Bone-anchored hearing implants in single-sided deafness patients: Long-term use and satisfaction by gender

Ten years' experience with bone conduction hearing aids in the Western Cape, South Africa

Untreated conductive and mixed hearing losses as a result of middle ear pathology or congenital ear malformations can lead to poor speech, language and academic outcomes in children. Lack of access to centralised hearing healthcare in resource-constrained environments limits opportunities for children with hearing loss. Red Cross War Memorial Children's Hospital (RCWMCH) is one of only two dedicated paediatric hospitals in sub-Saharan Africa. Between 2016 and 2021, 29 children received implanted bone conduction hearing devices, and 104 children were fitted with bone conduction devices on softbands. The authors' experience at RCWMCH suggests that bone-anchored hearing devices, either fitted on softbands or on implanted abutments, can provide solutions in settings where patients have limited access to hearing healthcare and optimal classroom environments. Hearing healthcare should be accessible and delivered at the appropriate level of care to mitigate the adverse effects of hearing loss in children.Contribution: This article describes strategies employed at RCWMCH such as fitting bone conduction hearing devices on a softband immediately after hearing loss diagnosis and conducting follow-up via remote technology to make hearing healthcare more accessible to vulnerable populations.

Hearing-Related Quality of Life in 75 Patients With a Percutaneous Bone Conduction Device

OBJECTIVE

To evaluate long-term hearing-related quality of life (HRQoL) and device use in bone conduction (BCD) users. Furthermore, to assess differences between indications and changes in HRQoL over time.

STUDY DESIGN

Prospective questionnaire survey.

SETTING

Tertiary referral center.

PATIENTS

Seventy-five patients with a percutaneous BCD.

MAIN OUTCOME MEASURES

Glasgow Benefit Inventory (GBI) at 3 and 12 months postoperatively, Glasgow Health Status Inventory (GHSI) preoperatively, and 6 and 36 months postoperatively, device use at 6, 12, and 36 months. Changes over time were assessed and outcomes were compared between indications.

RESULTS

After implantation, 97% of all patients reported a positive benefit on the GBI total. The GHSI total had improved with median 15 points (Interquartile range [IQR] 12). At 36 months, median device use was 15 hours/day (IQR 10) and one nonuser was reported. Patients with bilateral hearing loss (BHL) showed greater improvement on the GHSI total (median 18 vs 14, p < 0.0001) and used their devices more frequently (median 16 vs 8 h/day, p < 0.0001) than patients with unilateral HL (UHL). Postoperative GHSI and GBI scores were consistent over time, in the entire patient population and for every indication. Between 6 and 36 months, device use was stable over time, except for patients with single-sided deafness (SSD; median -6.4 h/day, p = 0.009).

CONCLUSION

The BCD improves HRQoL in patients with BHL, in patients with unilateral conductive/mixed hearing loss and in patients with SSD. Patients with BHL experienced a greater improvement in hearing status compared to patients with UHL. Although use decreased over time in SSD patients, device use was high for every indication.

Rerouting Hearing Aid Systems for Overcoming Simulated Unilateral Hearing in Dynamic Listening Situations

OBJECTIVES

Unilateral hearing loss increases the risk of academic and behavioral challenges for school-aged children. Previous research suggests that remote microphone (RM) systems offer the most consistent benefits for children with unilateral hearing loss in classroom environments relative to other nonsurgical interventions. However, generalizability of previous laboratory work is limited because of the specific listening situations evaluated, which often included speech and noise signals originating from the side. In addition, early studies focused on speech recognition tasks requiring limited cognitive engagement. However, those laboratory conditions do not reflect characteristics of contemporary classrooms, which are cognitively demanding and typically include multiple talkers of interest in relatively diffuse background noise. The purpose of this study was to evaluate the potential effects of rerouting amplification systems, specifically a RM system and a contralateral routing of signal (CROS) system, on speech recognition and comprehension of school-age children in a laboratory environment designed to emulate the dynamic characteristics of contemporary classrooms. It was expected that listeners would benefit from the CROS system when the head shadow limits audibility (e.g., monaural indirect listening). It was also expected that listeners would benefit from the RM system only when the RM was near the talker of interest.

DESIGN

Twenty-one children (10 to 14 years, M = 11.86) with normal hearing participated in laboratory tests of speech recognition and comprehension. Unilateral hearing loss was simulated by presenting speech-shaped masking noise to one ear via an insert earphone. Speech stimuli were presented from 1 of 4 loudspeakers located at either 0°, +45°, -90°, and -135° or 0°, -45°, +90°, and +135°. Cafeteria noise was presented from separate loudspeakers surrounding the listener. Participants repeated sentences (sentence recognition) and also answered questions after listening to an unfamiliar story (comprehension). They were tested unaided, with a RM system (microphone near the front loudspeaker), and with a CROS system (ear-level microphone on the ear with simulated hearing loss).

