A New Semi-Implantable Transcutaneous Bone Conduction Device: Clinical, Surgical, and Audiologic Outcomes in Patients With Congenital Ear Canal Atresia

Comparison of Transcutaneous and Percutaneous Implantable Hearing Devices for the Management of Congenital Aural Atresia: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare audiometric outcomes, complications, and revisions required for percutaneous (pBCD) versus transcutaneous (tBCD) implantable bone-conduction devices for the treatment of hearing loss associated with congenital aural atresia (CAA).Databases Reviewed.PubMed, Scopus, CINAHL.

METHODS

A systematic review was performed searching for English language articles from inception to December 14, 2022. Studies reporting audiometric outcomes or complications for either pBCDs or tBCDs for the treatment of CAA were selected for inclusion. A meta-analysis of single means and meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted.

RESULTS

A total of 56 articles with 756 patients were selected for inclusion. One hundred ninety patients were implanted with pBCDs, whereas the remaining 566 were implanted with tBCDs. Mean pure-tone audiometry improvement in the pBCD group (39.1 ± 1.1 dB) was significantly higher than in the tBCD group (34.6 ± 1.6 dB; Δ4.5 dB; 95% confidence interval, 4.2-4.7 dB; p < 0.0001). The average improvement in speech reception threshold was 38.6 ± 2.5 dB in the percutaneous group as compared with 32.7 ± 1.6 dB in the transcutaneous group (Δ5.9 dB [5.3-6.5 dB], p < 0.0001). Overall complication rates for patients implanted with pBCDs and tBCDs were 29.0% (15.7-44.4%) and 9.4% (6.5%-13.0%), respectively (Δ19.6% [12.0-27.7%], p < 0.0001).

CONCLUSIONS

Patients with CAA implanted with pBCDs had significantly better audiometric outcomes than those implanted with tBCDs. However, complication rates were significantly higher among the pBCD group.

Comparison of Outcomes of Surgery Versus Implantable Device for the Treatment of Hearing Loss Associated With Congenital Aural Atresia: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare audiometric outcomes, complications, and revisions required for implantable bone-conduction devices (BCDs) versus atresia surgery for the treatment of hearing loss associated with congenital aural atresia.

DATABASES REVIEWED

PubMed, Scopus, CINAHL.

METHODS

Databases were searched for English articles from inception to July 1, 2022, for studies reporting audiometric outcomes or complications for either BCDs or atresia surgery for the treatment of congenital aural atresia. Main outcome measures included pure-tone audiometry, air-bone gap, speech reception threshold, associated complications, and rates of revision for each treatment option.

RESULTS

We identified 973 abstracts, of which 89 were selected for data extraction and analysis. A total of 2,611 patients were included, 1,901 in the atresia surgery group and 710 in the BCDs group. A meta-analysis of single means was conducted for age and audiometric outcomes, and a meta-analysis of proportions was conducted for complications and revisions. The average short-term improvement in pure-tone audiometry for the BCDs group was 34.4 ± 1.6 dB compared with 22.4 ± 1.5 dB for the atresia surgery group, representing a significant difference (12.0 dB; 95% confidence interval, 11.9-12.2; p < 0.0001). A smaller proportion of complications were reported in the devices group (16.9%) compared with the atresia surgery group (45.7%). In addition, a smaller proportion of cases in the devices group required some degree of revision (17.8%) compared with the atresia surgery group (23.0%).

CONCLUSIONS

This study demonstrates that implantable BCDs have significantly better audiometric outcomes as well as a lower rate of complications and revisions required compared with atresia surgery.

Transcutaneous versus percutaneous bone-anchored hearing aids: A quality of life comparison

PURPOSE

To determine whether patients have improved quality of life outcomes with percutaneous bone conduction implant (p-BCI) versus transcutaneous bone conduction implant (t-BCI).

MATERIALS & METHODS

Retrospective chart review of patients who have undergone placement of a BCI in the Ascension St John Providence Health System from 2013 to 2018. Patient satisfaction of t-BCI and p-BCI was measured using a questionnaire that incorporated the Glasgow Benefit Inventory (GBI) and BAHA, aesthetic, hygiene & use (BAHU) survey. Key outcome variables were separated into 2 categories: (1) evaluation of wound healing and implant-associated complications, and (2) quality of life improvements.

RESULTS

Comparative analysis of the 27 p-BCI patients and 10 t-BCI patients showed overall positive benefit with no statistically significant difference on quality of life improvement between the two groups. Total complication rates for p-BCI (48.1 %) vs t-BCI (10 %) was marginally significant (p = 0.056). Rate of revision for p-BCI versus t-BCI was 14.8 % vs 0 %, respectively.

CONCLUSION

This study provides a much-needed comparative insight in patient's experience with these two devices. Understanding which device is preferable in the patient's view will offer helpful information for guiding proper implant selection.

Safety of active auditory implants in magnetic resonance imaging

Magnetic resonance imaging (MRI) has become the gold standard for the diagnosis of many pathologies. Using MRI in patients with auditory implants can however raise concerns due to mutual interactions between the implant and imaging device, resulting in potential patient risks. Several implant manufacturers have been working towards more MRI safe devices. Older devices are however often labelled for more stringent conditions, possibly creating confusion with patients and professionals. With this myriad of different devices that are implanted in patients for lifetimes of at least 20 years, it is crucial that both patients and professionals have a clear understanding of the safety of their devices. This work aims at providing an exhaustive overview on the MRI safety of active auditory implants. The available industry standards that are followed by manufacturers are outlined and an overview of the latest scientific developments focusing on the last five years is provided. In addition, based on the analysis of the adverse events reported to the Food and Drug Administration (FDA) and in literature within the past ten years, a systematic review of the most commonly occurring issues for patients with auditory implants in the MRI environment is provided. Results indicate that despite the release of more MRI conditional active hearing implants on the market, adverse events still occur. An extensive overview is provided on the MRI safety of active auditory implants, aiming to increase the understanding of the topic for healthcare professionals and contribute to safer scanning conditions for patients.

