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Behind The Ear (BTE) Hearing Aid

Bone Conduction Implant (Baha)

People have a lot of questions about which is the best communication aid for individuals with hearing loss. No one aid is perfect for everyone. Each individual must assess his/her own needs and evaluate what is best. Many individuals contact Gate asking about aids. This basic information should help provide a bit more clarification and a few resources which will be helpful. Keep in mind, THERE IS NO CURE FOR SENSORINEURAL DEAFNESS. Whether you choose a hearing aid, a cochlear implant, or other assistive technology, no device will cure Deafness. ALL devices have pros and cons, and the more invasive the more risk they are to the individual. Many Deaf individuals find success in using aids, but the success is relevant to the individual. For more information, peruse the information below, and visit the links provided. 




Conductive hearing loss occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones (ossicles) of the middle ear. Conductive hearing loss usually involves a reduction in sound level or the ability to hear faint sounds. This type of hearing loss can often be corrected medically or surgically.

For More Information: Visit Wikipedia


Causes of Conductive Hearing Loss: 

  • Malformation of outer ear, ear canal, or middle ear structures

  • Fluid in the middle ear from colds

  • Ear infection (otitis media - an infection of the middle ear in which an accumulation of fluid may interfere with the movement of the eardrum and ossicles

  • Allergies

  • Poor Eustachian tube function

  • Perforated eardrum

  • Benign tumors

  • Impacted earwax

  • Infection in the ear canal

  • Foreign body in the ear

  • Otosclerosis



Sensorineural hearing loss (SNHL) occurs when there is damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain. Most of the time, SNHL cannot be medically or surgically corrected. This is the most common type of permanent hearing loss. SNHL reduces the ability to hear faint sounds. Even when speech is loud enough to hear, it may still be unclear or sound muffled.

For More Information: Visit Wikipedia


Causes of Conductive Hearing Loss: 

  • Exposure to loud noise

  • Head trauma

  • Virus or disease

  • Autoimmune inner ear disease

  • Hearing loss that runs in the family

  • Aging (presbycusis)

  • Malformation of the inner ear

  • Meniere’s Disease

  • Otosclerosis - a hereditary disorder in which a bony growth forms around a small bone in the middle ear, preventing it from vibrating when stimulated by sound.

  • Tumors 

  • Genetic Origin



Sometimes a conductive hearing loss occurs in combination with a sensorineural hearing loss (SNHL). In other words, there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. When this occurs, the hearing loss is referred to as a mixed hearing loss.












An audiogram is a graphic chart of how we hear in certain frequencies (Hz). Decibels (dB) is how loud or soft we hear sounds. The Speech Banana is the area on the audiogram that represents the range of human speech. The audiologist will plot your responses on the audiogram using the symbols “O” and “X”. These symbols represent the softest level (threshold) of your responses to the beeps in each frequency. The symbol “O” marks responses of your right ear. The symbol “X” marks responses of your left ear. These are referred to as air conduction thresholds. The further down the graph these symbols are marked, the greater the hearing loss.


Hearing loss is often described as follows:


  • Normal=less than 25 db HL

  • Mild=25-40 db HL

  • Moderate=41-65 dB HL

  • Severe=66-90 db HL

  • Profound=more than 90 db HL



The audiometry tests are conducted in a quiet soundproof room. Earphones will be placed on your head. A person will be asked to sit still and not talk. The earphones are connected to a machine that will deliver the tones and different sounds of speech to his/her ears, one ear at a time. The audiologist will ask the patient to raise his/her hand when a sound is heard. For example, if the patient hears a sound with the left ear, the left hand is raised; if a sound is heard with the right ear, the right hand is raised. At some facilities, a patient may be asked to push a button or indicate a sound using another method. The audiologist will record each tone at the lowest possible volume that is able to be heard. Before or after the general audiometry test, tuning forks are also used to conduct the Rinne and Weber tests. Each test evaluates the potential for different kinds of hearing loss.


The video below helps you understand what a Hard of Hearing individual hears.  


There are a wide variety of devices which are available for individuals with hearing losses. Each one serves a different level of hearing loss and provides a different level of hearing intervention. Hearing aids do not heal hearing loss, and they do not allow the user to hear on an equivalent level with those who have no hearing loss. They can enhance sound enough to make it easier to hear. 

Hearing devices do not correct hearing loss but help the users to access sound on some level. The effectiveness depends on the device used and the patient's hearing loss. Even if a sound is heard, it does not mean it can be understood with a hearing aid. The greater the hearing loss, the greater the difficulty a patient has in understanding the sounds heard.


