Abstract
Purpose
To investigate whether the appearance of percutaneous bone conduction devices (perBCDs) or active transcutaneous bone conduction devices (atBCDs) is preferred by BCD-users and non-users. The second aim is to examine the degree to which the appearance of a device matters in comparison to other BCD traits, and whether certain participant characteristics predict this.
Methods
An online questionnaire was designed and administered to BCD-users and non-users (i.e., persons with no experience using a BCD). Pair-wise comparisons showing pictures of the latest generation perBCD and atBCD sound processors and implant sites were anonymously provided to participants, who could indicate their preference. Sum scores were calculated ranging from − 2 (strong preference for perBCD) to 2 (strong preference for atBCD). Means for the total score as well as sub scores of pictures showing either sound processor or implant site were calculated. Statements were presented in which the appearance of the device was weighed against other traits such as better hearing.
Results
The study population consisted of 102 BCD-users and 105 non-users. An overall preference for perBCD sound processors was observed (mean score − 0.50 (95% CI: -0.63, -0.37). BCD-users had no preference for implant sites whilst non-users preferred atBCDs (-0.03 (-0.27, 0.21) and 0.60 (0.40, 0.80) respectively, p < 0.01). Most participants found better hearing more important than having an appealing device (n = 150, 73.0%).
Conclusions
PerBCD sound processors were preferred over atBCD sound processors by both BCD-users and non-users. Functionality seems to be more important than the appearance of the device.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00405-025-09335-7.
Keywords: Bone conduction device, Patient preference, Appearance, Percutaneous, Active transcutaneous
Introduction
Bone conduction devices (BCDs) play a crucial role in hearing rehabilitation for patients with mixed or conductive hearing loss, and to a lesser extent, single-sided deafness (SSD) [1]. BCDs generate mechanical vibrations that either stimulate the bone directly (i.e., direct drive) or transmit vibrations to the skin and underlying tissue (i.e., skin drive) [2]. The applicability of passive transcutaneous skin drive BCDs is limited due to their inferior audiological performance compared to direct drive counterparts and the occurrence of skin complications such as pain or necrosis [3–4].
The first direct drive BCD, the percutaneous Bone Conduction Device (perBCD), was fitted by Tjellström et al. in 1977 [5]. The perBCD consists of an implanted osseointegrating screw in the temporal bone and a skin-penetrating abutment. Externally a sound processor is attached. In 2012, a new type of direct drive BCD was introduced: the active transcutaneous BCD (atBCD) [6]. An atBCD typically consists of an implant containing a receiver coil, transducer, and connecting magnet, with an externally attached sound processor that converts sound into an electromagnetic signal.
Both perBCDs and atBCDs have their respective advantages. PerBCDs can be used with higher bone conduction thresholds [7], have lower initial purchase costs [8], require less invasive surgery [2] and produce less bothersome artifacts on magnetic resonance imaging [9]. In contrast, some studies suggest that atBCDs offer a better safety profile concerning skin-related complications and implant loss [8, 10]. Another advantage of atBCDs is their lower susceptibility to feedback at higher frequencies [11]. Lastly, the appearance of transcutaneous systems is often deemed to be more appealing than percutaneous ones, primarily due to the absence of a skin-penetrating abutment [12–16].
To the best of our knowledge, no systematic studies have actually compared the physical appearance of perBCDs with transcutaneous systems. When retrospectively asked, both percutaneous and transcutaneous BCD users seem satisfied with the appearance of their device [17–19]. However, responses may be influenced by confirmation bias, where individuals justify past decisions [20]. Furthermore, persons who are bothered by the appearance may refrain from BCD use in the first place [13, 21, 22]. Regarding conventional hearing aids, persons tend to prefer the least visible device [23]. Congruously, in an effort to address hearing aid stigmatization, manufacturers have focused on developing increasingly smaller and less visible hearing aids [24]. This trend may also be observed with BCD sound processors. Yet, neither percutaneous nor transcutaneous systems are evidently less visible than its counterpart, making it difficult to compare the appearance of these BCDs in an objective manner.
