INNOVATIVE TECHNIQUES

THE BONE-ANCHORED HEARING DEVICE

(BAHA)
ROBERT A. BATTISTA, MD, FACS, STEVEN HO, MD

The bone-anchoring hearing device (BAHA) is an osseointegrated system that is used for hearing rehabilitation
through direct bone conduction. The indications for the BAHA include unilateral and/or bilateral conductive or
mixed hearing loss, and unilateral profound sensorineural hearing loss. When used for unilateral profound
sensorineural hearing loss, the BAHA acts as a bone conduction CROS (contralateral routing of off-side signal)
device transmitting the signal from the deaf side through the skull to the contralateral cochlea. The surgical
procedure to place the abutment and titanium screw is straightforward. In general, the satisfaction rate is very
high for patients using the BAHA system.

The bone-anchored hearing device (BAHA, Entific Medi-
cal Systems, Göteborg, Sweden) is an osseointegrated sys-
tem that is used for hearing rehabilitation through direct
bone conduction. As such, the BAHA is an alternative for
traditional bone-conduction and air-conduction hearing
devices. The BAHA system consists of 3 components: (1) a
titanium screw, (2) a percutaneous abutment, and (3) a
sound processor. The titanium screw is surgically im-
planted behind the hearing-impaired ear and is allowed to
osseointegrate into the skull. The percutaneous abutment
is then attached to the implant, and the sound processor
snaps onto the abutment after an appropriate period of
osseointegration. Unlike conventional bone conduction
devices, the BAHA does not require pressure on the skin
for coupling, and sound vibrations are not attenuated by
skin and soft tissue. Instead, the BAHA vibrates the skull
directly through the titanium screw. In addition, some of
the problems of air-conduction devices are avoided be-
cause the BAHA is not worn in the ear canal.
Auditory rehabilitation with the BAHA system is
achieved through transcranial vibration of cochlear fluids.
Vibratory energy reaching the cochlea generates segmen-
tal compression and expansion of the cochlear shell, which
in turn, causes compression of cochlear fluids.1 This form
of sound transmission can occur with a vibrational source
placed almost anywhere on the skull. Transcranial atten-
uation of signals does occur, with high-frequency signals
attenuated to a higher degree than low-frequency signals.2
Although high-frequency signals are partially attenu-
ated through transcranial stimulation, direct bone conduc-
tion with the BAHA achieves superior, high-frequency
hearing gain compared with conventional bone-conduc-
tion devices. The BAHA can achieve a relative 7 to 17 dB
From the Department of Otolaryngology-Head and Neck Surgery,
Northwestern University, Feinberg School of Medicine, Chicago, IL.
Address reprint requests to Robert Battista, Chicago Otology Group,
LLC, 950 N. York Rd., Ste. 102, Hinsdale, IL 60521.
© 2003 Elsevier Inc. All rights reserved.
1043-1810/03/1404-0010$30.00/0
doi:10.1053/S1043-1810(03)00095-2
gain between 3 and 8 kHz compared with conventional
bone-conduction devices.3 As a result, the satisfaction rate
is much higher for BAHA users than traditional bone-
conduction users (98% versus 73%, respectively). The
BAHA achieves similar audiometric results as those ob-
tained for air-conduction devices. In fact, the BAHA does
not sacrifice temporal processing ability or speech percep-
tion in noise.4
The BAHA has undergone many innovative changes
since the first clinical trial of the system in 1977 in Sweden.
These innovations, coupled with the widespread clinical
use of the system, have led to several clinical applications
for the BAHA. Currently, the BAHA has received Food
and Drug Administration clearance for use in adults and
children (age 5 or older) with unilateral or bilateral con-
ductive or mixed hearing loss and unilateral profound
sensorineural hearing loss, also known as Single-Sided
Deafness (SSD™; Entific Medical Systems). In 2001, the
Food and Drug Administration approved bilateral fittings
for conductive or mixed hearing losses.
SELECTION CRITERIA
GENERAL INDICATIONS
The surgical indications for BAHA implantation are
summarized in Table 1.
