Clinic Hearing Aid Comparisons: CROS Technology Scot Frink, AuD Salem Audiology Clinic California Academy of Audiology September, 2018

Disclaimer Independent practitioner; do not work for or have any vested interest in any hearing aid manufacturer.

Overview Brief review of available CROS / BiCROS Solutions for Single-Sided Deafness Review of the 2016 – 17 clinical study by Salem Audiology Clinic

Menti Question 1A!

Additional Disclaimer A weakness of product comparisons is technological turnover. Since this study was completed, all four manufacturers involved—Signia, Starkey, Phonak, and Widex have all released new product platforms, all CROS compatible, some with significant changes. Despite this, the information is still relevant.

Salem Audiology Clinical Comparison Studies 2000: Phonak (Adult utilization of FM technology) 2005: Phonak, Unitron, Interton (CROS) 2007: Phonak, Starkey (Feedback control) 2010: Phonak, Unitron (CROS) 2014: Phonak, Widex (CROS) 2015: Superpower BTE vs. RIC 2016-17: Phonak, Widex, Starkey, Signia (CROS) 2017-18: AmpCROS Case studies 2017 (in progress): Unitron, Widex, Signia (Tinnitus) 2018 (in development): OTC vs. Prescribed comparison

Salem Audiology Clinical Comparison Studies 2000: Phonak (Adult utilization of FM technology) 2005: Phonak, Unitron, Interton (CROS) 2007: Phonak, Starkey (Feedback control) 2010: Phonak, Unitron (CROS) 2014: Phonak, Widex (CROS) 2015: Superpower BTE vs. RIC 2016-17: Phonak, Widex, Starkey, Signia (CROS) 2017-18: AmpCROS Case studies 2017 (in progress): Unitron, Widex, Signia (Tinnitus) 2018 (in development): OTC vs. Prescribed comparison

Salem Audiology Clinical Comparison Studies 2000: Phonak (Adult utilization of FM technology) 2005: Phonak, Unitron, Interton (CROS) 2007: Phonak, Starkey (Feedback control) 2010: Phonak, Unitron (CROS) 2014: Phonak, Widex (CROS) 2015: Superpower BTE vs. RIC 2016-17: Phonak, Widex, Starkey, Signia (CROS) 2017-18: AmpCROS Case studies 2017 (in progress): Unitron, Widex, Signia (Tinnitus) 2018 (in development): OTC vs. Prescribed comparison

Salem Audiology Clinical Comparison Studies 2000: Phonak (Adult utilization of FM technology) 2005: Phonak, Unitron, Interton (CROS) 2007: Phonak, Starkey (Feedback control) 2010: Phonak, Unitron (CROS) 2014: Phonak, Widex (CROS) 2015: Superpower BTE vs. RIC 2016-17: Phonak, Widex, Starkey, Signia (CROS) 2017-18: AmpCROS Case studies 2017 (in progress): Unitron, Widex, Signia (Tinnitus) 2018 (in development): OTC vs. Prescribed comparison

Menti Question 1B!

Candidacy Very poor or no residual hearing is the worse ear. Aidable or normal hearing in the better ear CROS: No amplification to the better ear BiCROS: At least some amplification to the better ear I have personally found that most patients prefer BiCRO even if they are truly a CROS candidate

Candidacy Word Recognition tests If there is no residual hearing (confirmed) in the worse ear, test only the better ear. If there is any residual hearing in the worse ear, you must test binaural to avoid causing auditory deprivation and to truly rule the patient a CROS candidate.

Candidacy Word Recognition tests Good ear 80%, bad ear 20%, binaural 96% FIT BINAURAL! Good ear 80%, bad ear 20%, binaural 64% FIT CROS! Good ear 80%, bad ear 20%, binaural 80% ??? -- Toss up! Do a trial binaural first to determine perceived benefit Do a trial BiCROS second if no perceived benefit with binaural AmpCROS?

Study Results In 2016, both Starkey and Siemens introduced new CROS technology on their Muse and Primax platforms (respectively). In addition, both Phonak and Widex have launched newer platforms (Venture and Unique). How to do this study (four players!)

Methodology Study participants… 18 previous users, 10 new users Ages ranged from 26 to 86. Hearing loss in the better ear ranged from normal (CROS) to severe (60 sloping to 90).

Methodology Each patient utilized each CROS system for 2-3 weeks, returning weekly for adjustments and counseling. Upon completion of each trial, patients fill out subjective surveys on each product, evaluation perception of many areas…

Methodology Subjective survey analyzed… Sound Quality for Speech Sound Quality for Music Perception of Localization Improvement Performance in Background Noise Battery Life Cosmetics Ease of use Feedback

Methodology Objective testing was also completed, evaluating WRS in quiet when presented 90° azimuth to the poorer side Both sides off Better ear on (i.e. Aid only) Both sides on (i.e. CROS transmission utilized). Presentation at 65dBSPL, 25 words per run.

