Stabilising total ossicular replacement prosthesis for ossiculoplasty with an absent malleus in canal wall down tympanomastoidectomy - a randomised controlled study.

OBJECTIVES: To compare two titanium total ossicular replacement prosthesis (TORP) stabilisation techniques in canal wall down mastoidectomy presenting with footplate only and absent malleus handle. DESIGN: Prospective, controlled, randomised study. SETTING: Tertiary Otology Department. PARTICIPANTS: Patients operated on with canal wall down mastoidectomy between 1999 and 2009 were randomised into two groups. Two techniques enhancing the TORP stability were compared: Hüttenbrink's method (63 patients, Group 1) and author's (GB) procedure (62 patients, Group 2). Hüttenbrink's technique consists in placing a cartilage shave with a hole in the middle over the footplate. Through this hole, the end of the TORP is accommodated. The author's method involves using a cartilage split in the middle, to lodge the TORP's shaft at one end and to lay the opposite end over the fallopian canal. MAIN OUTCOME MEASURES: Mean postoperative air-bone gap, hearing gain and air-bone gap closure within 20 dB. Auditory outcomes were evaluated at 1 year postoperatively. RESULTS: Postoperative air-bone gap closure within 20 dB (successful outcome) at 1 year was achieved in 59% of patients in Group 1 and 72% in Group 2 (P = 0.03). Mean postoperative air-bone gap was 24.4 ± 10.8 dB for Group 1 and 20.17 ± 9.8 dB for Group 2. The difference is 4.23 dB (95% confidence interval, 0.65-07.81), statistically significant: P = 0.02. Hearing gain was 20.3 ± 9.5 in Group 1 and 25.1 ± 10.2 in Group 2, significantly superior: P = 0.007. CONCLUSION: Better hearing outcomes for author's method could be demonstrated, but our sample size cannot exclude small and possible trivial, group differences.

Clinical experience with the Vibrant Soundbridge implant device.

OBJECTIVE: To evaluate the full degree and range of benefits provided by the Vibrant Soundbridge (VSB; Symphonix Devices, Inc., San Jose, CA, U.S.A.) and analyze pre-and postoperative results of audiologic tests. STUDY DESIGN: Single-subject study with each subject serving as his or her own control. SETTING: Multicenter clinical study conducted at 10 centers in Europe. PATIENTS: 47 patients who met the selection criteria for participation in the study. INTERVENTIONS: Implantation of the VSB direct-drive middle ear hearing device. MAIN OUTCOME MEASURES: Average change in unaided thresholds with the patient wearing headphones at each frequency pre-and postsurgery was measured. A mean threshold change less than 5 dB across all frequencies was considered clinically nonsignificant. RESULTS: 47 patients had successful surgery for implantation and fitting with the VSB device. CONCLUSION: The VSB is a new middle ear implant device that can be used safely in the treatment of patients with moderate to severe sensorineural hearing loss.

Multicenter audiometric results with the Vibrant Soundbridge, a semi-implantable hearing device for sensorineural hearing impairment.

The Vibrant Soundbridge, a semi-implantable hearing device for subjects with moderate to severe sensorineural hearing impairment was introduced commercially. First audiologic results are presented on 63 patients from 10 European implant centers. Hearing loss was at 0.5, 1, 2, and 4 kHz varying between 43 and 81 dB HL. The patients used the analogue audio processor, type 302. Measured sound-field gain was compared with NAL-R target values. For most patients an acceptable agreement was found. There was a subgroup of patients, however, with relatively low gain. The results suggest that this was related to the suboptimal positioning and fixation of the transducer to the incus.

[Problems in cochlear implant surgery]. / Problemi nella chirurgia dell'impianto cocleare.

In cochlear implant surgery, major complications, requiring revision procedures, do not exceed 5% of cases reported. Less frequent are problems that call for specific technical solutions. In 44 multichannel implantations (out of 54 cases) adverse conditions occurred and were successfully resolved in 6 patients: 1) delayed wound breakdown (one case); 2) chronic otitis media (three cases); 3) cochlear obliteration (two cases). Problem 1 was managed with the excision of an ellipse of skin including the devitalized areas under local anesthesia. The electronic package was left untouched, and the freshly cutaneous edges were mobilized and layer-sutured. Problem 2 was solved through a two-stage procedure. The chronic ear was dealt with as usual (myringoplasty, tympanoplasty, revision of a radical mastoidectomy). In the second stage the cochleotomy and device implantation were carried out. Problem 3 is a major issue for the surgeon. Following the Lehnhardt technique we drilled along the basal cochlear turn using the sharp line between the yellowish otic bone and the white newly formed bone as a landmark, until a patent s.tympani was found at the ascending part of the 1st or at the beginning of the 2nd turn.

