Bone-anchored hearing systems

Sometimes, hearing aids are not the best option for people with hearing loss, and bone-anchored hearing systems are suggested as a more suitable choice. Yet, many people aren't aware of what they are, how they work, and how successful they can be.

Unlike hearing aids, bone-anchored hearing systems are surgically implanted devices. They treat hearing loss through bone conduction of sound vibrations to the inner ear—this is in contrast to regular hearing aids, which amplify acoustic sounds that enter the ear canal.

For this reason, bone-anchored systems are considered specialty devices for people who have outer or middle ear problems, but at least one functioning inner ear (cochlea).

Bone-anchored hearing systems (BAHS), also known as bone-anchored auditory implants or bone-anchored hearing aids (BAHA), are not to be confused with cochlear implants. While cochlear implants are also a type of surgically implanted device for hearing loss, the patient indications are different. In other words, they treat different hearing problems. To learn more, see our page on cochlear implants. 

Here's what to know:

Why bone-anchored hearing systems?

Bone-anchored hearing systems work best for people who have at least one inner ear (cochlea) that functions normally. They may have conductive hearing loss (their outer or middle ears do not transmit sound correctly) or complete hearing loss in one ear only. Candidacy is best determined by a hearing care professional like an otolaryngologist (ENT).

These types of devices bypass particular problems by sending sound vibration directly to the inner ear through the skull bone. This can be helpful because middle ear and ear canal problems might prevent sound waves and signals from reaching the inner ear. In those cases, standard hearing aids are ineffective. 

The most likely candidates for bone-anchored hearing systems are children or adults who have severe outer or middle ear malformations, or those with single-sided deafness.

That's why people who typically get the greatest benefit from bone-anchored hearing systems include those who have severe outer or middle ear malformations and those with single-sided deafness, also known as unilateral hearing loss. This type of hearing solution also may be recommended in extreme cases of chronic ear infections or allergies to traditional hearing aids. 

Malformations of the outer or middle ear

Malformations of the ear canal or middle ear, such as narrowing of the ear canal or a malformed or absent pinna (external ear) cause conductive hearing loss. These malformations are often congenital, or present at birth. A bone-anchored hearing solution delivers sound vibrations directly to the inner ear by being in direct contact with the skull bones. EarCommunity.org has a photo gallery of people with these conditions wearing bone-anchored hearing systems.

Single-sided deafness

Single-sided deafness (SSD) is a condition in which a person has lost all hearing in one ear, while having anywhere normal hearing or slight hearing loss in the other ear. Single-sided deafness makes it difficult to determine which direction sound is coming from (localization) and diminishes the ability to understand speech in noisy environments. Find out how bone-anchored hearing systems help with unilateral hearing loss.

Causes of SSD include acoustic neuroma (a tumor on the hearing nerve), Meniere's disease or sudden sensorineural hearing loss. If you have single-sided deafness, you can wear a special pair of hearing aids that route sounds from the poorer hearing side to the better hearing side (called a CROS device). A bone-anchored hearing system may be preferable because it requires the use of only one discreet device.

Ear allergies or irritation/annoyance from standard hearing aids

Because a bone-anchored hearing device does not block the ear canal, there are other, rarer conditions that might warrant this type of hearing treatment. For example, people with chronic ear infections may have difficulty wearing traditional hearing aids if they experience drainage of fluids from the middle ear into the ear canal. People who have extreme allergies to the materials used to fabricate custom hearing aids and earmolds may also prefer a bone-anchored system.

How do they work?

Bone-anchored hearing devices have two parts: a titanium bone implant and an external sound processor. The sound processor has microphones that pick up sounds and convert them into vibrations sent to the embedded implant. In turn, the implant vibrates the surrounding bone, which sets up sound waves in the inner ear that stimulate the hair cells and result in the firing of the auditory nerve.

What happens during surgery?

During an outpatient surgical procedure, an ear-nose-throat doctor (otolaryngologist) or other surgical specialist places a small titanium implant (3-4 mm) into the mastoid bone behind the ear. The implant may have a small abutment that sticks out through the skin for attaching the external part of the device or it may be completely under the skin. Over time, the titanium implant integrates with the bone. The removable sound processor can then be attached via a built-in magnet or by clipping onto the abutment. 

The goal is that all parts fit snugly together, as a snug fit helps hearing implants convey vibrations through the bone more effectively. 

The kind of operation you receive will be different depending on which manufacturer’s system you choose. For example, Oticon Medical utilizes MIPS (minimally invasive Ponto surgery), which takes an average of 15 minutes to perform and usually only requires local anesthesia. MIPS reduces the likelihood of complications because it doesn’t require suturing, which eliminates scarring and fosters rapid healing.

MIPS also reduces the likelihood of complications because it leaves more of the skin, blood vessels, and nerves intact. The operation was designed to create the smallest incision possible, leaving the skin and hair follicles around the new abutment intact. Recovery typically requires only a day or two of rest before you can return to your normal activities. With few exceptions, most candidates for a bone-anchored hearing device can safely undergo MIPS. Talk to your doctor to learn more.

If you're considering a bone-anchored device, but first want to get a sense of if this type of device would work well for you, your doctor or audiologist may be able to let you try out traditional bone conduction hearing aids (which don't require an implant or any surgery). Or, they may help you try out simulation devices.

Can you hear right away?

