Minimally Invasive Ponto Surgery Versus the Linear Incision Technique With Soft Tissue Preservation for Bone Conduction Hearing Implants: A Multicenter Randomized Controlled Trial

Provision of bone conduction hearing implants in England in adults and children: a review of Hospital Episode Statistics data 2012-2021

OBJECTIVE

Bone conduction hearing implants are a well-established method of hearing rehabilitation in children and adults. This study aimed to review any changes in provision in England.

METHODS

The total number of bone conduction hearing implantations performed was analysed from 2012 to 2021 utilising Hospital Episode Statistics data for England.

RESULTS

The total number of procedures has increased by 58 per cent. One-stage bone conduction hearing implantations in adults accounts for the largest proportion of this increase (93 per cent of the total). The number performed in children has remained stable and accounts for 73 per cent (n = 433) of all two-stage procedures.

CONCLUSION

The data show that bone conduction hearing implant surgery is becoming increasingly popular, particularly in adults. This has correlated with the increase in availability, national recommendations and choice of devices.

Surgical Outcomes of Modified Technique for Transcutaneous Bone Conduction Hearing Aid Implantation

OBJECTIVE

To detail a modified surgical technique for implantation of the Osia 2 Bone Conduction Hearing Aid (BCHA) system and to assess intra- and postoperative outcomes of this technique.

METHODS

A retrospective review was performed for cases undergoing implantation of an Osia 2 BCHA at a tertiary academic medical center. Modifications were made to the surgical procedure including: horizontal or curvilinear incisions, placement of the osseointegrated screw slightly superior to the plane of the external auditory canal, and double layer wound closure. Data regarding outcomes including demographics, incision type, surgical time, drilling requirements, and complications were collected using the electronic medical record.

RESULTS

A total of twenty-eight cases were evaluated with 57.1% and 42.9% utilizing horizontal and curved incisions, respectively. The median age for recipients was 43.1 years with six pediatric cases included in the study. Median operative time was 58 min (43-126 min). The majority of cases required minimal (60.7%) or no drilling (28.6%) with a significant increase in operative time for those requiring moderate drilling versus minimal to no drilling (F = 8.02, p = 0.002). There were no intraoperative complications. One (3.6%) postoperative seroma occurred which resolved with conservative management.

CONCLUSION

The proposed modified surgical technique is a safe and effective method for implantation of the transcutaneous BCHA system with a low complication rate. Keys include incision design, implant placement, and two-layered closure to minimize wound tension. These modifications can improve ease of the procedure and reduce operative time. These techniques also appear to be applicable to the pediatric population.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2401-2404, 2024.

Comparison of the MIPS technique versus linear incision with tissue preservation in osseointegrated implants in the Ponto model®

BACKGROUND AND OBJECTIVES

The surgery of osseointegrated implants has undergone different modifications over the years with the aim of achieving better results and facilitating the surgical technique. Today the most commonly used technique is the linear incision with tissue preservation and placement of the abutment and implant. The long-term success of this technique has served as the basis for the development of the so-called minimally invasive surgical approach (MIPS). This study compares the short-, medium- and long-term results between the classic linear incision technique and the MIPS technique.

MATERIAL AND METHODS

A prospective study was conducted on patients who had an osseointegrated implant placed between February 2016 and February 2020. A total of 59 surgeries were performed, 32 surgeries according to the linear incision technique with tissue preservation and 27 with MIPS technique. Outcomes were evaluated at one week, one month and one year.

RESULTS

Statistically significant differences were achieved between the 2 groups at one week after surgery. Eighty per cent of the MIPS patients had Holgers grades 0-1 compared to 35% of the linear technique patients (p = 0.001). No statistically significant differences were observed at one month (p = 0.457) and one year (p = 0.228). One case with grade 4 was recorded which resulted in implant extrusion one month after surgery with the MIPS technique. A new osseointegrated implant was placed 2 months after the fall using the same MIPS technique with good results. We were also able to verify that the duration of surgery was much shorter with the MIPS technique and better tolerated in terms of postoperative discomfort by the patient.

