JOURNAL CLUB

Bimodal Hearing: How to Optimize

Bimodal Fitting
By René H. Gifford, PhD

N
Downloaded from https://journals.lww.com/thehearingjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3sKTDgY9nEdvzECSf149tbFnwu++w2NhtQTr5Uvzo4xC88w7KILLCLA== on 03/09/2019

early three-fourths of adult cochlear implant (CI)

recipients have aidable acoustic hearing in the
non-implanted ear that could be used in a bi-
modal hearing configuration.1 For a typical CI
candidate, the amount of residual acoustic hearing is not suf-
ficient to allow high levels of daily communication; however,
that residual acoustic hearing can provide significant speech
recognition and sound quality benefit when paired with a CI in
a bimodal hearing configuration. Bimodal hearing also pro-
vides significantly improved performance on various tasks of
music perception, including chord, melody, melodic contour,
and timbre recognition, compared with a CI-alone condition.2-7
Several bimodal hearing solutions are available, but there
remains some confusion about optimal bimodal fittings, as the
degree of bimodal benefit resulting from adding a hearing aid
(HA) to a CI varies considerably among patients. Though un-
aided audiometric thresholds in a non-implanted ear and bi-

Shutterstock/edwardolive
modal benefits have an inverse correlation,8-9 this correlation
is driven by the extreme ends of the function, leaving little
clinical guidance for the majority of patients with moderate to
severe sensory losses in the non-implanted ear. While some
studies provide guidance for the clinical fitting of bimodal lis-
teners, there is a lack of prospective studies with large sam-
ple sizes that provide data-driven guidance for clinical fittings.
Optimal bimodal fitting holds high clinical relevance to pro- Vroegop and colleagues10 described findings on bimodal
vide maximum bimodal benefit to patients with unilateral CI fittings obtained from a systematic review of the peer-reviewed
and accurately determine bilateral CI candidacy. literature. They identified 1,165 records from which 17 were
While we await the outcomes of prospective clinical trials selected for review. The included articles primarily focused on
systematically investigating the efficacy of various approaches the HA fitting component for bimodal listeners, with results
to bimodal fitting in large populations, the following peer-­ summarized into four categories: (1) frequency response of
reviewed papers provide clinical guidance to inform and im- the HA, (2) use of frequency lowering technology, (3) syn-
prove current audiology practices. chronization of automatic gain control (AGC) between HA
and CI, and (4) interaural loudness balancing.

How to Optimally Fit a Hearing

Aid for Bimodal Cochlear Implant
Users: A Systematic Review.
Vroegop JL, Godegebure A, and van der
Schroeff MP. Ear Hear. 2018;39(6):1039-1045.
Ear Hear. 2018;39(6):1039-1045.
Dr. Gifford is a professor in the department of hearing
and speech sciences and the director of the Cochlear
Implant Program at the Vanderbilt Bill Wilkerson Cen-
ter. She’s also a member of The Hearing Journal’s
editorial board.
HA AUDIBILITY BANDWIDTH: LESS IS NOT
MORE
Several studies have investigated the appropriateness of
various iterations of the National Acoustic Laboratories (NAL)
prescriptive fitting formula. Compared to the base NAL
prescription, some patients reported subjective preference
for more gain, while others in the same study reported sub-
jective preference for less gain.11 In contrast, some studies
have also reported that the NAL prescriptive formula yielded
the best subjective bimodal benefit.12-14 These studies, how-
ever, did not compare speech recognition performance with
different frequency-gain responses, and thus it is unclear
whether subjective preference was correlated with patient
performance in all cases. Further more, in some cases, the
NAL fitting was compared to the subject’s own HA fitting,

