10.14639/0392-100X-N1668
Objectives. To evaluate the safety, speech performance in noise and subjective satisfaction of patients with congenital aural atresia (CAA) implanted with the active middle ear implant.Methods. This retrospective study included 13 patients (15 ears) implanted with middle ear implants with different methods of floating mass transducer attachment. In 6 ears, the floating mass transducer (FMT) was coupled with the short process of incus; in 8 ears, a clip coupler was used; and in one ear, a round window coupler was used. Patients were assessed preoperatively, and at one, three, and six months postoperatively. The assessment included Pure Tone Average (PTA4), Speech Reception Threshold (SRT) and Speech Discrimination Score (SDS). The Speech Spatial and Qualities of Hearing scale (SSQ12) was also used to evaluate levels of satisfaction.Results. The mean aided PTA4 using Vibrant Sound Bridge (VSB) was 26.44 4.03 dB HL compared to 61.88 ±1.53 dB HL unaided. The SDS improved significantly (p = 0.002) from 51% (± 9.17%) to 94.60% (± 4.43%). Furthermore, there was a significant improvement in SDS in noise (p = 0.008) and SSQ12 responses (p &lt; 0.0001).Conclusions. Patients with hearing loss due to CAA can substantially benefit from VSB, with highly satisfactory subjective results and a negligible rate of complications.
text/xml
1827-675X
1668
en
Medhat Yousef
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
hearing loss
Speech performance and subjective satisfaction of middle ear implant in congenital aural atresia
Text.Serial.Journal
https://www.actaitalica.it/
42
Otology
2022-05-16
2021-05-05
2022-05-23
2022-05-23
182-188
1
Medhat Yousef
2022/05/16
10.14639/0392-100X-N1668
182
1 King Abdullah Ear Specialist Center (KAESC), College of Medicine, King Saud University, Riyadh, Saudi Arabia; Audiology Unit, ENT Department, Menoufia University, Menoufia, Egypt
1827-675X
hearing loss
188
Speech performance and subjective satisfaction of middle ear implant in congenital aural atresia
https://www.actaitalica.it/article/download/1668/802
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:182-188; doi: 10.14639/0392-100X-N1668




Otology


Speech performance and subjective satisfaction
of middle ear implant in congenital aural atresia
Performance del parlato e grado di soddisfazione soggettiva del paziente affetto
da atresia auricolare congenita e sottoposto a impianto dell’orecchio medio
Farid Alzhrani1*, Salman F. Alhabib1*, Medhat Yousef 1,2
1
  King Abdullah Ear Specialist Center (KAESC), College of Medicine, King Saud University, Riyadh, Saudi Arabia;
2
  Audiology Unit, ENT Department, Menoufia University, Menoufia, Egypt
*
  F. Alzhrani and S.F. Alhabib contributed equally to this work.


