3. INTRODUCTION
ā¢ Hearing aids are the principal means of hearing rehabilitation
ā¢ Yet ,they remain a tough sell to many who could potentially benefit from them due
to some non-ideal features of Hearing Aids, and due the problems with EAC, chronic
infections ,discomfort..
ā¢ To overcome the shortcomings of conventional HA, implantable hearing devices
were introduced.
4.
5. Non-ideal features of conventional HA:
ā¢ Insufficient amplification(max:55-65dB for ITE)
ā¢ Acoustic feedback
ā¢ Spectral distortion
ā¢ Non linear/harmonic distortion
ā¢ Occlusion effects
ā¢ Appearance/visibility
ā¢ Lack of directionality
6.
7. ā¢ Potential for improved sound clarity
ā¢ Bypass the EAC
ā¢ No use of speaker
ā¢ Transducer coupled to ossicular chain/inner ear fluid
ā¢ Rx of SNHL,mixed HL,middle ear malformations
8. BASIC DESIGN FEATURES:
Microphoneļ processorļ transducerļ coupler
electromagnetic piezoelectric
no direct contact direct contact
smaller housing distortion free
eg:VSB eg :Carina
9. Partially implantable Fully implantable
ā¢ External microphone
ā¢ Speech processor
ā¢ Transmitter
ā¢ Internal receiving coil
ā¢ Mechanical driver
ā¢ Decreases the size of implanted
component
ā¢ Internal microphone, processor,
transmission coil
ā¢ Electromagnetic transducer in
contact with incus
ā¢ Reduces visibility
ā¢ Re-operate at 5 year interval
10. HISTORY
ā¢ WILSKA-first to use electromagnetic induction to stimulate the middle ear(1930s)
( Iron particles placed on TM, electromagnetic coil in EAC)
ā¢ Microphone in EAC to overcome pinna effect
ā¢ Transducer-electromagnetic/piezoelectric/hydro-acoustic transmission
11. CURRENT DEVICES
VIBRANT SOUNDBRIDGE(MED-EL, Innsbruck, Austria)
ā¢ AMEI with most clinical data
ā¢ Semi-implantable hearing device
ā¢ Developed by Symphonix, bought by MED-EL
ā¢ First FDA approved AMEI
ā¢ Treatment of conductive and mixed HL, moderate to severe
SNHL in adults and children
ā¢ Suitable for patients with hearing loss upto 70 dB
12. VSB..
ā¢ Parts : Internal surgically implanted part-VORP
External audio processor
ā¢ VORP: Receiving coil, conductor link, transducer
ā¢ Transducer-electromagnetic coil and a magnet to produce vibrations in the FMT,
which can be coupled to ossicles /round window
ā¢ Processor worn BTE contains microphone, audio processing electronics, magnet,
telemetry device,675 zinc battery.
13.
14.
15. DIRECT ACOUSTIC COCHLEAR
IMPLANT(COCHLEAR LTD,SYDNEY,AUSTRALIA)
ā¢ Initially called as Direct Acoustic Cochlear Stimulator and later Codacs
Investigational Device
ā¢ CE approved, but not FDA approved
ā¢ Treatment of profound mixed hearing loss
ā¢ It has an implantable electromagnetic transducer
16. ā¢ Transfers acoustic energy directly to the inner ear via a conventional stapes
prosthesis
ā¢ Stapes to be removed in total
ā¢ A second stapes prosthesis placed parallel to the first one into the oval window and
attached to the incus
ā¢ Audio processor worn externally behind the implanted ear
17. OTOLOGICS SEMI-IMPLANTABLE MIDDLE EAR TRANSDUCER(MET)
AND FULLY IMPLANTABLE CARINA
ā¢ (Otologics, Boulder, Colorado, USA, later Cochlear, Sydney, Australia)
ā¢ Fully implantable currently
ā¢ CE approved
ā¢ Semi-implantable MET :
ā¢ Button external audio processor-microphone, battery, signal processor transmitter
ā¢ Transducer drives an electromagnetic probe coupled to the body of incus
ā¢ Tip of probe-aluminium oxide, forms a fibrous connection with the incus body
ā¢ Ossicular chain left intact
18. MET..
ā¢ Fully implantable carina-
electromagnetic induction system ā
subcutaneous microphone, battery,
electronic reciever connected to a
transducer
ā¢ No external components apart from a
charger and a remote control unit
ā¢ Mixed hearing loss with variety of
implantation sites(round window and
footplate) and aetiologies
19. FULLY IMPLANTABLE ENVOY ESTEEM
DEVICE
ā¢ Piezo-electric sensor placed on the incus
body,acting as an internal microphone
ā¢ Driver cemented to the stapes head
ā¢ Ossicular chain disarticulated and lenticular
process removed
ā¢ Sensor interface linked to the body of incus
ā¢ Treatment of mild to severe SNHL with
SDS>/=60
ā¢ CE (2006)and FDA(2010) approved.
