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Hearing with Bone-anchored Hearing Aid (BAHA)

Article · May 2010

DOI: 10.5005/jp-journals-10003-1025

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Hearing with Bone-anchored Hearing Aid (BAHA)
REVIEW ARTICLE

Hearing with Bone-anchored

Hearing Aid (BAHA)
1
Gauri Mankekar, 2Payal Bhattacharya Chitranshi, 3MV Kirtane
1
ENT Consultant, PD Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
2
Clinical Assistant, PD Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
3
Professor Emeritus, GS Medical College and KEM Hospital, Consultant ENT Surgeon, PD Hinduja Hospital, Saifee Hospital
and Breach Candy Hospital, Mumbai, Maharashtra, India
Correspondence: Gauri Mankekar, ENT Consultant, PD Hinduja Hospital, Mahim, Mumbai-16, Maharashtra, India

Abstract
BAHA is a surgically implantable system for treatment of hearing loss in patients wherein conventional hearing aids are unable to provide
benefit. e.g. patients with microtia, chronic ear discharge or single sided hearing loss.
Keywords: Bone anchored hearing aid, osseointegration, sound processor, abutment, fixture.

INTRODUCTION
BAHA is a surgically implantable system for treatment of
hearing loss. The system is surgically implanted and allows
sound to be conducted through the bone rather than via the
middle ear by a process known as direct bone conduction.
Conventional hearing aids aim to overcome hearing loss
by amplifying the incoming signal and sending the amplified
sound via air conduction through the cochlea. Cochlear
implants on the other hand, are suitable for individuals with
bilateral severe to profound hearing loss, where the extent
of destruction of the cochlear hair cells is so great that
hearing aids are unable to provide benefit. BAHA provides
an ideal choice for those with conductive, mixed or a single Fig. 1: Osseointegration (Courtesy: Cochlear Ltd., Australia)
sided sensorineural deafness through direct bone conduction.
The prerequisite for a BAHA is a functioning cochlea. becoming rigidly and permanently fixed to the bone. These
screws then serve as the basis for prosthetic crowns that
HISTORY
can be applied after osseointegration. In the case of BAHA,
In the early 1960’s Professor Branemark, a dentist, the principle is identical. The fixture consists of a titanium
discovered that titanium is accepted by the human body screw, literally, that is surgically implanted into the bone
and bonds with the surrounding bone thus forming a directly behind the ear. Attached to the fixture, but not
permanent structure. He termed this process “osseo- actually integrated into the bone, is also a titanium compo-
integration” (Fig. 1). Osseointegrated implants were first nent, the abutment, which is held onto the fixture by means
introduced in dentistry in Sweden during the 1970s. Bone- of a very small central screw.
anchored implants were first described in, 1977 by The use of osseointegrated implants for bone-anchored
Tjellstrom to treat patients with a conductive or mixed hearing hearing aid (BAHA) retention is now a established practice
loss (HL) who could not use a conventional air conduction since the device became commercially available in 1987.
hearing aid to amplify and improve their hearing.1 The surgical implantation technique has gradually been
The BAHA has its origin with dental implant technology, simplified. The original 2-stage surgical procedure was
in which titanium screws are placed within the bone of the reduced to a 1-stage procedure in 1989 and has remained
maxilla or mandible, where they are osseointegrated, the surgical standard in adults since then. In the early 90s,
Otorhinolaryngology Clinics: An International Journal, May-August 2010;2(2):125-131 125
Gauri Mankekar et al

