1. The Laryngoscope
V 2010 The American Laryngological,
C
Rhinological and Otological Society, Inc.
Atresiaplasty Versus BAHA For Congenital Aural Atresia
Robert F. Yellon, MD, FACS
BACKGROUND complete closure of the air–bone gap following atresia-
For congenital aural atresia, surgical hearing reha- plasty may be corrected with a conventional hearing aid
bilitation may be accomplished with atresiaplasty or or BAHA. Cosmesis is generally good for atresiaplasty.
Bone Anchored Hearing Aid (BAHA, Cochlear Americas, An excellent hearing result for atresiaplasty is the best
Centennial, CO). The Jahrsdoerfer CT grading system possible outcome because the hearing improvement is
has been used to determine which patients are candi- continuous, spontaneous learning is always possible, and
dates for atresiaplasty.1 Patients with a Jahrsdoerfer no external electronic device is needed.
score of 6 or higher are considered to be candidates for BAHA fixture placement is relatively rapid and
atresiaplasty. The higher the grading score, the better simple, but two surgical stages are required for young
the chance for a favorable hearing outcome for atresia- children with thin skulls. Cosmesis is not ideal with a
plasty.1 Hearing results for atresiaplasty range from visible metal abutment and a snap-on hearing aid. Hear-
excellent to fair.1,2 BAHA is an alternative to atresia- ing results are usually excellent for BAHA with an
plasty. Hearing results for BAHA are generally expected air–bone gap of only 16–18 dB HL.3 BAHA
excellent.3 However, cosmesis is not very good with the complications include occasional loss of the fixture from
BAHA with a visible titanium abutment and snap-on infection, and fairly common surgical site infections with
hearing aid, and frequent wound care is required. A de- flap thickening that may require revision surgery.4 The
cision for BAHA versus atresiaplasty needs to be BAHA requires regular wound care, which may be diffi-
individualized for each patient because both have advan- cult in a young child (Table I). The child must also be
tages, disadvantages, and potential complications. careful to avoid trauma to the BAHA site, which may
result in loss.
The BAHA may be offered to all patients with a
Jahrsdoerfer score of 5 or less who are not considered to
be atresiaplasty candidates and are not satisfied with
LITERATURE REVIEW
their conventional hearing aid. BAHA is approved for
In the best of hands, the mean postoperative long-
children at least 5 years of age and is particularly im-
term speech reception threshold (SRT) was 25 dB HL
portant for children with bilateral microtia and aural
in 75% of atresiaplasties.1 However, other excellent sur-
atresia to overcome bilateral maximal conductive hear-
geons report more modest hearing results such as
ing loss. Microtia reconstruction and atresiaplasty may
Teufert and De la Cruz,2 who reported a mean long-term
be performed at a later date.
SRT of 35 dB HL. Atresiaplasty requires excellent judg-
Atresiaplasty may be performed at 4–5 years of age
ment and advanced skills. Atresiaplasty is relatively
for the occasional patient with congenital aural atresia
lengthy and carries a very small risk of facial nerve
without microtia. However, because most children with
injury and sensorineural hearing loss. Meatal stenosis
aural atresia also have microtia, atresiaplasty should fol-
and recurrent infection are fairly common.2 Failure of
low microtia reconstruction, which avoids potential
compromise of the temporal blood supply and gives the
best chance for successful microtia reconstruction.
From the Department of Pediatric Otolaryngology, Children’s Microtia reconstruction is best delayed until at least 7
Hospital of Pittsburgh of UPMC, Department of Otolaryngology,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,
years of age when more rib cartilage is present and the
U.S.A. children are more cooperative than younger children. As
The author has no commercial affiliations or conflicts of interest to an alternative, multiple unilateral BAHA fixtures may
disclose. be placed for the hearing aid and also as anchors for
The author has no financial disclosures for this article.
Send correspondence to Robert F. Yellon, MD, FACS, Department
a prosthetic auricle. Family preference for BAHA versus
of Pediatric Otolaryngology, Children’s Hospital of Pittsburgh of UPMC, atresiaplasty must be considered, as well as nonsurgical
45th Street and Penn Avenue, Pittsburgh, PA 15224. options such as BAHA Softband,5 conventional hearing
E-mail: robert.yellon@chp.edu
aids, and glue-on prosthetic auricles. BAHA Softband
DOI: 10.1002/lary.21408 is an excellent noninvasive device for hearing
Laryngoscope 121: January 2011 Yellon: Atresiaplasty versus BAHA
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2. TABLE I.
Comparison of Advantages and Disadvantages of Atresiaplasty versus BAHA.
Surgical
Surgery Hearing Results Cosmesis Wound Care Time Risk Complications
Atresiaplasty excellent to fair, continuous good occasional EAC cleaning long higher Rare seventh nerve
hearing improvement injury and SNHL;
fairly common EAC
stenosis and infections
BAHA Excellent, hearing only poor frequent wound care, short low Occasional fixture loss;
improved while must avoid trauma to site fairly common
using processor flap infections
EAC ¼ external auditory canal; SNHL ¼ sensorineural hearing loss.
rehabilitation in very young children with aural atresia5 LEVEL OF EVIDENCE
and may be used as a trial prior to the implantable Overall, the level of evidence concerning BAHA and
BAHA. atresiaplasty is low (level 4) for these five retrospective
studies. There are no prospective studies of atresiaplasty
or BAHA, and none that directly compare outcomes. The
authors of reference 3 disclose financial support from
the manufacturer of the BAHA that raises the possibility
BEST PRACTICE of study bias. More prospective independent studies are
For patients with Jahrsdoerfer grade 5 or less, who needed.
are poor candidates for atresiaplasty, BAHA is a good
option for auditory rehabilitation. It is safe, reliable, and
has low surgical risk, but is cosmetically less appealing,
requires regular wound care, and trauma to the site BIBLIOGRAPHY
must be avoided. In favorable surgical candidates for 1. Yeakley J, Jahrsdoerfer RA. CT evaluation of congenital aural atresia: what
atresiaplasty (Jahrsdoerfer grade 6 or higher), either the radiologist and surgeon need to know. J Comput Assist Tomogr
1996;20:724–731.
atresiaplasty or BAHA may be considered. Successful 2. Teufert KB, de la Cruz A. Advances in congenital aural atresia surgery:
atresiaplasty offers the best opportunity for life-long, effects on outcome. Otolaryngol Head Neck Surg 2004;131:263–270.
3. Pfiffner F, Kompis M, Stieger C. Bone Anchored Hearing Aids: correlation
continuous, amplification-independent improvement in between Pure-Tone Thresholds and outcomes in three user groups. Otol
hearing. Conventional hearing aids and BAHA may also Neurotol 2009;30:884–890.
4. Lloyd S, Almeyda J, Sirimanna KS, Albert DM, Bailey CM. Updated surgi-
be useful for rehabilitation of nonoptimal atresiaplasty cal experience with bone-anchored hearing aids in children. J Laryngol
hearing results. Nonsurgical options such as BAHA Soft- Otol 2007;121:826–831.
5. Verhagen CV, Hol MK, Coppens-Schellekins W, Snik AF, Cremers CW. The
band,5 conventional hearing aids, and family preference BAHA Softband. A new treatment for young children with congenital
must also be considered. aural atresia. Int J Pediatr Otorhinolaryngol 2008;72:1455–1459.
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