Long-Term, Multicenter Results With the First Transcutaneous Bone Conduction Implant

OBJECTIVE

Investigation of long-term safety and performance of an active, transcutaneous bone conduction implant in adults and children up to 36 months post-implantation.

STUDY DESIGN

Prospective, single-subject repeated-measures design.

SETTING

Otolaryngology departments of eight German and Austrian hospitals.∗†‡§||¶#∗∗†† Affiliations listed above that did not participate in the study.‡‡§§||||¶¶.

PATIENTS

Fifty seven German-speaking patients (49 adults and eight children) suffering from conductive or mixed hearing loss, with an upper bone conduction threshold limit of 45 dB HL at frequencies between 500 and 3000 Hz.

INTERVENTION

Implantation of the Bonebridge transcutaneous bone conduction hearing implant (tBCI).

MAIN OUTCOME MEASURES

Patients' audiometric pure tone averages (PTA4) (0.5, 1, 2, 4 kHz) thresholds (air conduction, bone conduction, and sound field) and speech perception (word recognition scores [WRS] and speech reception thresholds [SRT50%]) were tested preoperatively and up to 36 months postoperatively. Patients were also monitored for adverse events and administered quality-of-life questionnaires.

RESULTS

Speech perception (WRS: pre-op: 17.60%, initial activation [IA]: 74.23%, 3M: 83.65%, 12M: 83.46%, 24M: 84.23%, 36M: 84.42%; SRT50%: pre-op: 65.56 dB SPL, IA: 47.67 dB SPL, 3M: 42.61 dB SPL, 12M: 41.11 dB SPL, 24M: 41.74 dB SPL, 36M: 42.43 dB SPL) and sound field thresholds (pre-op: 57.66 dB HL, IA: 33.82 dB HL, 3M: 29.86 dB HL, 12M: 28.40 dB HL, 24M: 28.22 dB HL, 36M: 28.52 dB HL) improved significantly at all aided postoperative visits. Air and bone conduction thresholds showed no significant changes, confirming preservation of patients' residual unaided hearing. All adverse events were resolved by the end of the study.

CONCLUSIONS

Safety and performance of the tBCI was demonstrated in children and adults 36 months postoperatively.

Auricular reconstruction using Medpor combined with different hearing rehabilitation approaches for microtia

BACKGROUND

Congenital microtia-atresia affects patients in two specific ways: severe conductive hearing loss and difficulty in integrating into social environments due to auricle malformation.

AIMS/OBJECTIVES

To investigate the safety and efficacy of single-stage auricular reconstruction and hearing rehabilitation in children with microtia and external auditory canal atresia.

MATERIAL AND METHODS

From January 2016 to December 2019, we included 32 patients with microtia and external canal atresia who received auricle reconstruction with high-density polyethylene (Medpor) framework and three different hearing rehabilitation approaches at the Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine. Twenty patients underwent the traditional external auditory canal and middle ear repair (EACR), eight patients were implanted with Bonebridge (BB) devices, and four patients were implanted with bone-anchored hearing aid (BAHA) in one stage. Postoperative changes in auricle morphology and hearing and speech recognition and occurrence of complications were evaluated.

RESULTS

After 6-24 months of follow-up, the auricle shape recovered well in all three groups, and the average score of 14 fine structures in the auricle was 9.43 (EACR), 10.67 (BB), and 9.75 (BAHA) points. The average score of auricle symmetry was 6.83 (EACR), 6.00 (BB), and 6.44 (BAHA) points. No significant differences in auricle shape were observed among the three groups (p > .05). After surgery, the average hearing improvement in the BB group was 43.33 dB, and the average speech recognition threshold declined to 42.28 dB. In the BAHA group, the average hearing improvement was 35 dB, and the average speech recognition threshold declined to 33.5 dB, similar to that of the BB group. However, in the EACR group, the average hearing improvement was only 4.13 dB, and the average speech recognition threshold declined to 11.36 dB. No vertigo, tinnitus, cerebrospinal fluid leakage, facial nerve paralysis, osseointegration failure, and other complications occurred in all the patients. In the EACR group, auricle stent fracture, ear canal restenosis, and canal atresia occurred in one patient each. In the BAHA group, two patients developed local ear infections.

CONCLUSIONS AND SIGNIFICANCE

The procedure of single-stage auricular reconstruction and hearing rehabilitation for microtia is feasible and effective. The appropriate method of hearing reconstruction should be determined by evaluating the development of the inner and middle ear of the patients. For those patients with poor development of the mastoid and ossicular chain, hearing aid devices are recommended to achieve a stable and significant hearing effect.

Psychosocial outcome measures for conductive and mixed hearing loss treatment: An overview of the relevant literature

OBJECTIVE

To identify the psychosocial assessments utilized with individuals with conductive and/or mixed hearing loss as part of a broader effort by the Auditory Rehabilitation Outcomes Network (AURONET) group to develop a core set of patient-centred outcome measures.

DESIGN

A review of articles published between 2006 and 2016 was completed. Included studies had more than three adult participants, were available in English, and reported a psychosocial outcome from any treatment of mixed and/or conductive hearing loss.

STUDY SAMPLE

Sixty-six articles from seven databases.

RESULTS

Sixty-six articles met our inclusion/exclusion criteria. Within this set, 15 unique psychosocial or patient-reported outcome measures (PROs) were identified, with the Abbreviated Profile of Hearing Aid Benefit (APHAB) and Glasgow Benefit Inventory (GBI) being the most frequently dispensed. Five of the fifteen were only administered in one study. In-house questionnaires (IHQs) were reported in 19 articles.

CONCLUSIONS

Only 66 (22%) of the 300 articles with outcomes contained a PRO. Some of the mostly frequently employed PROs (e.g., APHAB) were judged to include only social items and no psychological items. Lack of PRO standardization and the use of IHQs make psychosocial comparisons across treatments in this population difficult for patients, clinicians and stakeholders.

