If you've been exploring options beyond traditional hearing aids, you've likely encountered bone conduction technology. As a consultant ENT surgeon in London, I've seen firsthand how these innovative devices can transform lives. The technology has advanced significantly, and it's time for an updated, unbiased guide to help you navigate your choices.

This comprehensive online guide will cover everything you need to know about bone conduction hearing devices in 2025, including:
* The fundamentals of bone conduction hearing.
* A comprehensive review of the main options available today.
* A head-to-head comparison of key differences in terms of surgery, visibility, power, and MRI compatibility.
* Crucial questions to ask before making your decision.

The Human Impact of Hearing Loss

Hearing is incredibly precious, yet the profound impact of hearing loss and deafness is often underestimated because it's largely invisible. People may mistake hearing difficulties for rudeness, and they're less likely to adjust for your needs compared to a visible disability.
Unmanaged hearing loss can directly lead to:
* Social isolation
* Strain on marriages and relationships
* Reduced employment prospects
* Increased daily listening effort and mental fatigue

Even single-sided hearing loss (unilateral profound deafness), often overlooked, significantly impacts your ability to hear in noisy environments and localize sound. It creates a "head shadow effect," meaning you miss an entire half of your auditory environment – a car approaching or someone calling your name. This constant high listening effort also contributes to tiredness.
So, what are the solutions available in 2025? To understand them, let's first delve into how hearing works.

Anatomy of Hearing & How It Determines Your Options
 

Your ear delivers sound to your brain through a conduction system and a microphonic system.
The conduction system includes your outer ear (ear canal), eardrum, and three tiny bones behind the eardrum. These components transmit sound vibrations and focus them onto a small window into the inner ear. The microphonic part, the cochlea, then converts these mechanical vibrations into electrical signals that are sent to the brain.
Hearing loss can occur at any point along this pathway. If the problem lies within the conduction system – due to scarring in the ear canal, damage to the eardrum or hearing bones, or even congenital absence of these parts – a surgeon will first consider microscopic surgical reconstruction. Procedures like canalplasty, tympanoplasty, and stapedectomy are generally explored first.

However, if these procedures aren't possible, are too risky, or have already been attempted, the next question is whether a conventional hearing aid is an option. Reasons like ear size and shape, recurrent infections, or very low hearing levels can preclude this. For those in this scenario, bone conduction offers a powerful alternative.

The Magic of Bone Conduction

To determine if bone conduction is suitable, we look at your audiogram, specifically your bone conduction thresholds, rather than your overall hearing levels (air conduction thresholds). Many people with outer and middle ear problems have poor hearing, but their bone conduction thresholds are quite good, a route we can't utilize with a regular hearing aid.
With bone conduction, we bypass the poorly functioning ear canal and middle ear entirely. The device picks up sound, converts it into a vibration, and delivers that vibration directly to the skull bone. This bone vibration travels directly to the inner ear on that side, where vibrations are converted into electrical signals for the brain, just as they normally would be.
A fascinating historical example is Beethoven, who, as he became deaf, would bite on his conductor's baton and press the other end to his piano to "hear" the music through the bones in his jaw.

Bone conduction can also help individuals with no microphonic hearing on one side, a condition known as Single Sided Deafness (or Unilateral Profound Deafness). If a device is placed on the deaf side, the vibration travels across the skull and stimulates the hearing ear on the other side. This effectively re-routes sound, overcoming the head shadow effect and preventing you from missing an entire hemisphere of sound, whether it's someone calling from your deaf side or unseen traffic.
 

Step 1: The Non-Surgical Trial
 

Before any discussion of surgery, a trial with a non-surgical device is crucial. It's the only way to experience this unique way of hearing, and it allows your audiology team to measure the potential benefit. For some, this type of device can even be a long-term solution to avoid surgery.
The classic non-surgical solution is the BAHA on Softband. A processor, identical to one used with a surgical implant, clicks onto a plastic plate, held firmly against the mastoid bone behind the ear by an elastic headband. This is an essential starting point for babies and young children to provide early access to sound. The BHM Contact Mini is another lower-cost option used by many audiology units.

For older children and adults, the cosmetic aspect can be a drawback. The Soundarc by Cochlear addresses this with a more stylish, lightweight frame, worn like glasses, positioning the vibrating component correctly. While more cosmetically acceptable for some, non-surgical devices still have limitations like potential headaches and whistling feedback.

