Standardization of the Punch Technique for the Implantation of Bone Anchored Auditory Devices: Evaluation of the MIPS Surgical Set

In-office Bone-Anchored Hearing Implants via Minimally Invasive Punch Technique in a Veteran Population

OBJECTIVE

Describe the feasibility and safety of completing bone-anchored hearing implants via the minimally invasive punch technique in the in-office setting.

STUDY DESIGN

This single-institution case series included 20 patients who underwent in-office bone-anchored hearing implant placement under local anesthesia from 2018 to 2021.

SETTING

Veterans Affairs Northern California Healthcare System.

METHODS

Following completion of the case series, patients were retrospectively surveyed regarding their satisfaction with this approach via a modified SSQ-8 (Surgical Satisfaction Questionnaire) to fit our purposes.

RESULTS

A total of 23 implants were completed in the in-office setting on 20 patients. Intra- and postoperative complication rates, including skin changes, irritation, infection, and poor wound healing, were similar to or better than currently published complication rates in the literature. In addition, patients reported overwhelmingly positive responses on the SSQ-8, almost universally stating that they were "very satisfied" with their clinic experience.

CONCLUSION

This case series suggests that it is feasible and safe to complete this procedure in the clinic under local anesthesia, but further prospective studies are needed to evaluate this in a more generalized population.

The Oticon Ponto System in Adults With Severe-to-Profound and Mixed Hearing Loss: Audiologic Outcomes and Patient Satisfaction

OBJECTIVE

To measure audiologic outcomes and self-assessed satisfaction with the Ponto system in a group of patients who had severe to profound and mixed hearing loss.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Sixteen patients aged 21 to 74 years with severe-to-profound and mixed hearing loss (bone conduction thresholds, ≥45 dB HL).

INTERVENTIONS

Ponto implant surgery.

MAIN OUTCOME MEASURES

Pure-tone audiometry, free-field hearing thresholds, effective gain, word recognition score in quiet, and speech reception threshold (SRT) in noise were assessed. Patient-reported outcomes were collected using the Clinical Global Impression Scale, Glasgow Benefit Inventory, and Abbreviated Profile of Hearing Aid Benefit. Information concerning any medical complications was also gathered.

RESULTS

Both word recognition score and SRT were significantly better after 12 months compared with before surgery. At normal speech level (65 dB SPL), 12 of 16 users had speech discrimination ≥70%. However, at the 12-month follow-up, the average effective gain was -6.2 dB. In general, the self-report outcomes showed good satisfaction in most patients. Postoperatively, skin complications were noted in six patients, of whom two underwent reoperation. All patients were still using the Ponto after an average observation time of 2.7 years.

CONCLUSION

Although skin complications were not uncommon, the Ponto system seems to be an effective method of improving hearing performance and provides subjective satisfaction in real-life situations in patients with severe-to-profound and mixed hearing loss. However, considering the significantly increased bone conduction thresholds and the risk of their further deterioration, long-term follow-up is still needed.

Ex vivo Evaluation of a New Drill System for Placement of Percutaneous Bone Conduction Devices

The procedure for installation of a percutaneous bone-conducting device has undergone significant improvements since its introduction 40 years ago. Today, the linear incision technique with tissue preservation (LITT-P) and the minimally invasive procedure (MIPS) are the most commonly used approaches. In both these techniques, a gradual increase of the osteotomy using a three-step drilling sequence is utilized, as this approach can allow a stepwise deepening and widening of the osteotomy in the mastoid and can prevent bone overheating. A new minimally invasive procedure (MONO) has been developed that allows an osteotomy to be performed and enables complete removal of the bone volume in one single drill step for a 4 mm implant using a novel parabolic twist drill. Here, the feasibility of the MONO procedure was qualitatively and quantitatively evaluated in terms of the dura response to drill trauma in comparison with the outcomes achieved with guide drills used for the LITT-P and MIPS techniques. Fresh frozen temporal bone from a human cadaver was subjected to penetration by three drills beyond the base of the mastoid bone to different depths. The sites were evaluated, and the damage to and possible penetration of the dura were determined. The results showed that for a drill depth exceeding mastoid bone thickness by not more than 1 mm, damage to the dura was limited or nonexistent, whereas for a drill depth exceeding bone thickness by 2 mm, damage increased, or the dura was penetrated. There was a trend toward more damage and penetration for both the round burr and MIPS guide drill compared with the MONO drill bit. From this experimental ex vivo study, it can be concluded that if the dura is encountered, the MONO system is not more inclined to penetrate the dura than the conventional LITT-P and MIPS systems.

Ultrasound-Guided Placement of Percutaneous Abutments for Bone Conduction Hearing Devices

OBJECTIVE

To introduce a minimally invasive and image-guided technique for staged placement of a percutaneous abutment after osseointegrated implantation.

