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Objectives/Hypothesis Soft tissue reactions around abutments are the most common complications of percutaneous osseointegrated implants. The main objective of this study was to review our series of osseointegrated implants, evaluate the degree of adverse skin reactions around the auricular abutments, and compare with skin reactions in the pediatric bone-anchored hearing aid (BAHA) population. The reason for comparing these two groups was the difference in abutment shape and position in skin with different characteristics. Study Design A retrospective case analysis of 131 patient notes. Methods We retrospectively studied 131 pediatric and adult patients who underwent an osseointegrated auricular prosthesis over a 10-year period (1997–2007). Results There were 95 adults and 36 children who had been implanted and fitted with an auricular prosthesis during the 10-year study period. All patients were followed up postoperatively for a 2-year minimum up to a 14-year maximum follow-up. Thirteen (13/36, 36%) children and seven adults (7/95, 7%) had a skin reaction around the ear prosthesis. Conclusions The literature review has supported our study results and has shown that children have higher skin reactions in both BAHA and auricular prostheses than adults. Adverse skin reactions in the pediatric auricular group were significantly lower that the pediatric BAHA group. Level of Evidence 4 Laryngoscope, 125:1934–1939, 2015

Copyright © 2014 Tom Williamson et al. Robotic assistance in the context of lateral skull base surgery, particularly during cochlear implantation procedures, has been the subject of considerable research over the last decade. The use of robotics during these procedures has the potential to provide significant benefits to the patient by reducing invasiveness when gaining access to the cochlea, as well as reducing intracochlear trauma when performing a cochleostomy. Presented herein is preliminary work on the combination of two robotic systems for reducing invasiveness and trauma in cochlear implantation procedures. A robotic system for minimally invasive inner ear access was combined with a smart drilling tool for robust and safe cochleostomy; evaluation was completed on a single human cadaver specimen. Access to the middle ear was successfully achieved through the facial recess without damage to surrounding anatomical structures; cochleostomy was completed at the planned position with the endosteum remaining intact after drilling as confirmed by microscope evaluation.

The authors wish to acknowledge financial support by Cochlear Ltd., Australia, and clinical support from Queen Elizabeth Hospital, Birmingham, UK in this work and the advice and enthusiasm of Mechtron Design Ltd, UK.

Objective To establish the cost-effectiveness of a bone-anchored hearing device (BAHD). To date, there has not been any formal economic analysis of this treatment. Study design A prospective cohort case-control analysis. Setting Tertiary referral center, university hospital. Patients Between April 2007 and June 2008, all adult patients undergoing their first BAHD were contacted and invited to take part in this study. Data of 70 patients were completed during the study period and were analyzed. Interventions A health utility measure was made before and after the insertion of a BAHD to estimate the utility gain associated with this intervention. Main outcome measures The cost and quality-adjusted life year (QALY) gain for each patient was established, and an incremental cost-effectiveness ratio (ICER) was calculated. Results The results of our analysis are that, compared with current standard care, the BAHD has an ICER of £17,610 (US $26,415) per QALY gained. The National Institute for Health and Clinical Excellence will endorse a health intervention as cost-effective if the ICER is below £20,000 to £30,000 per QALY (US $30,000-45,000). Conclusion This technology is likely to be cost-effective at the current thresholds used by National Institute for Health and Clinical Excellence. Therefore, this study suggests the BAHD may be a cost-effective method of auditory rehabilitation.

Clin. Otolaryngol. 2010, 35, 284–290 Objectives: To assess the efficacy of the bone-anchored hearing aid (BAHA) in the rehabilitation of single-sided deafness (SSD). Study design: Retrospective case–control series review. Setting: Tertiary referral unit. Patients: Fifty-eight consecutive patients that had a bone-anchored hearing aid for single-sided deafness completed outcome questionnaires, building upon earlier audiological assessment of 19 patients. Single-sided deafness controls (n = 49) were mainly acoustic neuroma patients. Main outcome measurements: speech discrimination testing in directional noise, speech and spatial qualities of hearing questionnaire and the Glasgow Benefit Inventory (GBI). Results: The mean follow-up time was 28.4 months. Five (13%) of the bone-anchored hearing aid patients were non-users because of lack of benefit. The audiometric testing confirmed that when noise was on the bone-anchored hearing aid side speech perception was reduced but benefited when noise was on the side of the hearing ear. There was no difference between the Speech and Spatial Qualities of Hearing Scores in bone-anchored hearing aid users and controls. In particular there was no difference in the spatial subscores. In the bone-anchored hearing aid users the median Glasgow Benefit Inventory score was 11. If the non-users are included then 13 (22%) patients had no or detrimental (negative) Benefit scores. No or negative benefit scores were more frequent in those deaf for

This is the author's accepted manuscript. The final published article is available from the link below. Copyright @ 2010 The Authors. This article describes a surgical robotic device that is able to discriminate tissue interfaces and other controlling parameters ahead of the drill tip. The advantage in such a surgery is that the tissues at the interfaces can be preserved. A smart tool detects ahead of the tool point and is able to control the interaction with respect to the flexing tissue, to avoid penetration or to control the extent of protrusion with respect to the position of the tissue. For surgical procedures, where precision is required, the tool offers significant benefit. To interpret the drilling conditions and the conditions leading up to breakthrough at a tissue interface, a sensing scheme is used that discriminates between the variety of conditions posed in the drilling environment. The result is a fully autonomous system, which is able to respond to the tissue type, behaviour, and deflection in real-time. The system is also robust in terms of disturbances encountered in the operating theatre. The device is pragmatic. It is intuitive to use, efficient to set up, and uses standard drill bits. The micro-drill, which has been used to prepare cochleostomies in the theatre, was used to remove the bone tissue leaving the endosteal membrane intact. This has enabled the preservation of sterility and the drilling debris to be removed prior to the insertion of the electrode. It is expected that this technique will promote the preservation of hearing and reduce the possibility of complications. The article describes the device (including simulated drill progress and hardware set-up) and the stages leading up to its use in the theatre. Queen Elizabeth Hospital, Birmingham, UK

