Beyond the surface: exploring contributing factors to bone anchored hearing implant complications.

INTRODUCTION: Bone anchored hearing implants (BAHI) are considered for conductive and mixed hearing loss, relying on osseointegration of a titanium implant. Limitations relate to constant skin contact, with resultant percutaneous infections and granulation. This study investigates whether patient characteristics and implant-specifications contribute to BAHIs' skin complications in a cohort with a uniform surgical approach. METHODS: A 10 year (2014-2024) retrospective cohort study was conducted on BAHI procedures that were undertaken using a tissue-preserving 'punch' technique. Data on patient demographics, co-morbidities, implant type, surgical approach, and complications were collected. Poisson regression analysis was used to identify predictors of complications. RESULTS: A total of 53 patients undergoing 55 BAHI surgeries by three ENT consultants were included. Factors that greatly increased implant-related percutaneous infections included the Cochlear™ BIA400 implant when compared to the Ponto™ BHX implant (twofold, CI 2.03-2.16), abutment sizes ≤ 10 mm (fourfold, CI 3.99-4.12) and male gender (9%, CI 1.07-1.12). Granulation episodes were affected by cardiovascular disease (CVD) status (1.5-fold, CI 0.26-0.78), BIA400 implant (threefold, CI 8.8.-9.2) and abutment sizes ≤ 10 mm (fourfold, CI 3.6-3.73). Revision surgery episodes increased with diabetic status (1.2-fold, CI 0.06-0.37) and abutment sizes ≤ 10 mm (threefold, 3.303-3.304). CONCLUSIONS: Larger cohort studies are required to confirm findings, particularly for implant and abutment size contributions. However, the findings suggest that using a larger abutment size when skin thickness meassuremets are borderline, improved hygiene education in male patients, pre-operative optimisation of CVD and diabetes, and adjusted patient follow-up based on risk stratification of the contributing factors to complication rates could reduce complication rates.

Surgical and audiological outcomes of a fully implantable middle ear implant: early results from a retrospective multicentre study.

PURPOSE: This paper reports the surgical and audiological outcomes of a large series of patients who received a fully implantable middle ear implant (MEI): carina (Cochlear, Australia). METHODS: This is a multicentre retrospective study involving three tertiary referral centres. Patient data were collected for the first 42 consecutive patients who were fitted with the MEI between 2014 and 2019 (Sheffield from February 2017 to January 2019; São Paulo from April 2015 to September 2017; Porto from December 2014 to May 2017). The main outcome measures included surgical results, free field speech testing with speech recognition thresholds (SRT) and audiological gain. RESULTS: There was one major complication due to infection resulting in a brain abscess and explantation of the device. Three other patients had minor skin infections; no other complications were reported. Results show a functional gain of 19.5 dB (p < 0.05) with the MEI versus unaided condition. SRT improved from 57.4 dB to 44.6 dB with the MEI (p < 0.05). CONCLUSIONS: This fully implanable active MEI offers a reliable option for patients with moderate-to-severe sensorineural or mixed hearing losses especially for those do not tolerate or cannot use conventional hearing aids. It provides significant improvement in hearing as shown in the audiological outcomes. The surgery is relatively straightforward but there is a steep learning curve. The devices are well tolerated by all patients.

Stapes Surgery for Otosclerosis in Patients Presenting with Mixed Hearing Loss.

OBJECTIVES: To evaluate the efficacy of stapes surgery in patients presenting with a preoperative mixed hearing loss (bone conduction thresholds ≥40 dB; 40 < air conduction thresholds (AC) < 85 dB). PATIENTS AND METHODS: A total of 30 patients (32 ears) with mixed hearing loss who underwent primary stapedotomy were evaluated. Audiometric parameters were assessed before and after surgery. Contralateral thresholds were also reported. The need for a hearing aid (HA) after surgery and its impact on quality of life were also measured. RESULTS: AC and word recognition at 40, 55 and 70 dB were significantly improved after stapes surgery. Only 16.6% of the patients needed an HA after surgery and reported being satisfied with the aid. CONCLUSION: Stapes surgery improved auditory function in patients with mixed hearing loss, allowing most patients to delay the need for an HA without worsening their quality of life.