Patient-reported long-term benefit with an active transcutaneous bone-conduction device

Purpose

To evaluate the long-term benefits in hearing-related quality of life, patient satisfaction and wearing time of patients rehabilitated with an active transcutaneous bone-conduction device. Adverse events and audiological outcomes are reported as secondary outcomes.

Methods

This retrospective, mono-centric cohort analysis involves 16 adults with conductive or mixed hearing loss with a mean device experience of 51.25 months. Patient-reported outcome measures were assessed using the short version of the Speech, Spatial and Qualities of Hearing Scale (SSQ12-B) and the German version of the Audio Processor Satisfaction Questionnaire (APSQ). Audiological outcomes as well as incidence of adverse events were obtained from patients´ charts.

Results

The hearing-related quality of life improved significantly within all subscales of the SSQ12-B scoring a mean overall of 2.95 points. Patient satisfaction measured with the APSQ scored 8.8 points on average. Wearing times differed considerably and patients with lower levels of education seemed to use their device longer compared to patients with academic education. Eight minor adverse events were documented, all of which resolved during follow-up. The mean gain in word recognition score at the last follow-up measured at 65 dB was 75.9%, while speech reception threshold was lowered by 35.1 dB.

Conclusion

Even after several years, patients report significant benefits in hearing-related quality of life and device satisfaction. In combination with a low rate of minor adverse events and significantly improved audiological outcomes, the device is considered as a comfortable and effective option in hearing rehabilitation.

M.ALSHEIKH Technique: Modification to the Soft Tissue Reduction in the Baha® Attract Surgery

To describe a modification to the Baha^® Attract surgical technique that aims to enhance skin closure, create smooth skin across the surface of the wound, reduce surgery time, and improve cosmetics of the surgical site. Retrospective chart review. Patients were implanted between 2014 and 2016 at King Fahad General Hospital (KFGH) (Jeddah, Kingdom of Saudi Arabia). 20 adult patients (11 males, 9 females), all eligible for Baha^® Attract system. One patient only had a previous Baha^® surgery. The normal Baha^® Attract surgical technique with modification to the soft tissue reduction stage is described. The mean surgical time was 35.25 min (range 25-55). Bleeding was present but not significant and easily controlled in four patients. All patients received the 4 mm implant. None of the patients experienced severe pain. The postoperative follow-up period was 6 months for 7 patients and 8 months for 13 patients. Patient feedback and monitoring indicates a good hearing performance and comfort in all patients. The modified Baha^® Attract surgical method causes less postoperative complication, improve cosmetic effect, and provide shorter operative time compared to the conventional Attract procedure.

Retrospective Analysis of Hearing-Impaired Adult Patients Treated With an Active Transcutaneous Bone Conduction Implant

OBJECTIVE

To determine the therapeutic success and safety of an active transcutaneous bone conduction implant (tBCI) in adult patients with conductive or mixed hearing loss.

STUDY DESIGN

Retrospective case review.

SETTING

Five university hospitals in Frankfurt, Hannover, Dresden, Würzburg, and Vienna.

PATIENTS

Data were analyzed from 61 patients (31 women, 30 men) with a mean age of 50 years (min. 26, max. 80). Forty patients had mixed, and 21 conductive hearing loss. Typical etiologies were history of otitis media (n = 20) and cholesteatoma (n = 17).

INTERVENTIONS

Implantation of the active tBCI.

MAIN OUTCOME MEASURES

Data were analyzed for the following time points: up to 6 months postoperatively ("short-term"), 6 to 37 months postoperatively ("long-term"), and the last available measurement per patient ("most recent"). Pure-tone audiometry (air and bone conduction, AC and BC) and sound field thresholds with warble tones (WT), word recognition scores with Freiburger monosyllables (WRS), as well as speech reception thresholds (SRT) using the Oldenburg sentence test (OLSA) in quiet (SRT) and in noise (signal-to-noise ratio, SNR) were collected.

RESULTS

No significant changes in air- and bone-conduction thresholds were observed after implantation. A mean WRS improvement of 54% using the active tBCI was shown at the short-term assessment, i.e., a mean score of 79% compared with 25% in the unaided condition. Results remained stable, with a mean score of 75% at the long-term assessment. SRT in noise improved by 3.6 dB SNR in the implanted ear at the short-term assessment. Overall six adverse events and four serious adverse events were reported, resulting in a rate of 9.84 and 6.56%, respectively.

CONCLUSION

The tBCI clearly improves speech intelligibility in patients with conductive or mixed hearing loss, showing stable results up to 1 year post-implantation.

Hearing Rehabilitation Implementing a Transcutaneous Bone Conduction Device: Single-Center Experience

Bone conduction implants based on percutaneous abutment acoustic transmission have been implemented in patients with satisfactory outcomes. However, adverse soft tissue outcomes present a limitation. Transcutaneous bone conduction devices (t-BCDs) are an alternative that may mitigate these complications. A retrospective review was performed of patients who underwent implantation of a t-BCD from 2013 to 2017. Surgical outcomes were reviewed including wound complications, frequency of device use, patient concerns regarding the device, and reported patient satisfaction. A total of 37 patients were implanted with the bone-anchored hearing aids, BAHA Attract (Cochlear™ Baha® Implant System). Average follow-up time was 271.8 days. Postoperatively, 7 (18.9%) patients complained of soft tissue changes or issues with wound healing. Twelve (32.4%) patients requested adjustment of their devices. The t-BCD is an excellent option for hearing rehabilitation. Overall, the complication rate is low, patient satisfaction is high, and successful conversion from a percutaneous device is possible with minimal risk.

Baha Attract Implantation Using a Small Incision: Initial Report of Surgical Technique and Surveillance

OBJECTIVES

To determine the appropriate anatomical borders of implantation on the temporal bone in a cadaver study, and to develop a simplified surgical technique for Baha Attract implantation through a small incision along the hairline using anatomical evidence and a navigation system.