The success rates and morbidity of operations on the ear, nose, and throat (ENT) have improved markedly in the last 20—25 years. This has been largely due to improved vision, by microscopes and endoscopes, and has led to a greatly reduced hospital stay. During this time there has been minimal improvement in surgical tools. This paper discusses the need for robotic tools, detailing the clinical constraints that proposed solutions need to adhere to, and presenting a recently trialled micro drilling robot for creating a cochleostomy in the cochlear implant procedure.

OBJECTIVE The purpose of the current study was to determine the presence of biomarkers of tissue and bone metabolism and 10 cytokines within the fluid exudate from around bone anchored hearing aids (BAHAs), with a view to understanding the mechanisms of peri-BAHA inflammation. STUDY DESIGN Fluid exudate from around BAHAs was collected from volunteers (n = 10) with inflammation and controls (n = 10) without inflammation around the BAHA. SETTING Studies of periodontitis and dental peri-implantitis have demonstrated that fluid exudate, arising from the hard tissue-soft tissue junction, is increased during disease; this fluid contains biomarkers of tissue metabolism, bone metabolism and inflammation. PATIENTS Volunteers were recruited from the Queen Elizabeth Hospital, Birmingham, UK and New Cross Hospital, Wolverhampton, UK. INTERVENTIONS This was an observational study and no interventions were carried out as part of the study. MAIN OUTCOME MEASURE Biomarkers of tissue metabolism (MMP9, TIMP1 and 2), bone metabolism (RANKL and OPG) and cytokines (GM-CSF, interferon (IFN)-*, IL-1A, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10 and TNF>) were measured in the fluid samples by Luminex multianalyte assay. RESULTS Volumes of fluid exudate were significantly higher (p < 0.05) at sites of inflammation than from un-inflamed tissues surrounding BAHAs. IL-1*, IL-6, IL-8, TNF*, MMP9, TIMP1 and 2 were found in both inflamed and un-inflamed samples and levels were significantly higher in samples from inflamed sites. RANKL, IFN*, IL-2, IL-4, and GM-CSF were detected only at inflamed sites whereas OPG, IL-5 and IL-10 were not detected in any samples. CONCLUSION These data demonstrate that peri-BAHA tissues showing clinical signs of inflammation are associated with increased fluid exudate, which contains elevated levels of key biomarkers of inflammation and a biomarker profile that is consistent with increased tissue and bone remodeling around BAHAs.

OBJECTIVE: To assess patient satisfaction with the Bone-Anchored Hearing Aid (BAHA) Cordelle device and to identify any user- and device-related issues. STUDY DESIGN: Retrospective, anonymized, cross-sectional postal survey using the Entific Medical Systems questionnaire. SETTING: Tertiary referral center. PATIENTS: Fifty adult patients who had been using the BAHA Cordelle for more than 6 months. INTERVENTION: Hearing rehabilitation using BAHA Cordelle. MAIN OUTCOME MEASURES: Patients' satisfaction with the BAHA Cordelle in a variety of real-life hearing scenarios, their actual use of the device, and other issues with the device. RESULTS: Response rate was 66%. Responders were happy with their Cordelle in quiet situations and 1-to-1 conversations but less so in noisy or in group situations.However, approximately 80% of Cordelle users will use their device everyday for more than 8 h/d, and the overall satisfaction level is high. Compared with ear-level BAHA patients, Cordelle users are older and have mixed hearing loss with poorer sensorineural reserve, making hearing rehabilitation more challenging. CONCLUSION: The findings of this study support the use of the BAHA Cordelle as a viable, safe, low-morbidity hearing rehabilitation option in patients with mixed hearing loss with poor sensorineural reserve. Patients should be counseled appropriately to help manage their expectations.

To evaluate the complication rates and outcomes of children who were fitted with a bone-anchored hearing aid (BAHA) on the Birmingham BAHA program.Retrospective case analysis of clinical records of all children implanted at Birmingham Children's Hospital since the beginning of the program in 1992 until February 2007.A total of 182 children younger than 16 years old fitted with a BAHA. Of these children, 107 had a significant medical history.Surgery was performed as a 2-stage procedure in 174 children. The healing time was between 3 and 4 months in 112 (64%) cases. Single-stage surgery was performed in 8 cases. Implant failures were 14% of 230 loaded fixtures (32 fixtures lost in total). Multiple-fixture failures (18 fixture failures) occurred in 7 patients. Adverse skin reactions appeared in 34 (17%) patients during a 15-year follow-up period. Revision surgery was undertaken in 14 (8%) cases because of skin overgrowth around the abutment. Five of these cases required multiple surgical skin reductions.The Birmingham Program has a high proportion of syndromic patients with complex medical problems. The fixture failure rate was found to be 14%. This included the multiple-fixture failures in children younger than 3 years old. There was 1 serious complication. The BAHA is a reliable and effective treatment for selected patients. Our program currently has 97% of its children wearing their BAHA on a daily basis with continuing audiologic benefit.

