Phase III clinical trial results with the Vibrant Soundbridge implantable middle ear hearing device: a prospective controlled multicenter study

Efficacy of vibrant sound bridge in congenital aural atresia: an updated systematic review

PURPOSE

The indications of Vibrant Soundbridge (VSB) have been expanded to include patients with conductive and mixed hearing loss due to congenital aural atresia (CAA). However, the current evidence supporting the auditory outcomes of VSB is based mainly on case reports and retrospective chart reviews. Therefore, the present systematic review aims to summarize and critically appraise the current evidence regarding the safety and effectiveness of VSB in children and adult patients with CAA.

METHODS

A systematic literature search retrieved studies that evaluated the outcomes of unilateral or bilateral implantation of VSB in patients with CAA. The bibliographic search was conducted in PubMed, Scopus, EBSCO, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from January 2000 to December 2022.

RESULTS

Twenty-seven studies were included in the present systematic review. Overall, the speech perception after VSB was good, with a mean word recognition score (WRS) score ranging from 60 to 96.7%. The mean postoperative speech recognition threshold (SRT) after implantation ranged from 20.8 to 50 dB. The effective gain was reported in 15 studies, ranging from 31.3 to 45.5 dB. In terms of user satisfaction with VSB, the included studies showed significant improvements in the patient-reported outcomes, such as the Speech Spatial and Qualities of Hearing scale and Glasgow Hearing Aid Benefit Profile. The VSB implantation was generally safe with low incidence of postoperative complications.

CONCLUSION

VSB provides significant benefits to individuals with hearing loss owing to CAA, with very good subjective outcomes and a low risk of complications.

Adverse events associated with Vibrant Soundbridge: A MAUDE study

OBJECTIVE

To summarize adverse events and their root causes reported to the United States Food and Drug Administration (FDA) on Vibrant Soundbridge (VSB) hearing device (Med-El, Innsbruck, Austria), an active middle ear implant for patients with moderate to severe hearing loss.

MATERIALS AND METHODS

The FDA's Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports of VSB adverse events from January 1, 2012, to July 27, 2022.

RESULTS

Six hundred sixty-three total medical device reports were identified, from which 913 adverse events were extracted. Of these, 498 (54.5 %) were adverse events to patients (AEPs), while 415 (45.5 %) were device malfunctions (DMs). The most common AEPs were hearing performance issues 428 (85.9 %). The most common DMs were compromised conductive link 125 (30.1 %). Root causes identified for DMs were iatrogenic 85 (58.6 %), patient-related 28 (19.3 %), and trauma and external causes 32 (22.1 %). The most common iatrogenic root cause 12 (14.1 %) involved damage to the conductive link during revision surgery. The most common patient-related causes of DMs were excessive middle ear tissue growth 16 (57 %), and abrupt body movements 5 (28.6 %). The most common external cause of DM was cleaning of the ear canal or mastoid cavity 20 (62.5 %).

CONCLUSIONS

Despite its well-known limitations, the MAUDE database provides valuable information on possible complications of VSB as it relates to device malfunction or adverse events for patients. Implementation of standardized reports with relevant and well-defined categories could certainly allow for a more meaningful analysis.

The influence of intraoperative auditory brainstem responses on vibroplasty coupling-quality and analysis of the impact of different fixation steps on the coupling

PURPOSE

The Vibrant Soundbridge (VSB) is an established active-middle-ear-implant for patients with moderate-to-profound hearing-loss. This surgery is referred to as "Vibroplasty". Sufficient transfer of the VSB's floating-mass-transducers (FMT) energy to the inner ear is a crucial factor influencing the coupling-quality (CQ). However, assessing CQ is hamper by two issues: the method of CQ-assessment itself and the method of FMT-fixation during Vibroplasty.

METHODS

This prospective study explored the influence of intraoperative auditory-brainstem-response (+ ABR) measurements and various fixation methods on postoperative CQ after Vibroplasty as compared to matched-patients after Vibroplasty without intraoperative ABR (-ABR). Propensity-score-matching was performed based on preoperative bone-conduction-pure-tone-average-3 (BC-PTA3) at 1-, 2- and 4 kHz. Primary outcome parameters were postoperative CQ-PTA3, intraoperative ABR threshold for various fixation methods and postoperative BC-PTA3.

RESULTS

A total of 28 patients were included, of which 14 were + ABR. Preoperative BC-PTA3, sex, age, and number of previous surgeries did not differ significantly between groups (all p > 0.301). Mean postoperative CQ-PTA3 was significantly better for + ABR (1.8 vs. 12.3 dB-HL; p = 0.006). Mean intraoperative ABR threshold was superior for cartilage-counter-bearing and cartilage-housing compared to additional fixation with injectable-platelet-rich- fibrin (53 vs. 56 & 57 dB-HL, respectively; p = 0.04; η2 = 0.33). Mean postoperative BC-PTA3 did not significantly differ between patients (41.4 vs. 41.8 dB-HL; p = 0.77). A total of 7% of the patients required intraoperative readjustment of the FMT based on unsatisfactory intraoperative ABR threshold.

CONCLUSION

Intraoperative ABR measurement resulted in significantly better postoperative CQ. Cartilage-counter-bearing and cartilage-housing were observed to have superior CQ. A total of 7% of the patients could be spared revision-Vibroplasty due to intraoperative ABR measurement.

Round-Window Vibroplasty: Systematic Review and Meta-Analysis of Audiological Effectiveness With Different Round-Window Coupling Techniques

OBJECTIVE

Active middle ear implants can be directly coupled to the round-window (RW) membrane via RW Vibroplasty. The objectives of this systematic review were to summarize data on different RW coupling techniques and to investigate their effect on audiological and safety outcomes using meta-analyses.

DATABASES REVIEWED

PubMed (MEDLINE), Cochrane Library, and Embase (DIMDI).

METHODS

All publications reporting on audiological outcomes in human patients after RW Vibroplasty were included. Two independent reviewers carried out screening and data extraction. Meta-analyses and meta-regression were used to evaluate the potential effects of surgical and demographic parameters on primary audiological outcomes. Adverse events were extracted and tabulated for qualitative analysis.

RESULTS

Fourteen different combinations of surgical coupling parameters were identified in 61 included publications. Overall, data from 23 publications could be used for meta-analyses. Significantly better aided sound-field thresholds were reported for RW Vibroplasty performed without a dedicated coupler and using fascia as interponate, compared with RW Vibroplasty with an RW coupler or without an interponate. These effects were not found in other outcomes (i.e., functional gain, word recognition score). Reporting of adverse events was relatively heterogeneous, with 32 explicit mentions of revision surgery after the loss of coupling efficacy.

CONCLUSION

There are numerous publications investigating the effectiveness of coupling active middle ear implants to the RW membrane. However, studies are typically undersampled and of low evidence level. Using meta-analyses, weighted means, and qualitative analyses enabled a summary of the existing literature on audiological and safety outcomes after RW Vibroplasty. Individual selection of the most appropriate coupling modality with standardized intraoperative measurement and careful patient follow-up may be considered key factors for achieving effective RW coupling.

