BAHA IN CHILDREN – SOFT SKIN MANAGEMENT Miguel B. Coutinho Department of Otolaryngology, Maria Pia Children’s Hospital, Rua da Boavista nº 827, 4050-111 Porto, Portugal, E-mail: mbcoutinho@netcabo.pt ABSTRACT OBJECTIVE: To evaluate the experience of Maria Pia Cildren’s Hospital in managing skin of children fitted with bone anchored hearing aids (BAHA). METHODS: The BAHA, in our Department is intended for patients older than five, with conductive or mixed hearing loss and selected patients with single-sided deafness. Thirty-three children (18 boys and 15 girls; age 4-17 years [mean, 9,7 years]) who undergone two-stage implantation of a BAHA between March 2003 and March 2007 were enrolled in this study. RESULTS: Of the 33 implanted children, 31 use their BAHA regularly. Osseointegration was achieved in 96,9%. In our cases we raised a flap at the implant site that was depilated and replaced; it takes a considerable amount of time to achieve well depilated flap but the results are very good with a 93,9% reaction-free skin penetration site (two patients required site revision for soft-tissue overgrowth at the abutment site, under local anaesthesia). Minor adverse skin reactions were easily treated with simple local hygiene procedures at home or in the office. We had no other important adverse skin reactions. We do not use the dermatome and exchange dressing and healing cap on days 2 and 8 post op. CONCLUSION: Close follow-up and education and communication with caregivers are the corner stone to avoid adverse skin reactions. Pre-operative Evaluation Audiological measurements Psychological aspects Familiar and environmental evaluation BAHA Support Group Implant Side Selection CT Scan TWO-STAGE SURGERY First Stage Fixture installation Osseointegration Period (3-6 months) Second Stage Abutment Connection Fitting (4-6 weeks after second stage) SOFT SKIN MANAGEMENT We do not use the dermatome because most of the children have some degree of craniofacial abnormality that precludes its use in our opinion. In all cases, in second stage, we raised a flap at the implant site that was carefully thinned with blades, well depilated and replaced; it takes a considerable amount of time to achieve well depilated flap but the results are very good with a 93,9% reaction-free skin penetration site. We are very careful with the periosteum and in the end of the procedure we give two or three anchorage stitches in the middle of the graft for better adherence to the underlying periosteum to achieve good blood supply and an immobile graft. Success of a percutaneous osseintegrated implant depends largely on the integrity and stability of surrounding soft tissues. The wound is managed as described in Table IV. THEATRE DRESSING Ointment soaked ribbon gauze (Terricil®) wrapped around the abutment Avoid formation of haematoma Avoid obstructing the blood supply Healing cap Cover with gauze and mastoid bandage TWO DAYS POST OP Remove outer bandage Remove ribbon gauze and healing cap Clean wound with normal saline 30 minutes open air Re-apply ribbon gauze with Terricil® around the abutment and healing cap 7-8 DAYS POST OP Remove healing cap and ribbon gauze Clean with normal saline 13-15 DAYS POST OP Remove dressing If healed, no further dressing required TABLE II – Treatment Planning RESULTS Between March 2003 and March 2007, twenty-three children had undergone surgery for BAHA application. Nineteen children (57,6%) had some kind of malformation in external or middle years and thirteenth patients (39,4%) had inflammatory and/or infectious problems in both years; in only one case (3,0%) a children with single sided deafness was considered for implantation Table III. MATERIALS AND METHODS This study was conducted during a 4-year period (2003-2007) in the Department of Otolaryngology of Maria Pia Children’s Hospital (tertiary care children’s hospital). Thirty-three children (18 boys and 15 girls; age 4-17 years [mean, 9,7 years]) who undergone two-stage implantation of a BAHA in that period were included. An accurate and careful selection of patients is the most important issue in achieving good results, particularly in the paediatric population and so is the awareness of the limitations of the devices and the contraindications for their use. The BAHA, in our Department is intended for patients older than five, with conductive or mixed hearing loss and selected patients with single-sided deafness. The selection criteria for the Maria Pia Children’s Hospital Program is presented in Table I. Number of children implanted 33 Age 4-17 Sex (♂/♀) 18/15 Etiology Bilateral microtia and ear canal atresia 10 Goldenhar syndrome 4 Treacher-Collins syndrome 2 Bilateral post radical mastoidectomy status 9 Bilateral chronic ear disease 3 Saethre-Chotzen syndrome Bilateral ear canal atresia Pierre-Robin syndrome 1 Turner syndrome Down syndrome Apert syndrome Fanconi anemia Single-Sided Deafness Fig.1 Skin reduction Hearing loss (conductive / mixed) > 5 years Unilateral or bilateral Bone conduction threshold ≤45 dB Speech perception score ≥ 60% Psicologically motivated (family) Review other options: surgery, hearing aids... Familiar responsibility and disponibility since the beginning of the program. Single sided deafness Careful selection TABLE IV – Wound management Minor adverse skin reactions were easily treated with simple local hygiene procedures. Revision surgery was undertaken in two cases under local anaesthesia, in both of them in two occasions, because of thickening of subcutaneous tissue for recurrent celullitis; the first case was the Fanconi patient and in the second one the problem subsided because poor compliance of caregivers. Regular cleaning is vital to maintain the health of surrounding skin and this meticulous hygiene that is the responsibility of the parents, along with good surgical reduction are the most import issues in successful soft skin management. Fig.2 Ointment soaked ribbon gauze and healing cap Day 2 post op TABLE III – BAHA Patient Characteristics Patients were all operated on a two-stage procedure. In first stage, only one fixture was placed in the mastoid process in all cases (in only one case was a 3 mm fixture placed having all of the rest been implanted with a 4 mm fixture). Second stage was performed 3 to 6 months after first stage and the BAHA was subsequently attached 4 to 6 weeks afterwards. Thirty-one children are still wearing the BAHA and in patients with chronic ear disease, most ear infections decreased in number. A single patient lost his fixture 6 months after completion of the second procedure and has been reimplanted in the same side without any problems 3 months afterwards on a two-stage procedure. Our failure rate of osseointegration was 3,0%. Two patients required skin site revision, one of them under local anaesthesia. In one of those patients (Fanconi anemia) episodes of recurrent cellulitis and skin overgrowth aggravated the disease itself, so suiting the pediatric haematologist opinion we remove the abutment and the problems disappeared. We had no other important adverse skin reactions. TABLE I – Selection Criteria for the Maria Pia Children’s Hospital Program Before surgery a Computerized Axial Tomography (CAT) helps us determining the thickness of the skull that can be a major limiting factor in paediatric BAHA placement. CAT also shows us the real anatomy of different parts of the ear. Psychological aspects are also very important and parental counselling is the key to successful long-term care. The surgical procedure was a two-stage procedure in all cases with 3 to 6 months between stages. Treatment planning is presented in Table II. Fig.3 Open air 2 days post op CONCLUSION Close follow-up and education and communication with caregivers are the corner stone to avoid adverse skin reactions.