Stability, Survival, and Tolerability of an Auditory Osseointegrated Implant for Bone Conduction Hearing: Long-Term Follow-Up of a Randomized Controlled Trial

Outcomes of a New Minimally Invasive Single-Drill Procedure for Installing Percutaneous Bone-Anchored Hearing Implants in Adult Patients

OBJECTIVE

To investigate the surgical and audiological outcomes in adult bone-anchored hearing system (BAHS) users who underwent implantation using a minimally invasive, single-drill procedure (MONO procedure).

STUDY DESIGN

Retrospective cohort design.

SETTING

University hospital.

PATIENTS

Adult subjects (≥18 yr), with conductive and mixed hearing loss, or single-sided deafness (SSD), who underwent BAHS surgery using MONO from 2021 to 2023.

INTERVENTION

BAHS implantation.

MAIN OUTCOME MEASURES

Surgical and postoperative complications were investigated during the entire follow-up period. Preoperative unaided air- and bone-conduction thresholds, pure-tone average (PTA), air-bone gap (ABG), and monosyllabic word recognition scores (unaided- and softband-aided) were compared with the postoperative BAHS aided PTA, remaining ABG, functional gain, and monosyllabic word recognition scores.

RESULTS

Forty-four subjects aged between 20 and 70 (52 ± 15) years met the inclusion criteria. One subject (2.3%) required two punch incisions due to implant instability during surgery. Two subjects (4.6%) experienced adverse skin reactions. Pain (6.9%) and moisture (6.9%) at implant site were also reported. No other complications were reported over a mean follow-up time of 12.2 ± 5.7 months. The mean BAHS aided score was significantly greater than the mean unaided- and softband-aided scores. All subjects showed functional improvements after surgery (25-31 dB), and the average effective gain was 1.3 dB.

CONCLUSION

The MONO procedure was shown to be a viable option for routine BAHS surgery in adults. The auditory performance of the subjects improved postoperatively, and complications were minimal and easily resolved. Further studies are required to investigate the long-term outcomes of MONO in this population.

LEVEL OF EVIDENCE

4-Retrospective review.

Hearing Performance and Soft-Tissue Outcomes of Minimally Invasive Ponto Surgery and Local Anesthesia in Children with Unilateral Craniofacial Malformation

Introduction  Minimally invasive Ponto surgery (MIPS) enables the installation of percutaneous bone-anchored hearing implants (BAHIs) with a drill guide through a hole punch incision. Despite being well established for adults, there is a lack of studies in the literature regarding its use in pediatric patients. Objective  The aim of the present study was to investigate the hearing performance and soft-tissue outcomes of the use of MIPS under local anesthesia in children with unilateral craniofacial malformation (UCM). Methods  The study used a retrospective cohort design. Nine subjects with UCM, aged between 6.5 and 17.1 (median = 12) years, who underwent the MIPS procedure under local anesthesia were included. Surgical procedure, intra, and postoperative complications were investigated. Speech recognition thresholds in quiet (SRTQ) and in noise (SRTN), daily use, satisfaction, and perceptual listening effort of the subjects were assessed after 4 months of postoperative follow-up. Results  It was possible to perform MIPS under local anesthesia in 8 of 9 subjects, with no intraoperative complications. One subject (11.11%) showed adverse skin reactions during a mean follow-up period of 11.4 months with MIPS. Speech recognition thresholds in quiet, SRTN, and subjective listening effort scores significantly decreased with the use of BAHI. The subjects were overall satisfied with the device and using it 8.2 hours/day, on average. Conclusion  Under local anesthesia, MIPS showed to be a viable option for BAHI installation in children with UCM. The hearing performance of the subjects improved, and they were globally satisfied with the device. Soft-tissue complications were minimal, and our results are comparable to those reported in the literature for adults.

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

OBJECTIVE

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

STUDY DESIGN

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

SETTING

Tertiary referral center.

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Very Early Loading of a Bone-Anchored Hearing System Is Safe

OBJECTIVE

To investigate the feasibility of early sound processor loading with two separate bone-anchored hearing aid implants 1 to 2 weeks after implantation. Secondary endpoints included registration of any postoperative complications, skin reactions, and any adverse events.

STUDY DESIGN

Prospective, nonrandomized, noncontrolled, multicenter clinical trial.

SETTING

Tertiary referral center.

PATIENTS

Sixty adult patients, eligible for bone-anchored hearing aid surgery, were enrolled.

INTERVENTION

Implantation of the bone-anchored hearing aid implants were done using minimally invasive surgery with tissue preservation.

MAIN OUTCOME MEASURE

Implant stability quotient (ISQ) values were recorded using resonance frequency analysis. Follow-ups were scheduled 5 to 12 days, 4 to 8 weeks, 6 months, and 12 months postoperatively. Differences between the lowest ISQ values (ISQ low) over time were analyzed by paired-samples t test with a significance level of 0.05. Skin and soft tissue reactions were assessed according to Holger's classification.