Auditory System Involvement in Psoriasis.

Psoriasis is a systemic inflammatory disorder associated with many other chronic and progressive diseases. There are few studies on the association of psoriasis with alterations in auditory function. A clinical and instrumental pilot study of auditory function was performed with 77 psoriatic patients and 77 age- and sex-matched healthy controls. The main results were: (i) hearing loss, mostly of sensorineural type, was significantly more frequent in patients than in controls; (ii) conductive and mixed hearing loss were more frequent in arthropathic than in non-arthropathic psoriatic patients; (iii) duration of psoriasis > 10 years or smoking were associated with higher frequency of hearing loss; (iv) psoriasis was more severe in patients with hearing loss than in those without hearing loss. Tympanogram abnormalities were found in patients more often than in controls. These data expand the list of extracutaneous conditions associated with psoriasis, and support the need for further basic and clinical research in this field.

Endoscopic stapedotomy: our view point.

Use of endoscope in middle ear surgery is not new, yet there is resistance to its use in stapedotomy. This is due to perceived long learning curve in shifting from conventional microscope to the endoscope and fear of one-handed work. (1) to present a case series of endoscopic stapedotomies and analyze the operative findings. (2) Discuss the merits and demerits of same. 20 patients with otosclerosis underwent stapedotomy over 5 years using 0°, 4 mm nasal endoscope of 18 cm length. Visualization of middle ear structures, surgical steps, operative time, hearing results and complications were analyzed. In all 20 cases, (13 males, 7 females, age: 32.7 years) manipulation of endoscope within the canal was easy facilitating endomeatal incision and elevation of tympanomeatal flap. An optimum exposure of incudo-stapedial joint was obtained in 88.24 % cases. Adequate exposure of crura was obtained in 82.35 % and the footplate in 95 %. The removal of postero-superior bony wall was required in 30 % and chorda tympani mobilization in 25 % of cases. The average operative time was 31 min. Audiometry done at 6 weeks showed, complete air-bone gap closure in 55 %, mild conductive hearing loss (up to 20 dB) in 30 % and mixed hearing loss in 2 cases (BC up to 30 dB and air-bone gap up to 20 dB). In one patient who initially had hearing improvement post operatively, developed moderate conductive hearing loss at 10 weeks. Performing fully endoscopic stapedotomy using a 4 mm nasal endoscope is a feasible option giving excellent visualization with good results.

Utility of basic fibroblast growth factor in the repair of blast-induced total or near-total tympanic membrane perforations: A pilot study.

OBJECTIVE: A pilot study was performed to investigate the utility of basic fibroblast growth factor (bFGF) in the repair of blast-induced total or near-total tympanic membrane perforations (TMPs). STUDY DESIGN: Prospective clinical study. SETTING: Tertiary university hospital. SUBJECTS AND METHODS: Patients who fulfilled the inclusion criteria were treated with 0.10-0.15 mL of bFGF solution applied directly to total or near-total TMPs once daily until the perforations closed or for a maximum of 6 months. The treatment response was monitored via serial otoendoscopy, and audiometric outcomes were evaluated. RESULTS: Complete TMP closure was achieved in 16 of 17 patients with a blast-induced total or near-total TMP. The mean closure time was 28.4 ± 10.9 days. The improvement in hearing from pre- to post-treatment was statistically significant. There were no complications or adverse outcomes. CONCLUSIONS: The direct application of bFGF to blast-induced total or near-total TMPs is a promising, minimally invasive alternative to conventional tympanoplasty, with a comparable success rate. As reported in the literature, the closure rate was higher than achieved with spontaneous healing. There was no effect of the inverted edge on healing outcome. The use of bFGF in this setting has immediate therapeutic applications for military personnel with blast-induced TMPs who are stationed in isolated, remote environments.

Sophono Alpha System and subtotal petrosectomy with external auditory canal blind sac closure.

