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Best Evidence Statement (BESt)
Audiology/Single Sided Deafness/Amplification/BESt 104
Date published/posted 6/20/11
Topic: Effects of Amplification on Quality of Life Among School Age Children with Single Sided
Deafness
Clinical Question
P: Among school age children with single sided deafness
I: does amplification bone conduction hearing aids
C: versus no amplification
O: improve quality of life (QoL)
Definitions:
Amplification:
For the purpose of this study, amplification is defined as: Contralateral routing of Signal (CROS), bone
anchored hearing aid (BAHA), bone conduction hearing aids (Transcranial aid).
.
Quality of Life:
For the purpose of this project, QoL is defined as the core dimensions of); physical functioning, emotional
functioning, social functioning, and school functioning.
Other important indicators of QoL in the pediatric population with SSD include hearing in noise, localization, ease of
listening and communicating, communication intent and behavior, nature of interpersonal relationships and
involvement in recreational activities.
Target Population
School age children (ages 7-18 years) with single sided deafness.
Children with additional learning disabilities are excluded.
Recommendation
It is recommended that for children with single sided deafness (SSD) amplification be offered (Hol,
2010 [3b], Christensen, 2010 [4a], House 2010 [3a]).
Note 1: Selected educational and family outcomes are important to monitor when amplification is
used or if a decision is made not to provide amplification (McKay 2010 [5a]).
Note 2: Utilize Quality of Life measurements with any child identified with SSD and their families
(Borton 2010 [3a]).
Note 3: Educate parents/families and the child on the impact of single sided deafness regarding the
potential effects of the hearing loss, current amplification options, costs, and realistic expectations
about the devices may increase their ability to make informed an decision regarding interventions
(Borton, 2010 [3a], McKay 2010 [5a]).
Copyright 2011 Cincinnati Children's Hospital Medical Center; all rights reserved
Page 1 of 5
Audiology/Single Sided Deafness/Amplification/BESt 104
Discussion/summary of evidence
A review of the current literature suggests that amplification versus no amplification improves quality of life
and therefore offered as a part of care (House, 2010 [4b], Hol, 2009 [3b], Yuen, 2009 [3a], Linstrom 2009
[3a], Christensen, 2010, [4a]). Two of the most commonly reported challenges for patients with SSD are
the ability to localize sound and speech understanding in noise (Bess, 1986 [5a]). Therefore, most research
studies have been designed to measure benefit with amplification in these two conditions, and failed to
consistently show improvement in both (Hol, 2009 [3b], Hol, 2005 [3a], Linstrom, 2009 [3a]). Quality of
life measures for adults, however, have consistently shown benefit in the following conditions: listening in
background noise, ease of communication and listening in reverberant conditions (House, 2010 [4b], Hol,
2009 [3b], Yuen, 2009 [3a], Newman, 2008 [3b], Linstrom, 2009 [3a]). The studies evaluating children
with SSD (Christensen, 2010 [4a], Christensen, 2008, [4b]) as well as studies involving children with
unilateral hearing loss (UHL), (Borton, 2008 [3a], Wendorf, 2010, [3a]) suggest that functional outcome
measures such as the CHILD, LIFE and a questionnaire by McKay (2002), indicate improvement in quality
of life with amplification. These findings suggest that more consistent test protocols utilizing quality of life
measures are necessary to gather information on the effects of amplification for children with SSD.
Health Benefits, Side Effects and Risks
The primary risk of amplification is dependent upon the amplification device chosen. Amplification options
are divided into surgical and nonsurgical options.
The most common surgical option is the Bone Anchored Hearing Aid (BAHA) which includes the general
risks involved in surgical procedures, such as anesthesia and infection as well as the potential failure of the
device to integrate with the bone. Another consideration is the high cost of the surgical procedure compared
to the outcome benefits. The appearance of the device has also been a concern reported by some patients.
The nonsurgical options include cross routing of signal hearing aids (CROS aids) and bone conduction
hearing aids (the TransEar and Transcranial CROS in-the-ear hearing aids). The cost of the device is a
consideration as most hearing aids are not covered by insurance companies. The appearance of these
devices has also been expressed as a concern by some patients and their parents.
