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bilateral congenital external auditory canal atresia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "288" "paginaFinal" => "294" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria Jorge Casanova, Sara Moreira Ferraz, Miguel Bebiano Coutinho, António Magalhães, Cecília Almeida e Sousa" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Maria Jorge" "apellidos" => "Casanova" "email" => array:1 [ 0 => "mariajorgecasanova@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sara Moreira" "apellidos" => "Ferraz" ] 2 => array:2 [ "nombre" => "Miguel Bebiano" "apellidos" => "Coutinho" ] 3 => array:2 [ "nombre" => "António" "apellidos" => "Magalhães" ] 4 => array:2 [ "nombre" => "Cecília" "apellidos" => "Almeida e Sousa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Otolaryngology and Head and Neck Surgery, Centro Hospitalar Universitário do Porto, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rehabilitación auditiva con implante auditivo osteointegrado en la atresia congénita bilateral del canal auditivo externo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1253 "Ancho" => 2167 "Tamanyo" => 122953 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Free field audiometric results without the osseointegrated hearing implant and audiometric gain with the osseointegrated hearing implant, in the 6 patients who underwent implantation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital external auditory canal (EAC) atresia is a birth defect that is characterized by partial or complete lack of development of the external auditory canal, often in association with dysmorphic features of the auricle.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,2</span></a> It has a prevalence of one in 10,000–20,000 births, and is bilateral in a quarter to a third of cases.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Congenital EAC atresia can be isolated or found in syndromes such as Treacher-Collins, Goldenhar, Pierre-Robin, Crouzon's, VATER, CHARGE, and DiGeorge.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,2,5,6</span></a> Other predisposing factors include teratogenic drugs, advanced maternal age, and low birth weight. Due to different embryologic sources and times of development, involvement of the inner ear structures is rare, while association with the middle ear cavity and ossicular chain is common.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Hearing status assessment is the most important functional investigation in these patients, as it plays a crucial role in the early stages of development.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6,7</span></a> Congenital EAC atresia leads to a moderate to severe conductive hearing loss, with an air-bone gap of 50–60<span class="elsevierStyleHsp" style=""></span>dB, which may delay speech development, particularly in bilateral cases.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,4,8</span></a> Patients with microtia-atresia are at risk for delay in cognition development, and behavioral problems from lower self-esteem and poor social integration.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Otoscopic examination is not possible in EAC atresia, therefore Computerized Tomography (CT) is the imaging method of choice for diagnosis and clinical evaluation. Cases with suspected genetic transmission require genetic analysis.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Initial steps in treatment include amplification and assistive auditory devices, lip-reading instruction, special education, and parental guidance.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Early amplification is fundamental in bilateral cases in order to ensure normal language development in these children.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Methods of hearing rehabilitation include surgical reconstruction of the EAC (atresiaplasty), conventional bone conduction hearing aids, and osseointegrated hearing implants, such as Bone Anchored Hearing Aids (BAHA™).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Our institution began performing osseointegrated hearing device implantation in 2003, and our first implantation in a patient with bilateral EAC atresia was in 2005.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of this study is to present osseointegrated hearing implants as a treatment for bilateral EAC atresia, to describe the surgical technique and to review this indication, hearing outcomes and the rate of complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors performed a retrospective analysis of all pediatric patients with a diagnosis of bilateral congenital EAC atresia attended in the Department of Otolaryngology and Head and Neck Surgery, in Centro Hospitalar Universitário do Porto, a Portuguese Tertiary Hospital Center, between 2003 and 2019. Patients with associated inner ear malformations were excluded.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors performed a review of medical records, collecting information on age, gender, medical history, initial hearing status evaluation and imaging when available. In the cases that have undergone osseointegrated hearing device implantation, follow-up details including immediate and long term post-operative complications were analyzed, as well as hearing outcomes.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hearing assessment was performed through pure tone audiometry when possible with patient cooperation, or free field audiometry with and without osseointegrated hearing implants.