Recently, a new acoustic device, the so-called Sophono Alpha System, has been introduced into clinical practice. The aim of this study was to assess Sophono Alpha System hearing aids in ten patients suffering from recurrent chronic middle ear disease who underwent subtotal petrosectomy. Presence of mixed hearing loss with bone conduction thresholds better than or equal to 45 dB was present in each patient. Audiometric tests were performed before and after Sophono implantation and using a conventional bone conduction hearing aid (hearing glasses). Speech audiometry data (speech recognition threshold and word recognition score) were also collected. Speech recognition threshold in dB and percentage of word recognition score at 65 dB were subsequently calculated. After implantation and activation of the Sophono Alpha System, audiological data showed an average air conduction value of 42.1 dB. By comparing this data with the values of air conduction following subtotal petrosectomy, an average acoustic improvement of 29.7 dB could be calculated. The hearing results showed significantly better outcomes of Sophono Alpha System vs. conventional bone conduction aid. Indications to MRI use in patients undergoing Sophono Alpha System implantation are also provided.

Pattern of hearing loss following cochlear implantation.

Cochlear implantation is associated with deterioration in hearing. Despite the fact that the damage is presumed to be of sensory origin, residual hearing is usually assessed by air-conduction thresholds alone. This study sought to determine if surgery may cause changes in air- and bone-conduction thresholds producing a mixed-type hearing loss. The sample included 18 patients (mean age 37 years) with an air-bone gap of 10 dB over three consecutive frequencies and measurable masked and reliable bone-conduction thresholds of operated and non-operated ears who underwent cochlear implant surgery. All underwent comprehensive audiologic and otologic assessment and imaging before and after surgery. The air-bone gap in the treated ears was 17-41 dB preoperatively and 13-59 dB postoperatively over 250-4,000 Hz. Air-conduction thresholds in the treated ears significantly deteriorated after surgery, by a mean of 10-21 dB. Bone-conduction levels deteriorated nonsignificantly by 0.8-7.5 dB. The findings indicate that the increase in air-conduction threshold after cochlear implantation accounts for most of the postoperative increase in the air-bone gap. Changes in the mechanics of the inner ear may play an important role. Further studies in larger samples including objective measures of inner ear mechanics may add information on the source of the air-bone gap.

Hearing disorders in Turner's syndrome: a survey from Iran.

Turner syndrome (TS) is one of the most frequently encountered sex-linked chromosomal abnormalities, occurring in one per 2,000 female births. These patients present with short stature and failure to begin puberty. In this syndrome, there are multiple organ abnormalities, including auditory disorders. TS patients were referred to the ENT clinic by a pediatric endocrinologist. A questionnaire was filled out and the patients went through a complete otologic examination. They were then referred to the audiology clinic to undergo audiologic test battery plus high-frequency pure tone audiometry. From a total of 48 ears examined, 11 (22.9 %) had a normal audiometry. Mid-frequency sensorineural hearing loss (SNHL), high-frequency SNHL, combined and mixed hearing loss were diagnosed in 6 (12/5 %), 20 (41/7 %), 6 (12/5 %) and 1 (2/1 %) ear, respectively. Tympanogram results showed normal compliance (A, As, Ad) in the majority of cases. B and C patterns were found in a few cases. Speech discrimination score was normal in all patients whereas speech reception threshold was normal in 92 % of the ears. Audiometry abnormality especially SNHL is common in TS patients, with the high-frequency pattern being the most frequent.

Active bone conduction system: outcomes with the Bonebridge transcutaneous device.

OBJECTIVE: To describe our experience with positioning the Bonebridge (BB) device, a semi-implantable transcutaneous bone conduction implant for patients with conductive and mixed hearing loss as well as for those suffering from single-sided deafness. METHODS: The following is a retrospective case review of 4 adults suffering from conductive or mixed hearing loss and single-sided deafness. The BB device was implanted unilaterally via 2 different approaches selected case by case: the presigmoid transmastoid and the retrosigmoid approach. An audiological evaluation in the free field was conducted to observe the functional benefit with this device. The Glasgow Health Status Inventory (GHSI) and the Glasgow Benefit Inventory (GBI) questionnaires were filled out to evaluate patients' quality of life in relationship to the intervention. RESULTS: No intra- or postoperative complications were observed. The performance in the speech test in all 4 cases reached 100% in the aided condition at 65 dB, while in the unaided condition at 65 dB, it was less than 10%. The GHSI and GBI questionnaires showed an improvement in quality of life after implantation. CONCLUSIONS: The BB device is a safe and effective solution for individuals with pathologies such as chronic otitis media, atresia auris and otosclerosis with inadequate benefit from conventional surgery or bone conduction hearing aids.