a simplified surgical technique was developed step-by-step over time integrates with the bone behind the ear. The hearing
in Nijmegen.2 device transmits sound vibrations through the titanium
BAHA was cleared by the US FDA in 1996 as a treatment implant to the skull and the inner ear, where the hearing
for conductive and mixed hearing losses in the United States. takes place.
In 2002, the FDA approved its use for the treatment of
INDICATIONS FOR BAHA
unilateral sensorineural hearing loss. The acronym BAHA is
a trademark. In 2005, Entific sold the rights of BAHA to The BAHA is used to rehabilitate people with conductive
Cochlear. Cochlear realized that many insurance companies and mixed hearing impairment. This includes people with
were having trouble distinguishing the BAHA as a sound chronic infection of the ear canal, people with absence of
processor and not a hearing aid, which makes a huge or a very narrow ear canal as a result of a congenital ear
difference for insurance coverage. They removed the malformation, infection, or surgery, and people with a single
acronym and have since called it strictly the BAHA. sided hearing loss as a result of surgery for a vestibular
schwannoma.
COMPONENTS OF BAHA (FIG. 2) 1. Conductive hearing loss: BAHA is frequently the ideal
choice for conductive hearing loss. This is because
BAHA has 3 components (Fig. 2). They are: conductive loss is often concomitant with various outer
1. The sound processor: A detachable electronic hearing and middle ear abnormalities (e.g. atresia) or middle ear
aid with a snap-fit coupling to the abutment. The user pathologies like continuously draining ear that prelude
takes the sound processor on and off as required, for the wearing of conventional hearing aids. With BAHA
example for hair washing or swimming. the conductive element of the hearing loss is bypassed
2. The abutment: A socket attached by an internal screw by sending sound vibrations directly from the BAHA
to the fixture. The abutment penetrates the surface of through the skull to the cochlea. BAHA often provides
the scalp and is shaped to hold the snap-fit coupling of benefits over conventional hearing aids in large conduc-
the sound processor. The abutment can be unscrewed tive losses due to their technical limitations of insufficient
from the fixture for maintenance or replacement by the gain, saturation, feedback and necessity of wearing a
specialist audiologist. tight ear mould.
3. The fixture (or implant): A small titanium screw, four 2. Mixed hearing loss: BAHA provides two-fold solution
millimeters long, implanted into the bone behind the ear. to all such patients. First, it closes the air-bone gap by
The fixture is permanent, it is not adjusted or removed. bypassing the conductive element. Second, it compen-
The metal becomes firmly anchored to living bone by sates for the remaining degree of sensorineural hearing
the process of osseointegration. loss. The overall amplification required for people with
The system works by taking the sound from the outside a mixed hearing loss is less with BAHA than conventional
and transmitting it to the inner ear through the bone. This hearing aids and it is recommended when conductive
bypasses the ear canal and the middle ear. The titanium component of the mixed hearing loss is greater than 30
implant is placed during a minor surgical procedure and dB.3,4
3. Single-sided sensorineural deafness (SSD): SSD causes
significant communication difficulties for the patient due
to inability to localize sound, more so when noise is
directed towards the good ear and the talker is near the
deaf ear. BAHA is worn on the deaf side and transfers
the signal directly across the skull via bone conduction
thus eliminating the head shadow effect. But these
patients must have normal hearing in the contra-lateral
ear (20 dB HL air conduction pure tone averages). BAHA
provides better directional 360 degree hearing in these
patients. Studies have shown that patients with BAHA
have better speech understanding than those with
Fig. 2: Components of BAHA (Courtesy: Cochlear Ltd., Australia) Contralateral Routing of Signal (CROS) hearing aids.5

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 Hearing with Bone-anchored Hearing Aid (BAHA)

