Hearing gain with a BAHA test-band in patients with

single-sided deafness

Do-Youn Kim, MD
a
, Tae Su Kim, MD
b
, Byoung Soo Shim, MD
c
, In Suk Jin, MS
a
,
Joong Ho Ahn, MD
a
, Jong Woo Chung, MD
a
, Tae Hyun Yoon, MD
a
, Hong Ju Park, MD
a,

a
Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Korea
b
Department of Otolaryngology, Kangwon National University, Korea
c
Department of Otolaryngology, Jeju Seogwipo Medical Center, Korea
A R T I C L E I N F O A B S T R A C T
Article history:
Received 9 July 2013
Purpose: It is assumed that preoperative use of a bone-anchored hearing aid (BAHA) test-
band will give a patient lower gain compared to real post-operative gain because of the
reduction of energy through the scalp when using a test-band. Hearing gains using a BAHA
test-band were analyzed in patients with unilateral hearing loss.
Materials and Methods: Nineteen patients with unilateral sensorineural hearing loss were
enrolled. A test-band, which was connected to BAHA Intenso with full-on gain, was put on
the mastoid. Conventional air-conduction (AC) pure-tone averages (PTAs) and sound-field
PTAs and speech reception thresholds (SRTs) were obtained in conditions A (the better ear
naked), B (the better ear plugged), and C (the better ear plugged with a test-band on the
poorer mastoid).
Results: Air-conduction PTAs of the poorer and better ears were 91 19 and 18 8 dB HL.
Sound-field PTAs in condition B were higher than those in condition A (54 vs. 26 dB HL),
which means that earplugs can block the sound grossly up to 54 dB HL through the better
ears. The aided PTAs (24 6 dB HL) in condition C were similar to those of the better ears in
condition A (26 9 dB HL), though condition C showed higher thresholds at 500 Hz and
lower thresholds at 1 and 2 kHz when compared to condition A. The hearing thresholds
using a test-band were similar to the published results of BAHA users with the volume to
most comfortable level (MCL).
Conclusion: Our findings showed that a BAHA test-band on the poorer ear could transmit
sound to the cochlea as much as the better ears can hear. The increased functional gain at 1
and 2 kHz reflects the technical characteristics of BAHA processor. The reduction of energy
through the scalp when using a test-band seems to be offset by the difference of output by
setting the volume to full-on gain and using a high-powered speech processor. Preoperative
hearing gains using a test-band with full-on gain seems to be similar to the post-operative
gains of BAHA users with the volume to MCL.
2014 Elsevier Inc. All rights reserved.
A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 5 ( 2 0 1 4 ) 3 7 4 1

The authors have none to declare.

Financial disclosure: None.

Conflict of interest: None.