Each of these hearing aids needs a special mold created for the patient in order to be sure they fit properly. 





Implants are becoming more and more popular these days. Let's take a look at the implants currently available. 


BONE ANCHORED HEARING AID (BAHA)   [Featured in the picture at the top of the page]

Bone anchored hearing aids are suitable for those with a mild-moderate mixed or conductive hearing loss.


A bone anchored hearing aid is an alternative to a regular hearing aid for those with problems in their outer or middle ears. It transfers sound by bone vibration directly to the cochlea, bypassing the outer and the middle ear. This means it is useful for conductive and mixed hearing losses. A bone anchored hearing aid relies on a working cochlea to send sound to the brain.


How does it work?


A bone anchored hearing aid has two parts: an external part (the ‘processor’) and a surgically implanted fixture placed in the bone behind the ear. The fixture protrudes through the skin so that the processor can attach onto it. A microphone on the  processor picks up the sound around it, and passes this to the implant. The implant sets up vibrations in the bone of the head, which triggers a response in the cochlea. This system uses natural bone conduction (transmission) of sound to the cochlea, but bypasses  the outer or middle ear.


Who can be considered?


A bone anchored hearing aid may be considered when a conventional hearing aid cannot be worn, (for example due to irritated or collapsed ear canals), or when a hearing aid does not give effective benefit. 


What can I expect from a bone anchored hearing aid?


A bone anchored hearing aid offers amplification without an ear mould in the ear. This makes them more comfortable if you experience discomfort or infections in your ear.  Some people also report that they have a more natural sound than conventional hearing aids for the same reason. They do not restore your hearing to normal, but can make managing in everyday situations easier.



Middle ear implants are suitable for those with a mild-moderate mixed or conductive hearing loss or a mild-severe sensorineural hearing loss.


A middle ear implant is a more recent hearing implant, offering an alternative to conventional hearing aids. It may be considered for those who suffer with earmould allergies, skin problems in their ears, outer ear infections, narrow, collapsed or closed ear canals, or malformed ears. 


It can also provide (for mixed or conductive hearing losses) an alternative to a bone anchored hearing aid for those with any of the above ear problems who also have healing issues, dexterity problems, or those who might find difficulty in keeping a bone anchored hearing aid clean.


How does it work?


An middle ear implant has two parts: an external part (the ‘processor’) and the surgically implanted internal part. The processor transmits sound to the internal part of the hearing implant. This consists of a receiver just below the skin to pick up the sound from the processor, together with the implant, which is attached to one of the bones in the middle ear, or attached near to the membrane window of the cochlea. The implant works by directly moving the bones of the middle ear, or by vibrating the membrane window of the cochlea. In either case, it is designed to amplify sounds by adding extra movement into the natural hearing pathway. The middle ear implant relies on a working cochlea and hearing nerve.


Who can be considered?


A middle ear implant may be considered when a conventional hearing aid cannot be worn, or does not give effective benefit.


What can I expect from a middle ear implant?


Middle ear implants offer amplification without an ear mould in the ear. This makes them more comfortable if you experience discomfort or infections in your ear. Some people also report that they have a more natural sound than conventional hearing aids for the same reason. They do not restore your hearing to normal, but can make managing in everyday situations easier.




  • Age of receiver at implantation –
    younger age groups are more successful

  • Age of receiver at loss of hearing –
    stage of development of communicative abilities

  • Period from loss of hearing to implantation –
    the shorter the period the higher the probability of success

  • Type of manufacture and variables of procedure

  • Professionalism and dedication of support team

  • How much the cochlea deviates from normal

  • Communicative abilities and intelligence of the receiver

  • Receivers' dedication and motivation to learn to hear

  • After implant the period of time lapsed in usage of the device




A cochlear implant is a surgically implanted electronic device that provides a sense of sound to a person who has a severe or profound hearing loss. A cochlear implant does not cure deafness or hearing impairment, but is a prosthetic substitute which directly stimulates the cochlea.  


The expectations of how well a cochlear implant will help someone hear have to be addressed prior to implantation, as although the device can help the person hear better and detect environmental sounds, it is not as good as the quality of sound processed by a natural cochlea and therefore will not restore hearing to normal levels. However it can be a significant improvement for the person in comparison to any previously tried hearing aids. Generally speaking if the person being implanted has lost their hearing after they have learnt language, cochlear implants can be a great help, in particular for people who have recently lost their hearing. 


