Tinnitus otitis externa 7.1,ear wax treatment for cats oral,tenis nike air max tailwind 5 w - Tips For You

Author: admin, 21.10.2013. Category: Treatment For Tinnitus

BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February 2007.
The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. Designations used by companies to distinguish their products are often claimed as trademarks. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. Thirty years ago Stephen Lock, then Editor of the British Medical Journal, asked me (HL) to produce a series of articles for the journal. Since that time the specialty of ENT has expanded, diagnostics have improved and treatment of many of diseases and disorders has changed, but the majority of patients seen in General Practice can be reassured by an accurate diagnosis and appropriate management advice. The aims of previous editions persist in this Sixth Edition, to include a readership of medical and dental students, nurses and all the many other health workers dealing with the problems embraced by our specialty. The larynx, pharynx (nasopharynx [or postnasal space], oropharynx and hypopharynx)a€”essential parts of the specialty (Figure 1.2) require specialist equipment, which is described in the relevant chapters.
The tympanic membrane consists of a lower pars tensa and an upper pars flaccida, hiding the attic of the middle ear (Figure 1.3). Seek scars, from surgical or other trauma, skin inflammation, swellings, pits or sinuses around the pinna.
Feel the mastoid tip, mastoid bone, the pinna itself, and also the parotid and temperomandibular joint area. The meatus and then the tympanic membrane should be inspected systematically, with attention to all the pars tensa and the pars flaccida, which may be obscured by a crust. Tuning fork tests in the non-specialist clinic include: the Rinne test and the Weber's test, which usually allow differentiation between conductive and sensorineural hearing loss. Rinne testa€”The fork is set vibrating quietly and held adjacent to the external ear canal and then, after a few seconds, the base of the tuning fork is moved and held against the mastoid bone behind ear. Tests with pure tonesa€”To produce a pure tone audiogram (PTA), for sound conducted through air and bone, require specialist facilities using an audiometer in a soundproofed room. The measurement of the a€?impedancea€™ of the middle ear to conducted sound is fully described in Chapter 5. This process can be automated by a a€?tympanometera€™, for use in non-specialist clinics to offer a quick, but often unreliable suggestion of middle ear fluida€”as in a€?glue eara€™. Look at the nose from the front, from either side and from above and below (see Figure 15.3). Inspect the nasal cavity using an otoscope or a nasal speculum (Figure 1.9a and b) commenting on the nasal septum, the floor of the nose and the laterally placed turbinate.
Using a light source, preferably head mounted, ask the patient to open their mouth and protrude their tongue. In a normal adult there are 32 teeth (4 a€?wisdoma€™ teeth, 8 molars, 8 premolars, 4 canines and 8 incisors). Palpation of the mouth floor should be bimanually from within and without, allowing the submandibular glands and the mucosa to be checked for thickening or other abnormalities, such as stones, cysts or ulcers that might suggest early cancer (Figure 1.11). The neck must be fully exposed from the chin above to below the level of the a€?collar bonesa€™. Any confirmed lump or lumps must be evaluated systematically by noting size, site, shape, skin (scars and colour), surface and margin, pulsation (if pulsatile, whether it is transmitted pulsation) and cross fluctuation. The neck should be felt from behind, so that both sides can be compared (Figure 1.12a and b). A systematic method for examining the neck is essential to avoid missing some areas which may later become important (Figure 1.13). My practice (PJB), is to palpate the cervical spinal area down to the upper thoracic spines, extending palpation to feel the whole of the posterior trianglea€”tissue between the anterior border of the trapezius and the posterior border of the SCM muscle (see Figure 23.2).
The neck examination ends in the midline of the neck, from the submental area, to the hyoid, thyroid, cricoid, thyroid gland, trachea and inferiorly the sternal notch (Figure 1.14). If a second palpation is needed, the clinician should return to that area or organ and examine that site specificallya€”say submandibular or parotid gland, as well as the thyroid gland. Examination of the nose, pharynx and larynx can be achieved without much discomfort in the majority of patients, even children, with a flexible fibre-optic instrument (Figure 1.16).