Choosing for either perBCD or atBCD is an effortful decision for the patient from a medical, audiological, cultural and psychosocial perspective. During this decision making process, the patients’ values and preferences should play a central role [25–26]. This is achieved by making use of decision making techniques such as shared decision making. It has been demonstrated that shared decision making can enhance patient satisfaction and adherence to long-term treatments [27]. A crucial aspect of this process is providing objective counselling on the advantages and disadvantages of the treatment options. However, the lack of literature regarding perBCD and atBCD appearance currently impedes the provision of such unbiased patient information.
The primary aim of this study is to gain insight in the subjective differences between perBCDs and atBCDs by investigating whether the appearance of either perBCDs or atBCDs is preferred by both BCD users and non-users. However, insight into BCD appearance preference would only be valuable when placed into context. Previous studies indicate that certain individuals place greater value on, or are more bothered by the appearance of a BCD [13, 21, 22]. Therefore, the second aim of this study is to examine the degree to which the appearance of the device matters in comparison to other BCD traits, and whether certain participant characteristics predict this. Lastly, the newly designed questionnaire will be evaluated for applicability to a broader audience.
Methods
Study design
The current study was conducted in a tertiary hospital). The study is of cross-sectional nature. An online questionnaire was administered using the online software Qualtrics (Provo, Utah; https://www.qualtrics.com). Incorporation of pictures of BCD users as well as the distribution of the questionnaire was approved by the Central Ethics Committee of our hospital (register number 19404).
Questionnaire design
The questionnaire was designed by two experts in the field along with two researchers and an epidemiologist specialized in psychometrics and health related outcome measurement (Supplementary Material A, English version of the questionnaire).
The questionnaire consisted of four domains. The first domain involves participant characteristics. The second domain was designed to compare the physical appearance of perBCDs and atBCDs. Professional photographs were taken of both males with short hair and females with long hair wearing a perBCD (Baha 5 or 6 by Cochlear ltd., Sydney, Australia, or Ponto 5 Mini by Oticon Medical, Vallauris, France) or a atBCD (Osia 2 by Cochlear or Sentio by Oticon Medical). Photographs were taken with the sound processor attached as well as from the implant site. PerBCD and atBCD photographs were placed in a panel to allow for pair-wise comparison (Fig. 1).
Fig. 1.
Example of a pair-wise comparison showing a perBCD (left, A) versus an atBCD (right, B) on models with short hair
Participants were instructed to indicate their preference on a 5-point Likert scale for either the left or right device for a total of 12 pair-wise comparisons in random order. A score of-2 represented a strong preference for the device on the left and 2 represented a strong preference for the device on the right.
In the third domain, respondents were instructed to pick the BCD model with the most preferrable appearance. Based on expert opinion and research group discussion, seven traits were identified that were weighed against the most preferrable BCD appearance. An example of such a statement is the following: ‘I would still choose the device with the most appealing appearance, even if my doctor would recommend a different device’. Participants were required to report their level of agreement on a 5-point Likert Scale ranging from − 2 (strongly disagree) to 2 (strongly agree). The forth domain of the questionnaire featured open questions, which are omitted from discussion for reasons of conciseness.
The questionnaire was primarily constructed in English to ensure future adoptability for the international public. Forward and backward translation was performed following the guidelines provided by Beaton et al. [28]. As the current questionnaire is not a validated instrument, the remaining translation steps were omitted.
Participants
The questionnaire was administered to two groups of individuals. The first group consisted of individuals who either have used a BCD in the past or are currently using one, herein referred to as BCD users, from a tertiary university medical. The second group consisted of participants from the general population who have never used a BCD, referred to as non-users.
The inclusion criteria for both groups the group was an age of older than 16 years. No further criteria were formulated.
BCD users were approached by e-mail. Non-users were recruited using social media.