Objective: To produce an autonomous drilling robot capable of performing a bony cochleostomy whilst minimising the damage to the underlying cochlear endosteum. Design: In this laboratory based study, a robotic drill was designed to measure the changes in force and torque experienced by the tool point during the drilling process. This information is used to predict the point of breakthrough and stop the drill prior to damaging the underlying endosteal membrane. Setting: Aston University. Participants: Five porcine cochleas. Main outcomes measures: An assessment was made of whether a successful bony cochleostomy was performed, the integrity of endosteal membrane was then assessed. Results: The autonomous surgical robotic drill successfully performed a bony cochleostomy and stopped without damaging the endosteal membrane in all five cases. Conclusions: The autonomous surgical robotic drill can perform a cochleostomy whilst minimising the trauma to the endosteal membrane. The system allows information about the state of the drilling process to be derived using force and torque data from the tool point. This information can be used to effectively predict drill breakthrough and implement a control strategy to minimise drill penetration beyond the far surface.

We describe the unusual complication of the cochlear implant electrode eroding through the lateral bony wall of the cochlear basal turn in 2 different patients. This complication, occurring during life, has not been previously described in the literature. Radiological investigations were vital in making this diagnosis. We also discuss the likely pathophysiology behind this complication. Copyright © 2007 John Wiley & Sons, Ltd.

Background In this paper we consider two relatively frequently performed operations in the field of ear, nose and throat (ENT) surgery and consider how they could be improved by using robotic applications. We consider currently available robots and propose theoretical robotic solutions. Methods The application of robotic systems for both cochlear implantation and endoscopic sinus surgery was considered. Currently available robotic systems were reviewed and those with potential use in ENT surgery were identified. For aspects of operations where there is no available technology, hypotheses are presented on how robots could help. Results Three robotic systems were identified with potential usage in ENT: the Pathfinder™ neurosurgical robot, the Acrobot® knee replacement system and the autonomous smart drill for drilling a cochleostomy. Conclusions The challenge for the future of ENT is being able to perform tasks beyond the level of human perception and abilities. The examples presented here demonstrate that microtechnologies could be used to reduce complications, decrease operating time and improve clinical results. Copyright © 2007 John Wiley & Sons, Ltd.

A mechatronic surgical micro-drill applied in practice has enabled new techniques for measurement in otology to understand the dynamic response of the cochlea hearing organ. In the interest of reducing trauma and to reinforce preservation of residual hearing during surgery, results point to choices in technique as mechatronic devices offer significantly less disturbance than conventional surgical tools used in cochlear electrode implantation. The cochlea transforms mechanical disturbances induced from incident ambient sound to electrical neuro-signals interpreted in the brain as sound, and is a closed volume of fluids and delicate membranes. The mechatronic drilling technique can expose consistently sized membranes at the base of a hole drilled through the bone tissue shell of the cochlea. The dynamic deflection of membrane windows, in response to fluid pressure transients, enables contrast between intra-cochlear disturbances at different locations within the cochlea, and between normal hearing disturbance amplitude and disturbances induced by surgical processes.

To evaluate the speech perception benefits of bilateral implantation for subjects who already have one implant.Repeated measures.Thirty adult cochlear implant users who received their second implant from 1 to 7 years with a mean of 3 years after their first device. Ages ranged from 29 to 82 years with a mean of 57 years.Tertiary referral centers across the United Kingdom.Monosyllabic consonant-nucleus-consonant words and City University of New York sentences in quiet with coincident speech and noise and with the noise spatially separated from the speech by +/-90 degrees .At 9 months, results showed the second ear in noise was 13.9 +/- 5.9% worse than the first ear (p0.001); a significant binaural advantage of 12.6 +/- 5.4% (p0.001) over the first ear alone for speech and noise from the front; a 21 +/- 6% (p0.001) binaural advantage over the first ear alone when noise was ipsilateral to the first ear; no binaural advantage when noise was contralateral to the first ear.There is a significant bilateral advantage of adding a second ear for this group. We were unable to predict when the second ear would be the better performing ear, and by implanting both ears, we guarantee implanting the better ear. Sequential implantation with long delays between ears has resulted in poor second ear performance for some subjects and has limited the degree of bilateral benefit that can be obtained by these users. The dual microphone does not provide equivalent benefit to bilateral implants.

The Birmingham bone-anchored hearing aid (BAHA) programme has fitted more than 300 patients with unilateral bone-anchored hearing aids since 1988. Some of the patients who benefited well with unilateral aids and who had used bilateral conventional aids previously applied for bilateral amplification. To date, 15 patients have been fitted with bilateral BAHAs. The benefits of bilateral amplification have been compared to unilateral amplification in 11 of these patients. Subjective analysis in the form of validated comprehensive questionnaires was undertaken.The Glasgow benefit inventory (GBI), which is a subjective patient orientated post-interventional questionnaire developed to evaluate any otorhinolaryngological surgery and therapy was administered. The results revealed that the use of bilateral bone-anchored hearing aids significantly enhanced general well being (patient benefit) and improved the patient’s state of health (quality of life). The Chung and Stephens questionnaire which addresses specific issues related to binaural hearing was used. Our preliminary results are encouraging and are comparable to the experience of the Nijmegen BAHA group.

