Henning Frenzel

Application of the Vibrant Soundbridge to unilateral osseous atresia cases.

Patients with high‐grade atresia‐microtia suffer from a combined malformation of the outer and middle ears, typically leading to a severe hearing impairment. Long‐term results of middle ear reconstruction with tympanoplasty are often insufficient due to persistent air‐bone gaps, and new techniques in hearing rehabilitation are required. The objective of this research is to evaluate the active middle ear implant, the Vibrant Soundbridge® (VSB), for hearing rehabilitation of patients with unilateral osseous aural atresia.

International consensus on Vibrant Soundbridge® implantation in children and adolescents☆

OBJECTIVE Active middle ear implants augment hearing in patients with sensorineural, conductive, and mixed hearing losses with great success. However, the application of active middle ear implants has been restricted to compromised ears in adults only. Recently, active middle ear implants have been successfully implanted in patients younger than 18 years of age with all types of hearing losses. The Vibrant Soundbridge (VSB) active middle ear implant has been implanted in more than 60 children and adolescents worldwide by the end of 2008. In October 2008, experts from the field with experience in this population met to discuss VSB implantation in patients below the age of 18. METHODS A consensus meeting was organized including a presentation session of cases from worldwide centers and a discussion session in which implantation, precautions, and alternative means of hearing augmentation were discussed. At the end of the meeting, a consensus statement was written by the participating experts. The present consensus paper describes the outcomes and medical/surgical complications: the outcomes are favourable in terms of hearing thresholds, speech intelligibility in quiet and in noise, with a low incidence of intra- and postoperative complications. CONCLUSIONS Taken together, the VSB offers another viable treatment for children and adolescents with compromised hearing. However, other treatment options should also be taken into consideration. The advantages and disadvantages of all possible treatment options should be weighed against each other in the light of each individual case to provide the best solution; counseling should include a.o. surgical issues and MRI compatibility.

A prospective evaluation of psychosocial outcomes following ear reconstruction with rib cartilage in microtia

Little is known about the psychosocial improvement of microtic patients following reconstruction with rib cartilage. Furthermore, no data exist on detailed follow-ups of patients who refused ear repair. To the best of our knowledge, this is the first report of a prospective evaluation of psychosocial outcomes with a validated instrument in ear reconstruction with rib cartilage. Twenty-one patients, who had undergone rib-cartilage reconstruction to treat a congenital auricular defect, were evaluated prospectively for psychosocial changes using a clinically validated questionnaire. In addition, patients were asked to judge the new auricle and thoracic scar. Twenty-three patients, who decided against an ear reconstruction following consultation, were analysed for the reasons behind their refusal. Almost 66% of the treated patients were able to integrate the new ear into their body concept. If faced with the same surgery decision again, 88% would still choose to undergo ear reconstruction with rib cartilage. There were strong postoperative improvements in psychosocial attitude (p=0.02). In our sample, patients who declined ear repair showed higher values of psychosocial attitude (p=0.006) compared with the preoperative results in treated patients. Our study shows that the clinically known improvement of psychosocial aspects can be documented by a validated psychological test. The patients expectations and surgical limits of the reconstruction with rib cartilage need detailed discussion prior to surgery to prevent dissatisfaction despite surgical success. Our data help to accept a childs denial as these patients have a good psychosocial standing even with an unrepaired microtia.

Application of the Vibrant Soundbridge® in bilateral congenital atresia in toddlers

Abstract Conclusion: The Vibrant Soundbridge® offers an excellent audiologic rehabilitation for toddlers with microtia and atresia. It provides direct stimulation of the cochlea and straightforward adaption to the given anatomical structures. The ‘posterior atresia incision’ preserves the physical integrity of the tissue layers around the ear remnant, which is essential for an aesthetic auricular reconstruction. Objectives: Patients with bilateral aural atresia require immediate auditory stimulation to ensure normal speech development. We present an operative technique that allows safe restoration of hearing before aesthetic reconstruction. Methods: A 6-year-old boy presented with bilateral microtia and osseous atresia. A hairline incision was performed through all layers and was followed by a subperiostal preparation towards the atresia plane. The fused malleus-incus-complex was removed and the transducer was crimped to the stapes suprastructure on both sides. Results: Speech performance is nearly normal in both quiet and noise conditions. The surgery did not affect the tissues that are important for the later ear reconstruction

The Psychosocial Consequences of Reconstruction of Severe Ear Defects or Third-Degree Microtia With Rib Cartilage