Inflammatory causes are recognized by skilled inspection of the external ear and tympanic membrane. The binocular microscope (functionally similar to microscopes used in otological surgery) is essential for the fine use of microinstruments and suction apparatus, providing stereoscopic magnification of 6A— or more (Figure 2.2). If the external ear canal and the tympanic membrane are definitely normal (Figure 2.3), then pain is not due to ear disease. Systemic antibiotics are only advised in acute otitis externa if there is fever or lymphadenitis. Acute suppurative otitis media causes deep-seated pain, impaired hearing and systemic illness with fever. Bacterial infection is usually by Streptococcus pneumoniae, or Haemophilus influenzae in very young children.
There is still disagreement about the need for every patient with ASOM to be treated with antibiotics, because of difficulties in analysing series in which the diagnosis has been made by groups of practitioners with varying skills in otoscopy. Recurrent acute otitis media, which is defined as three attacks within 6 months, may be provoked by predisposing causes, such as a persisting middle ear effusion, with a potentially infected accumulation of mucus persisting in the middle ear cleft. Acute mastoiditis is caused by the breakdown of thin bony partitions (trabeculae) between the mastoid air cells, which then become coalescent (Figure 2.10). The use of radiographs or, better, CT scans of the mastoid air cells helps to diagnose the condition, but not always.
These are all also possible complications of the bone erosive forms of chronic suppurative otitis media (Figure 2.13) (see Chapter 3).
Niggly, short-lived pain is a common feature of thick mucoid effusions in the middle ear air space a€?glue eara€™. An essential diagnostic feature, which can be elicited by an otologist using a headlight and a pneumatic speculum, is altered mobility of the tympanic membrane.
This is a rare but serious form of infection (not neoplastic, despite the unfortunate name), caused by Pseudomonas aeruginosa infection. Ramsay Hunt syndromea€”Another rarity caused by varicella-zoster virus associates sudden facial palsy with a herpetic rash on the pinna (see Figure 9.1).
If the external ear canal and drum are normal, with normal movement of the drum assessed with a pneumatic speculum, pain cannot be due to disease of the ear. Cerumen impaction is caused by abnormal self cleansing mechanism of the skin lining external canal in these patients. 30 years old male patient came with complaints of foul smelling discharge from his right ear - 10 days.
Otoscopy picture shows a tongue of granualtion tissue over the inferior quadrant of the ear drum.
7th cranial nerve and 8th cranial nerve functions can be tested by performing this investigation. Izabella Vince Garcia Pedriali1, Maurico Buschle2, Rita de Cassia Mendes3, Andre Luiz Ataide4, Rodrigo Pereira5, Trissia Maria Farah Vassoler6, Jose Fernando Polanski7, Angela Ribas8, Claudia Mittelmann Stumpf9, Raquel Alves Nobre10, Roberta Daroit11. Introduction: The implantable prosthesis of osseous conduction (BAHA) is deemed to be an excellent option in the auditory rehabilitation of patients with conductive and mixed hearing loss, unilaterally or bilaterally, and unilateral sensorineural hearing loss.
INTRODUCTIONThe osseointegrated implants were firstly introduced to clinical practice in Sweden in the 1970's, and they have ever since been widely accepted in such areas as dentistry, maxillofacial surgeries, and reconstructing and orthopedic surgeries (1).
Blackwell's publishing programme has been merged with Wiley's global Scientific, Technical and Medical business to form Wiley-Blackwell. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. However, some patients who present with a€?minor or triviala€? symptoms will reveal a significant diagnosis when investigated. Bradley joined as a co-editor for the Fifth Edition (2007), and introduced several colleague specialists, recognised as experts in various subspecialties within ENT.
The outer one-third passes through elastic cartilage, with hair bearing skin, the inner third is through bone, with no hair and much thinner skin, adherent to the periosteum.
Pressure on the mastoid tip and the region above and behind it must allow for any pain and tenderness of which the patient complains.
