Osseointegrated Auditory Devices-Transcutaneous: Sophono and Baha Attract.

Percutaneous osseointegrated bone conduction auditory devices provide excellent auditory rehabilitation. Device-related complications relate to skin abutment interface and cosmetic concerns, resulting in the development of transcutaneous devices. The Sophono and Baha Attract are safe and considered cosmetically superior to the percutaneous Baha Connect and Ponto. They provide excellent auditory enhancement; however, owing to indirect connectivity between processor and implant, there is on average 5- to 7-db less gain when compared with percutaneous bone-anchored implants. Surgical implantation of either device is usually performed under monitored sedation, in an ambulatory setting, with less than a 1-hour operative time, and minimal complications.

Osseointegrated Auditory Devices: Bone-Anchored Hearing Aid and PONTO.

Osseointegrated auditory devices (OADs) are hearing devices that use an external receiver/processor that stimulates bone conduction of sound via a titanium prosthesis that is drilled into the bone of the cranium. Since their introduction in 1977, OADs have undergone substantial evolution, including changes in manufacturing of the implant, improvements in the external sound processor, and simplification of implantation techniques. Expansion of criteria for patient candidacy for implantation has occurred corresponding with changes in the implants and processors.

Metastatic squamous cell carcinoma of the tonsil presenting as otorrhea: a case report.

We describe the case of a 52-year-old man with a history of squamous cell carcinoma (SCC) of the tonsil who presented with right subacute otalgia and otorrhea. Dedicated computed tomography of the temporal bones showed opacification within the mastoid process with destruction of bony mastoid septations consistent with coalescent mastoiditis. Preoperative imaging showed no destruction or expansion of the bony eustachian tube that would indicate that a direct spread had occurred. An urgent cortical mastoidectomy was performed. Intraoperatively, a friable white mass surrounded with purulence and granulation tissue was biopsied and returned as SCC. The discrete metastasis was removed without complication. Postoperatively, the patient was prescribed palliative chemotherapy. This case shows that a metastatic SCC can be masked by an overlying mastoiditis, and thus it should be considered in the differential diagnosis of a patient with a history of oropharyngeal cancer.

Pilot study of a high-frequency school-based hearing screen to detect adolescent hearing loss.

OBJECTIVE: Like most of the United States, school-based hearing screening in Pennsylvania focuses on low-frequency, conductive hearing losses typical for young children, rather than the high-frequency, noise-induced hearing loss more prevalent among adolescents. The objective of this study was to compare the sensitivity and specificity of current school hearing screening in Pennsylvania with hearing screening including high frequencies, designed to detect adolescent hearing loss. SETTING: A single public high school. METHODS: In the Autumn of 2011 the high-frequency screen was delivered alongside the Pennsylvania school screen for students in the 11(th) grade. Screening referrals and a subset of passes returned for "gold standard" testing with audiology in a sound treated booth, in order to determine the sensitivity and specificity of the screening tests. RESULTS: Of 282 participants, five (2%) were referred on the Pennsylvania school screen, and 85 (30%) were referred on the high-frequency screen. Of the 48 who returned for gold standard testing with audiology, hearing loss was diagnosed in 9/48 (19%). Sensitivity of the Pennsylvania and high-frequency screens were 13% (95% confidence interval [CI] 0-53%) and 100% (95% CI 66-100%) respectively. Specificity of the Pennsylvania and high-frequency screens were 97% (95% CI 87-100%) and 49% (95% CI 32-65%) respectively. CONCLUSIONS: Current school hearing screens have low sensitivity for detection of adolescent hearing loss. Modifying school-based protocols may be warranted to best screen adolescents, and make optimal use of school nurse time and effort.

Round window membrane permeability to golimumab in guinea pigs: a pilot study.

