To demonstrate the technique and clinical application of vibroplasty in which the floating mass transducer component of the Vibrant Soundbridge implant is coupled directly to the oval window niche, in patients with a mobile stapes footplate but a malformed or destroyed stapes suprastructure.

The underlying concept was to create a soft tissue casing for the floating mass transducer, while also firmly connecting the transducer to a small, solid cartilage ‘plunger’ attached to the stapes footplate. This was realised by removing almost all the cartilage from a larger piece of cartilage–perichondrium, leaving only a tiny cartilage island about half a millimetre in diameter, attached to a much wider ‘blanket’ of perichondrium.

By coupling the floating mass transducer directly to the oval window niche, patients' speech understanding was improved. Post-operative aided thresholds of 30–40 dB HL were achieved by all patients.

In patients with mixed hearing loss combined with a destroyed stapes suprastructure but a mobile stapes footplate, we describe the coupling of the floating mass transducer component of a Vibrant Soundbridge to the stapes footplate, as an alternative to coupling to the round window.

To assess the electrode pitch function in a series of adults with postlingually implanted cochlear implants and with contralateral residual hearing, in order to investigate the correlation between the degree of frequency map mismatch and the subjects' speech understanding in quiet and noisy conditions.

Case series.

Seven postlingually deafened adults with cochlear implants, all with detectable contralateral residual hearing. Subjects' electrode pitch function was assessed by means of a pitch-matching test, in which they were asked to match an acoustic pitch (pure tones delivered to the non-implanted ear by an audiometer) to a perceived ‘pitch’ elicited by stimulation of the cochlear implant electrodes. A mismatch score was calculated for each subject. Speech recognition was tested using lists of sentences presented in quiet conditions and at +10, 0 and 5 dB HL signal-to-noise ratio levels (i.e. noise 10 dB HL lower than signal, noise as loud as signal and noise 5 dB HL higher than signal, respectively). Correlations were assessed using a linear regression model, with significance set at p < 0.05.

All patients presented some degree of mismatch between the acoustic frequencies assigned to their implant electrodes and the pitch elicited by stimulation of the same electrode, with high between-individual variability. A significant correlation (p < 0.005) was found between mismatch and speech recognition scores at +10 and 0 dB HL signal-to-noise ratio levels (r2 = 0.91 and 0.89, respectively).

The mismatch between frequencies allocated to electrodes and the pitch perceived on stimulation of the same electrodes could partially account for our subjects' difficulties with speech understanding in noisy conditions. We suggest that these subjects could benefit from mismatch correction, through a procedure allowing individualised reallocation of frequency bands to electrodes.

Ossicular chain damage from chronic ear disease is a significant problem in the Australian population. The ideal ossicular chain reconstruction prosthesis has yet to be defined. This paper examines, for the first time, the use of a titanium prosthesis for ossicular chain reconstruction in Australian patients.

Retrospective chart review.

All patients undergoing ossicular chain reconstruction with a titanium prosthesis between 1 February 2002 and 31 March 2007.

Results showed a low complication rate, with only one extrusion out of 55 cases (1.8 per cent). Successful rehabilitation of conductive hearing loss (i.e. to ≤20 dB air–bone gap) was obtained in 85 per cent of the partial ossicular chain reconstruction group and 77 per cent of the total ossicular chain reconstruction group. Pure tone thresholds improved by an average 18 dB in the partial reconstruction group and 25 dB in the total reconstruction group.

Titanium is an ideal material for ossicular chain reconstruction due to its ease of insertion, low rate of extrusion and good functional results.

This study aimed to ascertain the usefulness of the bone-anchored hearing aid and its impact on the quality of life of patients fitted in Glasgow between 1996 and 2006.

The Entific Medical Systems questionnaire and the Glasgow Benefit Inventory were posted to patients in order to assess their satisfaction and quality of life changes.

Sixty adult patients were identified, with a questionnaire response rate of 63 per cent. Thirty-two respondents (85 per cent) reported using their bone-anchored hearing aid for more than eight hours per day. Twenty-nine respondents (75 per cent) found their bone-anchored hearing aid to be generally better than their previous, conventional aid. Twenty-seven respondents (71 per cent) reported that their bone-anchored hearing aid improved their quality of life. The median total Glasgow Benefit Inventory score was +33.3.

Bone-anchored hearing aid usage rates and satisfaction levels were high amongst patients in Glasgow. Glasgow Benefit Inventory indices were comparable to published findings from other centres. Despite this, bone-anchored hearing aid funding is still not universally available within the National Health Service in Scotland.

Bone-anchored hearing aids are well established, implanted devices. We present two patients who suffered mixed hearing loss and who underwent titanium implant placement in the temporal bone to enable attachment of bone-anchored hearing aids. Osseointegration is necessary for such implants to function. We report these two cases to highlight how such osseointegration may be disrupted.

Attached tissue from the explanted or removed titanium implants was examined by transmission electron microscopy and histopathological analysis.

Attached tissue from both implants showed the presence of keratinocytes at the titanium implant and living bone interface. This was confirmed by histopathological analysis. In one case, there was frank keratinocyte proliferation, which had led to osseointegration failure; in the other case, such proliferation was present but not so advanced.

