Bimodal hearing aid fitting: Benefits and update in Oticon ...

fitting flowchart and Quick fitting guide to bimodal fitting in Genie 2. (from left to right) *Compatible with Oticon Opn S™, Oticon Opn Play™, Oticon Xceed™ and Oticon Xceed Play™ A . Start with wideband fitting B. Is…

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Bimodal hearing aid fitting: Benefits and update in Oticon Genie 2
EDITOR OF ISSUE Elaine Ng, PhD, Senior Research Audiologist Centre for Applied Audiology Research, Oticon A/S
ABSTRACT This paper provides a brief summary of the benefits and different fitting approaches of bimodal fitting, and highlights the new overall gain trimmer and the existing bimodal fitting flowchart in the bimodal fitting panel in Oticon Genie 2.
Bimodal fitting: Benefits and different bimodal fitting approaches
In a bimodal fitting, one ear is stimulated electrically and the other acoustically. Candidates for bimodal fitting are people with severeto-profound hearing loss who receive cochlear implant in one ear and have residual hearing in the non-implanted ear. While cochlear implant provides good speech understanding especially in quiet listening situations, it does not give good representations of low frequency sounds. In a bimodal fitting, this shortcoming can be compensated by providing acoustic amplification of low frequency sounds in the non-implanted ear (Francart & McDermott, 2013).
Having more access to low frequency sounds can enhance auditory performance because these sounds carry phonemic and prosodic information, consonant voicing and acoustic cues, in particular the fundamental frequency (Brown & Bacon, 2009). Research studies have demonstrated that bimodal stimulation provides a wide variety of benefits over unilateral cochlear implantation such as speech recognition in noise, better music and pitch perception and perceived naturalness of sounds (e.g. Blamey et al., 2015; Ching et al., 2007, Illg et al., 2014; Morera et al., 2012) for adults.

tech paper
2019

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TECH PAPER � 2019 � BENEFITS AND UPDATE IN OTICON GENIE 2

In addition, by making binaural cues available, bimodal stimulation also enhances spatial listening and localization (e.g. Ching et al., 2007). Further, bimodal hearing has also been shown to improve quality of life in social activities (Farinetti et al., 2015). For children, in addition to better speech recognition in noise, localization and musical perception (e.g. Ching et al., 2006; Shirvani et al., 2016), bimodal stimulation has been demonstrated to improve language acquisition and outcome (Moberly et al., 2016; Nittrouer & Chapman, 2009).
A coordinated and balanced bimodal fitting is crucial for achieving optimal benefit and listening comfort. Common bimodal hearing aid fitting approaches in clinical practice include loudness balancing, frequency lowering, and bandwidth adjustment. Vroegop and colleagues (2018) systematically reviewed 17 studies which examined the effects of different bimodal hearing aid fitting approaches on auditory performance. Most of the studies reported some bimodal benefits, and some studies reported mixed results. However, it is pointed out that based on the existing literature, it is still unclear how the use of these fitting approaches contributes to optimal bimodal outcome. Davidson (2015) reviewed the effects of frequency lowering and frequency overlap on auditory performance in

children. It is concluded that bimodal benefits are mixed, which could be due to for instance variability across research methods, degree and configuration of hearing loss in the non-implanted ear and the choice of outcome measures. Owing to the inherent individual variation among the severe-to-profound population, the benefits from cochlear implant and bimodal fitting also vary greatly.
Bimodal fitting in Genie 2
Bimodal fitting generally provides greater benefits over unilateral cochlear implantation alone, but how different bimodal fitting approaches contribute to optimal benefits is still unknown. This indicates the great variability of this population, and that hearing care professionals fitting a bimodal hearing aid may need to apply individualized fitting approaches based on individual needs, preferences and performance. Currently, there is limited evidence and a lack of standardized procedures or guideline on bimodal hearing aid fitting. In light of this, Reyes (2016, Oticon whitepaper) developed bimodal hearing aid fitting guidelines featuring a bimodal flowchart, which serves as a guide to the hearing care professionals as they navigate the bimodal fitting process (Figure 1). A bimodal fitting panel is now available in Genie 2, equipped with fitting

Bimodal Hearing Aid Fitting Guidelines
ABSTRACT In a bimodal fitting, one ear is stimulated acoustically with a hearing aid and the other is stimulated electrically with a cochlear implant.
To bring bimodal benefits to all children and adults with unilateral implants and aidable hearing in the contralateral ear, Oticon has implemented a bimodal fitting guide in the Genie fitting software. As developed by Carisa Reyes, Staff Audiologist at Boys Town National Research Hospital, the bimodal fitting flowchart serves as a guide to clinical audiologists as they navigate the bimodal fitting process. The goal is to provide a logic- and evidence-based method for decision-making, yet keeping in mind the constraints in everyday clinical practice.
Based on the latest knowledge on bimodal research, this paper explains the rationale, the recommended strategies, the procedures and the caveats of the bimodal fitting.
� Candidates for bimodal fitting � When to fit the hearing aid � How to fit the hearing aid for bimodal patients � Bimodal flowchart � Evaluation of benefits � Case Studies
Acknowledgments: Thank you to Marc A. Brennan, Ph.D. and Lisa S. Davidson, Ph.D. for reviewing the manuscript.