Results and Quality of Life after Implantation of Active Middle Ear Implants

The provision of implantable hearing aids represents an area with high development and innovation potential. On the one hand, this review article provides an overview of current indication criteria for the treatment with active middle ear implants. On the other hand, outcome parameters as well as functional results after implantation of active middle ear implants are demonstrated and discussed. The focus is mainly placed on audiological results as well as the subjective health status. "Patient Reported Outcome Measures" (PROMs) have become an integral part of the evaluation of hearing implant treatment. Due to low evidence level criteria, the study situation regarding audiological as well as subjective outcome parameters is not satisfactory. The lack of an international consensus on accepted outcome parameters makes a meta-analytical analysis of results immensely difficult. In the studies published to date, patients with sensorineural hearing loss and patients with conductive or mixed hearing loss offered better speech recognition after implantation of an active middle ear implant compared to conventional hearing aids. Current analyses show a significant improvement in general as well as hearing-specific quality of life after implantation of an active middle ear implant. To date, no validated, hearing-specific quality-of-life measurement instruments exist for assessing the success of fitting in children. Especially in children with complex malformations of the outer ear and the middle ear, excellent audiological results were shown. However, these results need to be substantiated by quality-of-life measurements in future.

Modified Power Piston Versus Simultaneous Stapedotomy With Hearing Aids in Otosclerosis: A Follow-Up Study Exploring Speech Recognition, Quality of Life and Usage of Device

OBJECTIVE

To compare audiologic outcomes, quality-of-life (QoL) and usage-of-device (UoD) between case-matched, otosclerotic patients with mixed hearing loss (MHL) which received (a) stapedotomy and postoperative amplification with hearing aids (SDT+HA) or (b) short-incudial process coupled active middle ear implant with simultaneous stapedotomy (mPP).

STUDY DESIGN, SETTING, AND PATIENTS

Prospective, matched case-control, follow-up study conducted at two tertiary otologic referral centers. Eligible were all otosclerotic patients with MHL, which received mPP at either of the two institutions. A case-matched-cohort of SDT+HA-patients was generated from the hospitals database based on preoperative audiologic findings.

MAIN OUTCOME MEASURES

For sound- and speech perception, primary outcome parameters were the mean postoperative, aided air-conduction pure tone average (mpa-AC-PTA) and word recognition score at 80 dB speech level (mpa-WRS), for QoL the mean Nijmegen-Cochlear-Implant-Questionnaire (NCIQ) total-score, and for UoD the mean score rated on a 10-point Likert-scale.

RESULTS

A total of 28 patients were included; 14 received mPP; mpa-AC-PTA and mpa-WRS significantly improved from 47.1 dB-HL to 34.3 dB-HL (-12.8 dB-HL; p < 0.001) and from 75.0% to 93.2% (+18.2%; p = 0.002) compared to 46.5 dB-HL to 31.9 dB-HL (-14.8 dB-HL; p < 0.008) and 75.0% to 93.2% (+18.2%; p = 0.002) for SDT+HA. No significant difference between groups was observed (all p > 0.1). NCIQ total-score between groups did not significantly differ (70.4 vs. 69.9; p = 0.93). UoD for mPP was significantly higher (6.1 vs. 3.0; p < 0.001).

CONCLUSIONS

If medical/technical problems prevent usage of HA in otosclerosis with MHL, mPP can be considered as effective treatment option with similar audiological outcome and QoL. A significantly higher UoD for mPP was observed.

Progressive Sensorineural Hearing Loss in Vibrant Soundbridge Users Requiring Cochlear Implantation

Less than 20% of patients with sensorineural hearing loss (HL) provided with the Vibrant Soundbridge (VSB) experience a progressive HL and warrant cochlear implantation (CI). The aim of this study was to identify possible predictors of progressive HL prior to VSB implantation. This retrospective study included all consecutive ears with sensorineural HL provided with the VSB between 1998 and 2016. The patient cohort was divided in a study group comprising patients who underwent CI (CI group) after years of VSB usage and those who did not require VSB replacement during the observational time (control group). Pre- and postoperative pure-tone audiometry thresholds were compared among the two groups. Fifteen out of 81 VSB devices (18.5%) required a CI. The CI group had higher preoperative air-conduction (AC) thresholds than the control group (64.3 ± 8.9 dB vs. 56.3 ± 12.9 dB; p = 0.007) at the time of the VSB implantation. On average, the CI group was significantly younger (39.1 ± 12.3 years vs. 52.6 ± 16.2 years; p = 0.003). In conclusion, VSB users with higher preoperative AC thresholds and younger age at the time of VSB implantation might be at risk for progressive HL within the upcoming eight years and need a further CI surgery. Preoperative counseling is particularly advisable in this patient group.

Long-Term Outcome With an Active Middle Ear Implant in Patients to Bilateral Aural Atresia

OBJECTIVE

To describe the audiological results and complications following active middle ear implant (AMEI) surgery in users with bilateral ear atresia.

STUDY DESIGN

Observational and retrospective longitudinal follow-up.

SETTING

A tertiary referral hospital for hearing rehabilitation and craniofacial malformations.

PATIENTS

Medical records of 27 patients with bilateral congenital aural atresia (34 ears) who underwent surgery for AMEI were reviewed. Data were analyzed using descriptive and inferential statistics. The alpha error was assumed to be 5%.

OUTCOME MEASURES

Medical and technical complications and audiological results were observed during follow-up.

RESULTS

The median postoperative follow-up was 37.5 months (27.7-75.5 mo). Medical or technical complications occurred in 35.3% (n = 12) of patients during follow-up, 14.7% (n = 5) required surgical revision. The auditory thresholds in the free field improved from 53.75 dB (46.87-56.25) to 25 dB (21.25-32.5) after 6 months using the AMEI (p < 0.001) and remained stable till the last audiological evaluation (22.5: 21.25 26.25). Compared with the preoperative results, all speech perception tests also showed the benefits of AMEI at 6 months postoperatively and in the last audiological evaluation.

CONCLUSIONS

Monitoring the use of AMEI in this sample demonstrated the safety of these implants compared with data available in the literature. The rates of medical and technical complications were consistent with data published by other groups. Finally, the audiological results remained stable during follow-up.

A New Stapes-Head Coupler for the Vibrant Soundbridge System

INTRODUCTION

The Vibrant Soundbridge (MED-EL Medical Electronics, Austria) is an active middle ear implant with a floating mass transducer (FMT) for patients with conductive, sensorineural, or mixed hearing loss. While the FMT is vertically aligned above the stapes head (SH) with the current Vibroplasty Clip coupler (MED-EL Medical Electronics), the new SH coupler was developed to mount the FMT on the inferior side of the stapes and to fit in the reduced middle ear space after canal-wall-down mastoidectomy.

METHODS

Using 11 human cadaveric temporal bones (TBs), placements of the new SH couplers on the stapes were examined, and effective stimuli to the cochlea were evaluated by measuring piston-like motion of the stapes footplate with a current of 1 mA on the FMT. The results were assessed in comparison with the Vibroplasty Clip coupler.

RESULTS

The new SH coupler showed perfect coupling on the stapes in 9 out of 11 TBs. A small gap between the SH and the plate of the connection link part was unavoidable in 2 TBs but had negligible effect on vibrational motion of the stapes. Vibrational motion of the stapes with the new SH coupler was reduced at frequencies above 3 kHz compared to the corresponding motion with the current Vibroplasty Clip coupler, but the relative attenuation over all 11 cadaveric temporal bones was <10 dB.

CONCLUSIONS

The new SH coupler provides an alternative with more stable fixation when placement of the current Vibroplasty Clip coupler is limited due to insufficient space after canal-wall-down mastoidectomy, while still delivering effective stimuli to the cochlea.

Long term results and evaluation of device satisfaction in patients used the vibrant sound bridge (VSB)

BACKGROUND

Patients' satisfaction with the device is as important as the audiological gains in patients using these devices.