CONCLUSIONS

In our experience, the MIPS technique is the technique of choice for surgery of osseointegrated Ponto model implants as it is simpler, faster and presents fewer problems in the immediate postoperative period, with similar long-term postoperative results.

Long-Term Results of the Linear Incision Technique With Tissue Reduction Versus Tissue Preservation for Inserting Bone-Anchored Hearing Implants: The Ongoing Optimization in Bone Implant Surgery

OBJECTIVE

To compare the long-term outcomes of the linear incision technique with tissue reduction (LIT-TR) and the linear incision technique with tissue preservation (LIT-TP) for inserting bone-anchored hearing implants (BAHIs).

STUDY DESIGN

Single-center retrospective cohort study.

SETTING

Large general teaching hospital.

PATIENTS

A total of 231 adult patients were included between August 2005 and October 2020, with a minimum follow-up time of 6 months.

INTERVENTION

The test group received a BAHI using the LIT-TP (N = 147). The control group underwent surgery using the LIT-TR (N = 84).

MAIN OUTCOME MEASURES

Soft tissue reactions, skin thickening, postoperative complications (e.g., wound dehiscence), and implant loss were compared between the test and control group. Furthermore, Cochlear Bone Anchored Solutions AB (Mölnlycke, Sweden) and Oticon Medical AB (Askim, Sweden) implants/abutments within the LIT-TP cohort were compared. Validated questionnaires were used to quantify patients' health-related quality of life (HRQoL).

RESULTS

Significantly more cases with wound dehiscence and adverse soft tissue reactions (Holgers ≥2) were observed in the LIT-TR cohort (p < 0.001). However, the LIT-TP cohort showed significantly more cases with skin thickening (requiring treatment) within the first 2 years after implantation. There were no differences in implant loss rates, overall soft tissue reactions (Holgers >1), and overall HRQoL between the two patient groups. Significant improvement in the patients' HRQoL after implementation of a BAHI was found in both techniques. The Ponto Wide implant/abutment showed less frequent skin thickening (requiring treatment) and fewer soft tissue reactions compared with the BIA400 implant/abutment.

CONCLUSION

This large-scale study demonstrates that the LIT-TP shows excellent long-term outcomes, including a low incidence of implant failure.

Minimally invasive surgery as a new clinical standard for bone anchored hearing implants-real-world data from 10 years of follow-up and 228 surgeries

Purpose

To explore the clinical practice development of different surgical techniques when installing bone-anchored hearing implants and their associated trends in outcomes.

Design

Retrospective study of 228 bone-anchored hearing implants in 200 patients, performed over a 10-year period between 2012 and 2022 in a referral hospital.

Method

Real-world data of demography, etiology, surgical setup, complications, and audiological outcomes were collected. Eligibility criteria from clinical practice were applied.

Results

The minimally invasive technique is associated with shorter surgery duration, 20 vs. 44 min as compared to a linear incision technique. The minimally invasive technique was also associated with a lower occurrence of complications when compared to linear incision techniques (intraoperative; 1.8% vs. 4.9%, postoperative; 49% vs. 66%). Most differences were seen in complications relating to skin and wound healing.

Conclusion

Adoption of a minimally invasive surgical technique for the installations of bone-anchored hearing implants can reduce surgical complexity without compromising safety aspects or clinical benefits.

Health Economic Cost Analysis for Percutaneous Bone Conduction Devices: The Minimally Invasive Ponto Surgery Versus Linear Incision Technique with Tissue Preservation

OBJECTIVES

To identify differences in mean cost per patient between the Minimally Invasive Ponto Surgery (MIPS) and the linear incision technique with tissue preservation (LITT-P).

STUDY DESIGN

Health economic cost analysis.

SETTING

The analysis was performed in a randomized multicenter controlled trial cohort.

