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

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.

Comparison on intracochlear disturbances between drilling a manual and robotic cochleostomy.

During cochlear implantation, hearing preservation is a concern. Minimizing disturbances to the cochlea and protection of the underlying endosteal membrane during the formation of a cochleostomy are considered important factors. The robotic micro-drill system tested in this article is the first example of an autonomous surgical drill successfully producing a cochleostomy, which keeps the underlying endosteal membrane intact. This study compares induced disturbances within the cochlea during formation of cochleostomy using the robotic micro-drill with that of conventional manual drilling. The disturbance of the endosteal membrane is measured using a Microscope Scanning Vibrometer at a third window, produced in the cochlea. Results show that the highest velocity amplitude measured was associated with manual drilling technique. The robotic micro-drill technique produced only about 1% of the peak velocity amplitude seen in manual drilling and exhibited much more uniform behaviour, while keeping the underlying membrane intact. The technique applied when using the robotic drill could be a major step in reducing the trauma to the cochlea, by reducing disturbance levels.

Robustness analysis of a smart surgical drill for cochleostomy.

BACKGROUND: There is a need for sensor-guided robotic devices that discriminate working conditions and media, and control interaction of tool-points with respect to tissues. At the micro-surgical scale the need is to control exact penetration through flexible tissues and to control relative motion with respect to moving or deforming tissue targets and interfaces. METHODS: This paper describes a smart surgical drill that is able to control interaction with respect to the flexing tissue to avoid penetration or to control the extent of protrusion with respect to the position of the flexible tissue interface under drilling. The sensing scheme used is able to discriminate between the variations in types of conditions posed in the drilling environment. RESULTS: The fully autonomous system is able to respond to tissue type, behaviour and deflection in real time. The system is robust in terms of different drilling angle, thickness, stiffness, and disturbances encountered. Also it is intuitive to use, efficient to set up and uses standard drill bits. CONCLUSIONS: The smart drill has been used to prepare cochleostomies in theatre and was used to remove bone tissue leaving the endosteal membrane intact. This has enabled preservation of sterility and the drilling debris to be removed prior to insertion of the electrode. Results presented in this paper suggest that the robotic smart drill is tolerant and robust on various angled drilling trajectories with respect to tissues, tissue thickness, environmental disturbances, and has been used within the operating theatre.

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.

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.

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.

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.

Speech intelligibility with bilateral bone-anchored hearing aids: the Birmingham experience.

The Birmingham bone-anchored hearing aid (BAHA) programme, since its inception in 1988, has fitted more than 300 patients with unilateral bone-anchored hearing aids. Recently, some of the patients who benefited extremely well with unilateral aids 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 who have used their second BAHA for 12 months or longer. Following a subjective analysis in the form of comprehensive questionnaires, objective testing was undertaken to assess specific issues such as 'speech recognition in quiet', 'speech recognition in noise' and a modified 'speech-in-simulated-party-noise' (Plomp) test. 'Speech in quiet' testing revealed a 100 per cent score with both unilateral and bilateral BAHAs. With 'speech in noise' all 11 patients scored marginally better with bilateral aids compared to best unilateral responses. The modified Plomp test demonstrated that bilateral BAHAs provided maximum flexibility when the origin of noise cannot be controlled as in day-to-day situations. In this small case series the results are positive and are comparable to the experience of the Nijmegen BAHA group.

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.