METHODS

In a cadaver study, 20 human adult dry skulls were used to find flat areas of the temporal bone for Baha Attract magnet implantation. Four borders of the "optimal surgical site" were defined: Asterion line, occipitomastoid suture line, sigmoid sinus line, and digastric groove line. In three patients, we implanted the Baha Attract according to the newly developed surgical procedure and validated the feasibility of this technique with a navigation system.

RESULTS

We identified the appropriate position of the implant on the temporal bone, suggesting a simplified surgical technique for Baha Attract with a small incision. We determined the spot of implantation, and the implants were inserted through a small surgical incision (<2.5 cm) under local anesthesia; the procedure lasted approximately 30 minutes.

CONCLUSION

The optimal surgical site of the temporal bone is a safe and easily accessible location for implantation of the Baha Attract.

Comparison of Satisfaction Between Patients Using Percutaneous and Transcutaneous Bone Conduction Devices

BACKGROUND

Bone conduction devices are widely used to treat conductive and mixed hearing loss as well as single-sided deafness (SSD). A transcutaneous system was introduced recently with the clear advantage of fewer local reactions. Our goal was to evaluate and compare the satisfaction of patients with percutaneous and transcutaneous bone conduction devices.

METHODS

We divided a cohort of 72 patients into groups by type of hearing loss and their relation to the use of the percutaneous or transcutaneous system. The Glasgow Benefit Inventory (GBI) questionnaire, adapted for hearing aids, was employed to assess patient satisfaction, along with an additional questionnaire covering the general usefulness of the devices.

RESULTS

Overall median daily wearing time was 12 hours for the percutaneous and seven for the transcutaneous groups (p < 0.001). We found no correlation between the bone conduction level at any frequency and the GBI satisfaction score. The median total GBI score of the entire patient cohort was 30.1; median values for general, social support, and physical health subscales were 0, 37.5, and 16.7, respectively. People suffering from SSD had the lowest satisfaction rates, and these were significantly lower for the patients who used transcutaneous aids than for those with percutaneous devices (p = 0.033). Similarly, the percutaneous system brought more satisfaction to combined hearing loss patients than did the transcutaneous (p = 0.010).

CONCLUSION

Both types of bone conduction devices provide a safe and efficient way to improve hearing for candidates within correct indications. Our study revealed that patients wore the transcutaneous device less than they did the percutaneous. Satisfaction was the lowest among SSD patients who used the transcutaneous device; hence it is especially important to carry out preoperative counseling for such patients.

Transcutaneous bone conductive implants in patients with conductive/mixed hearing loss: audiological outcomes in noise condition

BACKGROUND

Recently, the use of transcutaneous bone conduction implants (BCIs) has been increased. However, scarce data about BCI hearing recovery in noise conditions have been reported.

OBJECTIVES

To investigate the audiological benefits obtained with transcutaneous BCI-Sophono Alpha System in noise conditions. To evaluate post-implantation clinical outcomes and patient satisfaction levels.

MATERIALS AND METHODS

Fourteen patients suffering from conductive or mixed hearing loss implanted with the Sophono Alpha System were evaluated. Patients underwent physical examination, free-field pure-tone and speech audiometry both in unaided and aided conditions. The matrix sentence test was employed with fixed noise at 65 dB, and with a fluctuating primary signal, in three different conditions of noise presentations (S0/N0, S0/Ncontra, S0/Nipsi).

RESULTS

Hearing gain, expressed as the difference between pre-implant AC and post-implant SAS free field, was on average 26.7 dB. The unaided speech recognition score in quiet conditions had a mean value of 64.6%, and improved after SAS implantation, achieving mean values of 98.2%. SRT₅₀ with the matrix sentence test improved in all three conditions of noise presentation.

CONCLUSIONS

Sophono Alpha System devices represent a valid treatment option for hearing rehabilitation of patients with conductive or mixed hearing loss. The audiological results regarding hearing gain in noise conditions were good.

Outcomes of adenotonsillectomy in severe pediatric obstructive sleep apnea

We conducted a retrospective chart review to examine the efficacy of adenotonsillectomy for the treatment of severe obstructive sleep apnea (OSA) in children. Our study population was made up of 85 patients-58 boys and 27 girls, aged 1 to 17 years (mean: 6.9 ± 4.4)-with severe OSA who had undergone adenotonsillectomy and pre- and postoperative attended polysomnography (PSG) over a 4-year period. Severe OSA was defined as an apnea-hypopnea index (AHI) of >10 events per hour of sleep. Patients who had an underlying genetic or craniofacial anomaly were excluded. In addition to demographic and PSG data, we compiled information on selected characteristics of patients according to postoperative residual AHIs of ≤5 and >5. Finally, information on body mass index z score was available on 72 patients; the mean score was 1.55 ± 1.51, with 36 patients (50.0%) fulfilling the criteria for obesity. In the group as a whole, we found that adenotonsillectomy resulted in a significant reduction in AHI from 35.4 to 7.1 (p < 0.001). We also found an improvement in mean oxygen saturation nadir from 75.2 to 85.5 (p < 0.001). Postoperatively, only 8 patients (9.4%) achieved an AHI of ≤1; AHIs were >1 to ≤5 in 39 patients (45.9%), >5 to ≤10 in 24 patients (28.2%), and >10 in 14 patients (16.5%). A significantly higher proportion of boys had a residual AHI of >5 after surgery compared with those whose postoperative AHI was ≤5 (78.9 vs. 59.6%; p = 0.04). We conclude that adenotonsillectomy leads to a significant improvement in sleep-disordered breathing in children with severe OSA, but residual disease is common so close postoperative follow-up is essential.

A functional and anatomical comparison between two passive transcutaneous bone conduction implants in children

OBJECTIVE

To compare anatomical and functional outcomes of two passive transcutaneous bone conduction implant systems: Sophono™ and BAHA Attract™.