PATIENTS

Adult patients eligible for unilateral bone conduction device surgery.

INTERVENTIONS

MIPS versus LITT-P surgery for bone conduction device implantation.

MAIN OUTCOME MEASURES

Perioperative and postoperative costs were identified and compared.

RESULTS

The difference in mean cost per patient between both techniques was €77.83 in favor of the MIPS after 22 months follow-up. The mean costs per patient were lower in the MIPS cohort for surgery (€145.68), outpatient visits (€24.27), systemic antibiotic therapy with amoxicillin/clavulanic acid (€0.30) or clindamycin (€0.40), abutment change (€0.36), and abutment removal (€0.18). The mean costs per patient were higher for implant and abutment set (€18.00), topical treatment with hydrocortison/oxytetracycline/polymyxine B (€0.43), systemic therapy with azithromycin (€0.09) or erythromycin (€1.15), local revision surgery (€1.45), elective explantation (€1.82), and implant extrusion (€70.42). Additional analysis of scenarios in which all patients were operated under general or local anesthesia or with recalculation when using current implant survival rates showed that differences in mean cost per patient were also in favor of the MIPS.

CONCLUSION

The difference between the MIPS and the LITT-P in mean cost per patient was €77.83 in favor of the MIPS after 22 months of follow-up. The MIPS is an economically responsible technique and could be promising for the future.

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.

Non-invasive sampling procedure revealing the molecular events at different abutments of bone-anchored hearing systems–A prospective clinical pilot study

Purpose

To investigate the molecular activities in different compartments around the bone-anchored hearing system (BAHS) with either electropolished or machined abutments and to correlate these activities with clinical and microbiological findings.

Materials and methods

Twelve patients received machined or electropolished abutments after implant installation of BAHS. Peri-abutment fluid and tissue were collected from baseline to 12 months. Gene expression of cytokines and factors related to tissue healing and inflammation, regeneration and remodelling, as well as bacterial recognition were determined using quantitative-polymerase chain reaction (qPCR). The clinical status was evaluated using the Holgers scoring system, and bacterial colonisation was investigated by culturing.

Results

The gene expression of inflammatory cytokines (IL-8, IL-1β, and IL-10) and bacteria-related Toll-like receptors (2 and 4) was higher in the peri-abutment fluid than at baseline and in the peri-abutment tissue at 3 and 12 months. Conversely, the expression of genes related to tissue regeneration (Coll1a1 and FOXO1) was higher in the tissue samples than in the peri-abutment fluid at 3 and 12 months. Electropolished abutments triggered higher expression of inflammatory cytokines (IL-8 and IL-1β) (in peri-abutment fluid) and regeneration factor FOXO1 (in peri-abutment tissue) than machined abutments. Several cytokine genes in the peri-abutment fluid correlated positively with the detection of aerobes, anaerobes and Staphylococcus species, as well as with high Holger scores.

Conclusion

This study provides unprecedented molecular information on the biological processes of BAHS. Despite being apparently healed, the peri-abutment fluid harbours prolonged inflammatory activity in conjunction with the presence of different bacterial species. An electropolished abutment surface appears to be associated with stronger proinflammatory activity than that with a machined surface. The analysis of the peri-abutment fluid deserves further verification as a non-invasive sampling and diagnostic procedure of BAHS.

Single-Center Experience Evaluating Clinical Outcomes of a Novel-Guided Drill System for Percutaneous Bone-Anchored Hearing Implant

OBJECTIVE

Evaluate intraoperative and postoperative outcomes of a novel guided drill system for percutaneous bone-anchored hearing implants.

METHODS

Between January 2016 and February 2021, patients age ≥18 years deemed potential candidates for a bone-anchored hearing device, were formally assessed for candidacy and counseling. Those that qualified and opted to proceed were added to a prospectively maintained database, including demographic, clinical, and audiologic data. Intraoperative findings were reported, as were clinical outcomes at 7 days, 4 weeks, 3 months and 6 months postoperatively. The Holgers index was used to grade soft tissue reactions.