OBJECTIVE

In this study, we aimed to evaluate the hearing aid satisfaction of individuals using The Vibrant Sound Bridge (VSB) (Vibrant Med-El, Innsbruck, Austria) and to compare this result with audiologic results ​​with and without devices.

MATERIAL AND METHODS

Patients who were using VSB were included in the study. Preoperative and postoperative pure tone averages and demographic datas of the patients to be included in the study were recorded. A shortened version of Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, was used to evaluate patients' device satisfaction.

RESULTS

Fifteen patients with VSB were included in the study. The mean follow-up was 9.13 years. The preoperative air conduction threshold and the air-bone gap in all frequencies were significantly higher than postoperative values (p < .05). The functional gain was found as 28 dB. In the APHAB questionnaire, there was a significant difference between total score results and EC, BN, RV subscales in the patients using the device (p < .01).

CONCLUSION AND SIGNIFICANCE

Patients with VSB give satisfactory results in auditory gains. In particular, good indication and long-term use of the device increases the suitability and satisfaction of the patients.

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.

Active middle ear implant (vibrant soundbridge) in children with unilateral congenital aural atresia

BACKGROUND

Detailed studies have not been conducted on sound localization and speech perception in noise in patients with unilateral congenital aural atresia (UCAA).

AIMS/OBJECTIVES

To evaluate the benefits of the use of the Vibrant Soundbridge (VSB) for UCAA by performing audiometric and sound localization tests.

MATERIALS AND METHODS

Four children with UCAA underwent VSB (VORP 503) implantation from 2018 to 2019. Speech perception tests in noise were conducted using the Japanese monosyllable test. The spatial configuration for speech testing consisted of speech presented from the front and noise presented into the normal ear (S₀N₉₀). The sound localization test was conducted using nine loudspeakers equally distributed in a semicircle.

RESULTS

The children's speech perception in noise 6 months after VSB activation was significantly better than before activation (p < .05). Additionally, the children's sound localization ability after VSB activation was significantly better than before VSB activation.

CONCLUSION AND SIGNIFICANCE

The benefits of VSB use in children with UCAA were revealed using audiometric and sound localization tests.

A Transcutaneous Active Middle Ear Implant (AMEI) in Children and Adolescents: Long-term, Multicenter Results

OBJECTIVE

Evaluation of the long-term safety and performance of an active middle ear implant (AMEI) in the treatment of hearing loss in children and adolescents with a primary focus on improvement in speech discrimination.

STUDY DESIGN

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

SUBJECTS

Thirty-one pediatric subjects aged 5 to 17 years.

INTERVENTION

Implantation of an active middle ear implant.

METHODS

Improvement in word recognition scores, speech reception thresholds (SRT) in quiet and noise, in addition to air conduction, bone conduction, and sound field thresholds were evaluated in two age groups.

RESULTS

Residual hearing did not change over time and speech intelligibility significantly improved and remained stable after 36 months. Children aged 5 to 9 improved in WRS from 21.92 to 95.38% and in SRT in quiet and in noise respectively from 62.45 dB SPL (sound pressure level) and +1.14 dB SNR to 42.07 dB SPL and -4.45 dB SNR. Adolescents aged 10 to 17 improved in WRS from 12.78 to 84.71% and in SRT in quiet and in noise respectively from 63.96 dB SPL and +3.32 dB SNR to 35.31 dB SPL and -4.55 dB SNR.

CONCLUSIONS

The AMEI, under investigation, is a safe treatment for children and adolescents, and significantly improved audiological performance that remains stable on the long-term scale (up to 36 mo postimplantation). In general, all adult-related issues and questions regarding safety and performance can also be applied to the pediatric population, as no apparent specific issues developed.

A retrospective European multicenter analysis of the functional outcomes after active middle ear implant surgery using the third generation vibroplasty couplers

Purpose

To evaluate the safety and performance of three novel vibroplasty couplers that allow attachment of the floating mass transducer of a transcutaneous active middle ear implant (AMEI) to the round window (RW) membrane, the long process (LP), or the incus body and the short process (SP) of the incus.

Methods

Retrospective multicenter cohort study of 25 AMEI users with sensorineural or mixed hearing loss that were among the first implanted with an AMEI vibrating ossicular prosthesis in combination with the third generation of vibroplasty couplers between 2014 and 2016. Main Outcome Measures were bone-conduction pure-tone and vibroplasty thresholds, postoperative aided sound field thresholds and postoperative aided word recognition score (WRS).

Results

Bone conduction threshold changes of more than 10 dB in 4PTA_BC were observed in two subjects. A mean improvement of 57.8% in speech recognition was observed with a mean WRS at 65 dB SPL improving from 14.8% (SD 21.9%) preoperatively to a mean aided score of 72.6% (SD 18.6%). Sound field thresholds improved from an average 4PTA_SF of 64.1 dB HL (SD 9.8 dB HL) to 37.0 dB HL (SD 8.9 dB HL), resulting in a mean functional gain of 27.1 dB. There was no significant difference in WRS or functional gain between the coupler types.

Conclusion

Initial experience shows that all three third generation vibroplasty couplers represent safe and efficient attachment options for the FMT allowing the surgeon to choose the coupling type based on the present pathology.

Modified-Power-Piston: Short-Incudial-Process-Vibroplasty and Simultaneous Stapedotomy in Otosclerosis

OBJECTIVE

If mixed-hearing-loss (MHL) occurs in otosclerosis, hearing-aids (HA) in addition to conventional-stapedotomy (SDT) may be necessary. If otosclerosis progresses or technical or medical problems prevent use of HA, combining active-middle-ear-implants (AMEI) with SDT ("power-piston") may be considered. Previously, AMEI-coupling to the long-incudial-process was suggested. Here, a "modified-power-piston" surgery (mPP) coupling to the short-incudial-process was proposed, so no coupling over the positioned stapes-piston is required. We questioned whether mPP is as safe and effective as SDT.

METHODS

Otosclerotic patients with MHL and limited satisfaction with previously worn HA receiving mPP were retrospectively reviewed at two Austrian tertiary otologic referral centers. Patients, receiving stapedotomy, were case-matched for preoperative pure-tone averages (PTA), bone-conduction (BC-PTA), air-conduction (AC-PTA), and air-bone gap (ABG-PTA). Postoperative changes in BC-PTA and in AC-PTA and ABG-PTA were defined as safety- and as efficacy outcome parameter.

RESULTS

Of 160 patients, 14 received mPP and 14 stapedotomy. Preoperative findings were comparable (all p = 1.000). BC-PTA improved from 38.0 to 36.7 and from 37.1 to 36.9 dB-HL for mPP and SDT, respectively (Δ -1.3 versus -0.2 dB-HL; p = 0.077). AC-PTA improved from 66.8 to 47.1 and from 66.3 to 46.5 dB-HL for mPP and SDT, respectively (Δ -19.6 versus -19.7 dB-HL; p = 0.991). ABG-PTA improved from 28.8 to 10.4 and from 29.1 to 9.6 dB-HL for mPP and SDT, respectively (Δ -18.3 versus -19.5 dB-HL; p = 0.771).

CONCLUSION

In otosclerosis with MHL and limited satisfaction with HA, mPP appeared as safe and effective as SDT and may be considered a treatment alternative in these patients.