</p><p id="par0060" class="elsevierStylePara elsevierViewall">All the implants were covered by the public health system.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical approach</span><p id="par0065" class="elsevierStylePara elsevierViewall">Osseointegrated hearing device implantation surgery for all cases was performed by the same surgeon, with experience in this field. Surgery was performed under general anesthesia.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Firstly, the location for osseointegrated hearing implant placement is marked, posterosuperiorly from the external meatus, along the temporal line. Next, a needle is used to mark the thickness of the subcutaneous tissue, which is then measured, to help with abutment selection. Then, the area is anesthetized, and the skin punch is performed using a size 4 or 5<span class="elsevierStyleHsp" style=""></span>mm punch, reaching the periosteum. The resulting skin plug is removed, and the underlying periosteum is then elevated to accommodate implant placement. The drill is set to 2000<span class="elsevierStyleHsp" style=""></span>rpm, and the 4<span class="elsevierStyleHsp" style=""></span>mm drill guide bit is attached to the drill, along with the 3<span class="elsevierStyleHsp" style=""></span>mm wide spacer. Drilling is performed perpendicularly, with heavy irrigation, until the wide spacer reaches the underlying bone. Following this the depth of the hole should be palpated with a thin, blunt instrument, to ensure there is no exposed dura, and then the wide spacer is removed. Then, with the 4<span class="elsevierStyleHsp" style=""></span>mm length screw, the hole is extended to the depth of 4<span class="elsevierStyleHsp" style=""></span>mm, in constant irrigation. Next, using a 4<span class="elsevierStyleHsp" style=""></span>mm countersink drill, the pole is inserted, as perpendicularly as possible to the surrounding skin. Next, adjusting the drill settings to 20–30<span class="elsevierStyleHsp" style=""></span>cm, the implant is placed, with the possibility of a posterior gentle manual tightening of the screw, to ensure good coupling. The base of the abutment is then examined to ensure that the screw has been fully inserted. If necessary, a suture can be placed to ensure the skin is tight around the post. A healing cap is then placed, and gauze is wrapped loosely around the abutment to help with stabilization. These are removed about one week after surgery.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">We present 8 pediatric patients with a clinical and imaging diagnosis of bilateral congenital EAC atresia. Ear CT scans excluded middle or inner ear involvement, and we present images from patient 4 as example (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">6 patients were female (75%) and 2 were male (25%), with a mean age at first consultation in our institution of 6.9 years.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Patient 7 was the only case to present with bilateral microtia associated with the EAC atresia.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Patient 2 presented with 18q deletion syndrome, and patient 8 with Down syndrome. The remaining patients did not present with any syndromic characteristics. We have access to audiometric examination of 6 cases, revealing a moderate to severe bilateral conductive hearing loss, with a mean Speech Recognition Threshold (SRT) of 51<span class="elsevierStyleHsp" style=""></span>dB (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows the audiometric results discriminated by frequency.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Patient 8 is the only patient born in our institution, and having failed the Universal Neonatal Hearing Screening, underwent Auditory Evoked Potentials at 4 months of age. The results were compatible with bilateral conductive hearing loss, with thresholds of 50<span class="elsevierStyleHsp" style=""></span>dB in the right ear, and 80<span class="elsevierStyleHsp" style=""></span>dB in the left ear.</p><p id="par0100" class="elsevierStylePara elsevierViewall">To date, 6 patients have undergone unilateral osseointegrated hearing device implantation. The side of implantation was chosen according to the ear with better sensorineural thresholds, as well as preference for the child's dominant hand, to allow for easier handling of the sound processor (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Average age at implantation was 10 years of age.</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows that in earlier years, two-stage surgery was performed, with an average time between stages of 7 months. More recently, preference was given to one-stage surgery.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Osteointegration varied from 2 to 3 months, after which the external processor was connected. All 6 patients had good hearing outcomes, with a mean SRT of 20<span class="elsevierStyleHsp" style=""></span>dB, and closure of the air-bone gap. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows mean results of hearing assessment without and with the osseointegrated hearing implant, discriminated by frequency.</p><p id="par0115" class="elsevierStylePara elsevierViewall">There were no immediate complications post-surgery. Follow-up for these patients after implantation varied from 2 to 14 years. Two years after implantation, patient 5 required surgical revision due to abutment overgrowth by skin. As for long term complications, patients 1 and 2 have had several episodes of soft tissue inflammation around the abutment, all resolved with topical antibiotics. No other complications were reported.