Introduction
The World Health Organization reports that more than 5 per cent of the global population experience a disabling level of hearing loss.1 Hearing devices, including active transcutaneous hearing implants, represent an important means of auditory rehabilitation. These implants deliver sound vibration directly to the inner ear via bone conduction and are indicated for patients with conductive, mixed or single-sided hearing loss.Reference Ellsperman, Nairn and Stucken2, Reference Ray, Wanees, Dawoud, Abu Elnaga and Abdelhafez3 Bone conduction refers to the transmission of sound energy through the skull to the inner ear, bypassing the middle ear mechanism.Reference Stenfelt4 Once this energy reaches the cochlea, it is converted into electrical impulses that are transmitted via the cochlear nerve to the primary auditory cortex.Reference Purves, Augustine, Fitzpatrick, Katz, LaMantia and McNamara5
Active transcutaneous systems consist of an external sound processor, typically held in place by a magnet, which captures environmental sound and transmits it to an internal component implanted beneath the skin.Reference Goycoolea, Ribalta, Tocornal, Levy, Alarcón and Bryman6 In contrast to percutaneous systems, which require a skin-penetrating abutment, active transcutaneous implants avoid a permanent breach of the skin and are therefore associated with reduced rates of skin complications and improved cosmetic outcomes, while maintaining favourable audiological performance.Reference Magele, Schoerg, Stanek, Gradl and Sprinzl7 The devices included in this study, the Osia® (Cochlear™) and Bonebridge® (MED-EL™), operate via distinct mechanisms. The Osia system utilises a piezoelectric actuator to generate vibrations through an osseointegrated titanium implant,Reference Goycoolea, Ribalta, Tocornal, Levy, Alarcón and Bryman6 whereas the Bonebridge system employs a floating mass transducer to achieve similar outcomes.Reference Zernotti and Sarasty8 Both devices have been shown to improve hearing thresholds and speech recognition outcomesReference Goycoolea, Ribalta, Tocornal, Levy, Alarcón and Bryman6–Reference Gawęcki, Gibasiewicz, Marszał, Błaszczyk, Gawłowska and Wierzbicka9 and are associated with low complication rates, supporting their role as effective interventions for hearing loss.Reference Magele, Schoerg, Stanek, Gradl and Sprinzl7
Despite robust evidence demonstrating audiological benefit,Reference Magele, Schoerg, Stanek, Gradl and Sprinzl7, Reference Gawęcki, Gibasiewicz, Marszał, Błaszczyk, Gawłowska and Wierzbicka9 there remains a relative paucity of data exploring the patient experience of living with an active transcutaneous hearing implant. Patient experience is increasingly recognised as a critical dimension of healthcare quality. Evidence suggests a positive association between patient experience, clinical effectiveness and safety,Reference Doyle, Lennox and Bell10 and it is widely used as an indicator of healthcare quality.Reference Wolf, Niederhauser, Marshburn and LaVela11 The The Beryl Institute defines patient experience as: “the sum of all interactions shaped by an organisation’s culture, that influence patient perceptions across the continuum of care.”12
Understanding patient experience provides valuable insight into aspects of care that may not be captured by clinical or audiological outcomes alone. Qualitative work in related otological conditions has demonstrated how patient perspectives can reveal gaps in clinician understanding and highlight opportunities to improve care pathways.Reference Owen, Abrar and Stapleton13 Similarly, previous research exploring decision-making around bone conduction implants has shown that factors influencing acceptance are complex, individual and context-dependent.Reference McFarland, Powell, Green, Andrew, Coppack and Hill-Feltham14 Broader evidence also highlights the wider psychosocial impact of hearing loss, including associations with depression and loneliness.Reference Pronk, Deeg and Kramer15, Reference Yanguas, Pinazo-Henandis and Tarazona-Santabalbina16 While this work offers insight into the decision-making process, the broader lived experience of patients with active transcutaneous implants remains underexplored.
