Surgical Treatment of Conductive Hearing Loss

Charles J. Limb, M.D.

Francis A. Sooy Professor

Chief, Division of Otology, Neurotology and Skull Base Surgery

Department of Otolaryngology-Head and Neck Surgery

UC San Francisco

Disclosures

n Advanced Bionics Corporationu Consultant (2006-present)u Research supportu Medical Advisory Board member

n Med-El Corporationu Research grants (2012-present) u Research support

n Oticon Medicalu Research support (Ponto and music)

n Spiral Therapeuticsu Consultant (Chief Medical Officer) and Stock Shareholder

Assumption:

All Conductive Hearing Loss Can Be Treated!

Hearing Loss

ARE YOU EXPERIENCING SIGNS OF HEARING LOSS?Hearing loss can typically be divided into two categories (Conductive & Sensorin

Conductive Hearing Loss applies to a loss of transmission of sound energy across the mec

Sensorineural Hearing Loss occurs in the inner ear, typically in the cochlea where the tiny h

HEARING QUIZDo you often ask others to repeat what they have said (i.e. "excuse me," "what

Do you have difficulty hearing in noisy places (i.e. background noise)?

Do you miss important words or phrases during conversations?

Is the volume of the television or radio uncomfortable for other listeners?

Do you miss the ringing of the telephone, microwave timer, or other high-pitche

Do you have a constant or intermittent ringing/buzzing in your ears?

Is it difficult determining which direction sounds are coming from?

Do you avoid social situations because you are concerned you will not hear prop

External auditory canal

n Atresian Exostosesn Canal cholesteatoman Acquired stenosisn Tympanic membrane issues

Severe Exostoses Can CauseConductive Hearing Loss

Tympanic Membrane Perforations

n All TM perforations can be fixedn Three reasons to fix:

u Conductive hearing lossu Recurrent infectionsu Prevent cholesteatoma formation

Total Drum Reconstruction

Middle Ear

n Otosclerosisn Ossicular discontinuityn Ossicular fracture

Ossicular reconstruction has many poor optionsThe status of the stapes is key!

Nitinol Prostheses for Otosclerosis / Stapedotomy

Nitinol stapedotomy outcomes

Loss of eardrum tension after showering

Isolated malleus fracture in a musician

Cartilage strut graft spans ossicular fraction defect

Always place biological material between prosthesis and eardrumCartilage works extremely well for this!

Complete Ossicular Fixation: How to Fix?

Inner Ear

n Cochlear conductive hearing lossn Superior canal dehiscence

Third mobile Window

Bone Anchored Hearing Implant Systems

Cochlear Baha

OticonPonto

Bone anchored hearing implant system has 3 main components

Bone-Anchored Hearing Advantages

Enhanced transmission efficiency of (direct) bone conduction

Predictable result, even for revision

Reduced operative time

Reversible

Enhanced high frequencies

Removes compressive band

Comfort

Aesthetics

Over air conduction

devices

Over reconstructive

surgery

Over bone conduction

devices

Indications and Audiologic Criteria

• Conductive/mixed hearing loss:– Up to 45 dB PTA bone conduction hearing 1kHz, 2kHz, 3kHz for standard processor

– Up to 55 dB PTA bone conduction hearing 1kHz, 2kHz, 3kHz for power processor

• Single sided deafness:– Up to 20 dB HL air conduction in better ear

• Both adults and children benefit greatly

Unilateral conductive hearing lossOsseointegrated systems close air‐bone gaps 

with remarkable efficiency

• Improved directional hearing

• Improved speech perception, especially in noise

• Positive subjective outcome

• See Lustig et al. 2001

Bone‐anchored deviceMixed hearing loss

• Conventional HA has to compensate for the conductive and the sensory hearing loss

• Bone anchored device has only to amplify to match the sensory component of loss

– Conductive component is effectively bypassed

• Bone‐anchored systems:

– Air‐Bone gap >35 dB, better results  

– General limit for sensory loss: 60 dBHL

‐Interaural transmission is frequency‐ and intensity‐dependent

‐Patient experience with the processor fitted with head band   

‐Approximately 1/3 proceed to surgery

See Niparko et al. 2003

Single‐Sided Deafness

MINIMALLY INVASIVE TECHNIQUESoft Tissue PreservationDermalock techniqueCochlear Connect

Prepare the site STEP 1

STEP 1 Choose abutment length

2‐3mm

MINIMALLY INVASIVE PONTO SURGERY (Oticon MIPS)

MIPS procedure summary1. Decide position and 

measure skin thickness

2. Punch

3. Insert Cannula

4. Drill: Guide and widening drilling

5. Insert implant

6. Fit Soft Healing cap 

1 2

3 4

5 6

33766‐00

33766‐00

Oticon PontoSoft healing cap

Patient outcomes 7 days post‐op

33766‐00

Complications

• Many studies

– Different methods and approaches

• Approximately 15% loss of implants 

• Percutaneous implants ~ 25% skin irritation and inflammation (≥ Holgers grade II)– 75‐85% of all patients should experience reaction‐free implant       

Stalfors & Tjellstrom,  2008

DIRECT DRIVEActive Transcutaneous Implants

BoneBridge, BCI

Active Bone Conduction ImplantsIntact skin solution

• Active implant allows for greater power

• Cosmetic advantages

• Vibration directly in contact with the bone

• One FDA approved Conduction Implant system:

– Bone Bridge (Med‐El, Austria)

Med-El Bonebridge

Conclusions

• Almost any conductive hearing loss can be fixed/improved

• Categorization into 3 anatomic regions is helpful

• The more isolated the problem, generally the better the results

• The status of the stapes is always critical!