Development and validation of the audio processor satisfaction questionnaire (APSQ) for hearing implant users

Objective: The satisfaction experienced with using an audio processor is very important to hearing implant system users. Currently there are no measures that can be used to assess user satisfaction with an audio processor. This study aims to develop and validate a specific and standardised questionnaire that focuses on user satisfaction with their audio processor.Design: A preliminary version of the questionnaire was initially developed by experts in the field. Following validation of these results, the final version of the Audio Processor Satisfaction Questionnaire (APSQ) was developed consisting of 15 items. Item analyses and questionnaire validation measurements were assessed.Study sample: Sixty-nine subjects were recruited and asked to complete the APSQ twice within 2-4 weeks.Results: Subjects reported a high user satisfaction with the questionnaire and with their audio processor. The questionnaire had good reliability and results for test-retest reliability were high and significant across all items and across subscale analyses.Conclusion: Item analyses and reliability analyses show that the questionnaire is a valid and reliable tool to assess user satisfaction across different audio processors and hearing implant systems. The APSQ is a quick and easy tool to measure user satisfaction with their audio processor.

ACTIVE MIDDLE EAR VIBRANT SOUNDBRIDGE SOUND IMPLANT

The Vibrant Soundbridge represents a new approach to hearing improvement in the form of active implantable middle ear hearing device. Unlike conventional acoustic hearing aids, which increase the volume of sound that goes to the eardrum, the Vibrant Soundbridge bypasses the ear canal and eardrum by directly vibrating the small bones in the middle ear. Because of its design, no portion of the device is placed in the ear canal itself. The Vibrant Soundbridge has been approved by the FDA as a safe and effective treatment option for adults with moderate to severe sensorineural, conductive or mixed hearing losses who desire an alternative to the acoustic hearing aids, for better hearing. The paper presents a review of the active middle ear implant Vibrant Soundbridge, which has been also implanted at the Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Center, which is the Referral Center for Cochlear Implantation and Surgery of Hearing Impairment and Deafness of the Ministry of Health, Republic of Croatia.

Stapedotomy with incus vibroplasty - A novel surgical solution of advanced otosclerosis and its place among existing therapeutic modalities - Hungarian single institutional experiences

OBJECTIVE

To delineate the advantages and steps of stapedotomy with incus vibroplasty, to assess the safety and efficacy of this method via the authors' experiences, and to overview the literature regarding other surgical options in advanced otosclerosis determining the place of stapedotomy with incus vibroplasty in the therapeutic range.

METHODS

Four patients were enrolled in the study presenting severe mixed hearing loss of at least one side on pure tone audiometry. Based on complementary audiological examinations including stapedial reflex test and multifrequency tympanometry, all cases were suspected as advanced otosclerosis. Stapedotomy with incus vibroplasty - the combination of laser stapedotomy and simultaneous Vibrant Soundbridge implantation - was performed in each patient. Preoperative pure tone average, speech recognition thresholds and word recognition scores were compared to one-year postoperative free-field values with the implant switched on focusing on functional gain.

RESULTS

Among 4 participants (3 females, 1 male) the mean age (SD) was 66 years (35). In three cases Nitinol, in one case NitiBond piston was inserted. One-year postoperative free-field functional gains were 30 dB, 34 dB, 42 dB and 51 dB, respectively. One-year postoperative free-field speech recognition thresholds were 45 dB, 45 dB, 49 dB and 50 dB, respectively, while word recognition scores were 70%, 70%, 70% and 75%, respectively.

CONCLUSION

Postoperative results in our serie regarding pure tone average and word recognition score proved to be better than those found in the literature. Stapedotomy with incus vibroplasty - through sufficient air-bone gap closure and simultaneous sensorineural component management - seems to be a promising surgical solution in advanced otosclerosis, requiring further investigation.

Treatment of moderate-to-severe otosclerosis with simultaneous piston surgery and incus vibroplasty

Objective:

Whereas the nature of otosclerosis has been extensively investigated, treatment modalities in advanced otosclerosis with the sensorineural hearing loss (SNHL) are relatively unexplored.

Materials and Methods:

This article presents a retrospective case series study of nine patients who received a one-stage piston coupled with Vibrant Soundbridge® vibroplasty in treating otosclerosis with moderate-to-severe SNHL.

Results:

The findings suggest that hearing loss could be restored across frequencies and no significant change in the bone-conduction threshold were measured.

Conclusion:

One-stage piston surgery coupled with incus vibroplasty is a safe procedure and has sufficient efficacy to restore hearing loss in patients with otosclerosis with moderate-to-severe SNHL.

The Vibrant Soundbridge: A Global Overview

The Vibrant Soundbridge is a semi-implantable, active middle ear implant that is a safe and effective treatment for patients with sensorineural hearing loss. Since Food and Drug Administration approval for this indication, many international investigators have expanded its use for conductive and mixed hearing losses. This article reviews the author's experience and the international uses of this versatile device.

The development of active middle ear implants: A historical perspective and clinical outcomes

Objective s

Energy emitting, active middle ear implants (aMEI) have taken more than two decades of research to reach technological sophistication, medical safety, and regulatory approval to become a powerful tool in treating sensorineural, conductive, and mixed hearing loss. The present review covers this era.

Data Source

Literature found from searching Pubmed (MEDLINE); EMBASE, SciSearch, German Medical Science Journals and Meetings, and The Cochrane Library; and published as of February 2017. Study bibliographies were hand-searched to find further materials.

Methods

A systematic literature review was conducted to identify studies evaluating the safety, efficacy, effectiveness, and subjective outcomes of partially implantable aMEIs. Data were extracted on systems with regulatory approval and summarized narratively. Meta-analyses were conducted for aMEIs with more than 25 publications. Study selection, data extraction, and quality appraisal for quantitative data synthesis was carried out by two reviewers.

Results

Four hundred thirty-one studies included in narrative synthesis describe that albeit good audiological outcomes, clinical safety and (dis)investment are major barriers to continued market access. The synthesised risk of adverse events was three fold with the MET than with the VIBRANT SOUNDBRIDGE. With the latter system, audiological outcomes were stable and similar for all indications and age groups.

Conclusion

To date, the majority of the literature covers the clinical application of the VIBRANT SOUNDBRIDGE system as it is applicable to a wide range of otologic and audiological conditions, particularly with the introduction of couplers to extend its clinical reach. The MAXUM and MET still have to find their way into surgical routine.Level of Evidence.

Long-Term Outcome of Hearing Rehabilitation With An Active Middle Ear Implant

Objective

To assess the audiological and long‐term medical and technical follow‐up outcomes of an active middle ear implant.

Methods

This was a retrospective medical chart analysis of all patients provided with an active middle ear implant in a tertiary academic medical referral center between September 1, 1998, and July 31, 2015. Main outcome measures were medical and technical complications, revisions, reimplantations, explantations, coupling approaches, mean time of use, pre‐ and postoperative hearing thresholds, functional hearing gain across frequencies (250–4,000 Hz), and Freiburg monosyllablic word test at 65 dB.

Results

One hundred and three patients were identified. Fifteen were implanted bilaterally (n = 118 Vibrant Soundbridge devices [MED‐EL, Innsbruck, Austria]). Seventy‐seven devices were implanted for sensorineural and 41 for mixed and conductive hearing loss. Patients used the implant for 6.7 years (range 0.7 months–17.9 years) on average. Ninety‐one patients (77.12%) were using the device at the end of the observation period. An overall complication rate of 16.1% was observed. The revision and explantation rates were higher for devices implanted between 2004 and 2006. The device failure rate was 3.4%. Audiological evaluation showed significant hearing gains for both hearing loss patient groups.