Common to all amplification devices is the time and effort to manage the hearing devices and the possibility
that some children may have difficulty appropriately managing their devices, depending on their dexterity
and developmental skills.
References (evidence grade in [ ]; see Table of Evidence Levels following references)
Christensen, AuD, L., Richter, MD, G. T., & Dornhoffer, MD, J. L. (2010). Update on Bone-Anchored
Hearing Aids. Arch Otolaryngol Head Neck Surg, 175-177.[4a]
Bess, F.H. (1986). An Introduction to Unilateral Sensorineural Hearing Loss in Children. Ear and Hearing,
3-13.[5a]
Borton, S. A., Mauze, E., & Lieu, J. E. (2010). Quality of Life in Children Wiith Unilateral Hearing Loss: A
Pilot Studey. American Journal of Audiology, 61-72.[3a]
Christensen, L., & Dornhoffer, J. L. (2008). Bone-Anchored Hearing Aids for Unilateral Haering Loss in
Teenagers. Otology & Neurology, 1120-1122.[4b]
Copyright 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
Page 5 of 5
Audiology/Single Sided Deafness/Amplification/BESt 104
Hol, M. K., & Kunst, S. J. (2010, June). Pilot study on the effectiveness of the conventional CROS, the
transcranial CROS and the BAHA transcranial CROS in adults with unilateral inner ear deafness.
European Archives of Oto-Rhino-Laryngology, 889896.[3b]
House, MD, J. W., Kutz, Jr. MD, J. W., Chung, MA, J., & Fisher, PhD, L. M. (2010). Bone-Anchored
Hearing Aid Subjective Benefit for Unilateral Deafness. The Laryngoscope, 601-607.[4b]
Lin, L.-M., Bowditch, S., Anderson, M. J., May, B., Cox, K. M., & Niparko, J. K. (2006). Amplification in
the Rehabilitation of Unilateral Deafness: Speech in Noise and Directional Hearing Effects with
Bone-Anchored Hearing and Contralateral Routing of Signal Amplification. Otology & Neurotology,
172-182.[3b]
Linstrom, MD, C. J., Silverman, PhD, MPH, C. A., & Yu, PhD, G.-P. (2009). Efficacy of the Bone-
Anchored Hearing Aid for Single-Sided Deafness. The Laryngoscope, 713-720.[3a]
Martin, T.P,C., Lowther, R., Cooper, H.,, Irving, R., Reid, A., & Proops, D. (2010). The bone-anchored
hearing aid in the rehabilitation of single-sided deafness: experience with 58 patients. Clin.
Otolaryngol, 284290.[3a]
Myrthe K. S. Hol, Hol, M. K., Bosman, A. J., Ad F. M. Snik,, Emmanuel A. M. Mylanus,, Mylanus, E. A.,
et al. (2005). Bone-Anchored Hearing Aids in Unilateral Inner Ear Deafness: An Evaluation of
Audiometric and patient Outcome Measurements. Otology & Neurotology, 9991006.[3a]
Newman, C. W., Sandridge, S. A., & Wodzisz, L. M. (2008). Longitudinal Benefit From and Satisfaction
With the Baha System for Patients with Acquired Unialteral Sensorinueral Hearing Loss. Otology &
Neurotology, 1123-1131.[3b]
Sammath, PhD, C. A., & Cire, AuD, G. (2009, April). Effectiveness in Treating Single-Sided Deafness with
the Baha System. Hearing Review.[5a]
Schroder, S. A., Tomaas Ravn,, Ravn, T., Per Bonding, & Bonding, P. (2010). BAHA in Single-Sided
Deafness: Patient Compliance. Otology & Neurotology, 404-408.[[3b]
Wazen, MD, J. J., Ghossaini, MD, S. N., Spitzer, PhD, J. B., & Kuller, MS, M. (2005). Localization by
unilateral BAHA users. OtolaryngologyHead and Neck Surgery, 928-932.[3b]
Wazen, MD, J. J., Spitzer, PhD, J. B., Ghossani, MD, S. N., Fayad, MD, J. N., Niparko, MD, J. K., Cox,
MS, CCC-A, K., et al. (2003). Transcranial contralateralcochlear stimulation in unilateral deafness.