RESULTS

Loading time of the Ponto Wide implant was 11.6 ± 1.4 days (SD) in average (median, 12 d; range, 7-19 d). Loading of the Ponto BHX implant was done 9.7 ± 3.5 days (SD) postoperatively (median, 9 d; range, 5-19 d). The implant stability increased significantly during the 12-month study period with both implants. One Ponto BHX implant was lost. Skin and soft tissue reactions were few in both groups. Across all planned follow-up visits, no skin and soft tissue reactions were observed in 86% (Ponto BHX implant) and 85% (Ponto Wide implant).

CONCLUSION

Very early loading of sound processors after percutaneous bone-anchored hearing system surgery is safe already 1 to 2 weeks postoperatively.

Symmetrical placement of bilateral percutaneous bone-anchored hearing systems via guide-marker

Objectives

To investigate the use of a novel technique to estimate the symmetrical placement of percutaneous bone-anchored hearing systems (BAHS) with a guide-marker in patients undergoing bilateral surgery with this device.

Study Design

Prospective cohort study.

Methods

A guide-marker and anatomical landmarks were used to estimate the implant placement and transferred to the contralateral ear in 12 subjects eligible for bilateral BAHS surgery. To investigate the bilateral symmetry, preoperative tri-dimensional (3D) computed tomography (CT) image reconstruction was used to compare the distances between the mandibular condyle and implant placement estimation (mandible-implant distance) in both the right and left ears of the subjects.

Results

The guide-marker could be used to estimate the bilateral implant placement in all subjects included in this study, simply and easily, including one subject with craniofacial malformation. The mean mandible-implant distances were 5.37 and 5.38 cm, in the right and left ears of the subjects, respectively, and no differences were observed between them, thereby indicating optimal bilateral symmetry.

Conclusion

The use of the guide-marker proved to be an effective tool to provide symmetrical placement of bilateral BAHS. We propose a novel method employing a simple guide-marker and tracing based on symmetrical anatomical landmarks to achieve precise placement and optimal symmetry and which may be easily adopted in the surgical routine of BAHS.

Level of Evidence

3.

Post-implantation clinical cost analysis between transcutaneous and percutaneous bone conduction devices

INTRODUCTION

Bone conduction devices (BCD) are effective for hearing rehabilitation in patients with conductive and mixed hearing loss or single-sided deafness. Transcutaneous bone conduction devices (tBCD) seem to lead to fewer soft tissue complications than percutaneous BCDs (pBCD) but have other drawbacks such as MRI incompatibility and higher costs. Previous cost analyses have shown a cost advantage of tBCDs. The purpose of this study is to compare long-term post-implantations costs between percutaneous and transcutaneous BCDs.

MATERIALS AND METHODS

Retrospective data from 77 patients implanted in a tertiary referral centre with a pBCD (n = 34), tBCD (n = 43; passive (tpasBCD; n = 34) and active (tactBCD; n = 9) and a reference group who underwent cochlear implantation (CI; n = 34), were included in a clinical cost analysis. Post-implantation costs were determined as the sum of consultation (medical and audiological) and additional (all post-operative care) costs. Median (cumulative) costs per device incurred for the different cohorts were compared at 1, 3 and 5 years after implantation.

RESULTS

After 5 years, the total post-implantation costs of the pBCD vs tpasBCD were not significantly different (€1550.7 [IQR 1174.6-2797.4] vs €2266.9 [IQR 1314.1-3535.3], p = 0.185), nor was there a significant difference between pBCD vs tactBCD (€1550.7 [1174.6-2797.4] vs €1428.8 [1277.3-1760.4], p = 0.550). Additional post-implantation costs were significantly highest in the tpasBCD cohort at all moments of follow-up.

CONCLUSION

Total costs related to post-operative rehabilitation and treatments are comparable between percutaneous and transcutaneous BCDs up to 5 years after implantation. Complications related to passive transcutaneous bone conduction devices appeared significantly more expensive after implantation due to more frequent explantations.

The Latest Craniofacial Reconstructive Techniques Using Anchored Implants after Surgical Treatment of Nasal and Paranasal Sinuses Tumors

Reconstructive surgery after surgical treatment of neoplasms in the head and neck region is always a challenge. Many factors are responsible for the success of reconstruction. The anatomy of the facial region is complex, which significantly influences the aesthetic effect of the reconstruction. Moreover, many patients undergo postoperative radiotherapy after surgical treatment, which affects the range of reconstructive techniques. The aim of this study is to review current reconstructive methods in the craniofacial region, using bone-anchored implants to attach nasal prostheses. The article also comprises the authors' own experience with successful single-stage, Vistafix 3 osseointegrated implants for the attachment of an external nasal prosthesis in a 51-year-old man after surgical removal of squamous cell carcinoma of the nose and paranasal sinuses. The literature search for articles regarding implants in craniofacial reconstructions was performed using the three following databases: Scopus, Web of Science and MEDLINE (through PubMed), and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA). A systematic literature search was set for 2018-2023 and retrieved 92 studies. From them, 18 articles were included in the review.