The patient has been asked whether he or she can hear the sound in each position and whether it is perceived to be louder at the side of the ear canal or when placed on the mastoid bone behind the ear. If the Weber's test is not lateralised, it indicates normal hearing or a symmetrically equal sensorineural loss. Airway patency can be tested by placing a cold Lack's depressor underneath and asking the patient to exhale (Figure 1.8). Observe the width of the opening, which should be more than 2A cm allowing a two-handed examination using two Lack's tongue depressors; move the tissues about and inspect the mouth contents. Commence superiorly with the hard and soft palate, tonsils and upper teeth, followed by the lateral mouth (the buccal mucosa), and then inferiorly with the tongue, floor of the mouth (Figure 1.10), lower teeth and lower lateral buccal area. When their teeth are fully erupted, children should have 20 primary teeth, which will all be replaced by permanent teeth during childhood and teens. In women, the cricoid cartilage is often obvious, while in men, the thyroid cartilage is easily seen. Then move from the lower pole of the parotid gland up onto the lateral parotid tissue lying on the body of the mandible up to the zygomatic arch. Palpating the supraclavicular area (from the acromioclavicular joint to the sternoclavicular joint) is followed by lateral neck palpation moving from below upwards along the anterior border of the SCM muscle to the mastoid tip. The identification of a a€?neck lumpa€™ in an adult may suggest a mucosal site for a potential primary malignancy.
In non-specialist environments, examination of the pharynx and larynx is limited, and reliance must be placed and acted upon from symptoms.

It is also possible to perform more extensive evaluation of the trachea and bronchi, and oesophogoscopy with a mild sedative and topical anaesthesia (see Figure 20.3). As described in Chapter 1, examination of and around the pinna, precedes that of the ear canal (external acoustic meatus) and tympanic membrane (drumhead). The reliability of this judgement depends entirely on the skill and experience of the examiner. It is always in the outer ear canal, where hair follicles are found, never in the inner bony meatus.
Meatal swelling is reduced by inserting a ribbon gauze wick impregnated with a deliquescent substance such as magnesium sulphate paste, or glycerine and 10% ichthammol (Figure 2.7).
A blocked feeling in the ear, then pain and fever, are followed (usually after a few hours) by discharge when the tympanic membrane perforatesa€”with relief of pain. Diagnosis is made by inspecting the tympanic membrane, which may be prevented by wax, or by swelling from a secondary otitis externa. Without considerable experience, the condition may be diagnosed in all patients presenting with apparent redness or injection of the tympanic membrane, which is found in other conditions. The commonest infecting organisms nowadays, having displaced the very destructive Group A Streptococci, are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
Only if a clearly aerated normal cell system is shown (Figure 2.11a and b) can mastoiditis be excluded. It may be totally immobile when external ear canal air pressure is raised and reduced, or there may be sluggish outward movement followed by a rapid a€?snapa€™ back when the partial vacuum is released. Viral (probably influenzal) infection causes haemorrhagic blistering of the eardrum (Figure 2.16) and external ear canal. It may well be referred from territory sharing its ultimate sensory innervation with the outer or middle ear (Figure 2.17).
Glomus jugulare - associated with pulsatile tinnitus, conductive deafness, positive Brown's sign.
To identify those patients who require abdominal ultrasound Wang's criteria should be used. It is classically seen in bone conduction audiogram of patients as a dip centered around 2000Hz.
It has been a good advantage over the conservative bone conduction apparatus and those of individual sound-amplifier apparatus (ISAA), when their usage becomes unfeasible because of chronic otitis externa, which has a hard clinic control. The Bone Anchored Hearing Aid (BAHA) system, which was originally used by Tjellstrom and his team in Sweden in 1977 (2), made the prospect of osseointegrated implants renowned in the area of otology. He wrote of the importance of our specialty a€?counting for a substantial fraction of all consultations in general practicea€? and emphasised their economic importance.
Following treatment most will be cured, while some will suffer some functional morbidity, and others may have a serious condition that, if not treated quickly and appropriately, may result in mortality. The clinical practice of ENT has seen an expansion of our a€?workloada€? and now involves joint management across several disciplines: embracing neurosurgery in the handling of skull base tumours, oncology and radiotherapy for head and neck cancer, endoscopy and robotics for the surgical excision of tumours, and facial plastic surgery for the management of cosmetic and facial lesions. The canal is S-shaped and must be straightened by pulling the pinna upward and backward in the adult (straight back in the child) for a better view of the tympanic membrane.
Its handle runs downwards and backwards from a lateral processa€”the most easily recognisable structure of the drumhead at its tip (called the umbo), which is in the centre of the pars tensa. The otoscope should be held braced against the subject's cheek to avoid injury if the patient suddenly moves. A positive Rinne test result indicates that the patient heard the sound louder through the ear canal than through the mastoid bone (air conduction >A bone conduction).
