Clinic Hearing Aid Comparisons CROS Technology Scot Frink

Clinic Hearing Aid Comparisons: CROS Technology Scot Frink, Au. D 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 / Bi. CROS Solutions for Single-Sided Deafness • Review of the 2016 – 17 clinical study by Salem Audiology Clinic

Menti Question 1 A!

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: Amp. CROS 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: Amp. CROS 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: Amp. CROS 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: Amp. CROS Case studies 2017 (in progress): Unitron, Widex, Signia (Tinnitus) 2018 (in development): OTC vs. Prescribed comparison

Menti Question 1 B!

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 Bi. CROS: At least some amplification to the better ear – I have personally found that most patients prefer Bi. CRO 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 Bi. CROS second if no perceived benefit with binaural Amp. CROS?

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 65 d. BSPL, 25 words per run.

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

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

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

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

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

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

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 (2 nd 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 v 70 and v 90 levels, not at v 50 or v 30 – 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 – 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 – 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 – 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 – 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 1 C!

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: Aid Only: 88% 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: Aid Only: 40% 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: Aid Only: 0% 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% @ 80 db. HL Right WRS: CNT (0%) Binaural WRS: 64% Preferred Phonak Audeo V 90 -312 Bi. CROS

Case Studies Case Study: Marc, age 25

Case Studies Case Study: Marc, age 25 • • • Congenitally SSD No previous use of amplification Left WRS: 100% @ 45 db. HL Right WRS: CNT (0%) Binaural WRS: DNT Preferred Phonak Audeo V 90 -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% @ 45 db. HL Right WRS: CNT (0%) Binaural WRS: DNT Preferred Signia Primax 3 Bi. CROS

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 V 70 ITC Bi. CROS

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% @ 45 db. HL • Right WRS: 88% @ 45 db. HL • Binaural WRS: 92% @ 45 d. BHL • 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 lowfrequency 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 • Amp. CROS 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, M 4 i, 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.