TABLE 1. Indications for BAHA Implantation
A. Conductive/mixed hearing loss
1. Chronic otorrhea
a. Chronic otitis externa
b. Chronic otitis media
2. Congenital aural atresia (microtia)
3. Other conductive/mixed hearing loss
a. Ossicular discontinuity/fixation in an only hearing ear
b. External canal closure from skull base procedure
4. Patients with air-conduction or conventional bone conduction
hearing aids who desire a more comfortable fit using the BAHA
B. Unilateral, profound sensorineural hearing loss (ie, single-sided
deafness)

272 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY—HEAD AND NECK SURGERY, VOL 14, NO 4 (DEC), 2003: PP 272-276
FIGURE 1. Bone-anchored hearing device (BAHA) system func-
tioning as a contralateral routing of offside signal (CROS) device
in single-sided deafness.
Chronic Otorrhea
Chronic ear drainage prevents air-conduction hearing
aids from being properly placed in the ear canal. The
BAHA can help this situation because the system is not
worn in the ear canal.
Ear Canal Atresia
Atresia surgery carries significant risks of hearing loss
and facial paralysis. The BAHA is a safer alternative for
hearing rehabilitation in these patients.
Conductive Loss in The Only Hearing Ear
Otologic surgery in the only hearing ear carries the
devastating risk of bilateral profound hearing loss. In
these cases, the conductive hearing loss can be corrected
using the BAHA system with no risk to hearing.
Conventional Bone and Air-Conduction Hearing
Device Failures
Patients may reject traditional bone-conduction and air-
conduction devices for many reasons, including skin irri-
tation, ear canal irritation from the mold, or discomfort
from the occlusion effects and feedback. These problems
can be overcome with the BAHA system.
Unilateral Sensorineural Deafness
Patients with unilateral deafness (ie, SSD) benefit signif-
icantly from BAHA placement on the deaf side.5 In the
case of SSD, the BAHA acts as a bone conduction con-
tralateral routing of offside signal (CROS) device, trans-
mitting the signal from the deaf side through the skull to
the contralateral cochlea (Figure 1). CROS with the BAHA
bypasses the head shadow effect on the deaf side and
improves speech intelligibility, especially in a noisy envi-
ronment.
TABLE 2. Audiological Criteria for BAHA Candidacy
A. Conductive/mixed hearing loss
1. Degree of air-bone gap irrelevant
2. Pure-tone average (PTA) (0.5, 1, 2, 3 kHz) bone conduction ⱕ45
dB for the Compact and Classic devices
3. PTA bone conduction ⱖ45 dB for the Cordelle device
B. Single-sided deafness
1. Profound SNHL in the impaired ear (PTA ⬎90 dB, WRS ⬍20%)
2. Normal hearing in the contralateral ear (SRT ⬍20 dB; SD ⬎80%)
BATTISTA AND HO
FIGURE 2. Bone-anchored hearing device (BAHA) Classic 300
device attached to the abutment behind the ear.
AUDIOLOGICAL CRITERIA
The audiological criteria for BAHA candidacy are sum-
marized in Table 2. For patients with a conductive or
mixed hearing loss, the BAHA system bypasses the air-
conduction mechanism. Therefore, the degree of conduc-
tive hearing loss is irrelevant in clinical decision making.
Only the sensorineural function is used in judging a pa-
tient’s suitability for the device. Three types of BAHA
sound processors are currently available, differing in their
sizes and maximum outputs:
1. Cordelle II, the body-worn system, provides suffi-
cient output to allow patients with sensory loss higher
than or equal to 45 dB to use the device.
2. Classic 300 (Figure 2) provides sufficient output such
that more than 80% of the patients with sensory loss up to
45 dB have reported satisfaction with the system. Patients
with sensory loss higher than 45 dB should be considered
a candidate for Cordelle II.
3. Compact, a smaller behind-the-ear sound processor
than the Classic, provides slightly less output than the
Classic 300. Patients with sensory loss up to 45 dB will
likely be satisfied with the Compact.
Word recognition scores should be at least 60%, regardless
of the type of sound processor used. The contraindications
to BAHA placement are listed in Table 3.