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The bimodal flowchart takes into account the four fitting approaches: wideband fitting, restricted bandwidth fitting, use of frequency lowering and loudness balancing. The chart is available in Genie when you fit Oticon Dynamo or Sensei Super Power.

whitepaper
2016

Carisa Reyes, Au.D., CCC-A. Staff Audiologist at Boys Town National Research Hospital

Bimodal flowchart
All unilateral cochlear implant recipients with aidable residual hearing in the other ear are candidates for hearing aid use. This flowchart provides an evidence based, yet practical, method for fitting a hearing aid on a bimodal patient. The flowchart takes into account wideband fitting, restricted bandwidth fitting, use of frequency lowering and loudness balancing.

A . Start with wideband fitting

YES
C. Create frequency lowering
program &
Verify loudness balance

B. Is the patient a candidate for
frequency lowering?
E. Return to wideband fitting

NO
F. Address any sound quality concerns with the hearing aid
& Verify loudness balance

Is the patient satisfied?

Is bimodal performance better

than or equal to CI alone?

YES

Use frequency lowering

Use wideband fitting Use reduced bandwidth

YES

J. Further evaluation needed

YES

H. Create restricted bandwidth program with or without low
frequency emphasis &
Verify loudness balance
I. Is the patient satisfied?
& Is bimodal performance better
than or equal to CI alone?

Try the interactive flowchart at bimodal.oticon.com
This bimodal fitting flowchart was developed by Carisa Reyes, Au.D., CCC-A, Staff Audiologist at Boys Town National Research Hospital"

Oticon Quick Fitting Guide to Bimodal Fittings in Genie 2

The Bimodal Fitting and Speech RescueTM tools together offer the dedicated handles to perform any of the following fitting approaches described by experts, all of which incorporate loudness balancing:
� Wideband fitting � Use of Speech Rescue frequency lowering � Restricted bandwidth fitting

Bimodal Fitting Panel

1. Bimodal Flowchart: Opens PDF fitting guide
2. Overall gain trimmer: Adjusts overall gain in 1 dB steps
3. High frequency cut-off trimmer: Default is deselected. Select checkbox to adjust cut-off frequency
4. Low frequency emphasis trimmer: Adjusts gain below 1000 Hz
5. Speech RescueTM tool: Select if frequency lowering is desired

The Bimodal PDF manual, accessed within the Bimodal Fitting panel, provides a simple, logical and evidence-based method to guide you towards an optimised solution. The flowchart also contains a link to the interactive bimodal guide at bimodal.oticon.com
Note: The Bimodal Fitting tool will only be visible in the Task Pane for a unilateral fitting with families that support bimodal fittings.

Figure 1. Materials supporting bimodal fitting with Oticon hearing aids: Bimodal hearing aid fitting guidelines, bimodal fitting flowchart and Quick fitting guide to bimodal fitting in Genie 2. (from left to right)
*Compatible with Oticon Opn STM, Oticon Opn PlayTM, Oticon XceedTM and Oticon Xceed PlayTM

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TECH PAPER � 2019 � BENEFITS AND UPDATE IN OTICON GENIE 2

tools that allow flexible fitting approaches (Figure 2). The Quick fitting guide to bimodal fittings in Genie 2 for Oticon hearing aids* describes the steps to perform four fitting approaches: wideband fitting, restricted bandwidth, frequency lowering and loudness balancing.
Overall gain trimmer: New in bimodal fitting panel
The overall gain trimmer replaces the overall loudness trimmer in the bimodal fitting panel in Genie 2 (Figure 2). Balancing loudness across the cochlear implant and the bimodal hearing aid is very often needed because of binaural loudness summation. People with severeto-profound hearing loss typically have a greatly reduced dynamic range and therefore a very steep loudness growth function. This means that a small change in sound level would make a larger change in their loudness perception compared to normal hearing people. To accommodate this, the step size of this new overall gain trimmer is now 1 dB (formerly 2 dB). This allows a finer adjustment and loudness balancing between the cochlear implant and hearing aid.