SUMMARY
Objectives. To evaluate the safety, speech performance in noise and subjective satisfac-
tion of patients with congenital aural atresia (CAA) implanted with the active middle ear
implant.
Methods. This retrospective study included 13 patients (15 ears) implanted with middle
ear implants with different methods of floating mass transducer attachment. In 6 ears, the
floating mass transducer (FMT) was coupled with the short process of incus; in 8 ears, a clip
coupler was used; and in one ear, a round window coupler was used. Patients were assessed
preoperatively, and at one, three, and six months postoperatively. The assessment included
Pure Tone Average (PTA4), Speech Reception Threshold (SRT) and Speech Discrimination
Score (SDS). The Speech Spatial and Qualities of Hearing scale (SSQ12) was also used to
evaluate levels of satisfaction.
Results. The mean aided PTA4 using Vibrant Sound Bridge (VSB) was 26.44 4.03 dB HL
compared to 61.88 ±1.53 dB HL unaided. The SDS improved significantly (p = 0.002) from
51% (± 9.17%) to 94.60% (± 4.43%). Furthermore, there was a significant improvement in
SDS in noise (p = 0.008) and SSQ12 responses (p < 0.0001).
Conclusions. Patients with hearing loss due to CAA can substantially benefit from VSB,              Received: May 14, 2021
with highly satisfactory subjective results and a negligible rate of complications.                 Accepted: February 1, 2022
KEY WORDS: middle ear implant, congenital aural atresia, vibrant soundbridge, hearing
                                                                                                    Correspondence
loss
                                                                                                    Farid Alzhrani
                                                                                                    King Abdullah Ear Specialist Center (KAESC),
RIASSUNTO                                                                                           College of Medicine, King Saud University, PO
Obiettivi. Valutare la sicurezza, la performance del parlato in ambiente rumoroso ed il             Box 245 Riyadh 11411, Saudi Arabia
grado di soddisfazione soggettiva dei pazienti affetti da atresia auricolare congenita (CAA)        Tel. 00966 11 4773101. Fax 00966 11 4775524
                                                                                                    E-mail: Faz1420@hotmail.com
e sottoposti ad impianto dell’orecchio medio.
Metodi. È stato condotto uno studio retrospettivo su 13 pazienti (15 orecchie) a cui sono
stati posizionati degli impianti a livello dell’orecchio medio con diversi metodi di fissaggio        How to cite this article: Alzhrani F, Alha-
del trasduttore di massa flottante. In 6 orecchie, l’FMT è stato abbinato al processo dell’in-        bib SF, Yousef M. Speech performance and
cudine; in 8 orecchie è stato utilizzato l’accoppiatore di clip; e in un orecchio è stato utiliz-     subjective satisfaction of middle ear implant
zato l’accoppiatore alla finestra rotonda. I pazienti sono stati valutati prima dell’intervento       in congenital aural atresia. Acta Otorhi-
e a uno, tre e sei mesi dopo l’intervento. La valutazione ha compreso il Pure Tone Avarage            nolaryngol Ital 2022;42:182-188. https://doi.
                                                                                                      org/10.14639/0392-100X-N1668
(PTA4), la soglia di percezione del parlato (SRT) e il punteggio di discriminazione vocale
(SDS). Per valutare i livelli di soddisfazione è stata utilizzata anche la scala Speech Spatial
                                                                                                    © Società Italiana di Otorinolaringoiatria
and Quality of Hearing (SSQ12).                                                                     e Chirurgia Cervico-Facciale
Risultati. Il PTA4 medio utilizzando Vibrant Sound Bridge (VSB) era di 26,44 ± 4,03 dB
HL rispetto a 61,88 ± 1,53 dB HL senza aiuto. L’SDS è migliorato significativamente                                OPEN ACCESS
(p = 0,002) dal 51% (± 19,17%) al 94,60% (±4,43%). Inoltre, c’è stato un miglioramento
significativo dell’SDS nel rumore (p = 0,008) e delle risposte SSQ12 (p < 0,0001).                  This is an open access article distributed in accordance with
                                                                                                    the CC-BY-NC-ND (Creative Commons Attribution-Non-
Conclusioni. I pazienti con ipoacusia dovuta a CAA possono beneficiare sostanzialmente di           Commercial-NoDerivatives 4.0 International) license. The
VSB, con risultati soggettivi altamente soddisfacenti e un tasso trascurabile di complicanze.       article can be used by giving appropriate credit and mentio-
                                                                                                    ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: impianto dell’orecchio medio, atresia auricolare congenita, ponte                    only in the original version. For further information: https://
sonoro vibrante, perdita dell’udito                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




182
                                                                                         Outcomes of middle ear implant in aural atresia