RESULTS

Relative to unaided listening, both rerouting systems reduced sentence recognition performance for most signals originating near the ear with normal hearing (monaural direct loudspeakers). Only the RM system improved speech recognition for midline signals, which were near the RM. Only the CROS system significantly improved speech recognition for signals originating near the ear with simulated hearing loss (monaural indirect loudspeakers). Although the benefits were generally small (approximately 6.5 percentage points), the CROS system also improved comprehension scores, which reflect overall listening across all four loudspeakers. Conversely, the RM system did not improve comprehension scores relative to unaided listening.

CONCLUSIONS

Benefits of the CROS system in this study were small, specific to situations where speech is directed toward the ear with hearing loss, and relative only to a RM system utilizing one microphone. Although future study is warranted to evaluate the generalizability of the findings, the data demonstrate both CROS and RM systems are nonsurgical interventions that have the potential to improve speech recognition and comprehension for children with limited useable unilateral hearing in dynamic, noisy classroom situations.

Expanding the indications for the bone anchored hearing system (BAHS) in patients with single sided deafness

PURPOSE

Provide data to support expansion of FDA indications for the Bone anchored hearing system (BAHS).

MATERIALS AND METHODS

This retrospective study in a tertiary otologic referral center included106 consecutive subjects who were implanted with a Bone Anchored Hearing System (BAHS) between January 2009 and January 2015 for single sided deafness. Subjects were divided into three groups by bone conduction pure tone average (PTA) of the better hearing ear: 0-20 dB (group 1), 21-40 dB (group 2) and 41-55 dB (group 3). All patients underwent BAHS implantation. Speech perception data (Hearing In Noise Test and Consonant-Nucleus-Consonant testing) was collected before and after surgical intervention. Patient-reported quality of life measures were obtained at least 6 months after activation. These included the Abbreviated Profile of Hearing Aid Benefit and Glasgow Benefit Inventory.

RESULTS

All three groups of subjects demonstrated statistically significant improvement in outcome measures following BAHS. Subject reported quality of life outcome measures demonstrated significant improvement in disability from hearing loss and in quality of life.

CONCLUSIONS

Patients with single sided deafness who have bone conduction thresholds worse than 20 dB in their contralateral ear are still able to benefit significantly from BAHS.

Use of a 3D reconstruction model in a patient with severe atresia auris for optimal placement of Bonebridge transcutaneous bone conduction implant

PURPOSE

Patients affected by severe atresia auris (AA) can be a challenge during hearing restoration surgery due to the abnormal position of vascular and nervous structures in the bone. A 3D reconstruction model of malformed temporal bones can be helpful for planning surgery and optimizing intra-, peri-, and post-operative results.

METHOD

A 5-year-old girl with severe AA on the right side was implanted with a Bonebridge transcutaneous bone conduction implant (tBCI). 3D printing was used to reproduce the malformed temporal bone, find a good position for the tBCI and plan out the surgical details in advance. Hearing tests were performed before and after surgery and information about intra-, peri-, and post-operative outcomes were collected.

RESULTS

The patient did not show any negative outcomes and, thanks to the Bonebridge, completely recovered hearing on the right side.

CONCLUSIONS

3D printing is a useful tool for planning surgery in AA patients and for preventing possible risks related to the unknown malformed anatomy.

A Multinational Cost-Consequence Analysis of a Bone Conduction Hearing Implant System-A Randomized Trial of a Conventional vs. a Less Invasive Treatment With New Abutment Technology

Background: It is hypothesized that, for patients with hearing loss, surgically placing an implant/abutment combination whilst leaving the subcutaneous tissues intact will improve cosmetic and clinical results, increase quality of life (QoL) for the patient, and reduce medical costs. Here, incremental costs and consequences associated with soft tissue preservation surgery with a hydroxyapatite (HA)-coated abutment (test) were compared with the conventional approach, soft tissue reduction surgery with an all-titanium abutment (control). Methods: A cost-consequence analysis was performed based on data gathered over a period of 3 years in an open randomized (1:1) controlled trial (RCT) running in four European countries (The Netherlands, Spain, France, and Sweden). Subjects with conductive or mixed hearing loss or single-sided sensorineural deafness were included. Results: During the first year, in the Netherlands (NL), France (FR), and Spain (ES) a net cost saving was achieved in favor of the test intervention because of a lower cost associated with surgery time and adverse event treatments [NL €86 (CI -50.33; 219.20), FR €134 (CI -3.63; 261.30), ES €178 (CI 34.12; 97.48)]. In Sweden (SE), the HA-coated abutment was more expensive than the conventional abutment, which neutralized the cost savings and led to a negative cost (SE €-29 CI -160.27; 97.48) of the new treatment modality. After 3 years, the mean cost saving reduced to €17 (CI -191.80; 213.30) in the Netherlands, in Spain to €84.50 (CI -117.90; 289.50), and in France to €80 (CI -99.40; 248.50). The mean additional cost in Sweden increased to €-116 (CI -326.90; 68.10). The consequences in terms of the subjective audiological benefit and Health-related quality of life (HRQoL) were comparable between treatments. A trend was identified for favorable results in the test group for some consequences and statistical significance is achieved for the cosmetic outcome as assessed by the clinician. Conclusions: From this multinational cost-consequence analysis it can be discerned that health care systems can achieve a cost saving during the first year that regresses after 3 years, by implementing soft tissue preservation surgery with a HA-coated abutment in comparison to the conventional treatment. The cosmetic results are better. (sponsored by Cochlear Bone Anchored Solutions AB; Clinical and health economic evaluation with a new Baha® abutment design combined with a minimally invasive surgical technique, ClinicalTrials.gov NCT01796236).