To avoid pressure, an adhesive solution is available: the MED-EL ADHEAR. This uses a new sticky adhesive pad daily on the skin behind your ear, onto which an external processor clicks. The benefit is no pressure or headaches. However, the limitation is the volume that can be delivered through a device held on by a band or adhesive.
The key takeaway is that while these devices are excellent for a trial, they have limitations in wearability and power. If your trial is successful, and you find yourself thinking, "I love the sound, but I don't like wearing this device," or you need higher levels of clarity and stronger amplification, you're ready to consider a permanent, surgical solution.

Surgical Option 1: Percutaneous Implants

Surgical implants broadly fall into two categories: percutaneous and transcutaneous. Let's start with percutaneous implants, often known as Bone-Anchored Hearing Aids (BAHAs), which mean the implant shows "through the skin."

The surgery involves placing a small titanium implant into the skull bone. An abutment is attached to this, passing through a tiny opening in the skin. After healing, the sound processor clicks directly onto this abutment. This direct connection is the system's greatest strength, as there's no skin or soft tissue to dampen the vibration, ensuring pure, efficient energy transfer. This provides exceptional sound quality and the most power, making it suitable for people with more significant hearing losses. The most powerful percutaneous BAHA can even accommodate bone conduction hearing levels as low as 65dB.

There are two main brands of percutaneous BAHA:

* The Cochlear BAHA System: Cochlear are pioneers in this field. Their latest processor is the BAHA 6 Max, which is small, very powerful, and features advanced sound processing and direct-to-phone connectivity. Abutments have evolved to be smaller with special coatings for better skin integration.
 

* The Oticon Ponto System: Oticon's latest processor is the Ponto 5 Superpower. With a strong background in conventional hearing aids, Oticon prides itself on sound processing technology that reduces listening effort. Oticon has also pioneered the MONO surgical technique for adults, which uses a tiny circular biopsy punch for the abutment opening instead of raising a skin flap, leading to faster healing and better cosmetic results. Both Ponto and BAHA surgery for adults can often be performed under local anaesthetic as an outpatient procedure, taking as little as 10-15 minutes.

 

This is a significant evolution from pre-2012 surgeries, which were much larger operations under general anaesthetic with hair loss around the implant site.

Surgical Option 2: Transcutaneous Implants

The idea of a permanent abutment through the skin isn't for everyone. It requires daily cleaning, and though much rarer now, there's still a small risk of minor skin irritation and even implant loss. This led to the development of transcutaneous implants, where the vibrating part of the system is buried under the skin. As of 2025, we have three excellent options in this category.
 

With a transcutaneous device, an internal implant is secured to the bone, and an external processor is worn on the head, held in place by a magnetic connection through the skin to the implant underneath. When you remove the processor, your skin is completely intact—no cleaning, no wound. This offers a huge lifestyle and cosmetic advantage for many. These devices are "active," meaning the part that creates the vibration is within the internal implant, making them far more effective than older, passive magnetic systems (like BAHA attract & Sophono).
 

Here are the three major transcutaneous options:
 

* Med-el Bonebridge: Med-el introduced the first active transcutaneous implant. Its internal implant uses a Bending Wave Transducer, secured to the bone with two screws. The external processor is the SAMBA 2. This is a proven, reliable system used successfully for years. We've been implanting the slimmer Bonebridge version 2 since 2019, bringing this technology to those who prefer to avoid a percutaneous device. It's suitable for patients with bone conduction hearing levels of at least 45dB. Direct streaming to your phone requires a separate accessory (the Samba2Go pendant). A CT scan is typically needed to assess the bone volume required to house the implant, as this can influence positioning. Because the bone footprint is larger than for percutaneous BAHAs, fitting this implant can be challenging for some patients, especially those with previous extensive surgery.
 

* Cochlear OSIA System: The Osia has been a very popular implant since its introduction in 2021. It aims to provide greater transcutaneous amplification while requiring the same bony footprint as a percutaneous BAHA. Its internal implant uses a Piezo Power™ transducer, which expands and contracts to create vibrations, offering more power in a given size and more effective amplification of higher frequencies. This is reflected in its candidacy range, including patients with bone conduction thresholds as low as 55dB (compared to 45dB for Bonebridge). The external Osia 2 Sound Processor offers direct streaming without an additional device, and patient feedback on its performance, particularly in noise, has been very positive. The main caution with Osia is its size; it's the largest of all transcutaneous implants. For patients with thin skin, this can result in a noticeable bump. Surgical positioning can also be more limited, often placing the magnetic processor higher and more noticeably than other implants.
 