Introduction                                                     the pathology, availability of other treatment modalities, VSB
                                                                 being a newly introduced option for such patients, and a limited
Congenital aural atresia (CAA) causes moderate to severe
                                                                 number of expert surgeons who conduct this procedure.
hearing loss, usually conductive or mixed type 1. The de-
                                                                 Moreover, the literature is lacking publications on patient
gree of external auditory canal (EAC) deformity varies
                                                                 performance, which is considered as a goal for the different
from complete absence to mild stenosis, with a small tym-
                                                                 treatment modalities. There is a limited number of studies
panic membrane. These deformities are often associated
                                                                 that reported on speech in noise outcomes and satisfaction
with ossicular chain malformations 2.
                                                                 levels on quality of sound with VSB in CAA patients.
The surgical techniques for reconstructing the EAC and os-       Therefore, there is a need for additional studies to confirm
sicular chain are sometimes difficult to perform, and the re-    the safety and efficacy of VSB in congenital aural atre-
sults may be unsatisfactory. EAC re-stenosis failed middle       sia. This study aimed to evaluate the safety, speech per-
ear prostheses, and synechiae formation are the main reasons     formance, and satisfaction levels of VSB in children and
for poor hearing outcomes after surgery 3,4. Moreover, most      adults with hearing loss due to CAA.
of these patients require hearing aids to obtain optimal bene-
fits. Unfortunately, earmolds are often not well-tolerated and
cause recurring infections in the reconstructed ear canals 2.    Materials and methods
Atresiaplasty is not recommended for children younger than       Subjects
6 years 5. Therefore, for very young children, bone conduc-      After the ethical approval of the Institutional Review
tion hearing aids (BCHAs) are a viable option 6. BCHAs           Board, data were retrospectively compiled for this study.
improve hearing; however, aided hearing thresholds are not       All aural atresia patients who underwent VSB implantation
often optimal. Other disadvantages of these devices include      at our university hospital (tertiary referral centre) between
discomfort due to pressure applied to the skull by the trans-    August 2017 and February 2020 were included.
ducer, inconsistent sound quality and poor cosmetics 6.          Data regarding the demographic characteristics, including
Percutaneous bone-anchored hearing implants (BAHIs)              patient age, sex, laterality of the aural atresia, duration of
have been approved for children aged 5 years and older.          follow-up, and previously reported otologic surgeries, were
Gain control and wearing comfort were found to be im-            collected. Moreover, patients who presented minor or ma-
proved using BAHIs compared to BCHAs. The major ben-             jor postoperative complications or those who required sur-
efits of the BAHI include steady hearing results, acceptable     gical revision were reported.
aided hearing thresholds and a simple surgical process7–9.
However, BAHIs may be associated with local inflamma-            Surgical procedure
tion, extrusion, or poor osseointegration and require con-       Surgery was performed under general anaesthesia and with
stant hygiene control to avoid infections 10. The aesthetic      intraoperative facial nerve monitoring. A post-auricular in-
aspect and psychological apprehension caused by a trans-         cision or posterior atresia incision was made according to
cutaneous implant are other reasons that make some par-          the degree of microtia and depending on the need for sub-
ents reluctant to choose this option 2,6,10.                     sequent auricular reconstruction.
The Vibrant Soundbridge (VSB; MED-EL, Innsbruck,
                                                                 Short process coupling
Austria) is an active middle ear implant. In 2006, VSB
                                                                 Mastoidectomy and superior tympanotomy were performed
extended its indications to include mixed or conductive
                                                                 to expose the whole attic region. After visualising the
deafness 6,11 in adults and, then, to children 6. The use of
                                                                 malformed malleus-incus complex, the middle ear was
VSB for hearing rehabilitation in patients with CAA was
                                                                 opened to assess the ossicle integrity and mobility via
first described in 2009 12. The use of VSB in CAA has been
                                                                 posterior tympanotomy, after identifying the facial and
reported using different sites of crimping for the floating
                                                                 chorda tympani nerves. After confirming the ossicle
mass transducer (FMT), which allows the rehabilitation
                                                                 integrity and mobility, the FMT was coupled to the short
of more complex ossicular malformations 1,2,6,10,12. Both
                                                                 process of incus 14.
BAHIs and VSB have been considered as alternatives or
adjuncts to conventional atresiaplasty 6,9.                      Other types of coupling
Although some articles have been published on the application    Mastoidectomy and access to the middle ear were per-
of VSB in atretic ears, most are case reports or case series.    formed by removing the bony atresia plate as well as the
The highest number of cases in one study was 28 patients         lateral chain of the malformed ossicles. Next, FMT place-
in a multicentric (4 centres) study 13. The reasons behind the   ment was decided based on the middle ear anatomy deter-
limited number of publications on this topic are the rarity of   mined from individual intraoperative findings.