Conclusion

This long‐term follow‐up reveals the reliability of the active middle ear implant in a single center. Overall complication rate and device failure rate are acceptable. The complication rate was higher during implementation of alternative coupling approaches. The audiological benefit was satisfactory in patients with all hearing loss types. The majority of implanted patients used the implant at the end of the observation period.

Level of Evidence

4 Laryngoscope, 129:477–481, 2019

Minimal Reporting Standards for Active Middle Ear Hearing Implants

There is currently no standardized method for reporting audiological, surgical and subjective outcome measures in clinical trials with active middle ear implants (AMEIs). It is often difficult to compare studies due to data incompatibility and to perform meta-analyses across different centres is almost impossible. A committee of ENT and audiological experts from Germany, Austria and Switzerland decided to address this issue by developing new minimal standards for reporting the outcomes of AMEI clinical trials. The consensus presented here aims to provide a recommendation to enable better inter-study comparability.

Benefits of active middle ear implants over hearing aids in patients with sloping high tone hearing loss: comparison with hearing aids

In this retrospective chart review we compared the subjective and objective benefits of active middle ear implants (AMEIs) with conventional hearing aids (HAs) in patients with sloping high tone hearing loss. Thirty-four patients with sensorineural hearing loss were treated with AMEIs. Of these, six had sloping high tone hearing loss and had worn an HA for more than 6 months. Objective assessments, a pure-tone audiogram, as well as a word recognition test, and the Korean version of the Hearing in Noise Test (K-HINT), and a subjective assessment, the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, were performed. Tests were conducted under three circumstances: 1) the unaided state before surgery; 2) the HA-aided state before surgery; and 3) the AMEI-aided state 3 months after surgery. The average high-frequency hearing gain (≥ 2 kHz) was significantly better with AMEIs than with HAs. Although the result had no statistical significance, AMEIs showed a superior word recognition score (WRS) compared to HAs. However, the most comfortable hearing level at which the WRS was tested was significantly decreased with an AMEI compared to an HA. In the K-HINT, patients with an AMEI showed greater recognition than those fitted with an HA under both quiet and noisy conditions. The APAHB scores revealed that patients were more satisfied with an AMEI rather than an HA on all subscales. The use of vibroplasty in patients with sloping high tone loss resulted in positive hearing outcomes when compared to conventional HAs. Based on the data from this study, AMEIs provided better objective and subjective results and could, therefore, be a better alternative for the treatment of sloping hearing loss.

Comparison of an Electromagnetic Middle Ear Implant and Hearing Aid Word Recognition Performance to Word Recognition Performance Obtained Under Earphones

OBJECTIVE

To report the results of patients with the Maxum middle ear implant (MEI) and compare word recognition scores (WRS) and speech perception gap (SP Gap) of Maxum versus optimally fit hearing aids (HA).

STUDY DESIGN

Case series with chart review.

SETTING

Single, private otology clinic.

PATIENTS

Eleven ears, in nine adult patients (two women; average age 62.7 yr).

INTERVENTIONS

Twelve consecutive ears with moderate to severe sensorineural hearing loss (SNHL) underwent implantation of the Maxum system. One patient was not included due to inadequate preoperative testing.

MAIN OUTCOME MEASURES

Primary outcome measures included word recognition score (WRS) and SP Gap (maximum word understanding [PB max] - WRSaided) improvement compared with HAs.

RESULTS

The average Maxum WRS was 64.7% (range, 28-94%), a 41.6% improvement (range, 10-66%) over HAs (p < 0.001). The average Maxum SP Gap was 6.6% (range, -8 to 24%), a 41.6% improvement (range, 10-66%) over HAs (p < 0.001).

CONCLUSION

These data demonstrate that the Maxum provides superior WRS than HAs for patients with significant aided SP Gaps. There is a significant, very strong correlation between Maxum WRS and PB max (r = 0.85, p = 0.001). This implies that PB max may reasonably predict WRS outcomes with Maxum before implantation, and the SP Gap can reasonably predict the degree of additional potential benefit with Maxum. In advising patients who may be candidates for both a CI and MEI, PB max and SP Gap measurements will provide useful predictive information to help clinicians counsel patients on their choice of hearing technology.

LEVEL OF EVIDENCE

4.

Vibrant Soundbridge Implantation: Floating Mass Transducer Coupled with the Stapes Head and Embedded in Fat

Subtotal petrosectomy may be performed for refractory chronic middle ear diseases, such as massive cholesteatoma or recurrent otitis media. It involves permanent obliteration of the operative cavity, thus precluding the chance to restore conductive hearing via traditional inertial ossicular prostheses. The Vibrant Soundbridge (VSB) is an alternative option for hearing rehabilitation. Vibrant energy is delivered into the inner ear via a floating mass transducer (FMT), which can be coupled with any part of the middle ear acoustic transmission structure. To restore the hearing of a young woman with cholesteatoma, we combined subtotal petrosectomy with obliteration of the cavity and VSB implantation with an FMT coupled to the stapes head. Two years of follow-up demonstrated excellent auditory rehabilitation, improved sound source localization ability, and a lower speech recognition threshold. This study showed that the FMT works well in an obliterated cavity, and the experience acquired through this successful exploration is worth disseminating.

Evaluation of Maximal Speech Intelligibility With Vibrant Soundbridge in Patients With Sensorineural Hearing Loss

OBJECTIVE

The study investigated improvements in maximal speech intelligibility after Vibrant Soundbridge (VSB) implantation and analyzed the effect of the hearing loss pattern on maximal speech intelligibility represented by a phonetically balanced word score (PBmax). The effect of middle ear implants on PBmax has not been evaluated yet.

STUDY DESIGN

Study.

SETTING

Tertiary academic medical center.

PATIENTS/INTERVENTIONS

Sixty patients who underwent VSB from December 2011 to January 2016 were retrospectively reviewed. All the patients had hearing aids preoperatively.

MAIN OUTCOME MEASURES

Pure-tone and speech audiometry were checked with and without hearing aids and then with the VSB. The patients were divided into two groups: flat and down-sloping type of hearing loss. PBmax score was evaluated at the most comfortable listening level before and after VSB implantation and compared with scores with/without HA.

RESULTS

PBmax for both conventional HA and VSB were significantly higher compared with the unaided condition. The improvement in speech recognition was significantly better using VSB than using HA (p = 0.003). However, there was no significant difference in the improvement provided by VSB and HA in patients with a flat hearing loss. Patients with a down-sloping audiogram showed significantly better improvement with VSB than with HA (p = 0.003). Moreover, patients with greater preoperative high-frequency hearing loss had greater improvement in PBmax after VSB implantation.

CONCLUSION

Speech intelligibility can be significantly improved by VSB implantation, especially in patients with a down-sloping hearing loss. This finding can help select patients who will benefit most from VSB implantation.

Round Window Application of an Active Middle Ear Implant: A Comparison With Hearing Aid Usage in Japan

Objective:

To report on the safety and efficacy of an investigational active middle ear implant (AMEI) in Japan, and to compare results to preoperative results with a hearing aid.

Design:

Prospective study conducted in Japan in which 23 Japanese-speaking adults suffering from conductive or mixed hearing loss received a VIBRANT SOUNDBRIDGE with implantation at the round window. Postoperative thresholds, speech perception results (word recognition scores, speech reception thresholds, signal-to-noise ratio [SNR]), and quality of life questionnaires at 20 weeks were compared with preoperative results with all patients receiving the same, best available hearing aid (HA).