PATIENTS

Adults undergoing temporal bone resection at two academic medical centers.

INTERVENTIONS

Ultrasound-guided percutaneous installation of a bone conduction hearing device abutment. All patients had lateral temporal bone resection with osseointegrated implantation. Abutment placement followed as a planned staged procedure 3 to 6 months later depending on the use of radiotherapy.

MAIN OUTCOME MEASURES

Ability to use a bone conduction hearing device and occurrence of skin reactions or wound complications.

RESULTS

Twelve patients successfully underwent abutment installation through a 5 mm skin biopsy punch incision, nine of which had minimal to no skin reaction surrounding the abutment. Two patients developed Holgers grade 1 skin reaction (redness with slight swelling). One patient experienced an osseointegration failure 152 days after abutment placement.

CONCLUSIONS

Ultrasound is a widely available imaging modality that can be used to precisely localize subcutaneous osseointegrated implants, allowing for minimally invasive percutaneous placement of an abutment under local or general anesthesia.

Comparison between linear incision and punch techniques for bone anchored hearing aid surgery

Objectives

To evaluate mean surgical time, incidence of soft tissue reactions, implant survival and intraoperative complications in both minimally invasive ponto surgery (MIPS) and the linear incision with tissue preservation technique (LT).

Methods

A retrospective review was carried out on 48 bone anchored hearing system (BAHS) patients between 2014 and 2019: 13 patients had undergone LT and formed one group, while 35 patients had undergone MIPS and formed the second group. Mean surgical time, intraoperative complications, implant loss and skin reaction were assessed at each post-operative examination. The Mann-Whitney U test was used for statistical analysis.

Results

The difference in the mean surgical time of 15 mins for MIPS and 36 mins for LT was statistically significant. No intraoperative complications were reported and implant survival was 100% in both groups. The incidence of adverse skin reactions was 7.7% for the LT group and 0% for the MIPS group at first follow-up examination.

Conclusions

Surgical mean time is shorter for MIPS, making this procedure more suitable for local anaesthesia and more cost effective. Moreover, both LT and MIPS demonstrate good surgical outcomes in terms of skin reactions according to Holgers score and equally excellent implant survival.

A Clinical Evaluation of Minimally Invasive Ponto Surgery With a Modified Drill System for Inserting Bone-Anchored Hearing Implants

OBJECTIVE

To compare 6-months outcomes of the modified minimally invasive Ponto surgery (m-MIPS) to both the linear incision technique with soft tissue preservation (LIT-TP), and original MIPS (o-MIPS) for inserting bone-anchored hearing implants (BAHIs).

STUDY DESIGN

Exploratory pilot study with one test group and two historical control groups.

SETTING

Tertiary referral center.

PATIENTS

In the test group, 24 patients (25 implants) were prospectively included. Each control group comprised 25 patients (25 implants) who participated in previously conducted clinical trials.

INTERVENTIONS

The test group received a BAHI using m-MIPS. The two control groups underwent surgery using the LIT-TP and o-MIPS, respectively.

MAIN OUTCOME MEASURES

Implant survival, implant stability, and surgery-related variables were compared between the test and control groups. Soft tissue status, skin sensibility, and subjective numbness were compared between m-MIPS and LIT-TP only.

RESULTS

Implant survival was comparable between m-MIPS and LIT-TP, whereas implant stability measurements were slightly lower for m-MIPS. M-MIPS resulted in comparable adverse skin reactions and skin sensibility, significantly reduced surgical time and slightly improved subjective numbness, compared with LIT-TP. Between m-MIPS and o-MIPS, no statistically significant differences in implant survival, implant stability and surgical time were observed.

CONCLUSIONS

A trend toward lower implant loss rates after m-MIPS was observed, when compared with o-MIPS. M-MIPS seems to be a good alternative to LIT-TP for inserting BAHIs, since most clinical outcomes were either comparable or slightly better for m-MIPS. Upon deciding on which technique to use, larger studies on implant survival should be performed. Furthermore, other aspects such as costs, training aspects and surgical experience should be evaluated.

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.

Post-operative infection rates in linear vs. punch technique for bone anchored hearing systems

PURPOSE

This study investigates the post-operative infection rates between two surgical approaches: linear incision and the punch technique for bone anchored hearing systems. Secondarily, it investigates the impact of smoking, comorbid disease, and operative conditions on post-operative skin reactions and infections.

METHODS

A retrospective study was conducted at a single tertiary care institution. A single surgeon completed either of the two techniques on adult patients with mixed, conductive hearing loss, or single sided-deafness. Patients included had at least 6 months follow-up, and were evaluated for preexisting illnesses, perioperative complications, length of surgery, and post-operative complications including infection after surgery. Post-operative soft tissue around the abutment was assessed with Holgers Classification scale.