Long-Term Follow-up of a Wide-Diameter Bone-Anchored Hearing Implant: 10-Year Experience on Stability, Survival, and Tolerability of an Implant-Abutment Combination

OBJECTIVE

To compare stability, survival, and soft tissue reactions between a wide-diameter (test) and previous-generation small-diameter (control) bone-anchored hearing implant and to ascertain the safety of loading the test implant 3 weeks after surgery, at a long-term follow-up of 10 years.

STUDY DESIGN

This study is a continuation of two previously completed, multicenter, randomized, controlled trials and consisted of one to two additional follow-up visits until 10 years after surgery.

PATIENTS

Fifty-one of the 72 participants from the previous trials were included. Patients received a test or control implant. All control implants were loaded 6 weeks after surgery (group A). Test implants were loaded 3 (group B) or 6 weeks (group C) after surgery.

RESULTS

The test implant showed significantly higher implant stability quotient (ISQ) values than the control implant throughout the 10-year follow-up. At 10 years, the mean ISQ-high values for both implants were higher than at the first follow-up visit. No significant differences in change of ISQ-high from baseline to 10 years were noticed between both implants and loading groups. Soft tissue reactions were rarely seen. At 10-year follow-up, no patients presented with adverse soft tissue reactions. Excluding explantations, the implant survival rate was 78.6% (group A), 100% (group B), and 90.0% (group C).

CONCLUSIONS

The test implant showed superior mean ISQ values and significantly better implant survival throughout 10-year follow-up. In addition, the current study concludes that it is safe to load the test implant at 3 weeks after surgery, as long-term results show high ISQ values and good implant survival.

Surgery Training System Supported by Organic Materials

The aim of the study was the qualitative assessment of new materials based on a polycarbonate matrix in terms of its use in 3D printing and its processing and geometric modification (cutting). Filaments made of the new material doped with talc in five different proportions were visually inspected with a microscope. The calibration and test models were made using the FFF (fused filament fabrication) technique. In addition, its susceptibility to the drill and the behavior of the shavings were assessed and the temperature changing during drilling was measured. The implant was inserted to measure its resonance stability in each of the holes made and translated into the value of the implant stability quotient (ISQ) ranging from 1 to 100. The results were compared to those obtained for the training model of the skull bone. The amount of filler has been shown to affect the composite. Moreover, due to the properties of talc, a compatibilizer (polyol) was used. Differences were observed between the model made of the commercial material, the model made of the dried, tested material, and the model made of the undried material. It was confirmed that the presence of water in the material during its processing is important.

Clinical Evaluation of a Novel Laser-Ablated Titanium Implant System for Bone Anchored Hearing Systems in a Pediatric Population and the Relationship of Resonance Frequency Analysis With Implant Survival

OBJECTIVE

To evaluate the clinical outcomes of pediatric patients implanted a novel 4.5 mm wide laser ablated titanium bone anchored implant system and to evaluate the implant stability over the first 12-month period.

STUDY DESIGN

A prospective, single-subject, repeated measure, cohort study. Participants served as their own controls.

SETTING

Community and tertiary referral hospital pediatric assessment center.

PATIENTS

A total of 115 consecutive pediatric patients aged 4 to 15 years were implanted with 176 laser ablated titanium bone anchored implants from January 2016 to January 2019.

MAIN OUTCOME MEASURE

Clinical outcomes, implant failure rates, and post implantation implant stability quotient (ISQ) scores were studied over the first 12-month period. Data were analyzed for statistical significance through mixed effect modeling, with the significance level p = 0.01.

RESULTS

A median 12-month survival of 96.6% was observed. Six implants (3.5%) were lost in total, one of these (0.6%) was lost due to trauma. Adverse skin reactions (Holgers grade 2-4) were observed in 4.4% of all postoperative visits, occurring in 22 individuals (19.1%). Neither the ISQ high (ISQH) nor ISQ low (ISQL) values increased significantly between the stage 1 and 2 surgeries. In contrast, the ISQ results, irrespective of abutment size, demonstrated an increasing trend from 49.1 to 57 over the 12 months review period. A statistically significant change was only demonstrated from the 3 months follow up onwards.

CONCLUSION

The use of 4.5 mm wide laser-ablated titanium bone anchored hearing implants resulted in superior survival rates and excellent clinical outcomes compared with previous implant systems.