The concept of a hand guided robotic drill has been inspired by an automated, arm supported robotic drill recently applied in clinical practice to produce cochleostomies without penetrating the endosteum ready for inserting cochlear electrodes. The smart tactile sensing scheme within the drill enables precise control of the state of interaction between tissues and tools in real-time. This paper reports development studies of the hand guided robotic drill where the same consistent outcomes, augmentation of surgeon control and skill, and similar reduction of induced disturbances on the hearing organ are achieved. The device operates with differing presentation of tissues resulting from variation in anatomy and demonstrates the ability to control or avoid penetration of tissue layers as required and to respond to intended rather than involuntary motion of the surgeon operator. The advantage of hand guided over an arm supported system is that it offers flexibility in adjusting the drilling trajectory. This can be important to initiate cutting on a hard convex tissue surface without slipping and then to proceed on the desired trajectory after cutting has commenced. The results for trials on phantoms show that drill unit compliance is an important factor in the design.

Soft tissue reactions around abutments are the most common complications of percutaneous osseointegrated implants. The main objective of this study was to review our series of osseointegrated implants, evaluate the degree of adverse skin reactions around the auricular abutments, and compare with skin reactions in the pediatric bone-anchored hearing aid (BAHA) population. The reason for comparing these two groups was the difference in abutment shape and position in skin with different characteristics.A retrospective case analysis of 131 patient notes.We retrospectively studied 131 pediatric and adult patients who underwent an osseointegrated auricular prosthesis over a 10-year period (1997-2007).There were 95 adults and 36 children who had been implanted and fitted with an auricular prosthesis during the 10-year study period. All patients were followed up postoperatively for a 2-year minimum up to a 14-year maximum follow-up. Thirteen (13/36, 36%) children and seven adults (7/95, 7%) had a skin reaction around the ear prosthesis.The literature review has supported our study results and has shown that children have higher skin reactions in both BAHA and auricular prostheses than adults. Adverse skin reactions in the pediatric auricular group were significantly lower that the pediatric BAHA group.4

OBJECTIVE To the best of our knowledge, the use of the 8.5-mm abutment and its long-term outcome in the pediatric population has not been reported in the medical literature. We describe our experience with the use of the 8.5-mm abutment in a series of 16 children who have required a long abutment. STUDY DESIGN Retrospective case series review. SETTING Tertiary hospital. PATIENTS Patients younger than 16 years who had an 8.5-mm bone-anchored hearing aid abutment fitted. INTERVENTION Use of an 8.5-mm bone-anchored hearing aid abutment. MAIN OUTCOME MEASURES Indications and complications with using the 8.5-mm abutment. RESULTS We have used the longer abutment on both 3- and 4-mm fixtures. We have found the need to use it particularly around the time of puberty when we observed soft tissue problems develop. Follow-up after insertion of the long abutment ranged from 6 months to 6 years. There was 1 fixture extrusion 2 years after a long abutment had been fitted. CONCLUSION Overall, we have found the long abutment to be useful in a selected pediatric population.

Objective A trial of a bone conductor is traditionally used to determine whether a bone-anchored hearing aid (Baha) will be beneficial to a child. However there is a subgroup of children where a Baha assessment is not possible due to severe behavioural/mental/sensory disorders. We describe our experience in a small series of such children. Method Retrospective case series review of four children at the severe end of the spectrum of behavioural difficulties who underwent Baha implantation where no formal preoperative hearing aid assessment was possible. The Glasgow Children's Benefit Inventory and a visual analogue scale assessing health status were used to determine the benefit of Baha implantation in this group. Results There was no surgical morbidity in this group although a more intensive postoperative follow up was required. All four children wore their hearing aids at least 8 h a day. Parents reported a positive impact of the Baha on the behaviour and mood of their children. The Baha showed a positive benefit when assessed using the Glasgow Children's Benefit Inventory and showed a positive change in health status. Conclusions We feel that our early experience with Baha in children with severe behavioural difficulties has been positive to date. Multidisciplinary teams should not dismiss these children even if a trial of a bone conductor is not possible. We feel that the bone-anchored hearing aid has been successful in our cases because the children do not physically feel the presence of the hearing aid.

During cochlear implantation, hearing preservation is a concern. Minimizing disturbances to the cochlea and protection of the underlying endosteal membrane during the formation of a cochleostomy are considered important factors. The robotic micro-drill system tested in this article is the first example of an autonomous surgical drill successfully producing a cochleostomy, which keeps the underlying endosteal membrane intact. This study compares induced disturbances within the cochlea during formation of cochleostomy using the robotic micro-drill with that of conventional manual drilling. The disturbance of the endosteal membrane is measured using a Microscope Scanning Vibrometer at a third window, produced in the cochlea. Results show that the highest velocity amplitude measured was associated with manual drilling technique. The robotic micro-drill technique produced only about 1% of the peak velocity amplitude seen in manual drilling and exhibited much more uniform behaviour, while keeping the underlying membrane intact. The technique applied when using the robotic drill could be a major step in reducing the trauma to the cochlea, by reducing disturbance levels.

Since 1988, 309 patients have been referred to the Birmingham bone anchored hearing aid programme for assessment. One hundred and eighty-eight have been fitted with bone anchored hearing aids (BAHA). Of these 169 have been fitted with a BAHA alone and 20 with a BAHA and auricular prosthesis(es).Only four (2.1 per cent) are not wearing their BAHAs. Three cases because the hearing had continued to deteriorate and in one case because of repeated failure to integrate. Nineteen patients (10.1 per cent) have lost fixtures but all but one of these have been successfully reimplanted. Of these 19 patients 10 (52.6 per cent) were syndromal and 10 (52.6 per cent) were under 16 years of age.A surgical method has been evolved both to cope with predictable failure of integration and soft tissue control.

