Surgical management of conductive hearing loss in children

Polymer-Based Nanoparticles for Inner Ear Targeted Trans Differentiation Gene Therapy

Hearing loss is a significant disability that often goes under recognised, largely due to poor identification, prevention, and treatment. Steps are being made to amend these pitfalls in the investigation of hearing loss, however, the development of a cure to reverse advanced forms remains distant. This review details some current advances in the treatment of hearing loss, with a particular focus on genetic-based nanotechnology and how it may provide a useful avenue for further research. This review presents a broad background on the pathophysiology of hearing loss and some current interventions. We also highlight some potential genes that may be useful in the amelioration of hearing loss. Pathways of cellular differentiation from stem or supporting cell to functional hair cell are covered in detail, as this mechanism represents a key means of regenerating these cell types. Overall, we believe that polymer-based nanotechnology coupled with novel excipients represents a useful area of further research in the treatment of hearing loss, although further studies in this area are required.

Transcanal endoscopic management of isolated congenital middle ear malformations

BACKGROUND

A few studies have reported transcanal endoscopic management of isolated congenital middle ear malformations (CMEMs).

OBJECTIVE

The purpose of this study is to describe our surgical experience in endoscopic ear surgery for isolated CMEMs and evaluate the surgical effect of hearing reconstruction.

METHODS

From January 2017 to January 2022, a retrospective study was performed on 36 patients (37 ears) with isolated CMEMs who all underwent endoscopic surgery. Demographic data, high-resolution computed tomography (HRCT) findings, intraoperative findings, surgical management and audiometric data were recorded.

RESULTS

Anomalies were categorized according to the Teunissen and Cremers classification system: 8 ears were categorized as class I, 8 ears as class II, 19 ears as class III and 2 ears as class IV. The air conduction pure tone average (AC-PTA) of 37 cases was 61.5 ± 8.6 dB preoperatively and 29.6 ± 6.9 dB postoperatively (p < 0.001). The mean preoperative air-bone gap (ABG) significantly decreased from 43.1 ± 8.7 dB to 12.8 ± 5.5 dB postoperatively. 36 of 37 cases (97%) met the criteria for successful operation.

CONCLUSION

Isolated CMEMs are mainly manifested as aplasia of the stapes' superstructure and dysplasia of the long process of the incus. Transcanal endoscopic surgery seems a safe technique for the management of isolated CMEMs.

Multicenter Study of Congenital Middle Ear Anomalies. Report on 246 Ears

OBJECTIVES/HYPOTHESIS

Congenital middle ear anomalies represent a relatively rare condition. This study aimed to describe the characteristics and the surgical outcomes for patients with middle ear anomalies.

METHODS

A multicenter study was conducted of consecutive patients with congenital middle ear anomalies who underwent primary surgical treatment between January 2008 and December 2017. Demographics, surgical procedures, and audiometric data were registered into the institutional database. Hearing changes and postoperative air-bone gap (ABG) were evaluated 1 year after surgery.

RESULTS

A total of 246 patients (246 ears) (median age: 14 years, range: 4-75 years old) were included in this study. Anomalies were subdivided using the Teunissen and Cremers classification: 53 ears (22%) were categorized as class I, comprising only stapes ankylosis; 35 ears (14%) as class II, having ossicular chain anomalies with stapes ankylosis; 139 ears (57%) as class III, having ossicular chain anomalies with a mobile stapes-footplate; and 19 ears (8%) as class IV, with aplasia of the oval window. Evaluation of hearing outcomes for 198 ears with more than 1 year of follow-up revealed that good postoperative ABG (≤20 dB) was achieved in 82% of class I, 68% of class II, 74% of class III, and 23% of class IV anomalies. The postoperative ABG in class IV was significantly worse than in class I (P < .001) or class III (P < .01).

CONCLUSIONS

This study demonstrated that class III anomalies comprised the majority of middle ear anomalies and surgical outcomes for class IV anomalies are unfavorable.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2323-E2328, 2021.