Otolaryngology - Head and Neck Surgery, 248-254.[3b]
Wazen, MD, J. J., Spitzer, PhD, J., Ghossaini, MD, S. N., Kacker, MD, A., & Zschommler, A. (2001).
Results of the Bone-Anchored Hearing Aid in Unilateral Hearing Loss. The Laryngoscope, 955-
958.[3b]
Yuen, Yuen, MBBS, MRCS, DOHNS, H.-W., Bodmer, MD, PhD, D., Smilsky, MclSci, K., Nedzelski, MD,
FRCSC, J. M., & Chen, MD, FRCSC, J. M. (2009). Management of single-sided deafness with the
bone-anchored hearing aid. Otolaryngolgoy-Head and Neck Surgery, 16-23.[3a]
Note: Full tables of evidence grading system available in separate document:
Grading a Body of Evidence to Answer a Clinical Question
Judging the Strength of a Recommendation (abbreviated table below)
Table of Evidence Levels (see note above)
Quality level
1a or 1b
2a or 2b
3a or 3b
4a or 4b
5 or 5a or 5b
a = good quality study; b = lesser quality study
Definition
Systematic review, meta-analysis, or meta-
synthesis of multiple studies
Best study design for domain
Fair study design for domain
Weak study design for domain
Other: General review, expert opinion, case
report, consensus report, or guideline
Copyright 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Audiology/Single Sided Deafness/Amplification/BESt 104
Table of Recommendation Strength (see note above)
Strength
Strongly recommended
Recommended
No recommendation made
Definition
There is consensus that benefits clearly outweigh risks and burdens
(or visa-versa for negative recommendations).
There is consensus that benefits are closely balanced with risks and burdens.
There is lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process
that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
1. Grade of the Body of Evidence (see note above)
2. Safety / Harm
3. Health benefit to patient (direct benefit)
4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
5. Cost-effectiveness to healthcare system (balance of cost / savings of resources, staff time, and supplies based on published studies or
6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention,
onsite analysis)
comparison, outcome])
7. Impact on morbidity/mortality or quality of life
Background Information
Children identified with single sided deafness (SSD) are frequently not offered amplification due to limited
treatment options and unknown benefits (Kiese-Himmiel, C., 2002[4a], McKay 2008 [4a]). The difficulties
children experience with unilateral hearing loss (UHL) are described in the literature but there is limited
evidence to support the benefit of amplification for SSD, especially with the pediatric population. Current
amplification options are inconsistently offered by audiologists (McKay, 2008 [5a], McKay 2010 [5a]).
This project was developed to discover the evidence around the quality of life benefits for children with
SSD fit with amplification.
Supporting information
Group/team members
Team Leader: Lori Garland, M.S, Pediatric Audiologist II, Division of Audiology, Cincinnati Childrens
Hospital Medical Center
Support Personnel: Barbara K. Giambra, MS, RN, CPNP, Center for Professional Excellence/Research
and Evidence-based Practice, Cincinnati Childrens Hospital Medical Center
Search strategy
Databases: Ovid Medline, PubMed, Google Scholar and hand search.
Keywords: single sided deafness, unilateral hearing loss, unilateral deafness, amplification, quality of life,
treatment, outcomes, guidelines
Limits: English language, all dates included
Retrieved: July 29, 2010 November 22, 2010
Copies of this Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of
improving child health outcomes. Website address: http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm
Examples of approved uses of the BESt include the following:
copies may be provided to anyone involved in the organizations process for developing and implementing evidence-based care;
hyperlinks to the CCHMC website may be placed on the organizations website;
the BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or
electronic documents; and
copies may be provided to patients and the clinicians who manage their care.
Copyright 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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Audiology/Single Sided Deafness/Amplification/BESt 104
Notification of CCHMC at HPCEInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is
appreciated.
For more information about CCHMC Best Evidence Statements and the development process contact .the Center for Professional
Excellence/Research and Evidence-based Practice office at CPE-EBP-Group@cchmc.org .
Note
This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive
practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This
Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current
revision of this document. This document is not intended to impose standards of care preventing selective variances from the
recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The
clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of
any specific procedure.
Reviewed against quality criteria by two independent reviewers
Copyright 2011 Cincinnati Children's Hospital Medical Center; all rights reserved.
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