                                                                                                                                  183
F. Alzhrani et al.




Audiological assessment                                                       subjects and then re-administered every three months after
Audiological evaluations were conducted for all subjects                      receiving the implant to assess performance. This question-
preoperatively, and at one, three, and every six months post-                 naire consists of 12 items; each item evaluates the patient’s
operatively. The audiological results of the last postoperative               satisfaction and difficulties in different realistic communi-
follow-up visit were used for analysis. The mean follow-up                    cation scenarios of daily life. The subjects/caregivers rate
period was 15 ± 8 months (range, 6-36 months). Pure tone                      their communication performance using a score of 0 to 10,
average (PTA4) for air conduction (AC) and bone conduc-                       where 10 indicates that the patient was able to perform per-
tion (BC) thresholds were obtained. The thresholds of 0.5, 1,                 fectly in that situation and 0 indicates extreme difficulty in
2, and 4 kHz were utilised to calculate PTA4. Clinical mask-                  that situation.
ing was applied when required. Unaided thresholds were ad-
ditionally measured in the sound-field.                                       Statistical analysis
The speech reception threshold (SRT) was measured us-                         The following steps were performed to analyse the differ-
ing spondee words. The speech discrimination score (SDS)                      ences between the patient outcomes pre- and postopera-
was tested using phonetically balanced monosyllabic                           tively, in other words, in the unaided and aided situations.
words and all speech stimuli were presented at 65 dB HL in                    First, we computed the descriptive values, including the
a quiet environment and in the presence of speech noise (+5                   mean, standard deviation, and ranges (i.e., minimum, and
dB SNR) positioned from the front (90° azimuth). Postop-                      maximum values). Second, the normality of data in both
eratively, all measurements were reconducted in the aided                     situations was tested. Therefore, the appropriate t-test was
conditions using the SAMBA audio-processor. The mean                          selected to check for differences. Statistical significance
functional gain (for each frequency and the PTA4) was cal-                    was set at p < 0.05. Statistical analyses were performed us-
culated as the difference between the unaided preoperative                    ing GraphPad Prism™ version 8.4.0 (GraphPad Software,
and aided postoperative sound field thresholds.                               La Jolla, CA, USA).

Subjective evaluation
The short version of the Speech, Spatial and Qualities of
                                                                              Results
Hearing Scale (SSQ12) was used to evaluate the partici-                       Demographic
pants’ satisfaction with VSB. The SSQ12 questionnaire 15                      The individual demographic and clinical data for the 15
was administered at the preoperative assessment for all                       implanted ears are shown in Table I. The study population


Table I. Demographic and clinical data for the implanted ears.
 Subjects            Implanted ear               Age at        Follow-up duration     Jahrsdoerfer        Complications         Type of the
                                              implantation          (months)          grading scale                               coupler
                                                 (years)
 Subj#1L                         Left                     18         36                    9                  None                  SP
 Subj#1R                         Right                    19         24                    9                  None                  SP
 Subj#2L                         Left                     24         26                    8                  None                  SP
 Subj#2R                         Right                    25         12                    6               Haematoma               Clip
 Subj#3                          Left                     23         18                    8           Secondary facial palsy       SP
 Subj#4                          Right                     6         17                    8                  None                  SP
 Subj#5                          Right                     6         15                    8                  None                  SP
 Subj#6                          Right                    16         13                    5                  None                 RWS
 Subj#7                          Left                     11         12                    7                  None                 Clip
 Subj#8                           left                    35         10                    5                  None                 Clip
 Subj#9                          Right                     6          9                    7                  None                 Clip
 Subj#10                         Right                    36          9                    8                  None                 Clip
 Subj#11                         Left                      9          6                    7                  None                 Clip
 Subj#12                         Right                     5          6                    8                  None                 Clip
 Subj#13                         Right                    58          6                    6                  None                 Clip
 Average                                                18 ± 14    15 ± 8
L: Left; R: Right; SP: short process; RWS: round window soft.