RESULTS

One hundred patients underwent the procedure. There were 56 women, and mean age was 54 years (18-84 yr). Ninety-six were done under local anesthetic. Mean surgical time was 13 minutes (9-27 min). No significant intraoperative events were noted. There were nine cases of implant loss, all in the first 50 cases. Mean duration of implant loss was 3.6 weeks (range, 2-5 wk). At the first postoperative visit, 82 had Holgers 0, 16 Holgers 1, 2 Holgers 2, and none Holgers 3. At the second postoperative visit, excluding the 9 with implant loss, 83 (91%) had Holgers 0, 6 (7%) Holgers 1, and 2 (2%) Holgers 2. None were Holgers 3.

CONCLUSIONS

The current study represents, to our knowledge, the largest series on the novel guided drill technique. Results show it is safe and efficient with low soft tissue complication rates. Drill bit design and technical modifications may have helped lower implant loss rate in this series over time.

The Minimally Invasive Star-Shaped Incision Technique and the Linear Incision Technique With Tissue Preservation for Percutaneous Bone Conduction Devices: A Retrospective Cohort Study

Purpose

To compare intra- and postoperative outcomes between the standard linear incision technique with tissue preservation (LITT-P) and the minimally invasive star-shaped incision (SSI).

Study Design

A retrospective cohort study.

Methods

Primary outcomes evaluated operative time, implant survival, and intra-operative complications. A secondary outcome evaluated soft tissue tolerability assessed by the Holger's classification.

Results

A total of 38 implants were placed (19 LITT-P; 19 SSI). The median and mean surgical duration for the LITT-P group was statistically shorter than the SSI group (p = 0.0001). No intra-operative complications were reported for both surgical approaches. Five implants were lost during postoperative follow-up: one in the LITT-P and four in the SSI cohort. Both cohorts showed favorable soft tissue tolerability. Less Holgers 1 and 2 and more Holgers 3 soft tissue reactions were observed after the LITT-P compared to the SSI.

Conclusion

The novel SSI approach could be an alternative option based on the theoretical benefits and found favorable (and similar) soft tissue outcomes. Implant loss and surgical time are aspects to investigate regarding long-term durability and warrant further research.

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.

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.

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.

Tissue Preservation Techniques for Bone-Anchored Hearing Aid Surgery

OBJECTIVE

Compare outcomes of surgical techniques in percutaneous bone-anchored hearing implant surgery.

STUDY DESIGN

Matched retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

Electronic review of adult and pediatric patients who underwent bone conduction device surgery by either the Minimally-invasive Ponto Surgery (MIPS) technique or the linear incision with no soft tissue removal (LnSTR) technique or between August 2015 and April 2018 at our facility.

INTERVENTION

Patients in MIPS group underwent Minimally invasive Ponto Surgery (MIPS) technique, while those in LnSTR group underwent LnSTR technique.

MAIN OUTCOME MEASURE

Major outcome was presence/severity of localized skin reaction. Secondary outcomes included cosmetic outcome, revision surgery, minor adverse events, device utilization, and postoperative aided speech recognition thresholds (SRTs) across 250 to 4000 Hertz (Hz).

RESULTS

Fifty patients met inclusion criteria. There was a significantly lower rate of localized cutaneous reactions for the MIPS group (4.5%) compared with LnSTR group (33.3%; p = 0.026). Rate of revision surgery was significantly less for MIPS (13.6%) compared with LnSTR (20.8%; p = 0.008). Occurrence of poor cosmetic outcome was noted significantly less for the MIPS group (9.1%) compared with LnSTR patients (20.8%; p = 0.005). Minor adverse events and aided SRTs were comparable between groups.

CONCLUSIONS

MIPS leads to a statistically significant decrease in localized cutaneous reaction compared with LnSTR. Both the LnSTR and MIPS techniques are safe and effective in the treatment of hearing loss, however MIPS may be superior in certain cases by offering improved healing, decreasing needs for wound care, and possibly decreasing need for frequent follow up.