PREOPERATIVE EVALUATION
SIDE SELECTION
Side selection may be an issue when a single BAHA is
considered in cases of bilateral conductive or mixed hear-
ing loss. In general, the side with the best cochlear function
should be implanted. There are times when audiological
information does not adequately determine the most ap-
propriate side. In these cases, a test rod or band is another
TABLE 3. Contraindications for BAHA Implantation
1. Word recognition score of the indicated ear ⬍60%
2. Patients who are developmentally delayed
3. Lack of motivation of patient or caretaker (if applicable) to care for
implanted area
4. Age ⬍5 years
5. Insufficient bone volume and bone quality to ensure adequate
osseointegration
6. Local skin or bone disease at the site of implantation
273
 TABLE 4. Indications for 2-Stage BAHA Procedure
A. Children younger than 18 years of age
B. Previous temporal bone irradiation
way to assess implant candidacy. To use the test rod/
band, the BAHA is connected to the rod/band that is
pressed firmly against the mastoid bone on one side, then
the other. The BAHA itself should not be touched during
this test. The patient can determine the better hearing side,
if any.
INFORMED CONSENT
Patients must be given realistic expectations of the
BAHA. A patient with chronic otorrhea can expect a re-
duction or elimination of ear drainage but may not have
better sound quality with the BAHA compared with their
conventional air-conduction hearing device. On the other
hand, patients who have previously worn bone-conduc-
tion hearing devices will have improved wearing comfort.
Patients with SSD can expect a broadening of the sound
field for awareness and improved speech recognition abil-
ity in noise.
SURGICAL TREATMENT
In most adults, a single-staged procedure can be per-
formed with the patient under local anesthesia, with or
without intravenous sedation. The indications for a 2-stage
procedure are listed in Table 4. In either a 1-stage or a
2-stage procedure, a 3-month period is necessary to allow
for complete osseointegration before loading the implant
with the sound processor. Throughout the surgical proce-
dure, the surgeon must keep thermal and mechanical
trauma to a minimum to ensure adequate osseointegra-
tion. The final result of the soft tissue work should be a
very thin, hairless skin around the abutment. The absence
of interposing soft tissue ensures direct bone conduction,
which results in better sound quality, requires less energy,
and offers more comfort.6
(The special instruments for fixture and abutment place-
ment discussed in the following sections are available
from Entific Medical Systems.)
Preoperative Preparations
The surgical site is typically 5 to 5.5-cm posterior and
slightly superior to the external auditory canal (Figure 3).
FIGURE 3. The surgical placement of bone-anchored hearing
device (BAHA). Marking of the abutment site is shown.
274
FIGURE 4. The inferiorly based, split-thickness skin flap. Center
marker represents the position of the abutment.
In this manner, the sound processor will not touch the
auricle, which could cause acoustic feedback.
Anesthesia
Local infiltration with 2% lidocaine and adrenaline
should cover an area at least 5 cm in diameter. The anes-
thetic should be infiltrated under both the skin and the
periosteum.
Skin Flap
An inferiorly based, split-thickness skin flap is elevated
with a specially designed dermatome set to 10/1000th flap
thickness (Figures 4 and 5). The flap should be approxi-
mately 2.5 cm in width and length. The dermal side of the
flap should be examined to make sure that no follicles are
present. After the skin flap is elevated, the subcutaneous
tissue is removed down to the periosteum. In the center of
the dissection, a hole, approximately 6 mm, is made in the
periosteum to allow placement of the titanium fixture.
Drilling The Guide Hole
A guide hole is first created in preparation for subse-
quent fixture insertion (Figure 6A). The cutting guide drill
has a safety guard to prevent drilling past the prescribed
length. A 3-mm guide drill should be used with the rota-
tion speed set at 1,500 rpm. Generous irrigation should be
used to prevent excessive heat trauma to the drill site.
Heat trauma can result in local fibrous reaction, leading to
poor osseointegration and implant failure. In approxi-
mately 10% of cases, the sigmoid sinus or the dura of the
middle cranial fossa can appear at the bottom of the guide
FIGURE 5. The specially designed dermatome for elevating the
skin flap.
THE BONE-ANCHORED HEARING DEVICE
FIGURE 6. (A) Initial guide hole being drilled. The number 4 in
the center of the drill indicates a 4-mm drill bit being used. (B)
Countersinks being created with the spiral drill, which also taps
the hole for fixture insertion. (C) Fixture being inserted. The fixture
is seen here attached to the drill via a special fixture mount.
hole. In these cases, a 3-mm long implant should be used.
In the majority of cases, a 4-mm long guide drill can be
used to provide a deeper fixture seat. Through the guide
hole, a spiral drill with a countersink is used to provide the
exact diameter and direction for the tap (Figure 6B).
