137 5 General Discussion that binaural cues improved directional hearing, increased safety, feeling of comfort and understanding, particularly important in the paediatric patient group [8]. Systematic reviews of the impact of the use of bilateral BCHDs provide evidence of objective and subjective benefits [11,12] however, the quality on numbers of this type of study are limited especially in the paediatric population. Interestingly similar findings are demonstrated in children and adults with non-surgical BCHDs such as the ADHEAR [13,14,15], softband and Sound arc [16]. Shiraishi et al reported a comprehensive review of bilateral BCHD studies and concluded that bilateral devices improve sound localisation and lateralisation. However, the degree of accuracy in sound localisation by bilateral BCHD varied considerably among patients [17]. Previous research conducted at BWCH by Banga et al concluded that all children with bilateral losses benefit from bilateral aiding especially those under the age of 5 [18]. These principles are reflected in the overall number of patients that ultimately receive bilateral implantation at BWCH being 49% [19] and 53% [20] in the studies presented in this thesis. Complication rates are reported to be higher in the paediatric population, especially those under the age of 5 years. The introduction of the soft band mounted bone conduction hearing device as well as an adhesive ADHEAR hearing device allow for earlier intervention without concerns of surgical intervention. As demonstrated in the wider literature and from the presented findings of this thesis, skin complication and fixture failure rates have continued to improve over time: This is a direct result of innovations in implant and abutment design as well as surgical techniques that moved away from skin grafts and soft tissue reduction and moved to minimally invasive, tissue sparing techniques. These improved outcomes both in adults and children, have allowed clinicians the confidence to bilaterally implant without fear of additional complication. There has also been a move towards earlier implantation in younger children with increasing evidence that this is safe and effective. Core principle 2 – Careful Assessment of all aspects of the Child’s history. Assessment of the paediatric population creates additional challenges as compared to an adult group. In the adult population, audiological testing generates objective thresholds which can be compared and contrasted in both the unaided and aided environments with each hearing aid device. These can then be applied directly to each patient and their personal circumstances and own considerations can be incorporated into the decision making, following appropriate consultation, and counselling. The ultimate decision to provide an implant and choice of implant system is a collaboration between clinicians and the patient, led by a patient centered approach.
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