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Patients 7 and 8 are currently using softband bone-anchored conduction devices due to young age, with an average reduction of air-bone gap by 30<span class="elsevierStyleHsp" style=""></span>dB.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The goal of the treatment of EAC atresia in the bilateral form is the achievement of a socially beneficial hearing threshold, allowing for adequate language and cognitive development. Early hearing rehabilitation is essential in these cases in order to provide access to speech sounds, in order to reach optimal speech and educational potential.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,10,11</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">From 3 months of age, infants can be rehabilitated with softband bone-anchored hearing devices, before the skull is sufficiently thick for implantation surgery. Patients 7 and 8 presented in this study have been fitted with these devices. After 6 months of use, most patients achieve the development level of healthy infants.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">7,12</span></a> Afterwards, they may advance to bone-conduction hearing aids, initially forehead bands, and osseointegrated hearing device implantation from the age of 5. Osseointegrated hearing implants works through direct bone conduction, and consists of a titanium piece, implanted on the cortex of the mastoid bone, and an abutment, which is adjusted in the titanium piece and removable. The abutment attaches to an external sound processor that receives the environmental sound energy, transforming it in mechanical energy (vibration) and stimulating the cortex of the bone.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6,13</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The introduction of these devices was a major step forward in the treatment of these patients, as they offer higher acoustic gain with less surgical complications, with a good cost-benefit ratio. Osseointegrated hearing device implantation has become the first-line treatment in many centers for bilateral EAC atresia. However, the esthetic issue with the external ear malformation leaves the option of surgical reconstruction available.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,8</span></a> In this study, only patient 7 presented with microtia, and so far the child's social development and follow-up with the parents have not created concern for the necessity of this procedure.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Osseointegrated hearing implants are indicated for patients with conductive and mixed hearing loss, as well as for patients with single-sided deafness, in individuals who cannot benefit from conventional hearing aids.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,6</span></a> Aural atresia is currently the main indication for the use of osseointegrated hearing devices in pediatric patients, as these patients usually present good cochlear reserve.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Osseointegrated hearing device implantation surgery can be performed in one or two stages. Two-stage surgery involves separating the implant placement and abutment attachment, in order to allow time for implant osseointegration. Historically, until two decades ago, this was the only procedure performed, however technologic and surgical technique development now allow for the surgery to be performed safely in one procedure.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> This study also shows this evolution, as the patients who underwent two-stage surgery were those implanted in earlier years. The interval between stages can be from 2.8 to 6.8 months, and in this study it was an average of 7 months. However, patient 3 required an interval of 11 months, as seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, due to poor bone quality found in the first stage of implantation, which led to the decision to prolong the waiting time for the second stage to allow for good osseointegration.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The majority of patients with bilateral hearing loss are fitted with a unilateral osseointegrated hearing implant. Sound vibrations from one osseointegrated hearing implant are transmitted via the skull bone not only to the ipsilateral cochlea, but also to the contralateral cochlea to almost the same extent. Therefore, one osseointegrated hearing implant should theoretically be sufficient for good hearing amplification even though the hearing loss is bilateral.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> In our institution, all patients were fitted with unilateral osseointegrated hearing implant, after a test with softband to predict efficacy of treatment. All 6 patients have had positive hearing outcomes, with closure of the air-bone gap, and high satisfaction by both patients and caregivers. Recent studies in adults have shown additional benefits of bilateral osseointegrated hearing implants in terms of improved sound localization and speech recognition. At present, some centers already provide bilateral osseointegrated hearing implants for children with bilateral hearing loss, however there is still no definite evidence of benefit in this population.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Osseointegrated hearing device implantation is safe in children, as it does no irreversible damage to the EAC, middle or inner ear.