Statistical analysis
All characteristics will be stratified into total group, BCD users and non-users and presented using appropriate statistics depending on data type). Differences between BCD users and non-users were statistically tested using either t-test, Kruskal-Wallis, Mann-Whitney U oror Chi-square.
All Likert scale preference ratings were transformed so that a score of -2 reflects a strong preference for perBCD and 2 a strong preference for atBCD. Mean scores were calculated for the total of 12 pair wise comparisons and for the sub scores of pictures showing BCD users with and without the sound processor attached and with long and short hair. All mean scores were tested against the null hypothesis of equals to zero using one sample t-test. The total and sub scores were presented with means and 95% confidence intervals. Further stratification for BCD-users and non-users was performed and scores were presented. Potential differences between BCD-users and non-users for the total and sub scores were tested by using two-sample t-tests, and the effect size was estimated using Cohen’s d.
For the importance of BCD appearance, the answers to the 5 point Likert scales were presented with frequencies in a diverging stacked bar chart. Further, a mean score was calculated and presented with mean and SD. Potential mean score differences based on participant characteristics will be tested with appropriate statistical tests.
The internal consistency reliability will be analyzed by means of Cronbach’s alpha. A Cronbach’s alpha of larger than 0.7 was considered acceptable. Improvement of the scale by more than 0.1 was considered a substantial improvement upon item deletion.
P-values of < 0.05 were considered to be statistically significant. In case of paired testing a Bonferroni correction was applied. All data was analyzed using IBM’s Statistical Package for the Social Sciences (SPSS) version 28. Visual representation of mean preference scores was performed using GraphPad Prism (GraphPad Software, San Diego, CA) version 10.2.3. Diverging stacked bar chart was created using R package version 4.4.0 (R Foundation for Statistical Computing; https://www.r-project.org).
Results
In total, 274 participants were recruited (123 BCD users versus 151 non-users, response rate for BCD users 51.6%). After deletion of incomplete responses, responses with missing age and age of < 16 years, 207 participants remained (102 BCD users versus 105 non-users). Nine participants filled in the English version of the questionnaire, whilst 198 filled in the Dutch version. BCD users were significantly older than non-users (61.8 years versus 39.7 respectively, p < 0.01) (Table 1). Non-users were more frequently of male gender when compared to BCD users (64.8% versus 52.0% respectively), although this difference was marginally non-significant (p = 0.06). Most BCD users used a perBCD (93.8%) and used their BCD for 8–16 h per day (87.9%). Nine BCD users (8.8%) reported having an outer ear malformation.
Table 1.
Participant characteristics stratified by BCD use
| Variable | Total group (n = 207) | BCD users (n = 102) a | Non-users (n = 105) | P value b |
|---|---|---|---|---|
| Age (years), mean (SD) | 50.6 (20.3) | 61.8 (15.7) | 39.7 (18.3) | < 0.01 |
| Gender | 0.06 | |||
| Male | 121, 58.5% | 53, 52.0% | 68, 64.8% | |
| Female | 84, 40.6% | 48, 47.1% | 36, 34.3% | |
| Not specified | 2, 1.0% | 1, 1.0% | 1, 1.0% | |
| Hair style (long) | 75, 36.2% | 32, 31.4% | 43, 41.0% | 0.15 |
| Hearing loss (yes) c | - | - | 23, 21.9% | - |
| Hearing aid user (yes) c | - | - | 14, 13.3% | - |
| BCD knowledge (yes) | - | 102, 100.0% | 35, 33.3% | - |
| Quit using BCD (yes) d | 9, 8.8% | - | - | |
| BCD type | - | |||
| perBCD | - | 90, 93.8% | - | |
| atBCD | - | 3, 3.1% | - | |
| Other e | - | 3, 3,1% | - | |
| Daily hours of BCD use | ||||
| 0–4 h | - | 5, 5.5% | - | |
| 4–8 h | - | 6, 6.6% | - | |
| 8–16 h | - | 80, 87.9% | - | |
| Outer ear malformation (yes) c | - | 9, 8.8% | - | |
BCD: bone conduction device; SD: standard deviation; perBCD: percutaneous BCD; atBCD: active transcutaneous BCD a BCD-users were defined as anyone who has used or currently uses a BCD; bp-values of < 0.05 were considered statistically significant; c As reported by the participant; d BCD-users who do not use a BCD anymore; e Other types of BCD included Baha Attract (n = 2) and one person with a spectacle BCD
BCD appearance preference
A preference for perBCD sound processors was observed (Fig. 2) (mean score − 0.50 (95% CI: -0.63, -0.37)). For the implant sites, atBCDs were preferred (mean score 0.29 (95% CI: 0.13, 0.45)). PerBCD sound processors were preferred in individuals with long hair (-0.72 (95% CI: -0.85, -0.59)). For pair wise comparisons showing the implant sites of individuals with short hair, atBCD was preferred (0.90 (95% CI: 0.72–1.08).