* Oticon Medical Sentio: The newest transcutaneous implant, which we started offering in 2025, is the Oticon Medical Sentio. We're in the early stages of experience with this device, but I anticipate it will be very popular. It offers the same amplification power as the Bonebridge and is noticeably slimmer than the OSIA. The surgery is relatively uncomplicated, and the internal implant is secured by screws and uses an electromagnetic transducer. The external processor is stylish, and Oticon's sound processing technology aims for clarity and improved conversation in noise. Currently, we offer this to adults and older children with bone conduction hearing of at least 45dB. The internal component has the capability for more power, so a future larger external processor offering greater power and reserve for patients with worse bone conduction thresholds is anticipated. I also suspect the age licensing will drop to younger ages as more studies are completed. I'll provide updates on social media as we gather more long-term data.
 

The surgery for all active transcutaneous devices is generally more involved than for a percutaneous implant, typically requiring a general anaesthetic and around 60 minutes or less in surgery, meaning you'll usually spend most of the day in the hospital. Technically, all implants could be installed with local anaesthetic, but this is a discussion to have with your surgeon based on your individual factors.

The Critical Comparison: Percutaneous vs. Transcutaneous
 

Now for the most important part: how do you choose between percutaneous and transcutaneous? A direct abutment or a hidden magnet? All devices mentioned are fully funded by the UK NHS, and you can have one for each ear if needed. All implant processors come in a range of customizable colours. So, what else is important in making your decision?

Here are the five biggest considerations to help you choose your category:

1. Power & Future-Proofing

Your audiogram is key here. A percutaneous system's direct link offers the widest fitting range and can handle more severe conductive and mixed hearing losses. This also provides more "reserve." As we age, our inner ear function can naturally decline. A more powerful implant means it's more likely to be sufficient for your needs in 10, 15, or 20 years. That said, the transcutaneous implants we have are still very powerful and suitable for the vast majority of candidates. But if your bone conduction hearing levels are close to the line, you might consider a device that offers more room for your hearing to worsen, ensuring maximum longevity.

2. Lifestyle, Cosmesis & Daily Care

On the surface, you might wonder why you'd choose a visible implant if a hidden one is an option. With a transcutaneous implant, no one knows you have an implant when the processor is in your pocket, and there's no daily cleaning. However, there's a trade-off. The external processors are inherently a bit thicker and bulkier to house the magnet and can create more of a bulge under the hair. We've found that these processors often need to be sited higher on the skull rather than discreetly tucked behind the ear, sometimes making the "discrete" option more noticeable when worn.

A percutaneous abutment is always visible, but the processor itself can be much smaller and more discreet. The downside is that percutaneous implants require more daily care – a quick clean with a soft wipe, similar to cleaning a piercing. This is a daily commitment, and neglecting it can lead to persistent wound issues, hospital visits for nursing attention and creams, and even the risk of the implant needing removal.

3. Retention & Skin Issues

A percutaneous device clicks on and is incredibly secure, very difficult to knock off. A transcutaneous device is held on by a magnet. While the magnets are strong, a hard knock or even pulling a jumper over your head can sometimes dislodge it. This can be a concern for very active individuals or children, and processor loss is a real issue. Magnet strength can be adjusted, but too strong a magnet can cause pressure, redness, and pain on the skin – it's a fine balance.
 

4. The Surgery and Recovery

As mentioned, percutaneous surgery is quicker and often done under local anaesthetic, making it less invasive. This is a popular choice for patients who have undergone multiple surgeries for chronic middle ear disease and prefer a simple, minimally disruptive solution. Transcutaneous surgery typically requires a general anaesthetic, though you should discuss this with your individual surgeon. Recovery is straightforward for both, but the timeline differs. With a percutaneous abutment, we often wait 4-8 weeks for the skin to fully integrate with the titanium before "loading" it with the processor. With a transcutaneous implant, you can sometimes be switched on a little sooner, perhaps 2-4 weeks post-op.

