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Interview with Gregory J. Artz, MD, Neurotologist and Assistant Professor, Thomas Jefferson University

Gregory Artz

October 8, 2012

Topic: Medical Advances in Bone Conduction Implantation, and Pre- and Post-surgical Patient Management

Gregory Artz, MD

CAROLYN SMAKA: I'm talking about bone-conduction hearing systems today with Dr. Gregory Artz, who was referred to us by Oticon Medical. Dr. Artz, can you tell me about your role as a physician - where you work and your background?

GREGORY ARTZ: Sure. I'm an otolaryngologist, and I was also fellowship-trained in neurotology. I'm currently Assistant Professor at the Thomas Jefferson University in Philadelphia, Pennsylvania. We have six full-time audiologists, as well as a second-year student and a fourth-year extern. Our practice consists of two neurotologists, of which I'm one, and we have a total of 13 otolaryngologists. We have a busy hearing and balance center that sees all types of patients with complex hearing disorders, as well as balance disorders.

SMAKA: Sounds like an exciting place to work. Getting right to our topic, why don't you think there's more uptake on bone conduction solutions for patients?

ARTZ: I think there are two reasons really. The first is that, in the past, it wasn't really offered to patients as an option for single-sided deafness (SSD). I think a lot of general otolaryngologists who often are the first physicians to see the patient don't always think of it as an option for SSD. The other obstacle is the fact that some patients prefer a removable device to one that's permanent. We may see this changing as the technology continues to advance and as we are seeing smaller and sleeker permanent osseointegrated solutions.

SMAKA: Can you talk about recent advances in the surgery for an osseointegrated implant?

ARTZ: The procedure has gone through a transition over the last couple of years. The initial procedure used a dermatome creating a skin graft, probably about one by two centimeters in dimension. That area would be completely devoid of any hair follicles, so patients would have a bald patch surrounding the implant site. It was obvious, and sometimes unsightly. However, from a surgical perspective it was though to be necessary to have a very thin skin graft to adhere to the bone around the implant.

Well, that philosophy has changed dramatically, and now we're using what's called the "linear incision technique." You don't use a dermatome and do not need a skin graft. Instead, you create what I call "sub-dermal flaps" around the incision. I don't remove any hair follicles. The implant is placed in the bone. It is quite hidden, particularly in patients who have longer hair. The only circumstance where the implant is noticeable is when the patient has very short hair. Otherwise, it's nearly invisible.

SMAKA: In terms of post-op, what kinds of questions do patients about the surgery?

ARTZ: Well, before the surgery, they want to know the details of how involved the surgery is: Is there going to be a lot of pain? Is it done under general or local anesthesia?

I present to patients that surgery can be done in approximately 30 minutes. In general, it is not painful. Patients may take a little bit of pain medication after surgery, but typically only for a day or two at most.

The procedure itself can be done either under general anesthesia if patients are a little anxious, but most of the time we can do it under a local anesthetic, which is great. So, patients with any kind of medical history can often have the procedure done. Also, the patients who have local anesthetic only go home much more quickly than those who go under general anesthesia, as you would expect.

Now, with regard to the post-operative period, patients do fantastic. They really have very little pain. They use what we call a "healing cap" that snaps on to the abutment for one week, and underneath that is packing that acts as a biological dressing on the incision.

If there are any problems post-operatively, it is usually a skin reaction around the actual abutment. This can be managed with various topical medications. We may prescribe clobatesol or bacitracin ointment, and follow-up with the patient regularly. Kenalog injections also can help, and occasionally I have to excise some inflamed skin around the abutment place. That can be easily done in the office and it usually heals within a week. The patient can continue to use the hearing processor during the healing process.

As long as the site is healing well, patients can continue with their typical daily activities. They can get the area wet, but they just need to blow it dry with a hair dryer. We just want to keep the wound from becoming saturated. Then after a week, I take the dressing off, and usually it's very well-healed.