Fig. 2.
Mean preference scores for perBCD or atBCD in the total population. CI: confidence interval; perBCD: percutaneous bone conduction device; atBCD: active transcutaneous bone conduction device. Error bars represent 95% CI’s. A score of -2 reflects strong preference for perBCD and 2 a strong preference for atBCD. All mean scores that do not cross the 0 axis remain significantly different from 0 after Bonferroni correction
Cronbach’s alpha was 0.83 for the total score, 0.81 for the sub score showing sound processors and 0.88 for the sub score showing implant sites. Deletion of items did not lead to a substantial improvement of Cronbach’s alpha.
BCD users have a slight preference for perBCDs whilst non-users do not (mean score − 0.25 (-0.44, -0.09) versus 0.03 (-0.11, 0.17), respectively, p = 0.02) (Table 2). For implant sites, BCD-users have no preference (mean score − 0.03 (95% CI: -0.27, 0.21) whilst non-users prefer atBCDs (mean score 0.60 (95% CI: 0.20, 0.80). The effect size for the difference in preference for implant sites between BCD users and non-users is moderate (cohen’s d -0.56). BCD-users had a weaker preference for atBCD implant sites of short haired individuals when compared to non-users (0.42 (95% CI: 0.15, 0.69) versus 1.37 (95% CI: 1.17, 1.57), cohen’s d -0.77).
Table 2.
Differences between BCD users and non-users in mean preference scores for perBCD or atBCD
| Property | Mean score BCD users a | Mean score non-users a | P-value b | Cohen’s d |
|---|---|---|---|---|
| Total | -0.25 (-0.44, -0.09) | 0.03 (-0.11, 0.17) | 0.02 | -0.34 |
| Sound processor | -0.46 (-0.67, -0.26) | -0.54 (-0.70, -0.37) | 0.72 | 0.08 |
| Implant Site | -0.03 (-0.27, 0.21) | 0.60 (0.40, 0.80) | < 0.01* | -0.56 |
| Total long hair | -0.48 (-0.66, -0.31) | -0.26 (-0.41, -0.11) | 0.48 | -0.27 |
| Total short hair | 0.23 (0.02, 0.45) | 0.60 (0.44. 0.80) | < 0.01* | -0.38 |
| Sound processor, long hair | -0.71 (-0.92, -0.51) | -0.73 (-0.88, -0.56) | 0.60 | 0.01 |
| Sound processor, short hair | 0.04 (-0.23, 0.31) | -0.16 (-0.38, 0.06) | 0.06 | -0.38 |
| Implant site, long hair | -0.25 (-0.50, 0.00) | 0.21 (-0.01, 0.45) | 0.22 | 0.16 |
| Implant site, short hair | 0.42 (0.15, 0.69) | 1.37 (1.17, 1.57) | < 0.01* | -0.77 |
BCD: bone conduction device; a Mean scores on a scale of -2 to 2 were presented with mean and 95% confidence intervals; bp-values were derived from two-sample t-tests or Mann-Whitney U in case of skewed data and substantial differences between parametric and non-parametric tests; asterisk denotes p values that are statistically significant after Bonferroni correction
Valued importance of BCD appearance
Most participants agreed with the statements ‘I would still choose the device with the most appealing appearance, even if the surgical installation procedure takes 45 minutes longer’ (n = 137, 66.2%) (Fig. 3). Conversely, most participants disagreed with the statement ‘I would still choose the device with the most appealing appearance, even if I could achieve better hearing with a different device’ ( n = 151, 73.0%).