The aim of this study is to explore and understand the patient journey of individuals with active transcutaneous hearing implants. By capturing patient perspectives, this study seeks to provide a more comprehensive understanding of the impact of these devices and to identify areas within the patient pathway that may be improved.
Materials and methods
A total of seventy adult patients had received one or more active transcutaneous hearing implants in our tertiary referral centre, at the time of data collection in April 2024. Recipients were identified using the audiology database. In total, 26 Osia implants and 44 Bonebridge implants had been performed.
A questionnaire exploring patient experience (Table 1) was developed with input from six patient representatives to ensure relevance to patient priorities and clarity of the questions. The final questionnaire comprised open-ended questions regarding patient experience. It was distributed to patients with a recorded email address, resulting in 46 invitations. Patients without an email address were not contacted. To ensure participants had sufficient experience of their device to reflect on its impact, only patients who were at least one year post-activation were invited to participate. The accompanying information sheet stated that participation was voluntary. The project was conducted as service evaluation; therefore, formal ethical approval was not required.
Open-ended questions sent to patients
Table 1 Long description
Content consists of five numbered open ended questions directed to patients. Question 1 asks patients to describe their experience of hearing loss. Question 2 asks how patients felt about having a hearing implant. Question 3 asks patients to describe their experience of getting their hearing implant. Question 4 asks patients to describe how the hearing implant has impacted their life. Question 5 asks whether there is anything else they would like to tell the researchers.
One of the 46 emails was undeliverable. Responses were collected using Microsoft Forms and analysed qualitatively using NVivo® software. Data analysis commenced upon receipt of the first responses. Reminder emails were sent to maximise participation.
Data collection and analysis were conducted concurrently. Responses were independently reviewed and coded by two investigators (A.A. and E.S.) using an inductive thematic approach. Coding was compared throughout the analysis process, with discrepancies resolved through discussion and consensus. Data collection continued until thematic saturation was achieved, defined as the point at which additional responses generated no new codes or themes and further data collection was unlikely to yield additional thematic insights. Following analysis of 31 responses, no novel codes were identified and thematic saturation was deemed to have been reached, at which point the questionnaire was closed. As responses frequently addressed overlapping concepts across multiple questions, all qualitative data were analysed collectively using a thematic approach rather than on a question-by-question basis. Codes were subsequently grouped into themes and subthemes representing key aspects of the patient experience.
Results
Of 46 patients contacted, one email was undeliverable and 31 responses were received, representing a response rate of 69 per cent.
Six key themes were identified: detrimental impact of hearing loss on everyday life; pre-operative experience; positive impact of the hearing implant; drawbacks of the hearing implant; varied experience of audiology; and limited awareness of hearing implants, incorporating gaps in clinician awareness of hearing implants leading to treatment delays and societal perspectives of hearing implants. These are summarised, with sample quotes, in Table 2.
Outline of themes and subthemes with sample quotes
Table 2 Long description
Columns list Theme, Subtheme, and Evidence, with each row pairing a theme and subtheme with a sample patient quote. Detrimental impact of hearing loss includes difficulty hearing, relationships with friends and family, impact on employment, and impact on mental health, with quotes about missing words, social challenges, work impact, and feeling depressed and ignored. Pre-operative experience includes mixed feelings towards the operation, cosmetic concerns, and gaining information about the implant, with quotes about being apprehensive but excited, concerns about how it would feel and look, and meeting a previous patient to learn and handle the sound processor. Positive impact of the hearing implant includes improved hearing, life changing, and gain of confidence, with quotes about improved hearing, being able to chat without saying pardon, and increased confidence at work and socially. Drawbacks to the hearing implant include post-operative discomfort, disappointment with new level of hearing, concerns with background noise, and problems with the magnet, with quotes about brief pain, hearing quality compared with an old bone conduction hearing aid, difficulty with wind or background noise, and a magnet that can get knocked off. Varied experience of audiology has no subthemes and includes a quote about multiple visits to tweak settings and hearing a wider range of sounds. Limited awareness of hearing implants includes awareness within healthcare and awareness within society, with quotes about not being well known to a GP or ENT and about others overcompensating after noticing disability.