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                                                                                                                Outcomes of middle ear implant in aural atresia




A                                      B                                          Audiological outcomes
                                                                                  To assess the safety of the surgical procedure, the pre- and
                                                                                  postoperative BC thresholds were compared. The mean dif-
                                                                                  ference was 2 dB, which was not greater than the safe level
                                                                                  of 5 dB for any patient at all frequencies (Fig. 2A). Across
                                                                                  all frequencies, the aided sound field (SF) thresholds were
                                                                                  significantly improved by using the VSB. The mean aided
                                                                                  PTA4SF was (26.44 ± 4.03 dB HL) compared with the
Figure 1. Intraoperative illustration showing the placement of (A) short pro-     mean unaided PTA4SF of (61.88 ± 1.53 dB HL). The aver-
cess coupler, and (B) clip coupler.                                               age functional gain was 35.44 dB, as shown in Figure 2B.
                                                                                  The analysis of this improvement revealed a significant dif-
                                                                                  ference (p < 0.0001).
                                                                                  Speech understanding in a quiet environment also showed
was comprised of 13 patients: 6 adults (30±13 years), and 7                       significant improvement. The SRT measurements with
children (7.2 ± 2.3 years). Eight patients (61.5%) were uni-                      VSB were significantly better in all patients compared to
lateral atretic, and 5 (38.5%) were bilaterally atretic. Two                      preoperative measurements (p < 0.0001). The mean pre-
patients underwent bilateral implantation. The Jahrsdoerfer                       operative SRT (Fig. 3) decreased from 63.33 ± 10.63 dB
classification was used to categorise congenital aural atre-                      HL to 24.67 ± 8.95. Before implantation of the VSB, the
sia 16. All operated ears had a grading score between 5 and                       mean SDS in quiet conditions was 51% (SD 19.17%) in
9 (Tab. I).                                                                       the unaided condition. The post-implantation mean aided
In 6 ears, the FMT was coupled to the short process of in-                        SDS was 94.60 % (SD 4.43%) for monosyllables at 65 dB
cus (Fig. 1A), in 8 ears the Clip coupler was used (Fig. 1B),                     HL. The improvement in speech discrimination was sta-
and in one ear the round window coupler was used. No in-                          tistically significant (p = 0.002), as shown in Figure 4A.
traoperative, minor, or major complications were observed.                        Moreover, speech discrimination in noise was significantly
One patient developed secondary facial palsy 3 days post-                         improved (p = 0.008) from (27.75% ± 12.49) preoperative-
operatively, which completely resolved with oral steroids.                        ly to (78.50% ± 11.75) postoperatively (Fig. 4B).
Another patient had a postoperative haematoma that re-
solved spontaneously within 2 days. No revision surgery                           Subjective evaluation
was reported in any of the patients.                                              The SSQ12 questionnaire was used to evaluate the subjec-



A                                                                                  B




Figure 2. (A) Pre- and postoperative bone conduction threshold showed stable results. (B) The post-operative sound field using VSB was significantly better than
the preoperative unaided one.



                                                                                                                                                          185
F. Alzhrani et al.




                                                                                   Figure 5. Comparison of SSQ12 score preoperatively unaided with
                                                                                   postoperative aided one using VSB.