During the operation the surgeon makes an incision behind the ear being treated in order to gain access into the middle ear and cochlea. The skull in the surrounding area behind the ear will be shaved to facilitate this and this will quickly regrow. The operation lasts about three hours and typically people spend one night in hospital.


Cochlear implants are the most common implanted device.





CIs don't allow Deaf people to hear like Hearing people but they can be very successful in some individuals. Usually the individuals experiencing the greatest success are young prelingually implanted children or latened Deaf adults who have heard and understood speech throughout their lifetime. 


Implanted children who have success with the implant can sometimes speak similar to Hearing people. They can sometimes understand speech without lipreading if the sounds are clear and located at a distance in close proximity. Some individuals can talk on the phone. Many parents have stated that children can understand 35% - 50% of what is said with an implant which for a profoundly Deaf individual is significant.


Some implanted individuals have little to no success with the device. 





RISK FACTORS [According to the FDA]


  • Injury to the facial nerve --this nerve goes through the middle ear to give movement to the muscles of the face. It lies close to where the surgeon needs to place the implant, and thus it can be injured during the surgery. An injury can cause a temporary or permanent weakening or full paralysis on the same side of the face as the implant.

  • Meningitis --this is an infection of the lining of the surface of the brain. People who have abnormally formed inner ear structures appear to be at greater risk of this rare, but serious complication.

  • Cerebrospinal fluid leakage --the brain is surrounded by fluid that may leak from a hole created in the inner ear or elsewhere from a hole in the covering of the brain as a result of the surgical procedure.

  • Perilymph fluid leak --the inner ear or cochlea contains fluid. This fluid can leak through the hole that was created to place the implant.

  • Infection of the skin wound.

  • Blood or fluid collection at the site of surgery.

  • Attacks of dizziness or vertigo.

  • Tinnitus, which is a ringing or buzzing sound in the ear.

  • Taste disturbances --the nerve that gives taste sensation to the tongue also goes through the middle ear and might be injured during the surgery.

  • Numbness around the ear.

  • Reparative granuloma --this is the result of localized inflammation that can occur if the body rejects the implant.

  • There may be other unforeseen complications that could occur with long term implantation that we cannot now predict.




  • May hear sounds differently. Sound impressions from an implant differ from normal hearing, according to people who could hear before they became deaf. At first, users describe the sound as "mechanical", "technical", or "synthetic". This perception changes over time, and most users do not notice this artificial sound quality after a few weeks of cochlear implant use.

  • May lose residual hearing. The implant may destroy any remaining hearing in the implanted ear.

  • May have unknown and uncertain effects. The cochlear implant stimulates the nerves directly with electrical currents. Although this stimulation appears to be safe, the long term effect of these electrical currents on the nerves is unknown.

  • May not hear as well as others who have had successful outcomes with their implants.

  • May not be able to understand language well. There is no test a person can take before surgery that will predict how well he or she will understand language after surgery.

  • May have to have it removed temporarily or permanently if an infection develops after the implant surgery. However, this is a rare complication.

  • May have their implant fail. In this situation, a person with an implant would need to have additional surgery to resolve this problem and would be exposed to the risks of surgery again.

  • May not be able to upgrade their implant when new external components become available. Implanted parts are usually compatible with improved external parts. That way, as advances in technology develop, one can upgrade his or her implant by changing only its external parts. In some cases, though, this won't work and the implant will need changing.

  • May not be able to have some medical examinations and treatments. These treatments include:

    • MRI imaging. MRI is becoming a more routine diagnostic method for early detection of medical problems. Even being close to an MRI imaging unit will be dangerous because it may dislodge the implant or demagnetize its internal magnet. FDA has
      approved some implants, however, for some types of MRI studies done under controlled conditions.

    • neurostimulation.

    • electrical surgery.

    • electroconvulsive therapy.

    • ionic radiation therapy.

  • Will depend on batteries for hearing. For some devices new or recharged batteries are needed every day.

  • May damage their implant. Contact sports, automobile accidents, slips and falls, or other impacts near the ear can damage the implant. This may mean needing a new implant and more surgery. It is unknown whether a new implant would work as well as the old one.

  • May find them expensive. Replacing damaged or lost parts may be expensive.

  • Will have to use it for the rest of life. During a person's lifetime, the manufacturer of the cochlear implant could go out of business. Whether a person will be able to get replacement parts or other customer service in the future is uncertain.