OBJECTIVES/HYPOTHESIS: Autoimmune inner ear disorder is one of a few types of sensorineural hearing loss that is treatable and potentially reversible. Treatment involves oral steroids and methotrexate. Other treatment modalities have been tried with variable success. All such treatments are systemic, with inherent side effects limiting their effectiveness. Recently, tumor necrosis factor (TNF)-α blockers have been suggested as a modality of treatment. The objective of this study was to assess the round window membrane permeability to golimumab, a TNF-α blocker. This study is the first to look at the feasibility of local golimumab delivery into the inner ear, which may allow for targeted immune modulation of autoimmune inner ear disorders without the consequences of systemic treatment. STUDY DESIGN: This is a single-blinded, placebo-controlled, pilot study using guinea pigs to assess round window membrane permeability to golimumab. METHODS: Golimumab was instilled into the guinea pigs' middle ear. Inner ear fluid was sampled through the round window membrane after approximately 30 minutes of drug exposure. Golimumab presence in the inner ear was assessed by enzyme-linked immunosorbent assay in both drug-treated and control ears. RESULTS: Higher concentrations of golimumab were detected in the inner ear fluid samples of golimumab-exposed ears than in the control ears. The difference was statistically significant (P < .001). CONCLUSIONS: Golimumab crosses the round window membrane and is detected in measurable concentrations in the inner ear fluid after 30 minutes of exposure to the membrane. Further studies are needed to learn its pharmacokinetics and the time needed to reach optimal concentration in the inner ear. LEVEL OF EVIDENCE: NA. Laryngoscope, 123:2840-2844, 2013.

Vestibular pneumolabyrinth: why assessment with temporal bone computed tomography utilizing dynamic focal spot mode is important for the diagnosis.

We present an interesting and relatively uncommon case of vestibular pneumolabyrinth in a young child post-trauma. His initial clinical exam and imaging studies of the head and cervical spine were negative. He subsequently developed nystagmus and a dedicated temporal bone study demonstrated a subtle fracture and vestibular pneumolabyrinth. Temporal bone fractures can be difficult to appreciate, and therefore, associated findings of fluid in the middle ear, stapes dislocation, or vestibular pneumolabyrinth must be carefully evaluated. Temporal bone computed tomography is a high resolution study, utilizing dynamic focal spot mode which leads to increased sampling and resolution, thereby reducing aliasing artifacts but a longer scan time and increased radiation dose. CT head and cervical spine normally obtained without using this technique leads to aliasing artifacts where even the normal endolymph in the inner ear structures appear hypodense mimicking pneumolabyrinth, thereby obscuring true pneumolabyrinth. It is important to be aware of this finding and technique-related artifact, if a temporal bone injury is suspected, to ensure an earlier diagnosis and optimum management.

Reconstruction of congenital microtia-atresia: outcomes with the Medpor/bone-anchored hearing aid-approach.

Ideal surgery for congenital microtia-atresia would offer excellent cosmetic and hearing rehabilitation, with minimal morbidity. Classic approaches require multiple procedures, including rib cartilage harvest and aural atresia repair. Our facial plastic and otologic team approach incorporates a high-density porous polyethylene (Medpor, Porex Surgical, Newnan, GA) auricular framework, followed by single-stage bone-anchored hearing aid (BAHA) implantation. We evaluated the efficacy, safety, and morbidity of this 2-stage dual system approach. A prospective database of microtia patients was used to identify patients undergoing combined Medpor/BAHA auricular reconstruction and hearing rehabilitation between 2003 and 2006. The first stage involves placement of a Medpor framework beneath a temporoparietal fascia flap, followed by a second-stage procedure for lobule transposition and BAHA implantation. Twenty-five patients (28 ears) were evaluated. Aesthetic quality of the implants was excellent, with a high degree of framework detail visible, and a postauricular crease created in all patients. All patients were satisfied with the cosmetic result. There were no major Medpor complications such as infection, extrusion, loss of implant, or flap necrosis, and a 10.7% incidence of minor complications requiring operative revision. BAHA significantly improved hearing in all patients, with a complication rate of 31.8%, mainly skin overgrowth and cellulitis. The Medpor/BAHA dual plastic-otologic approach to microtia-atresia has produced excellent cosmetic results and hearing outcomes, which compare favorably to traditional microtia-atresia repair. This is a 2-stage aesthetic and functional protocol with an acceptably low rate of complications, which safely and efficiently achieves both aesthetic and functional goals.

Successes and complications of the Baha system.