Microbiome on the Bone-Anchored Hearing System: A Prospective Study

The bone-anchored hearing system (BAHS) has evolved to a common treatment option for various types of hearing revalidation. The BAHS consists of an implant in the skull that breeches the skin. Soft tissue reactions are a common complication associated with BAHS and are generally poorly understood. This study aims to investigate the influence of BAHS and associated skin reactions around the implant. A total of 45 patients were prospectively followed from implantation up to at least 1 year. Swabs were obtained at baseline, 12 weeks follow-up and during cases of inflammation (Holgers score ≥2). The microbiota was assessed using IS-pro^TM, a bacterial profiling method based on the interspace region between the 16S–23S rRNA genes. Detection of operational taxonomic units, the Shannon Diversity Index, sample similarity analyses and Partial Least Squares Discriminant Analysis (PLS-DA) were employed. Staphylococcus epidermidis, Streptococcus pneumoniae/mitis, Propionibacterium acnes, Staphylococcus capitis, Staphylococcus hominis, Bifidobacterium longum, Haemophilus parainfluenzae, Lactobacillus rhamnosus, Bordetella spp., Streptococcus sanguinis, Peptostreptococcus anaerobius, Staphylococcus aureus, Lactococcus lactis, Enterobacter cloacae, and Citrobacter koseri were the most commonly found bacterial species. S. pneumoniae/mitis was significantly more often observed after implantation, whereas P. acnes was significantly less observed after implantation compared with baseline. The relative abundance of S. epidermidis (17%) and S. aureus (19.4%) was the highest for the group of patients with inflammation. The Shannon Diversity Index was significantly increased after implantation compared with pre-surgical swabs for Firmicutes, Actinobacteria, Fusobacteria, Verrucomicrobia (FAFV), but not for other phyla. When combining all phyla, there was no significant increase in the Shannon Diversity Index. The diversity index was similar post-surgically for patients experiencing inflammation and for patients without inflammation. With a supervised classifier (PLS-DA), patients prone to inflammation could be identified at baseline with an accuracy of 91.7%. In addition, PLS-DA could classify post-surgical abutments as non-inflamed or inflamed with an accuracy of 97.7%. This study shows the potential of using IS-pro^TM to describe and quantify the microbiota associated with the percutaneous BAHS. Furthermore, the results indicate the possibility of an early identification of patients susceptible to adverse skin reaction following implantation. Both S. aureus and S. epidermidis should be considered as relevant bacteria for BAHS-associated inflammation.

Current concepts in the management of idiopathic sudden sensorineural hearing loss

PURPOSE OF REVIEW

The purpose of this manuscript is to review the initial management strategies for idiopathic sudden sensorineural hearing loss, with an emphasis on the role that steroids play in treatment of this condition, and discuss options for auditory rehabilitation of persistent unilateral hearing loss.

RECENT FINDINGS

Recent data suggest that hearing improvement may be greater for patients initially treated with both systemic and intratympanic steroid when compared with those treated with systemic steroids alone. Salvage intratympanic steroids have been shown to confer hearing benefit if initial management fails. The ideal dosing regimen for intratympanic steroids has not been established, but evidence supports that higher dosing strategies are advantageous. Cochlear implantation has emerged as a strategy for auditory rehabilitation of persistent unilateral hearing loss. Recent studies have demonstrated high patient satisfaction, subjective improvement in tinnitus, and objective performance benefit after cochlear implantation for single-sided deafness.

SUMMARY

Patients can be offered steroid therapy in the initial management of idiopathic sudden sensorineural hearing loss, but should be counseled that the efficacy of steroids remains unclear. If patients fail to improve with initial management, salvage intratympanic steroid administration should be considered. If hearing loss persists long term, options for auditory rehabilitation should be discussed.