Results:

Statistically significant improvements in postoperative AMEI-aided thresholds (1, 2, 4, and 8 kHz) and on the speech reception thresholds and word recognition scores tests, compared with preoperative HA-aided results, were observed. On the SNR, the subjects’ mean values showed statistically significant improvement, with −5.7 dB SNR for the AMEI-aided mean and −2.1 dB SNR for the preoperative HA-assisted mean. The APHAB quality of life questionnaire also showed statistically significant improvement with the AMEI.

Conclusion:

Results with the AMEI applied to the round window exceeded those of the best available hearing aid in speech perception as well as quality of life questionnaires. There were minimal adverse events or changes to patients’ residual hearing.

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.

Light-Driven Contact Hearing Aid for Broad-Spectrum Amplification: Safety and Effectiveness Pivotal Study

Objective:

Demonstrate safety and effectiveness of the light-driven contact hearing aid to support FDA clearance.

Study Design:

A single-arm, open-label investigational-device clinical trial.

Setting:

Two private-practice and one hospital-based ENT clinics.

Patients:

Forty-three subjects (86 ears) with mild-to-severe bilateral sensorineural hearing impairment.

Intervention:

Bilateral amplification delivered via a light-driven contact hearing aid comprising a Tympanic Lens (Lens) with a customized platform to directly drive the umbo and a behind-the-ear sound processor (Processor) that encodes sound into light pulses to wirelessly deliver signal and power to the Lens.

Main Outcome Measures:

The primary safety endpoint was a determination of “no change” (PTA4 < 10 dB) in residual unaided hearing at the 120-day measurement interval. The primary efficacy endpoint was improvement in word recognition using NU-6 at the 30-day measurement interval over the baseline unaided case. Secondary efficacy endpoints included functional gain from 2 to 10 kHz and speech-in-noise improvement over the baseline unaided case using both omnidirectional and directional microphones.

Results:

The results for the 86 ears in the study determined a mean change of −0.40 dB in PTA4, indicating no change in residual hearing (p < 0.0001). There were no serious device- or procedure-related adverse events, or unanticipated adverse events. Word recognition aided with the Earlens improved significantly (p < 0.0001) over the unaided performance, by 35% rationalized arcsine units on average. Mean functional gain was 31 dB across 2 to 10 kHz. The average speech-recognition threshold improvement over the unaided case for the Hearing in Noise Test was 0.75 dB (p = 0.028) and 3.14 dB (p < 0.0001) for the omnidirectional and directional microphone modes, respectively.

Conclusion:

The safety and effectiveness data supported a de novo 510(k) submission that received clearance from the FDA.

The Vibrant Soundbridge® middle ear implant: A historical overview

OBJECTIVE

To present a historical overview of the Vibrant Soundbridge^® (VSB) middle ear implant (MEI), since its beginning in the 1990s to date and to describe its course and contemplate what it might become in the future.

HISTORY

MEIs started to take form in researchers' mind in the 1930s with the first experiment of Wilska. In the 1970s, several devices, such as the Goode and Perkins', the Maniglia's, or the Hough and Dormer's were created but remained prototypes. It is only in the 1990s the devices that emerged remained on the market. In 1994, Symphonix, Inc. was created and aimed to manufacture and commercialize its semi-implantable MEI, the VSB. The principle of the VSB lies on a direct drive of the sound to a vibratory structure of the middle ear through an electromagnetic transducer, the floating mass transducer (FMT). The particularity of the system VSB is the simplicity of the transducer which is made of both the magnet and the coil; thus, the FMT, fixed on a vibrating middle ear structure, mimics the natural movement of the ossicular chain by moving in the same direction. The goal of the VSB was to give an alternative to patients with mild-to-severe sensorineural hearing loss who could not wear hearing aids (HAs) or who were unsatisfied conventional HA users. Subsequent to Tjellström's experiment in 1997, implantations started to include etiologies such as otosclerosis, radical mastoidectomy, failed ossiculoplasty/tympanoplasty, and atresia. Nowadays, the VSB, with more than 20 years of experience, is the oldest and most used middle ear implant worldwide. It is well acknowledged that the straightforward design and reliability of the transducer have certainly contributed to the success of the device.

Evaluating speech perception of the MAXUM middle ear implant versus speech perception under inserts

OBJECTIVES/HYPOTHESIS

To evaluate the speech perception of the Ototronix MAXUM middle ear implant relative to the cochlear potential for speech perception of patients.

STUDY DESIGN

Clinical study chart review.

METHODS

We performed an evaluation of data from a prospective clinical study of 10 MAXUM patients. Primary outcome measures included comparison of word recognition (WR) scores with MAXUM (WR_MAXUM ) versus word recognition under inserts (WR_inserts ), and the functional gain improvement for pure-tone average (PTA) (0.5, 1, and 2 kHz) and high-frequency pure-tone average (2, 3, and 4 kHz).

RESULTS

Ten ears in 10 adult patients (six female; average age 68.7 years) were included. The average speech perception gap (difference between WR_inserts and WR_MAXUM ) with MAXUM was -9.2% (range, -26% to 4%). A negative number indicates that WR_MAXUM was higher than the WR_inserts . The average PTA with MAXUM was 23.1 dB (range, 18.7-30 dB), a 38.0-dB gain over the preoperative unaided condition (range, 20-53.3 dB). The average high-frequency pure-tone average with MAXUM was 34.4 dB (range, 26-43.3 dB), a 42.8-dB gain over the preoperative unaided condition (range, 32.3-58.7 dB).

CONCLUSIONS

These data demonstrate that a significant, very strong correlation was observed between WR_inserts and WR_MAXUM scores (r = 0.86, P = .001), and a patient's WR_inserts score may be used to reasonably predict the word recognition outcomes with MAXUM.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:456-460, 2018.

Systematic review to evaluate the safety, efficacy and economical outcomes of the Vibrant Soundbridge for the treatment of sensorineural hearing loss

Introduced in the late 90s, the active middle ear implant Vibrant Soundbridge (VSB) is nowadays used for hearing rehabilitation in patients with mild to severe sensorineural hearing loss (SNHL) unable to tolerate conventional hearing aids. In experienced hands, the surgical implantation is fast done, safe and highly standardized. Here, we present a systematic review, after more than 15 years of application, to determine the efficacy/effectiveness and cost-effectiveness, as well as patient satisfaction with the VSB active middle ear implant in the treatment of mild to severe SNHL. A systematic search of electronic databases, investigating the safety and effectiveness of the VSB in SNHL plus medical condition resulted in a total of 1640 papers. After removing duplicates, unrelated articles, screening against inclusion criteria and after in-depth screening, the number decreased to 37 articles. 13 articles were further excluded due to insufficient outcome data. 24 studies remained to be systematically reviewed. Data was searched on safety, efficacy and economical outcomes with the VSB. Safety-oriented outcomes included complication/adverse event rates, damage to the middle/inner ear, revision surgery/explant rate/device failure and mortality. Efficacy outcomes were divided into audiological outcomes, including hearing thresholds, functional gain, speech perception in quiet and noise, speech recognition thresholds, real ear insertion gain and subjective outcomes determined by questionnaires and patient-oriented scales. Data related to quality of life (QALY, ICER) were considered under economical outcomes. The VSB turns out to be a highly reliable and a safe device which significantly improves perception of speech in noisy situations with a high sound quality. In addition, the subjective benefit of the VSB was found to be mostly significant in all studies. Finally, implantation with the VSB proved to be a cost-effective and justified health care intervention.