Direct round window stimulation with the Med-El Vibrant Soundbridge: 5 years of experience using a technique without interposed fascia.

The objective of this study was to present 5 years of surgical experience, and the extended results of hearing preservation (based on 3-year follow-up), with the Med-El Vibrant Soundbridge (VSB) in which the floating mass transducer (FMT) is placed directly against the round window membrane, and the fascia is used only as covering tissue to keep it in position. A retrospective survey of surgical and audiological data was conducted to evaluate the performance and stability of patient hearing, with audiometric measurements performed over fixed time intervals up to 36 months. 21 patients, aged 19-62 years (mean 48.4), with mixed or conductive, bilateral or unilateral hearing loss were included in this study. Surgical intervention involved monaural implantation of the Med-El VSB between 2006 and 2009. The results were assessed using pure tone audiometry. In 5 years of experience with the technique, no significant complications or device extrusion were observed except for two revision surgeries requiring FMT repositioning. In the 3-year follow-up, we observed stable hearing in the implanted ear. It is concluded that direct round window stimulation without interposed fascia is an alternative for patients with hearing impairment caused by chronic otitis media and/or lack of ossicles, especially after modified radical mastoidectomy. It allows good results in a selected group of patients, although further observation on a larger population is needed to confirm long-term validity and effectiveness.

Are computed tomography and densitometric measurements useful in otosclerosis with mixed hearing loss? A retrospective clinical study.

The objective of the study was to investigate the relationship between extent of otosclerotic foci and audiological findings in otosclerotic patients with mixed hearing loss using high-resolution computed tomography (HRCT) and also to measure the density of bony labyrinth in otosclerotic patients and compared with control group. This was a retrospective study. Twenty-five patients with clinical otosclerosis and mixed hearing loss were included in the study. The average threshold of air-bone conductions (AC, BC) within the 0.5-4 kHz frequency range, and average air bone gap (ABG) were calculated. Eleven patients with normal HRCT who received cochlear implant were included in the study as the control group. The lesions in HRCT were staged according to their extension. Eight different points of the otic capsule in each patient were measured using HRCT. Fifty ears total, from 25 patients, had bilateral otosclerosis. The mean AC of all the ears was 63 dB, mean BC was 35.2 dB, and mean ABG was 27.8 dB. HRCT staging indicated 22 ears had Grade 1, 21 ears had Grade 2, and 7 ears had Grade 3 lesions. There was a statistically significant difference between the mean AC, BC of ears with Grade 1 and Grade 2 when compared with the mean AC, BC of ears with Grade 3. When comparing the densitometric measurements of fissula ante fenestram localizations, a statistically significant difference was observed. HRCT examination and densitometric measurements in otosclerotic patients with mixed hearing loss presented significant results. We were unable to show a significant relationship between early stage and hearing thresholds, but there was a significant relationship in advanced stage. Densitometric measurements may provide significant results for otosclerosis, particularly for the FAF region when comparing with control group.

Enlarged vestibular aqueduct syndrome mimicking otosclerosis in adults.

INTRODUCTION: An enlarged vestibular aqueduct (EVA) results in hearing loss which is often progressive and heterogenous, the long-term natural history of which is not well understood. Patients born before the era of newborn hearing screening can present as adults with previously undiagnosed EVA. METHODS: A retrospective chart review of patients seen at a tertiary adult academic otologic clinic from 2004 to 2012 were reviewed and cases of EVA were identified. RESULTS: Adult EVA was found to present with a mixed progressive hearing loss with absent stapedial reflexes. CONCLUSION: Enlarged vestibular aqueduct abnormality can present in adulthood and mimic other more common pathology such as otosclerosis.

