Tag Archives: Oticon Medical Ponto System

A Reconstructive Surgeon Shares His First MIPS Experience

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Dr. Youssef Tahiri performed his first combination of ear reconstructive surgery and minimally invasive Ponto™ surgery (MIPS) in December of 2022. The procedure was conducted on a pediatric microtia/atresia patient, Sean, under general anesthesia (due to the reconstruction) in a surgical center under the guidance of an Oticon Medical representative.

Previously, Sean wore his Ponto processor on a softband, which he received when he was only three months old. At the age of 8[1], it was determined that Sean had reached the right age and bone density to proceed with implantation so he could wear his new Ponto 5 SuperPower on an abutment for improved access to sound.

The following is an interview conducted by Oticon Medical with Dr. Tahiri regarding his experience with the procedure.

Did you encourage Sean’s parents to move forward with implantation

I definitely encouraged them to move forward with MIPS to help with hearing on Sean’s microtia/atresia side. Sean had been using the Ponto already and were loving the product. Importantly, he was very comfortable with the Ponto. So we all agreed to go ahead with a Ponto implant system placement.

How long did Sean’s procedure take?

The MIPS portion took approximately 20 minutes.

How did your Oticon Medical representative assist you in working with Sean and his family?

She was so useful since it was my first time using the Ponto system. She supported me through the different steps of the procedure. She made sure we had everything we needed for a successful procedure.

In this experience, did your patient experience a significant improvement in performance/hearing after implantation vs. wearing the processor on a softband?

Absolutely! His hearing outcome was significantly improved after implantation as compared to the softband.

What would you like other surgeons to know about MIPS who might not have tried it yet?

It is a straightforward and easy procedure. The risks are minimal while the benefits are great. Hearing is so important and thus implantation should not be delayed (once deemed medically safe for the patient), particularly with such a minimal, simple procedure.

Click through the link to watch what Sean and his mother have to say about his Ponto 5 SuperPower and experience undergoing MIPS.

About Dr. Tahiri

Dr. Youssef Tahiri is a Board Certified Plastic and Reconstructive Surgeon with a subspecialty in Craniofacial Surgery. After graduating from McGill Medical School, in Montreal, Canada, he completed his Plastic and Reconstructive Surgery residency at McGill University and a Craniofacial Surgery Fellowship at the University of Pennsylvania and the Children Hospital of Philadelphia. He also pursued a Masters Degree in Experimental Surgery, which he obtained with Honors. He embraces the most innovative, cutting-edge technique available in craniofacial and microtia surgery. He has published a very large number of peer-review articles and presented his work at numerous regional, national and international scientific meetings. His research interests include outcomes evidence based clinical studies and translational research to enhance patients’ care and safety through improved techniques and technology.

[1] MIPS is recommended for: 
- Adult patients with normal bone quality and bone thickness above 3mm, where no complications during surgery are expected
- Children with normal bone quality and a bone thickness above 4mm (typically 12 years or older), and other known factors have been considered and found suitable for single-stage surgery
- Patients, as per above, with a skin thickness of 12mm or less
Refer to Surgical Manual for complete information on MIPS

 

Evaluating Benefit and Monitoring Progress in Young Children with a Bone Conduction Hearing Device

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Providing early access to sound is critical for children with prelingual hearing loss to develop speech and language skills on par with their typical hearing peers (Sininger, Grimes, and Christensen 2010; Bagatto et al. 2011, 2016; Tomblin et al. 2015). Evidence-based prescriptive formulae, such as DSL v 5.0 and NAL-NL2, are available in hearing aid fitting software and real-ear verification measures when fitting air conduction hearing aids to infants and children who have hearing loss (Scollie et al. 2005; Keidser et al. 2012).

However, strategies for fitting a bone conduction hearing device (BCHD) to a young child is lacking.  Additionally, the use of a consistent protocol within pediatric clinics for children with a BCHD has not been well defined.  In fact, a survey completed by Gordy and Bagatto (2020) found that audiologists are seeking guidance on how to provide optimal amplification to children who use BCHDs, and the aided audiogram is the only consistent measure used to verify BCHD fittings.

Given the limited availability of clinical tools, such as a skull simulator and prescriptive targets, audiologists need to consider other subjective test measures to use when fitting young children that are readily available in most pediatric audiology clinics.  These include, but are not limited to, parent report measures (e.g., The Auditory Skills Checklist, LittleEARs,) the Ling Six Sound Test, closed-set and open-set speech perception test measures, as well as standardized speech and language assessment measures.

As a leading manufacturer of bone anchored hearing solutions, we felt compelled to develop a suggested assessment protocol for monitoring the auditory skills of children ages three-to-five years fit with the Ponto bone anchored hearing system. This blog provides an overview of a straightforward assessment process that clinicians can incorporate into their fitting and management of young children with a BCHD.