Figure 3. The postoperative speech reception threshold using VSB was               jective benefits of VSB in patients with hearing loss due
significantly lower than the preoperative unaided one.                             to congenital aural atresia. The audiological and speech
                                                                                   evaluations showed improved PTA4, SRT, and SDS values
                                                                                   with the VSB. Significant audiological improvement using
tive sound quality using the VSB. The overall satisfaction
                                                                                   VSB in aural atresia cases has been reported in the litera-
of participants regarding sound quality after using the VSB
                                                                                   ture 1,2,10,12,14. In addition to the improvement in the audio-
system was better than that of the preoperative one (Fig.
                                                                                   logical outcome of VSB in atretic ears, the patient satisfac-
5). All participants had a clear improvement in the SSQ12
score postoperatively compared to the preoperative score                           tion scores with the SSQ12 questionnaire were also high.
(p < 0.0001).                                                                      Leinung et al. 17 studied the acceptance and benefit of the
                                                                                   VSB by means of a questionnaire and compared the results
                                                                                   with questionnaires filled for conventional BCHA used
Discussion                                                                         previously in preschool children with unilateral congenital
This study demonstrates the clinical, subjective and ob-                           aural atresia. They found significant improvements in all


 A                                                                                  B




Figure 4. The postoperative speech discrimination score using VSB in a quiet situation (A) and in noise (B) was significantly better than the preoperative unaided
one.



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                                                                                                 Outcomes of middle ear implant in aural atresia




questionnaire sections, with higher acceptance in favour of         studies with a larger number of participants and a longer
VSB than for BCHAs.                                                 follow-up period.
The post-operative functional gain in our present study was
35.44 dB. This outcome was comparable to prior studies              Conclusions
on individuals with congenital aural atresia who used
other BAHI devices. The functional gain of bone anchored            In conclusion, patients with hearing loss due to CAA ben-
hearing aids and bone bridge devices was 33.1 and 47.2              efit substantially from VSB with highly satisfactory subjec-
dB, respectively 18,19. They also reported improved word            tive results and negligible rate of complications. In addi-
recognition and quality of life following implantations. In         tion, the presence of different couplers allows the surgeon
terms of directional hearing, it was observed that localisation     to attach the FMT to different anatomic sites, suitable for
abilities were increased when either active middle ear              ears with malformations.
implants or BAHI devices were used, with no statistically
significant differences between the two systems 20,21.              Conflict of interest statement
In agreement with other recent reports 1,2,10-12,14, we demon-      The authors declare no conflict of interest.
strated that the VSB implant procedure can be considered
safe, as the postoperative BC thresholds remained stable            Funding
in all the patients, implying that their residual hearing was       This research did not receive any specific grant from fund-
unaffected by the surgical procedure. Moreover, only two            ing agencies in the public, commercial, or not-for-profit
minor postoperative complications were documented in the            sectors.
present study, which completely resolved.
The youngest patient in the current series was 5 years old          Authors’ contributions
at the time of implantation. An international consensus on
                                                                    FA and SFA contributed with idea generation, methodo-
VSB in children published in 2010 stated that the com-
                                                                    logical development, data analysis, and writing the manu-
mittee decided not to limit the age at implantation; rather,
                                                                    script. MY was in charge of data collecting and analysis.
it mentioned that the decision for implantation should be
based on the surgeon’s judgement and expertise 6. The low-          Moreover, assessing and approving the final manuscript
est Jahrsdoerfer score in the present study was five. McKin-        version.
non et al. 13 reported a successful VSB implantation with a
Jahrsdoerfer score of four. Moreover, they found that the           Ethical consideration
scores did not correlate to or predict postoperative audio-         This study was approved by the Institutional Ethics Com-
logical outcomes 13.                                                mittee (King Saud University) (approval No. E-19-4224).
Coupling FMT to stapes superstructure is the most                   The research was conducted ethically, with all study pro-
commonly used technique in aural atresia cases 1,10,12,13,22.       cedures being performed in accordance with the require-
However, FMT placement to multiple middle ear structures            ments of the World Medical Association’s Declaration of
has been described previously, such as footplate, round             Helsinki.
window, long process of the malformed malleus-incus                 Written informed consent was obtained from each partici-
complex, and promontory fenestration 1,2,6,10,12,13,22. Recently,   pant/patient for study participation and data publication.
coupling the FMT to the short process of incus proved its
efficiency in aural atresia cases 15,23,24. Furthermore, the        References
VSB was implanted successfully in external and middle
                                                                    1
                                                                        Zernotti ME, Arauz SL, Di Gregorio MF, et al. Vibrant Soundbridge
ear malformations for different reasons, such as Fanconi
                                                                        in congenital osseous atresia: multicenter study of 12 patients with
anaemia and fibrous dysplasia of the temporal bone 25,26.               osseous atresia. Acta Otolaryngol 2013;133:569-573. https://doi.org/
Reconstructive surgery for conductive hearing loss in                   10.3109/00016489.2012.762117
patients with fibrous dysplasia of the temporal bone                2
                                                                        Colletti L, Carner M, Mandalà M, et al. The floating mass transducer for
(FDTB) carries a high risk of poor hearing rehabilitation               external auditory canal and middle ear malformations. Otol Neurotol
due to the chance of restenosis of the EAC, graft failure and           2011;32:108-115. https://doi.org/10.1097/MAO.0b013e3181ff752a
EAC cholesteatoma. Therefore, VSB can be an alternative
                                                                    3
                                                                        De la Cruz A, Teufert KB. Congenital aural atresia surgery: long-term
                                                                        results. Otolaryngol Head Neck Surg 2003;129:121-127. https://doi.
choice for hearing rehabilitation in patients with FDTB 25.             org/10.1016/S0194-5998(03)00531-X
The limitations of the present study are the limited num-           4
                                                                        Digoy GP, Cueva RA. Congenital aural atresia: review of short- and
ber of participants, retrospective study design and short               long-term surgical results. Otol Neurotol 2007;28:54-60. https://doi.
duration of follow-up. Therefore, we recommend further                  org/10.1097/01.mao.0000227897.73032.95