Performing auscultation using a stethoscope may reveal a vascular bruit, but this must be done in quiet surroundings. Onwards posteriorly to the mastoid tip, behind the ear and finally, complete the upper neck examination to include the occipital area and the cervical spine.
Surgical oncologists divide the neck into six regions in the neck, with three areas having subregions (Figure 1.15). Hearing is impaired only if the meatus becomes blocked by swelling or discharge, and fever occurs only if infection spreads in front of the ear, as cellulitis or erysipelas. Proprietary expandable a€?Popea€™ wicks (Xomed), are thin and stiff allowing careful insertion with small forceps. Systemic analgesics, together with warmth applied through a hot pad, heat lamp, or warm oil drops, relieve pain.
Only if the whole drum can be certified as normal and there is no conductive hearing loss (demonstrated by tuning fork tests with a Weber test heard centrally), can otitis media confidently be excluded. It may be over-diagnosed in trials, to include patients who would recover without medication.
Adenoid enlargement provoking repeated infection is also probably a cause; however, the role of adenoidectomy remains controversial. Throughout that time, continuing and increasingly copious discharge through a perforation in the drum persists, with general malaise and fever, unless this has been suppressed by antibiotics.
The classical appearance of breakdown of intracellular trabeculae is not always easily seen. Complications occurring within the petrous temporal bone include facial palsy, suppurative labyrinthitis and lateral sinus thrombophlebitis; those occurring within the cranial cavity are meningitis, extradural abscess, subdural abscess and brain abscess (in the temporal lobe or cerebellum). Classically, there is injection with visible radial vessels, which may prompt a misdiagnosis of otitis media. This altered mobility can also be demonstrated by tympanometry using an impedance measuring meter during continuously changing ear canal pressure, from above to below normal atmospheric level. It should be suspected if patients in this group suffer severe pain, excessive for the signs of otitis externa. There is often an associated haemorrhagic effusion in the middle ear and it may be difficult to distinguish this condition from otitis media. Objective: To introduce the first BAHA case performed in Brazil, as duly authorized by ANVISA (National Agency for Sanitary Surveillance), to rehabilitate the mixed hearing loss with occurrences of chronic otitis externa. BAHA system is comprised of two major parts: a titanium screw with an abutment implanted in the cortical part of the mastoid bone and one external unit named processor, which is connected to the abutment.
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. He said that the work was a€?collected together to provide the busy clinician with a practical, reliable source for these common problemsa€?.
These, the minority of patients, need to be recognised and referred quickly and appropriately for evaluation, diagnosis and treatment.
Current practice continues to emphasise that eradication of disease remains the priority, but the preservation or retention of function, so intimately associated with ENT, is given equal status in modern clinical and surgical practice. The tympanic membrane lies at an angle to the canal, facing forwards and downwards, with an antero-inferior recess, where debris or foreign bodies may collect.
The otoscope should be held with a a€?pencil or pen gripa€™ (as if writing), with the little finger gently touching the face, to protect against accidental over-insertion. This positive result is found if the patient has normal hearing in the test ear, or a sensorineural loss. Bone-conducted sound is presented through a transducer held tightly against bone behind the pinna with a spring headband, while a suitable a€?maskinga€™ noise is delivered to the opposite ear, to protect it from skull-transmitted signals.
Between the mastoid tip and the angle of the mandible, the transverse process of the C1 vertebra is sometimes palpable, especially in underweight females.
Movement of a midline lump on the patient sticking out or the physician protruding the tongue will confirm whether the lesion is adherent to the trachea.
The region IIa is the most frequent site presenting in clinical practice and the differential diagnosis most frequently requires a needle biopsy and a CT scan to make a firm diagnosis. But the specialist examination and investigation is the only definitive current method to ensure a definitive correct diagnosis resulting in correct and appropriate management. They soften and swell gently against the meatal walls when moistened with liquid medication.
Any discharge should be swabbed for laboratory examination, but treatment is started before awaiting a report. That is the entire air-containing space comprising the Eustachian (pharyngeal) tube, the middle ear cavity, the mastoid antrum and its adjacent mastoid air cells (Figure 2.9). However, the usual advice is for all suspect ASOM sufferers to be treated with systemic antibioticsa€”it would be impractical for all to be referred for confirmation in a specialist clinic.