The hardest part for patients is the waiting time after surgery. The FDA has approved that the patient can receive the speech processor after three months of healing. It seems more and more physicians are 'loading' these patients' implants at six weeks, or even earlier at the four weeks.

SMAKA: How are patients referred to you - are they self-referred, coming from their general practice physician, or from an audiologist? And, what kinds of outcomes are you seeing with patients after they are fit with the processor?

ARTZ: The patients who are referred to me come from three different areas. Audiologists refer patients to me; other otolaryngologists outside our practice who do not perform this procedure also refer to us for a second opinion or consultation regarding the osseointegrated implants. The third area is self-referral from patients who have various types of hearing loss and bone conduction solutions were never offered to them as an option in the past.

The vast majority of patients in our practice who opt for this treatment have SSD, but we also have patients who have a conductive hearing loss with a mastoid cavity who can't really tolerate a hearing aid due to chronic drainage or chronic infections. We also see patients with mixed hearing loss.

One thing that I love about the Baha and the Ponto, which are the two different options for osseointegrated implants, is that we are able to conduct an osseointegrated evaluation in the office. It's a one-hour hearing evaluation where the patients are presented with different options for their hearing loss. One of those options is the implants we are discussing today. There's a headband that you place on the patient so they can experience right there in the office how they would hear with the implant. If the patient likes it in the office and during the evaluation, they will love it once it's implanted and they're given the processor.

SMAKA: How does a patient with SSD tell in the office with the soft band what kind of benefit they will receive, since they're hearing out of their good ear anyway? If you're office is quiet, they may not notice benefit, and where they have difficulty is in noisy situations. Do you have to set up certain listening scenarios?

ARTZ: Yes, a hearing-in-noise test is one of them. But what you just mentioned is an important issue that underscores why managing patient expectations is critical. In background noise or really crowded, loud situations patients with SSD are always going to have some issues, regardless of what solution they use.

As long as you manage their expectations appropriately and tell them it gives them the ability to hear with sounds directed towards their bad side, they do great. For example, they may get benefit in meetings, when they're talking to clients, or in a classroom, those are some situations where they should do great with it. If they have unrealistic expectations, obviously they are not going to be satisfied.

SMAKA: What kind of long-term medical follow up is needed for patients that are using these systems?

ARTZ: I see them at one week post-op, just to make sure the incision is healing well, that there's no infection, and they're really on track to heal well. Then I see them again at six weeks, and the audiologist sees them on the same day. I check the incision, and the audiologist does a one-hour evaluation where they load the processor, program it and give it to the patient so they can start hearing better.

The audiologist starts with a program that eases the patient in to getting used to it. They're really encouraged to wear it as much as they can so they get used to it. And then they come back one month later, and that's when the audiologist gives them a more advanced, louder program so they can hear better with the new implant.

SMAKA: What kinds of patients or diagnoses would present a contraindication for this kind of solution?

ARTZ: Patients who are relative contraindication patients include those who have have eczema, or skin or scalp disorders that require continuous management by a dermatologist. This may not be the best option for them, because really the only complication that arises in the implant post-operatively is skin reaction around the implant site.

SMAKA: The last question that I have is about future directions. Where do you see this technology going, either from the surgery side or the speech processor side, in ten years?

ARTZ: The ideal hearing aid would be invisible. So future directions should be aimed at decreasing the size of the processor, making the abutment in the skin less visible and decreasing skin reaction, which can be a major nuisance.

ARTZ: With regard to the different type of implants, we provide patients with a choice of systems, and Oticon Medical's Ponto really has become a favorite with our patients. We provide a choice, give them the literature and have the patient make the decision. The majority of our patients now choose the Ponto. There are three reasons. One, the appearance is very sleek; two, the controls are easier to manage for patients. Third, the feedback reduction program is excellent and currently superior to its competitor.

SMAKA: Thanks for your time today, Greg. I appreciate your time and hearing your insight.

ARTZ: My pleasure.

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Gregory Artz

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