MATERIALS AND METHODS

Twenty patients, affected by bilateral conductive hearing loss, underwent unilateral transcutaneous bone conduction implant surgery. Ten children received a Sophono™ implant (6 males, 4 females, mean age 11 years, mean unaided Pure Tone Average (PTA) 0.25-4kHz = 69.70dB HL) and 10 a BAHA Attract™ system (7 males, 3 females, mean age 19 years, mean unaided PTA0.25-4kHz = 66.40dB HL). The following outcomes were considered: incidence of local complications, hearing aid benefit, hearing aid gain and changes in quality of life (QOL), as measured by the Glasgow Children's Benefit Inventory (GCBI).

RESULTS

One patient in the Sophono group experienced magnet-related skin decubitus, while two patients (one per group) had skin hyperemia in the area overlying the magnet. The mean BAHA-aided threshold was 23.70dB, whereas the mean Sophono-aided threshold was 31.60dB. The mean gain was significantly different for lower frequencies, the BAHA having better functional outcomes. All patients reported an improvement in their QOL.

CONCLUSION

Given the lower thickness of the internal magnet, the Sophono™ system might be more suitable for younger children, whereas BAHA offered better functional results. Both systems can be considered valid and safe options for the functional rehabilitation of conductive hearing loss in children, provided that precautions are observed, such as a gradual use of the device and use of the least powerful magnets in the first months after the activation.

Passive Transcutaneous Bone Conduction Hearing Implants: A Systematic Review

OBJECTIVE

To systematically review the literature on currently available passive transcutaneous bone conduction hearing implants (pTCBI) with regard to complications, audiological outcomes, and quality-of-life scores.

DATA SOURCES

MEDLINE, EMBASE, Scopus, and Cochrane Library.

STUDY SELECTION

All identified English-language articles reporting on the implantation of currently available pTCBI's and their complications. Both pediatric and adult patients were included. No limitation was placed on study design or level of evidence.

DATA EXTRACTION

Complications, audiological outcomes including mean pure-tone average gain and mean speech reception threshold gain, and quality-of-life outcomes.

DATA SYNTHESIS

Twenty-six articles were included in the review. Four hundred eighty-two pTCBIs have been reported in the literature. Major complications including skin breakdown, wound dehiscence, hematoma, seroma, and inability to use the device occurred in 5.2% of patients. Minor complications including pain and self-resolving erythema at the implant site occurred in 13.1% of the patients. The weighted mean pure-tone average gain of the two included devices was 28.4 ± 2.1 dB and the mean speech reception threshold gain was 32.9 ± 3.9 dB. Favorable quality-of-life scores have been demonstrated with pTCBIs.

CONCLUSION

pTCBIs are a viable alternative to percutaneous devices in a carefully selected group of patients. These devices have demonstrated good audiological outcomes, low morbidity, and high patient satisfaction.

A Bone Conduction Implantable Device as a Functional Treatment Option in Unilateral Microtia with Bilateral Stapes Ankylosis: A Report of Two Cases

BACKGROUND Implantable devices have been proposed as an alternative to hearing aids and auditory canal reconstruction in patients with microtia (congenital aural atresia), which includes a malformation of the external and middle ear. This report is of two rare cases of microtia associated with congenital stapes ankylosis treated with an implantable device and describes the treatment outcomes. CASE REPORT Two siblings from Ecuador, a 29-year-old woman, and her 35-year-old brother, were born with unilateral type II microtia with bilateral external auditory canal atresia and conductive hearing loss. Pre-operatively, high-resolution computed tomography (HRCT) imaging was performed using FastView software to allow placement of a bone conduction-floating mass transducer (BC-FMT) to couple a Bonebridge bone conduction implant (BCI) system in both patients. Pure-tone audiometry (PTA) testing and speech audiology were performed. The Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Speech, Spatial and Qualities (SSQ) of hearing scale questionnaires and scoring systems were used. Following activation of the implantable device, both patients achieved improved bilateral conductive hearing with sound-field (field-free) thresholds >25 dB, and speech recognition scores >90%. In both cases, hearing improvement remained at three years following surgery. CONCLUSIONS To our knowledge, these are the first reported cases of microtia with congenital stapes ankylosis successfully treated with a bone conduction implantable device. Patients with microtia and stapes ankylosis who are reluctant to undergo surgery may benefit from unilateral or bilateral, short-term or long-term use of a Bonebridge bone conduction implantable device.

Implantable hearing devices

Combined hearing loss is an essential indication for implantable hearing systems. Depending on the bone conduction threshold, various options are available. Patients with mild sensorineural deafness usually benefit from transcutaneous bone conduction implants (BCI), while percutaneous BCI systems are recommended also for moderate hearing loss. For combined hearing losses with moderate and high-grade cochlear hearing loss, active middle ear implants are recommended. For patients with incompatibilities or middle ear surgery, implants are a valuable and proven addition to the therapeutic options.

Preliminary audiologic and peri-operative outcomes of the Sophono™ transcutaneous bone conduction device: A systematic review

OBJECTIVE

To delineate the auditory functional improvement and peri-operative outcomes of the Sophono™ transcutaneous bone conduction device.

METHODS

Eligible articles presenting patients implanted with the Sophono™ were identified through a comprehensive search of PubMed and Embase electronic databases. All relevant articles were reviewed to justify inclusion independently by 2 authors. Studies that successfully passed critical appraisal for directness of evidence and risk of bias were included.

RESULTS

From a total of 125 articles, 8 studies encompassing 86 patients using 99 implants were selected. Most patients (79.1%) were children. Ear atresia (67.5%) was the most frequently reported indication for Sophono™ implantation. Overall pure tone average auditory improvement was 31.10 (±8.29) decibel. During a mean follow-up time of 12.48 months, 25 patients (29%) presented with post-operative complications from which 3 were deemed as serious implant-related adverse events (3.5%).

CONCLUSIONS

The Sophono™ transcutaneous bone conduction device shows promising functional improvement, no intra-operative complications and minor post-operative skin related complications. If suitable, the device could be a proposed solution for the rehabilitation of hearing in children meeting eligibility criteria. A wearing schedule must be implemented in order to reduce magnet-related skin complications.