Study Results: Objective Measures   Aid Aided CROS Overall Unaided Company Only w/CROS Improvement 43% Starkey 62% 79% 19% 17% 36% Signia 69% 82% 26% 13% 39% Phonak 67% 87% 24% 20% 44% Widex 77% 89% 34% 12% 46% Average 84% 16% 41%

Study Results: Objective Measures   Aid Aided CROS Overall Unaided Company Only w/CROS Improvement 43% Starkey 62% 79% 19% 17% 36% Signia 69% 82% 26% 13% 39% Phonak 67% 87% 24% 20% 44% Widex 77% 89% 34% 12% 46% Average 84% 16% 41%

Study Results: Objective Measures   Aid Aided CROS Overall Unaided Company Only w/CROS Improvement 43% Starkey 62% 79% 19% 17% 36% Signia 69% 82% 26% 13% 39% Phonak 67% 87% 24% 20% 44% Widex 77% 89% 34% 12% 46% Average 84% 16% 41%

Study Results: Objective Measures   Aid Aided CROS Overall Unaided Company Only w/CROS Improvement 43% Starkey 62% 79% 19% 17% 36% Signia 69% 82% 26% 13% 39% Phonak 67% 87% 24% 20% 44% Widex 77% 89% 34% 12% 46% Average 84% 16% 41%

Study Results: Objective Measures   Aid Aided CROS Overall Unaided Company Only w/CROS Improvement 43% Starkey 62% 79% 19% 17% 36% Signia 69% 82% 26% 13% 39% Phonak 67% 87% 24% 20% 44% Widex 77% 89% 34% 12% 46% Average 84% 16% 41%

Study Results: Objective Measures   Aid Aided CROS Overall Unaided Company Only w/CROS Improvement 43% Starkey 62% 79% 19% 17% 36% Signia 69% 82% 26% 13% 39% Phonak 67% 87% 24% 20% 44% Widex 77% 89% 34% 12% 46% Average 84% 16% 41%

Study Results: Subjective Survey Sound Quality for Speech 18 preferred Widex 7 preferred Phonak 2 preferred Signia 1 preferred Starkey

Study Results: Subjective Survey Sound Quality for Music 15 preferred Widex (broader dynamic range) 10 preferred Starkey (2nd chip?) 4 preferred Phonak None preferred Signia

Study Results: Subjective Survey Perception of Localization Improvement 14 preferred Phonak 11 preferred Widex 3 preferred Signia 1 preferred Starkey

Study Results: Subjective Survey Performance in Background Noise 17 preferred Phonak (Speech in Loud Noise Algorithm) Available at the v70 and v90 levels, not at v50 or v30 9 preferred Widex 2 preferred Signia None preferred Starkey

Study Results: Subjective Survey Battery Life 10 preferred Widex 8 preferred Signia 5 preferred Phonak 5 preferred Starkey

Study Results: Subjective Survey Cosmetics 14 preferred Phonak 8 preferred Starkey 3 preferred Widex 3 preferred Signia

Study Results: Subjective Survey Ease of use (controls) 9 preferred Signia 8 preferred Starkey 8 preferred Phonak 3 preferred Widex

Study Results: Subjective Survey Feedback 12 preferred Phonak 6 preferred Starkey 6 preferred Widex 4 preferred Signia

Study Results: Subjective Survey Overall Results 19 preferred Widex 6 preferred Phonak 2 preferred Signia 1 preferred Starkey However…

Study Results: Subjective Survey Purchasing Patterns… 10 purchased Widex 10 purchased Phonak 4 purchased Starkey 4 preferred Signia Pricing was equal to eliminate that effect

Study Results Reasons for specific purchases Cosmetics Control manipulation Specific sound qualities (music) Specific features (Zen Sounds) Reserve gain (Phonak Naida)

Study Results Summary of findings Widex performed exceptionally, but wasn’t always the best choice What to do when—specific choices based on options available.

Study Results Widex strengths Widex weaknesses Best performance for WRS (46% improvement) Good performance for music Best battery life and tinnitus options Widex weaknesses Limited form factors (312 BTE, 312 RIC, 13 BTE) Difficult manual controls / Ease of use

Study Results Phonak strengths Phonak weaknesses Good performance for WRS Best perception of performance in BGN. The most form factors offered (675 BTE, 13 BTE & RIC, 312 BTE & RIC, FS ITE, ITC) Best perception of cosmetics Phonak weaknesses Battery life (but improved) Limited tinnitus options

Study Results Starkey strengths Starkey weaknesses Better performance for music Good for each of use / manual controls Starkey weaknesses Lowest improvement in WRS Lowest perception of performance in BGN Limited form factors (RIC and BTE) Limited tinnitus options

Study Results Signia strengths Signia weaknesses Best ease of use Good for tinnitus options Signia weaknesses Poorer cosmetics Limited form factors (312 RIC—at that time)

Study Summary Each manufacturer have their strengths and weaknesses. Widex: Speech clarity, music, tinnitus Phonak: Background noise, cosmetics, form factors. New product introductions may change this Rechargeable options (Starkey, Phonak) Own speech quality (Signia)

Menti Question 1C!