BACKGROUND There are few data focusing on the improvement of psychosocial functioning and self-esteem in patients with congenital or acquired severe auricular defects. OBJECTIVE We investigated the satisfaction of patients following auricular reconstruction with rib cartilage. METHODS One hundred patients treated for reconstruction with rib cartilage for congenital or traumatic auricular defects have been evaluated retrospectively for changes in self-esteem, performance ability, and psychosocial attitude using a clinically established questionnaire, Frankfurter Selbstkonzeptskalen (FSKN). In addition, patients were asked to judge the new auricle and the thoracic scar using a new questionnaire. RESULTS Of 68 patients who took part in this study, almost 90% could integrate the new ear into their body concept. If faced with the same decision for surgery again, 75% would again choose a reconstruction with rib cartilage. More than three-quarters rated the thoracic scar as acceptable in relation to the benefits of the new ear, although one-third felt uncomfortable with the pain and cosmetic appearance of the thoracic scar. According to the results of the FSKN questionnaire, values in psychosocial abilities improved postoperatively. There was no clear change in either self-esteem or performance ability. CONCLUSIONS Ear reconstruction with rib cartilage remains, under most circumstances, the procedure of choice for repairing auricular defects. There is a high acceptance of this method among patients, although the impact of the thoracic scar needs to be discussed extensively before surgery. The importance of the surgeons experience cannot be underestimated, because it determines the aesthetic results and the patients satisfaction in this challenging area of plastic surgery.

The Lübeck flowchart for functional and aesthetic rehabilitation of aural atresia and microtia.

Objective Current strategies for functional rehabilitation of microtia-atresia patients with bone-anchored implants or surgical atresia repair have been extended by the feasibility of active middle ear implants. The aim of the present research is to evaluate a new flowchart of the treatment of these patients that considers active middle ear implants. Patients Congenital aural atresia and microtia. Intervention(s) Bilateral cases are provided with a conductive hearing aid after birth and implanted with an active middle ear implant within the second year. Unilateral cases are provided with a conductive hearing aid and implanted with a middle ear or bone-conduction device in early childhood. Unilateral cases without amplification in the vulnerable time after birth are carefully selected for late implantation. At age 8 to 10, the auricular reconstruction is completed. Main Outcome Measure(s) Feasibility of implantation irrespective of age, functional gain in audiometry. Results The results of early implantation are as good as those previously published for adolescents. Mean reaction threshold with the Vibrant Soundbridge was 21 dB. Mean functional gain was 48 dB. The local tissues are unaltered and ready for auricular reconstruction. Conclusion Active middle ear implants allow early and selective stimulation of the auditory pathway in children with congenital conductive hearing loss and are expected to lead to the normal development of the binaural hearing functions. To date, it is the only option if the stimulation is to be started at the age of 12 to 18 months. This was implemented into a new flowchart for aural atresia-microtia.

Grading system for the selection of patients with congenital aural atresia for active middle ear implants

IntroductionActive middle ear implants (aMEI) are being increasingly used for hearing restoration in congenital aural atresia. The existing gradings used for CT findings do not meet the requirements for these implants. Some items are expendable, whereas other important imaging factors are missing. We aimed to create a new grading system that could describe the extent of the malformation and predict the viability and challenges of implanting an aMEI.MethodsOne hundred three malformed ears were evaluated using HRCT of the temporal bone. The qualitative items middle ear and mastoid pneumatization, oval window, stapes, round window, tegmen mastoideum displacement and facial nerve displacement were included. An anterior- and posterior round window corridor, oval window and stapes corridor were quantified and novelly included. They describe the size of the surgical field and the sight towards the windows.ResultsThe ears were graded on a 16-point scale (16–13 easy, 12–9 moderate, 8–5 difficult, 4–0 high risk). The strength of agreement between the calculated score and the performed implantations was good. The comparison of the new 16-point scale with the Jahrsdoerfer score showed that both were able to conclusively detect the high-risk group; however, the new 16-point scale was able to further determine which malformed ears were favorable for aMEI, which the Jahrsdoerfer score could not do.ConclusionThe Active Middle Ear Implant Score for aural atresia (aMEI score) allows more precise risk stratification and decision making regarding the implantation. The use of operative corridors seems to have significantly better prognostic accuracy than the Jahrsdoerfer score.

Psychometric validation of the youth quality of life-facial differences questionnaire in patients following ear reconstruction with rib cartilage in microtia.