Subdural Hematoma: A Rare Adverse Complication From Bone-Anchored Hearing Aid Placement

OBJECTIVE

Bone-anchored hearing aids (BAHA) are bone conduction hearing aids commonly implantated by Ear, Nose, and Throat surgeons. We present the first documented case of a subdural hematoma secondary to primary fixation of a BAHA.

PATIENT

We present a 65-year-old male patient undergoing a left sided BAHA for bilateral chronic ear infections and difficulty wearing conventional hearing aids. The procedure was uneventful, however, the patient developed a postoperative large acute left temporoparietal intracerebral hematoma associated with an ipsilateral acute subdural hematoma. This required emergency transfer to the local tertiary neurosurgical center for a left decompressive craniotomy and evacuation of the hematoma.

RESULTS

The patient required a prolonged stay on an intensive care unit and was eventually discharged to the community for on-going neurological rehabilitation.

CONCLUSION

This is a rare and devastating complication BAHA surgery. Otologist, general ENT surgeons, and neurosurgeons should be aware of this life-threatening complication of BAHA surgery.

Intermediate outcomes of a transcutaneous bone conduction hearing device in a paediatric population

OBJECTIVE

The aim of this study was to review the outcomes of Bone Anchored Hearing Aid (BAHA^®) Attract implantation in a cohort of paediatric patients.

METHODS

Prospective data collection and case review were undertaken in a paediatric tertiary referral centre. We have included patients under the age of 16 years with unilateral or bilateral hearing loss that met the criteria for BAHA^® Attract implantation. The main outcome measures were surgical complications and Patient Reported Outcomes including the 'Speech, Spatial and Qualities of Hearing scale' (SSQ-12) and 'Qualitative Feedback for BAHA^® 5 Hearing Aids'.

RESULTS

Twenty-five paediatric patients were implanted with the BAHA^® Attract between June 2014 and July 2016. Nine of them had a conversion from a percutaneous Bone Conduction Hearing Device (BCHD). Four children had minor skin problems that settled with conservative measures. Two children with a previous percutaneous BCHD developed skin dehiscence over the magnet after conversion to the transcutaneous version. The SSQ-12 was completed by 6 children and an improvement of 22% was noted between the unaided and aided condition. The patients and their parents were generally satisfied with the BAHA^® Attract.

CONCLUSIONS

The BAHA^® Attract offers a good solution for hearing rehabilitation in appropriately selected and counseled patients. The complication rate was low for primary surgery but higher in cases of conversion from a percutaneous device. Large, prospective data is needed to evaluate the relative risks and benefits of this BCHD.

The Prediction of Speech Recognition in Noise With a Semi-Implantable Bone Conduction Hearing System by External Bone Conduction Stimulation With Headband: A Prospective Study

Semi-implantable transcutaneous bone conduction devices are treatment options for conductive and mixed hearing loss (CHL/MHL). For counseling of patients, realistic simulation of the functional result is desirable. This study compared speech recognition in noise with a semi-implantable transcutaneous bone conduction device to external stimulation with a bone conduction device fixed by a headband. Eight German-language adult patients were enrolled after a semi-implantable transcutaneous bone conduction device (Bonebridge, Med-El) was implanted and fitted. Patients received a bone conduction device for external stimulation (Baha BP110, Cochlear) fixed by a headband for comparison. The main outcome measure was speech recognition in noise (Oldenburg Sentence Test). Pure-tone audiometry was performed and subjective benefit was assessed using the Glasgow Benefit Inventory and Abbreviated Profile of Hearing Aid Benefit questionnaires. Unaided, patients showed a mean signal-to-noise ratio threshold of 4.6 ± 4.2 dB S/N for speech recognition. The aided results were -3.3 ± 7.2 dB S/N by external bone conduction stimulation and -1.2 ± 4.0 dB S/N by the semi-implantable bone conduction device. The difference between the two devices was not statistically significant, while the difference was significant between unaided and aided situation for both devices. Both questionnaires for subjective benefit favored the semi-implantable device over external stimulation. We conclude that it is possible to simulate the result of speech recognition in noise with a semi-implantable transcutaneous bone conduction device by external stimulation. This should be part of preoperative counseling of patients with CHL/MHL before implantation of a bone conduction device.

Three year experience with the cochlear BAHA attract implant: a systematic review of the literature

BACKGROUND

Bone conduction devices are widely used and indicated in cases of conductive, mixed or single sided deafness where conventional hearing aids are not indicated or tolerated. Percutaneous bone-conduction devices gave satisfactory hearing outcomes but were frequently complicated by soft tissue reactions. Transcutaneous bone conduction devices were developed in order to address some of the issues related to the skin-penetrating abutment. The aim of this article is to present a systematic review of the indications, surgical technique and audiological, clinical and functional outcomes of the BAHA Attract device reported so far.

METHODS

A systematic computer-based literature search was performed on the PubMed database as well as Scopus, Cochrane and Google Scholar. Out of 497 articles, 10 studies and 89 reported cases were finally included in our review.

RESULTS

The vast majority of implanted patients were satisfied with the aesthetics of the device scoring highly at the Abbreviated Profile of Hearing Aid Benefit, Glasgow Benefit Inventory and Client Oriented Scale of Improvement. Overall, hearing outcomes, tested by various means including speech in noise, free field hearing testing and word discrimination scores showed a significant improvement. Complications included seroma or haematoma formation, numbness around the area of the flap, swelling and detachment of the sound processor from the external magnet.

CONCLUSIONS

The functional and audiological results presented so far in the literature have been satisfactory and the complication rate is low compared to the skin penetrating Bone Conduction Devices. Further robust trials will be needed to study the long-term outcomes and any adverse effects.

