What is the recommended treatment plan for a patient with conductive hearing loss or single-sided deafness considering bone conduction devices, taking into account their age, medical history, and nature of hearing loss?

Bone Conduction Devices for Conductive Hearing Loss and Single-Sided Deafness

Direct Recommendation

For patients with conductive or mixed hearing loss who cannot use conventional hearing aids, bone conduction devices (both implantable and non-implantable) are effective treatment options, while for single-sided deafness, osseointegrated bone conduction implants provide superior outcomes compared to CROS devices. 1, 2

Patient Evaluation and Referral Requirements

Clinicians must evaluate or refer patients with conductive or mixed hearing loss for specialized assessment, as mandated by the American Academy of Otolaryngology-Head and Neck Surgery guidelines 3. This evaluation should include:

• Otoscopic examination to identify cerumen impaction, infection, tympanic membrane perforation, or other ear canal abnormalities 3
• Complete audiometric testing documenting the degree and type of hearing loss, including pure tone averages and word recognition scores 3
• Assessment of sociodemographic factors and patient preferences that influence access to hearing healthcare 3

Bone Conduction Device Selection Algorithm

For Conductive or Mixed Hearing Loss:

Non-implantable bone conduction devices serve as first-line options when conventional air conduction hearing aids are contraindicated or ineffective 4. These devices demonstrate good audiological outcomes and subjective benefit in both adults and children with conductive hearing loss 4.

Implantable bone conduction devices should be considered when:

• Non-implantable devices fail to provide adequate benefit 2
• Skin irritation or cosmetic concerns make headband devices unsuitable 2
• Patient has adequate bone thickness for implantation 2

Device-Specific Considerations:

Active transcutaneous systems (e.g., Osia System) are preferred when:

• Good hearing performance is the priority 2
• Patient has limited dexterity for cleaning percutaneous sites 2
• Aesthetic concerns are significant 2
• Future MRI procedures are anticipated 2

Passive percutaneous systems (e.g., Baha Connect) are more suitable when:

• Minimally invasive surgery under local anesthesia is required 2
• Patient has contraindications to general anesthesia 2
• Frequent head MRI scans will be needed 2
• Cost constraints are paramount 2

Single-Sided Deafness Management

For unilateral hearing loss, osseointegrated bone conduction implants are the recommended surgical option per American Academy of Otolaryngology-Head and Neck Surgery guidelines 1. The American Academy of Pediatrics specifically endorses bone-anchored hearing aids for congenital malformations including aural atresia when patients reach appropriate age 1.

Critical point: CROS amplification is specifically NOT recommended for children with unilateral hearing loss 1. This represents a common pitfall to avoid.

Bone conduction implants for single-sided deafness provide:

• Improved sound localization 5
• Better speech reception in noise 5
• Enhanced quality of life scores compared to no treatment 5, 6

Asymmetric Hearing Loss (AHL):

Patients with severe-to-profound loss in one ear and impaired hearing contralaterally show even greater benefit from bone conduction implants than those with true single-sided deafness 5. These patients demonstrate:

• Measurable pure tone average threshold gains 5
• Improved speech audiometry in quiet and noise 5
• Significantly better quality of life and quality of sound scores compared to SSD patients 5

Pediatric Considerations

For children with congenital aural atresia or conductive hearing loss, the American Academy of Pediatrics recommends:

• Assessment for hearing aid fitting based on individual circumstances 1
• Surgical treatment including bone-anchored hearing aids when appropriate age is reached 1
• Consideration of skull bone thickness and maturity before osseointegrated implant placement 1

When Bone Conduction Devices Are NOT Appropriate

Bone conduction devices are contraindicated in bilateral profound sensorineural hearing loss 7. These patients require cochlear implantation, not bone conduction devices, as bone conduction requires functional cochlear function to transmit sound 7.

Do not use CROS aids for bilateral profound hearing loss, as they are designed only for single-sided deafness and require a functioning contralateral ear 7.

Follow-Up and Outcome Assessment

Clinicians must assess whether communication goals have been met and if hearing-related quality of life has improved within 1 year of device fitting 3. This represents a quality improvement measure mandated by the American Academy of Otolaryngology-Head and Neck Surgery 3.

Reassess hearing at least every 3 years in patients with known hearing loss or reported changes in hearing 3.

Common Pitfalls to Avoid

• Do not delay appropriate referral for patients with conductive or mixed hearing loss who fail conventional amplification 3
• Do not use CROS devices in children with unilateral hearing loss, as this is specifically contraindicated by pediatric guidelines 1
• Do not recommend bone conduction devices for bilateral profound sensorineural hearing loss, as these patients require cochlear implantation 7
• Do not overlook skin infection risks with percutaneous systems in patients with limited dexterity or hygiene concerns 2
• Ensure comprehensive audiometric documentation before device selection to confirm appropriate candidacy 1