Perioperative considerations for children undergoing bone anchored hearing device surgery: an observational study.

The objective of the study was to identify important factors in the perioperative management of children undergoing bone anchored hearing device (BAHD) surgery in a paediatric tertiary centre. We also aim to compare current practice and identify any changes in practice with the previous study carried out in the same paediatric tertiary centre in 2000. Children undergoing BAHD surgery between January 2008 and January 2011 were identified on a departmental database. A retrospective case note review was performed and compared with data collected prior to 2000. In the study period, 194 children were identified to have had BAHD surgery. 134 case notes were available for analysis and of these children, 353 anaesthetics were identified. 45.5% of the children had a recognised syndrome or dysmorphism and 17% had a congenital cardiac anomaly. 16% of the children were classified as a grade 3 or 4 laryngoscopy, but 83.3% were managed with a laryngeal mask. 11.9% of the children had an intraoperative complication and 4.8% a postoperative complication. 88.4% of children were managed as day cases. Compared with the previous study in 2000, there was a smaller proportion of syndromic or dysmorphic children and a larger proportion of children were managed with a laryngeal mask. As BAHD surgery has become more common and as its indications have expanded, the perioperative management has evolved. The proportion of children with congenital heart disease has remained constant, but there has been a marked reduction in the number of children with syndromes involving the head and neck. We have found that even in complex craniofacial cases, the laryngeal mask is increasingly being used with good results. However, advanced paediatric airway experience was still required in a small number of cases, heightening the awareness that specialised paediatric support services are necessary for a comprehensive BAHD programme.

Preclinical Validation of a Novel Device Designed to Reduce Biofilms on Percutaneous Osseointegrated Abutments.

AIM: To assess the efficacy of a prototype cleaning device in removing biofilm from skin-penetrating abutments. BACKGROUND: Adverse skin reactions around percutaneous osseointegrated implants have been linked to poor hygiene and infection. A cleaning device made from open-cell polyfoam has been developed to facilitate manual cleaning of abutments by the patient. METHODS: Serratia biofilm was grown on clean and sterile conical bone-anchored hearing system abutments including both pre-2007 (straight sided) and post-2007 (conical-sided) designs. Eighteen were photographed and then subjected to cleaning using a toothbrush or the cleaning device soaked in water or a proprietary mouthwash. Biofilm on a further group of 10 conical abutments was recorded using a scanning electron microscope before and after cleaning with the test device soaked in water. Quantitative analysis of the efficiency of the cleaning was made using image analysis. RESULTS: Removal of biofilm using a dry or wet toothbrush was not as effective as cleaning with the device. In 10 cases subjected to image analysis, approximately 90% of the biofilm was removed from the top third of the abutments, 85% from the middle third, and 48% from the basal third. CONCLUSION: The cleaning device is effective in removing most biofilm from the test abutments and represents a significant improvement in comparison with traditional methods such as a toothbrush.

The role of bone anchored hearing aids in children with Down syndrome.

OBJECTIVES: To evaluate complication rates and outcomes of children with Down syndrome fitted with a Bone Anchored Hearing Aid (Baha). To evaluate whether the Bone Anchored Hearing Aid is a successful form of aural rehabilitation in children with Down syndrome from a patients' perspective. STUDY DESIGN: Retrospective case analysis and postal questionnaire study. SETTING: The Birmingham Children's Hospital, UK. METHODS: A total of 15 children were fitted with a Baha between February 1992 and February 2007. The age range was 2-15 years. A postal questionnaire was sent to each family. The Glasgow Children's Benefit Inventory (GCBI) was used in this study. OUTCOME MEASURES: Implantation results, skin reactions and other complications were recorded. Quality of life after receiving a Baha was assessed with the GCBI. RESULTS: All 15 patients are using their Baha 7 days a week for more than 8h a day after a follow-up of 14 months with continuing audiological benefit. No fixtures were lost, and skin problems were encountered in 3 (20%). Regarding quality of life, all 15 patients had improved social and physical functioning as a result of better hearing. CONCLUSIONS: Baha has an important role in the overall management of individuals with Down syndrome after conventional hearing aids and/or ventilation tubes have been considered or already failed. This study has shown a 20% rate of soft tissue reaction and there were no fixture losses in this group. No significant increase in complication rates was identified in children with Down syndrome. Finally, there was a significantly improved quality of life in children with Down syndrome after receiving their Baha. There was a high patient/carer satisfaction with Baha. Two of our series had bilateral two stage fixture procedures without any complications. More consideration should be given to bilateral bone anchored hearing aids in this group.