  • May have lifestyle changes because their implant will interact with the electronic environment. An implant may

    • set off theft detection systems

    • set off metal detectors or other security systems

    • be affected by cellular phone users or other radio transmitters

    • have to be turned off during take offs and landings in aircraft

    • interact in unpredictable ways with other computer systems

  • Will have to be careful of static electricity. Static electricity may temporarily or permanently damage a cochlear implant. It may be good practice to remove the processor and headset before contact with static generating materials such as children's plastic play equipment, TV screens, computer monitors, or synthetic fabric. For more details regarding how to deal with static electricity, contact the manufacturer or implant center.

  • Have less ability to hear both soft sounds and loud sounds without changing the sensitivity of the implant. The sensitivity of normal hearing is adjusted continuously by the brain, but the design of cochlear implants requires that a person manually change sensitivity setting of the device as the sound environment changes.

  • May develop irritation where the external part rubs on the skin and have to remove it for a while.

  • Can't let the external parts get wet. Damage from water may be expensive to repair and the person may be without hearing until the implant is repaired. Thus, the person will need to remove the external parts of the device when bathing, showering, swimming, or participating in water sports.

  • May hear strange sounds caused by its interaction with magnetic fields, like those near airport passenger screening machines.






Auditory Brainstem Implants are suitable for those with a profound sensorineural hearing loss, leading to near total loss of sound. An auditory brainstem implant has two parts: an external part (the ‘processor’, worn on the ear) and the surgically implanted internal part. A microphone on the processor picks up the sound around it, and turns it from a sound wave into an electrical signal. The processor then transmits the sound signal to the internal part of the hearing implant. This consists of a receiver just below the skin, together with the implant array which is positioned within the brainstem. This means that the implant is bypassing both the cochlea and the hearing nerve, taking a short cut to the brainstem. In this way the auditory brainstem implant aims to give a sense of sound when the hearing nerve is not working. 








One main use of the auditory brainstem implant is for those with the condition Neurofibromatosis type 2 (NF2).  If you have NF2, you are likely to have a tumour on or near the hearing nerve. If this tumor is removed for medical reasons, the surgeons may well have to cut across the nerve of hearing. This brings about a complete breakdown of natural hearing in that ear. During the tumour removal surgery, the surgeon may consider placing an auditory brainstem implant as an alternative method of hearing. Other uses of the auditory brainstem implant are for people who are born with no functioning nerve of hearing in either ear, or people who are deaf because of an unusually shaped cochlea. Sometimes meningitis leads to deafness but leaves the cochlea too damaged to take a cochlear implant. However, an auditory brainstem implant for one of these reasons is very rare, because the auditory brainstem implant requires neurosurgery.




An auditory brainstem implant may provide a link to sounds when there would otherwise be no natural hearing at all. An auditory brainstem implant may help with lip-reading. 




An auditory brainstem implant involves complex neurosurgery to the brainstem. Your consultant would need to discuss all the risks with you.


The results of an auditory brainstem implant are extremely variable. It is a difficult task to position the auditory brainstem implant on the brainstem exactly to deliver sound. It is possible that there is no hearing sensation at all from the auditory brainstem implant.

In some cases the hearing sensation is within a narrow range so that sounds are not well differentiated. It takes time to adjust to the sound perceived through an auditory brainstem implant.







Many parents are told that it is not a good idea to teach their children sign language in addition to using aids or implants. We do strongly encourage using sign language in the home in addition to any assistive listening devices. This provides accessibility in locations when it is difficult to use aids or implants. Examples of locations where children often won't have devices accessible or will not find them effective even if they are effective in some locations (not an exhaustive list): 

1) Swimming 

2) Bathing 

3) Busy & loud restaurants 

4) Amusement parks

5) Medical environments where devices are not allowed

6) Underwater activities 

7) Sports environments 

8) Performance environments 

9) Venues with loud music  

10) Conferences


Our office recommends that all families learn to communicate with their children in sign language. We have never seen a family regret it


When have we seen individuals regret not learning sign language? 


We have seen parents look back in regret when medical issues have arisen where their children could not wear their implants. When those days have come many parents feel guilty over not being able to communicate with their children in a time of extreme need. We have seen implanted and non-implanted adults regret not encouraging their families to use sign language in moments where one-on-one communication is not possible (e.g.: the dinner table) or when a family member is difficult to understand. We have seen individuals regret not using sign language when they later want to interact with Deaf individuals who use sign language and the language barrier makes that interaction difficult. If you have any additional questions, don't hesitate to contact our office! We would be happy to discuss any questions with you. 





Sign language does not negatively effect the progression of a child's speaking ability or ability to manage and define the sounds they hear. Some doctors will state that it does, but there is no evidence to back that theory. Usually medical bias' encourage that suggestion. 

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