid azimuth cue, we randomly varied stimulus presentation levels over a broad range (45–65 dB SPL). Several listeners with SSD could localize HP and BB sound sources in the horizontal plane, but inter-subject variability was considerable. Localization performance of these listeners strongly reduced after diminishing of their spectral pinna-cues. We further show that inter-subject variability of SSD can be explained to a large extent by the severity of high-frequency hearing loss in their hearing ear.

Conductive Hearing Loss and Bone Conduction Devices: Restored Binaural Hearing?

An important aspect of binaural hearing is the proper detection of interaural sound level differences and interaural timing differences. Assessments of binaural hearing were made in patients with acquired unilateral conductive hearing loss (UCHL, n = 11) or congenital UCHL (n = 10) after unilateral application of a bone conduction device (BCD), and in patients with bilateral conductive or mixed hearing loss after bilateral BCD application. Benefit (bilateral versus unilateral listening) was assessed by measuring directional hearing, compensation of the acoustic head shadow, binaural summation and binaural squelch. Measurements were performed after an acclimatization time of at least 10 weeks. Unilateral BCD application was beneficial, but there was less benefit in the patients with congenital UCHL as compared to patients with acquired UCHL. In adults with bilateral hearing loss, bilateral BCD application was clearly beneficial as compared to unilateral BCD application. Binaural summation was present, but binaural squelch could not be proven. To explain the poor results in the patients with congenital UCHL, two factors seemed to be important. First, a critical period in the development of binaural hearing might affect the binaural hearing abilities. Second, crossover stimulation, referring to additional stimulation of the cochlea contralateral to the BCD side, might deteriorate binaural hearing in patients with UCHL.

Bilateral bone conduction devices: improved hearing ability in children with bilateral conductive hearing loss

Objectives: The aim of the study was to investigate whether children with bilateral conductive hearing loss benefit from their second device (i.e., the bilateral bone conduction device [BCD]). Design: Speech recognition in noise was assessed in 10 children fitted with bilateral BCDs during childhood. Speech recognition was measured in 2 conditions with both BCDs active. Spatial resolution was tested with the Minimum Audible Angle test in the bilateral and monaural listening conditions. Results: Children demonstrated an improvement in speech recognition when speech was presented from the front and noise was presented from the right-hand side as compared with both speech and noise being presented from the front. The minimum audible angle decreased from 57° in the best monaural condition to 13° in the bilateral condition. Conclusions: The audiological outcomes demonstrate the advantage of bilateral BCD fitting in children with bilateral conductive hearing loss.

Three-year experience with the Sophono in children with congenital conductive unilateral hearing loss: tolerability, audiometry, and sound localization compared to a bone-anchored hearing aid

Bone conduction devices (BCDs) are advocated as an amplification option for patients with congenital conductive unilateral hearing loss (UHL), while other treatment options could also be considered. The current study compared a transcutaneous BCD (Sophono) with a percutaneous BCD (bone-anchored hearing aid, BAHA) in 12 children with congenital conductive UHL. Tolerability, audiometry, and sound localization abilities with both types of BCD were studied retrospectively. The mean follow-up was 3.6 years for the Sophono users (n = 6) and 4.7 years for the BAHA users (n = 6). In each group, two patients had stopped using their BCD. Tolerability was favorable for the Sophono. Aided thresholds with the Sophono were unsatisfactory, as they did not reach under a mean pure tone average of 30 dB HL. Sound localization generally improved with both the Sophono and the BAHA, although localization abilities did not reach the level of normal hearing children. These findings, together with previously reported outcomes, are important to take into account when counseling patients and their caretakers. The selection of a suitable amplification option should always be made deliberately and on individual basis for each patient in this diverse group of children with congenital conductive UHL.

How to quantify binaural hearing in patients with unilateral hearing using hearing implants

Application of bilateral hearing devices in bilateral hearing loss and unilateral application in unilateral hearing loss (second ear with normal hearing) does not a priori lead to binaural hearing. An overview is presented on several measures of binaural benefits that have been used in patients with unilateral or bilateral deafness using one or two cochlear implants, respectively, and in patients with unilateral or bilateral conductive/mixed hearing loss using one or two percutaneous bone conduction implants (BCDs), respectively. Overall, according to this overview, the most significant and sensitive measure is the benefit in directional hearing. Measures using speech (viz. binaural summation, binaural squelch or use of the head shadow effect) showed minor benefits, except for patients with bilateral conductive/mixed hearing loss using two BCDs. Although less feasible in daily practise, the binaural masking level difference test seems to be a promising option in the assessment of binaural function.

Amplification options in unilateral aural atresia: an active middle ear implant or a bone conduction device?

Background There is no consensus on treatment of patients with congenital unilateral aural atresia. Currently, 3 intervention options are available, namely, surgical reconstruction, application of a bone-conduction device (BCD), or application of a middle ear implant. Objective The present study aims to compare the BCD with the application of a middle ear implant. We hypothesized that cross-hearing (stimulating the cochlea by means of bone conduction contralateral to the implanted side) would cause BCD users to have difficulty performing localization tasks. Methods Audiologic data of 4 adult patients with a middle ear implant coupled directly to the cochlea were compared with data of 4 adult patients fitted with an osseointegrated BCD. All patients were fitted during adulthood. The emphasis of this study is on directional hearing. Results The middle ear implant and the BCD improved sound localization of patients with congenital unilateral aural atresia. Unaided scores demonstrate a large variation. Conclusion Our results demonstrate that there was no advantage of the middle ear implant over the BCD for directional hearing in patients who had no amplification in childhood. The BCD users had the best bandwidth.

Spontaneous behavior in noise and silence: a possible new measure to assess tinnitus in Guinea pigs.

This study describes two experiments that were conducted in search for a behavioral paradigm to test for tinnitus in guinea pigs. Conditioning paradigms are available to determine the presence of tinnitus in animals and are based on the assumption that tinnitus impairs their ability to detect silent intervals in continuous noise. Guinea pigs have not been subjected to these paradigms yet; therefore, we investigated whether guinea pigs could be conditioned in the two-way shuttle-box paradigm to respond to silent intervals in noise. Even though guinea pigs could be trained relatively easy to respond to the presence of a noise interval, training guinea pigs to silent intervals in noise was unsuccessful. Instead, it appeared that they became immobile when the continuous stimulus was suddenly stopped. This was confirmed by the next experiment, in which we subjected guinea pigs to alternating intervals of noise and silence with a random duration between 30 and 120 s. Indeed, guinea pigs were significantly longer immobile during silence compared to during noise. By interpreting immobility as a signature of perceiving silence, we hypothesized that the presence of tinnitus would reduce immobility in silence. Therefore, we unilaterally exposed one group of guinea pigs to an 11-kHz tone of 124 dB sound pressure level for 1 h. A subset of the exposed animals was significantly more active in silence, but also more active in noise, as compared to the control group. The increased mobility during silent intervals might represent tinnitus. However, the increased mobility in noise of this group implies that the observed behavior could have derived from, e.g., an overall increase in activity. Therefore, conducting validation experiments is very important before implementing this method as a new screening tool for tinnitus. Follow-up experiments are discussed to further elucidate the origin of the increased mobility in both silence and noise.