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The LaryngoscopeVC 2012 The American Laryngological,Rhinological and Otological Society, Inc.

Optimal Management of Single-Sided Deafness

Hwa J. Son, MD; Daniel Choo, MD

BACKGROUNDCurrent trends in auditory rehabilitation for single-

sided deafness (SSD) reflect a renewed interest in the

functional impact of unilateral hearing loss and also in

the advances in technologies for SSD that make inter-

ventions more effective and more appealing to patients.

Clinicians are now equipped with an array of therapeu-tic options ranging from Bluetooth contralateral routing

of signal (CROS) devices to in-the-ear TransEar hearing

aids (Ear Technology Corp., Johnson City, TN), as well

as bone-anchored hearing aids (BAHA). Even unilateral

cochlear implantation represents a current investiga-

tional intervention that may offer yet another option to

patients in the future.

A prominent deficiency in this field is the absence

of concise and evidence-based guidelines for patient and

intervention selection. Factors to consider when recom-

mending the best treatment include functional

handicapping due to SSD, speech understanding in

noise, localization, ease of use, the need for surgery and

cost. This article seeks to review the pertinent literature

on this topic and offer a best-practice framework.

LITERATURE REVIEWBoth BAHA and CROS devices enable patients to

pick up sound from the deaf side, thus effectively

expanding the sound field.1 Patients are bothered by the

occlusion effect a CROS device presents by having an

ear mold in their better hearing ear, whereas some reject

the BAHA because of the need for surgery. Niparko

et al.1 compared both objective and subjective measures

on 10 patients with SSD who underwent a 1-month trial

period with a conventional CROS device and subsequent

BAHA implantation. All quality-of-life measure tests

showed greater subjective satisfaction with the BAHA

compared to the CROS device. The localization test

showed poor performance across the board, with no sta-

tistical difference among unaided, CROS device, and

BAHA, but the BAHA was superior for speech discrimi-

nation in noise. It was conjectured that the speech innoise performance was better with the BAHA compared

to the CROS device due to the tighter and more efficient

transcranial routing of sound from osseointegration.

The TransEar hearing aid offers a nonsurgical

bone-conduction hearing aid option that can be inserted

in the algorithm in addition to the BAHA and CROS de-

vice for some patients. The TransEar requires a deeply

fitted ear mold that allows bone transmission of sound

by means of an in-the-ear hearing aid but eliminates

occlusion in the better hearing ear as in the CROS de-

vice. To date, there remains a paucity of data about its

use in the literature, and audiologic familiarity/expertise

is required to make this an effective hearing rehabilita-tive option.

A prospective pilot study conducted in Europe by

Hol et al.2 had 10 subjects with SSD use all three devi-

ces: the BAHA soft band, CROS device, and a device

that is placed completely in the canal (CIC), in a random

order for an 8-week trial period each. The localization

was poor across the board, but the results on quality-of-

life issues were mixed with some surprising benefits

with the CIC device. At the end of trying all three devi-

ces, only 3/10 of the patients chose to proceed with

BAHA implantation and 1/10 for a CROS device. The

authors emphasized that all patients derived some form

of benefit for each device, but there is a real need for a

sufficient trial period for patients before making aninformed decision.

Complications and long-term satisfaction with the

BAHA needs to be considered before committing to a

surgery. Gluth et al.3 summarized a long-term satisfac-

tion and complication rate of the BAHA, with average

use duration of 3.5 years. Seventy percent of all users

thought their overall quality of life improved, which was

maintained at long term with an 81% continued-user

rate for the BAHA. For complications, 38% of patients

experienced skin reactions, whereas 66.7% required the

processor to be repaired. This article highlights the fact

From the Department of OtolaryngologyHead and Neck Surgery(H.J.S.), University of Cincinnati, Cincinnati; and Cincinnati ChildrensHospital (D.C.), Cincinnati, Ohio, U.S.A.