[Selective vestibular neurectomy: a comparison of techniques]. / Neurotomia vestibolare selettiva: tecniche a confronto.

The surgical treatment of patients suffering from incapacitating peripheral vertigo is still controversial. In the ENT Department of the Civil Hospital of Venice 43 patients with disabling menieric vertigo spells underwent a selective vestibular nerve section employing either a retrosigmoid (25 cases) or a retrolabyrinthine approach (18 cases) between 1991 and 1993. The two approaches are compared with regard to surgical technique, pre- and postoperative complications and i.e. functional results, i.e. vertigo control and hearing preservation. Functional results, classified according to the guidelines reported by the Committee on Hearing and Equilibrium of the AAO-HNS in 1985 did not show substantial differences. We obtained complete vertigo control in 95% of the patients and hearing was conserved at the preoperative level in almost all of the cases. The retrosigmoid approach demonstrated distinct advantages with regard to the surgical technique employed; it was faster, offered a wider surgical field in the cerebello-pontine angle and brought about fewer peri- and postoperative complications.

[Considerations on the rehabilitation of the hearing in cochlear implant patients]. / Considerazioni sulla riabilitazione della funzione uditiva nei pazienti con impianto cocleare.

In this study, the Cochlear Implant Programme of the ENT Department of Ospedale Civile di Venezia, is presented. Between 1989 and 1994, after a rigorous selection process, 36 patients were selected to be implanted with a cochlear prostheses: 28 with the multichannel Nucleus 22 device, 5 with the Clarion implant and 3 with the single channel Med-E1 BTE device. The distribution of the patients according to age, etiology, duration of auditory deprivation, age at onset of deafness, is presented. The different speech-coding strategies of the Nucleus system (Wearable Speech Processing, Multipeak speech processing and Spectral Maximum Sound processor) and the stimulation mode (common ground, bipolar, bipolar + 1) as well as the Clarion speech coding strategy (Continuous Interleaved Samples and Compressed Analog) are briefly discussed. The rehabilitation programme, the specific speech recognition assessment test batteries-Consonant Confusion Test, Vocal Confusion Test, Speech Tracking, MAC battery-as they are employed in our department, are presented. As we have analyzed our results, certain factors appear as predicting a favourable outcome: - age of onset of deafness; postlingual patients, who have developed communication skills compare favourably to the perilingual group. - durations of auditory deprivation, as it is related to surviving cells in the cochlea: the shorter the period of deafness, the better the results. - length of electrode insertion, as it is determined by ossification of the cochlea. - high dynamic range of the MAP. - percent of activated electrodes: a number of 10 active electrodes or less predicts a poor outcome. - for simplification reasons, a new variable is introduced-Auditory Deprivation Index- and its positive correlation to the performance presented. - the time period of experience with the device, length and quality of rehabilitation and family support have to be mentioned.

[Multichannel cochlear implant: personal experience]. / L'impianto cocleare multicanale. Nostra esperienza.

Cochlear Implantation is a recognized procedure for acoustical rehabilitation of the profoundly or totally deaf unable to effectively use a traditional hearing aid. Since 1989, 30 patients (27 postlingual and 3 perilingual) have been operated on by the senior Author with the implantation of a multichannel device: Med-El (3 cases), Clarion (3 case) and Nucleus Mini-22 (24 cases). The first 24 Nucleus cases, with a multipeak speechcoding strategy, are the object of this retrospective report. Selection of patients was performed according to an international protocol which includes PTA and Speech Audiometry, CT and/or MRI imaging of the ear, the Promontorial Test, an evaluation of lip reading ability, a psychological evaluation, a trial with two recent and currently available aids. The operation was carried out under general anesthesia. An extended endaural approach was adopted. The internal package of the device was firmly seated onto the temporalis squama and the electrode array was introduced into the tympanic cleft via a posterior tympanotomy. The electrode system was inserted into the scala tympani through a cochleotomy drilled out at the anteroinferior border of the round window. The whole system was fixed to the bony walls of the mastoid and squama using an ionomeric bone bonding agent. Starting at the second postoperative month and up to the 24th month of utilization of the device, each patient was evaluated with regard to his or her ability to recognize environmental sounds, to detect prosody transitions and to understand speech with and without visual cues. Selected tests, either close or open set, were used from the MAC and the Iowa Cochlear Implant Battery, as well as the Helen test. Telephone conversation was also evaluated. Results were very encouraging in all cases, showing that the multichannel cochlear device provides the properly selected patient a substantial auditory rehabilitation allowing him or her to understand speech in most instances without any visual cue.