Audiological Results and Quality of Life of Sophono Alpha 2 Transcutaneous Bone-Anchored Implant Users in Single-Sided Deafness

Single-sided deafness (SSD) represents one of the most difficult audiological conditions to rehabilitate. The aim of this prospective study was to evaluate the audiological benefits and quality of life of patients affected by SSD who had previously been users of the Alpha 1® when upgrading them to the Sophono Alpha 2® external processor (Boulder, Colo., USA). Nine patients were included in the study. They underwent physical examination, free-field speech audiometry at 40 and 60 dB, a hearing-in-noise test (Hirsch's test and the squelch test), the Glasgow Benefit Inventory (GBI) questionnaire, and a specific questionnaire on patient satisfaction with Alpha 1. Afterwards, the Alpha 2 external processor was delivered to all patients, and the above-mentioned protocol was repeated after 1 month with the Alpha 2. A statistically significant improvement was found in the speech discrimination score at 40 dB and in the squelch test when using the Alpha 2 external processor compared to the Alpha 1. Alpha 2 had a good clinical tolerance and gave similar results in the specific questionnaire and the GBI to Alpha 1. In conclusion, the new Alpha 2 external processor represents a safe and effective device for the rehabilitation of SSD, and there is an audiological benefit to upgrading to the Alpha 2 external processor for patients who had previously been users of the Alpha 1. The improvement in quality of life is similar to that with other bone-anchored hearing devices.

Surgical and Audiologic Comparison Between Sophono and Bone-Anchored Hearing Aids Implantation

OBJECTIVES

Bone-anchored hearing aids (BAHA) occasionally cause soft tissue problems due to abutment. Because Sophono does not have abutment penetrating skin, it is thought that Sophono has no soft tissue problem relating to abutment. On the other hand, transcutaneous device's output is reported to be 10 to 15 dB lower than percutaneous device. Therefore, in this study, Sophono and BAHA were compared to each other from surgical and audiological points of view.

METHODS

We retrospectively reviewed the medical records of 9 Sophono patients and 10 BAHA patients. In BAHA cases, single vertical incision without skin thinning technique was done. We compared Sophono to BAHA by operation time, wound healing time, postoperative complications, postoperative hearing gain after switch on, and postoperative air-bone gap.

RESULTS

The mean operation time was 60 minutes for Sophono and 25 minutes for BAHA. The wound healing time was 14 days for Sophono and 28 days for BAHA. No major intraoperative complication was observed. Skin problem was not observed in the 2 devices for the follow-up period. Postoperative hearing gain of bilateral aural atresia patients was 39.4 dB for BAHA (n=4) and 25.5 dB for Sophono (n=5). However, the difference was not statistically significant. In all patients included in this study, the difference of air-bone gap between two groups was 16.6 dB at 0.5 kHz and 18.2 dB at 4 kHz. BAHA was statistically significantly better than Sophono.

CONCLUSION

Considering the audiologic outcome, BAHA users were thought to have more audiologic benefit than Sophono users. However, Sophono had advantages over BAHA with abutment in cosmetic outcome. Sophono needed no daily skin maintenance and soft tissue complication due to abutment would not happen in Sophono. Therefore, a full explanation about each device is necessary before deciding implantation.

Three-year experience with the Sophono in children with congenital conductive unilateral hearing loss: tolerability, audiometry, and sound localization compared to a bone-anchored hearing aid

Bone conduction devices (BCDs) are advocated as an amplification option for patients with congenital conductive unilateral hearing loss (UHL), while other treatment options could also be considered. The current study compared a transcutaneous BCD (Sophono) with a percutaneous BCD (bone-anchored hearing aid, BAHA) in 12 children with congenital conductive UHL. Tolerability, audiometry, and sound localization abilities with both types of BCD were studied retrospectively. The mean follow-up was 3.6 years for the Sophono users (n = 6) and 4.7 years for the BAHA users (n = 6). In each group, two patients had stopped using their BCD. Tolerability was favorable for the Sophono. Aided thresholds with the Sophono were unsatisfactory, as they did not reach under a mean pure tone average of 30 dB HL. Sound localization generally improved with both the Sophono and the BAHA, although localization abilities did not reach the level of normal hearing children. These findings, together with previously reported outcomes, are important to take into account when counseling patients and their caretakers. The selection of a suitable amplification option should always be made deliberately and on individual basis for each patient in this diverse group of children with congenital conductive UHL.

The Vibrant Soundbridge in Children and Adolescents: Preliminary European Multicenter Results

OBJECTIVE

Evaluation of safety and efficacy of the Vibrant Soundbridge in the treatment of hearing loss in children and adolescents with primary focus on improvement in speech discrimination.

STUDY DESIGN

Prospective, single-subject repeated-measures design in which each subject serves as his/her own control.

SETTING

Tertiary referral center.

PATIENTS

Nineteen patients aged 5 to 17 years.

INTERVENTION

Implantation of an active middle ear implant.

MAIN OUTCOME MEASURE

Improvement in word recognition scores, speech reception thresholds, and signal-to-noise ratios (SNRs) were evaluated, in addition to air and bone conduction. Oldenburger Kids Satztest/Oldenburger Satztest sentences and Göttinger/Freiburger monosyllables at 65-dB hearing level were tested in two age groups.

RESULTS

Significant speech discrimination improvement was seen in all patients after 6 months. In children 5 to 9 years old, mean monosyllable recognition improved from 28.9% (unaided) to 95.5% (Soundbridge-aided). Aided 50% sentence discrimination at 44.1 dB and SNR of -4.9 dB were measured. In patients 10 to 17 years old, mean word recognition improved from 18.5% to 89.0%, sentence reception threshold improved to 40.2 dB, and SNR to -3.6 dB. Comparison between age groups indicated a slight trend toward quicker adaptation by older subjects. However, after initial adjustment, a higher level of overall benefit was seen at 6 months in younger children.

CONCLUSIONS

Currently, the only middle ear implant approved for pediatric patients, the Vibrant Soundbridge, provides an option in cases of congenital aural atresia or disease-induced defects, when surgical intervention and reconstruction is indicated. The 6-month results in this comparatively large study population validated conclusions found in previous trials.

Individual computer-assisted 3D planning for surgical placement of a new bone conduction hearing device

OBJECTIVE

To evaluate the benefit of a preoperative three-dimensional (3D) planning tool for surgically placing the bone conduction floating mass transducer (BC-FMT) of the Bonebridge (BB) bone conduction implant.