Endolymphatic sac tumors: experience of three cases.

OBJECTIVES: To describe the clinical features, radiological findings, treatment and outcomes of three cases of endolymphatic sac tumors (ELST). METHODS: Retrospective analysis of three cases of ELST. RESULTS: The first patient had a large ELST invading the labyrinth after a long history of vertigo. He was recurrence-free 1 year after retrolabyrinthine surgical removal. In the second case, an acute peripheral facial nerve paralysis associated with ipsilateral sensorineural hearing loss led to the diagnosis. A translabyrinthine approach was used to remove the tumor, which recurred three times over 10 years. The third patient was a young woman suffering from von Hippel-Lindau (VHL) disease and referred for a sudden sensorineural hearing loss due to an intralabyrinthine hemorrhage secondary to a 2 mm-large endolymphatic sac-confined ELST. Her hearing was totally lost after the deafness recurred 1 month after this first episode. MRI demonstrated a small bilateral ELST. The patient refused surgery on the deaf side. CONCLUSION: ELST are difficult to diagnose due to the wide variety of their presentations. Patients with ELST should be screened for VHL disease. Dural invasion and tumor hypervascularization increase the risk of local recurrences after surgery. Early surgical resection may lead to complete tumor removal and inner ear preservation.

[Endoscopic ear surgery for traumatic ossicular disruptions].

Although endoscopic ear surgery (EES) has been used to perform middle ear surgery since 1993, it has not become as common in otologic surgery as it is in endoscopic sinus surgery. This report discusses the problems and the indications for EES in traumatic ossicular disruptions in two cases. Case 1 was a 33-year-old man with a left longitudinal temporal bone fracture who presented with mixed hearing loss, with an average hearing level of 45.0 dB in the left ear. He underwent EES, which revealed incudostapedial joint disrutption. Repositioning of the incus resulted in an improvement in hearing to 18.3 dB postoperatively. Case 2 was a 30-year-old man with a right mixed hearing loss of 56.7 dB. Computed tomography showed a right longitudinal temporal bone fracture and dislocation of the incus. EES revealed dislocation of the incus and fracture of the anterior crus of the stapes. A type IV tympanoplasty was performed, interpositioning the autologous incus between the footplate and the malleus handle. Postoperatively, the average hearing level was 18.3 dB, with a 1.7-dB air-bone gap. Traumatic ossicular disruptions are considered to be a good indication for EES.

Advances in auditory implants.

Auditory implants are classified into bone conduction (BAHA and Bonebridge; BB) and active middle ear implants (Vibrant Soundbridge; VSB) that stimulate cochlear hair cells, and cochlear implants (CIs) that stimulate neural structures. CIs should be performed as early as possible, and bilateral CIs have become popular because sound localization and speech recognition can be improved. CI is also considered a desirable treatment option for patients with single-sided deafness. VSB provides a safe and effective option for patients with conductive or mixed hearing loss and moderate to severe sensorineural hearing loss (SNHL); however, it use in patients with conductive or mixed hearing loss have only been approved in Japan. BAHA and BB implants have been approved by national insurance in Japan as bone conduction implants for patients with conductive or mixed hearing loss. Two fully implantable devices (Cochlear Carina and Envoy Esteem) are provided for patients with SNHL.

Mixed hearing loss in iatrogenic tympanic membrane perforations over the round window niche and the immediate effect of paper patch myringoplasty.

OBJECTIVES: Report the immediate audiologic effect of paper patch myringoplasty to repair iatrogenic tympanic membrane perforations directly over the round window. METHODS: Retrospective case-control study of 15 patients treated for inner ear disease with a MicroWick and dexamethasone for 1 month, resulting in 2-mm perforations over the round window. Paper patch myringoplasties were performed to repair the perforations. Audiograms were performed before and immediately after the paper patch myringoplasty. RESULTS: After paper patch placement, there was a significant improvement in air-bone gap at 250 (p < 0.001), 500 (p = 0.003), and 1000 Hz (p = 0.004) and a significant improvement in bone conduction (BC) threshold at 250 (p = 0.002), 500 (p < 0.001), 1000 (p = 0.002), 2000 (p = 0.003), and 3000 Hz (p = 0.02). CONCLUSIONS: Paper patch myringoplasty improves both air conduction and BC hearing from small perforations over the round window. The decrease in BC hearing is a result of middle ear mechanics and is not a true sensorineural hearing loss.