HOW DOES THE BAHA WORK? Surgical Assessment

The principle of bone conduction for hearing forms the • BAHA is commonly used to treat conductive hearing
basis for both simple and complex tests of hearing function loss due to chronic ear infections. It can also be used to
(ranging from tuning fork testing at the bedside to extended treat single sided sensorineural deafness, where one
frequency bone conduction threshold audiometry). Sound, cochlea (inner ear) is no longer working. Before
which is a form of vibrational energy, requires a medium in recommending BAHA as a treatment, a specialist
which to travel. Typically, we consider this medium to be assessment is needed to confirm the diagnosis. Ear
the environmental air. Yet the moment that sound reaches microscopy with suction of the ear may be needed.
the eardrum, it no longer travels through the air. Rather, • HRCT temporal bone axial (Fig. 3) and coronal cuts
through an elegant process of impedance matching and with simple cursor markings to determine the thickness
energy amplification, sound waves ultimately produce a of the bone in front of and behind the temporoparietal
wave of energy that vibrates fluids within the inner ear, suture line. The implant fixture is sited just behind the
leading to the production of neural impulses that travel down suture line. If the cortical bone thickness is less than
the cochlear nerve. Because the inner ear is encased in bone 3 mm then a two stage BAHA surgery is recommended
(the temporal bone of the skull), the normal pathway of but if the bone thickness is more than 3 mm, then a
hearing from eardrum to inner ear is not the only means of single stage (fast) surgery can be performed.
provoking vibration within its fluids. By placing a sound • It is important to know the patients expectations from
source directly on the bones of the skull, sound will travel BAHA and to decide whether the BAHA is likely to fulfil
through the skull using the bone itself as a medium, where those expectations since having any form of implant
it in turn causes fluids of the inner ear to vibrate, leading to surgery is an important decision with a lifelong
production of neural impulses and sound perception. This commitment.
mechanism forms the basis by which traditional bone
conduction hearing aids work. SURGERY
BAHA technology addresses these issues precisely. The In recent years, improvements in the surgical procedures
titanium implant is placed during a short surgical procedure have resulted in most patients being able to have a single
and over time osseointegrates with the skull bone. For stage (fast) procedure carried out under local or a short
hearing, the sound processor transmits sound vibrations
through the external abutment to the titanium implant. The
vibrating implant sets up vibrations within the skull and inner
ear that finally stimulate the nerve fibers of the inner ear,
allowing hearing.

PREOPERATIVE ASSESSMENT
Audiological Assessment
• Pure tone audiometry (air conduction and bone
conduction): Depending on the results of the bone
conduction audiogram, it is decided whether a head
mounted sound processor, or the more powerful
bodyworn sound processor would be suitable.
• A headband test: The candidate gets the opportunity to
“try out” a BAHA on a headband. The sound quality
from the headband is not nearly as good as the real
thing, because the sound is muffled by having to pass
through the soft tissues of the scalp. If the candidate
can hear reasonably well with the headband BAHA, then Fig. 3: HRCT temporal bone to confirm thickness of bone around
he will hear better with the implant proper. the temporoparietal suture

Otorhinolaryngology Clinics: An International Journal, May-August 2010;2(2):125-131 127

Gauri Mankekar et al

general anesthesia. Most patients are able to leave hospital BAHA marker, the site is selected and marked with ink.
within a few hours, or the day after their procedure and Using methylene blue and a needle, the marking is extended
many patients do not even require analgesia in the following through the skin and subcutaneous tissue to the mastoid
days. bone. Then a small 1 by 1 cm section of skin behind the ear
In many cases, the surgeon will implant a second is peeled back followed by drilling one or more holes for
“sleeper” receptacle for use should the initial receptor fail the fixture. The minimum recommended fixture depth is 3
mm7 (Fig. 5).
or be damaged.6
Throughout the surgical procedure, the surgeon must
A double stage procedure is sometimes carried out for
keep thermal and mechanical trauma to a minimum to
small children/babies and for patients with a previously
ensure adequate osseointegration. The skin is then
irradiated temporal bone wherein the bone thickness is grafted back and the child waits for the skull to continue to
inadequate for the fixture to be implanted. The first stage thicken and for osseointegration to occur properly. After
involves marking the incision (Fig. 4)—the canthomeatal osseointegration (a minimum of 3 to 6 month period), the
line, mastoid tip are identified. The site is selected 5 to 5.5 second stage is performed. The second stage is another
cm from the external auditory meatus so that any planned surgery in which the “post” is attached, and the skin is
pinna reconstruction (in cases with microtia/anotia) or the grafted around the “post”. In the second stage, a skin flap
pinna will not influence the BAHA processor. Using the is created using a Dermatome (Fig. 6) designed specifically
for BAHA surgery. The dermatome creates a skin flap with
a thickness of 0.6 mm. At this thickness, the surgeon is
ensured of a depilated flap of sufficient depth for proper
wound healing. Then the soft tissue around the fixture
implant is reduced up to a circumference of at least 1.5 cm
with more soft tissue being removed superiorly. The removal
of surrounding subcutaneous tissue is a crucial step in
BAHA because shorter lengths have a much greater chance
for failure.8 The titanium fixture should never come in
contact with anything other than implant. Removal of soft
tissue helps to prevent postoperative prolapse of soft tissue
onto the abutment with subsequent granulation tissue around
the implant. Therefore the tissue reduction should result in
an area of very thin, hairless skin around all around the
implant. Finally, prior to securing the skin flap, the
periosteum under the skin flap should be thinned to one
layer thickness. There should be little or no tension on the
Fig. 4: Marking the site of incision