Leveraging the Pediatric Minimum Speech Test Battery (PMSTB) developed by Kristin Uhler and colleagues in 2017, we created a streamlined assessment protocol for audiologists to consider when fitting young children with a BCHD.  This protocol is purely based on subjective assessment measures and a way for clinics to establish consistency among audiologists.  Beginning by verifying that a young child can detect the Ling Six Sounds, an audiologist would move to a closed-set speech perception test measure designed to evaluate a child’s pattern perception abilities and word identification skills.  Assuming the child demonstrated consistent word identification we suggest evaluating how the child responds to recorded open-set word and sentence recognition test measures. Finally, we recommend using a parent report measure to end the evaluation.

The protocol consists of a laminated card outlining the straightforward steps to evaluating benefit using a combination of speech perception measures, a parent report measure, and aided soundfield testing. The protocol provides guidance on the test administration, including suggested test level in dBA and calibration of the audiometric equipment.  A suggested test measures flow chart is provided along with a record sheet to document the child’s results. The protocol is recommended for all BCHD indications for a child ages three-to-five years.

Until a standardized objective verification protocol using a skull simulator with prescriptive targets is developed for young children, we would encourage clinicians to consider using this protocol or something similar to monitor a young child’s auditory development with a BCHD.

To learn more about this protocol, we encourage you to reach out to your regional clinical specialist.  

About the Author

Carissa Moeggenberg is an audiologist who has worked in the hearing healthcare field for 29 years. She is presently the Training Manager for Oticon Medical.

References

1. Bagatto, M. P., S. T. Moodie, R. C. Seewald, D. J. Bartlett, and S. D. Scollie. 2011. “A Critical Review of Audiological Outcome Measures for Infants and Children.” Trends in Amplification 15 (1): 23–33. doi:10.1177/1084713811412056.
2. Bagatto, M., S. Moodie, A. Malandrino, C. Brown, F. Richert, D. Clench, and S. Scollie. 2016. “Prescribing and Verifying Hearing Aids Applying the American Academy of Audiology Pediatric Amplification Guideline: Protocols and Outcomes from the Ontario Infant Hearing Program.” Journal of the American Academy of Audiology 27 (3): 188–203. doi:10.3766/jaaa.15051.
3. Dave Gordey & Marlene Bagatto (2020): Fitting bone conduction hearing devices to children: audiological practices and challenges, International Journal of Audiology, DOI: 10.1080/14992027.2020.1814970
4. Keidser, G., H. Dillon, L. Carter, and A. O’Brien. 2012. “NAL-NL2 Empirical Adjustments.” Trends in Amplification 16 (4): 211–223. doi:10.1177/1084713812468511.
5. Scollie, S., Seewald, R., Cornelisse, L., Moodie, S., Bagatto, M., Laurnagaray, D., … & Pumford, J. 2005. The desired sensation level multistage input/output algorithm. Trends in Amplification, 9 (4): 159–197.
6. Sininger, Y. S., A. Grimes, and E. Christensen. 2010. “Auditory Development in Early Amplified Children: Factors Influencing Auditory-Based Communication Outcomes in Children with Hearing Loss.” Ear and Hearing 31 (2): 166–185. doi:10.1097/AUD.0b013e3181c8e7b6.
7. Tomblin, J. B., E. A. Walker, R. W. McCreery, R. M. Arenas, M. Harrison, and M. P. Moeller. 2015. “Outcomes of Children with Hearing Loss: Data Collection and Methods.” Ear and Hearing 36 (01): 14S–23S. doi:10.1097/AUD.0000000000000212.
8. Uhler, K., Warner-Czyz, A., Gifford, R. and PMSTB Working Groups. 2017. “Pediatric Minimum Speech Test Battery” J Am Acad Audiol 28:232–247. DOI: 10.3766/jaaa.15123

Counseling Patients through the Ponto Trial Journey

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Benefits of Direct Sound Transmission

Patients considering a bone anchored solution for their hearing loss have many options.  As clinicians begin the process of discussing patient choices there are many factors patients often consider, including sound processor style, surgical features, wearing comfort, and cosmetic appeal. However, the candidate often overlooks or undervalues intangible benefits. These benefits relate to the importance of a solution that provides clarity of the signal without distortion or feedback, ample amount of power output to overcome the hearing loss and a broad frequency response to capture all of the acoustic elements important for the understanding of speech.

