Alternative Inverted Middle Fossa Approach in Bonebridge Surgery. Technique, Results and Complications

Abstract Introduction The transmastoid approach is the most recommended technique to Bonebridge surgery, while in patients with bad anatomy or in the canal wall down technique, retrosigmoid or Middle Fossa Approaches are the alternative surgical options. Objective To describe a novel alternative approach called inverted middle fossa approach (IMFA) and its technique and audiological outcomes. Methods Seven patients submitted to the IMFA were included. All patients presented conductive and mixed hearing loss with bone thresholds of the audiogram > 40 dB. The audiological test was conducted pre- and postoperatively. Results A total of 5 males and 2 females, aged 13,8 years old (range 6-25 years old) were studied. The average follow-up was of 20 months (12 to 32 months). All patients presented aural atresia, except one with severe osseous-fibrous dysplasia of the temporal bone. Two patients showed bilateral compromise, three patients had associated Goldenhar and Treacher Collins syndrome. On the preoperative audiograms, air conduction (AC) thresholds showed a PTA4 (0.5, 1, 2 and 4 kHz) of 66.7 dB (standard deviation [SD] = ± 7.8), while the bone conduction thresholds reached an average of 11.2 dB (SD = ± 6.9). The postoperative thresholds did not change, and additional sensorineural damage was not observed before activation. Four weeks after surgery, all the patients were fitted with the external processor. The postoperative audiological aided exam showed AC PTA 4 thresholds of 18.9 dB (SD = ± 5.9). Conclusion The IMFA allows the nearest position of the microphone to the external auditory canal. The technique is a suitable option to the 3 classical approaches with similar rate of audiological results. More investigation is needed to determine the benefit of the novel approach compared with the others.

Improving the Accuracy of Baha(R) Fittings through Measures of Direct Bone Conduction

OBJECTIVES: Variability in Baha(R) sound processor fittings may arise from the nature of the implant-to-bone transmission as well as transcranial attenuation for patients with single-sided sensorineural deafness (SSD). One method of improving the predictability of Baha fittings is to measure the individual patient's actual bone conduction thresholds, thereby removing the influences of skin thickness and/or the implant location site. METHODS: Twenty adult wearers of the Baha bone conduction implant system participated in the study. Direct bone conduction thresholds were obtained through the BC Direct function of the Baha Fitting Software combined with the Cochlear Baha BP100 sound processor. For comparison, the masked and unmasked bone conduction responses of the patients were collected through standard audiometric testing techniques. Test-retest reliability measurement was performed for all participants. Data for each frequency and frequency range were analyzed separately. RESULTS: The results confirm the improved transmission of sound through the implant rather than transcutaneously through the skin. On average, the BC Direct thresholds were closer to the patient's unmasked thresholds than the masked values. In subjects with SSD, BC Direct results were poorer than contra-lateral bone conduction thresholds, most likely due to transcranial attenuation. The test-retest reliability for the BC Direct measurements was within +/-5 dB. The comparison of preferred amplification, based on direct bone conduction or bone conduction audiometry, found higher agreement for fittings based on direct bone conduction measurements. CONCLUSION: While the transfer function between the implant and the skin can be predicted on average, there are a number of patients for whom measurement is essential to determine the required amplification. These were patients with: 1) SSD, 2) asymmetrical hearing loss, 3) unusual implant location or skull formation, and 4) users of Testband or Softband. The result for the clinician is that a fitting can take place with less fine-tuning and a greater understanding of the variability of bone conducted sound transmission.

Hearing Performance Benefits of a Programmable Power Baha(R) Sound Processor with a Directional Microphone for Patients with a Mixed Hearing Loss

OBJECTIVES: New signal processing technologies have recently become available for Baha(R) sound processors. These technologies have led to an increase in power and to the implementation of directional microphones. For any new technology, it is important to evaluate the degree of benefit under different listening situations. METHODS: Twenty wearers of the Baha osseointegrated hearing system participated in the investigation. The control sound processor was the Baha Intenso and the test sound processor was the Cochlear(TM) Baha(R) BP110power. Performance was evaluated in terms of free-field audibility with narrow band noise stimuli. Speech recognition of monosyllabic phonetically balanced (PB) words in quiet was performed at three intensity settings (50, 65, and 80 dB sound pressure level [SPL]) with materials presented at 0 degrees azimuth. Speech recognition of sentences in noise using the Hearing in Noise Test (HINT) in an adaptive framework was performed with speech from 0 degrees and noise held constant at 65 dB SPL from 180 degrees. Testing was performed in both the omni and directional microphone settings. Loudness growth was assessed in randomly presented 10 dB steps between 30 and 90 dB SPL to narrow band noise stimuli at 500 Hz and 3,000 Hz. RESULTS: The test sound processor had significantly improved high frequency audibility (3,000-8,000 Hz). Speech recognition of PB words in quiet at three different intensity levels (50, 65, and 80 dB SPL) indicated a significant difference in terms of level (P0.05). Speech recognition of sentences in noise demonstrated a 2.5 dB signal-to-noise ratio (SNR) improvement in performance for the test sound processor. The directional microphone provided an additional 2.3 dB SNR improvement in speech recognition (P<0.0001). Loudness growth functions demonstrated similar performance, indicating that both sound processors had sufficient headroom and amplification for the required hearing loss. CONCLUSION: The test sound processor demonstrated significant improvements in the most challenging listening situation (speech recognition in noise). The implementation of a directional microphone demonstrated a further potential improvement in hearing performance. Both the control and test sound processors demonstrated good performance in terms of audibility, word recognition in quiet and loudness growth.