[Hearing rehabilitation with the Vibrant Soundbridge in patients with congenital middle ear malformation]

BACKGROUND

Congenital aural atresia, which is usually unilateral, causes hearing loss and aesthetic impairment. Besides tympanoplasty with/without canalplasty and bone conduction devices, active middle ear implants are also available for functional rehabilitation.

OBJECTIVE

This article aims to present a contemporary review on the treatment possibilities for middle ear malformations, with a focus on audiological rehabilitation with the Vibrant Soundbridge.

MATERIALS AND METHODS

A selective literature search for treatment possibilities was performed in PubMed up to October 2020, and personal clinical experiences are reported.

RESULTS

The Vibrant Soundbridge, which is approved for children ≥ 5 years, is suitable for treatment of middle ear malformations with a Jahrsdoerfer score ≥ 5. Although implantation of a Vibrant Soundbridge is surgically more demanding than implantation of a bone conduction device, the method is safe, delivers good auditory results (superior to bone conduction devices in terms of speech understanding and spatial hearing), does not involve intensive postsurgical care, and rarely requires revision surgery. The Vibrant Soundbridge can be coupled to (remnants of) the ossicular chain or the round window.

CONCLUSION

The Vibrant Soundbridge is an appropriate treatment method in patients with middle ear malformations who have suitable anatomical preconditions.

Endoscopic findings and long-term hearing results for pediatric unilateral conductive hearing loss

OBJECTIVES

Analyze reasons for unilateral conductive hearing loss (CHL) with unknown etiology in children.

INTRODUCTION

Unilateral conductive hearing loss (HL) without known etiology can be undiagnosed despite of hearing screening programs. It can be difficult to find the reason for HL and to make a treatment plan. Middle ear endoscopy gives hard-evidence diagnosis and basis for an individual treatment plan.

METHODS AND MATERIAL

Prospective clinical follow-up study for a cohort of generally healthy elementary school age children with unilateral conductive HL with unknown etiology. The study population was 192 children, of which 46 had a HL of at least 25 dB with more than 10 dB conductive component. Mean age was 8.7 years. Preoperative tests included otomicroscopy, bone- and air-conduction audiogram, tympanometry, stapes reflex tests, Rinne and Weber test and Otoacoustic emissions. The children underwent endoscopy of the middle ear with an individual treatment plan and long-term follow-up. The aim was to explore etiology and to give a treatment plan for hearing loss. Follow-up included air- and bone conduction hearing tests annually or every other year. Mean follow-up was 5.2 years.

RESULTS

A clear etiological finding was found in 36 (78%) ears, stapes anomaly (23) as the most common (64%) finding. Other findings were two cholesteatomas, 2 status after trauma, 5 middle ear anomalies, 5 incus fixations and one incus erosion. Air conduction hearing improved spontaneously during follow-up in 81% (17/21, 2 dropouts) of the stapes anomaly ears (mean 11,3 dB, range 4-32 dB), and none of these ears showed hearing deterioration. In the incus fixation group, one ear showed hearing deterioration. There were no major complications for exploration, and 5 minor postoperative infections.

CONCLUSIONS

The most common reason for pediatric unilateral conductive hearing loss was stapes anomaly/fixation. The HL does not deteriorate. Hearing loss in stapes anomalies shows a tendency for spontaneous recovery. Stapes surgery can be postponed or avoided.

Isolated Congenital Middle Ear Malformations: Comparison of Preoperative High-Resolution CT and Surgical Findings

Objectives:

To compare preoperative temporal bone high-resolution computed tomography (HRCT) readings to intraoperative findings during exploratory tympanotomy for suspected cases of isolated congenital middle ear malformations (CMEMs) and summarize the malformations that can and cannot be diagnosed with HRCT.

Methods:

A retrospective study was conducted. All cases were confirmed as isolated CMEMs during surgery. Detailed clinical records were reviewed, with a focus on imaging and surgical findings.