If a patient has pain a few days after the tympanic membrane has been reliably judged to be normal, then that patient cannot have developed mastoiditis. Otitis externa may cause apparent clouding of the air cell system from oedema of soft tissues over the mastoid process. Simple automatic tympanometers print out a quickly available chart indicating middle ear air pressure and its changes (if any) as the external ear air pressure is raised and then lowered. For that reason alone, antibiotics may be administered, but the only necessary treatment is potent analgesia.
Method: 50-year-old female patient with right-ear moderate and left-ear severe hearing loss, bilateral tinnitus derived from otosclerosis, was submitted to 04 surgeries of stapedotomy and unable to use ISAA as a result of otorrhea and bilateral otalgia. The processor is intended to receive the environmental sounds and convert them into a mechanical energy, what is turned into vibration and transmitted to the abutment, which, in turn, shall stimulate the cortical part of the temporal bone. It is sold on the understanding that the publisher is not engaged in rendering professional services. This edition continues to emphasise when referral for specialist diagnosis is needed, and has been brought up to date.
If the patient perceives the ringing to be louder by bone conduction than through the ear canal, drum and ossicles, then there must be a fault in the conducting mechanism.
The audiograms obtained enable the assessment of the severity of hearing loss in each ear, and what proportion of the loss is conductive or sensorineural (Figure 1.7). The carotid bulb or bifurcation can also be felt pulsating at about the level of the hyoid bone, just beneath the sternocleidomastoid (SCM) muscle, and it can be mistaken for a mass.
These are not always confidently recognised, but are irrelevant to any acute inflammatory disease. The pinna is tender to movement in acute otitis externa, but this is never the case in acute otitis media.

For this reason, deep pressure over the mastoid antrum behind the pinna elicits tenderness in acute otitis media, but does not imply the development of mastoiditis. An alternative to consider is long-term antibiotic treatment, with ampicillin or co-trimoxazole for 3 months to 2 years. Difficulties arise when a patient is thought to have recovered from acute otitis media, but in reality the condition has a€?grumbled ona€™ under suppression of the systemic effects with antibiotics. The often-described traditional classical sign of a swelling behind the ear with downward displacement of the pinna (Figure 2.12) implies a later subperiosteal abscess.
The child is well and afebrile however, and the associated hearing loss has usually been recognized for some time. Facial paralysis and other cranial nerve palsies may develop and strongly suggest the diagnosis. If professional advice or other expert assistance is required, the services of a competent professional should be sought. If there is any doubt, or if parts such as the attic cannot be seen, an expert otological opinion is needed (Figure 2.4). Discharge, if any, is usually thick and scanty, unlike the copious mucoid discharge through a tympanic membrane perforation from acute middle ear infections.
After any episode, a return to normal is expected, and should always be confirmed clinically within 3 weeks of onset. Mastoiditis should be suspected in any patient with continuous discharge from the middle ear for over 10 days, particularly if continually unwell. Having surgery been performed and BAHA implemented, the patient showed a significant improvement in audiometric thresholds, speech perception and distinction, as well as she declared to be extremely satisfied with the esthetic factor. In some special occasions, such as surgeries on small children, the surgery can be performed in two different times: firstly, by placing the titanium screw and, secondly, by coupling the abutment with this osseointegrated screw. Fungal skin infections cause severe pain with wet desquamation of keratin and black or coloured granules of the fruiting heads of conidiophores.
If I? lactamase-producing organisms are likely, amoxicillin combined with clavulanic acid (as Augmentin), or trimethoprin combined with sulphamethoxazole as co-trimoxazole, is preferred.
A subperiosteal abscess can also, by erosion of the bony outer attic wall, cause swelling in the roof of the deep part of the external ear canal, in contrast with a furuncle, which can arise only in its outer part.
A suspicious finding is granulation tissue in the ear canal, which must be investigated by technetium Tc-99 bone scanning.