A new retractor for cochlear implantation.

In cochlear implantation and other major ear surgeries a post auricular incision is often used. Following this, fascia, muscle and fat is divided, and then a periosteal flap is raised. This creates different tissue planes which need to be held back and protected from the surgeon and the drill. We present a new device which provides excellent retraction for this procedure, does not put undue pressure on the pinna, while at the same time it allowing the surgeon an unobstructed view.

Unexpected exit of a cochlear implant electrode through the wall of the basal turn of the cochlea - a report on two patients.

We describe the unusual complication of the cochlear implant electrode eroding through the lateral bony wall of the cochlear basal turn in 2 different patients. This complication, occurring during life, has not been previously described in the literature. Radiological investigations were vital in making this diagnosis. We also discuss the likely pathophysiology behind this complication.

Evaluation of bilaterally implanted adult subjects with the nucleus 24 cochlear implant system.

OBJECTIVE: To evaluate the speech perception benefits of bilateral implantation for subjects who already have one implant. STUDY DESIGN: Repeated measures. PATIENTS: Thirty adult cochlear implant users who received their second implant from 1 to 7 years with a mean of 3 years after their first device. Ages ranged from 29 to 82 years with a mean of 57 years. SETTING: Tertiary referral centers across the United Kingdom. MAIN OUTCOME MEASURES: Monosyllabic consonant-nucleus-consonant words and City University of New York sentences in quiet with coincident speech and noise and with the noise spatially separated from the speech by +/-90 degrees . RESULTS: At 9 months, results showed the second ear in noise was 13.9 +/- 5.9% worse than the first ear (p < 0.001); a significant binaural advantage of 12.6 +/- 5.4% (p < 0.001) over the first ear alone for speech and noise from the front; a 21 +/- 6% (p < 0.001) binaural advantage over the first ear alone when noise was ipsilateral to the first ear; no binaural advantage when noise was contralateral to the first ear. CONCLUSIONS: There is a significant bilateral advantage of adding a second ear for this group. We were unable to predict when the second ear would be the better performing ear, and by implanting both ears, we guarantee implanting the better ear. Sequential implantation with long delays between ears has resulted in poor second ear performance for some subjects and has limited the degree of bilateral benefit that can be obtained by these users. The dual microphone does not provide equivalent benefit to bilateral implants.

Consensus statements on the BAHA system: where do we stand at present?

After more than 25 years of clinical experience, the BAHA (bone-anchored hearing aid) system is a well-established treatment for hearing-impaired patients with conductive or mixed hearing loss. Owing to its success, the use of the BAHA system has spread and the indications for application have gradually become broader. New indications, as well as clinical applications, were discussed during scientific roundtable meetings in 2004 by experts in the field, and the outcomes of these discussions are presented in the form of statements. The issues that were discussed concerned BAHA surgery, the fitting range of the BAHA system, the BAHA system compared to conventional devices, bilateral application, the BAHA system in children, the BAHA system in patients with single-sided deafness, and, finally, the BAHA system in patients with unilateral conductive hearing loss.

Medical and surgical complications of the second 100 adult cochlear implant patients in Birmingham.