Over a five-year period, 34 patients have been referred to the Birmingham bone anchored hearing aid programme, paediatric section, of whom 21 are now wearing the bone anchored hearing aid (BAHA) and four are awaiting surgery for fitting of the BAHA. Of the patients assessed, found to be suitable and who proceeded to surgery for the BAHA, 44 per cent had Treacher Collins syndrome, 28 per cent had bilateral atresia or microtia, 16 per cent had Goldenhaar's syndrome, four per cent (one patient) had branchio-oto-renal syndrome and eight per cent had chronic suppurative otitis media. This paper presents objective and subjective data collected from these patients. It is shown that the BAHA is a very effective hearing aid for children with congenital hearing loss.

The ability of cholesteatoma to grow rapidly within the ear is well recognized. This study aimed to quantify the in vitro growth of cholesteatoma derived cells. Following removal of cholesteatoma explant cultures were established. Cellular outgrowths were subcultured and a colony forming assay performed. Cells were repeatedly passaged every 14 days until senescence was observed. In comparison with cells derived from normal scalp skin, cholesteatoma derived cells demonstrated a lower colony forming efficiency in both primary and secondary subcultures, achieved fewer passages and cell generations in serial culture, and achieved a lower total population expansion. No evidence was found to suggest an intrinsic loss of growth control. It is proposed that the majority of cholesteatoma is composed of cells with a limited capacity for growth. Explant studies suggested that these may be the progeny of more highly proliferative cells situated at the neck of the cholesteatoma sac.

Severe inflammation and infection of the middle ear occasionally results in clinical evidence of bone resorption but with the addition of the cholesteatoma epithelium it becomes inevitable. This study examined production by the cholesteatoma epithelium of a bone resorbing factor, namely parathyroid hormone-related protein (PTH-rP), which would not be expected in inflammatory states alone. PTH-rP was detected in the conditioned medium of primary and secondary cell cultures derived from 12 cholesteatoma biopsies. The levels of PTH-rP were significantly greater than in control cultures of cells derived from normal scalp tissue. Production by the cholesteatoma epithelium may explain the increased incidence of bone resorption in this disease, particularly in cases where inflammation is minimal.

The first report of a patient with metastatic bronchogenic carcinoma of the skin surrounding the abutment of a bone anchored hearing aid (BAHA) is presented. Complications of bone anchored hearing implantation have been well documented to date. We present a 68-year-old lady who presented with an unusual skin lesion surrounding the abutment of her BAHA. This was the first presentation of her bronchogenic tumour.We also review the literature regarding cutaneous metastasis and complications of BAHA.

Background: Cochleostomy formation is a key stage of the cochlear implantation procedure. Minimizing the trauma sustained by the cochlea during this step is thought to be a critical feature in hearing preservation cochlear implantation. The aim of this paper is firstly, to assess the cochlea disturbances during manual and robotic cochleostomy formation. Secondly, to determine whether the use of a smart micro-drill is feasible during human cochlear implantation. Materials and methods: The disturbances within the cochlea during cochleostomy formation were analysed in a porcine specimen by creating a third window cochleostomy, preserving the underlying endosteal membrane, on the anterior aspect of the basal turn of the cochlea. A laser vibrometer was aimed at this third window, to assess its movement while a traditional cochleostomy was performed. Six cochleostomies were performed in total, three manually and three with a smart micro-drill. The mean and peak membrane movement was calculated for both manual and smart micro-drill arms, to represent the disturbances sustained within cochlea during cochleostomy formation. The smart micro-drill was further used to perform live human robotic cochleostomies on three adult patients who met the National Institute of Health and Clinical Excellence criteria for undergoing cochlear implantation. Results: In the porcine trial, the smart micro-drill preserved the endosteal membrane in all three cases. The velocity of movement of the endosteal membrane during manual cochleostomy is approximately 20 times higher on average and 100 times greater in peak velocity, than for robotic cochleostomy. The robot was safely utilized in theatre in all three cases and successfully created a bony cochleostomy while preserving the underlying endosteal membrane. Conclusions: Our experiments have revealed that controlling the force of drilling during cochleostomy formation and opening the endosteal membrane with a pick will minimize the trauma sustained by the cochlea by a factor of 20. Additionally, the smart micro-drill can safely perform a bony cochleostomy in humans under operative conditions and preserve the integrity of the underlying endosteal membrane.

OBJECTIVE To investigate whether the fitting of bilateral Bone-anchored Hearing Aid (BAHA) would result in any additional improvement in patients' quality of life (QOL) over and above what we would experience from the fitting of a single-sided BAHA. STUDY DESIGN Retrospective, anonymized, cross-sectional postal survey using the Glasgow Benefit Inventory (GBI). SETTING Tertiary referral center. PATIENTS All 93 adult patients who had been using bilateral BAHA for more than 6 months. INTERVENTION(S) Hearing rehabilitation using bilateral BAHA. MAIN OUTCOME MEASURE(S) These include the GBI benefit scores across the following domains: "overall benefit," "general health benefit," "physical health benefit," and "social benefit." Comparison of GBI scores against other otological interventions including single-sided BAHA. RESULTS Response rate was 76%. Ninety-two percent of patients reported improvement in QOL. Positive QOL improvement scores were reported across all domains. Overall GBI benefit score was +ve 38. This is higher than the benefit scores reported by patients with single-sided BAHA, although this may not be statistically significant. CONCLUSION After fitting the second BAHA, patients may report additional improvement in their QOL (of a smaller magnitude) over and above the initial improvement in their QOL after fitting of their first BAHA. In fact, the overall benefit score for bilateral BAHA seem to be close to that for cochlear implantation.