Molecular Response to Nanopatterned Implants in the Human Jaw Bone

Implant surface modification by nanopatterning is an interesting route for enhancing osseointegration in humans. Herein, the molecular response to an intentional, controlled nanotopography pattern superimposed on screw-shaped titanium implants is investigated in human bone. When clinical implants are installed, additional two mini-implants, one with a machined surface (M) and one with a machined surface superimposed with a hemispherical nanopattern (MN), are installed in the posterior maxilla. In the second-stage surgery, after 6-8 weeks, the mini-implants are retrieved by unscrewing, and the implant-adherent cells are subjected to gene expression analysis using quantitative polymerase chain reaction (qPCR). Compared to those adherent to the machined (M) implants, the cells adherent to the nanopatterned (MN) implants demonstrate significant upregulation (1.8- to 2-fold) of bone-related genes (RUNX2, ALP, and OC). No significant differences are observed in the expression of the analyzed inflammatory and remodeling genes. Correlation analysis reveals that older patient age is associated with increased expression of proinflammatory cytokines (TNF-α and MCP-1) on the machined implants and decreased expression of pro-osteogenic factor (BMP-2) on the nanopatterned implants. Controlled nanotopography, in the form of hemispherical 60 nm protrusions, promotes gene expressions related to early osteogenic differentiation and osteoblastic activity in implant-adherent cells in the human jaw bone.

Clinical evaluation and resonance frequency analysis of laser-ablated titanium bone-anchored hearing implant system in children with Down Syndrome

OBJECTIVES

To evaluate complication rates and resonance frequency analysis (RFA) of the stability of a new laser-ablated titanium Bone Anchored hearing Implant system in children with Down syndrome.

METHODS

A prospective, single-subject, repeat measure, cohort study in which each participant served as their own control. Consecutive paediatric patients 4yrs- 15 years old, with a primary diagnosis of Down syndrome (trisomy 21) were implanted between January 2015-January 2020 with BHX Oticon wide implants. Evaluation of soft tissue reactions, fixture failure rates and post implantation Implant stability Quotient (ISQ) at both fixtures and abutment levels were studied over a 12-month period. Data was analysed for statistical significance through mixed effect modelling with significance set at p = 0.01.

RESULTS

31 consecutive paediatric patients with a diagnosis of Down syndrome were implanted with 43 Ponto BHX Oticon™ implant system. Twelve children had bilateral implants and nineteen were unilateral. Over the 12 month follow up 2 fixtures (4.6%) were lost, and adverse skin reactions (Holgers >2) were recorded in 3.2% of all clinical reviews. Implant level stability quotient showed no statically significant change between first and second stage 71.1-71.7. Abutment level ISQ increased from 46.2 to 56.7 p = 0.0001 at the 12-month review point as compared to that recorded at loading.

CONCLUSION

Implant survival and adverse skin reactions were found to be in keeping with those in published literature and much improved compared to previous implant systems placed at this centre. Although abutment level ISQ showed an increase over the review period no correlation between this and implant loss can be concluded.

Rehabilitation for unilateral deafness - Narrative review comparing a novel bone conduction solution with existing options

Patients with single sided deafness (SSD) struggle with sound localization and speech in noise. Existing treatment options include contralateral routing of signal (CROS) systems, percutaneous bone conduction hearing devices (BCHDs), passive transcutaneous BCHDs, active BCHDs, and cochlear implants. Implanted devices provide benefits in speech in noise compared to CROS devices. Percutaneous BCHDs transmit sound efficiently but have aesthetic drawbacks and skin complications. Scalp attenuation impacts passive transcutaneous BCHD performance. Active BCHDs overcome these issues and provide benefits for speech in noise. Cochlear implantation is the only existing option that restores binaural input but introduces electrical rather than acoustic stimuli to the deaf ear. Active BCHDs have been designed to maintain efficient sound transmission and avoid chronic skin irritation and cosmetic concerns that may occur with percutaneous BCHDs. Cochlear implantation may be a superior option for recently deafened SSD patients, though this requires further study. The duration of deafness, patient age and comorbidities, and a shared decision-making model among patients, surgeons, and audiologists should be considered in device selection. The aim of this manuscript is to review available devices, discuss surgical considerations for implantable devices, review available published results for speech in noise and sound quality with each device, and provide an overview to guide shared decision making for patients and providers. This review consolidates available literature and reviews experience with a newer active transcutaneous active BCHD available for use in the SSD population.

Multicenter Clinical Investigation of a New Active Osseointegrated Steady-State Implant System

Objective:

A new active transcutaneous bone conduction hearing implant system that uses piezoelectric technology has been developed: an active osseointegrated steady-state implant system (OSI). This was the first clinical investigation undertaken to demonstrate clinical performance, safety, and benefit of the new implant system.

Study Design and Setting:

A multicenter prospective within-subject clinical investigation was conducted.