5. MRI Compatibility & The MRI Shadow

This is a vital consideration. While all these devices are safe for MRI scans, their compatibility differs.
With a percutaneous implant, you simply remove the processor. The tiny titanium screw is safe in any MRI scanner up to 3 Tesla. It creates a very small artifact or "shadow" on the scan, unlikely to interfere with a diagnosis on any future brain imaging.
With a transcutaneous implant, the internal magnet is the issue. The Bonebridge, Osia, and Sentio all allow for safe MRI scans. For Bonebridge and Sentio, this is up to 1.5 Tesla; for Osia, it's 3 Tesla, and sometimes special headband precautions are used by radiographers. Crucially, all these magnetic implants create a significant shadow on an MRI brain scan, which can obscure the view of the brain on that side. This is vital if you have a condition requiring future brain scans, particularly for patients who have had chronic middle ear disease surgery (e.g., for cholesteatoma) and rely on future MRI scanning to detect disease recurrence. This factor alone can significantly narrow the decision for many patients.

8 Further Questions to Discuss with Your Team

Armed with this knowledge, you'll likely have a clearer idea of which implant aligns with your preferences. This information should empower you to have a high-quality discussion with your healthcare team.

For those who enjoy in-depth research, here are eight other frequently asked questions that influence patients' decisions:

* My Anatomy: Based on my bone thickness and the position of vital structures, am I a candidate for all implant types? Will there be any implications for where it is positioned? A CT scan is sometimes needed, especially for transcutaneous devices with a larger internal "footprint." Also, if I need implants for both ears, can I have both during the same operation, or does it need to be done one at a time? Your surgeon may have a specific recommendation.

 

* Connectivity: Which devices will stream directly to my phone (iPhone/Android)? Which require an extra streaming accessory? What is the app like to use? Do I have any niche requirements, such as being a musician? It's worth visiting the manufacturer's websites yourself, as audiology appointments may have limited time for this. Check the latest compatibility list for your exact phone model and operating system.

 

* The 'Other' Ear: If I already wear a hearing aid in my other ear, will this device be compatible if I ever need a conventional hearing aid in that ear? Your audiologist can help answer this.

 

* Dexterity & Batteries: Can I try holding and attaching dummy versions of the processors? How easy is battery changing? Is it rechargeable or disposable? What's the typical battery life? For children, is the battery compartment tamper-proof?

 

* Helmets & Headwear: I regularly wear a [cycling helmet/hard hat/headscarf]. How will each processor type work with this? Can we trial the position?

 

* Age Licensing: Are there any age restrictions on these devices? Some are not licensed for very young children. Are there any medical considerations that might necessitate an off-license decision?

 

* Accessories: What accessories come as standard? Items like a remote microphone or a TV streamer can make a huge difference, and the bundles offered by each company can vary.

 

* Could a Middle Ear Implant be an option? This is a different implant type, but there's often overlap, and many patients could be suitable for either. If you think this might apply to you, it's worth asking if a middle ear implant is suitable. It's particularly good for people with hearing loss related to ear canal problems but a healthy middle ear space. The currently available option is the Vibrant Soundbridge implant by Med-el, which I've covered in a separate video.

 

The Importance of Multi-Professional Involvement

Crucially, your recommendation will come from a Multi-Disciplinary Team (MDT). This isn't just a surgeon's or an audiologist's decision. It's a significant choice for you, and we want to ensure we get it right. It often involves a complex weighing of factors. For bone conduction implants, at a minimum, recommendations will involve a surgeon and audiologist, and may also include a speech therapist, teacher of the deaf, psychologist, and radiologist.
Your team will help you understand what's technically suitable. The process is then enriched when you help your team understand what works best for your life and individual circumstances. I've compiled all this information into a single comparison table to assist both patients and clinicians globally.

Final Thoughts

This has been a complete deep dive into the world of bone conduction implants in 2025. This technology evolves almost every year, and the challenge is to ensure patients have access to all suitable devices. As you can see, there is no single "best" device, but there is almost certainly a best device for you, based on your hearing, your lifestyle, and your priorities.
Hearing is precious. It is the window to our social, professional, and family lives, and our mental health. That's something definitely worth investing in.

 

Joseph Manjaly MBChB BSc DOHNS FRCS (ORL-HNS)

Consultant Otologist, Auditory Implant & ENT Surgeon

The Royal National ENT Hospital & University College London Hospitals & OneWelbeck ENT