Use of the longer (8.5 mm) abutment for a Bone-Anchored Hearing Aid has been helpful for a certain group of patients. The most common reason for its use is soft tissue problems with tissue overgrowth interfering with device function. The longer abutment has been used in our institution, a tertiary referral center, on a named patient basis since 2002, and more than 100 patients have received it.This paper will review this subgroup of patients and describe their demographics. Comorbidity, smoking history, graft failure, infection, and index of deprivation will be looked at as contributing factors for this group with soft tissue problems.We identified 111 patients who had longer abutments ordered for them, and a retrospective case review was performed.Eighty-one patients required soft tissue reduction surgery because of overgrowth, and all but one (80/81 [98.8%]) of these patients required no further surgery after having their 5.5-mm abutment changed to the 8.5-mm version. One patient underwent further surgery 10 months after the longer abutment was inserted but has been problem-free for 16 months since then. Length of follow-up ranged from 6 months to 5 years after converting to the longer abutment.We have found the longer abutment to be very successful for the small proportion of patients with troublesome soft tissue overgrowth. We would advocate its use when topical management and surgical intervention have failed to control the skin reaction.

In this paper, a surgical robotic micro-drill is described that has been applied in the preparation of cochleostomies. The critical point of the procedure requires the penetration of the bone tissue of the cochlea while preserving the endosteal membrane tissue at the inner interface. This gives robotic technology the edge over manual approaches as there are benefits relating to the preservation of hearing and reduced possibilities for complications achieved through particularly precise control of the tool-point with respect to moving and deforming tissues. Using a novel approach to interpreting force sensory data the micro-drill operates autonomously guided by the state of the tissue/ tool interaction in order to discriminate tissue types and to detect the tissue interface before penetration occurs. The device also uses standard drill-bits.

Cochlear implantation has become the standard treatment for severe to profoundly deaf patients over the last 20 years and is likely to increase as instrumentation systems improve such that patients with less deficiency can benefit and if the procedure can lead to accurate and a more efficient process of implantation. The critical step in the operation appears to be creating the cochleostomy, through which the implant electrode can be passed. A cochleostomy is created by drilling away the bony outer cochlea wall and, ideally, leaving the underlying endosteal membrane intact. The membrane is opened with a knife and implant is inserted. Inadvertent protrusion of the drill through the endosteal membrane may damage the scala tympani or osseous spiral lamina, and will contaminate the endolymph and perilymph with bone dust which, combined with the pressure surge experienced, may lead to a reduction in residual hearing. If the endosteal membrane is not perforated during the drilling process, and is opened by a knife, the damage to the cochlea will be minimised and residual hearing will be preserved. It has been shown that robotics can be applied in microsurgical tasks as a tool by automatically controlling the interaction between tissue and the tool point. The research reported here has led to clinical trials of an autonomous surgical robot system able to carry out the critical process of penetrating the bone tissue of the wall of the cochlea without penetration of the endosteal membrane located immediately inside the cochlea. Use of the robotic micro-drill in theatre represents the first application of an autonomous surgical robotic device and has shown that this is the ideal way to prepare a cochleostomy. The consistent results and the smooth form of the cochleostomy will enable more consistent insertion of implant electrodes and the likelihood of consistent results in terms of electrode performance. The means to avoid penetration of the endosteal membrane is expected to lead to a reduced complication rate.

The current state of the art robotic surgical systems allow surgeons to accurately, pre-operatively, localise disease and extent, and intra-operatively to improve access and vision. They have not yet enabled the surgeon to determine tissue interfaces, which would allow the precise removal of disease without the need to rely on vision or human touch. There is a great need for smart surgical tools to aid discrimination of tissue types within the body. The ability to determine diseased from disease free tissue would allow surgeons to limit their operations to the disease entities, and allow improved functionality of surrounding structures.

In the published series of our first 100 cochlear implants only three developed major complications (Proops et al., 1999). We present a rare case of late granulations forming around a Nucleus cochlear implant, giving rise to erosion of the entire cochlea and adjacent mesotympanum. This pathology has only been reported once in the literature (Bertuleit et al., 1999).

In cochlear implantation and other major ear surgeries a post auricular incision is often used. Following this, fascia, muscle and fat is divided, and then a periosteal flap is raised. This creates different tissue planes which need to be held back and protected from the surgeon and the drill. We present a new device which provides excellent retraction for this procedure, does not put undue pressure on the pinna, while at the same time it allowing the surgeon an unobstructed view. Copyright © 2008 John Wiley & Sons, Ltd.

Eighty-eight fine needle aspirates from 79 salivary gland lesions in 77 patients were examined. The overall diagnostic sensitivity was 84% and the specificity 98.41%. When the 14 unsatisfactory specimens were excluded the sensitivity rose to 95.45%. Correct identification of the disease process was possible in nearly 80% of cases with a final benign diagnosis. The histological tumour type was correctly predicted in 75% of the malignancies. In the others the cytological diagnosis was anaplastic malignant neoplasm.