Long-term Stability of the Active Middle-ear Implant with Floating-mass Transducer Technology: A Single-center Study

OBJECTIVE

To examine the long-term results of an active middle-ear implant (AMEI) with floating-mass transducer (FMT) technology.

STUDY DESIGN

Prospective cohort study of German-speaking patients implanted with an AMEI between 2006 and 2013.

SETTING

Single-center study.

PATIENTS

Eighty-three patients.

INTERVENTION

AMEI with FMT technology implantation.

MAIN OUTCOME MEASURES

Long-term outcome (27 mo; range, 12-84 mo) for FMT position in correlation with pure-tone audiometry, auditory thresholds for frequency-modulated (warble) tones, vibroplasty thresholds for pure tones, and speech audiometry in quiet and noise.

RESULTS

In 15.6% of patients, a revision surgery was necessary to improve functional performance of the AMEI, and the highest revision rate was found with FMT coupling to the round window not using couplers. A peak number of revision surgeries were observed 3 years after the initial surgery. Stable audiological results (pure-tone audiometry and speech audiometry in quiet and noise) were observed up to 84-month post-surgery. Incus vibroplasty (classic indication) showed a significantly lower functional gain compared with oval and round window vibroplasty. Vibroplasty in combined or conductive hearing loss showed no functional difference between forward and reverse stimulation of the cochlea; however, significantly lower vibroplasty thresholds were detected when using a coupler.

CONCLUSIONS

The AMEI with FMT technology can be safely used in treatment of patients with mild-to-severe sensorineural, conductive, or mixed hearing loss. Optimized coupling, especially in incus vibroplasty, has to be developed to achieve enhanced audiological results.

A tri-coil bellows-type round window transducer with improved frequency characteristics for middle-ear implants

A number of methods to drive the round window (RW) using a floating mass transducer (FMT) have been reported. This method has attracted attention because the FMT is relatively easy to implant in the RW niche. However, the use of an FMT to drive the RW has been proven to produce low outputs at frequencies below approximately 1 kHz. In this study, a new tri-coil bellows-type transducer (TCBT), which has excellent low frequency output and is easy to implant, is proposed. To design the frequency characteristics of the TCBT, mechanical and electrical simulations were performed, and then a comparative analysis was conducted between a floating mass type transducer (like the FMT) and a fixed type transducer (like the TCBT). The features of the proposed TCBT are as follows. First, the TCBT's housing is fixed to the RW niche so that it does not vibrate. Second, the internal end of a tiny bellows is connected to a vibrating three-pole permanent magnet located within three field coils. Finally, the rim of the bellows bottom is attached to the end of the housing that hermetically encloses the three field coils. In this design, the only vibrating element is the bellows itself, which efficiently drives the RW membrane. To evaluate the characteristics of this newly developed TCBT, the transducer was installed in the RW niche of temporal bones and the velocity of the stapes was measured using a laser Doppler vibrometer. The experimental results indicate that the TCBT can produce 100, 111, and 129 dB SPL equivalent pressure outputs at below 1 kHz, 1-3 kHz, and above 3 kHz, respectively. Thus, the TCBT with one side coupled to the RW via a bellows will be easy to implant and offer better performance than an FMT.

Audiologic limitations of Vibrant Soundbridge device: Is the contralateral hearing aid fitting indispensable?

OBJECTIVES/HYPOTHESIS

The purpose of this study was to evaluate the audiologic limitations of the Vibrant Soundbridge (VSB) implant and the benefits of contralateral hearing aid (HA) fitting in VSB recipients.

STUDY DESIGN

Retrospective study.

METHODS

Twenty-three patients with symmetrical sensorineural or mixed hearing loss were enrolled in this study. The patients underwent VSB implantation in one ear and HA fitting in the other. Aided pure-tone audiometry was performed to measure the functional gains of each device. The Korean version of the Hearing in Noise Test (K-HINT) was used to determine the sentence speech perception in a quiet environment and the signal-to-noise ratio (SNR) in a noisy environment.

RESULTS

VSB implantation resulted in hearing gains comparable to that of conventional HAs at high frequencies, whereas the functional gains at low frequencies were not satisfactory in the mixed hearing loss group. In these patients, the contralateral HA sufficiently amplified the low frequencies. The results of the K-HINT of the SNR in the VSB-aided ear were not significantly improved when compared to HA-aided contralateral ear. However, binaural fitting of a VSB and HA resulted in substantially improved SNR when compared to the unaided condition. This improvement of the SNR strongly correlated with functional gains at low frequencies in the contralateral HA-aided ear.

CONCLUSIONS

Although unilateral VSB implantation is limited in terms of low-tone enhancement and speech perception in noisy environments, contralateral HA fitting can overcome these limitations and increase the efficacy of hearing rehabilitation.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:2116-2123, 2016.

Middle ear implants for rehabilitation of sensorineural hearing loss: a systematic review of FDA approved devices

OBJECTIVE

To systematically review the safety and efficacy of the 3 Food and Drug Administration-approved middle ear implant (MEI) systems currently in use for the rehabilitation of sensorineural hearing loss.

DATA SOURCES

MEDLINE and Cochrane Library databases were systematically searched by 2 independent reviewers.

STUDY SELECTION

An initial search yielded 3,020 articles that were screened based on title and abstract. A full manuscript review of the remaining 80 articles was performed, of which 17 unique studies satisfied inclusion criteria and were evaluated.

DATA EXTRACTION

Variables including functional gain, speech recognition score improvement, audiometric threshold shift following surgery, adverse events, and patient reported outcome measures were recorded. Study quality was appraised according to author conflict of interest, prospective or retrospective study design, inclusion criteria, number of patients, proper use of study controls, outcome measures reported, length of follow-up, and level of evidence.

DATA SYNTHESIS

Heterogeneous outcome reporting precluded meta-analysis; instead a structured review was performed using best available data.

CONCLUSION

The majority of studies evaluating the safety and efficacy of MEIs are retrospective in nature with limited follow-up. To date, no prospective randomized controlled trial exists comparing contemporary air conduction hearing aid performance and MEI outcomes. Based on available data for patients with sensorineural hearing loss, functional gain and word recognition improvement seems similar between conventional hearing aids and MEIs, whereas patient-perceived outcome measures suggest that MEIs provide enhanced sound quality and eliminate occlusion effect.

[Differential indication of active middle ear implants]

INTRODUCTION

Hearing aids (HA) provide adequate support for many patients with hearing loss, but not all. Around one third of 10.000 patients provided with hearing aids in the Abbreviated Profile of Hearing Aid Benefit felt no actual benefit when using the hearing aid, although they demonstrated the necessary hearing improvement on speech audiometry. Epidemiological data show bad compliance, especially in older people. Only one in three hearing aid owners wears their device regularly. For this subpopulation of patients active middle ear implants (AMEIs) have been used since 1998. In the present review, the current indications for AMEIs are presented.

MATERIAL AND METHODS

A selective literature search in PubMed, as well as a guideline search at the Arbeitsgemeinschaft der Wissenschaftlichen Fachgesellschaften e. V. (German Association of Scientific Societies), was carried out.

RESULTS

The present review shows that when there is an adequate indication the hearing capacity of patients can be thoroughly rehabilitated and thus their quality of life improved with the help of AMEIs. Although most commercially available systems have a satisfactory risk profile, increased extrusion rates, malfunctioning and facial paresis have been reported in older implant series. The advantages of AMEIs include increased hearing gain, reduced feedback, increased hearing quality, increased speech discrimination in the presence of background noise, and an absence of occlusion.