GP = general practitioner.
Theme 1: detrimental impact of hearing loss on everyday life
Most patients described a significant negative impact of their hearing loss across multiple aspects of daily life, including social interactions, home life, employment and overall well-being. Four subthemes were identified: difficulty hearing; relationships with friends and family; impact on employment; and impact on mental health.
Difficulty hearing
Patients consistently described difficulty hearing, particularly in noisy environments, often leading to misinterpretation and frustration.
“I was however struggling to pick out some words and found myself ‘filling in the gaps’, but not always correctly…” (patient 7)
“Hearing loss affects the ability to hear in busy or noisy places…” (patient 17)
Relationships with friends and family
Hearing loss adversely affected relationships, with patients describing social withdrawal, frustration in communication and feelings of exclusion.
“People are impatient when they have to repeat… degrades close relationships” (patient 4)
“Unable to engage in social occasions…” (patient 20)
Impact on employment
Patients reported challenges in communication and role fulfilment, with some describing altered career trajectories.
“It severely impacted work as a teacher and trainer” (patient 16)
“I had to change my job because of my hearing loss” (patient 21)
Impact on mental health
Many patients described reduced confidence, isolation and low mood.
“I felt isolated and also stupid…” (patient 3)
“Withdrawal… leads to depression” (patient 4)
Theme 2: Pre-operative experience
Patients described varied pre-operative experiences, grouped into mixed emotions, cosmetic concerns and information-seeking.
Mixed feelings towards the operation
Patients commonly reported a combination of apprehension and optimism.
“Nervous at first but excited” (patient 1)
“Apprehensive but excited…” (patient 2)
Cosmetic concerns
Some patients expressed concern regarding the visibility of the device and potential social perceptions.
“I did worry about feeling embarrassed and self-conscious…” (patient 29)
Gaining information about the implant
Patients valued opportunities to trial devices and speak with other implant users.
“It really helped being able to talk to someone who already had [an implant]” (patient 29)
“The device trial was truly invaluable…” (patient 30)
Theme 3: Positive impact of the hearing implant
A total of 77 per cent of respondents voluntarily reported a positive impact of their hearing implant. Subthemes included improved hearing, life-changing impact and increased confidence.
Improved hearing
Patients frequently reported improved clarity and awareness of sounds.
“The sound… is amazing and so clear” (patient 3)
“Hearing sounds I have never heard before” (patient 8)
Life-changing impact
Many patients described the implant as “life-changing”, with improvements in communication, social interaction and quality of life.
“I’m my old self again… life changing” (patient 1)
“Massively… I’ve embarked on a new career” (patient 30)
Increased confidence
Patients reported improved confidence in social and professional settings.
“I feel more confident…” (patient 4)
“Confidence is the main thing it has given me” (patient 7)
Theme 4: Drawbacks of the hearing implant
Despite overall positive experiences, 42 per cent of patients also reported drawbacks. Subthemes included post-operative discomfort, unmet expectations, background noise and magnet-related issues.
Post-operative discomfort
“Painful afterwards but not for long” (patient 3)
“Recovery… took longer than I thought” (patient 30)
Disappointment with hearing outcomes
“The sound quality just isn’t there for me” (patient 2)
“I expected to have a better level of hearing” (patient 15)
Concerns with background noise
“Background noise sometimes takes over” (patient 8)
“It is still hard to understand voices in busy environments” (patient 11)
Problems with processor retention
“It fell off quite a lot initially” (patient 16)
“Sometimes gets knocked off” (patient 21)
Theme 5: Varied experience of audiology
Patients described mixed experiences of audiology support, particularly regarding device programming and fine-tuning. Some found the process straightforward, while others reported difficulty achieving optimal settings.