Patients:

Fifty-one adult subjects with mixed and conductive hearing loss (MHL/CHL, n = 37) and single-sided sensorineural deafness (SSD, n = 14) were included.

Main Outcome Measure:

Audiological evaluations included audiometric thresholds, speech recognition in noise, and quiet. Hearing and health-related patient-reported outcomes (PROs; health utilities index [HUI], abbreviated profile of hearing aid benefit [APHAB], and speech, spatial of qualities of hearing scale [SSQ]), daily use, surgical and safety parameters were collected.

Results:

Intra- and postoperative complications were few. One implant was removed before activation due to post-surgical infection. Compared with the preoperative softband tests, a significant improvement in speech recognition-in-noise was observed in the MHL/CHL group (–7.3 dB, p ≤ 0.0001) and the SSD group (–8.1 dB, p = 0.0008). In quiet, word recognition improved in the MHL/CHL group, most markedly at lower intensity input of 50 dB SPL (26.7%, p ≤ 0.0001). The results of all PROs showed a significant improvement with the new device compared with preoperative softband in the MHL/CHL group. In the SSD group significant improvements were observed in the APHAB and SSQ questionnaires.

Discussion:

The results confirmed the clinical safety, performance, and benefit of this new treatment modality for subjects with CHL, MHL, and SSD.

Six-Month Clinical Outcomes for Bone-Anchored Hearing Implants: Comparison Between Minimally Invasive Ponto Surgery and the Linear Incision Technique With Tissue Preservation

OBJECTIVES

The aim of this study is to investigate and compare the clinical outcomes of minimally invasive ponto surgery (MIPS) to the linear incision technique with soft tissue preservation (LIT-TP) for percutaneous bone-anchored hearing implants (BAHI).

STUDY DESIGN

Prospective cohort study with a historical control group.

SETTING

Tertiary referral center.

PATIENTS

Twenty-five patients were prospectively included in the test group. The control group consisted of 25 patients who previously participated in another clinical trial and already underwent BAHI surgery.

INTERVENTION

All patients were implanted with a 4.5-mm-wide implant, using MIPS in the test group and the LIT-TP in the control group. Follow-up visits were scheduled 7 days, 21 days (sound processor fitting), 12 weeks and 6 months after surgery.

MAIN OUTCOME MEASURES

The primary outcome measure was skin sensibility around the abutment 6 months after surgery. Secondary outcomes were subjective numbness, surgery time, wound healing, adverse soft tissue reactions, cosmetic outcomes, implant stability quotient (ISQ), implant survival, and sound processor use.

RESULTS

Skin sensibility, adverse soft tissue reactions, and sound processor use were comparable between groups. The test group had a shorter surgery time and better cosmetic outcomes. More skin dehiscences and a statistically nonsignificant higher implant loss rate (12% vs 0%, p = 0.079) were observed in the test group.

CONCLUSION

MIPS is comparable to the LIT-TP regarding skin sensibility at 6 months and soft tissue tolerability. With MIPS, surgery time is further reduced and better cosmetic outcomes are reported. More research into MIPS, exact drill protocol, used instruments, and associated implant loss is warranted.

Results of a 2-Year Prospective Multicenter Study Evaluating Long-term Audiological and Clinical Outcomes of a Transcutaneous Implant for Bone Conduction Hearing

To evaluate 2-year audiological and clinical outcomes of a transcutaneous implant for bone conduction hearing of a previously published 6-month evaluation.

Multimodal Analysis of the Tissue Response to a Bone-Anchored Hearing Implant: Presentation of a Two-Year Case Report of a Patient With Recurrent Pain, Inflammation, and Infection, Including a Systematic Literature Review

Osseointegration is a well-established concept used in applications including the percutaneous Bone-Anchored Hearing System (BAHS) and auricular rehabilitation. To date, few retrieved implants have been described. A systematic review including cases where percutaneous bone-anchored implants inserted in the temporal bone were retrieved and analyzed was performed. We also present the case of a patient who received a BAHS for mixed hearing loss. After the initial surgery, several episodes of soft tissue inflammation accompanied by pain were observed, leading to elective abutment removal 14 months post-surgery. Two years post-implantation, the implant was removed due to pain and subjected to a multiscale and multimodal analysis: microbial DNA using molecular fingerprinting, gene expression using quantitative real-time polymerase chain reaction (qPCR), X-ray microcomputed tomography (micro-CT), histology, histomorphometry, backscattered scanning electron microscopy (BSE-SEM), Raman spectroscopy, and fluorescence in situ hybridization (FISH). Evidence of osseointegration was provided via micro-CT, histology, BSE-SEM, and Raman spectroscopy. Polymicrobial colonization in the periabutment area and on the implant, including that with Staphylococcus aureus and Staphylococcus epidermidis, was determined using a molecular analysis via a 16S-23S rDNA interspace [IS]-region-based profiling method (IS-Pro). The histology suggested bacterial colonization in the skin and in the peri-implant bone. FISH confirmed the localization of S. aureus and coagulase-negative staphylococci in the skin. Ten articles (54 implants, 47 patients) met the inclusion criteria for the literature search. The analyzed samples were either BAHS (35 implants) or bone-anchored aural epitheses (19 implants) in situ between 2 weeks and 8 years. The main reasons for elective removal were nonuse/changes in treatment, pain, or skin reactions. Most samples were evaluated using histology, demonstrating osseointegration, but with the absence of bone under the implants’ proximal flange. Taken together, the literature and this case report show clear evidence of osseointegration, despite prominent complications. Nevertheless, despite implant osseointegration, chronic pain related to the BAHS may be associated with a chronic bacterial infection and raised inflammatory response in the absence of macroscopic signs of infection. It is suggested that a multimodal analysis of peri-implant health provides possibilities for device improvements and to guide diagnostic and therapeutic strategies to alleviate the impact of complications.