Tapping The Guide Hole
When positioning the tap, the direction of the drilling
should be perpendicular to the cortex. With the rotation
speed set to low (8 to 15 rpm), the tap is allowed to make
its way to the bottom of the hole. The drill is torque
adjusted so that the tap will automatically stop when it
reaches the bottom.
Fixture Insertion
After the hole is tapped, the titanium fixture is ready to
be secured into the hole. With low speed and light pres-
sure on the drill, the fixture will engage the tapped hole.
Copious irrigation should be used only after engagement
of the fixture into the hole. Irrigation before fixture en-
gagement results in solution being compressed into the
marrow spaces of the bone by the fixture. When the fixture
has reached the bottom, the drill will stop at the selected
torque level (Figure 6C). In adults, the drill torque is set to
40 Ncm. In children (or adults with a soft cortex), the
torque should be lowered to 30 or 20 Ncm to avoid strip-
ping the threads.
FIGURE 7. Cross-section view of the surgical site illustrating the
tissue-thinning technique. By beveling the dissection, a smooth
crater will form with only skin surrounding the abutment.
BATTISTA AND HO
FIGURE 8. The abutment being screwed onto the implanted
fixture.
Resurfacing The Wound
Once the fixture is secured, the soft tissue around the
edge of the wound should be lowered to allow the skin
surrounding the wound to slope gently down into the
implant area (Figure 7). Soft tissue reduction may be fa-
cilitated by 4 radial incisions, 1 cm in length, extending
from the circumference of the wound.7 After soft tissue
reduction, the radial incisions are closed, and the skin flap
is then sutured to the edges of the wound with a fast
absorbing suture. The removal of surrounding subcutane-
ous tissue is a crucial step in BAHA implantation. Ade-
quate soft tissue must be removed to prevent prolapse of
soft tissue onto the abutment postoperatively.
Attaching The Abutment
After the flap is secured, a 4-mm dermatologic punch is
used to create a hole in the flap exactly over the fix-
ture. The abutment is the then secured onto the fixture
(Figure 8).
Two-Stage Surgery
During the first stage of a 2-stage operation, an inferi-
orly based, full-thickness skin flap is elevated in the same
location as the skin flap for the 1-stage procedure. The
titanium fixture is inserted in the manner described pre-
viously, and a cover screw is inserted into the fixture to
protect the internal threads. Soft tissue reduction is not
performed. The wound is closed. The second stage is
performed 3 months after the initial stage. At the second
operation, an inferiorly based skin graft is elevated. Com-
plete soft tissue reduction is performed, the cover screw is
removed, and the skin graft is replaced over the wound.
The abutment is then attached to the fixture.
SUMMARY
The BAHA is a safe and effective, direct, osseointegrated
bone conduction hearing system with various clinical ap-
plications. These applications include hearing rehabilita-
tion for various causes of unilateral or bilateral conductive
or mixed hearing losses, as well as for SSD. The BAHA is
available for pediatric and adult patients. In general, the
275
satisfaction rate is very high for patients using the BAHA
system.
REFERENCES
1. Barany E: A contribution to the physiology of bone conduction. Acta
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2. Stenfelt S, Hakansson B, Tjellstrom A: Vibration characteristics of bone
conducted sound in vitro. J Acoust Soc Am 107:422-431, 2000
3. Tjellstrom A, Hakansson B, Granstrom G: Bone-anchored hearing
aids: Current status in adults and children. Otolaryngol Clin North
Am 34:337-364, 2001
276
4. Bance M, Abel SM, Papsin BC, et al: A comparison of the audiometric
performance of bone anchored hearing AIDS and air conduction hear-
ing AIDS. Otol Neurotol 23:912-919, 2002
5. Niparko JK, Cox MC, Lustig LR: Comparison of the bone anchored
hearing aid implantable hearing device with contralateral routing of
offside signal amplification in the rehabilitation of unilateral deafness.
Otol Neurotol 24:73-78, 2003
6. Tjellstrom A, Granstrom G: Long-term follow-up with the bone-an-
chored hearing aid: A review of the first 100 patients between 1977
and 1985. Ear Nose Throat J 73:112-114, 1994
7. Reddy TN, Dutt SN, Gangopadhyay K: Modified incisions for reduc-
tion of soft tissue for one-stage, bone-anchored hearing aid implanta-
tion. Laryngoscope 110:1584-1585, 2000
THE BONE-ANCHORED HEARING DEVICE