One hundred consecutive adult cochlear implant patients, numbered 101 to 200 in an ongoing series, were prospectively monitored and data collected using the same protocol as for the first 100 patients. The study period was 1999 to 2001. The total number of procedures was 122. Changes in practice following the first 100 implants included a standard surgical technique with a smaller incision and lesser flap mobilization, and routine facial nerve monitoring. As far as was practicable, the same commercial type of implant was used. There were 111 (91 per cent) implantation episodes, five (4 per cent) explantation episodes, four (3.3 per cent) reimplantation episodes and two (1.6 per cent) revision procedures. Eighty-nine patients underwent unilateral implantation and 11 underwent bilateral implantation. Major complications included flap breakdown (1.6 per cent), extrusion of electrode array (0.8 per cent) and device failure (0.8 per cent). The overall major complication rate was 3.2 per cent (4/122). The overall minor complication rate was 18 per cent. In addition, 7.3 per cent experienced transient vertigo and 5.7 per cent experienced local discomfort lasting three days on average with complete resolution. The overall complication rate in the second 100 implant patients was lower than in the first 100. Smaller incision and lesser flap mobilization reduced the minor complication rate.

A ten-year review of soft tissue reactions around percutaneous titanium implants for auricular prosthesis.

OBJECTIVES/HYPOTHESIS: Soft tissue reactions around abutments are the most common complications of percutaneous osseointegrated implants. The main objective of this study was to review our series of osseointegrated implants, evaluate the degree of adverse skin reactions around the auricular abutments, and compare with skin reactions in the pediatric bone-anchored hearing aid (BAHA) population. The reason for comparing these two groups was the difference in abutment shape and position in skin with different characteristics. STUDY DESIGN: A retrospective case analysis of 131 patient notes. METHODS: We retrospectively studied 131 pediatric and adult patients who underwent an osseointegrated auricular prosthesis over a 10-year period (1997-2007). RESULTS: There were 95 adults and 36 children who had been implanted and fitted with an auricular prosthesis during the 10-year study period. All patients were followed up postoperatively for a 2-year minimum up to a 14-year maximum follow-up. Thirteen (13/36, 36%) children and seven adults (7/95, 7%) had a skin reaction around the ear prosthesis. CONCLUSIONS: The literature review has supported our study results and has shown that children have higher skin reactions in both BAHA and auricular prostheses than adults. Adverse skin reactions in the pediatric auricular group were significantly lower that the pediatric BAHA group. LEVEL OF EVIDENCE: 4

Cochlear implantation in 53 patients with otosclerosis: demographics, computed tomographic scanning, surgery, and complications.

OBJECTIVES: To collect data from a large number of cochlear implant recipients with otosclerosis and to make an assessment of these patients' clinical characteristics, computed tomographic scans, surgical findings, and complications, and to quantify the occurrence of postoperative facial nerve stimulation. STUDY DESIGN: Retrospective multicenter study. PATIENTS: Fifty-three patients with otosclerosis from four cochlear implant centers in the United Kingdom and The Netherlands were reviewed. Sixty surgical procedures were performed in these patients: 57 devices were placed in 56 ears. RESULTS: The computed tomographic imaging demonstrated retrofenestral (cochlear) otosclerotic lesions in the majority of patients. Although not statistically significant, the extent of otosclerotic lesions on the computed tomographic scan as categorized in three types tends to be greater in patients with rapidly progressive hearing loss, in patients in whom there is surgically problematic insertion of the electrode array, and in patients with facial nerve stimulation. In four patients, revision surgery had to be performed. Twenty of 53 (38%) patients experienced facial nerve stimulation at various periods postoperatively. CONCLUSION: Cochlear implant surgery in patients with otosclerosis can be challenging, with a relatively high number of partial insertions and misplacements of the electrode array demanding revision surgery. A very high proportion of patients experienced facial nerve stimulation mainly caused by the distal electrodes. This must be discussed with patients preoperatively.

Osseointegrated implants in the management of childhood ear abnormalities: with particular emphasis on complications.

Little has been published about the difficulties encountered during the insertion of osseointegrated implants for the attachment of bone anchored hearing aids (BAHA) and auricular prostheses in children. This study examines this issue in the first 51 children implanted at our centre. During surgery, the most common problem encountered was the presence of thin bone resulting in incomplete insertion of fixtures. Five fixtures had failed to integrate and six fixtures were lost in the long-term, however, only five children required revision surgery. The reason why few patients require revision was due to the judicious insertion of 'sleeper' fixtures. At follow-up, seven children required counselling for psychological problems. It is apparent from this study that osseointegrated implants in children are associated with difficulties, re-emphasizing that a paediatric osseointegration programme requires significant investment, and should only be undertaken by institutions that are committed to its success.