Corresponding author. Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul
138-736, Korea. Tel.: +82 2 3010 3700; fax: +82 2 489 2773.
E-mail address: dzness@hotmail.com (H.J. Park).
0196-0709/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2013.08.015
Avai l abl e onl i ne at www. sci encedi r ect . com
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www. el sevi er . com/ l ocat e/ amj ot o
1. Introduction
Bone-anchored hearing aids (BAHAs) have been used to treat
conductive or mixed hearing loss [1] and single-sided deafness
(SSD) by inducing the trans-cranial contralateral routing of
signal [26]. The implanted titaniumscrewallows the acoustic
energy to be transmitted into the inner ears without any
reductionof energy throughthe scalp. Thus, it is assumed that
the functional gain achieved by a test-band on the mastoid
will be lower than the post-operative gain that can be obtained
by direct stimulation of the skull. Indeed, it has been reported
that the transmission to the cranium is dampened by the
underlying scalp by 1020 dB [7]. However, this numerical
value is not useful in helping patients to obtain a realistic
expectation of the hearing they will gain after surgery.
Therefore, we wanted to know how much gain the patients
with single-sided deafness can get by using a BAHA test-band
and compare the results with the published post-operative
gains of BAHA users. To test this, the hearing gains by using a
BAHA test-band were estimated in patients with SSD.
2. Patients and methods
2.1. Study population
The study group consisted of 19 patients with single-sided
sensorineural hearing loss. The conventional air-conduction
(AC) pure-tone averages of the ears of each patient differed by
at least 35 dB (Table 1). All patients had normal otoscopic
examination and tympanometry showed type A. Intact ears
showed a pure-tone average of less than 33 dB at 500 Hz,
1000 Hz, 2000 Hz and 4000 Hz.
2.2. Sound-field audiologic measurements
All audiometric tests were performed in an acoustic chamber
when using a BAHA test-band. Sound-field testing was
performed with placing the sound source 1 m away from the
patient. Two loud speakers were set at an angle of 45 just off
the horizontal axis and were placed in a slightly elongated
acoustic chamber to provide maximal space behind the
loudspeakers and to prevent summation of the first re-
flections. The subjects sat with their heads forming an angle
of 90 between the two speakers (Fig. 1). Warble tone
thresholds were measured at frequencies of 0.25, 0.5, 1, 2, 3,
and 4 kHz. Speech recognition thresholds in quiet (i.e. levels
required for 50% speech understanding) were measured by
using two-digit numbers. The order of testing as well as the
order of the test lists varied systematically between subjects,
to avoid bias due to training or fatigue. Approval for the study
was obtained from the institutional review board of Asan
medical center.
All subjects were fitted with a BAHA steel test-band, which
was connected to BAHA Intenso. For all measurements
involving BAHAs, the subjects used the same devices, in
which new batteries had been installed, at the same settings
with full-on gain. For each patient, the sound-field pure-tone
and speech threshold tests were measured in three different
conditions (Fig. 1):
Condition A (hearing when the better ear was naked)
In this condition, audiometric testing was performed in
a sound-field without ear plugs or a BAHA test-band.
Condition B (hearing when the better ear was plugged)
To specify the degree of sound attenuation induced by
an earplug, the better ear was occluded with an earplug
(E.A.R. plugs classic, Aero, Inc., Indianapolis, IN, USA) that
attenuated the hearing of sound ranging from 125 to
8000 Hz by between 23 and 42 dB.
Condition C (hearing when the better ear was plugged with a
BAHA test-band on the poorer mastoid)
The better hearing ear was occluded with an earplug.
Audiometric testing was done in the sound-field with a
BAHA test-band with full-on gain that had been placed on
the mastoid of the poorer ear.
2.3. Statistical analysis
The data were analyzed by using SPSS version 11.0 (SPSS, Inc.,
Chicago, IL, USA). Statistical analysis of paired hearing
threshold observations was performed by using the Wilcoxon
signed-rank test. Two-sided p values of <0.05 were regarded
as being statistically significant.
3. Results
Pure-tone averages of the poorer ears ranged 61110 (91 19)
dB HL and PTAs of the contralateral better ears ranged 1340
(18 8) dB HL. Speech reception thresholds of the poorer ears
ranged 56100 (91 19) dB HL and SRTs of the contralateral
better ears ranged 425 (13 6) dB HL.
3.1. The attenuating effect of an earplug in the better ear
When the better ear was naked (condition A), the sound-field
hearing thresholds were 2034 dB lower than those when the
intact ear was plugged with an earplug (condition B): at
frequencies of 0.25, 0.5, 1, 2, 3, and 4 kHz, the tonal hearing
thresholds when the better ear was plugged were higher by 20,
25, 26, 29, 34, and 33 dB, respectively, than when the better ear
Table 1 Descriptive data of the patient population
(n = 19).
Variables Mean (range) or Number (%)
Gender
Male : Female 9 (47%) : 10 (53%)
Age 52 17 (2869)
Better ears
AC PTAs, in dB HL 18 8 (533)
SRTs, in dB HL 13 6 (425)
Poorer ears
AC PTAs, in dB HL 91 19 (61110)
SRTs, in dB HL 80 16 (56100)
AC PTAs, air-conduction pure-tone averages; SRTs, speech
reception thresholds.
38 A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 5 ( 2 0 1 4 ) 3 7 4 1
was naked (Fig. 2). When the better ear was plugged (condition
B), the mean speech reception threshold (SRT) was higher by
26 dB than when the better ear was naked (45 10 vs. 19
9 dB HL).
3.2. Hearing thresholds with a BAHA test-band on the
mastoid of the poorer ear
In condition C, sound-field PTAs/SRTs (24 6/17 7 dB HL)
were similar to those of conditionA(26 9/19 9 dBHL). There
was no significant difference in PTAs in conditions A and C.
Speech reception thresholds at conditions A and C also did not
differ from each other. Hearing gains with a BAHA test-band,
which were the difference between the air-conduction PTAs of
the poorer ears and sound-field PTAs in condition C, showed a
wide range (3394 dB) according to the hearing difference
between the better and poorer ears because the aided hearing
level was similar to the hearing level of the better ear.
Although there was no significant difference in PTAs in
conditions A and C, sound-field tonal hearing thresholds in
condition C at 1 and 2 kHz were significantly lower by 7 and
2 dB than those in condition A (p < 0.05). The sound-field
tonal hearing thresholds in condition C at 250 Hz were
significantly higher by 8 dB than those in condition A
(p < 0.05). Speech reception thresholds at conditions A and C
did not differ (17 7 dB HL and 19 9 dB HL, respectively).
3.3. Comparison with published post-operative
BAHA gains
Only two patients of the study underwent BAHA surgery and
we present a representative case. The patient suffered from
sudden sensorineural hearing loss in the left ear 4 years ago
without any improvement. She underwent BAHA surgery and
used BP100 speech processor. She underwent preoperative
and postoperative hearing evaluation (Fig. 3A). Preoperative
air-conduction PTAs of the better ear were 5 dB HL. Preoper-
ative sound-field thresholds in conditions A and C were
slightly lower than postoperative thresholds using BAHA with
the better ear plugged. The air-conduction thresholds of the
better ear were lower than those of sound-field tonal
thresholds in condition A and C.
Similarly, the air-conduction thresholds of the better ears
of the 19 patients in this study were lower than those of
sound-field tonal thresholds in condition C by 9 9, 4 6, 4
6, 4 8, 6 10, and 11 14 dB at frequencies of 0.25, 0.5, 1, 2, 3,
and 4 kHz, respectively (Fig. 3B). These threshold differences
were similar to the post-operative differences experienced by
BAHA users, as published by Pfiffner et al. [8], in which the
volume was set to the most comfortable level (MCL). These
findings suggest that preoperative hearing thresholds using a
BAHA test-band (condition C) are similar to or slightly better
than the postoperative hearing thresholds using BAHA.
4. Discussion
In the present study, the better ear was plugged to ensure that
the aided sound-field hearing thresholds with a BAHA test-
band on the mastoid of the poorer ear (condition C) only
reflected the hearing through the BAHAtest-band not through
testband
ear-plug ear-plug
Fig. 1 Three different conditions for sound-field audiometry.
4,000 3,000 2,000 1,000 500 250
-10
0
10
20
30
40
50
60
70
80
90
100
110
Hearing with the better ear (condition A)
Aided hearing with a BAHA test-band (condition C)
Frequency (Hz)
S
o
u
n
d
-
f
i
e
l
d