                                                                                                                                          187
F. Alzhrani et al.




5
     Ali K, Mohan K, Liu YC. Otologic and audiology concerns of                17
                                                                                    Leinung M, Zaretsky E, Lange BP, et al. Vibrant Soundbridge® in
     microtia repair. Semin Plast Surg 2017;31:127-133. https://doi.                preschool children with unilateral aural atresia: acceptance and
     org/10.1055/s-0037-1603957                                                     benefit. Eur Arch Otorhinolaryngol 2017;274:159-165. https://doi.
6
     Cremers CWRJ, O’Connor AF, Helms J, et al. International consensus             org/10.1007/s00405-016-4265-1
     on Vibrant Soundbridge® implantation in children and adolescents.         18
                                                                                    Zernotti ME, Chiaraviglio MM, Mauricio SB, et al. Audiological
     Int J Pediatr Otorhinolaryngol 2010;74:1267-1269. https://doi.                 outcomes in patients with congenital aural atresia implanted with
     org/10.1016/j.ijporl.2010.07.028                                               transcutaneous active bone conduction hearing implant. Int J
7
     Bouhabel S, Arcand P, Saliba I. Congenital aural atresia: Bone-                Pediatr Otorhinolaryngol 2019;119:54-58. https://doi.org/10.1016/j.
     anchored hearing aid vs. external auditory canal reconstruction. Int J         ijporl.2019.01.016
     Pediatr Otorhinolaryngol 2012;76:272-277. https://doi.org/10.1016/j.
     ijporl.2011.11.020
                                                                               19
                                                                                    Ricci G, della Volpe A, Faralli M, et al. Bone-anchored hearing aids
                                                                                    (Baha) in congenital aural atresia: personal experience. Int J Pedi-
8
     Evans AK, Kazahaya K. Canal atresia: “Surgery or implantable                   atr Otorhinolaryngol 2011;75:342-346. https://doi.org/10.1016/j.
     hearing devices? The expert’s question is revisited.” Int J Pediatr
                                                                                    ijporl.2010.11.027
     Otorhinolaryngol       2007;71:367-374.      https://doi.org/10.1016/j.
     ijporl.2006.09.003                                                        20
                                                                                    Agterberg MJH, Frenzel H, Wollenberg B, et al. Amplification op-
9
     Yellon RF. Atresiaplasty versus BAHA for congenital aural atresia.             tions in unilateral aural atresia. Otol Neurotol 2014;35:129-135. htt-
     Laryngoscope 2011;121:2-3. https://doi.org/10.1002/lary.21408                  ps://doi.org/10.1097/MAO.0b013e31829b579f
10
     Roman S, Denoyelle F, Farinetti A, et al. Middle ear implant in con-
                                                                               21
                                                                                    Vogt K, Frenzel H, Ausili SA, et al. Improved directional hearing of
     ductive and mixed congenital hearing loss in children. Int J Pediatr           children with congenital unilateral conductive hearing loss implanted
     Otorhinolaryngol 2012;76:1775-1778. https://doi.org/10.1016/j.                 with an active bone-conduction implant or an active middle ear