Occult bronchogenic carcinoma presenting as metastasis to the site of a bone anchored hearing aid.

The first report of a patient with metastatic bronchogenic carcinoma of the skin surrounding the abutment of a bone anchored hearing aid (BAHA) is presented. Complications of bone anchored hearing implantation have been well documented to date. We present a 68-year-old lady who presented with an unusual skin lesion surrounding the abutment of her BAHA. This was the first presentation of her bronchogenic tumour. We also review the literature regarding cutaneous metastasis and complications of BAHA.

Case report: explantation of a cochlear implant secondary to chronic granulating labyrinthitis.

In the published series of our first 100 cochlear implants only three developed major complications (Proops et al., 1999). We present a rare case of late granulations forming around a Nucleus cochlear implant, giving rise to erosion of the entire cochlea and adjacent mesotympanum. This pathology has only been reported once in the literature (Bertuleit et al., 1999).

Explantation and reimplantation of cochlear implants.

This study looks at the rates of explantation and reimplantation surgery in adult cochlear implant patients between 1990 and 2002 and also evaluates the surgical and audiological implications. 15 (5.5%) out of 272 adult cochlear implantees (288 cochlear implants: 282 Nucleus, 4 MED-EL Combi 40, 2 Clarion) needed their devices removed (explanted). 14 out of the 15 patients selected received explantation, reimplantation or revision surgery. The main reasons included device failure (2.2%), wound and flap problems (1.8%), and electrode extrusion (0.73%). Wound and flap problems were more common with larger skin incisions. In staged reimplantations, reinsertion was made easier if the electrode was retained in situ until reimplantation. Performance of the replacement device was not related to the aetiology of deafness or to the cause of explantation. These data will be useful in counselling patients.

An intra-individual comparison of the previous conventional hearing aid with the bone-anchored hearing aid: The Nijmegen group questionnaire.

By spring 2000, a total of 351 patients were implanted in the Birmingham bone-anchored hearing aid (BAHA) programme. This group consisted of 242 adults and 109 children. The aim of this retrospective questionnaire study was to directly assess patient satisfaction with their current bone-anchored hearing aid in comparison with their previous conventional air and/or bone-conduction hearing aids. The Nijmegen group questionnaire was sent by post to 312 patients who used their BAHA for six months or longer. The questionnaire used was first described by Mylanus et al. (Nijmegen group) in 1998. The total response rate was 72 per cent (227 of 312 patients). The bone-anchored hearing aid was found to be significantly superior to prior conventional hearing aids in all respects.

Day to day use and service-related issues with the bone-anchored hearing aid: the Entific Medical Systems questionnaire.

Over a 12-year period, the Birmingham implantation otology unit has implanted more than 300 patients with bone-anchored hearing aids (BAHA). The Entific Medical Systems questionnaire was administered to these patients to evaluate the day to day use of the BAHA, professional needs, after-care, wear and tear concerns and service related issues. Data analysis revealed that most patients used their BAHA for more than eight hours a day (90 per cent of BAHA users) and every day of the week (93 per cent of BAHA users). A high degree of satisfaction was expressed as regards sound amplification, listening to radio or television news, listening to music, speech perception in quiet conditions, during conversation with one person in noisy surroundings and conversation with family at home. Some degree of difficulty was expressed with the use of the BAHA during conversation with two or more people in noisy surroundings. A slow process of perceptual acclimatization was noticed with the majority of the patients. The majority of patients were pleased with the service as regards care of the wound, BAHA nursing clinics, device repairs and other service-related issues.

Disability, handicap and benefit analysis with the bone-anchored hearing aid: the Glasgow hearing aid benefit and difference profiles.