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10,15</span></a> The main complications of osseointegrated hearing implants include implant displacement, soft tissue complications, abutment overgrowth by skin or granulation tissue, keloid formation, failure of osseointegration or delayed osseous disintegration, as well as the stigmatization of patients.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13,16,17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The development of new surgical techniques in recent years has led to a lower incidence of soft-tissue reactions, revision surgeries and implant loss. One-stage surgery has allowed for earlier rehabilitation, and the reduction of anesthetic exposure with the elimination of a second procedure.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The frequency of these complications is low, and only a few require surgical revision. Skin and soft tissue problems are the most common, but also the mildest, including tissue overgrowth, skin infection, and granulation tissue at abutment site.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,18</span></a> Educating patients on local hygiene techniques may help minimize theses complications.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Treatment for infectious complications includes topical or oral antibiotics and excision of granulation tissue. Abutment overgrowth by skin or granulation tissue can be treated with revision and placement of a longer abutment combined with control of infection. Keloid formation can be treated with steroid injection and compression, and excision as needed.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Implant loss rates in children are around 13%.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> Failure of osseointegration or abutment dislodgement are infrequent, and risk factors include trauma, younger patient age at implantation, and incomplete insertion of the implant. Exposed bone at abutment site, skull paresthesia, and persistent bleeding are even rarer.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In this study, no severe complications have occurred thus far in the follow-up time, which goes up to 14 years. 2 cases have presented with recurrent episodes of soft tissue inflammation and infection requiring topical antibiotics. One case developed skin overgrowth at the abutment site and required surgical revision, two years after osseointegrated hearing device implantation.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Another treatment option is atresiaplasty, a complex and challenging surgery. Both the osseointegrated hearing implant and reconstruction surgery may allow for good hearing outcomes, however the main advantage for surgery is the resolution of the atresia without the necessity of an external device that affects the esthetic component. There are certain criteria the patient must meet to be eligible for surgery, as well as a grading system based on the candidate's CT scan, so as to select patients with a good chance of restoring hearing to an acceptable level, where the potential benefits outweigh the risk of the surgery.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The surgery requires specialized surgical skills, and complications may be severe.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> The most serious are sensorineural hearing loss and facial nerve paralysis. Other complications include canal restenosis, chronic infections, salivary fistulae, and lesions on the temporomandibular articulation.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,4,6,13</span></a> It is particularly challenging due to the level of development of the mastoid and tympanic cavities, absence of anatomical landmarks, abnormal position of the facial nerve and other anatomical structures, and structural deformities of the ossicles.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> However, evolving changes in surgical techniques have achieved better hearing outcomes and lower rate of complications, even long-term.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">As this is a retrospective study, its main drawback is the lack of detail and clarity of medical records that would be considered optimal for complete analysis. In addition, EAC atresia is a rare condition, therefore few cases were included in the study, which also constitutes a limitation. Furthermore, most cases were only referred to our institution at older ages after inadequate improvement with conventional hearing aids, which lead to adequate treatment being delayed for several years.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">Osseointegrated hearing device implantation was an effective treatment option in these patients, as described in literature, and all without significant morbidity or complications.</p><p id="par0205" class="elsevierStylePara elsevierViewall">In these cases it was decided for unilateral implantation. Recent studies have shown advantages in bilateral use, however definite evidence of benefit in children has yet to be determined.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Osseointegrated hearing device implantation should be considered a first-line treatment for children with congenital bilateral EAC atresia, as it presents good hearing outcomes and a high level of satisfaction by patients. Surgical reconstruction should be weighted in cases with microtia, with consideration to the difficulty and complications of surgery, as well as the debatable esthetic results.