Boning Up on BAIs How do you answer when a parent asks you: When is a bone-anchored implant the right choice for my child—and why choose this option over traditional hearing aids or a cochlear implant? We talked with a pediatric audiologist for the latest intelligence. Features
Features  |   March 01, 2015
Image provided courtesy of Cochlear Americas, © 2014 Cochlear Americas.
Boning Up on BAIs
Author Notes
  • Bridget Murray Law is editor-in-chief of The ASHA Leader.
    Bridget Murray Law is editor-in-chief of The ASHA Leader.×
Article Information
Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / Features
Features   |   March 01, 2015
Boning Up on BAIs
The ASHA Leader, March 2015, Vol. 20, 50-55. doi:10.1044/
The ASHA Leader, March 2015, Vol. 20, 50-55. doi:10.1044/
When it comes to the array of hearing impairments speech-language pathologists see on an average caseload, it’s not always clear which type of audiologic intervention would be most appropriate for which kind of hearing loss.
So it can get tricky when parents start asking questions like: When does a bone-anchored implant make more sense than using traditional hearing aids? Or than getting a cochlear implant? Who’s the best candidate for this type of technology, and is it better to get the BAI implanted surgically, or just to wear it on a headband or “softband”?
When facing such questions, the SLP would obviously refer parents to an audiologist for a full evaluation and recommendations. But, given that SLPs commonly find themselves first in line for parental questions about hearing aids, and as arbiters of speech-language follow up, they obviously want to know the latest hearing-aid intel. To find out the most up-to-date answers to typical BAI questions, we talked to pediatric audiologist and BAI expert Jillian Kimberlain, of Arkansas Children’s Hospital.
In the young child, age 0 to 4, who has a more profound hearing loss, when would a BAI make more sense than a CI?
Essentially, the three patient populations that we use a BAI for are: conductive hearing losses, some mixed hearing losses up to a certain degree, and then single-sided deafness.
For the child that you describe here, if she has a bilateral profound hearing loss, then she would not be a candidate for a BAI. She would either be fit with traditional hearing aids or be referred for evaluation for a cochlear implant (or bilateral implants). But, if she has single-sided deafness—meaning that one side is normal and the other side has the profound hearing loss—then she could be a candidate for a BAI. At the age that you described, we would fit the BAI on a softband and not do the surgical implantation.
Why would a child not be a CI candidate in the case of unilateral hearing loss?
Currently in the United States, CIs are not FDA-approved for single-sided deafness. However, there are studies being conducted, including clinical trials, to look at the effectiveness of the CI in unilateral hearing loss. CIs are approved for single-sided deafness in other countries, but have not been cleared by the FDA in the United States yet.
There’s some confusion on this point because there are a lot of kids in the United States who just get a CI in one ear.
Yes, that is true, and it can be confusing to non-audiologists and to parents. For example, if you see a child at the grocery store who has only one CI, that child likely has profound hearing loss in both ears or may have severe hearing loss with poor speech recognition.
Back to the BAIs. In what cases would you recommend BAI over traditional hearing aids?
BAIs may be used in children with single-sided deafness. The purpose here is not to amplify their “bad” ear but to give them auditory input from both sides. This can help with localization of sound, as well as being able to pick up speech from the side where their hearing is poor. Also, if the child has microtia or atresia we would recommend a BAI over a traditional hearing aid. When a child has a malformed or absent outer ear (pinna), that is called microtia. Atresia is when there’s no opening to the ear canal for the sound to get in.

BAIs may be used in children with single-sided deafness. The purpose here is not to amplify their “bad” ear but to give them auditory input from both sides.

So a traditional hearing aid often will not work in these cases because there’s no place to seat the hearing aid on the outer ear or there is no opening in the canal for the earmold to funnel sound to the middle ear. In atresia, even when there is a pinna or outer ear to hold the hearing aid, the sound from the hearing aid will have feedback because we have no ear canal opening for the sound to enter.
A BAI sits on the temporal bone, either on a soft band or an implanted post, and it sends a signal through bone conduction to the cochlea. It skips what you could call the “bad part” of the ear which, in this case, is the outer and middle ear, and it takes the signal straight to the inner ear—or the “good part.”
Other uses of the BAI in kids include those who have chronic ear infections and are always draining. And I’ve also had some situations where a child has autism or some other sensory issue and cannot stand having hearing aids in their ears. So we try a BAI because up to a certain hearing loss, it can work. Some of these children can handle a headband or an implant better than they can two hearing aids on and in their ears.
But do some patients object to BAIs because they don’t like the look of the soft band or don’t want the surgery involved?
Of course. For most children, I do a trial period. I’ll give a child a softband BAI on loan for about a month to see how they do. Most BAI patients see an immediate difference.
You see, when we are amplifying sound for a purely conductive hearing loss, making the sound louder improves speech recognition ability in most cases. This is in contrast to amplifying sound or speech for a sensorineural hearing loss. For the most part, everybody’s okay with the headband because the child does so well with it. And if they do well with the headband, they’re going to like the sound just a little bit more when it’s implanted—it’s even clearer because it’s direct bone conduction instead of going through the hair, headband and skin.
Courtesy of Oticon Medical
You’re not seeing resistance to the look of the headband?
Not at all. I just saw a little boy last week with single-sided deafness, and I put it on him and he was like, [gasp] “I love this!” And his mom was crying, and he kept saying, “Hey, Mom, can you hear me? Hey, Mom—I can hear you!”