[Speech perception test in Italian language for profoundly deaf children]. / Test di misura della percezione verbale nei bambini sordi profondi.

Speech perception tests are an important part of procedures for diagnosing pre-verbal hearing loss. Merely establishing a child's hearing threshold with and without a hearing aid is not sufficient to ensure an adequate evaluation with a view to selecting cases suitable for cochlear implants because it fails to indicate the real benefit obtained from using a conventional hearing aid reliably. Speech perception tests have proved useful not only for patient selection, but also for subsequent evaluation of the efficacy of new hearing aids, such as tactile devices and cochlear implants. In clinical practice, the tests most commonly adopted with small children are: The Auditory Comprehension Test (ACT), Discrimination after Training (DAT), Monosyllable, Trochee, Spondee tests (MTS), Glendonald Auditory Screening Priocedure (GASP), Early Speech Perception Test (ESP), Rather than considering specific results achieved in individual cases, reference is generally made to the four speech perception classes proposed by Moog and Geers of the CID of St. Louis. The purpose of this classification, made on the results obtained with suitably differentiated tests according to the child's age and language ability, is to detect differences in perception of a spoken message in ideal listening conditions. To date, no italian language speech perception test has been designed to establish the assessment of speech perception level in children with profound hearing impairment. We attempted, therefore, to adapt the existing English tests to the Italian language taking into consideration the differences between the two languages. Our attention focused on the ESP test since it can be applied to even very small children (2 years old). The ESP is proposed in a standard version for hearing-impaired children over the age of 6 years and in a simplified version for younger children. The rationale we used for selecting Italian words reflect the rationale established for the original version, but the choice of single words follows different criteria from the original version. In fact, the two languages differ in important linguistic features so that the test can not be not adapted to the Italian language by simply translating the words involved. As currently there is no children's language dictionary in Italian arranged according to age bracket, we chose words used in children and in pre-school reading material.

[Extreme stapedectomy]. / La stapedotomia estrema.

Extreme stapedectomy is an operation aimed at restoring a serviceable hearing in patients affected by far-advanced otosclerosis with profound hearing loss. Surgery is performed on the understanding that the hearing aid will still be needed after the operation. Therefore, patient's expectations should be confined to possibly improved performance with a hearing aid as a consequence of the operation. Clinical as well as audiological preoperative assessment must be very rigorous. Counselling is mandatory and a trial period with a hearing aid is strongly advisable. Our experience is based on 15 cases, operated on between 1984 and 1988. A small fenestra technique was performed using wire-teflon piston prostheses. Results were satisfactory and in accordance with the ratio of the procedure in 8 cases (53%). 7 patients (47%) yielded an unsuccessful outcome and 2 of them had a dead ear (13%). This high rate of labyrinthine failure, the improvement in hearing aids and cochlear implants technologies well are likely to reduce the number of potential candidates for an extreme stapedectomy. However, this operation should be still kept in the otologist's armamentarium as a possible option in borderline cases.

[Introduction to the surgery of the middle ear: general principles]. / Introducción a la cirugía del oído medio. Principios generales.

We study the basic guidelines of the middle ear surgery, having as target the recuperation of the anatomic functional integrity of ear. There are different important elements in the quality/quantity of the functional results as follows: The surgery technical method used. The actual pathology in the middle ear. The quality of eustachian tube function. The surgeon's experience and ability and several factors. We review the concept introduced by Wullstein called it tympanoplasty from 1952 till nowadays. Finally, we described the most frequent surgery procedures used in the daily practice.