Review of Bone Conduction Hearing Devices

Bone conduction is an efficient pathway of sound transmission which can be harnessed to provide hearing amplification. Bone conduction hearing devices may be indicated when ear canal pathology precludes the use of a conventional hearing aid, as well as in cases of single-sided deafness. Several different technologies exist which transmit sound via bone conduction. Here, we will review the physiology of bone conduction, the indications for bone conduction amplification, and the specifics of currently available devices.

A New Active Osseointegrated Implant System in Patients with Single-Sided Deafness

OBJECTIVE

The Cochlear™ Osia® System (Osia) is an active transcutaneous bone conduction implant system intended for patients with conductive and mixed hearing loss but can also be used in cases of single-sided deafness (SSD) for the contralateral routing of signal (CROS). The Osia implant is placed subcutaneously under the intact skin behind the ear with the piezoelectric actuator connected to an osseointegrated BI300 implant - a titanium screw used for a 2-stage Baha surgery - on the mastoid. The external processor is magnetically attached to the subcutaneous implant receiver coil. As the Osia has recently been CE certified and is new on the market, with limited patient outcome data for SSD available, the objective of this study was the evaluation of surgical procedure, audiological results, and patient satisfaction for the Osia in SSD patients.

STUDY DESIGN

In a prospective, monocentric clinical observation study, 6 patients (18 years of age or older) with SSD and bone conduction thresholds pure tone average 0.5, 1, 2, and 4 kHz ≤25 dB HL on the contralateral side were implanted with an Osia. Analysis of clinical outcome data with respect to surgical technique, adverse events, audiological measurement, and subjective benefit for SSD patients was conducted. Audiological measurements performed included hearing thresholds, sound field thresholds, word recognition scores (WRS; in %) in quiet, and speech recognition thresholds in noise (in dB SNR). All tests were performed unaided and aided with the Osia. The subjective benefit with the Osia was determined by using 2 questionnaires; the Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Bern Benefit in Single-Sided Deafness (BBSSD).

RESULTS

Preliminary results indicate a straightforward surgical procedure with a low rate of complications and an improvement in speech perception in quiet, listening performance in everyday situations and patient satisfaction. However, in one of 6 subjects, a revision surgery had to be performed.

CONCLUSION

Provided that SSD patients are open for CROS hearing, they can benefit from the Osia by reduced head shadow effects and better speech recognition. Special caution should be given to the skin at the site of implantation to avoid complications.

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.

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.

Long-Term Outcomes of the Minimally Invasive Ponto Surgery vs. Linear Incision Technique With Soft Tissue Preservation for Installation of Percutaneous Bone Conduction Devices

Objective: Comparing the surgical outcomes of the Minimally Invasive Ponto Surgery (MIPS) technique with the linear incision technique with soft tissue preservation (LITT-P) for bone conduction devices after a follow-up of 22 months.

Methods: In this multicenter randomized controlled trial, there was the inclusion of 64 adult patients eligible for unilateral surgery. There was 1:1 randomization to the MIPS (test) or the LITT-P (control) group. The primary outcome was an (adverse) soft tissue reaction. Secondary outcomes were pain, loss of sensibility, soft tissue height/overgrowth, skin sagging, implant loss, Implant Stability Quotient measurements, cosmetic scores, and quality of life questionnaires.

Results: Sixty-three subjects were analyzed in the intention-to-treat population. No differences were found in the presence of (adverse) soft tissue reactions during complete follow-up. Also, there were no differences in pain, wound dehiscence, skin level, soft tissue overgrowth, and overall quality of life. Loss of sensibility (until 3-month post-surgery), cosmetic scores, and skin sagging outcomes were better in the MIPS group. The Implant Stability Quotient was higher after the LITT-P for different abutment lengths at various points of follow-up. Implant extrusion was nonsignificantly higher after the MIPS (15.2%) compared with LITT-P (3.3%).