Bone anchored hearing devices can be placed into two broad categories: either they deliver sound via Skin Transmission, where the vibrating unit is placed on top of the skin and the sound vibrations have to pass through the skin and are attenuated before they reach the bone or via Direct Sound Transmission, with sound vibrations going directly to the bone and then on to the inner ear. Skin Transmission solutions are non-surgical options (e.g., a softband) versus Direct Sound Transmission percutaneous solutions, where the processor sends sound information through the skin to an implanted vibrating unit in direct contact with the bone.

Is there a difference between these two solutions?

Clinical evidence comparing patient outcomes between a skin transmission device and a direct transmission device indicates there is a significant difference. It has been shown that hearing thresholds obtained with Direct Sound Transmission solutions are about 5-20 dB lower (better) between 600 and 6000 Hz and speech reception thresholds are also 4-7 dB lower (better) than with conventional devices (Håkansson et al., 1984; Verstraeten et al., 2009). Beyond this fact, research shows that by choosing Direct Sound Transmission, such as a Ponto percutaneous solution, recipients can learn faster and remember more Pittman (2019) and Lunner et al. (2016) found that using Direct Sound Transmission can increase the learning speed in children by 2.5 times and improve recall abilities by 13 percent in adults.

It is widely established that children with a hearing loss have a reduced vocabulary compared to normal-hearing children (Blamey et al., 2001; Pittman et al., 2005). Hearing solutions for children with a hearing loss should help to close this gap. This is why the results seen by the Andrea Pittman (2019) study are so significant. The Pittman study is the first to show the influence of different sound transmission pathways on the essential domain of auditory learning with the effects of Direct Sound Transmission clear – children learn new words faster.

It has been shown that adults with hearing loss use many additional cognitive resources to recognize, listen to and process sounds. One of these cognitive resources is our working memory. Working memory can be used for both processing and storing information. Thus if more resources are used for processing, fewer resources are left for storage. In fact the ability to remember information can be used as an estimate of how many resources are left for storage, and how effortful it was to process that signal. Lunner and colleagues (2016) compared the ability to remember information using Ponto connected to either a softband (Skin Transmission) or an abutment (Direct Sound Transmission). Their results showed that the Ponto users’ recall ability was significantly higher with the sound processor connected to the abutment (52%) as compared to the Softband solution (46%). These findings suggest that transmitting the sound via Direct Sound Transmission to the temporal bone without skin dampening yields better signal quality and less effortful processing.

 

To summarize, the Ponto System uses Direct Sound Transmission, allowing for the most efficient transmission of speech and sounds via the skull bone directly to the cochlea without skin dampening. With the most powerful abutment-level sound processors available on the market, we can provide access to a larger range of everyday sounds with less distortion.

We believe that counseling on the benefits of a system beyond what is concrete to the patient will impact their future hearing outcomes and contribute to their overall quality of life. So, moving patients from softband to an abutment should include discussion of the advantages of Direct Sound Transmission.

To learn more about the benefits of direct sound transmission, we encourage you to register for our upcoming training on March 24, 2021 or reach out to your regional clinical specialist.

 About the Author

Carissa Moeggenberg is an audiologist who has worked in the hearing healthcare field for the past 28 years. She is presently the Training Manager for Oticon Medical.

References:

Blamey, P. J., Sarant, J. Z., Paatsch, L. E., Barry, J. G., Bow, C. P., Wales, R. J., Wright, M., Psarros, C., Rattigan, K., Tooher, R. (2001). Relationships among speech perception, production, language, hearing loss, and age in children with impaired hearing. Journal of Speech, Language, and Hearing Research 44: 264–285.
Håkansson, B., Tjellstrom, A., Rosenhall, U. (1984) Hearing thresholds with direct bone conduction versus conventional bone conduction. Scand Audiol 13: 3-13.
Lunner, T., Rudner, M., Rosenbom, T., Ågren, J., and Ng, E.H.N. (2016) Using Speech Recall in Hearing Aid Fitting and Outcome Evaluation Under Ecological Test Conditions. Ear Hear 37 Suppl 1: 145S-154S.
Pittman, A. L., Lewis, D.E., Hoover, B.M., and Stelmachowicz, P. G. (2005). Rapid word-learning in normal-hearing and hearing-impaired children: Effects of age, receptive vocabulary, and high-frequency amplification. Ear Hear 26: 619–629. Plack, C. J. (2005). The sense of hearing.
Pittman, A. L. (2019) Bone conduction amplification in children: Stimulation via a percutaneous abutment vs. a transcutaneous softband. Ear Hear.
Verstraeten, N., Zarowski, A. J., Somers, T., Riff, D. and Offeciers, E. F. (2009). Comparison of the audiologic results obtained with the bone anchored hearing aid attached to the headband, the testband, and to the “snap” abutment Otol. Neurotol 30: 70-75.