Fig. 3.
Responses of the total population on questions about the importance of BCD appearance. Q: question. In the bar chart, counts are presented, with the total count in every question amounting to n = 207
Cronbach’s alpha for the importance of BCD appearance items was 0.65. Deletion of items did not lead to a substantially higher reliability measured by Cronbach’s alpha. All items had low to moderate correlation with the total score (Supplement Material B1, Correlation of item scores to total scores for participant valued BCD appearance).
Participant age was negatively correlated with the total mean score for valued BCD appearance (Pearson’s r -0.19, 95% CI -0.31 to -0.05) (Supplementary Material B2, Participant characteristics and total score of participant valued BCD appearance). Furthermore, BCD users with an outer ear malformation had a higher mean when compared to those without (mean difference 0.58 (95% CI 0.06 to 1.11, P = 0.03). However, these dependencies did not hold after Bonferroni correction.
Discussion
Both Bone Conduction Device (BCD) users and non-users preferred the appearance of percutaneous BCD (perBCD) sound processors. Non-users preferred the implant sites of active transcutaneous BCDs (atBCDs). BCD-users had an overall preference for perBCDs whilst non-users did not. Most participants found the appearance of a BCD less important than optimal hearing or the advice of their counsellor. The appearance of a BCD may be more important for younger individuals or those affected by an outer ear malformation.
Appearance preferences
The stronger preference for perBCDs by BCD-users in comparison to non-users may be explained by the occurrence of a confirmation bias. Almost all BCD-users used a perBCD. It has been established that persons tend to answer in a way that is consistent with decisions made in the past [20]. As such, having made the investment associated with the uptake and use of a perBCD, one may be more likely to respond in favor of this type. However, presence of a confirmation bias may only be confirmed if the questionnaire were to be conducted in a larger atBCD population as well.
Many studies have claimed that transcutaneous systems have a preferable appearance [12, 14–16]. This claim is contradicted by the total preference and sound processor-based preference for perBCDs observed in this study. Contrastingly, perBCD implant site appearance does seem inferior to transcutaneous implant sites, which is line with previous work [13].
The difference in perBCD versus atBCD preference based on hair style of the depicted model may be explained by the following. Newer perBCDs have a smaller surface area than atBCDs but protrude more due to the abutment. Studies show that the least visible device is commonly preferred [23]. For individuals with long hair, the protrusion is less noticeable, making the smaller perBCD the preferred device. Contrarily, for those with short or no hair, the protrusion is more visible, making atBCDs the preferred option in the current evaluation.
Importance of appearance
Most participants found optimal hearing rehabilitation more important than having a BCD with the most appealing appearance. It has been described that concerns regarding self-image and perception by others due to the use of a BCD are outweighed by increased social functioning gained by hearing rehabilitation [29]. If this benefit is not perceived, disadvantages such as the appearance of a device may logically bear greater weight for the user.
Participants also valued the advice of their doctor during the decision-making process, highlighting the need for unbiased counselling when discussing perBCD and atBCD options. Fewer than one fourth of participants would not want the BCD with the most appealing appearance if a screw were visible when the device is disconnected. In previous work, authors do mention the visibility of an abutment to deter patients [12–13]. For these individuals, a atBCD would be a valuable alternative to a perBCD.
