Middle ear implants

Definiton
Middle ear implants

represent type of hearing aid designed for

induvisuals who are not complaining of being unable to hear with conventional aids , and are looking for improvements in sound quality, comfort and cosmesis.

Indicated for both conductive and

sensorineural hearing loss

History
Wilska (1935 ) used electromagnetic

induction to stimulate the middle ear.He

placed small pieces of iron on the tympanic membrane and a coil within the ear canal.The coil created a magnetic field which in turn caused the iron and the tympanic membrane

to vibrate.Patient reported gain in tone

reception.

Principle

Works on direct drive principle Transducer is directly coupled to one of the ossicles or cochlear windows

Drives ossicular chain directly using mechanical vibrations while leaving the ear canal completely open.

Types of Middle ear implants

1. Piezoelectric device

When a voltage is applied to a particular ceramic causes proportional deformation

and hence displacement of that ceramic

Peizoelectric transducer in turn is coupled to the ossicles and drives the ossicular chain by vibration

Ex: Envoy, Rion, TICA

Disadvantage

power output is directly related to the size of the

crystal.

benefits only people with up to moderate (about 60 dB) hearing loss

Advantage

Inert in a magnetic field and therefore compatible

with magnetic resonance imaging (MRI)

Rion Device E-type

One of the earliest piezoelectric

devices

Used for both conductive and sensorineural losses

Not gained FDA approval

partially implanted device

composed of an external earlevel microphone and amplifier

and an internal electromagnetic

coil and vibrator element ( Transducer )

Microphone converts sounds into electrical

signals that are fed into amplifier

After amplification, transferred to piezoeletric transducer which is connected

to stapes with a hydroxyapatite tube at one

end and anchored to the squamous portion of the temporal bone with a titanium screw at the other end.

Transforms electrical signals into vibrations

, vibrating stapes

Envoy Esteem

First fully implantable device to

use piezo electric ceramics

Manufactured by St. Crois company, Minneapolis

Not gained FDA approval Consists of sound processor and 2 piezo electric ceramic

units
1.Driver transducer

2.Sensor transducer

Sensor attaches to malleus

Detects movement of
malleus resulting from tympanic membrane vibration

Mechanical signal thus

generated is transformed
into electrical signal that is then amplified

Amplified electric signal is

relayed to the driver which is attached to the stapes and

Totally Integrated Cochlear Amplifier

(TICA)

Totally implantable Microphone is implanted in the external ear adjacent to the tympanic membrane

Digitally programmable processor located on the mastoid processes the signal

Piezoelectric transducer is coupled to the body of the incus and drives the ossicular chain by vibratory actions.

2. Elecromagnetic device Passes electric current into a coil which creates a magnetic flux. This then drives adjacent magnet that is attached to the ossicles to transfer vibrations to the cochlea. Ex : Vibrant sound bridge, MET

1. Med-EL Vibrant sound bridge

Earlier Manufactured by

Symphonix company, San jose,

Californiay , Currently by Med-EL

Semi implantable device

FDA approved

Has 2 components

Internal implanted part

Also known as VORP (Vibrating ossicular prosthesis ), made of 3 parts

Reciever, FMT ( Floating mass

transducer),conductor link between the
The Vibrant Soundbridge system.

two External wearable part

Known as audio processor Worn behind the ear Consists a microphone that picks up sound from environment Transmits across skin by radiofrequency waves to the internal

Candidacy profile

Age > 18yrs Moderate to Severe SNHL ( PTA >30dB)

SDS > 50% Normal middle ear function No h/o chronic middle ear disease

Prior h/o hearing aid trial and failed

Procedure

Done under GA Type of incision Reverse question mark Simple mastoidectomy performed delineating sigmoid sinus, tegmen , posterior bony canal wall

Horizontal SCC identified Fossa incudis enlarged Reciever positioned under skin over mastoid bone Conductor link sloped into mastoidectomy

Facial recess opened ( posterior tympanotomy ) and extended posteriorly

and inferiorly to visualise long process of

incus and incudostapedial joint

Facial nerve identified leaving thin layer of

bone over the nerve

widened tympanotomy

Posterior buttress not to be removed to avoid injury to posterior incudal ligament

FMT passed through facial recess and clip portion of FMT positioned over long process of incus

FMT not to make contact with promontary, tympanic membrane , pyramidal eminence
Floating Mass Transducer secured to the incus

6 to 8 weeks after the procedure,

external audio processor is fitted on the

back of ear

Processor is then programmed

Advantages of direct drive Hearing devices

Provides mechanical energy directly to ossicles bypassing ear canal and tympanic membrane Provides improved sound quality to
Functional gain 6 weeks postoperatively

hearing impaired particularly in noisy

environment

Eliminates problems of conventional hearing aids such as occlusion, feedback, discomfort and wax related

Otologics Middle ear Transducer ( MET )

Manufactured by Otologics
Not gained FDA approval

Indications - SDS > 20%, mod severe

to severe SNHL

Implanted via atticotomy Electromagnetic transducer has a probe which is coupled to the body of incus and vibrates the ossicular chain

The external sound processor

Advantage

Offers better impedance matching with more efficient transmission of sound

Implanted Middle Ear Transducer Ossicular Stimulator

Sensor attaches to malleus

Detects movement of
malleus resulting from tympanic membrane vibration

Mechanical signal thus

generated is transformed
into electrical signal that is then amplified

Amplified electric signal is

relayed to the driver which is attached to the stapes and

Advantages

Allows tremendous reduction in

amount of energy required to

drive the system with potential

battery life of greater than 5

yrs.

Indications

Severe MHL with average

bone conduction levels for the speech frequencies not

exceeding 50 dB and SDS

better tha 70% Advantage Provides natural quality of sound very close to

physiologic hearing without

discomfort and feedback

Disadvantages of middle ear implants Though it provides good sound amplification and sound quality to patients there is potential risk for

Ossicular necrosis Stereophonic hearing is lost Insurance nor covered