Verification: CROS transmission Procedure: Real Ear or VSM Place patient at 90 degrees azimuth, with the “dead” ear facing the presentation speaker(s). Place the probe mic in the better ear, on the far side from the presentations speaker(s). Measure as follows: Unaided (both sides off) Aided (better ear on only) Aided with CROS Repeat with face-to-face, 0 degrees azimuth

Verification: CROS transmission Procedure: Sound Field Place patient at 90 degrees azimuth, with the “dead” ear facing the presentation speaker(s). Measure puretones and speech as follows: Unaided (both sides off) Aided (better ear on only) Aided with CROS Repeat with face-to-face, 0 degrees azimuth

Verification: Sample #1

Verification: Sample #1 Speech Discrimination Unaided: 88%

Verification: Sample #1 Speech Discrimination Unaided: 88% Aid Only: 92%

Verification: Sample #1 Speech Discrimination Unaided: 88% Aid Only: 92% Aid w/CROS: 100%

Verification: Sample #1 Speech Discrimination Unaided: 88% Aid Only: 92% Aid w/CROS: 100%

Verification: Sample #2

Verification: Sample #2 Speech Discrimination Unaided: 40%

Verification: Sample #2 Speech Discrimination Unaided: 40% Aid Only: 72%

Verification: Sample #2 Speech Discrimination Unaided: 40% Aid Only: 72% Aid w/CROS: 96%

Verification: Sample #2 Speech Discrimination Unaided: 40% Aid Only: 72% Aid w/CROS: 96%

Verification: Sample #3

Verification: Sample #3 Speech Discrimination Unaided: 0%

Verification: Sample #3 Speech Discrimination Unaided: 0% Aid Only: 32%

Verification: Sample #3 Speech Discrimination Unaided: 0% Aid Only: 32% Aid w/SR on: 40%

Verification: Sample #3 Speech Discrimination Unaided: 0% Aid Only: 32% Aid w/SR on: 40% Aid, SR, CROS: 60%

Case Studies Case Study: John, age 72

Case Studies Case Study: John, age 72 History of Acoustic Neuroma Previous binaural user Left WRS: 80% @ 80dbHL Right WRS: CNT (0%) Binaural WRS: 64% Preferred Phonak Audeo V90-312 BiCROS

Case Studies Case Study: Marc, age 25

Case Studies Case Study: Marc, age 25 Congenitally SSD No previous use of amplification Left WRS: 100% @ 45dbHL Right WRS: CNT (0%) Binaural WRS: DNT Preferred Phonak Audeo V90-312 CROS

Case Studies Case Study: Norma, age 76

Case Studies Case Study: Norma, age 76 Sudden SNHL (viral) No previous use of amplification Left WRS: 96% @ 45dbHL Right WRS: CNT (0%) Binaural WRS: DNT Preferred Signia Primax3 BiCROS

Case Studies Case Study: Ambrose, age 36 (not included in formal study)

Case Studies Case Study: Ambrose, age 36 Hearing loss since age 6 due to scarlet fever Right WRS: 76% @ MCL Left WRS: CNT Binaural WRS: DNT Fit with Phonak Virto V70 ITC BiCROS

Case Studies Case Study: Irma, age 56

Case Studies Case Study: Irma, age 56 Initially presented with a mild binaural loss with slight symmetry (September 2016) Left WRS: 80% @ 45dbHL Right WRS: 88% @ 45dbHL Binaural WRS: 92% @ 45dBHL Previous user (fit elsewhere) of both CICs and RICs Fit with Unitron Stride Pro CICs

Case Studies Case Study: Irma, age 56 Many issues with performance and fluctuation in volume Many complaints about the loudness of her own voice (occlusion?) Despite good VSM results, generally preferred gain set higher than recommended. Patient had many problems, nearly cancelled purchase

Case Studies Case Study: Irma, age 56 October, 2016: Problems with perception of loudness continued along with increasing perception of tinnitus, particularly in the left ear. Re-tested, and demonstrated significant asymmetrical low-frequency decrease in her left ear. Referred to ENT.

Case Studies Case Study: Irma, age 56

Case Studies Case Study: Irma, age 56 December, 2016: Diagnosed with Meniere’s Disease What do we do now?

Case Studies Case Study: Irma, age 56 AmpCROS time! Re-set start-up program to Acoustic program Took appropriate measures for matching to Right ear VSM target. Reprogrammed automatic program for traditional settings when Meniere’s isn’t an issue.

New offerings? Phonak: CROS B and rechargeable Widex: Evoke and rechargeable Signia: Nx, M4i, Silk and rechargeable Starkey: Muse IQ and rechargeable

Summary Candidacy evaluation is very important to avoid auditory deprivation Verification of CROS transmission is just as important for these fittings as regular verification Analyze and compare; don’t stay in your comfort zone.