PATIENTS

Adult patients (n = 5) and one pediatric patient (n = 1) with conductive or mixed hearing loss caused by chronic ear disease, malformation, or single-sided deafness.

INTERVENTION(S)

Development of a preoperative planning tool that allowed free adjustment of the implant in an individual 3D model of the skull to evaluate completely fitting the BC-FMT into a bony bed and to identify an optimal implant position. Implantation of the BB with mastoid or retrosigmoid placement after individual preoperative planning and "virtual surgery".

MAIN OUTCOME MEASURES

Feasibility of the preoperative 3D planning process, transfer into the intraoperative situation, and audiologic results after BB implantation.

RESULTS

Individual preoperative planning was considered beneficial especially in cases of small mastoid bone volume, for example, because of previous canal wall down mastoidectomies, and in the case with malformation.

CONCLUSION

For optimal placement of the BC-FMT of the BB, preoperative 3D planning is recommended especially in primarily small poorly pneumatized mastoids, hypoplastic mastoids in malformations, reduced bone volume after canal wall down mastoidectomy, or the small mastoids in children. Effort should be made to reduce segmentation and surgical planning time by means of automation.

Quality standards for bone conduction implants

CONCLUSION

Bone conduction implants are useful in patients with conductive and mixed hearing loss for whom conventional surgery or hearing aids are no longer an option. They may also be used in patients affected by single-sided deafness.

OBJECTIVES

To establish a consensus on the quality standards required for centers willing to create a bone conduction implant program.

METHOD

To ensure a consistently high level of service and to provide patients with the best possible solution the members of the HEARRING network have established a set of quality standards for bone conduction implants. These standards constitute a realistic minimum attainable by all implant clinics and should be employed alongside current best practice guidelines.

RESULTS

Fifteen items are thoroughly analyzed. They include team structure, accommodation and clinical facilities, selection criteria, evaluation process, complete preoperative and surgical information, postoperative fitting and assessment, follow-up, device failure, clinical management, transfer of care and patient complaints.

New developments in bone-conduction hearing implants: a review

The different kinds of bone-conduction devices (BCDs) available for hearing rehabilitation are growing. In this paper, all BCDs currently available or in clinical trials will be described in categories according to their principles. BCDs that vibrate the bone via the skin are referred to as skin-drive devices, and are divided into conventional devices, which are attached with softbands, for example, and passive transcutaneous devices, which have implanted magnets. BCDs that directly stimulate the bone are referred to as direct-drive devices, and are further divided into percutaneous and active transcutaneous devices; the latter have implanted transducers directly stimulating the bone under intact skin. The percutaneous direct-drive device is known as a bone-anchored hearing aid, which is the BCD that has the largest part of the market today. Because of some issues associated with the percutaneous implant, and to some extent because of esthetics, more transcutaneous solutions with intact skin are being developed today, both in the skin-drive and in the direct-drive category. Challenges in developing transcutaneous BCDs are mostly to do with power, attachment, invasiveness, and magnetic resonance imaging compatibility. In the future, the authors assume that the existing percutaneous direct-drive BCD will be retained as an important rehabilitation alternative, while the transcutaneous solutions will increase their part of the market, especially for patients with bone-conduction thresholds better than 35 dB HL (hearing level). Furthermore, the active transcutaneous direct-drive BCDs appear to be the most promising systems, but to establish more detailed inclusion criteria, and potential benefits and drawbacks, more extensive clinical studies are needed.

Speech understanding with a new implant technology: a comparative study with a new nonskin penetrating Baha system

OBJECTIVE

To compare hearing and speech understanding between a new, nonskin penetrating Baha system (Baha Attract) to the current Baha system using a skin-penetrating abutment.

METHODS

Hearing and speech understanding were measured in 16 experienced Baha users. The transmission path via the abutment was compared to a simulated Baha Attract transmission path by attaching the implantable magnet to the abutment and then by adding a sample of artificial skin and the external parts of the Baha Attract system. Four different measurements were performed: bone conduction thresholds directly through the sound processor (BC Direct), aided sound field thresholds, aided speech understanding in quiet, and aided speech understanding in noise.

RESULTS

The simulated Baha Attract transmission path introduced an attenuation starting from approximately 5 dB at 1000 Hz, increasing to 20-25 dB above 6000 Hz. However, aided sound field threshold shows smaller differences and aided speech understanding in quiet and in noise does not differ significantly between the two transmission paths.

CONCLUSION

The Baha Attract system transmission path introduces predominately high frequency attenuation. This attenuation can be partially compensated by adequate fitting of the speech processor. No significant decrease in speech understanding in either quiet or in noise was found.

Sophono in Pediatric Patients

Objective

Since 2011, a transcutaneous bone-anchored auditory implant (Sophono) has been available for patients affected by bilateral, conductive hearing loss that cannot be corrected by surgery. To date, very few cases of device application in the pediatric population have been described. The aim of the present study is to report on complications, functional outcome, and health-related quality of life of the first pediatric cases in Italy.

Study Design

Case series with planned data collection.

Setting

Tertiary care pediatric center.

Subjects and Methods

Of 25 candidates with bilateral, conductive hearing loss screened between January 2012 and July 2013, 6 were included in the study (3 male and 3 female; median age, 9 years; age range, 5-17 years). Data concerning surgery, complications, functional outcome, and health-related quality of life were gathered prospectively.

Results

No major intraoperative complications occurred. Postoperative complications included 1 patient developing a skin ulceration below the external magnet and 1 patient reporting pain from using the device for more than 4 hours a day consecutively. Median free-field pure tone average (0.5-3 kHz) with the device was 32.5 dB HL, and median functional gain was 33 dB HL. Median Glasgow Children’s Benefit Inventory score was +42.

Conclusion

Sophono implants can be a valuable alternative to percutaneous implants in patients with bilateral, conductive hearing loss. To ensure the success of the treatment, several precautions should be taken, including a careful preoperative assessment of skull bone thickness and a close postoperative follow-up of the skin under the external processor, especially over the first months.