10 The Hearing Journal  February 2019

JOURNAL CLUB
though the audibility provided by the baseline fitting was not
discussed.
Several studies have also investigated the usefulness of
a broadband HA response compared with restricted high-
frequency amplification. A majority reported significant bi-
modal benefit for broadband HA audibility compared with a
restricted HA bandwidth.15,16 However, the referenced stud-
ies either did not include individuals with cochlear dead re-
gions or did not assess for cochlear dead regions. In contrast,
some evidence suggests that restricting high-frequency am-
plification may yield significantly higher speech recognition
scores in some patients.17-18 One of these studies had tested
for the presence of cochlear dead regions and found that
for patients with confirmed dead regions, restriction of high-
frequency amplification produced significantly higher bi-
modal speech recognition compared to full HA bandwidth.17-18
FREQUENCY LOWERING TECHNOLOGY:
HOW LOW CAN YOU GO?
Many current HA systems make use of frequency lowering
technologies, such as nonlinear frequency compression and
frequency transposition, to deliver critical high-frequency in-
formation to a cochlear region where viable inner and/or
outer hair cells are available to process the stimuli. Since
many of these technologies are active in the default para­
meters of an HA fitting software, investigating its efficacy is
warranted in the case of bimodal listeners for which the
high-frequency stimuli are provided via the CI ear.
Bimodal studies on the efficacy of frequency lowering tech-
nology have focused on both speech recognition16,19-22 and
horizontal plane localization.16,20 For speech recognition in quiet
and noise, frequency-lowering technology provided either
equivocal16,19-22 or significantly poorer 20 outcomes compared
with conventional amplification. For localization, this technology
provided significant benefit in some cases16 or no benefit com-
pared with conventional amplification.20 Overall, studies show
little evidence to recommend the use of frequency lowering
technology in a bimodal hearing configuration.
IS IT A PERFECT MATCH?
Most bimodal patients are fitted with a CI and HA that have
entirely different automatic gain control (AGC) characteristics
across ears, including different compression thresholds, com-
pression ratios, and time constants. Thus, one can imagine
how difficult it can be for a bimodal listener to integrate the
signals from the different ears. A current CI system has an HA
that matches AGC characteristics across the ears. One study
investigated the effects of matched AGCs across the HA and
CI in a group of 15 adult bimodal listeners.23 They evaluated
the speech recognition in noise for various speech and noise
spatial configurations. Compared with the unmatched HA and
CI condition, the matched AGC resulted in statistically sig-
nificant benefit at the group level for conditions in which sta-
tionary noise was presented at ±90 degrees as well as a
single-talker distracter presented to the HA ear. They also re-
ported subjective preference for the matched AGC in nine of
15 participants.
12 The Hearing Journal 
IT’S ALL ABOUT BALANCE—OR IS IT?
Loudness balancing across the HA and CI ears can be diffi-
cult given the different audible bandwidths across ears and
the dramatically different hearing modalities. Several studies
investigated various HA programming methods required to
achieve interaural loudness balance. The trends were similar
to that in HA frequency response. Specifically, some studies
showed that listeners preferred less gain than the NAL pre-
scriptive formula for interaural balance,11,23 while others re-
ported that desired HA gain for interaural balance was roughly
equivalent to NAL-R prescriptive gain settings.14 None of the
studies, however, investigated whether the HA gain required
to achieve subjective loudness balance yielded significantly
higher outcomes compared with the base prescriptive for-
mula.
Loudness balancing across the HA
and CI ears can be difficult given the
different audible bandwidths across ears
and the dramatically different hearing
modalities.
CLINICAL RECOMMENDATIONS
Vroegop and colleagues10 observed significant bimodal ben-
efits across studies; however, there were multiple inconsis-
tencies with respect to the implementation of HA fitting.
Despite inconsistencies in the literature, there are valuable
data that we can use to guide our clinical practice for HA fit-
tings in adult bimodal patients. Below are clinical recommen-
dations from the studies discussed by Vroegop, et al.10
HA Audibility and Bandwidth. Though there were no stud-
ies that directly compared speech recognition performance
across various validated prescriptive fitting formulae, there
was one common thread among these studies: HA verifica-
tion via real ear measures yielded significant bimodal and
subjective benefits. Thus, it would follow that clinicians
should be completing real ear verification of HA audibility
as prescribed by a validated fitting formula. With respect
to audibility bandwidth, the best way to apply the results to
our clinical practice would be to implement a test for co-
chlear dead regions, such as the threshold equalizing
noise (TEN) test. If there is evidence for dead regions, one
could reasonably program an HA using full and restricted
bandwidths. Using both subjective preference and aided
speech recognition assessments with recorded stimuli will
allow us to gauge the effectiveness of these two HA fitting
strategies and provide an evidence base for our clinical
practice.
Frequency Lowering Technology. Because most studies dem-
onstrated no significant difference in performance between
February 2019

conventional amplification and frequency lowering amplification,
a simple way to apply these data clinically would be to provide
patients with both a conventional frequency response and fre-
quency lowering response for the HA, gauge their subjective
preference, and compare bimodal speech recognition perfor-
mance with both HA responses.
AGC Match. Because the matched AGC system is only cur-
rently available in one CI/HA system, it is not possible to im-
plement this clinically without the use of an Advanced Bionics
Naida CI processor and Link HA. However, it is possible to
match compression threshold and ratio manually for MED-EL
cochlear implants if one considers the function of the device.
Using the recommended sensitivity setting of 75 percent, the
MED-EL AGC kneepoint is fixed at 53 dB SPL, beyond which
the default compression ratio is 3:1 up to 100 dB SPL, at
which point infinite compression is applied. Clinicians could
match these settings in various HA systems with manual ad-
justments in the HA software. CI systems by Cochlear™ have
a more complex AGC system with activation of autosensitivity
control, making it a bit more complicated to manually program
an HA to match the CI processor AGC. However, given Co-
chlear’s partnership with GN Resound, it is highly likely that
matched AGC systems will be available in the near future.
Should we manually adjust HA settings to try to match the CI
AGC settings, it is advised that both patient preference and
February 2019 The Hearing Journal 13
JOURNAL CLUB
bimodal aided speech recognition testing be completed to
validate the fitting.
Loudness Balance. Most clinicians may already be assessing
loudness balance across the CI and HA ears for bimodal pa-
tients. It is possible to adjust the HA ear, CI ear, or both to
provide interaural balance for our patients. In the absence of
data-driven guidance, the current systematic review would sug-
gest that we start with the base HA prescriptive formula, verify
the HA fitting via probe microphone measures, then adjust ac-
cordingly. As always, subjective preference and aided speech
recognition assessment are both recommended to ensure that
bimodal listeners are achieving their maximal hearing potential.
Hearing health care needs a large-scale, prospective study
of bimodal fitting methods as well as criteria for identifying bi-
lateral CI candidates following bimodal optimization. While this
is no small task and one that will likely require years of experi-
mentation and data dissemination, current research provides
us with clinical guidance for HA fittings in bimodal listeners.
Applying these data to our practice will allow us to offer pa-
tients the best chance to reach optimal bimodal benefit. 
References for this article can be found online at http://
www.thehearingjournal.com