     ijporl.2012.08.022                                                             implant. Hear Res 2018;370:238-247. https://doi.org/10.1016/j.
11
     Colletti V, Soli SD, Carner M, et al. Treatment of mixed                       heares.2018.08.006
     hearing losses via implantation of a vibratory transducer on              22
                                                                                    Frenzel H, Sprinzl G, Streitberger C, et al. The vibrant soundbridge
     the round window. Int J Audiol 2006;45:600-608. https://doi.                   in children and adolescents: preliminary European multicenter
     org/10.1080/14992020600840903                                                  results. Otol Neurotol 2015;36:1216-1222. https://doi.org/10.1097/
12
     Frenzel H, Hanke F, Beltrame M, et al. Application of the Vibrant              MAO.0000000000000796
     Soundbridge® to unilateral osseous atresia cases. Laryngoscope            23
                                                                                    Célérier C, Thierry B, Coudert C, et al. Results of VSB implantation
     2009;119:67-74. https://doi.org/10.1002/lary.20036                             at the short process of the incus in children with ear atresia. Int J
13
     McKinnon BJ, Dumon T, Hagen R, et al. Vibrant Soundbridge                      Pediatr Otorhinolaryngol 2017;93:83-87. https://doi.org/10.1016/j.
     in aural atresia: does severity matter? Eur Arch Otorhinolaryngol              ijporl.2016.12.038
     2014;271:1917-1921. https://doi.org/10.1007/s00405-013-2680-0             24
                                                                                    Thomas JP, Voelter C, Neumann K, et al. Vibroplasty in severe
14
     Alzhrani F, Halawani R, Yousef M. Feasibility and efficacy of                  congenital or acquired meatal stenosis by coupling an active middle ear
     Vibrant Soundbridge short process coupler in patients with aural
                                                                                    implant to the short process of the incus. Otol Neurotol 2017;38:996-
     atresia. Otol Neurotol 2020;41:e1219-e1223. https//doi:10.1097/
                                                                                    1004. https://doi.org/10.1097/MAO.0000000000001459
     MAO.0000000000002801
15
     Noble W, Jensen NS, Naylor G, et al. A short form of the Speech,
                                                                               25
                                                                                    Al-Shawi Y, Alsughayer L, Alradhi A, et al. Middle ear implant in a
     Spatial and Qualities of Hearing scale suitable for clinical use: the          patient with fibrous dysplasia: an alternative for hearing restoration.
     SSQ12. Int J Audiol 2013;52:409-412. https://doi.org/10.3109/1499              Ear Nose Throat J 2021;100(3_suppl):207S-211S. https://doi.
     2027.2013.781278                                                               org/10.1177/0145561320960542
16
     Jahrsdoerfer RA, Yeakley JW, Aguilar EA, et al. Grading system            26
                                                                                    Alanazi Y, Halawani R, Alzhrani F. Vibrant Soundbridge implant in a
     for the selection of patients with congenital aural atresia. Am J Otol         patient with Fanconi anemia. Acta Oto-Laryngol Case Rep 2020;5:42-
     1992;13:6-12.                                                                  46. https://doi.org/10.1080/23772484.2020.1756295




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