[Nonsurgical attachment possibilities for bone conduction hearing aids : Comparison of coupling using external pressure versus an adhesive plate]. / Nichtoperative Ankopplungsmöglichkeiten von Knochenleitungshörgeräten : Vergleich der Ankopplung mittels äußeren Andrucks und Klebung.

BACKGROUND: Bone conduction hearing systems are used for patients with conductive or combined hearing loss who cannot be adequately treated with air conduction hearing aids or surgery. These hearing systems can be surgically implanted or reversibly attached using bone conduction eyeglasses or a rigid or soft headband. A nonsurgical and pressure-free alternative is fixation via an adhesive plate. OBJECTIVE: The aim of this study was to compare the energy transferred from the hearing aid to the mastoid when attached via a new adhesive plate versus via a soft headband. In addition, the comfort and the durability of the adhesive plate was evaluated. MATERIALS AND METHODS: A total of 30 subjects were tested. The transferred energy was measured by accelerometer, which recorded the sound energy at the maxillary teeth. Wearing comfort, fixation duration (until plate becomes loose), and the skin reaction were examined using a questionnaire after the subjects had worn the adhesive plate with and without hearing aid for a maximum of 7 days. The skin reaction was also assessed clinically. RESULTS: There was a significant difference in the transferred energy in favor of the soft headband at 0.5, 1, and 2 kHz. On the other hand, there was a high level of satisfaction and acceptance regarding the aesthetics and the wearing time of the adhesive plate, without skin irritations. CONCLUSION: The difference in the transferred energy up to 2 kHz is probably due to the lack of pressure from the adhesive plate. This could possibly be compensated after appropriate adjustment of the speech processor. Based on the positive properties of the adhesive plate in terms of comfort, it could be used as an alternative to the soft headband.

Otoplasty and Auricular Reconstruction.

Due to the variety of abnormalities, surgery of the auricle is one of the most complex challenges in facial plastic surgery. They reach from mild protruding ears or isolated abnormalities of the supporting structures, mainly the helical rim and antihelix, over cup ear deformities and miniears all the way to severe microtia and anotia. In this article, the authors present a short overview of auricular abnormalities and malformations and their treatment options based on their experiences gained over three decades of special service for patients with auricular malformations.

International Consensus Recommendations on Microtia, Aural Atresia and Functional Ear Reconstruction.

The aim of this report is to provide international recommendations for functional ear reconstruction in patients with microtia and aural atresia. All patients with microtia and external auditory atresia should be seen in the setting of a multidisciplinary team and agreed treatment outcomes should be measured, so that techniques, approaches, and results can be compared. The methods are expert opinion from the members of the International Microtia and Atresia Workgroup (IMAW). The consensus recommendations reported herein take into account the variability in practice patterns present among experts in the field; the degree of consensus was quantified by presenting the percentage of above authors who agree or partially agree with each statement. Recommendations include the definition and classification of microtia/atresia, treatment of microtia, treatment of congenital aural atresia, flowchart of functional ear reconstruction, and future research directions. Patients with microtia and aural atresia can be guided by the consensus recommendations provided herein.

Periosteal Flap Technique for Elevation of the Pinna in Microtia.

IMPORTANCE: For optimal aesthetic construction of the auricle in patients with severe microtia, it is important to construct an exquisite framework and place it in the correct natural position. In addition to its accurate vertical and sagittal positioning, normal elevation is of utmost importance because this determines the auricular width from the common anterior view in interpersonal communication. Many techniques have been described to stabilize the constructed auricle in the elevated position. Some of the techniques are prone to relapse (eg, simple skin transplantation), while others are intricate (eg, using cartilage, huge pedicled flaps, and free skin grafts). OBSERVATIONS: The objective of the study was to describe a simple and reliable periosteal flap technique and present our experience in 158 patients with complete unilateral or bilateral ear deformity (with possible defects of the external auditory meatus) who were operated on between February 3, 2005, and August 27, 2012. Principles of the technique include elevating the framework from the posterior aspect, stabilizing it with autogenous rib cartilage, covering this with a novel periosteal flap, and skin grafting. CONCLUSIONS AND RELEVANCE: The periosteal flap technique proved to be straightforward and reliable. All flaps had unrestricted microcirculation. Good and stable projection of the auricle was achieved in all patients.

Auricular reconstruction: surgical innovations, training methods, and an attempt for a look forward.

The construction of an auricle from autologous tissue is highly complex and demanding for a reconstructive surgeon. Depending on the characteristics of the underlying malformation, there are various surgical techniques available, which in specialized hands, promise regularly achievable attractive and stable results. To achieve this goal, a long-term training in super specialized centers is required. Training models available today, can partially systematize this training. The future of auricular reconstruction lies probably in the tissue engineering of organ complexes, including their nerve and vascular supply.

Malformation and plastic surgery in childhood.