20. EMERGING TECHNOLOGIES
MAXUM HEARING IMPLANT (Ototronix, LLC, Texas, USA)
ā¢ SOUND TEC Direct Drive Hearing System(DDHS)
ā¢ FDA approved
ā¢ Semi-implantable device containing an electromagnetic transducer-external part in
the EAC
ā¢ Implanted part-magnet attached to the IS joint via a titanium alloy wire ring
ā¢ Placement ātrans meatal approach
ā¢ Upgradation by Ototronix -self crimping Nitinol wire that obviates ISJ separation.
21.
22. SEMI-IMPLANTABLE MIDDLE EAR ELECTROMAGNETIC HEARING DEVICE
ā¢ Magnet cemented to the incus body
ā¢ Titanium frame fixed to the temporal bone supports an implanted electromagnetic
coil
ā¢ Magnet and coil encased in titanium
ā¢ Human study has been proposed
23. PIEZOELECTRIC ROUND WINDOW IMPLANT WITH INFRARED OPTICAL SIGNAL
ā¢ Microtransducer placed on the round window
ā¢ It can receive power and signal transmitted through
an infrared optical transmitter located in the external unit
ā¢ Microphone, sound processor and battery placed in the ear canal
ā¢ Implanted endaurally without mastoidectomy
ā¢ Not yet tested in vivo
24.
25. EARLENS TYMPANIC CONTACT TRANSDUCER
ā¢ A magnet placed in a silicone lens that sticks to the tympanic membrane by oil
induced surface tension
ā¢ A small induction coil placed in the ear canal
26. DEVICES NO LONGER AVAILABLE
SEMICIRCULAR CANAL PIEZOELECTRIC VIBRATOR
ā¢ Stimulates inner ear fluids directly by means of a lateral canal
fenestration ,bypassing the middle ear.
ā¢ Piezoelectric biomorph material(Welling and Barnes)-activate
auditory system via vibromechanical stimulation
27. UNIVERSITY OF BORDEAUX IMPLANTABLE PIEZOELECTRIC TRANSDUCER
ā¢ Piezoelectric biomorphic material with a short rod and platinum ball placed against
the round window
ā¢ No reports published regarding the application of this technology in vivo
28. RION PARTIALLY IMPLANTABLE HEARING AID
ā¢ Piezoelectric transducer connected to the head of stapes or footplate by a
hydroxyapatite coupling
ā¢ Transducer held in place by a fixing plate screwed to the temporal bone
ā¢ Was used in Japan but is no longer produced.
29. TOTALLY IMPLANTABLE COCHLEAR AMPLIFIER
ā¢ Developed by Implex
ā¢ First fully implantable middle ear device
ā¢ Ear canal subcutaneous microphone and piezoelectric transducer
ā¢ Problems with feedback necessitated disarticulation of the chain
ā¢ No longer in production
ā¢ The technology was purchased by cochlear to be implemented in cochlear implants
30. PATIENT SELECTION
CANDIDATES
ā¢ High frequency SNHL/Mixed HL
ā¢ Amplification with conventional HA/BAHA failed
ā¢ Failure due to acoustic feedback, occlusion effect, insufficient high frequency
amplification or wearing discomfort
ā¢ VSB,MET/Carina-can be used in patients below 18
31. ā¢ Candidates should not have any skin conditions preventing the attachment of
external device
ā¢ Relapsing SNHL after stapes surgery
ā¢ Medical fitness for anaesthesia and surgery
ā¢ Appropriately conselled for realistic expectations
ā¢ Audiological and otological conditions to be met
32. AUDIOLOGICAL
ā¢ Mild to severe SNHL
ā¢ In COHL/Mixed HL, aim is to overcome the residual sensorineural component
ā¢ Hearing loss should be ideally stable
ā¢ Codacs system for profound mixed HL like advanced otosclerosis
33. ā¢ Aided threshold for the present HA should be considered
ā¢ Tympanometry and acoustic reflexes to assess middle ear function
ā¢ Speech audiometry to assess retrocochlear loss
ā¢ Worse ear is selected for implantation
34. OTOLOGICAL
ā¢ Absence of retrocochlear or central involvement
ā¢ Middle ear inflammation should be controlled prior to implantation
ā¢ Assess the ear canal before surgery if external processor is worn in the EAC