Final commentaries: BAHA surgical process is safe, simple and swift, thus providing excellent audiological results and a higher degree of satisfaction to patients. The titanium screw is surgically implemented, and this procedure can be performed by way of a local anesthesia. If the patient has a very severe sensorineural deafness in one ear only, when the vibrating tuning fork is placed on the mastoid process of that side, the sound waves are transmitted through the bones of the skull to the other cochlea. Oral administration is advised, even for the first dose (which used to be given by injection to start the course). If any doubt persists after mastoid imaging, surgical exploration leading to a so-called a€?cortical mastoidectomya€™ is advisable. Treatment with intravenous gentamicin, with monitoring of daily blood levels, or with oral ciprofloxacin, must be administered continuously for several weeks until pain ceases, and accompanied by analgesia. The processor shall be inserted only after the osseointegration period, which is three months for adults and six months for children. The patient hears this, so that bone conduction seems louder than air conduction (which was not heard at all). This negative Rinne test does not indicate a conductive deafness on the side of the tested ear but is a false negative due to the totally deaf ear on that side. Although it has been long used in Europe and the United States, in Brazil BAHA system has been recently used, and it has a scarce national publication and only a few surgical cases. The team at the Audiological Diagnostic Center of Iguacu Hospital (CDAH) in Curitiba has been the first one to implant BAHA after it has been authorized by the National Agency for Sanitary Surveillance.In the meantime, the team faced some difficulties with respect to methodology of audiological evaluation of the different hearing loss cases on BAHA candidates. If the tympanic membrane perforates, the ensuing discharge should be always be cultured, but an antibiotic should be changed on clinical and never solely on bacteriological grounds; however, the culture results will help to guide a change in medication, if clinical conditions suggest the need.
This fact led to understanding that it is urgent to develop a protocol to audiologically evaluate and follow-up with patients who are candidates to the procedure. Rarely nowadays the drum may bulge outwards under pressure without rupture, requiring urgent incision under general anaesthetic to release pus (myringotomy). The present study intends to show the first case of BAHA performed in Brazil, as duly approved by ANVISA, having the surgery been performed by Hospital Iguacu's team, as well as to describe the protocol used during the service.
This was a commonly needed procedure in the UK 50 years ago, and its need may still arise often in parts of the world where medical access is more limited than in the UK.
A more recent indication is for patients with unilateral sensorineural hearing loss or Single Sided Deafness (SSD), presenting contralateral ear with an average bone conduction equal to or above 20 dBNA (3). Conductive and mixed hearing losses are highly prevailing disorders that can be either treated with surgical techniques or rehabilitated by an individual sound-amplifier apparatus (ISAA).
BAHA can overcome all these hassles because it does not place any pressure on skin, but it is discreet and esthetically well-accepted instead, besides being safely tightened to the implant, always in the right place of stimulation (5). BAHA system presents some outstanding results in cases of conductive and mixed hearing disorders, despite having some restraints on the gain provided to the sensorial component of mixed hearing loss (6).CASE REPORTVLVM, 50-year-old female, presented a moderate left-ear and severe right-ear mixed hearing loss, both of which with ascending configurations and progressive characteristics, caused by bilateral osteosclerosis. The patient appeared at CDAHI after being submitted to three surgeries of stapedotomy on the right ear and one surgery on the left one, all of which were unsuccessful, and subsequent worsening of the hearing thresholds.
She mentioned a continual tinnitus in the right ear, which was more noticeable during silence, deemed to have a medium impact according to the visual analogue scale (VAS) and vertigo when placing and using ISAA.She did not actually use ISAA, due to showing chronic otitis externa associated with otorrhea and otalgia.
The image test found permeable cochleas and a medium metallic prosthesis in the right vestibule.The evaluation with BAHA tester was performed with the arch-coupled processor, providing the patient with a hearing sensitivity caused by the processor vibration (3).
By way of an open-field audiometry, pure-tones thresholds issued by a lateral acoustic box were evaluated, and a 60-dBNA monosyllable word-distinction test was performed with a concurring 55-dBNA speech noise before the patient. An external test has also been performed, in which the patient stayed with the tester for one day, using it on the right side during the morning and on the left side during the afternoon. After the patient's exams were analyzed, she has been indicated to use BAHA Cochlear Divine on her left ear, which is the ear with best bone conduction thresholds and the side preferred by the patient during the external test.
The evaluation results were explained and the patient was guided with respect to the risks and benefits of the surgery.