Malformations of the head and neck show a huge variety of clinical symptoms with functional and esthetic consequences. Often times its rehabilitation requires multi-staged and multi-disciplinary procedures and concepts. These must consider eating, speech, mimic expression, hearing and "esthetics" or at least "normality". A survey of the most common head and neck malformations and their treatment options are presented here.

Reconstruction of the avulsed auricle after trauma.

Severe auricular trauma is a rare injury. In addition to the type of injury, the location and the extent of the involved auricular structures have an important influence on the selection of an appropriate replantation or reattachment technique. A satisfactory primary reconstruction is not always possible to obtain and the remaining defects must be reconstructed secondary. The localization of the defect, its extent, and the condition of the tissue surrounding the defect are essential criteria for further treatment planning. This article provides an overview of the treatment of acute auricular trauma and of important aspects of secondary defect repair of the pinna.

A new semi-implantable transcutaneous bone conduction device: clinical, surgical, and audiologic outcomes in patients with congenital ear canal atresia.

INTRODUCTION: Patients with air-bone-gaps that cannot be corrected successfully by tympanoplasty or with mixed hearing loss may be treated with bone conducting hearing aids. Their disadvantages are the obvious external fixation components or the biological and psychosocial problems of open implants. We have developed a new partially implantable Bone Conduction Hearing Device (BCHD) without a percutaneous abutment and have been using them clinically for over 6 years. The principle of these BCHD is a magnetic coupling and acoustic transmission between implanted and external magnets. The goal of this study was to evaluate its clinical and audiologic results in patients with unilateral or bilateral congenital aural atresia. METHODS: Magnets are implanted into shallow bone beds in a 1-step procedure. The skin above the magnets is slightly thinned. The external device fixed with counter magnets in a base plate. PATIENTS: Twenty-one patients who have been implanted due to congenital atresia showed up for this follow-up study. The follow-up period was 19.3 ± 12.2 months, with a range of 0.2 to 46.6 months. The average age of the patients at the time of implantation was 12.4 years with a wide range from 6.0 to 50.0 years. RESULTS: The average hearing gain was 31 ± 8 dB, and the suprathreshold word recognition tests increased by 57% ± 23%. Strength of the magnetic force that the patients had chosen themselves measured 0.9 ± 0.4 N with a range from 0.3 to 1.8 N. Skin thickness over the implants measured sonographically was 3.9 ± 0.8 mm (range, 2.5-5.6 mm). DISCUSSION: This new bone conducting hearing device only needs one operation, has a very low risk for complication, and a hearing gain similar to other bone conducting hearing aids. We have found high comfort and safety of this system and conclude that it could be a valuable alternative to other conventional or percutaneous bone conducting hearing solutions.

Sulcus construction in microtia repair: a retrospective comparison of different techniques.

OBJECTIVE: To compare the auricular projection results across 3 different techniques of sulcus construction in microtia repair (using a temporoparietal fascial flap, a retroauricular fascial flap from the mastoid region, or a superficial muscular aponeurotic system advancement flap). METHODS: All the patients had been photographed at least 3 months after the second stage (construction of the retroauricular sulcus) in auricular reconstruction for microtia. The auricular projection of each patient was measured, and the results of 3 different techniques were compared. RESULTS: No statistically significant differences in the auricular projection results were observed among patients operated on using the 3 techniques. CONCLUSIONS: The superficial muscular aponeurotic system advancement flap is suitable for patients requiring middle ear and auricle reconstruction. The performance of this flap is easier, quicker, less expensive, and associated with fewer perioperative complications compared with the other 2 techniques described herein.

Partially implantable bone conduction hearing aids without a percutaneous abutment (Otomag): technique and preliminary clinical results.

INTRODUCTION: Patients with air-bone gaps who cannot be corrected successfully by tympanoplasty or with mixed hearing loss may be treated with bone conduction hearing aids. Their disadvantages are the obvious external fixation components or the biological and psychosocial problems of open implants. We have developed new partially implantable bone conduction hearing aid without a percutaneous abutment and have been using them clinically for 4 years. The principle of these bone conduction hearing aids is a magnetic coupling and acoustic transmission between implanted and external magnets. The goal of this study was to evaluate clinical and audiological results. METHODS: Magnets are implanted into shallow bone beds in a one step procedure. The skin above the magnets is also reduced to a thickness of 4-5 mm, which reduces the attenuation to less than 10 dB compared to direct bone stimulation. Over 100 patients have been implanted in the last 5 years. RESULTS: Except for temporary pressure marks in 4%, which healed after careful shimming of the external base plate, there were no other complications. DISCUSSION: The holding strength of the external components is equivalent to partially implantable hearing aids and cochlea implants and the hearing improvement is similar to other bone conduction hearing aids. We have found the comfort and safety of this system is significantly improved compared to conventional or percutaneous bone conduction hearing aids.

Combined reconstruction of congenital auricular atresia and severe microtia.