Conclusion: The long-term results show favorable outcomes for both techniques. The MIPS is a promising technique with some benefits over the LITT-P. Concerns regarding nonsignificantly higher implant loss may be overcome with future developments and research.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02438618.

Punch vs open surgical techniques for placement of bone-anchored hearing implants: a systematic review and meta-analysis of skin reactions and operating time

PURPOSE

Several authors have reported their experience with the punch technique as compared to open surgical methods for bone-anchored hearing implants (BAHI). However, no study has attempted to aggregate current evidence. We aimed to compare post-operative skin complications and operating time between punch and open surgical techniques of BAHI via a systematic review and meta-analysis.

METHODS

Databases of PubMed, Embase, Scopus, BioMed Central, Ovoid, and CENTRAL were screened up to 15th February 2020 to include studies comparing punch and open surgical technique for BAHI.

RESULTS

Eight studies were included. Punch technique was compared with dermatome and linear incision techniques with and without soft tissue reduction. There was no difference in normal-to-moderate skin reaction between the punch and open surgical techniques (OR: 0.86 95% CI 0.23, 3.28 I² = 0%). The incidence of adverse skin reactions were also not different between the two groups. Meta-regression for different follow-up periods did not demonstrate any statistically significant results. Our results also indicated that punch technique requires less operating time, however, the inter-study heterogeneity in the analysis was very high. Similar results were seen on sub-group analysis based on the type of open surgical technique.

CONCLUSION

There may be no difference in skin tolerance between the punch technique and open surgical techniques. Operating time may be significantly reduced with the punch technique. Strong conclusions cannot be drawn owing to a limited number of studies. Further large-scale randomized trials are required.

Estudio sobre los implantes percutáneos de conducción ósea: Evolución y resultados de 8 años

Introducción: Los implantes de conducción de vía ósea percutáneos son una alternativa a los audífonos convencionales en hipoacusias de transmisión, mixtas y neurosensoriales unilaterales, en pacientes con imposibilidad de usar los primeros. Mediante este estudio analizamos diferentes aspectos de los sistemas osteointegrados en el Hospital Clínico Universitario Lozano Blesa de Zaragoza (España). Método: Se ha realizado un estudio observacional basado en historias clínicas, incluyendo a los pacientes que han sido implantados con un sistema osteointegrado de tipo percutáneo desde el año 2010. Entre los datos recogidos se valoraron datos demográficos, datos clínicos y analíticos referentes su hipoacusia y complicaciones post-implante entre otros. Resultados: Se han analizado 59 implantes percutáneos; un 44,1% tipo Baha y un 55,9 % tipo Ponto. La indicación audiológica mas frecuente fue la hipoacusia mixta (64,40%). El diagnóstico clínico más frecuente fue la otitis media crónica (83%). La ganancia auditiva funcional de los pacientes implantados debido a hipoacusia de transmisión fue de 26,92 ± 7,65 dB. La técnica quirúrgica más empleada fue el colgajo en U llevada a cabo en el 42,40% pacientes. Se ha objetivado cierta tendencia a la relación en el número de complicaciones y el hecho de realizar una reducción de tejido subcutáneo circundante al implante (p=0,051). Conclusiones: Aunque no se hayan encontrado diferencias significativas, los resultados tanto demográficos, como de indicación de la implantación, la ganancia funcional y las complicaciones son similares a los datos encontrados en la literatura médica.

Surgical and audiological results of bone-anchored hearing aids: comparison of two surgical techniques

INTRODUCTION

The bone-anchored hearing system has become the most viable treatment option for subjects with conductive or mixed hearing loss, who are unable to benefit from conventional hearing aids or middle ear surgery.

OBJECTIVE

To compare the surgical and audiological outcomes between the minimally-invasive Ponto surgery and a linear incision with soft tissue preservation techniques in bone-anchored hearing system recipients.