p
u
r
e
-
t
o
n
e

t
h
r
e
s
h
o
l
d

(
d
B

H
L
)
Hearing with the better ear plugged (condition B)
*
*
*p<0.01, Wilcoxon's signed-ranks test
Fig. 2 Sound-field tonal thresholds (mean SE) at 3
different conditions (A, B, and C). Compared to condition A
(hearing with better ear), the hearing thresholds in condition
C (hearing with a BAHA test-band with the better ear
plugged) were higher at 250 Hz and lower at 1 and 2 kHz.
39 A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 5 ( 2 0 1 4 ) 3 7 4 1
the better ear canal itself. Because the mean sound-field
speech reception thresholds (45 10 dB HL) when the better
ear was plugged (condition B) were higher than those in
condition C (17 7 dB HL), we could be sure that earplugs
effectively blocked hearing through a better ear canal.
A previous study has shown that the pre-operative bone-
conduction threshold of the intact ear correlates well with the
post-operative aided thresholds of BAHA users, especially in
patients withSSD, and thus can be used to estimate the degree
of improvement after surgery [8]. In the present study, the
speech reception thresholds (17 7 dB HL) in condition C,
which represent the aided hearing level by using BAHA, were
similar to those (19 9 dB HL) in condition A, which represent
the threshold of the better ear. Even, the tonal hearing
thresholds in condition C were lower (better) than those at 1
and 2 kHz in condition A (Fig. 2). This can be explained, given
the manufacturers data sheet [9], in which BAHA is reported
to have maximal output at 5002000 Hz in the frequency
response curve.
When using a BAHA test-band, the BAHA interfaces with
the bone through a layer of soft tissue which can dampen the
transmission and decrease the effective amplification [7]. This
sound attenuation is reported to be 520 dB at frequencies of 1
to 4 kHz [10]. Our tonal and speech test results using a test-
band were similar to those reported in an earlier study [8],
where the post-operative gains of BAHA users were examined
with the volume control set at MCL. In the present study, the
increase of output by setting the volume control of speech
processor to full-on gain might have been offset by the
attenuation effect of the soft tissue. The functional gain is
also influenced by the types of BAHA processors. Because
there was a trend toward higher gains with Intenso and Divino
than with Compact [11,12], the increase of output could have
been added by using Intenso in this study.
In summary, our findings showed that a BAHA test-band
on the poorer ear could transmit sound to the cochlea as much
as the better ears can hear. The increased functional gain at 1
and 2 kHz reflects the technical characteristics of BAHA
processor. The reduction of energy through the scalp when
using a test-band seems to be offset by the difference of
output by setting the volume to full-on gain and using a high-
powered speech processor. Preoperative hearing gains using a
test-band with full-on gain seem to be similar to the post-
operative gains of BAHA users with the volume to MCL.
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70
60
50
40
30
20
10
0
-10
-20
4,000 3,000 2,000 1,000 500 250
Frequency (Hz)
A
i
d
e
d

P
T
A
s

m
i
n
u
s

A
C

P
T
A
s

o
f

b
e
t
t
e
r

e
a
r
s

(
d
B
)
*
*
*
*
S
S
S
S
S S
C
C C
C
C
A
A A
A
A C A
A
B
H
e
a
r
i
n
g

L
e
v
e
l

i
n

d
B

H
L
Fig. 3 (A) Audiologic results in a patient with single-sided
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Preoperative air-conduction pure tone thresholds (O), sound-
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with a BAHA test-band with the better ear plugged (C), and
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(S) were displayed. (B) In this study, sound-field thresholds
with a BAHA test-band with the better ear plugged were
higher than air-conduction (AC) pure-tone thresholds of the
better ears. For comparison, the post-operative differences
between the air-conduction pure-tone thresholds of the
better ears and the aided hearing with a BAHA on the poorer
side and with the better ear plugged froma previous study by
Pfiffner et al. are displayed as asterisks. The negative values
indicate over-closure.
40 A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 5 ( 2 0 1 4 ) 3 7 4 1
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41 A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 5 ( 2 0 1 4 ) 3 7 4 1