The skull and skin have to heal before the external device can be clipped on or magnetically connected. The time needed for healing is specified differently by each manufacturer, from 3 weeks to 3 months. Once the external device is attached, it can be programmed for the patient's specific hearing loss. Wearing a bone-anchored hearing system would be similar to wearing an acoustic hearing aid moving forward—there may be some adjustments needed as the patient gets accustomed to hearing and listening to amplified sounds.

Can older adults use bone-anchored hearing systems?

Yes, a bone-anchored hearing device can be used to treat hearing loss in older adults caused by changes to the outer or middle ear, or the onset of single-sided deafness (SSD) that cannot be treated sufficiently or at all by traditional hearing aids.

For example, adults who gave up on wearing their hearing aids due to repeated ear infections, allergic reactions of the skin, or other medical conditions may find implantable treatments a viable alternative for improving their hearing. That's because a processor can be snapped onto an implanted abutment, rather than resting against the skin, and the wearer doesn’t have to insert any components into their ear canal.

Alternative to hearing aids

A BAHS can help older adults unwilling or unable to benefit from traditional hearing aids continue participating in social situations and better enjoy their daily lives by helping them:

• Better understand speech
• Take part in conversations during meals or social events
• Watch television and listen to music without having to turn the volume up beyond levels their family can enjoy
• Participate more easily in sports and other recreational activities

On the market

Currently, there are two manufacturers with FDA-approved bone-anchored hearing systems: Oticon Medical and Cochlear Americas. Each device brand fits a little differently but they're both placed behind the ear on the mastoid bone. Indications for child wearers may require a soft headband to ensure the device stays in place during active play. 

What is a BAHA?

People sometimes refer to any brand of bone-anchored hearing devices as a BAHA (short for "bone-anchored hearing aids"). However, BAHA™ also is the name of a specific brand of bone-anchored hearing device, made by the Cochlear Americas company. People also may refer to any of the several brands as a "bone-anchored hearing device" or a "bone-anchored hearing system" (BAHS).

What is a Ponto?

Ponto™ is the brand name of Oticon Medical’s bone-anchored device, and various models have been on the market since 2009. The latest model is the Ponto 5, which is the smallest available bone-anchored hearing device currently on the market that also offers full wireless capabilities.

The retail price is around $5,000, though this is often covered by medical insurance. It should be noted that Ponto devices can be worn on a soft band. This is appropriate for: children under the age of five, wearers who only require temporary hearing assistance or are just trying it out, and anyone with physical conditions that preclude implantation (e.g., lack of sufficient skull density).

What is the Sentio System?

The Sentio™ System from Oticon Medical was approved by the FDA in 2024 for wearers aged 12 and up. It is a transcutaneous system, which means there is no implanted abutment. The device combines the Sentio Ti implant, which is placed under the skin, and the Sentio 1 Mini sound processor, which is held over the implant by magnets. This allows the processor to lie flat and flush against the skull.

This device is appropriate for wearers with a lack of sufficient skull density or those who are concerned about potential issues with the abutment, such as potential skin overgrowth or crusting at the site.

What kinds of accessories work with bone-anchored hearing aids?

The accessories and apps available for bone-anchored hearing device users are very similar to those used by regular hearing aid wearers, and are often referred to generally as assistive listening devices. They include:

• Audio streamers – relay devices worn around the neck or as clips that allow wearers to stream sound from televisions, cellphones, or music players directly into their sound processor.
• FM/DM receiver – frequently used by students to tap into a school’s FM system and stream a teacher or lecturer’s voice directly into the wearer’s processor. Very helpful in crowded, noisy, or large, echoing venues like auditoriums.
• TV streamers – these can be hooked up to most televisions or computers and allow bone-anchored device wearers to stream the audio wirelessly directly into their BAHA for greater clarity and speech comprehension.
• Smartphone apps – depending on how advanced your bone-anchored hearing system is, you might be able to use an app to learn how to use your new BAHS or control your device’s volume and other functions right from your cellphone. These apps are typically provided free of charge from Oticon Medical or Cochlear Americas and can be downloaded from the Google Play™ or Apple® App stores. Ask your manufacturer which ones are compatible with your specific device.
• Depending on the type of phone you have, some bone-anchored hearing devices will stream directly without the need for an added accessory. Talk to your audiologist about these options when selecting which is right for you.

How much does a bone-anchored hearing device cost?

While the exact cost of surgery differs depending on the kind of operation to implant the device you have and other criteria, the average cost is between $10,000 and $17,000. In addition, the sound processor price ranges between $5,000 and $8,000 depending on the manufacturer you choose, and the variety of features included in the specific device.

The good news? Bone-anchored hearing aids and the procedures to implant them are frequently covered by insurance, at least in part. To find out what your insurer will cover, contact them for details. Most manufacturers also offer insurance support staff to assist you with checking your coverage and help you appeal a denial or find other options to afford your bone-anchored hearing system if needed.

What about Medicare?

Bone-anchored hearing systems and cochlear implants are covered under the statutory Medicare benefit provision for prosthetic devices. Medicare has a longstanding policy of providing coverage for cochlear implants when the patient meets the coverage criteria and without regard to whether the implant is unilateral or bilateral (one ear or both ears). Medicare reimbursement rules, however, are complex and can change.

What about Medicaid?

If you have Medicaid, your coverage for implantable hearing devices will depend largely on what state you live in. The Hearing Loss Association of America maintains a page with the latest details on which state Medicaid programs cover hearing care.

Interested in a bone-anchored hearing system?

If you think you may be a candidate for a bone-anchored hearing system and you would like to find out more, contact an ear, nose and throat doctor in your area, or you can search this directory of providers from Oticon Medical.