METHODS

A retrospective study was carried out from January 2017 to June 2018. Forty-two adult patients eligible for unilateral bone-anchored hearing system surgery with the Ponto system were included in the study. The implant and abutment lengths used varied from 3 to 4mm and from 6 to 14mm, according to the bone and skin thickness of the participants, respectively.

RESULTS

Twenty-two surgeries were performed using the minimally invasive Ponto surgery technique (52.4%) and 20 (47.6%) using the linear incision. The mean age of the subjects implanted with minimally invasive Ponto surgery and linear incision techniques were 42.0 and 33.3 years old, respectively. Ten male (45,5%) and 14 (70%) female patients were implanted using minimally invasive Ponto surgery and the linear incision techniques, respectively. There were no differences between pure tone audiometric thresholds and monosyllabic word recognition scores of the subjects, when comparing both surgical techniques. The minimally invasive Ponto surgery technique significantly reduced the surgical time compared to the linear incision technique. There were no differences between both surgical techniques for skin-related complications; they occurred in 45% of the subjects, regardless of the surgical technique employed. Subjects included in the minimally invasive Ponto surgery technique group showed a superior cosmetic outcome, with no surgical scar or additional sutures.

CONCLUSION

The surgical and audiological outcomes were satisfactory and were not correlated to the surgical technique selected in all subjects. When compared to the linear incision, the minimally invasive Ponto surgery technique showed reduced surgical time and superior esthetic outcomes in the postoperative follow-up.

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.

Microbiome on the Bone-Anchored Hearing System: A Prospective Study

The bone-anchored hearing system (BAHS) has evolved to a common treatment option for various types of hearing revalidation. The BAHS consists of an implant in the skull that breeches the skin. Soft tissue reactions are a common complication associated with BAHS and are generally poorly understood. This study aims to investigate the influence of BAHS and associated skin reactions around the implant. A total of 45 patients were prospectively followed from implantation up to at least 1 year. Swabs were obtained at baseline, 12 weeks follow-up and during cases of inflammation (Holgers score ≥2). The microbiota was assessed using IS-pro^TM, a bacterial profiling method based on the interspace region between the 16S–23S rRNA genes. Detection of operational taxonomic units, the Shannon Diversity Index, sample similarity analyses and Partial Least Squares Discriminant Analysis (PLS-DA) were employed. Staphylococcus epidermidis, Streptococcus pneumoniae/mitis, Propionibacterium acnes, Staphylococcus capitis, Staphylococcus hominis, Bifidobacterium longum, Haemophilus parainfluenzae, Lactobacillus rhamnosus, Bordetella spp., Streptococcus sanguinis, Peptostreptococcus anaerobius, Staphylococcus aureus, Lactococcus lactis, Enterobacter cloacae, and Citrobacter koseri were the most commonly found bacterial species. S. pneumoniae/mitis was significantly more often observed after implantation, whereas P. acnes was significantly less observed after implantation compared with baseline. The relative abundance of S. epidermidis (17%) and S. aureus (19.4%) was the highest for the group of patients with inflammation. The Shannon Diversity Index was significantly increased after implantation compared with pre-surgical swabs for Firmicutes, Actinobacteria, Fusobacteria, Verrucomicrobia (FAFV), but not for other phyla. When combining all phyla, there was no significant increase in the Shannon Diversity Index. The diversity index was similar post-surgically for patients experiencing inflammation and for patients without inflammation. With a supervised classifier (PLS-DA), patients prone to inflammation could be identified at baseline with an accuracy of 91.7%. In addition, PLS-DA could classify post-surgical abutments as non-inflamed or inflamed with an accuracy of 97.7%. This study shows the potential of using IS-pro^TM to describe and quantify the microbiota associated with the percutaneous BAHS. Furthermore, the results indicate the possibility of an early identification of patients susceptible to adverse skin reaction following implantation. Both S. aureus and S. epidermidis should be considered as relevant bacteria for BAHS-associated inflammation.