Fig. 5: Fixture abutment insertion Fig. 6: Fast surgery flap elevation with a dermatome

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 Hearing with Bone-anchored Hearing Aid (BAHA)

skin flap, when reapproximating the flap to the skin edges. Surgery to implant a BAHA fixture is not an ear operation
Thinning the periosteum and creating a tension-free skin since the ear itself is not operated on. Mastoid air cells
flap helps prevent movement of the skin flap during healing. decrease bone–titanium contact and should be avoided.
A dressing is positioned over the abutment. It is held in
Complications of BAHA Insertion
place by the temporary white plastic healing cap, which
1. Infection: Local wound inflammation around the
snap-fits into the abutment. The head bandage is taken off
abutment is commonly classified according to the clinical
the day after surgery. The plastic healing cap is left alone
scoring system of Holgers and colleagues,9 as follows:
and removed at first follow-up visit, some two weeks
Grade 0: No irritation;
following surgery. This will require healing for 3 to 6 months,
Grade 1: Slight redness;
at which point the BAHA can be fitted.
Grade 2: Red and moist;
In a single stage or fast procedure, all the steps from
Grade 3: Same as 2, but also with granulation tissue
creating a skin flap, reducing the soft tissue to drilling and
formed; and
insertion of fixture abutment and bringing it out through the
Grade 4: Skin irritation of such a degree that the
skin flap (Fig. 7) is done at one time. The processor can be
abutment has to be removed.
fitted (Fig. 8) three months after the surgery once the wound
Treatment of the skin reaction may vary, depending
is healed and osseointegration has been completed.
on its grade. For Grade 1 reactions, local antibiotic
ointment is recommended. Reapplying the healing cap,
and wrapping the area with antibiotic gauze for a period
of time may treat Grade 2 reactions. Grade 3 and
4 reactions require revision surgery.
Inflammation around the abutment is, in general,
more common in children than in adults.10 Persistent,
chronic infections around the implant may be due to
Staphylococcus aureus. More severe infections can also
occur, ranging from osteomyelitis with loss of the fixture,
to intracerebral abscess.11
2. Failure of osseointegration: Symptoms and signs of
osseointegration failure can vary. In the most severe
situation, the abutment-fixture complex may be so loose
that it falls out. At other times, a fibrous attachment is
Fig. 7: Fast surgery easing the skin over the abutment present; the fixture remains in place but the patient
experiences little or no sound, or complains of sound
distortion when the sound processor is fitted. In these
situations, the abutment-fixture complex will spin freely
when an attempt is made to tighten the abutment in the
office. Several factors must be considered for adequate
osseointegration. Proper surgical technique at the initial
surgery is paramount. The thickness of the bone is also
important. The thickness of the temporal bone is often
a function of the patient’s age at implantation and his/
her craniofacial anatomy. Patients with craniofacial
syndromes often have thin bone in the area of planned
implantation. One reason for implant losses without any
known trauma is idiopathic bone resorption at the bone-
metal interface.12
3. Bone overgrowth: The possibility of bone overgrowth
should be considered when a loose abutment cannot be
tightened. Bone overgrowth is found exclusively in
Fig. 8: Fitting of BAHA processor children, especially between the ages of 5 and 11.13 Bone
Otorhinolaryngology Clinics: An International Journal, May-August 2010;2(2):125-131 129
Gauri Mankekar et al

growth during this time period is significant, with the

growth of the temporal and parietal bones being
appositional (i.e. lamellar). Because growth is
appositional, bone overgrowth can occur while the
implant position does not change in the sagittal direction.

