bone anchored hearing aids b.a.hbone anchored hearing aids b.a.h.a dr. abdulrahman hagr mbbs frcs(c)...
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Bone Anchored Hearing AidsB.A.H.A
Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor King Saud University
Otolaryngology ConsultantOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz Hospital
23 Moharram 1426
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Specific Indications• Intolerance of conventional hearing aids
– Draining ear– Mastoid cavity (feedback)– Topical sensitivity
• Congenital malformations– Microtia / atresia– Syndromic / sporadic
• Conductive loss in an only hearing ear• Single-sided deafness
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Conductive Defects
• Wax & foreign bodies• Otitis externa• Acute suppurative otitis media (ASOM)• Otitis media with effusion (OME)• Chronic otitis media (CSOM)
– Scarring; perforation• Cholesteatoma• Otosclerosis• Ossicular chain disruption
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Drawbacks traditional alternativeAir conduction devicesAir conduction devices• Presence of ear mould
aggravates infection• Acoustic feedback• Dependent on middle
ear function
Reconstructive surgeryReconstructive surgery• Potential risk of
hearing damage• Less predictable
outcome
Bone conduction Bone conduction devicesdevices
• Discomfort• Poor sound quality• Cumbersome
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Advantages
• No occlusion of the ear canal
• No feedback problems
• Sound bypasses the middle ear
• Predictable results• Low risk for the
patient• Reversible
surgery
• More comfortable• Better sound
quality• Aesthetic
appearance
Over air conduction Over air conduction devicesdevices
Over reconstructive Over reconstructive surgerysurgery
Over bone conduction Over bone conduction devicesdevices
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- Classic- Compact- Cordelle- Digital
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Contraindications• Average bone threshold worse than 45 dB• Patients who may be non-compliant
– Anatomical– Psychiatric – Social
These are recommendations and not absolute contraindicationsFDA approved for children above the age of 5
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Basic principles
• Careful patient selection
• Meticulous surgical technique– Secure osseointegration– Stable skin surrounding the implant site
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Patient selection
• Medical
• Audiological
• Psychological
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Pre-implantation assessment
• Pure tone audiogram B.C. 45dB
• Speech Discrimination score >60%
• “Bite bar”
Try them today• “Head band”
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Pre-Op Assessments • 78 Y• Rt dead ear (XRT)• Left ear
– Mix HL– HA– Wet
• Video
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Pre-operative test equipment
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Pre-implantation assessment
• Verbal & written information exchange
• entific.com website
• Meet implantee
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Contraindications
• Poor Hygiene
• Insufficient bone volume
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Surgical technique
• Single – stage• Two stages
• General or local anaesthetic
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Two stagesTwo stages
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Preparation
• Mark skin
• Infiltrate
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Skin graft technique
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Skin graft technique
• Modification
• Inferiorly-based implant-site split-skin graft
• Knife
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Wide under-mining of soft tissues
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Different way
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Removal of peri-cranial tissues
Clean skin graft
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Test drill & countersink
• High speed drill– 3 mm– 4 mm – Countersink
• Constant irrigation
• Check for adequatebone thickness
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Fixture placement
• Slow speed drill
• Constant irrigation
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Replace graft and suture
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Graft
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Suture
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Layered sponge dressing & healing cap
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Layered sponge dressing
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Healing cap
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Essential steps• Take the split-skin graft as thin as possible
• Widely undermine the edges
• Over-excise soft tissue esp. superiorly
• Remove peri-cranial tissues down to periosteum
• Drill with correct speed and always with cooling
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First visit
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First visit
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The ideal implant site
• Thin
• Hairless
• Immobile
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Post-op guidelines• OPA. 1 week post-op.
• Remove healing cap• Change dressing (possibly reapply)• Clean wound (polysporin)
• OPA. 2 weeks later• Clean wound
• OPA 1 month later• Baby’s tooth brush
• Fitting @ 3 months post-op
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Cleaning with brush
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Hygeine
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Fitting
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ComplicationsComplications
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Complications• Wound complications
– Infection/granulation– Overgrowth of soft tissue– Skin graft non-take
• Operative complications– Unable to find bone thick enough– Sigmoid sinus injury– Dural Injury– Facial nerve injury
• Bone complications– Non-osseointegration– Bone fracture
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In reality: most common problems
• Skin site granulation• Sagging and drooping of superior skin• Thickening of subcutaneous tissues• Whistling and feedback• Insufficient power• Skull numbness or pain• Placed too far back
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The The ‘‘drifterdrifter’’
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Sebaceous skin at graft site
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Poor hygeine
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Hygiene
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Complications - granulation
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Infected sebaceous cyst
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The ‘overhang’
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Case• 4 Y Girl • Congenital Aural Atresia• For atresia repair consult
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MicrotiaMicrotia / / atresiaatresia
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MicrotiaMicrotia
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Case • 17 Y• Left FD SNHL• Right CSOM • HA not good• ? Right / Left BAHA
L R
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CaseCase• 19 Y old Female• Hemifacial microsomia• Bilateral CSOM• Can not use HA• Bilateral CHL 45 db
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Hemifacial microsomia
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CaseCase• 75 Y old Male• Left Lipoma
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• Florid granulation tissue• Debridement• Topical cautery
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CaseCase• 44 Y Old Female• Left severe retraction• Fail surgeries post-
Stapedectomy• No more ear surgery• Policewoman• Video-1• Video-2
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Nonsurgical Treatment
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Paediatrics
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Add Speech presentation
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Summary• BAHA is excellent for bilateral conductive
hearing loss with good bone curve• Less benefit for unilateral conductive loss • Better than CROS aids• Problems are relatively minor• Skin graft site is the biggest early and long
term challenge• Easy operation, but lots of little “tips”
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Al-Baha
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Bone Anchored Hearing AidsAl-B.A.H.A
Dr. Abdulrahman Hagr Al-Ghamdi MBBS FRCS(c)Assistant Professor King Saud University
Otolaryngology ConsultantOtologist, Neurotologist & Skull Base Surgeon
King Abdulaziz Hospital
23 Moharram 1426
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