1. Cho BC, Lee SH. Surgical results of two-stage reconstruction of the auricle in congenital microtia using an autogenous costal cartilage alone or combined with canaloplasty. Plast Reconstr Surg. 2006;117:936–947. 2. Moore KL, Dalley AF. Clinically Oriented Anatomy. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 3. Briscoe C. The interchondral joints of the human thorax. J Anat. 1925;59:432–437. 4. Chin W, Zhang R, Zhang Q, Xu Z, Li D, Wu J. Modifications of three-dimensional costal cartilage framework grafting in auricular reconstruction for microtia. Plast Reconstr Surg. 2009; 124:1940–1946. Psychometric Validation of the Youth Quality of Life-Facial Differences Questionnaire in Patients following Ear Reconstruction with Rib Cartilage in Microtia Sir: M icrotia repair with rib cartilage leads to superior aesthetic results.1 Several surgeons have reported increased quality of life using polyethylene implants.2 More attention has been paid to the psychosocial situations of patients with microtia using validated psychometric instruments.2,3 In particular, disease-related quality-of-life tools offer the opportunity to recognize specific everyday problems of patients with facial deformities in a standardized manner. Because adolescents represent the most relevant age group and because age dependency is well known in the psychosocial context,4 the age aspect requires consideration. The Youth Quality of Life-Facial Differences questionnaire is a validated instrument that focuses on head and neck deformities and concentrates on adolescents,5 and is available in English and Spanish. Our study aimed to establish a linguistic German translation according to the Youth Quality of Life-Facial Differences questionnaire guidelines and to assess psychometric test criteria. A forward translation was established by two German native speakers. After clarifying different interpretations, a backward translation was performed by a bilingual English native speaker who had not read the original version. In a third step, six German adolescents with different congenital conditions in the head and neck area filled out the quesFig. 1. The operative technique is shown. (Left) The helix from the eighth costal cartilage and the antihelix from the lateral

In vivo perfusion analysis of normal and dysplastic ears and its implication on total auricular reconstruction

INTRODUCTION During the first stage of total auricular reconstruction with autologous rib cartilage, according to Nagata, the cartilage framework is placed in a subcutaneous pocket. Its posterior skin flap is relatively large and can be prepared with or without a subcutaneous pedicle. This represents the crucial part of the procedure, as impaired healing and infection can occur due to low perfusion. Nothing was known about the blood supply of ear remnants or flap perfusion during reconstruction. It was not clear whether the preservation of the additional subcutaneous pedicle secures high blood supply. METHODS We used laser fluorescence angiography with indocyanine green dye for anatomical and functional perfusion studies in eight normal ears. Subsequently the anatomical and functional vessel architecture of 18 dysplastic ears was investigated. Finally, five patients each were operated on with or without subcutaneous pedicle during auricular reconstruction and intraoperatively monitored with laser fluorescence angiography. RESULTS We showed that the vessel structure of normal ears detected by fluorescence angiography is equivalent to anatomical preparations. The surrounding skin in high grade microtia remnants is biphasically perfused by deep perforators and by the cutaneous vessel network. The preservation of the subcutaneous pedicle during auricular reconstruction leads to significantly better perfusion of the posterior skin flap. No signs of critical perfusion or complications were observed in these patients. DISCUSSION We present the feasibility of laser fluorescence angiography to simultaneously gain anatomical and functional data about skin blood supply. The first anatomical and functional description of blood supply of ear remnants in third grade microtia is given. Functional data of skin flap perfusion during and after complete ear reconstruction were evaluated. The present study shows that the subcutaneous pedicle of Nagatas procedure is of great importance for success of the first stage operation as it prevents impaired wound healing. In contrast, patients without a subcutaneous pedicle had a broad spectrum of reduced perfusion and therefore some had complications.

Borderline indications for ear reconstruction.

While the indication for an ear reconstruction with rib cartilage is clear in pediatric patients and patients without previous surgery, there are borderline cases in which neither a reconstruction nor a prosthesis seems to be first choice. Within the last 6 years, approximately 120 patients were treated with a reconstruction with rib cartilage and 20 with a prosthesis at our hospital. Patients without extensively scarred periauricular tissue clearly benefit by a reconstruction with cartilage. The classic indication for an ear prosthesis is status post-malignant tumor resection. In borderline cases presenting with heavy scars, the most favorable repair method has to be decided upon individually. Under these circumstances, one of the main criteria for a reconstruction with rib cartilage is a viable temporoparietal fascia flap. A consideration that is important to note is that an unfavorable ear reconstruction can be converted almost always into a prosthesis repair but very rarely vice versa.