OBJECTIVE: To determine the incidence and type of complications, as well as patient satisfaction, associated with the Baha system. STUDY DESIGN: Retrospective case review. SETTING: The Silverstein Institute, Sarasota, Florida, and the Columbia University Medical Center, New York, New York. PATIENTS: Patients with conductive/mixed hearing loss and single-sided deafness implanted with the Baha system between June 1998 and December 2007. INTERVENTION: Implantation with the Baha system. MAIN OUTCOME MEASURE: Incidence and type of complications associated with Baha implantation and patient satisfaction as measured by a questionnaire administered on site or by telephone. RESULTS: : In our series of 218 patients (223 ears), there were no major complications. Of these patients, 4.5% required revision surgery for soft tissue complications and 1.3% needed revision for failure of osseointegration. Eight percent (8%) required local care and resolved within 2 to 3 weeks of treatment. Five percent (5%) required in office procedures. One hundred six (106) patients satisfactorily completed the survey questionnaire. Ninety-two percent (92%) reported using the device regularly and 77% were happy with the device. On average, patients reported using the device 10.1 h/d, 5.6 d/wk. CONCLUSION: The Baha system is safe and effective in the rehabilitation of patients with conductive or mixed hearing losses and with single-sided deafness. The high success rate, patient satisfaction rate, and predictable auditory outcome place the Baha among the leading choices for auditory rehabilitation.

Osseointegration timing for Baha system loading.

OBJECTIVES: The process of osseointegration for creating a biological bond between titanium oxide and bone is time dependent. However, different surgeons have used very varied time frames before loading the implant. The waiting time in dental implant loading ranged from immediate to 6 months. The Baha system (Cochlear Limited, Englewood, CO) traditional waiting period consisted of 3 months for adults and 4 to 6 months for children. The purpose of the study was to evaluate the safety of reducing the waiting time to 6 weeks in adults. STUDY DESIGN: Retrospective study of patients who underwent Baha implantation and exteriorization between March, 2004 and July 2005. METHODS: Twenty-six adult patients underwent Baha titanium implantation and exteriorization in a single stage. They were loaded with the external processor after an average of 6.5 weeks. The etiology of their hearing loss (HL) included conductive HL, mixed HL, and unilateral sensorineural HL. Follow-up period ranged between 6 and 20 months. RESULTS: All patients were successfully implanted with the titanium implants, loaded at the 6 week interval, and have safely retained their prosthesis. The only reported complication was dermatitis, which occurred in three patients. Patients were pleased to receive the external processor earlier. CONCLUSION: The reduction of the waiting period from 3 months to 6 weeks did not result in any failure of osseointegration of the titanium implants. The earlier activation resulted in enhanced patient satisfaction. A larger series would be needed to definitively recommend shortening of the interval between Baha implantation and device loading.

An update on the surgical treatment of Ménière's diseases.

Various surgical procedures have evolved for the treatment of Ménière's disease patients who are refractory to medical therapy. These can be in the form of conservative surgeries as in endolymphatic sac surgery or in the form of destructive procedures. The latter include labyrinthectomy and vestibular nerve section, which result in deafferentation of the vestibular end organ. In the past decade, intratympanic therapy with gentamycin and steroids has evolved as new methods for the treatment of Ménière's disease. The literature witnesses controversies in the effectiveness of endolymphatic sac surgery in the treatment of Ménière's disease. The choice of the surgical procedure depends on the degree of serviceable hearing, the severity of the spells, and the condition of the contralateral ear. The most commonly used procedures in the treatment of Ménière's disease and their indications are reviewed.

Localization by unilateral BAHA users.

OBJECTIVES: Patients with unilateral hearing loss report difficulty hearing conversation on their impaired side, localizing sound, and understanding of speech in background noise. The bone-anchored cochlear stimulator (BAHA) (Entific, Gothenburg, Sweden) has been shown to improve performance in persons with unilateral severe-profound sensorineural loss (USNHL). The purpose of this study is to evaluate the effectiveness of BAHA in sound localization for USNHL listeners. STUDY DESIGN: Prospective study of 12 USNHL subjects, 9 of whom received implants on the poorer hearing side. A control group of 10 normal hearing subjects were assessed for comparison. Localization with and without BAHA was assessed using an array of 8 speakers at head level separated by 45 degrees. Error analysis matrix was generated to evaluate the confusions, accuracy in response, and laterality judgment. RESULTS: The average accuracy of speaker localization was 16% in the unaided condition, with no improvement with BAHA use. Laterality judgment was poorer than 43% in both aided and nonaided conditions. CONCLUSIONS: Patients with UNSNHL had poor sound localization and laterality judgment abilities that did not improve with BAHA use.

High-frequency pulsed electromagnetic energy in tinnitus treatment.

