(Last updated Oct 7, 2019)

Esteem Hearing Aid Implant

The past decade has seen enormous advancements in the invisible hearing aid realm. From incredibly intelligent traditional invisible hearing aids, to extended wear devices like the Lyric hearing aid, to other entrants as late as 2010, such as the Esteem Hearing Implant by Envoy Medical. I get asked a lot what my opinion of this device is, and I’ve never really been able to give a good answer as I’ve never fit it because the Esteem fit has to be by an Otolaryngologist (ear nose & throat doctor), working in tandem with an audiologist.

I wanted to look in to the Esteem though and do my best to evaluate it, so at the least I could point people to this post and let them read a bit more than the manufacturer provides. So as you read this post, consider the fact that I have never fit the Esteem and am not medically qualified to fit it. This post is merely based on what I have both heard from patients and gathered from reading information made available from the manufacturer.

The Esteem is the first and only FDA approved, totally implantable, active middle ear implant. It was granted FDA approval on March 17, 2010, after years of clinical studies. I have reviewed these clinical studies and they are impressive- will touch on that more below. Before you read too far in to this post, you should see if you are even an Esteem candidate, based on the guidelines from Esteem . Please take a minute to review that list before you proceed- there are quite a few reasons why you may not be a good candidate.

How does the Esteem work?

Unlike a traditional hearing aid, the Esteem has no speaker or artificial microphone, does not interface directly with the outer ear, has no external components, and there is nothing in the ear canal. Watch this brief video by Envoy Medical to get an idea of how the Esteem works.

As the video explains, the Esteem has 3 main parts, the Sensor, the Driver, and the Processor. These parts (in function), are not very different from the parts of a traditional hearing aid. Let’s make a few comparisons:

The sensor: The sensor “senses” vibration from the incus as the input signal. This is comparable to the mic on a hearing aid.
The driver: The driver delivers amplified output signals as vibration to the stapes- just like a speaker or receiver on a conventional hearing aid.
Sound Processor: The Sound processor “processes” and amplifies acoustic signals according to programmed settings and algorithms- just like a processor in a conventional hearing aid.

So in theory, the Esteem does the same thing that traditional hearing aids do, but it does it in a very different way. For starters, after a complete audiological evaluation, you are sent for CT scans, and this is to ensure that your anatomy is compatible with the Esteem. If everything checks out, the Esteem has to be implanted by an Otolaryngologist. You are awake during the 60 minute procedure, and it can be performed in-office under local or sometimes general anesthesia. At the conclusion of that procedure, once your incision heals, you are then sent to the audiologist so you can get the Esteem activated and programmed.

Esteem hearing aid

Esteem Remote Control

In most cases, you will probably have already had some familiarity with the audiologist that does that programming, because it is required (though I’m not sure how strict they are on this requirement), that you wear traditional hearing aids for at least 30 days before you get the Esteem. The audiologist then programs your Esteem in a similar fashion they would program any other hearing device. They’ll adjust the gain across various frequencies, and set you up with multiple listening environments or “programs”, and you’ll be given a programming remote control so you can make adjustments at home or on-the-go as well. The Esteem has 3 programmable memories, and up to 16 different volume steps- though most people use much fewer.

The battery on the Esteem will last approximately 4.5 to 9 years, with 5.5 years being the medium. Battery life depends on sound levels and gain programmed into the Esteem. One of the reasons the Esteem is able to get such great battery life is because it uses analog signal processing, which requires very low energy (as opposed to digital devices).

As I mentioned earlier, I did review the clinical trials for the Esteem and they were impressive. If you have any familiarity with hearing aids or hearing loss, you probably recognize a few of the measurements performed. The most notable in my opinion, is the WRS (discrimination scores) which were improved by 63% over unaided baseline. This means that individuals were read a list of words both unaided, and then with the Esteem, and their scores were 63% better when using the Esteem. This number is comparable to what you might achieve with the best hearing aids out there. This is an impressive figure.

So the Esteem looks can be a great solution for some people, but in my opinion there are some caveats as well. For starters, it is surgical procedure- so you have to consider all the risks that go along with that. In order to make room for the implant, you must undergo a mastoidectomy which means the doctor will hollow out a portion of the mastoid bone behind your ear- in other words- clear out some space for the device. In addition, the all-important ossicular chain is dis-articulated during this procedure. The 3 bones in the chain are pulled apart so the hammer’s vibration is no longer directly coupled to the stirrup via the anvil. So essentially, the anvil is cut out of the chain. In short, this means that you lose whatever hearing you had left, and are totally dependent on the Esteem.

It’s also important to remember that the Esteem will not always match the performance of a well-fit hearing aid. For one, the Esteem’s functional gain maxes out at around 50db. That means if your hearing gets worse and the Esteem isn’t loud enough- you are stuck. You cannot get more gain out of the Esteem when you need it (beyond the allowable volume range), like you would with traditional hearing aids. At that point, the entire process would need to be reversed and you would go back to either traditional hearing aids, or cochlear implants if your loss is severe enough. So the Esteem is reversible, but it appears one would need to be implanted with a prosthetic incus bone if you chose to reverse it.

Beyond that, it’s an expensive solution. The upfront costs (which insurance almost never covers) is around $35,000. The cost of the CT scan is usually included in this total, and it is most often considered an outpatient procedure so there is no hospital bill. However, there are recurring costs with the Esteem. When the battery quits every 4.5-9 years, you have an additional outlay of around $6,500 to put a new battery in as well.

In short, I think for all the upside to wearing a device like the Esteem, there are certainly downfalls, and would would be wise to learn as much about this process as possible before moving forward. Have you worn the Esteem or know someone else that has? Please have them leave a comment below for our readers!

If you’d like to read more about the Esteem, check out some of the links below.

Article by Neil Bauman, Ph.D.
Blogger with hearing loss with lots of good comments

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