A Clinical Evaluation of Minimally Invasive Ponto Surgery With a Modified Drill System for Inserting Bone-Anchored Hearing Implants

Long-Term Clinical Outcomes for Bone-Anchored Hearing Implants: 3-Year Comparison Between Minimally Invasive Ponto Surgery and the Linear Incision Technique With Tissue Preservation

OBJECTIVE

To compare the 3-year outcomes of the modified minimally invasive Ponto surgery (m-MIPS) to both the original MIPS (o-MIPS) and linear incision technique with soft tissue preservation (LIT-TP) for inserting bone-anchored hearing implants (BAHIs).

STUDY DESIGN

Prospective study with three patient groups: m-MIPS, o-MIPS, and LIT-TP.

SETTING

Tertiary referral center.

PATIENTS

In the m-MIPS group, 24 patients with 25 implants were enrolled. The o-MIPS and LIT-TP groups included 25 patients (25 implants) each.

INTERVENTIONS

The patients underwent BAHI surgery using m-MIPS, o-MIPS, or LIT-TP.

MAIN OUTCOME MEASURES

Implant survival and implant stability were compared between all groups. Soft tissue status, skin sensibility, subjective numbness, and hearing-related quality of life (HRQoL) were compared between m-MIPS and LIT-TP and o-MIPS and LIT-TP, respectively.

RESULTS

Implant survival was comparable between m-MIPS and LIT-TP (96 versus 100%), with o-MIPS showing nonsignificant lower survival (88%). Both MIPS groups exhibited fewer (adverse) skin reactions, better skin sensibility, and less subjective numbness than LIT-TP throughout visits. At 3 years, soft tissue status, sensibility, and numbness were comparable between groups. Device use was consistent among groups (83-86% daily users). All groups demonstrated significant improvement in HRQoL post-surgery based on GBI, GHSI, and APHAB total scores.

CONCLUSIONS

Compared with LIT-TP, m-MIPS showed comparable long-term implant survival, fewer (adverse) skin reactions, and earlier sensibility and numbness recovery. M-MIPS resulted in favorable clinical and QoL outcomes with low intra- and postoperative complication rates until 3 years after surgery. It is therefore considered a safe technique for BAHI insertion. Moreover, with a shorter surgery time and the ability to operate under local anesthesia in a controlled outpatient setting, m-MIPS appears to be a more efficient alternative to LIT-TP.

Evaluation of Clinical Performance of Ponto Implantation Using a Minimally Invasive Surgical Technique-A Prospective Multicenter Study

OBJECTIVE

To investigate the clinical outcomes of bone-anchored hearing implant surgery using the MONO procedure.

STUDY DESIGN

Multicenter, multinational, single-arm, prospective trial with a 12-month follow-up.

SETTING

Seven European university hospitals from the United Kingdom, Sweden, Denmark, and The Netherlands.

PATIENTS

Fifty-one adult patients requiring surgical intervention for bone conduction hearing.

INTERVENTION

Bone-anchored hearing implant surgery using the MONO procedure.

MAIN OUTCOME MEASURES

The primary endpoint assessed implant usability 3 months after surgery. Implant status, soft tissue reactions, pain and numbness, postoperative events, and sound processor usage were assessed at all follow-up visits. Hearing-related quality of life was evaluated using the Glasgow Benefit Inventory (GBI).

RESULTS

At 3 months, 94.2% of the implant/abutment complexes provided reliable anchorage for sound processor usage. No severe intraoperative complications occurred. Sixty-nine percent of surgeries were performed under local anesthesia, with surgery lasting 10 minutes on average. Four implants were lost due to trauma (n = 2), spontaneous loss of osseointegration (n = 1), or incomplete insertion (n = 1). Adverse soft tissue reactions occurred in 2.6% of visits, with a maximum Holgers grade of 3 (n = 1) and grade 2 (n = 5) across patients. Hearing-related quality of life at 3 months improved in 96% of patients.

CONCLUSION

The MONO procedure provides a safe and efficient surgical technique for inserting bone-anchored hearing implants with few and minor intra- and postoperative complications.

Long-Term Outcomes of a Percutaneous Wide-Diameter Bone-Anchored Hearing Implant: A Clinical Evaluation of More than 800 Implants

OBJECTIVE

This study evaluates the clinical outcomes of 807 percutaneous wide-diameter bone-anchored hearing implants (BAHIs) in 701 patients. In addition, it compares patient groups and examines bone conduction device (BCD) usage.

STUDY DESIGN

Retrospective cohort study. Mean follow-up period of 3.8 years.

SETTING

Tertiary referral center.

PATIENTS

All patients implanted with a percutaneous wide-diameter BAHI until December 2020 were included. Patients were divided into age groups, "loading-time" groups, and, if applicable, specific subgroups thought to be at risk for complications postsurgery, e.g., intellectual disability and comorbidities.

MAIN OUTCOME MEASURES

Soft tissue reaction, implant survival, revision surgery, and BCD usage.