Systematic Review on the Trial Period for Bone Conduction Devices in Single-Sided Deafness: Rates and Reasons for Rejection

OBJECTIVE

To systematically review the literature to evaluate the trial period of bone conduction devices (BCDs) for adult patients with single-sided deafness (SSD).

DATA SOURCES

The PubMed, Embase, and Cochrane Library databases were searched from their inception up to August 15, 2016 for SSD, BCD, and their synonyms.

STUDY SELECTION

In total, 523 articles were retrieved, of which 12 satisfied the eligibility quality criteria. Our outcomes of interest were: 1) the BCD implantation rejection percentage, 2) reasons to reject BCD implantation, and 3) possible prognostic factors predicting the trial outcome.

DATA EXTRACTION AND SYNTHESIS

At critical appraisal, six studies (n = 471 patients) scored a moderate to high directness of evidence and a medium or low risk of bias and were selected for data extraction. Due to heterogeneity between studies, pooling of data for meta-analysis was not feasible. Therefore, results of studies were summarized per outcome: 1) after the BCD trial, 32.0 to 69.6% of SSD patients rejected BCD implantation, 2) the three main reasons for rejection were experiencing limited benefit from the device, patients fearing or being unfit for surgery and cosmetic aspects, 3) no clear prognostic factors predicting the trial outcome could be identified.

CONCLUSION

Roughly half of patients rejected BCD implantation after a trial period. From the current literature it is unclear which patients could benefit most from BCD implantation. High level of evidence studies should be conducted to investigate possible prognostic factors that predict the BCD trial outcome.

Long term benefit of bone anchored hearing systems in single sided deafness

CONCLUSION

Bone Anchored Hearing Systems (BAHS) can be expected to still be used by ∼85% of patients with single sided deafness (SSD) 5 years after implantation, and by ∼50% after 10 years.

OBJECTIVES

To investigate the long-term use of BAHS and the reasons to stop.

METHOD

This was a retrospective chart review of all 33 German speaking adults with SSD who had been implanted with a BAHS at one center and of whom the implant status and use of the BAHS were known.

RESULTS

Ranging from 2.6-12.3 years after BAHS implantation, 21 implantees (63.6%) were still using their device (average use = 7.9 years). Seven (21.2%) had stopped using their BAHS because of insufficient benefit (audiologic reasons). The subjective assessment of the benefit of the BAHS differs significantly from the users. Five former users (15.2%) became non-users for reasons unrelated to their hearing performance, namely infections, implant loss, difficulties with the handling, or aesthetic reasons.

Minimally Invasive Ponto Surgery compared to the linear incision technique without soft tissue reduction for bone conduction hearing implants: study protocol for a randomized controlled trial

BACKGROUND

Over the last years, less invasive surgical techniques with soft tissue preservation for bone conduction hearing implants (BCHI) have been introduced such as the linear incision technique combined with a punch. Results using this technique seem favorable in terms of rate of peri-abutment dermatitis (PAD), esthetics, and preservation of skin sensibility. Recently, a new standardized surgical technique for BCHI placement, the Minimally Invasive Ponto Surgery (MIPS) technique has been developed by Oticon Medical AB (Askim, Sweden). This technique aims to standardize surgery by using a novel surgical instrumentation kit and minimize soft tissue trauma.

METHODS

A multicenter randomized controlled trial is designed to compare the MIPS technique to the linear incision technique with soft tissue preservation. The primary investigation center is Maastricht University Medical Center. Sixty-two participants will be included with a 2-year follow-up period. Parameters are introduced to quantify factors such as loss of skin sensibility, dehiscence of the skin next to the abutment, skin overgrowth, and cosmetic results. A new type of sampling method is incorporated to aid in the estimation of complications. To gain further understanding of PAD, swabs and skin biopsies are collected during follow-up visits for evaluation of the bacterial profile and inflammatory cytokine expression. The primary objective of the study is to compare the incidence of PAD during the first 3 months after BCHI placement. Secondary objectives include the assessment of parameters related to surgery, wound healing, pain, loss of sensibility of the skin around the implant, implant extrusion rate, implant stability measurements, dehiscence of the skin next to the abutment, and esthetic appeal. Tertiary objectives include assessment of other factors related to PAD and a health economic evaluation.

DISCUSSION

This is the first trial to compare the recently developed MIPS technique to the linear incision technique with soft tissue preservation for BCHI surgery. Newly introduced parameters and sampling method will aid in the prediction of results and complications after BCHI placement.

TRIAL REGISTRATION

Registered at the CCMO register in the Netherlands on 24 November 2014: NL50072.068.14 . Retrospectively registered on 21 April 2015 at ClinicalTrials.gov: NCT02438618 . This trial is sponsored by Oticon Medical AB.