With the Birmingham osseointegrated implant programme there have been several patients with severe pre-lingual conductive hearing loss. The majority of these have been patients with Treacher Collins syndrome. There are characteristic features of speech and voice in those with long-standing conductive hearing loss. In addition, the associated abnormalities of jaw, teeth and palate may amplify the problem. There may be spontaneous improvement in features such as voice pitch, quality and intensity following the fitting of a BAHA. However, in those with a pre-lingual hearing impairment, speech therapy may be necessary. Patients assessed as suitable for BAHA have a full assessment of communication skills including audio recording of speech and voice. Post-operative training improves auditory discrimination and perception and is followed by training in the production of the newly perceived speech sounds.