MODELS
Currently four BAHA systems are available:
• BAHA Cordelle II: It is a body worn BAHA for people
with a severe hearing loss who need more amplification.
It compensates up to 65 dBHL of hearing loss. The
Cordelle II consists of a transducer which snaps onto
the abutment and a body worn unit. This is the only
BAHA to have an induction telecoil receiver built-in.
• BAHA Divino: It is a digital BAHA with a built-in
directional microphone and compensates for 45 dB HL
of sensorineural hearing loss. Even though the Divino Fig. 9: Soft band (Courtesy: Cochlear Ltd., Australia)
takes a while to get used to for adolescents, in the long
run it has been proven to be successful for most ages. BAHA CARE
• BAHA Intenso: More power and clearer sound quality
in all types of listening environments plus far less 1. The patient is advised to clean the area around the
irritation. It compensates for up to 55 dB HL of abutment daily: Washing hair will soften any crust. The
sensorineural hearing loss. patient is also advised to use the soft cleaning brush
• BP 100: It is the largest generation of BAHA processors supplied with the BAHA kit and gently wipe the bristles
which is slimmer and smaller than the previous generation against the side of the abutment, not the skin. All debris
processors. It uses signal processing and fitting around or inside the abutment should be removed and
strategies uniquely developed to take advantage of bone use of antibacterial soap is recommended. Then the skin
conduction hearing. should be dried gently.
2. Patient should not allow hair to wrap itself around the
BAHA IN CHILDREN
abutment.
In the United States, the FDA requires that children be at 3. Patient should avoid blowing hot air from a hair dryer
least 5 years old to ensure adequate skull maturity before
on the abutment for a long period.
receiving implant surgery. Researchers at the Hospital for
4. It is advisable to cover the abutment and skin graft site
Sick Children in Toronto, Ontario have performed implants
with plastic to protect the skin and the abutment from
in children as young as 14 months of age and conclude that
the chemicals especially whenever strong chemicals,
age does not appear to be an impediment for the successful
use of bone-anchored aids. In their view, younger patients such as hair dying solutions, are being applied to your
benefit from earlier speech and language acquisition, hair as the skin surrounding the abutment may become
according to an online news article.14 red, swollen, infected, or burned.
For children in the United States or elsewhere deemed 5. The external BAHA processor should be removed before
too young for implant surgery, a Soft band (Fig. 9) is undergoing MRI imaging.
available with the sound processor connected to a plastic 6. For best benefit, it should be worn all through the day.
snap connector sewn into the band and held against the 7. If the processor whistles when touched or when it comes
skin through the pressure from the band. Researchers in into contact with other objects then the whistling can
the Netherlands concluded that the Soft band was a “valid be reduced by simply repositioning the processor.
intervention in children with congenital bilateral aural atresia 8. During windy conditions, outdoors, if the directional
who were too young for percutaneous BAHA application.”15 microphones may pick up wind sounds, the processor
These children can then have a fixed BAHA once the skull needs to be rotated on the abutment 90 degrees or until
thickness increases to more than 3 mm. the wind sound stops.

130
JAYPEE
 Hearing with Bone-anchored Hearing Aid (BAHA)

CONCLUSION emphasis on complications. J Laryngol Otol 2002;116(2):

87-91.
BAHA is ideal for those who have problems with their outer 7. Granstrom G, Bergstrom K, Odersjo M, et al. Osseointegrated.
and middle ears and of course for those with unilateral implants in children: Experience from our first 100 patients.
deafness who cannot use conventional hearing aids. In Otolaryngol Head Neck Surg 2001;125(1):85-92.
addition, it is very comfortable to use surpassing all other 8. Tjellstro¨ mA, Granstrom G. One-stage procedure to establish
types of hearing aid solutions, and it only requires to be osseointegration: A zero to five years follow-up report. J
implanted properly, after which the patient will not even Laryngol Otol 1995;109(7):593-98.
notice its presence nor will others be aware that it is being 9. Holgers KM, Tjellstro¨ MA, Bjursten LM, et al. Soft tissue
reactions around percutaneous implants: A clinical study on
worn. It also does not slip off or loosen unlike conventional
skin-penetrating titanium implantsts used for bone-anchored
hearing aids and also does not require any refitting once it auricular prostheses. Int J Oral Maxillofac Implants 1987;2(1):
has been successfully implanted. 35-39.
10. Papsin BC, Sirimanna TK, Albert DM, et al. Surgical experience
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