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Challenges and specific considerations for surgery in the use of the MedEl Bonebridge in patients with
chronic ear disease
Acharya A. , Marino R. , Dayse T. , Kadhim A.L. , Rodrigues S. , Rajan G.P.
Fremantle Hospital & Health Service, ENT Department, Fremantle, Australia, 2Royal Perth Hospital, Perth, Australia, 3Princess Margaret
Hospital for Children, Perth, Australia, 4University of Western Australia, Perth, Australia
Introduction: Hearing rehabilitation in patients that are unable to wear conventional hearing aids (due to the
occlusion effect or intolerance of the hearing aid mould material) can be challenging. A bone conduction hearing
device may be necessary in such cases. The use of percutaneous bone conduction devices can be complicated
by skin problems around the abutment. Passive devices are limited by reduced power as compared with active
devices. The MED-EL Bonebridge, a transcutaneous active bone conduction device, has a comparatively large
floating mass transducer (FMT). Its positioning within the mastoid bone must satisfy the requirements of the
depth of the recess, the thickness of adjacent bone for fixation and avoidance of critical anatomical structures. In
patients with chronic ear disease, who commonly have a comparatively small mastoid bone and may have
undergone previous surgery, adequate positioning of the Bonebridge FMT may be challenging and it may be
necessary to sacrifice one or more of these ideals. We present our experience in the use of the MedEl
Bonebridge in such cases, using case examples to highlight specific challenges encountered and describe
techniques adopted to overcome these, thereby ensuring secure and suitable positioning of the FMT in such
Methods: Retrospective case note analysis of patients with chronic ear disease who have undergone MED-EL
Bonebridge implantation for hearing rehabilitation in a tertiary referral hearing implant centre. The use of imaging
in facilitating effective pre-operative surgical planning, that will raise suspicion of challenges and in turn allow
adequate preparations to be made to address these intra-operatively.
Results: All patients with chronic ear disease who have undergone implantation with the MedEl Bonebridge
required decompression of their middle fossa dura and/or sigmoid sinus in order to adequately accommodate
that Bonebridge FMT within the mastoid bone. In one case a longer screw and spacer were required to ensure
secure placement and optimal positioning for bone conduction. Such maneuvers did not aversely affect
audiological outcome.
Conclusion: Positioning the MedEl Bonebridge FMT in patients with chronic ear disease can be challenging.
Appropriate pre-operative planning is critical to predicting this and surgeons should expect to have to
decompress critical structures to suitably accommodate the FMT within the mastoid bone. Such techniques do
not compromise audiological outcome and the MedEl Bonebridge remains a suitable alternative for the hearing
rehabilitation of such patients provided they satisfy the published audiological threshold criteria.
Learning outcome: The role of pre-operative surgical planning including appropriate imaging is mandatory to
ensure adequate preparation and the availability of the necessary instruments and equipment to address specific
challenges to the placement of the MedEl Bonebridge FMT in patients with chronic ear disease.