Moreover, adjustment using this gain trimmer does not alter the maximum power output (MPO), which prevents any unintended change in the MPO settings. The overall gain trimmer, together with the other existing bimodal fitting tools in Genie 2, including the high frequency bands trimmer, low frequency bands trimmer and Speech Rescue frequency lowering, allow more accurate and flexible fittings. Any adjustments made using these tools in Genie 2 will apply to the hearing aid only.
Concluding remarks
There are well-documented benefits of bimodal fitting over unilateral cochlear implant alone for adults and children, even though there is no standardized procedures on bimodal fitting for optimal benefit. The bimodal hearing aid fitting guidelines and flowchart developed by Reyes (2016) provide a good basis for use of different fitting approaches and decision-making in the bimodal fitting process. The updated bimodal fitting tools in Genie 2 allow finer adjustments, which support hearing care professionals to fit optimally the hearing aid to complement the implanted ear.

Figure 2. Bimodal fitting panel in Genie 2. Cochlear Implant on the right ear, hearing aid fitted to the left ear. Hearing aid settings can be sound balanced to the cochlear implant.

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TECH PAPER � 2019 � BENEFITS AND UPDATE IN OTICON GENIE 2

References
1. Blamey, P. J., Maat, B., Baskent, D., Mawman, D., Burke, E., Dillier, N., ... & Huber, A. M. (2015). A retrospective multicenter study comparing speech perception outcomes for bilateral implantation and bimodal rehabilitation. Ear and Hearing, 36(4), 408-416.
2. Brown, C. A., & Bacon, S. P. (2009). Low-frequency speech cues and simulated electric-acoustic hearing. The Journal of the Acoustical Society of America, 125(3), 1658-1665.
3. Ching, T. Y., Incerti, P., Hill, M., & van Wanrooy, E. (2006). An overview of binaural advantages for children and adults who use binaural/bimodal hearing devices. Audiology and Neurotology, 11(Suppl. 1), 6-11.
4. Ching, T. Y. C., Van Wanrooy, E., & Dillon, H. (2007). Binaural-bimodal fitting or bilateral implantation for managing severe to profound deafness: a review. Trends in Amplification, 11(3), 161-192.
5. Davidson, L. S. (2015). Fitting bimodal devices in children � A review. In A sound foundation through early amplification: Proceedings of the 2013 International Conference (pp. 123-129).
6. Farinetti, A., Roman, S., Mancini, J., Baumstarck-Barrau, K., Meller, R., Lavieille, J. P., & Triglia, J. M. (2015). Quality of life in bimodal hearing users (unilateral cochlear implants and contralateral hearing aids). European Archives of Oto-rhino-laryngology, 272(11), 3209-3215.
7. Francart, T., & McDermott, H. J. (2013). Psychophysics, fitting, and signal processing for combined hearing aid and cochlear implant stimulation. Ear and Hearing, 34(6), 685-700.
8. Illg, A., Bojanowicz, M., Lesinski-Schiedat, A., Lenarz, T., & B�chner, A. (2014). Evaluation of the bimodal benefit in a large cohort of cochlear implant subjects using a contralateral hearing aid. Otology & Neurotology, 35(9), e240-e244.
9. Moberly, A. C., Lowenstein, J. H., & Nittrouer, S. (2016). Early bimodal stimulation benefits language acquisition for children with cochlear implants. Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 37(1), 24.
10. Morera, C., Cavalle, L., Manrique, M., Huarte, A., Angel, R., Osorio, A., ... & Morera-Ballester, C. (2012). Contralateral hearing aid use in cochlear implanted patients: Multicenter study of bimodal benefit. Acta Oto-laryngologica, 132(10), 1084-1094.
11. Nittrouer, S., & Chapman, C. (2009). The effects of bilateral electric and bimodal electric--acoustic stimulation on language development. Trends in Amplification, 13(3), 190-205.
12. Reyes, C. (2016). Bimodal hearing aid fitting guidelines. Oticon Whitepaper.
13. Shirvani, S., Jafari, Z., Motasaddi Zarandi, M., Jalaie, S., Mohagheghi, H., & Tale, M. R. (2016). Emotional perception of music in children with bimodal fitting and unilateral cochlear implant. Annals of Otology, Rhinology & Laryngology, 125(6), 470-477.
14. Vroegop, J. L., Goedegebure, A., & van der Schroeff, M. P. (2018). How to optimally fit a hearing aid for bimodal cochlear implant users: A systematic review. Ear and hearing, 39(6), 1039-1045.

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