35. CLASSIFICATION BASED ON COUPLING
ā¢ Type A Vibroplasty: coupling of an AMEI to an intact ossicular chain in patients with
mild to moderate SNHL(umbo, incus, stapes head/footplate)
ā¢ VSB,MHI and CARINA
ā¢ Type B Vibroplasty: AMEI coupled to a remnant of ossicular chain(stapes/footplate)
ā¢ VSB mostly
36. ā¢ Type C Vibroplasty: coupling of the actuator on one of the middle ear window
membranes
ā¢ VSB
ā¢ Type D Vibroplasty: direct coupling of an AMEI to the inner ear fluid
ā¢ oval window is commonly used
ā¢ DACI system, VSB combined with a conventional stapes piston
37. SURGICAL CONSIDERATIONS
ā¢ Similar to cochlear implantation
ā¢ Retroauricular trans mastoidal access to the middle ear via facial recess
(VSB),atticus (Carina), round window niche (Codacs)
ā¢ Combined approach:(Carina, Esteem and Codacs) for joined placement with a
passive implant
ā¢ Implant bed drilled in the cortical temporal bone to accommodate the internal
reciever and conductor link
38. ā¢ Trans-meatal tympanotomy: MHI and EarLens
ā¢ -seperated coil and magnets
ā¢ Performance depends on the distance between the coil and magnets
39. ā¢ Posterior tympanotomy: (VSB) FMT placed and crimped over the long process of
incus
ā¢ Short process clip/stapes head, footplate, round window
ā¢ āDirect coupling of FMT onto the stapes footplate without the coupler is a reliable
procedure ,and is a good option for rehab in mixed HL in patients who have
undergone CW down mastoidectomy and in difficult RW vibroplastiesā
40. ā¢ Retromeatal approach(Codacs): to assess the facial recess at the level of oval window
ā¢ MET/Carina device:
ā¢ Atticotomy to expose incus body and malleus head
ā¢ Laser to make a hole in the body of incus
ā¢ Transducer inserted into the mounting system, and probe tip aligned with the hole
41. ā¢ Anatomic limitations in the surgical procedure in regard to the dimensions of
antrum and attic
ā¢ Adequately estimated with HRCT Temporal bone and measurement of dura-meatal
distance
ā¢ Dura-meatal distance >8mm-implant placed safely
ā¢ If < 8mm,require surgical experience
ā¢ If< 5 mm, Carina is not advocated
42. Esteem system:
ā¢ Large facial recess opening
ā¢ Resection of chorda tympani
ā¢ Intra-op testing by laser doppler vibrometry to assess the mobility of incus and
stapes
ā¢ āThe pathological status of middle ear and the skill of surgeon are as
important as the implant materials in the determination of surgical successā
43. COMPLICATIONS
ā¢ Damage to chorda tympani
ā¢ Dislocation of FMT(esp. in type2 vibroplasty)
ā¢ Extrusion of passive prosthesis
ā¢ Aural fullness(VSB)
45. PATIENT REPORTED OUTCOME
MEASURES
ā¢ Improved quality of sound
ā¢ Elimination of occlusive effect
ā¢ Improved ability to lead an active lifestyle
ā¢ High fidelity due to direct ossicular stimulation
ā¢ Reduced distortion due to proximity of transducer to cochlea
46. AUDIOLOGY RESULTS
ā¢ Type A Vibroplasty (AMEIs in SNHL): AMEIs have a better functional gain compared
to conventional HA
ā¢ Type B,C,D Vibroplasty (AMEIs in mixed HL):
ā¢ Status of middle ear affects the performance
ā¢ Round window placement (type C) depends on the effectiveness of coupling
47. ā¢ Adequate coupling-20 dB hearing benefit
ā¢ Gain of 30-35 dB for coupling to stapes and 30-55 dB for coupling to RW
ā¢ Significant improvement in terms of functional gain, speech perception in noise and
word recognition scores noted with Codacs.
48. WHERE DO MEIS FIT??
Beyond hearing aidsā¦
before cochlear implants..
49. REFERENCES
ā¢ SCOTTBROWN 8TH EDTN
ā¢ CUMMINGS 6TH EDTN
ā¢ COCHLEAR IMPLANTS AND OTHER IMPLANTABLE HEARING DEVICES
ā¢ BASICS OF AUDIOLOGY