These findings suggest that, in the cases reported, keratinocytes implanted between the titanium and the living bone, leading to disruption of osseointegration.

Bone-anchored hearing aid surgery in younger children is a two-stage procedure, with a titanium fixture being allowed to osseointegrate for several months before an abutment is fitted through a skin graft. In the first procedure, it has been usual to place a reserve or sleeper fixture approximately 5 mm from the primary fixture as a backup in case the primary fixture fails to osseointegrate. This ipsilateral sleeper fixture is expensive, is often not used, and is placed in thinner calvarial bone where it is less likely to osseointegrate successfully. The authors have implanted the sleeper fixture on the contralateral side, with the additional objective of reducing the number of procedures for bilateral bone-anchored hearing aid implantation, providing a cost-effective use for the sleeper.

The authors implanted the bone-anchored hearing aid sleeper fixture in the contralateral temporal bone instead of on the ipsilateral side in seven successive paediatric cases with bilateral conductive hearing loss requiring two-stage bone-anchored hearing aids, treated at the Royal Manchester Children's Hospital, UK.

The seven patients ranged in age from five to 15 years, with a mean age of 10 years; in addition, a 20-year-old with learning disability was also treated. In each case, the contralateral sleeper fixture was not needed as a backup fixture, but was used in four patients (57 per cent) as the basis for a second-side bone-anchored hearing aid.

In children with bilateral conductive hearing loss, in whom a bilateral bone-anchored hearing aid is being considered and the second side is to be operated upon at a later date, we recommend placing the sleeper fixture on the contralateral side at the time of primary first-side surgery. Our technique provides a sleeper fixture located in an optimal position, where it also offers the option of use for a second-side bone-anchored hearing aid and reduces the number of procedures needed.

We report the second published case of a child with a serious traumatic injury involving the fixture and abutment of their bone-anchored hearing aid.

Case reports and review of the world literature concerning unusual complications following trauma to bone-anchored hearing aids.

A nine-year-old girl with Dubowitz syndrome sustained an intrusion injury of her bone-anchored hearing aid fixture and abutment following a fall. No other injury was sustained, and there was no neurological complication. The patient underwent immediate removal of the implant and subsequently made a full recovery. Such serious and unusual complications are fortunately very rare. On review of the literature, four cases of similar complications were identified. Only one involved a traumatic injury in a child.

Provision of bone-anchored hearing aids involves many clinicians. All clinicians involved in this procedure must be aware of the need to monitor their patients carefully, and to remember that unusual and unexpected complications, although rare, do happen. The patient's need for care continues long after the surgery is complete.

To report cases of long-term surgical complications, implant failure and revision surgery, within a large bone-anchored hearing aid programme.

Retrospective, case–cohort study.

Tertiary referral centre.

One hundred and sixty-five adults and children who had undergone a total of 177 bone-anchored hearing aid implantations.

Diagnosis and explanation of adverse events and device failure.

Operative complications and survival analysis, surgical challenges related to revisions, and causes of failure.

Twenty-one per cent of patients (3.4 per cent of those observed) suffered from skin reactions; this rate did not increase over time. Seventeen per cent had loss of osseointegration at a median interval of 6.3 months. Loss of osseointegration was observed more frequently in patients with a 3 mm compared with a 4 mm fixture (p < 0.001). Intra-operatively, the only complication was bleeding, occurring in 3 per cent of patients. Post-operative complications included: primary bleeding (2 per cent); severe skin reactions requiring intravenous antibiotics, cautery or grafting (8 per cent); thickening or overgrowth of skin requiring excision (8 per cent); failure of osseointegration requiring a new fixture (18 per cent); and graft necrosis requiring revision (1 per cent). In two patients, it was necessary to explore the area to remove overgrowth of bone. In 16 patients (10 per cent), the bone-anchored hearing aid had to be abandoned due to failure of osseointegration (n = 4), dissatisfaction with the aid (n = 6), intolerable pain (n = 4), hair growth around the abutment (n = 1) or recurrent infections (n = 1). In 12 of these patients, the bone-anchored hearing aid was removed surgically. Overall, 57 patients (34 per cent) underwent revision surgery.

Awareness of complications is becoming increasingly important in bone-anchored hearing aid programme. A substantial workload of device maintenance should be anticipated, and patients should be appropriately counselled beforehand. Ninety per cent of our patients chose to persevere with this form of hearing rehabilitation.

We present a patient with persistent hypertrophic skin surrounding the percutaneous implant of a bone-anchored hearing aid system, successfully treated with intralesional applied corticosteroids.

Case report and review of the world literature concerning bone-anchored hearing aid implantation and intralesional applied corticosteroids for the treatment of hypertrophic scars and keloids.

Eight weeks after revision surgery to reduce surplus skin and subcutaneous scar tissue overgrowing the abutment, skin and subcutaneous scar tissue overgrowth reoccurred. As an alternative to yet another surgical procedure, the hypertrophic skin was treated with intralesional injections of triamcinolone acetonide. Three weeks after the treatment, a satisfying result was seen, and no subsequent relapse was observed.

To our knowledge, this is the first, photographically well documented case report of a patient with persistent hypertrophic skin surrounding a percutaneous bone-anchored hearing aid implant, successfully treated with intralesional applied corticosteroids.