Whether individuals with younger age or an outer ear malformation attribute greater value to the appearance of a BCD could not be confirmed with certainty in this study. However, such associations may exist. To illustrate, studies have linked younger age with greater stigmatization in the context of conventional hearing aids [24]. Further, younger persons attribute greater value to appearance than their older counterparts in general [30]. Persons with an outer ear malformation experience social difficulty and psychological problems due to appearance issues [31–32]. Having faced the negative consequences of an atypical appearance, these individuals may place greater emphasis on wanting to look ‘normal’.
Strengths and limitations
A strength was the recruitment of both BCD-users and non-users, which provided a relevant nuance to our findings. Another strength was the primary construction of the questionnaire in English. By doing so, we provide a solid basis for future studies on this subject.
There are several limitations to this study and areas for improvement concerning the questionnaire. First, real-life patients were used as models for pairwise comparisons of perBCD versus atBCD. As a result, the comparisons lacked absolute objectivity, displaying differences such as age, earrings, or slight skin inflammation at the implant site. On the other hand, one might find that this rightly depicts reality.
Another limitation regarding the pair-wise comparisons was the absence of a short-haired model using an Osia 2 system. Due to this, the finding that atBCD implant sites were preferred in short haired individuals should be interpreted with care. The Osia 2 system shows more bulk beneath the skin (i.e.,lies more proud due to different implantation techniques) than the Sentio system, tending to increase its visibility, although this is somewhat dependent on the patients’ skull. Assuming that the most preferred implant site is the one with least visibility, inclusion of a short haired individual with an Osia may have decreased the observed atBCD implant site preference.
A third limitation of this study relates to the question phrasing. Phrasing such as “slightly higher risk of skin inflammation” or “better hearing” might have been interpreted differently by each participant, potentially reducing inter-responder reliability. In future studies, it may be relevant to avoid such questions, or rephrase them in a manner that facilitates more uniform interpretation.
Future implications
At present, manufacturers have shifted their focus from percutaneous to active transcutaneous BCDs. Numerous studies examine the objective differences between these device types, but personal preferences remain relatively underexplored. This study suggests that common assumptions, such as the superior appearance of atBCDs compared to perBCDs, may not fully reflect reality. Gaining insight into patients’ personal preferences when choosing between device types is essential for enhancing the decision-making process.
To gain a better understanding of these preferences, future studies should address several aspects. First, appearance preferences should be investigated among atBCD users, as they were underrepresented in this study. Second, since this study featured a local population of BCD users and non-users, it would be valuable to explore appearance preferences in populations with different cultural or socioeconomic backgrounds. Third, as appearance is only one factor, studies should also explore other personal preferences, such as financial concerns. Combining these research efforts could ultimately aid in developing a decision-making tool for choosing between perBCDs and atBCDs.
Conclusion
This newly designed questionnaire suggests that the appearance of perBCD sound processors is preferred by both BCD-users and non-users. Non-users preferred the implant site of atBCDs. The appearance of a BCD is considered less important than optimal hearing or the advice of their counsellor. The appearance of a BCD may be more important for younger individuals or those affected by an outer ear malformation. Further studies, involving a larger group of atBCD users and persons from other cultural or socioeconomic backgrounds, are necessary to confirm or contradict these findings.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Author contributions
All authors contributed to the study conception and design. Conceptualization: Hidde K. Krijnen, Tjerk W. Aukema, Myrthe K.S. Hol. Data collection and analysis: Hidde K. Krijnen and Tjerk W. Aukema. The first draft of the manuscript was written by Hidde K. Krijnen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
No funding was received for conducting this study.
Declarations
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Central Ethics Committee of the University Medical Center Groningen (register number 19404). After providing patients with all the relevant information about the study and answering questions, written informed consent was obtained from all patients whose photographs have been used for the purpose of the questionnaire and manuscript.
Consent for publication
All patients whose photographs have been used have granted permission for publication.
Competing interests
The authors have no competing interests to declare that are relevant to the content of this article.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Hidde K. Krijnen and Tjerk W. Aukema are the co-first authors.
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