CONCLUSIONS

The audiological indication for AMEIs in primary care is usually controversial, since the functional hearing gain and increase in speech discrimination may be small compared with modern conventional hearing aids. AMEIs thus play a main role in the secondary care of patients who do not have sufficient benefit or who have side effects after having a conventional hearing aid fitted.

The envoy® totally implantable hearing system, st. Croix medical

The Totally Implantable Envoy® System is currently undergoing clinical trials in both the United States and Europe. The fully implantable hearing device is intended for use in patients with sensorineural hearing loss. The device employs piezoelectric transducers to sense ossicle motion and drive the stapes. Programmable signal processing parameters include amplification, compression, and variable frequency response. The fully implantable attribute allows users to take advantage of normal external ear resonances and head-related transfer functions, while avoiding undesirable earmold effects. The high sensitivity, low power consumption, and high fidelity attributes of piezoelectric transducers minimize acoustic feedback and maximize battery life (Gyo, 1996; Yanagihara, (1987) and 2001). The surgical procedure to install the device has been accurately defined and implantation is reversible.

Preservation of auditory brainstem response thresholds after cochleostomy and titanium microactuator implantation in the lateral wall of cat scala tympani

HYPOTHESIS

The safety of implanting a titanium microactuator into the lateral wall of cat scala tympani was assessed by comparing preoperative and postoperative auditory brainstem response (ABR) thresholds for 1 to 3 months.

BACKGROUND

The safety of directly stimulating cochlear perilymph with an implantable hearing system requires maintaining preoperative hearing levels. This cat study is an essential step in the development of the next generation of fully implantable hearing devices for humans.

METHODS

Following GLP surgical standards, a 1-mm cochleostomy was drilled into the lateral wall of the scala tympani, and a nonfunctioning titanium anchor/microactuator assembly was inserted in 8 cats. The scala media was damaged in the 1 cat. ABR thresholds with click and 4- and 8-kHz stimuli were measured preoperatively and compared with postoperative thresholds at 1, 2, and 3 months. Nonimplanted ear thresholds were also measured to establish statistical significance for threshold shifts (>28.4 dB). Two audiologists independently interpreted thresholds.

RESULTS

Postoperatively, 7 cats implanted in the scala tympani demonstrated no significant ABR threshold shift for click stimulus; one shifted ABR thresholds to 4- and 8-kHz stimuli. The eighth cat, with surgical damage to the scala media, maintained stable click threshold but had a significant shift to 4- and 8-kHz stimuli.

CONCLUSION

This cat study provides no evidence of worsening hearing thresholds after fenestration of the scala tympani and insertion of a titanium anchor/microactuator, provided there is no surgical trauma to the scala media and the implanted device is securely anchored in the cochleostomy. These 2 issues have been resolved in the development of a fully implantable hearing system for humans. The long-term hearing stability (combined with histologic studies) reaffirm that the microactuator is well tolerated by the cat cochlea.

Vibromechanical assessment of active middle ear implant stimulation in simulated middle ear effusion: a temporal bone study

HYPOTHESIS

Active middle ear implant (AMEI) generated vibromechanical stimulation of the ossicular chain (ossicular chain vibroplasty [OCV]) or the round window (round window vibroplasty [RWV]) is not significantly affected by simulated middle ear effusion in a human temporal bone model.

BACKGROUND

OCV and RWV may be employed for sensorineural, mixed, and conductive hearing losses. Although middle ear effusions may be encountered across patient populations, little is known about how effusions may affect AMEI vibromechanical efficiency.

METHODS

Laser Doppler vibrometry of stapes velocities (SVs) were performed in a human temporal bone model of simulated effusion (N = 5). Baseline measurements to acoustic sinusoidal stimuli, OCV, and RWV (0.25-8 kHz) were made without effusion. The measurements were repeated with simulated middle ear effusion and compared with baseline measurements. Data were analyzed across 3 frequency bands: low (0.25-1 kHz), medium (1-3 kHz), and high (3-8 kHz).

RESULTS

Acoustic stimulation with simulated middle ear effusion resulted in a significant (p < 0.001) frequency-dependent attenuation of SVs of 4, 10, and 7 dB (low, medium, and high ranges, respectively). OCV in simulated effusion resulted in attenuated SVs of 1, 5, and 14 dB (low, medium, and high) compared to without effusion; however, this attenuation was not significant (p = 0.07). Interestingly, in the setting of RWV, simulated effusion resulted in significantly (p = 0.001) increased SVs of 16, 11, and 8 dB (low, medium, and high). A 3-dB variance in AMEI efficiency was observed in repeated measurements in a single temporal bone.

CONCLUSION

The efficiency of OCV was not significantly affected by the presence of a middle ear effusion. Improved efficiency, however, was observed with RWV.

Round window stimulation for conductive and mixed hearing loss

OBJECTIVE

Assess surgical complications, postoperative residual hearing, and speech perception outcomes of placement of a middle ear implant on the round window in conductive and mixed hearing loss cases.

STUDY DESIGN

Single-subject, repeated-measures design where each subject served as his or her own control.

SETTING

Tertiary referral medical systems.

SUBJECTS

Eighteen subjects with either conductive or mixed hearing loss who could not benefit from conventional amplification were enrolled in a clinical trial investigating vibratory stimulation of the round window.

INTERVENTION

The floating mass transducer (FMT) was positioned in the round window niche.

MAIN OUTCOME MEASURES

Unaided residual hearing, and aided sound field thresholds and speech perception abilities were evaluated preoperatively, and at 1, 3, 6, and 10 months post-activation of the external speech processor.

RESULTS

Six subjects experienced complications that either required further medical management or resolved on their own. There was no difference in residual bone conduction thresholds or unaided word discrimination over time. All subjects experienced a significant improvement in aided speech perception abilities as compared to preoperative performance.

CONCLUSION

Subjects with conductive and mixed hearing loss with placement of the FMT in the round window niche experienced improved sound field thresholds and speech perception, without compromising residual hearing thresholds. Vibratory stimulation of the round window via a middle ear implant may be an appropriate treatment option for patients with conductive and mixed hearing loss. Additional research is needed on the preferred placement of the FMT, improvement of functional gain, and methods to limit postoperative complications and need for revision surgery.

Consensus statement on round window vibroplasty

OBJECTIVE

This study aimed to review current knowledge regarding implantation of the Vibrant Soundbridge floating mass transducer (FMT) at the round window (round window vibroplasty) as well as to form a consensus on steps for a reliable, stable surgical procedure.

DATA SOURCES

Review of the literature and experimental observations by the authors.

CONCLUSION

Round window (RW) vibroplasty has been established as a reliable procedure that produces good and stable results for patients with conductive or mixed hearing loss. The experience gained over the past few years of the authors' more than 200 implantations has led to consensus on several key points: (1) a wide and bloodless access to the middle ear with facial nerve monitoring, (2) the careful and correct identification and exposure of the round window membrane, (3) a good setup for efficient energy transition of the FMT, namely, perpendicular placement of the FMT with no contact to bone and the placement of cartilage behind the FMT to create a preloaded "spring" function, and (4) 4 points of FMT fixation: a rim of the round window bony overhang left intact both anterior and posterior to the FMT, conductor link stabilization, and cartilage behind the FMT. In addition, the FMT should be covered with soft tissue.