“Audiologist was great in programming the device” (patient 20)
“The wearing of facemasks… hindered fine tuning” (patient 27)
“It’s very hard to recreate real-life environments…” (patient 29)
Theme 6: Limited awareness of hearing implants
Patients highlighted limited awareness of hearing implants in both healthcare and society.
Awareness within healthcare
Over 50 per cent of participants commented that earlier access to a hearing implant may have been possible with better clinician awareness.
“If my GP or ENT knew about [hearing implants] I could have had it sooner” (patient 9)
“It would be good… to refer people sooner” (patient 21)
Awareness in society
Some patients described social perceptions related to device visibility.
“People treat me as if I’m an invalid…” (patient 4)
“Occasionally… self-conscious… but generally I’m not too bothered” (patient 29)
Discussion
The aim of this study was to explore and better understand the patient experience of active transcutaneous hearing implants. Thematic analysis identified six key themes: the impact of hearing loss on everyday life; pre-operative experience; positive impact of the hearing implant; drawbacks of the implant; varied experience of audiology; and limited awareness of hearing implants. Together, these findings provide a comprehensive overview of the patient journey and highlight areas in which care may be optimised.
Patients described hearing loss as having a pervasive and detrimental impact across multiple domains of life, including social interaction, relationships, employment and psychological well-being. Feelings of isolation, frustration and reduced confidence were commonly reported. These findings are consistent with previous literature demonstrating associations between hearing loss, depression and social isolation, including work by Pronk et al.Reference Pronk, Deeg and Kramer15 The broader consequences of loneliness and social isolation on physical health have also been well described,Reference Yanguas, Pinazo-Henandis and Tarazona-Santabalbina16 underscoring the importance of timely and effective intervention for hearing loss.
The pre-operative experience was characterised by a combination of apprehension and optimism, alongside practical concerns such as cosmesis and uncertainty regarding outcomes. Patients valued opportunities to access information, particularly through direct interaction with individuals who had undergone implantation. This highlights the importance of peer support and realistic expectation-setting within pre-operative counselling. While facilitating contact between patients may be beneficial, this must be balanced with appropriate governance and respect for patient confidentiality.
The majority of patients reported a positive impact following implantation, with over three-quarters describing improvements in hearing, communication and overall quality of life. Notably, many patients described the intervention as “life-changing”, with particular benefits in social engagement and occupational functioning. Improvements in confidence were also frequently reported, suggesting that the benefits of implantation extend beyond audiological outcomes alone. These findings reinforce the value of active transcutaneous hearing implants as an effective intervention from the patient perspective.
Despite these positive findings, several drawbacks were identified. Post-operative discomfort was reported but was generally transient and manageable. A minority of patients expressed disappointment with hearing outcomes, often in the context of prior experience with other hearing devices or high pre-operative expectations. This suggests that patient expectations and previous experiences may play an important role in shaping perceived outcomes. Difficulties with background noise were also reported and, in some cases, continued to impact social functioning. Practical issues, such as concerns regarding magnet retention and comfort, were described by a small number of patients. Although these issues were not universal, they represent important considerations in optimising patient experience.
Experiences of audiology support, particularly in relation to device programming and fine-tuning, were variable. While many patients reported positive interactions, others described challenges in achieving optimal settings, including difficulties replicating real-world listening environments during clinic-based assessments. These findings highlight the importance of adequate time and flexibility within audiology services to support individualised optimisation of device performance.
An important finding of this study is the frequency with which patients identified limited awareness of hearing implants within healthcare as a barrier to timely access. More than half of respondents commented that earlier referral for assessment, or earlier implantation, may have been possible had clinicians been more aware of these treatment options. Notably, these comments arose spontaneously from patients, despite the questionnaire not specifically focusing on referral pathways or clinician knowledge, suggesting that this issue formed a meaningful part of their overall experience.