RESULTS

Fifty-one patients were included in this study, 28 female and 23 males with an average age of 68.8. Thirty-three patients underwent linear incision surgery and 18 had the punch technique. Overall 9 patients (17.6%) had post-operative infections requiring topical or oral antibiotic treatment. Six (18.2%) were in the linear group and 3 (16.7%) in the punch group. There was no statistically significantly difference (p = 1). A multivariate analysis compared age, sex, obesity, DM, operative time, skin thickness, and abutment size to post-operative skin infection rates requiring treatment. Only DM was statistically correlative with infection (p = 0.02).

CONCLUSION

No significant differences in post-operative infections were identified comparing linear incision and the punch techniques. Patients with diabetes had a higher incidence of post-operative skin infections rates.

Ten years of experience with the Ponto bone-anchored hearing system-A systematic literature review

Background

Bone‐anchored hearing systems (BAHSs) are widely used for hearing rehabilitation and are indicated in cases of conductive and mixed hearing loss and in single‐sided deafness. The Ponto system, that is one available option, has been on the market since 2009.

Objective of review

The aim of this study is to systematically review the literature reporting on the Ponto system, with regard to audiological and surgical outcomes and patient's quality‐of‐life scores.

Type of review

A systematic literature search was performed in the PubMed database 2009‐July 2019.

Search strategy

Search term: ((osseointegrated hearing aid) OR (bone conduction implant) OR (bone anchored hearing) OR BAHA OR BAHS OR BAHI). Pre‐defined inclusion and exclusion criteria were applied.

Evaluation method

English‐language articles reporting original clinical data (audiological, surgical or quality‐of‐life outcomes) on the Ponto system were included.

Articles reporting on Ponto and another BAHS system where the results on Ponto constituted less than 50% of the patient population or including only results on testband or softband devices were excluded.

Results

Audiological outcomes were discussed in 20 publications. Improvement against the unaided thresholds was demonstrated. The functional improvement was on average 33.9 dB. The effective gain or remaining air‐bone gap was on average 6.7 dB. All evaluated data showed aided speech reception thresholds significantly below normal speech level. Twenty‐seven publications reported surgical and follow‐up data for the Ponto system. Implant survival was 97.7%, adverse skin reactions (Holgers ≥ 2) were 5% across visits and 15% across patients. No complications were life‐threatening, causing permanent disability/damage or requiring a hospitalisation. Five studies reported quality of life using the Glasgow benefit inventory, 98% reported an improvement when analysing the score on an individual level.

Conclusions

The outcomes of this systematic review confirm that percutaneous systems provide consistent audiological benefits and improved quality of life for patients. Further, the review demonstrates that the percutaneous systems are safe, with relatively low complication rates. Skin‐related complications are the most common complication type and are experienced by approximately one patient out of seven, or in less than one of 20 follow‐up visits.

Next-Day Loading of a Bone-Anchored Hearing System: Preliminary Results

OBJECTIVES

To demonstrate the feasibility and efficacy for next-day loading of a percutaneous bone-anchored hearing device.

STUDY DESIGN

Multicenter prospective cohort study.

SETTING

Tertiary neurotologic referral centers.

SUBJECT AND METHODS

In this multicenter prospective study, a 4.5-mm laser-etched bone-anchored hearing device was implanted in adult subjects who had conductive/mixed hearing loss or single-sided deafness. One day following implantation, the surgical site was assessed for soft tissue reaction per the Holgers Scale, and implant stability was evaluated by manual palpation and resonance frequency analysis. On the same day, subjects were fitted with the processor. Follow-up evaluations were at 1 week, 4 weeks, 3 months, 6 months, and 12 months. The Glasgow Benefit Inventory and Abbreviated Profile of Hearing Aid Benefit questionnaires were completed postoperatively.

RESULTS

Fourteen devices were implanted in 12 subjects. Two subjects underwent bilateral implantation. Implant stability was rated as firm at every interval for all ears, and the Implant Stability Quotient values at 3 months were stable or increased as compared with day 1 measurements. Skin irritation was limited to Holgers grade 0 and 1, with the majority having no skin irritation. The mean Glasgow Benefit Inventory global score was +43.8, and the mean Abbreviated Profile of Hearing Aid Benefit global benefit score was 60.2%. All 14 implants have remained firmly anchored.

CONCLUSIONS

Next-day loading of this 4.5-mm-diameter percutaneous bone-anchored hearing device appears to be a feasible alternative to the original 3-month delayed loading. Although this is a preliminary study, the results support continued investigation of a next-day loading strategy.