Results:

One hundred and thirty-two patients and 145 ears were reviewed. Ninety cases (62.1%) could be identified as isolated CMEMs and at least one as middle ear anomaly using preoperative HRCT. Fifty-five cases (37.9%) were reported to be completely normal and the patients underwent exploratory tympanotomy to determine the final diagnosis. Stapes fixation, either alone or associated with other ossicular chain anomalies, contributed to 53.1% of the cases. Most cases of aplasia or dysplasia of the ossicular chain, for example, aplasia/dysplasia of the long process of the incus, aplasia of the stapes’ superstructure, and atresia of the oval window were easily identified in preoperative HRCT. However, fixation of the ossicular chain can be elusive in HRCT, and exploratory tympanotomy is needed for a definitive diagnosis.

Conclusions:

HRCT provides helpful preoperative clinical information in CMEM and may obviate the need for middle ear exploration in some cases. The negative findings (anomalies that are difficult to identify through preoperative HRCT) and the positive findings (anomalies that are relatively easy to identify through preoperative HRCT) were summarized.

Reporting and Description for Congenital Middle Ear Malformations to Facilitate Surgical Management

Introduction:

The aim of this work was to report and describe the different types of congenital middle ear malformations in order to guide surgical treatment approaches and improve outcomes for affected patients.

Methods:

The authors reviewed patients with congenital middle ear malformations who received surgical treatment between September 2010 and March 2017. Patient characteristics, middle ear deformities, and surgical procedures were documented.

Results:

In this retrospective study, 35 patients were reviewed. A description of middle ear malformation was proposed that considers ear embryogenesis and focuses on stapes deformity, with the main purpose of facilitating surgical approach selection to reconstruct the ossicular chain. Patients were classified into 3 categories: type I (19 cases), mobile stapes footplate, which included type Ia with normal stapes suprastructure and type Ib with abnormal stapes suprastructure; type II (4 cases), fixed stapes footplate, which included type IIa with normal ossicular chain and type IIb with abnormal ossicular chain; and type III (12 cases), oval window bony atresia or aplasia, with or without round window atresia. Types II and III could have concomitant aberrant facial nerve. Different surgical approaches are described.

Conclusions:

The authors describe the different types of congenital middle ear malformations. This category description considers ear embryogenesis and is focused on stapes deformity. It may provide better understanding of disease development and guide modern hearing reconstructive surgery.

Congenital Familial Fixation of the Malleus

We present a familial association of radiographically and surgically demonstrated mallear fixation with concurrent stapedial abnormality and dehiscence of the facial nerve in a father and son, including history, physical findings, surgical findings, radiologic analyses, and a literature review. A 12-year-old boy presented with long-term left-sided conductive hearing loss, and was found to have mallear fixation and a dehiscent facial nerve on a computed tomographic (CT) scan of the temporal bone. Release of the malleus was performed at surgery, revealing hypermobility of the remaining ossicular chain. A repeat CT scan of the temporal bone showed successful release of the mallear head. The patient's father later presented with bilateral hearing loss, and a CT scan of the temporal bones showed bilateral osseous fixation of the mallear head to the tegmen and bilateral facial nerve dehiscences. He underwent right middle ear exploration, but release of the malleus was not performed because of the risk to the dehiscent facial nerve. The stapes crurae were found to be filiform at surgery. This is the first reported familial association of mallear fixation. Mallear fixation with facial nerve dehiscence and an abnormal stapes occurring in a parent and his child is interesting embryologically, and suggests that these anomalies may be genetically linked.

Congenital oval or round window malformations in children: Surgical findings and results in 17 cases

OBJECTIVES/HYPOTHESIS

To prospectively evaluate surgical findings and hearing results in children undergoing surgery for congenital oval or round window malformations (class IV malformations).

STUDY DESIGN

A nonrandomized, nonblinded, case series of prospectively collected data.