OBJECTIVES/HYPOTHESIS: Electromagnetic therapy has been used with reported success in multiple clinical settings, including the treatment of seizure disorders, brain edema, migraine headaches, revascularization of burn wounds, and diabetic ulcers. The purpose of the study was to investigate the effect of pulsed high-frequency electromagnetic therapy on chronic tinnitus. STUDY DESIGN: A randomized, prospective, double-blind, placebo-controlled pilot study was conducted to evaluate the effectiveness of high-frequency pulsed electromagnetic energy using the Diapulse device in the treatment of chronic tinnitus. Thirty-seven adult patients with chronic tinnitus of at least 6 months' duration were recruited and randomly assigned to either a treatment or a placebo group. METHODS: Patients received 30-minute treatments with the Diapulse device three times a week for 1 month. The unit was set to deliver electromagnetic energy at a frequency of 27.12 MHz at a repetition rate of 600 pulses per second. All subjects had pretreatment and post-treatment audiological testing, including tinnitus frequency and intensity matching. They responded to a tinnitus rating questionnaire and the Tinnitus Handicap Inventory before and after treatment. RESULTS: There was no significant change in the pretreatment and post-treatment audiometric thresholds in either group. There were no significant differences between the pretreatment and post-treatment Tinnitus Handicap Inventory scores or the tinnitus rating scores in either subject group (Student t test). No diagnosis-specific differences were identified. CONCLUSION: High-frequency pulsed electromagnetic energy (Diapulse) at the settings used in the study showed no role in the therapy of patients with chronic tinnitus.

Transcranial contralateral cochlear stimulation in unilateral deafness.

OBJECTIVES: The purpose of this study is to evaluate the effectiveness of Bone Anchored Cochlear Stimulator (BAHA) in transcranial routing of signal by implanting the deaf ear. Study design and settings Eighteen patients with unilateral deafness were included in a multisite study. They had a 1-month pre-implantation trial with a contralateral routing of signal (CROS) hearing aid. Their performance with BAHA was compared with the CROS device using speech reception thresholds, speech recognition performance in noise, and the Abbreviated Profile Hearing Benefit and Single Sided Deafness questionnaires. RESULTS: Patients reported a significant improvement in speech intelligibility in noise and greater benefit from BAHA compared with CROS hearing aids. Patients were satisfied with the device and its impact on their quality of life. No major complications were reported. Conclusion and significance BAHA is effective in unilateral deafness. Auditory stimuli from the deaf side can be transmitted to the good ear, avoiding the limitations inherent in CROS amplification.

Oral-facial-digital syndrome type II variant associated with congenital tongue lipoma.

We report a case with several congenital anomalies, including polysyndactyly, hypertelorism, partial median cleft of the upper lip, and 2 solitary tongue masses. These features are consistent with oral-facial-digital (OFD) type II syndrome. This case, however, had tongue lipomas with pathosis instead of the usually described tongue hamartomas. In addition, our patient had a sacral dermal pit, which is not a known characteristic of patients with OFD type II. The patient had a younger sister with the same anomalies who died at the age of 10 days and thus was unavailable for examination. We propose to distinguish patients with tongue lipomas and features of OFD type II as a variant of that syndrome.

Rhinolithiasis: a forgotten entity.

OBJECTIVE: To review the clinical presentation of patients with rhinoliths, which are calcareous concretions with an unclear pathogenesis. STUDY DESIGN AND SETTING: Using retrospective chart review we analyzed clinical, radiological, and demographic data as well as our diagnostic work-up and management of 8 patients. RESULTS: Most patients presented with nonspecific nasal complaints; most commonly, purulent rhinorrhea and nasal obstruction. The rhinolith was discovered incidentally in some patients. CONCLUSION: Rhinoliths are rare and can have various clinical presentations. The treatment of choice is surgical removal. SIGNIFICANCE: A high index of suspicion is required for the diagnosis of such a forgotten entity.

Evolving applications in the use of bone-anchored hearing aids.

The bone-anchored hearing aid (BAHA) is an effective means of intervention, its use being well documented in persons with chronic conductive pathology and congenital aural anomalies. This article describes the standard guidelines (both auditory and extraauditory aspects) for patient selection and expands the criteria to include bilateral BAHA implantation, unilateral conductive hearing loss, and unilateral profound sensorineural hearing loss. The BAHA's development, design features, and patient outcomes are also reviewed. Suggestions are presented for fitting, counseling, and following BAHA users.