This finding is consistent with qualitative work in other otological conditions demonstrating that patient perspectives can reveal gaps in clinician awareness and referral pathways.Reference Owen, Abrar and Stapleton13 Advances in hearing implant technology and surgical techniques can only benefit patients if suitable candidates are identified and referred appropriately. Delayed recognition of candidacy may prolong the functional, social and psychological consequences of hearing loss described elsewhere in this study. Improving awareness among healthcare professionals, particularly within primary care, general otolaryngology and audiology services, therefore may represent an important opportunity to improve access to care. Further work is warranted to explore clinician awareness of hearing implant options and identify barriers within referral pathways that may contribute to delays in access.
A notable feature of the findings is the relative consistency in how patients described the positive impact of implantation, compared to the more individualised nature of reported drawbacks. While many patients used similar language to describe the benefits, including the term “life-changing”, negative experiences were more variable and context-specific. This observation reflects the heterogeneity of patient expectations, prior experiences and individual circumstances, all of which contribute to the overall patient experience.
This study has several limitations. As a qualitative study, the findings are inherently interpretive and may be influenced by researcher perspective, although efforts were made to apply a systematic approach to coding and theme development. As questionnaires were completed anonymously, demographic and clinical characteristics could not be linked to individual responses. Consequently, it was not possible to explore whether experiences differed according to factors such as age, sex, hearing loss type, employment status, implant type or time since implantation.
Data were collected using an online questionnaire, which may have introduced selection bias, as only patients with access to and familiarity with email were able to participate. In addition, patients who chose to respond may have had different experiences from non-responders. Consequently, the findings may over-represent individuals who were more engaged with their hearing implant journey or more motivated to share their experiences.
In addition, responses were self-reported and may be subject to recall bias or influenced by individual expectations and experiences. The study was conducted at a single centre, and experiences may differ across other institutions with varying clinical pathways and resources. Furthermore, the inability to link responses to specific device types limits the ability to compare experiences between different implant systems.
• The patient experience of active transcutaneous hearing implants remains underexplored in the literature
• Qualitative analysis identified six key themes: impact of hearing loss on everyday life; pre-operative experience; positive impact of the hearing implant; associated drawbacks; variation in audiology support; and limited awareness of hearing implants
• Patient experience is influenced by prior experience with hearing devices, expectations and individual circumstances
• Access to first-hand accounts from previous patients may support informed decision-making and help align expectations with likely outcomes
• Limited awareness of hearing implants within healthcare may represent a barrier to timely referral and access to treatment
Conclusion
This study has identified key themes that characterise the patient experience of active transcutaneous hearing implants, including the impact of hearing loss on everyday life, pre-operative experience, positive outcomes following implantation, associated drawbacks, variation in audiology support and limited awareness of these devices. Collectively, these findings fulfil the study objective and provide a comprehensive overview of the patient journey.
The majority of patients reported a positive and meaningful impact on their lives, with improvements in communication, confidence and social participation. However, patient experience was also shown to be highly individual, influenced by factors such as prior experience with hearing devices, expectations and personal circumstances.
Opportunities to enhance patient experience were identified. In particular, facilitating access to first-hand patient perspectives may support more informed decision-making and help to align expectations with likely outcomes. In addition, the reported lack of awareness of hearing implants within healthcare highlights a potential barrier to timely access. Further work is warranted to explore clinician awareness and referral pathways, with the aim of improving access to these interventions for appropriate patients.
Declaration of funding
None.
Acknowledgements
This research was supported by the National Institute for Health Research Manchester Biomedical Research Centre.
Competing interests
The author(s) have no conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethics approval
Not required, data were acquired as routine service evaluation.
Data sharing and availability
Primary data are available as supplemental files.
Authorship statement
E.S. designed the work; all authors acquired and analysed data, drafted, revised and approved the manuscript; all authors agree to be accountable for all aspects of the work. All authors have read and approved the final manuscript.
Open access