METHODS

Fourteen consecutive pediatric patients who underwent 17 surgical procedures for congenital oval or round window malformations in a tertiary referral center were included. Postoperative pure-tone audiometry was available in 15 cases. The surgical technique for repair of the ossicular chain was dictated by the surgical findings at the time of surgery. The majority of the cases underwent ossiculoplasty using a Teflon piston, bucket-handle prosthesis, or total ossicular replacement prosthesis. Associated surgical techniques included malleus relocation and oval window drill-out procedure. The main outcome measures were preoperative and postoperative hearing status using four-frequency (0.5, 1, 2, and 4 kHz) audiometry. Air-conduction thresholds, bone-conduction thresholds, and air-bone gap were measured. Postoperative audiometry was performed at 3, 6, 9, 12, 18, and 24 months after surgery and at a yearly interval thereafter.

RESULTS

Postoperative air-bone gap closure to 10 dB or less was achieved in 47%. A postoperative air-bone gap closure to within 20 dB or less was achieved in 60%. Postoperative sensorineural hearing loss did not occur in this series.

CONCLUSIONS

Middle ear surgery for class IV abnormalities is feasible, but success percentages are much lower compared to other types of congenital ossicular malformations. Surgeons should be particularly careful in case of facial nerve abnormalities on computed tomography or during middle ear exploration.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:2552-2558, 2016.

High-resolution CT findings in children with a normal pinna or grade I microtia and unilateral mild stenosis of the external auditory canal

SUMMARY

A subset of patients presents with unilateral conductive hearing loss, a normal pinna or grade I microtia, and mild external auditory canal stenosis. The physical findings of microtia and a small external canal are commonly absent or subtle in this group of patients, who are being commonly referred for imaging to evaluate isolated conductive hearing loss. We present a case series of patients with unilateral conductive hearing loss and characteristic ossicular abnormalities, commonly anterior fixation of the malleus. All patients had a significantly increased distance from the cochlear promontory to the handle of the malleus and an abnormal incudostapedial angle, indicative of an abnormal ossicular position and/or morphology. Successful surgical reconstruction of the ossicular chain was attempted and accomplished in 3 patients.

Hearing results of stapedotomy and malleo-vestibulopexy in congenital hearing loss

AIMS

To analyze hearing results of surgical treatment of hearing loss associated with the congenital stapes ankylosis with or without malformations of ossicular chain.

STUDY DESIGN

Retrospective chart review.

METHODS

The charts of 1369 stapedotomies performed by senior author (JH) from 1991 to 2006 were reviewed. In 40 cases operative findings were consistent with isolated congenital stapes fixation or associated with middle ear malformations. The modified stapedotomy technique was employed in 33 cases and malleo-vestibulopexy was used in 7 cases. Operative findings were standardized according to Cremers' classification. The outcomes of 40 surgeries were analyzed according to the 1995 AAO-HNS Committee on Hearing and Equilibrium guidelines. High frequency hearing results on 4, 8 and 12kHz were reported in addition to standard frequencies. Results of stapedotomies and malleo-vestibulopexies were calculated separately. Surgical complications were described.

RESULTS

The mean post-operative air conduction (AC) was 33 dB, bone conduction (BC) 22 dB and speech reception thresholds (SRT) 31 dB. Closure of the air-bone gap (ABG) to within 10 dB was achieved in 24/40 (60%) of cases. Lack of improvement was observed in 3/40 (8%) patients. In 26/32 (81%) of cases with potential for bilaterally serviceable hearing it was achieved. In 24/40 (60%) of cases symmetrical hearing with interaural difference of less than 10 dB was demonstrated.

CONCLUSION

Significant hearing gain in patients with congenital stapes ankylosis makes surgical treatment a valuable adjunct or an alternative to hearing aids in selected cases.

Otologic findings in Antley-Bixler syndrome: a clinical and radiologic case report

Antley-Bixler syndrome (ABS) is characterized by craniofacial dysmorphism and radiohumeral synostosis with other associated anomalies. Prior studies have commonly described the entirety of the syndrome or the genetic abnormalities underlying the syndrome, however, no study has specifically addressed the otologic findings of ABS. We present a case of ABS, specifically focusing on the otologic ramifications of the disease, and provide recommendations for approaching the otologic management of these complex patients.