OBJECTIVES: Due to their embryological development, auricular atresia and severe microtia are, in most cases, combined malformations. The aims of this study were firstly to develop a surgical technique for combined esthetic and functional reconstruction with a minimum of operations and secondly to evaluate its results. STUDY DESIGN: Prospective clinical evaluation. PATIENTS AND METHODS: Fifty-two patients with third-degree microtia and congenital aural atresia with a sound-conducting block of about 50 dB were treated. In the first operation, autogenous cartilage was harvested, and the auricular framework was fabricated and implanted. In addition, the tympanic membrane and the external ear canal were prefabricated, and stored in a subcutaneous pocket. In the second step, the elevation of the new framework was combined with the operation for atresia, utilizing the prefabricated tympanic membrane and external ear canal. In the third step, the cavum concha was deepened, and the external ear canal was opened and covered with a skin graft. RESULTS: In total, 76% of the patients had a final conductive hearing loss of 30 dB or less. No restenosis of the new external ear canal was observed. The esthetic results of the constructed auricles are shown in this report. CONCLUSION: With this combination of plastic surgery for the auricle and functional surgery for the middle ear, no additional operations are necessary and the prefabrication of the external ear canal and the tympanic membrane gives stable and reliable results. This combined technique offers the best chance of optimal esthetic and functional rehabilitation for patients with these malformations.

Basic techniques in autogenous microtia repair.

Although several techniques can be used for microtia repair, some standard procedures have been developed over the past few decades. In specialized centers, these techniques are performed most frequently. They include two to four operative steps using autogenous rib cartilage for the framework and local skin for its tegument. We have been using this technique presented here in more than 800 cases over the past two decades with good and mostly stable results.

Reducing the morbidity involved in harvesting autogenous rib cartilage.

Although the use of autogenous cartilage is the gold standard in auricular reconstruction, its main disadvantage is the morbidity due to harvesting the cartilage. This includes postoperative pain, visible scar, and possibly asymmetry and reduced stability of the thorax. To reduce all of these drawbacks, we describe some modifications that reduce pain to a low tolerable level, hide the scar invisibly in the submammary fold in females, and induce regeneration as well reestablish stability of the rib defect.

Special reconstruction techniques for special circumstances.

Auricular reconstruction is a challenging, mostly multistaged procedure that requires many different techniques. Whereas standard techniques have been developed for the standard severe, third-degree dysplasia, we are often confronted with severely scarred patients due to excess trauma or prior operations. These special situations need a variety of special techniques; some of those are described here to be considered as alternative options.

[Localization of lacrimal drainage system obstruction by diaphanoscopy]. / Lokalisation von Tränenwegsstenosen durch Diaphanoskopie.

Endonasal dacryocystorhinostomy is the standard treatment for obstruction of the lacrimal drainage system. Localization of the stenosis can be difficult intraoperatively, especially in chronic sclerosing dacryocystitis or re-operations. We present a technique of intraoperative diaphanoscopic localization of the stenosis with the use of a special small light fiber that is inserting through the lacrimal points down to the stenosis. The lighted fiber illuminates the area, which has to be exposed endonasally and drain to the nose. This little addition contributes to a meticulous and straightforward operative technique.

Fully implantable hearing aids in patients with congenital auricular atresia.

INTRODUCTION: Patients with congenital auricular atresia suffer from a conductive hearing loss (HL) with an air-bone gap of 50 to 60 dB. Conventional bone conducting or bone anchored hearing aids are treatment options with several disadvantages and a biophysical limitation of almost no sound attenuation in the skull bone. Surgical construction of the sound conducting apparatus has been performed by others and modified by us into a three-step procedure with in vivo prefabrication of the external ear canal and the tympanic membrane. Although the results improved after inauguration of our modifications, there still remains an air-bone gap that makes air conducting hearing aids necessary in many patients. Implantable hearing aids have been developed for patients with perceptional HL and normal middle ear function but not for patients with middle ear disease or malformation. OBJECTIVES: Our objectives were to improve the hearing results of auricular atresia. STUDY DESIGN: Prospective. METHODS: The surgical instruments, the transducer, and the operative technique of the only fully implantable hearing aid (Otologics Fully Implantable Middle Ear Transducer) clinically available were modified. They were implanted in five patients with congenital auricular atresia and their audiologic outcome evaluated. RESULTS: After activation and fitting of the devices, patients experienced an improvement of sound-field thresholds up to 50 dB HL. The mean functional gain in a three frequency pure-tone average was approximately 35 dB HL. CONCLUSIONS: This technique appears to provide a completely new dimension for the audiologic rehabilitation of patients with severe malformation of the middle ear.

Reconstruction of the auricle.

Reconstructive and aesthetic surgery of the auricle is one of the most challenging and diverse tasks in plastic head and neck surgery. Injuries, defects and malformations require multiple different techniques, some of which are standardized, other situations require huge experience and artistic creativity. It is a specialty that will never become monotone.