Bilateral duplicated internal carotid arteries presenting as middle ear masses: a case report and review of the literature.

OBJECTIVES: We seek to describe an individual with bilateral duplicated internal carotid arteries (ICAs) presenting as middle ear masses, to discuss the anatomy and characteristic imaging findings associated with this condition, and to familiarize clinicians with effective methods to prevent and manage complications related to this entity. METHODS: The clinical presentation of an individual with this unusual vascular anomaly was reviewed. A literature search was then performed to identify previously reported studies describing aberrant ICAs in order to characterize the presentation, anatomy, imaging findings, and management of this condition. RESULTS: An aberrant ICA presenting as a middle ear mass is uncommon; there are only approximately 45 reported cases to date. The majority of these cases presented as a unilateral anomaly without a duplication, were associated with pulsatile tinnitus and hearing loss, and were diagnosed during middle ear procedures. Bilateral aberrant ICAs are exceedingly rare, with only 14 existing reports. Only 1 of these cases presented with duplicated ICAs. Our report demonstrates an unusual presentation of aberrant ICAs, as pulsatile tinnitus was absent and previous middle ear surgery had been performed without establishing this diagnosis and without any resulting complications. Furthermore, this case represents the first known instance of a bilateral duplicated ICA system without persistent stapedial arteries. Although vascular middle ear anomalies are unusual, complications of surgical manipulation have been documented. CONCLUSIONS: The clinician must have a high index of suspicion for vascular lesions in patients presenting with a retrotympanic mass. Appropriate diagnostic imaging studies should be performed to exclude this diagnosis before middle ear exploration. Should injury to the carotid artery occur, surgeons should follow specific guidelines to avoid potentially serious complications.

Do signs of natural plugging of superior semicircular canal dehiscence exist?

Our experience with 102 patients having superior semicircular canal dehiscence confirm that the clinical manifestations of the disease are very diverse; we also identified 3 patients who showed Meniere-like symptoms. Clinical examination during an acute vertigo attack of a patient with Meniere disease for several years and whom we subsequently diagnosed as having large superior semicircular canal dehiscence on the affected side allowed us to hypothesize that a natural plugging of the superior semicircular canal by the overhanging dura mater could be responsible for the recurrence of symptoms. Clinical and instrumental data were very similar to those recorded in 7 of 9 patients immediately after surgical plugging. The aim of the study was to understand which semiological and instrumental elements could be clinically useful, first in distinguishing Meniere disease from superior semicircular canal dehiscence and, secondly, in understanding if signs of natural plugging are present.

Challenges in fitting a hearing aid to a severely collapsed ear canal and mixed hearing loss.

BACKGROUND: Collapsed ear canals typically occur when an outside force, such as a headset for audiometric testing, is present. However, when a collapsed ear canal occurs without external pressure, this creates a challenge not only for performing audiometric testing but also for coupling a hearing aid to the ear canal. PURPOSE: This case report highlights the challenges associated with fitting a hearing aid on a patient with a severe anterior-posterior collapsed ear canal with a mixed hearing loss. RESEARCH DESIGN: A 67-yr-old female originally presented to Washington University in St. Louis School of Medicine in 1996 with a long-standing history of bilateral otosclerosis. She had chronic ear infections in the right ear and a severely collapsed ear canal in the left ear and was fit with a bone anchored hearing aid (BAHA®) on the right side in 2003. However, benefit from the BAHA started to decrease due to changes in hearing, and a different hearing solution was needed. It was proposed that a hearing aid be fit to her collapsed left ear canal; however, trying to couple a hearing aid to the collapsed ear canal required unique noncustom earmold solutions. CONCLUSIONS: This case study highlights some of the obstacles and potential solutions for coupling a hearing aid to a severely collapsed ear canal.