A retrospective evaluation of minimally invasive ponto surgery (MIPS) in two pediatric centers

BACKGROUND

Percutaneous bone anchored hearing systems have been used effectively for over forty years with low rates of complications. Minimally Invasive Ponto Surgery (MIPS) is a surgical technique performed through a puncture hole that has been reported to minimize soft tissue trauma and decrease operative time. Due to it being a relatively new procedure there remains a paucity of pediatric outcomes data.

METHODS

Pediatric patients from two tertiary pediatric otolaryngology centers between 2016 and 2019 who underwent MIPS were included in this study. Charts were retrospectively reviewed for indications for surgery, implant and abutment type, overlying skin thickness, skin-to-skin time, Holgers score at three, six and twelve months, revision surgery and time to abutment fitting.

RESULTS

Fourteen patients, two with bilateral procedures met inclusion criteria (mean age = 8.07 ± 2.87years). The mean overlying skin thickness was 5.13 ± 3.18mm. 9.44% of visits had an adverse skin reactionOne patient required surgery forskin overgrowth. One implant loss (6.3%) was reported, following trauma to the abutment. Mean MIPS skin to skin times were 12.4 ± 2.6 min, markedly different that the Baha^® Attract and Connect which were 56 and 53 min, respectively.

CONCLUSION

This study represents the largest pediatric MIPS cohort to date, and our results are similar to published adult studies.

Five year clinical outcomes and evaluation following implantation of the Oticon™ wide bone anchored hearing system in 47 children

OBJECTIVES

The Oticon™ wide implant system was launched in 2009 and used at Birmingham Children's Hospital from 2014. To evaluate clinical outcomes of the Oticon™ wide implant (Oticon Medical), with a focus on skin complication rates and fixture loss over a 5-year period in a tertiary paediatric hospital in the UK.

METHODS

Retrospective 5-year longitudinal case record review of 47 children who were implanted with the Oticon™ wide implant system at Birmingham Children's Hospital (BCH) between January 2014 and January 2016.

RESULTS

47 children (27 M:20F) were implanted with 70 Oticon wide implants 23 bilateral, 27 unilateral. Mean age at the time of implantation was 9y 6 m. The follow up was for a mean of 5.4 years. Significant soft tissue complications requiring treatment was found in 11% (n = 8) of loaded fixtures, abutment tightening on two patients, abutment exchange 6% (n = 4) and a 10% (n = 7) fixture failure.

CONCLUSION

The Oticon™ wide implant system produces favourable results with regards to peri-abutment skin complications, fixture stability and revision surgery rates when compared to similar cohorts of children studied at Birmingham Children's Hospital.

Clinical Presentation, Management, and Outcomes of Idiopathic Pain in Percutaneous Bone-anchored Hearing Implants

OBJECTIVE

To identify clinical features and investigate treatment outcomes of patients with idiopathic pain related to a percutaneous bone-anchored hearing implant (BAHI) and to propose management recommendations.

STUDY DESIGN

Retrospective chart analysis.

SETTING

Tertiary referral center.

PATIENTS

The clinical data of 14 patients who were treated for idiopathic pain around their percutaneous BAHI between May 2007 and February 2018 at our tertiary referral center were reviewed.

MAIN OUTCOME MEASURES

Pain after treatment and implant loss.

RESULTS

All 14 patients received treatment with oral antibiotics. Nine patients received oral antibiotic combination therapy for 4 weeks, whereafter pain resolved in 4. Out of the five other patients, receiving either antibiotic monotherapy or shortened antibiotic combination therapy, pain resolved in two. In case of persistent pain (57.1%) after initial treatment, other pain management therapies were attempted, however all with only limited effect. Six patients (42.8%) underwent elective removal of the implant. In two patients spontaneous implant loss occurred. In two of the four patients who underwent reimplantation, pain relapsed. In one of these, pain resolved after the removal of the new implant. In the other patient, pain persisted, despite abutment removal. With exception of this latter patient, all other 13 patients were pain free at the latest follow-up. Cone beam computed tomography did not offer additional information regarding diagnosis or treatment.