The patient signed both a term of consent and an authorization for the images to be used in this work. The surgeryThe surgery was performed on February 28, 2008 by a one-time method, in which the screw and the abutment are connected and placed in the same surgical time. Processor placement and post-surgical evaluationAfter three months after surgery, the patient has attended the phonoaudiological session to adapt the process and be guided how to handle and take care of BAHA. Open-field audiometry with pillar-coupled BAHA, external test and use of telephone were performed. Pre-surgical pure-tone threshold audiometry - Better bone conduction in the left ear, side preferable to use BAHA, according to the patient.Figure 2. Flap repositioning by drilling its central area to exteriorize the external implant area.Figura 5.
Abutment-coupled BAHA processor.DISCUSSION OF RESULTSIn the cases of chronic otitis externa and open mastoid cavity, for occluding MAE, using ISAA mold can induce or worsen the infectious feature, leading to continual otorrhea (7). This advantage was observed in this case, mainly in 4,000-Hz frequency, where there was a 15-dBNA difference when using BAHA in comparison with ISAA.
Additionally, an improvement occurred when distinguishing words, being 92% of right answers with ISAA and 100% of right answers with BAHA.
In our evaluation, we observed it did not occur only in the 500-Hz frequency, we had a worse 10 dBNA threshold with implant-coupled BAHA. In the 1,000 and 3,000 Hz frequencies, there was no difference between them both, and at 2,000 and 4,000 Hz, our findings agree with the cited authors, as we observed better 5 dBNA thresholds with pillar-coupled BAHA, in comparison with the arch-coupled tester. Maybe we could have better thresholds with an implanted BAHA, if the adjustments used in the processor were the same as those in the pre-surgical evaluation, however it did not occur because the patient was discomforted when we adjusted the processor at a maximum gain, and we accordingly chose a lower gain adjustment, which would give her more comfort in the post-surgical evaluation.If we should analyze the average between the frequencies 50, 1,000, 2,000 and 3,000 Hz, the pre-surgical and post-surgical thresholds are the same, what makes us trust the pre-surgical evaluation as a preview of the result that shall be achieved in the post-surgical period. It has been observed that the airway thresholds on open-field audiometry with BAHA have exceeded the patient's best pre-surgical bone conduction, what LUSTIG and colleagues (5) refer to as 'overclosure'. Since it is a breakthrough in the Brazilian practice, a few difficulties were faced regarding this patient's audiological evaluation, for there is not a standardization of the methodology to be used. We suggest the exchange of experiences between the centers providing this service, so that by standardizing the audiological evaluation, we can compare results and pursue a better quality of service. The reliability in the pre-surgical audiological evaluation as a preview of the post-surgical result, the outstanding audiological results achieved, as well as the patient's high degree of satisfaction provided by BAHA system, turns it into an advantageous option to rehabilitate conductive and mixed hearing losses when ISAA is not possible to be used.BIBLIOGRAPHICAL REFERENCES1. Bone Anchored Hearing Aids in patients with sensorioneural hearing loss and persistrent otitis externa. A comparison of the audiometric performance of bone anchored hearing aids and air conduction hearing aids. Lustig LR, Arts HA, Brackmann DE, Francis HF, Molony T, Megerian CA, Moore GF, Moore KM, Morrow T, Potsic W, Rubenstein JT, Srireddy S, Syms CA 3rd, Takahashi G, Vernick D, Wackym PA, Niparko JK.
Assistant Professor at UFPR's Department of Ophthalmology-Otorhinolaryngology (OFT-ORL).3 Master in Surgical Clinics - UFPR's. Predecessor in Otology in Residence at Santa Casa de Curitiba's ORL and President of Fisch Foundation in Brazil.5 Post-Graduation Coordinator in Otorhynolaryngology at Pequeno Principe Hospital. Post-Graduation Coordinator at Otorhinopediatrics at Pequeno Principe Hospital.6 Specialized in Otorhinolaryngology from the Brazilian Society of Otorhinolaryngology and Cervicofacial Surgery. Otorhinolaryngologist Doctor.7 Master in Otorhinolaryngology from Federal University of Sao Paulo. Predecessor in Medical Residence in Otorhynolaryngology at Evangelical Hospital of Curitiba.8 Doctor in Environment and Urban Development.

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