Over the last 20 years, robotic surgery has made its mark as a precise means of tool deployment in surgical procedures. The majority of applications have focused on the control of tools on trajectories defined using pre-operative scan data. These pre-determined trajectories are appropriate where tissue movement between scanning and surgical therapy processes can be considered insignificant, or within acceptable limits. This level of assistance has its value in many procedures, however more complex tool paths and variations in strategy are required in many other procedures that will benefit from the precise nature of robotic manipulation technology. (Dario et al. 2000), (Davies 2000) are different example systems. To an extent this has been achieved by introducing the surgeon operator into the control loop, where master-slave systems have attempted to harness the decisions on interpretation of the state of tissue tool interaction, the formulation of strategy by the surgeon and the response and accuracy of the robotic device. Unfortunately there is always a dilemma associated with the perception of interaction with the tissue at the tool point. This is particularly true in minimal access procedures or in procedures requiring microscopic tool interaction, where information based on visual perception is compromised and the sense of tactile information is lost.

In this paper a robotic micro-drilling technique for surgery is described. The device has been deployed in cochleostomy, a precise micro-surgical procedure where the critical stage of controlling penetration of the outer bone tissue of the cochlea is achieved without penetration of the endosteal membrane at the medial surface. The significance of the work is that the device navigates by using transients of the reactive drilling forces to discriminate cutting conditions, state of tissue and the detection of the medial surface before drill break-out occurs. This is the first autonomous surgical robot to use this technique in real-time as a navigation function in the operating room and unlike other fully autonomous surgical robotic processes it is carried out without the use pre-operative data to control the motion of the tool. To control tool points in flexible tissues requires self-referencing to the tissue position in real time. There is also the need to discriminate deflections of the tissue, tissue interface, involuntary patients/ tissue movement and indeed movement induced by the drill itself, which require different strategies to be selected for control. As a result of the design of the final system, the break-out process of the drill can either controlled to the required level of protrusion through the flexible interface or can be avoided altogether, with the drill bit at the medial surface. This enables, for the first time, the control of fine penetration with such great precision.

Keypoints • Septal obturators and buttons for nasal septal perforations are often poorly tolerated. • We describe a new method of obturator construction using three-dimensional imaging which more closely replicates the true anatomy of the defect. • Patients were assessed using a questionnaire relating to how symptoms had changed between having no obturator, a conventional obturator and the new CT obturator. • Eight of nine patients had an improvement in total symptom scores comparing old obturators to new CT obturators and this was significant with a P-value of 0.018 using Student's paired t-test. • The majority of patients were satisfied with the new obturators and reported an overall improvement of symptoms.

The otosclerotic process commonly involves the otic capsule and may cause quite widespread demineralisation which leads to a progressive and often profound bilateral sensorineural hearing loss. In this situation cochlear implantation may be the only effective treatment. This chapter considers the pathology of this hearing loss, the effects of cochlear obliteration on implantation, and the effects of demineralisation of the otic capsule on placement of the electrode and nonauditory stimulation. A study is reported from 4 cochlear implant centres in the UK and the Netherlands of 53 patients with cochlear otosclerosis who received cochlear implantation. The CT features of their petrous bones are presented and a classification of the radiological features suggested. 38% of patients experienced facial nerve stimulation presumably due to spread of current through an otic capsule with lower than usual electrical impedance. The most common rogue electrodes were in the proximity of the geniculate ganglion. These could usually be successfully programmed out of the MAP.

The otosclerotic process commonly involves the otic capsule and may cause quite widespread demineralisation which leads to a progressive and often profound bilateral sensorineural hearing loss. In this situation cochlear implantation may be the only effective treatment. This chapter considers the pathology of this hearing loss, the effects of cochlear obliteration on implantation, and the effects of demineralisation of the otic capsule on placement of the electrode and nonauditory stimulation. A study is reported from 4 cochlear implant centres in the UK and the Netherlands of 53 patients with cochlear otosclerosis who received cochlear implantation. The CT features of their petrous bones are presented and a classification of the radiological features suggested. 38% of patients experienced facial nerve stimulation presumably due to spread of current through an otic capsule with lower than usual electrical impedance. The most common rogue electrodes were in the proximity of the geniculate ganglion. These could usually be successfully programmed out of the MAP.

In this paper a robotic micro-drilling technique for surgery is described. The device has been deployed in cochleostomy, a precise micro-surgical procedure where the critical stage of controlling penetration of the outer bone tissue of the cochlea is achieved without penetration of the endosteal membrane at the medial surface. The significance of the work is that the device navigates by using transients of the reactive drilling forces to discriminate cutting conditions, state of tissue and the detection of the medial surface before drill break-out occurs. This is the first autonomous surgical robot to use this technique in real-time as a navigation function in the operating room and unlike other fully autonomous surgical robotic processes it is carried out without the use pre-operative data to control the motion of the tool. To control tool points in flexible tissues requires self-referencing to the tissue position in real time. There is also the need to discriminate deflections of the tissue, tissue interface, involuntary patients/ tissue movement and indeed movement induced by the drill itself which require different strategies to be selected for control. As a result of the design of the final system, the break-out process of the drill can either controlled to the required level of pro-trusion through the flexible interface or can be avoided altogether, with the drill bit at the medial surface. This enables, for the first time, the control of fine penetration with such great precision.Copyright © 2007 by ASME

Item does not contain fulltext OBJECTIVES: To collect data from a large number of cochlear implant recipients with otosclerosis and to make an assessment of these patients' clinical characteristics, computed tomographic scans, surgical findings, and complications, and to quantify the occurrence of postoperative facial nerve stimulation. STUDY DESIGN: Retrospective multicenter study. PATIENTS: Fifty-three patients with otosclerosis from four cochlear implant centers in the United Kingdom and The Netherlands were reviewed. Sixty surgical procedures were performed in these patients: 57 devices were placed in 56 ears. RESULTS: The computed tomographic imaging demonstrated retrofenestral (cochlear) otosclerotic lesions in the majority of patients. Although not statistically significant, the extent of otosclerotic lesions on the computed tomographic scan as categorized in three types tends to be greater in patients with rapidly progressive hearing loss, in patients in whom there is surgically problematic insertion of the electrode array, and in patients with facial nerve stimulation. In four patients, revision surgery had to be performed. Twenty of 53 (38%) patients experienced facial nerve stimulation at various periods postoperatively. CONCLUSION: Cochlear implant surgery in patients with otosclerosis can be challenging, with a relatively high number of partial insertions and misplacements of the electrode array demanding revision surgery. A very high proportion of patients experienced facial nerve stimulation mainly caused by the distal electrodes. This must be discussed with patients preoperatively.

