Exploring Ponto Candidacy Through Surgical Cases
AudiologyOnline: When a patient comes in, how do you approach patient education and counseling in terms of the benefits, the risks, and any expectations associated with the Ponto surgery?
Dr. Rebecca Chiffer: Once evaluated and the patient is deemed to be a good candidate - a good surgical candidate and a good candidate audiometrically [I talk] about the surgery [and] the risks I describe are pretty basic. A little bit of pain - the pain is actually quite minimal in this. Every once in a while, there is a patient that experiences a little bit more pain than I would predict, but most of the time I'll tell them Tylenol or Motrin is fine. They [may] expect maybe a day or two of pain.
We go over the risks of the anesthesia. I do this under general anesthesia, mostly because I'm working with residents, and they'll be helping me, I'll be teaching, et cetera. So, I choose to do this under general anesthesia. We do have to talk about the risks of going under general with a breathing tube. The reason for the breathing tube is because when you turn the patient's head, if they have something like a [laryngeal mask airway] LMA* in, it can get dislodged. So, I do tell them that this will be done under general anesthesia with an endotracheal tube, although it is quite quick. I've gotten the procedure down to, I think, about seven to nine minutes. Not that it's a race, but it is very quick.
Other things, probably the most common thing I can see is some scalp infection. Some patients have an oily scalp or a very thick scalp, really thick hair follicles. There can be little areas of scalp infection or folliculitis, and that's pretty easily treated with either some oral or topical antibiotics, sometimes a little bit of a steroid cream or an oral steroid pack. Then, I do tell them the risk of lack of osseointegration. I counsel them to just be cautious that there's an implant in place and that the company's guidelines are ideally 12 weeks of osseointegration.
I'm most concerned [about this] in folks like let's say younger kids that play sports, football, rugby, any contact sports, I am a little bit concerned about them hitting the head, having some type of head trauma. If you hit the implant and it's less than that 12 weeks, there is a chance that you can displace the implant or disrupt the osseointegration.** If that happens, then we do need to go back to the operating room and place a new implant. So that can happen, I tell them to just be cautious. They're fine to lay on that side. They're fine to shower in a couple of days, but just be careful with any type of contact.
Bleeding is probably the other thing that I talk about the most. The scalp obviously can be very vascular. Every once in a while, you know, you can have a lot of intraoperative bleeding, which is not dangerous, more of an annoyance than anything else. Again, just because it's a vascular area. Every once in a while, I do have patients that have some bleeding at home calling for that reason. Very easy to treat with just some pressure, a little pressure dressing, and generally it's no big deal. Those are probably the most common things.
Then the benefits, …it's great to have something that's not in the ear canal. So for folks that are chronically draining or for folks that just don't like to have a hearing aid, either on the auricle, the BTE or in the canal, there's a lot of patients that just can't tolerate it for one reason or another. This is a great option for somebody that just can't wear a conventional on the ear in the canal.
One of the other things that I do tell patients and they'll actually come and ask me about is the cost. So oftentimes, this is covered by insurance, whereas conventional hearing aids are usually not. This…for the appropriate candidate, can be an excellent option financially for them. Again, if it's covered by their insurance. I tell them it's a very quick recovery. They can usually go back to work maybe in a day or two, so it's very, very quick and easy.
*Laryngeal mask airways (LMA) are supraglottic airway devices. They may be used as a temporary method to maintain an open airway during the administration of anesthesia or as an immediate life-saving measure in a patient with a difficult or failed airway.
**Although unlikely, implant displacement is possible after 12 weeks of osseointegration.
AudiologyOnline: Is there anything when a patient comes in that makes you automatically think Ponto or this is a Ponto candidate?
Dr. Rebecca Chiffer: Definitely. I think the most obvious would be a microtia or atresia. So somebody that absolutely cannot wear a conventional hearing aid. I think those are, again, the most obvious candidates. Other candidates, mastoid cavities, chronically draining cavities, or very, very large [mastoid] cavities. There are, you know, folks that have, let's say, had their canal well down mastoidectomy 20, 30, 40 years ago and sometimes the mastoid cavity is enormous. It's like you can drive a truck through them and It's really hard to get a, you know, it's a very big mold. It's just not an ideal situation to wear a conventional hearing aid with a huge mold. And the other thing is, most likely, all of their ossicles would have been gone, especially if this was done, you know, years and years and years ago.
[This type of patient] probably had multiple surgeries as a kid. You know, they [likely] have no ossicles, so they have a very large conductive or mixed loss. Those are, again, ideal candidates for a bone anchored device.
I did have a patient that had a large mastoid cavity done a long time ago. Not by me, don't even know where but she was seen at a community hearing aid place. They were fitting her for hearing aids and they did a mold. The mold material actually got stuck in the cavity to the point where I actually had to take her to the operating room because she came in and she was in a lot of pain and nobody could get the mold out. It was so uncomfortable for her. I took her to the operating room, got it out, no problem under anesthesia, but she was not a great candidate for a mold. She would be somebody absolutely that could use a bone angered device.
AudiologyOnline: Is there any advice that you would give patients who are considering Ponto surgery and sort of just starting their process of thinking about it?
Dr. Rebecca Chiffer: I counsel patients that are, let's say, on the fence, let's say they're trying to decide between, you know, a conventional hearing aid, maybe a CROS or a biCROS, depending on what their audiogram looks like, or a bone anchored device.
I tell everybody to demo them in the office. I have an excellent audiology team that I work with so I do request that they come in and do a demo of the conventional hearing aids, demo the CROS hearing aids or biCROS hearing aids to see what they sound like, what they feel like in their ears. Then we always have somebody do a demo of the [Ponto] on a soft band demo. Maybe even [have them] walk around the office with the hearing aids on or with the soft band on, or maybe do the visit with me with let's say the soft band on their head. Just to get an idea about what the sound quality would be like in a more day to day scenario. So not just in a soundproof booth, not just in a little room, but let's say have them walk in the waiting room, walk in the hallways and just get an idea of what it would sound like.
I tell folks that I'm happy with whatever they choose. I would want them to choose something that is going to give them the best sound quality and I tell them to take as long as they need. I mean, this is not something urgent. I tell them to do as many demos as they need to with the audiology team to choose something that they think gives them the most hearing.
One of the things that sways them besides the financial decision is whether or not they need something on the other ear - that's a big one. Let's say somebody has a normal ear on one side, they don't love the idea of wearing two hearing aids [like with a] CROS system. Tthey don't want the hearing aid on their normal ear. The bone anchored, the ponto, for example, is just going to be on one side and they do they do like that option. So that's one thing I counsel on.
AudiologyOnline: Where can we learn more about Ponto Bone Anchored Hearing Systems?
Dr. Rebecca Chiffer: To learn more about Oticon Intent visit www.oticonmedical.com/us. Check out Oticon Medical's new counseling website, BAHSJourney.com.
To learn more about Dr. Chiffer, visit her Jefferson University Hospital profile.
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Rebecca Chiffer, MD
Dr. Chiffer is an assistant Professor of Otolaryngology at Thomas Jefferson University Hospital, division of Otology/Neurotology. She is also co-director of the hospitals new temporal bone and skull base lab and is a member of the Admissions Committee for the Medical College and the Education & Resident Selection Committee within the Oto department. Dr. Chiffer currently lives in Philadelphia, PA with her two French bulldogs, Penny and Muffin.