RESULTS

In 9.1% of the 5,188 observations of 807 implants, an adverse soft tissue reaction was reported according to the Holgers' scale. Significantly more (adverse) soft tissue reactions were observed in children and intellectually disabled (ID) patients (p < 0.05). Comorbidity subgroups showed no significant differences in soft tissue reactions. Implant loss percentage, including explantations, was 6.2%. Implant survival was significantly worse in patients with ID (14.1%; p = 0.021). Pediatric age, early loading, or comorbidities did not significantly influence implant survival. At least 592 implants (73.4%) were used for bone conduction hearing, of which 65.4% were used daily.

CONCLUSION

Both children and ID patients are more prone to (adverse) soft tissue reactions, ID patients only have a higher risk of implant loss. The rate of implant loss in children seemed to be reduced compared to previous studies and thus more comparable to adults since using wide-diameter implants.

Minimally invasive surgery as a new clinical standard for bone anchored hearing implants-real-world data from 10 years of follow-up and 228 surgeries

Purpose

To explore the clinical practice development of different surgical techniques when installing bone-anchored hearing implants and their associated trends in outcomes.

Design

Retrospective study of 228 bone-anchored hearing implants in 200 patients, performed over a 10-year period between 2012 and 2022 in a referral hospital.

Method

Real-world data of demography, etiology, surgical setup, complications, and audiological outcomes were collected. Eligibility criteria from clinical practice were applied.

Results

The minimally invasive technique is associated with shorter surgery duration, 20 vs. 44 min as compared to a linear incision technique. The minimally invasive technique was also associated with a lower occurrence of complications when compared to linear incision techniques (intraoperative; 1.8% vs. 4.9%, postoperative; 49% vs. 66%). Most differences were seen in complications relating to skin and wound healing.

Conclusion

Adoption of a minimally invasive surgical technique for the installations of bone-anchored hearing implants can reduce surgical complexity without compromising safety aspects or clinical benefits.

Health Economic Cost Analysis for Percutaneous Bone Conduction Devices: The Minimally Invasive Ponto Surgery Versus Linear Incision Technique with Tissue Preservation

OBJECTIVES

To identify differences in mean cost per patient between the Minimally Invasive Ponto Surgery (MIPS) and the linear incision technique with tissue preservation (LITT-P).

STUDY DESIGN

Health economic cost analysis.

SETTING

The analysis was performed in a randomized multicenter controlled trial cohort.

PATIENTS

Adult patients eligible for unilateral bone conduction device surgery.

INTERVENTIONS

MIPS versus LITT-P surgery for bone conduction device implantation.

MAIN OUTCOME MEASURES

Perioperative and postoperative costs were identified and compared.

RESULTS

The difference in mean cost per patient between both techniques was €77.83 in favor of the MIPS after 22 months follow-up. The mean costs per patient were lower in the MIPS cohort for surgery (€145.68), outpatient visits (€24.27), systemic antibiotic therapy with amoxicillin/clavulanic acid (€0.30) or clindamycin (€0.40), abutment change (€0.36), and abutment removal (€0.18). The mean costs per patient were higher for implant and abutment set (€18.00), topical treatment with hydrocortison/oxytetracycline/polymyxine B (€0.43), systemic therapy with azithromycin (€0.09) or erythromycin (€1.15), local revision surgery (€1.45), elective explantation (€1.82), and implant extrusion (€70.42). Additional analysis of scenarios in which all patients were operated under general or local anesthesia or with recalculation when using current implant survival rates showed that differences in mean cost per patient were also in favor of the MIPS.

CONCLUSION

The difference between the MIPS and the LITT-P in mean cost per patient was €77.83 in favor of the MIPS after 22 months of follow-up. The MIPS is an economically responsible technique and could be promising for the future.

Ex vivo Evaluation of a New Drill System for Placement of Percutaneous Bone Conduction Devices

The procedure for installation of a percutaneous bone-conducting device has undergone significant improvements since its introduction 40 years ago. Today, the linear incision technique with tissue preservation (LITT-P) and the minimally invasive procedure (MIPS) are the most commonly used approaches. In both these techniques, a gradual increase of the osteotomy using a three-step drilling sequence is utilized, as this approach can allow a stepwise deepening and widening of the osteotomy in the mastoid and can prevent bone overheating. A new minimally invasive procedure (MONO) has been developed that allows an osteotomy to be performed and enables complete removal of the bone volume in one single drill step for a 4 mm implant using a novel parabolic twist drill. Here, the feasibility of the MONO procedure was qualitatively and quantitatively evaluated in terms of the dura response to drill trauma in comparison with the outcomes achieved with guide drills used for the LITT-P and MIPS techniques. Fresh frozen temporal bone from a human cadaver was subjected to penetration by three drills beyond the base of the mastoid bone to different depths. The sites were evaluated, and the damage to and possible penetration of the dura were determined. The results showed that for a drill depth exceeding mastoid bone thickness by not more than 1 mm, damage to the dura was limited or nonexistent, whereas for a drill depth exceeding bone thickness by 2 mm, damage increased, or the dura was penetrated. There was a trend toward more damage and penetration for both the round burr and MIPS guide drill compared with the MONO drill bit. From this experimental ex vivo study, it can be concluded that if the dura is encountered, the MONO system is not more inclined to penetrate the dura than the conventional LITT-P and MIPS systems.