The protean manifestations of child abuse continue to cause diagnostic difficulty. Recent observations of the high mortality in victims of Munchausen syndrome by proxy, and their siblings, reinforce the need for early diagnosis and appropriate intervention. We report the nasal manifestations which unmasked Munchausen syndrome by proxy in an infant who presented with intestinal and peri-orifical signs masquerading as Crohn's disease. The possibility of Munchausen syndrome by proxy should be considered in an infant with persistent nasal excoriation presenting as part of an undiagnosed illness.

The Birmingham bone-anchored hearing aid programme began in 1988 and by autumn 2000 a total of 351 patients had been fitted with such an aid. The aim of this study was to assess the effectiveness of hearing rehabilitation with the bone-anchored hearing aid. This was a prospective interview-based questionnaire study carried out in the autumn 2000. A total of 84 adult patients were interviewed. Each patient had worn their BAHA for more than one year.The questionnaire used during these interviews was the Glasgow hearing aid benefit profile (GHABP) and the Glasgow hearing aid difference profile (GHADP). This was first derived and validated by Gatehouse in 1999. The use of bone-anchored hearing aids was found to reduce the level of disability and handicap and provided the most patient benefit and satisfaction.

The first report of a patient with gross Paget’s disease and progressive hearing loss who successfully underwent hearing rehabilitation with an osseo-integrated hearing aid is presented. The otological manifestations of Paget’s disease and the principles of osseo-integration are discussed. The use of a bone-anchored hearing aid (BAHA) in selected patients with Paget’s disease can provide useful amplification and hearing rehabilitation.

The first 300 patients referred from 11 participating general practices (GPs) to the Hoarse Voice Clinic, Queen Elizabeth Hospital, Birmingham, were studied prospectively to estimate the accuracy of GPs' diagnosis of laryngeal symptoms and to assess whether the provision of a direct referral immediate access service for the assessment of persistent laryngeal symptoms is an effective way of ensuring early referral and detection of laryngeal cancer. The GPs' assessment of laryngeal symptoms was inaccurate. Diagnosis after the initial clinic visit was accurate, predicting all histological cases of cancer. Laryngoscopy was possible in all patients at the first clinic visit. Disease requiring admission for direct laryngoscopy and biopsy was found in 39 patients (14%). Ten (3.3%) were found to have laryngeal cancer, of which eight were early lesions. When seen in the clinic 102 (34%) had normal voices and larynxes. A hoarse voice is a symptom requiring specialist assessment. By using the flexible fibreoptic nasendoscope all patients larynxes can be seen in clinic, an accurate diagnosis quickly made and the appropriate management instigated. It is feasible to offer this service without appointments to patients with persistent hoarseness.

The Birmingham bone anchored hearing aid team is part of the Birmingham osseointegrated programme. In the first seven years of its existence it has received 309 referrals. Twenty-six per cent had suffered a congenital conductive hearing loss and 74 per cent had an acquired conductive hearing loss; the majority secondary to chronic suppurative otitis media.This report is of 68 out of 106 adults wearing bone anchored hearing aids (BAHAs). Ninety-eight per cent showed audiological improvement with the congenital group demonstrating marginally the best freefield thresholds and speech discrimination. Questionnaire data as to the patient experience confirms the benefits especially hearing in noise, and comfort, and the vast majority were more satisfied with the bone anchored hearing aid than their previous aid.

Bone anchored hearing aids are gaining wide acceptability in the treatment of patients with congenital ear problems, chronic suppurative otitis media (CSOM) and in some cases otosclerosis. To date little information on the effect of the bone anchored hearing aid on the symptoms of chronic suppurative otitis is available. This retrospective study based on notes review and telephone interviews was to assess the outcome of bone anchored hearing aid surgery in patients with CSOM in terms of: ear discharge; surgical techniques and complications; the number of hours the aid is worn compared with the previous aid.One hundred and forty-two patients were fitted with bone anchored hearing aids without additional prostheses in Birmingham between 1989 and 1995. Sixty-nine (48.5 per cent) of these were for chronic suppurative otitis media, 45 of these were female and 24 were male with a mean age of 58 years. Most (85 per cent) had undergone previous ear surgery with 65 per cent having mastoid surgery. Ninety-eight per cent of this patient group had undergone single stage surgery and 65 per cent under local anaesthetic as a day case. A variety of techniques for soft tissue reduction were employed.The mean follow-up time for these patients was 24 months (range one month to seven years). No patients experienced worse discharge following their BAHA and 84 per cent had significantly reduced discharge, 16 per cent had no change. Complications included skin reactions, 15; failure to integrate, one; late loss of fixture, three. Seventy-three per cent wore their bone anchored hearing aid more than eight hours per day and 58 per cent were more satisfied with their bone anchored hearing aid than their previous aid.