The Birmingham bone-anchored hearing aid programme began in 1988 and by autumn 2000 a total of 351 patients had been fitted with such an aid. The aim of this study was to assess the effectiveness of hearing rehabilitation with the bone-anchored hearing aid. This was a prospective interview-based questionnaire study carried out in the autumn 2000. A total of 84 adult patients were interviewed. Each patient had worn their BAHA for more than one year. The questionnaire used during these interviews was the Glasgow hearing aid benefit profile (GHABP) and the Glasgow hearing aid difference profile (GHADP). This was first derived and validated by Gatehouse in 1999. The use of bone-anchored hearing aids was found to reduce the level of disability and handicap and provided the most patient benefit and satisfaction.

The Glasgow benefit inventory in the evaluation of patient satisfaction with the bone-anchored hearing aid: quality of life issues.

The Birmingham osseointegration programme began in 1988 and during the following 10 years there were a total of 351 bone-anchored hearing aid (BAHA) implantees. In the summer of 2000, a postal questionnaire study was undertaken to establish the impact of the bone-anchored hearing aid on all aspects of patients' lives. We used the Glasgow benefit inventory (GBI), which is a subjective patient orientated post-interventional questionnaire especially developed to evaluate any otorhinolaryngological surgery and therapy. It is maximally sensitive to any change in health status brought about by a specific event: in this case the provision of a BAHA. A total of 312 bone-anchored hearing aid patients, who had used their aids for a minimum period of six months, were sent GBI questionnaires. Two hundred and twenty-seven questionnaires were returned and utilized in the study. The results revealed that the use of a bone-anchored hearing aid significantly enhanced general well being (patient benefit), improved the patient's state of health (quality of life) and finally was considered a success by patients and their families.

Prescription of binaural hearing aids in the United Kingdom: a knowledge, attitude and practice (KAP) study.

The purpose of this questionnaire study was to evaluate the existing knowledge of binaural hearing and the attitudes and practices of prescribing bilateral hearing aids amongst otolaryngologists in the United Kingdom. Of the 950 questionnaires sent to the current members of the British Association of Otolaryngologists and Head and Neck Surgeons (BAO-HNS), there were 591 respondents (62 per cent). The true response rate with completed questionnaires was 59 per cent. Eighty-one per cent of the respondents were aware of the importance of binaural hearing and had a positive attitude towards binaural fitting. The practice of bilateral hearing aid prescriptions was found to be poor amongst all grades on the NHS (less than 10 per cent of all hearing aid prescriptions). This practice in the private sector was variable, dependent largely on patient preference and affordability. The practice of binaural prescription was higher for patients in the paediatric age group than amongst adults. Two common indications for hearing aid prescriptions for unilateral deafness were otitis media with effusion in children (23 per cent of respondents) and for tinnitus masking in adults (12 per cent of respondents). Many otolaryngologists believed that there was not enough evidence to support bilateral bone-anchored hearing aid implantation and bilateral cochlear implantation. Ninety-four per cent of the respondents believed that binaural hearing was as important as binocular vision.

Patient satisfaction with bilateral bone-anchored hearing aids: the Birmingham experience.

The Birmingham bone-anchored hearing aid (BAHA) programme has fitted more than 300 patients with unilateral bone-anchored hearing aids since 1988. Some of the patients who benefited well with unilateral aids and who had used bilateral conventional aids previously applied for bilateral amplification. To date, 15 patients have been fitted with bilateral BAHAs. The benefits of bilateral amplification have been compared to unilateral amplification in 11 of these patients. Subjective analysis in the form of validated comprehensive questionnaires was undertaken. The Glasgow benefit inventory (GBI), which is a subjective patient orientated post-interventional questionnaire developed to evaluate any otorhinolaryngological surgery and therapy was administered. The results revealed that the use of bilateral bone-anchored hearing aids significantly enhanced general well being (patient benefit) and improved the patient's state of health (quality of life). The Chung and Stephens questionnaire which addresses specific issues related to binaural hearing was used. Our preliminary results are encouraging and are comparable to the experience of the Nijmegen BAHA group.