Bone Conduction Implants for Hearing Rehabilitation in Skull Base Tumor Patients

Bone conduction implants transfer sound to the inner ear through direct vibration of the skull. In patients with skull base tumors and infections, these devices can bypass a dysfunctional ear canal and/or middle ear. Though not all skull base surgery patients opt for bone conduction hearing rehabilitation, a variety of these devices have been developed and marketed over time. This article reviews the evolution and existing state of bone conduction technology.

Long term follow-up demonstrating stability and patient satisfaction of minimally invasive punch technique for percutaneous bone anchored hearing devices

OBJECTIVE

Minimally Invasive Ponto Surgery (MIPS) was recently described to facilitate the placement of percutaneous bone anchored hearing devices. As early adopters of this new procedure, we sought to perform a quality assurance project using our own small prospective cohort to justify this change in practice. We chose to examine device stability and to gauge our patients' perspective of the surgery and their overall satisfaction with the process.

METHODS

A total of 12 adult patients who underwent MIPS between 2016 and 2017 with a minimum post-operative follow-up of 12 months were included in this study. A prospective MIPS research clinic was used to follow patients, assess the implant site soft tissue status and gather qualitative information through patient interviews and surveys.

RESULTS

The mean (SD) soft tissue status score averages using the IPS Scale were low for inflammation 0.1 (0.1), pain 0.1 (0.1), skin height 0.2 (0.1) and total IPS score 0.4 (0.3) indicating minimal soft tissue changes. Patient experiences with MIPS were overwhelmingly positive in reports through the MIPS modified SSQ-8. All patients reported speedy recoveries and no long-term complications. There were zero device losses.

CONCLUSION

The series presented in this paper represents the first MIPS cohort with long term follow-up to be published to date in North America. Our findings conclude both device stability and patient satisfaction with no loss of fixtures. Consequently, we have adopted MIPS as our procedure of choice for the placement of all percutaneous BAHDs.

The clinical outcome and microbiological profile of bone-anchored hearing systems (BAHS) with different abutment topographies: a prospective pilot study

Purpose

In this prospective clinical pilot study, abutments with different topologies (machined versus polished) were compared with respect to the clinical outcome and the microbiological profile. Furthermore, three different sampling methods (retrieval of abutment, collection of peri-abutment exudate using paper-points, and a small peri-abutment soft-tissue biopsy) were evaluated for the identification and quantification of colonising bacteria.

Methods

Twelve patients, seven with machined abutment and five with polished abutment, were included in the analysis. Three different sampling procedures were employed for the identification and quantification of colonising bacteria from baseline up to 12 months, using quantitative culturing. Clinical outcome measures (Holgers score, hygiene, pain, numbness and implant stability) were investigated.

Results

The clinical parameters, and total viable bacteria per abutment or in tissue biopsies did not differ significantly between the polished and machined abutments. The total CFU/mm² abutment and CFU/peri-abutment fluid space of anaerobes, aerobes and staphylococci were significantly higher for the polished abutment. Anaerobic bacteria were detected in the tissue biopsies before BAHS implantation. Anaerobes and Staphylococcus spp. were detected in all three compartments after BAHS installation. For most patients (10/12), the same staphylococcal species were found in at least two of the three compartments at the same time-point. The common skin coloniser Staphylococcus epidermidis was identified in all patients but one (11/12), whereas the pathogen Staphylococcus aureus was isolated in five of the patients. Several associations between clinical and microbiological parameters were found.

Conclusions

There was no difference in the clinical outcome with the use of polished versus machined abutment at 3 and 12 months after implantation. The present pilot trial largely confirmed a suitable study design, sampling and analytical methodology to determine the effects of modified BAHS abutment properties.

Level of evidence

2. Controlled prospective comparative study.

Electronic supplementary material

The online version of this article (10.1007/s00405-018-4946-z) contains supplementary material, which is available to authorized users.