Editors Note: This Manuscript was accepted for publication May11, 2012.

The authors have no funding, financial relationships, or conflictsof interest to disclose.

Send correspondence to Hwa J. Son, MD, Department of Otolar-yngologyHead and Neck Surgery, University of Cincinnati, P.O. Box670528, 231 Albert Sabin Way, Cincinnati, OH 45267. E-mail: hwajson@gmail.com

DOI: 10.1002/lary.23483

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that patient satisfaction with the BAHA is maintained

even at long term, but that diligent care for the abut-

ment site is required due to frequent skin reaction.

Patients need to be aware of such requirement as well

as high rate of processor failure preoperatively. Sophono

(Sophono, Inc., Boulder, CO) is a newer bone-conduction

device that is implanted underneath the skin without

any percutaneous abutment. This not only eliminates

the cosmetic concerns that patients have with an abut-ment but also the need for a meticulous cleaning of the

abutment site and associated wound issues.4

A Danish prospective study5 of 59 patients with

SSD after translabyrinthine acoustic neuroma (AN)

resection focused on functional impairment of AN resec-

tion 2 to 3 years after the surgery and what their

satisfaction rate was following a trial of a BAHA head-

band. These data showed that 80% of the respondents

experienced and perceived a hearing handicap, but even-

tually only 54% of those who tried decided to proceed

with the implantation, citing insufficient benefit. The

authors showed the significant hearing handicap these

patients experience with SSD. However, they argued

that the BAHA should not be routinely offered as a part

of tumor resection, but rather that the patient should be

given some time to decide whether or not to pursue a

hearing intervention.

BEST PRACTICEAs a best practice, it is reasonable to consider a se-

quential interventional approach for SSD patients that

takes into consideration the degree of invasiveness or

risk associated with each intervention. For example, an

initial trial of a CROS or TransEar type hearing aid can

be recommended as a nominal risk, noninvasive option

for patients with SSD. If those trials prove unsatisfac-

tory, the patient might then be considered an

appropriate candidate for an implantable bone conduc-

tion device (e.g., BAHA or Sophono). Extensive

counseling about peri- and postoperative care as well as

complication rates for the BAHA need to be discussed

with the patient preoperatively. Those patients likely to

require magnetic resonance imaging (MRI) should also

be counseled against Sophono implantation due to MRI

incompatibility. Finally, patients should understand therealistic benefits offered by hearing interventions

(whether CROS, TransEar, BAHA, or Sophono). There is

no cost-effectiveness analysis comparing the use of the

BAHA versus other modalities.

LEVEL OF EVIDENCEOne study involved prospective randomized trial

thus qualifying for level I evidence. Three studies used

prospective cohort observational studies which fall under

level II. One study is level IV.

BIBLIOGRAPHY1. Niparko JK, Cox KM, Lustig LR. Comparison of the bone anchored hearing

aid implantable hearing device with contralateral routing of offside sig-nal amplification in the rehabilitation of unilateral deafness. Otol Neu-rotol 2003;24:7378.

2. Hol MKS, Kunst SJW, Snik AFM. Pilot study on the effectiveness of theconventional CROS, the transcranial CROS and the BAHA transcranialCROS in adults with unilateral inner ear deafness. Eur Arch Otorhino-laryngol 2010;267:889896.

3. Gluth MB, Eager KM, Eikelboom RH, et al. Long-term benefit perception,complications, and device malfunction rate of bone-anchored hearing aidimplantation for profound unilateral sensorineural hearing loss. OtolNeurotol 2010;31:14271434.

4. Siegert R. Partially implantable bone conduction hearing aids without apercutaneous abutment (Otomag): technique and preliminary clinicalresults. Adv Otorhinolaryngol 2011;71:4146.

5. Anderson HT, Schroder SA, Bonding P. Unilateral deafness after acousticneuroma surgery: subjective hearing handicap and the effect of thebone-anchored hearing aid. Otol Neurotol 2006;27:809814.

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