CONCLUSION

Idiopathic pain in BAHI is a rare but bothersome symptom which can result in implant removal. After oral antibiotic combination treatment, symptoms resolved in approximately 40% of patients. Therefore, we think conservative treatment with these antibiotics before implant removal surgery, is worth considering.

The efficacy of bone-anchored hearing implant surgery in children: A systematic review

OBJECTIVE

To evaluate the efficacy of Bone-Anchored Hearing implants (BAHIs) in children and to elucidate the usage and outcomes of new surgical techniques and implants in this specific population.

DATA SOURCES

Embase and PubMed.

STUDY SELECTION

We identified studies evaluating surgical outcomes of BAHIs in children. Retrieved articles were screened using predefined inclusion and exclusion criteria. Critical appraisal included directness of evidence and risk of bias. Studies that successfully passed critical appraisal were included.

DATA EXTRACTION

Outcome measures included patient demographics, follow-up time, surgical technique (one-versus two-stage surgery), tissue handling technique (reduction versus preservation), type of implant used, and complications.

DATA SYNTHESIS

We selected 20 articles published between 2000 and 2017 for data extraction, encompassing 952 implanted BAHIs. The overall mean age at implantation was 8.6 years (range, 2-21 years). Adverse soft-tissue reactions occurred in 251 of the 952 implants (26.4%; range 0%-89% across studies). Revision surgery was performed in 16.8% (142 of the 845) of the implants. The total rate of implant loss, i.e. caused by OIF (n = 61), trauma (n = 33), recurrent infection (n = 15), elective removal due to insufficient benefit (n = 1), cosmetic reasons (n = 1), or unknown reason (n = 16), was 13.3% of the implants (127 out of 952; range 0%-40% across studies). Differences are seen in the type of implants used; wide-diameter implants seem to be superior in terms of implant survival, and similar in terms of adverse skin reactions, while one-stage surgery and soft-tissue preservation do not seem to result in higher implant loss rates or increased adverse skin reactions based upon limited amounts of literature.

CONCLUSION

In general, BAHIs are a safe method for hearing rehabilitation in children, although large differences between studies are observed. The outcomes of new surgical techniques and implant designs in the pediatric population seem promising, but more research is needed before definitive conclusions can be drawn.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Auricular prostheses attached to osseointegrated implants: multidisciplinary work-up and clinical evaluation

PURPOSE

Not long after the introduction of osseointegrated implants outside the oral cavity, auricular prostheses are retrained on osseointegrated implants. New insights have been gained with the next-generation percutaneous osseointegrated titanium implants for bone conduction hearing since its introduction in 2010. As a result, the same technology was introduced in the Vistafix^® system (VXI implant) to retain auricular prostheses. The aim of this study is to evaluate the surgical procedure, clinical outcome, and satisfaction of the patient of osseointegration-retained auricular prosthesis using VXI implants.

MATERIALS AND METHODS

11 patients who received an auricular prosthesis using VXI implants between December 2012 and November 2017 were evaluated retrospectively. The patient's medical files were reviewed to assess clinical complications and the necessity for revision surgery. The subjective outcome was measured using the Glasgow benefit inventory (GBI).

RESULTS

In total, 31 implants were placed in 11 patients. None of these implants were lost nor revision surgery needed. An adverse skin reaction was observed in 13.0% of the implants and in 27.2% of the patients, adequately treated with an antibiotic ointment. The average follow-up time was 2 years and 7 months. The GBI displayed a positive score in every patient.

CONCLUSIONS

The VXI implants used are a safe and reliable treatment option for retaining auricular prostheses in patients with an absent auricle. Patients were satisfied with their auricular prosthesis and showed benefit in quality of life. Studies with larger numbers and preferably a prospective character are needed to draw statistically significant conclusions.

Complications of bone-anchored prostheses for individuals with an extremity amputation: A systematic review

BACKGROUND

This study aimed to provide an overview of device-related complications occurring in individuals with an upper or lower extremity amputation treated with a screw, press-fit or other type of bone-anchored implant as well as interventions related to these complications.

METHOD

A systematic literature search was conducted in the MEDLINE, Cochrane, EMBASE, CINAHL and Web of Science databases. The included studies reported on device-related complications and interventions occurring in individuals with bone-anchored prostheses. The outcomes evaluated were death, infection, bone/device breakage, implant loosening, soft tissue complications, systemic events, antibiotic and surgical treatment. Subgroup analyses were performed for the following groups: a) implant type (screw, press-fit and other types of implants) and b) level of amputation (transfemoral, transtibial and upper extremity amputation).