I just saw a little boy last week with single-sided deafness, and I put the bone-anchored implant on him and he was like, [gasp] “I love this!” And his mom was crying, and he kept saying, “Hey, Mom, can you hear me? Hey, Mom—I can hear you!”

Are there certain dangers or complications that would keep you from recommending a BAI to some candidates?
The headband would be OK for anyone. It’s not dangerous at all, and it’s not going to be too loud for the child because I’m programming it to the child’s specific hearing loss. Now with the surgery, there could be issues if the child’s had radiation or chemotherapy and has lost hearing on one side. Sometimes when you have had a lot of radiation to the bone, it can make the bone weak and unable to support the implant. So the surgeon would obtain CT scans and make sure that the bone can support the implant.
Generally, the BAI is implanted when the child is 5, right?
The child has to be at least 5 years old. But it can be later. The team looks at the child as a whole, and if there are orofacial and bone-density concerns or if mom and dad aren’t comfortable implanting yet, we may wait. So there’s a lot of counseling and answering questions by the audiologist and the ENT physician.
You said generally kids are compliant with the headband. But how do get compliance if you’ve got a younger kid with major developmental challenges, such as severe autism?
I tell the parent we need consistent use. Because if you give them a break for a day or two, they’re going to think, “Oh, I don’t have to wear it.” I tell them that if the child takes the headband off, put it back on him. It’s just like a pair of glasses or a brace for an ankle. So if everybody in his environment consistently puts the BAI back on every time he takes it off, eventually he’s going to say, “Oh, this helps me. Oh! This is a part of me.”
Sometimes we come up with sticker charts to encourage compliance and make it more fun for them. For girls, we sometimes use little barrettes to keep the band in their hair so that they can’t pull it off. For boys, we recommend a ball cap if needed.
You were an investigator on a study in the Journal of the American Academy of Audiology that had compared the headband to the implant in 10 kids with bilateral conductive hearing loss. Tell us about the findings.
Yes, we found that when testing a patient in the booth with the implant, the results were similar to presurgical testing via standard bone conduction techniques. The implant was just a little bit better and clearer, than the soft band. And it should be, because with the soft band there’s dampening of the sound, and with the implant, there’s no dampening of the sound—it’s just direct bone conduction.
And hence the reason why you would, in most cases, suggest the surgery, right?
Right. When they’re ready. I have a 10-year-old patient who’s waited and waited and waited, and hasn’t wanted to have the surgery. But now he’s thinking the headband’s not cool anymore. So when they get older, if they haven’t had the surgery yet, often they’re ready for it.
Do kids tend to have a preference for the type of BAI they get: the one that’s like a box (from Cochlear) versus the one that looks like a little ear (from Oticon Medical)?
At Arkansas Children’s Hospital, we use the products from both companies, and we involve the parents in choosing. The sound quality on both products is very good. My younger kids may go with Cochlear BAI because there’s blue- tooth wireless technology in them. Cochlear has a little mini-mic that you can hook into a computer or hook into a cellphone, and it just transmits the sound to their BAI and they don’t have to wear headphones. That’s easy for mom and a 3-year-old listening to the DVD player in the car, right?
Now, Oticon Medical has a streamer that you pair up to seven or eight devices. It’s more techie. So my teenagers love it because they can be hands-free in the car. It’s on a little loop so they can wear it around their neck and listen to music through blue tooth and talk on their phone without ever having to touch it.
Are there some instances where a child’s hearing issue can be “fixed” and they don’t need to wear the BAHA anymore?
I work really closely on the child’s plan of care with the ENT physician on the team. And yes, sometimes if a child has, say atresia, they might try a canaloplasty when the child is age 7 or 8, if the parent wants to go that route. But opening up an ear canal is a big surgery. And, statistically, sometimes it works, sometimes it doesn’t. So we lay it out for the parents to choose which route they would like to take. And we support parents in whatever they choose.
There’s always something we can do. In the end, it’s about what is best for that child and that family at the time.
What’s ahead for BAI technology. Do you have any predictions?
Wireless is where it is right now. Bluetooth was a great accessory last year, and the kids that I see love it. The sound quality of listening to music through the bluetooth accessory with the BAI is great.
Also, the companies are working on putting a telecoil into their BAI devices. This will make it easier to use with phones that don’t have blue tooth. Currently, you have to plug in a telecoil to the bottom of the BAI, and it’s about two inches long so we rarely have anyone who wants that.
Another innovation that both companies are working on is a BAI without an abutment—which is the silver titanium snap that sticks out of the skin when you take your BAI processor off. Cochlear has already come out with its first generation of this and Oticon Medical is working on theirs. I haven’t used one of these yet at ACH, but we’re looking at it.
The manufacturers of the BAIs are always doing research and development to improve these products. When I first fit someone with a new device, they are going to have so much to learn, so much information to sort through, so the device needs to be easy. So anytime the manufacturer is making the product easier to use, it’s good for all of us: patients, parents and audiologists.
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March 2015
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