RESULTS

Of 309 studies, 12 cohort studies were eligible for inclusion, all of which had methodological shortcomings and 12 studies were excluded due to complete overlap of patient data. Implant infection were rare in certain transfemoral implants (screw: 2-11%, press-fit: 0-3%, Compress: 0%) but common in transtibial implants (29%). The same was observed for implant loosening, in transfemoral (screw: 6%, press-fit: 0-3%, Compress: 0%), transtibial implants (29%) as well as for upper extremity implants (13-23%). Intramedullary device breakage were rare in transfemoral implants (screw: 0%, press-fit: 1%, Compress: unknown) but frequent in individuals with transradial implants (27%) and absent in transtibial implants. Soft tissue infections and complications were common and underreported in most articles.

CONCLUSIONS

Major complications (e.g. implant infection, implant loosening and intramedullary device breakage) are rare in transfemoral bone-anchored prosthesis and seem to occur less frequently in individuals with press-fit implants. Minor complications, such as soft tissue infections and complications, are common but are substantially influenced by the learning curve, implant design and surgical technique. Data for patients treated with a transtibial, upper extremity or Compress implant are underreported, precluding definitive conclusions. There is a need for either an international database to report on or a standard core set of complications as well as the need to follow classification systems that result in unequivocal data.

Three-year Outcomes of a Randomized Controlled Trial Comparing a 4.5-mm-Wide to a 3.75-mm-Wide Titanium Implant for Bone Conduction Hearing

OBJECTIVE

To compare 3-year implant stability, survival, and tolerability of a 4.5-mm-wide (test) and a 3.75-mm-wide (control) percutaneous titanium implant for bone-conduction hearing, loaded with the sound processor after 3 weeks.

METHODS

Sixty implants were allocated in a 2:1 ratio (test-control) in 57 adult patients included in this prospective randomized controlled clinical trial. Follow-up visits were performed at 7, 14, 21, and 28 days; 6 and 12 weeks; 6 months; and at 1, 2, and 3 years after implantation. During these visits, the implant stability quotient (ISQ) was measured by means of resonance frequency analysis (RFA). The peri-abutment soft tissue status was assessed according to the Holgers classification. Skin height around the abutment was evaluated.

RESULTS

The mean area-under-the-curve (AUC) of ISQ-low was statistically significantly higher for the test implant (65.7 versus 61.4, p = 0.0002). Both implants showed high survival rates (97.4% versus 95.0%, p = 0.6374). Adverse soft tissue reactions were observed sporadically, with no significant inter-group differences. Skin thickening was seen in the majority of the patients, but no correlation with adverse soft tissue reactions or implant type was observed.

CONCLUSION

The 4.5-mm-wide implant provides significantly higher ISQ values during the first 3 years after surgery compared with the previous generation 3.75-mm-wide implant. Both implants showed high survival rates and good tolerability. These long-term results indicate that the wider implant, loaded with a sound processor at 3 weeks, is a safe and well-performing option for hearing rehabilitation in specific types of hearing loss.

Percutaneous bone-anchored hearing implant surgery: linear incision technique with tissue preservation versus linear incision technique with tissue reduction

OBJECTIVES

To identify differences in skin thickening and soft tissue reactions between the linear incision technique with tissue reduction (LITT-R) and the linear incision technique with tissue preservation (LITT-P).

STUDY DESIGN

Retrospective cohort study.

METHODS

All adult patients who underwent the LITT-R or LITT-P between August 2005 and December 2016 at a large general teaching hospital with a minimum follow-up of 6 months were included.

RESULTS

A total of 83 implants were included using the LITT-R with a median follow-up of 74.0 months. In the LITT-P cohort 58 implants were included with a median follow-up of 16.5 months. Skin thickening was seen in seven implants (8.4%) in LITT-R cohort and 11 implants (19.0%) in the LITT-P cohort in the first 2 years of follow-up (p = 0.024). Skin thickening in need of treatment was registered in 5 (6.0%), respectively, 6 (10.3%) implants (p = 0.100). Moreover, treatment was successful in all cases. A soft tissue reaction (Holgers ≥ 1) was noticed in 28 (33.7%) implants in the LITT-R group compared to 16 implants (27.6%) in the LITT-P group (p = 0.679). An adverse soft tissue reaction (Holgers ≥ 2) was registered in 16 (19.2%), respectively, 2 (3.4%) implants. This difference was significant (p = 0.040).

CONCLUSION

LITT-P has a significantly higher rate of skin thickening and LITT-R has a significantly higher proportion of adverse soft tissue reactions. Nevertheless, combined with the advantages of LITT-P described in other studies, this can be advocated as the preferred technique.