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Early referral of these cases to an ENT will contribute to minimize the impact of this condition in the child's cognitive, language, and behavioral development.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors report no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1567875" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1412780" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1412781" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1567876" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1412782" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical approach" ] ] ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-21" "fechaAceptado" => "2020-08-05" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1412780" "palabras" => array:5 [ 0 => "Congenital atresia of the external auditory canal" 1 => "Hearing implant" 2 => "Bone conduction" 3 => "Hearing loss" 4 => "Children" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1412781" "palabras" => array:4 [ 0 => "EAC" 1 => "BAHA" 2 => "CT" 3 => "SRT" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1412782" "palabras" => array:5 [ 0 => "Atresia congénita del canal auditivo externo" 1 => "Implante auditivo osteointegrado" 2 => "Conducción ósea" 3 => "Hipoacusia" 4 => "Niños" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congenital atresia of the external auditory canal (EAC) is a congenital defect present in one in every 10,000–20,000 births. It causes conductive hearing loss, with an air-bone gap of 50–60<span class="elsevierStyleHsp" style=""></span>dB. Early amplification is essential in bilateral cases to ensure normal language development. The aim of this study is to present the osseointegrated hearing implant as a treatment for bilateral EAC atresia, reviewing the audiometric results and the rate of complications.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective analysis of patients diagnosed with bilateral congenital EAC atresia under follow-up in the pediatric ENT clinic of the ENT and Head and Neck Surgery department of a Portuguese Tertiary Hospital, between 2003 and 2019. We reviewed the medical records and collected information on the assessment of the initial audiometric status. In the cases submitted for implantation with an osseointegrated hearing implant, we analyzed the details of follow-up, including immediate and long-term post-operative complications, as well as the audiometric results.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We present 8 pediatric patients, 6 girls and 2 boys, with a diagnosis of bilateral congenital EAC atresia. The audiometric assessment revealed moderate to severe bilateral conductive hearing loss with a mean speech recognition threshold (SRT) of 51<span class="elsevierStyleHsp" style=""></span>dB. Six patients underwent osseointegrated hearing implantation. All 6 patients showed good audiometric results, with an average SRT of 20<span class="elsevierStyleHsp" style=""></span>dB and closure of the air-bone gap.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The osseointegrated hearing implant was an effective treatment option in these patients, without significant morbidity or complications. Osseointegrated hearing implantation should be considered first line treatment for children with bilateral congenital EAC atresia, as it presents good functional results and a high level of patient satisfaction.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La atresia congénita del canal auditivo externo (CAE) es un defecto congénito presente en uno de cada 10.000-20.000 nacimientos. Origina una pérdida auditiva conductiva, con un <span class="elsevierStyleItalic">gap</span> aire-hueso de 50-60<span class="elsevierStyleHsp" style=""></span>dB. La amplificación temprana es fundamental en casos bilaterales para garantizar el normal desarrollo del lenguaje. El objetivo de este estudio es presentar el implante auditivo osteointegrado como tratamiento para la atresia bilateral del CAE, revisando los resultados audiométricos y la tasa de complicaciones.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Análisis retrospectivo de pacientes diagnosticados con atresia congénita bilateral del CAE en seguimiento en la consulta de otorrinolaringología pediátrica del departamento de otorrinolaringología y cirugía de cabeza y cuello, en un centro hospitalario terciario portugués, entre 2003 y 2019. Revisamos los registros médicos y recopilamos información sobre la evaluación del estado audiométrico inicial. En los casos sometidos a la implantación con implante auditivo osteointegrado, se analizaron los detalles del seguimiento, incluyendo las complicaciones postoperatorias inmediatas y a largo plazo, así como los resultados audiométricos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presentamos los casos de 8 pacientes pediátricos, 6 niñas y 2 niños, con diagnóstico de atresia congénita bilateral del CAE. La evaluación audiométrica reveló una pérdida auditiva de conducción bilateral de grado moderado a grave, con un Speech Recognition Threshold (SRT) medio de 51<span class="elsevierStyleHsp" style=""></span>dB. Seis pacientes han sido sometidos a implantación con implante auditivo osteointegrado. Los 6 pacientes presentaron buenos resultados audiométricos, con un SRT medio de 20<span class="elsevierStyleHsp" style=""></span>dB y cierre del <span class="elsevierStyleItalic">gap</span> aire-hueso.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El implante auditivo osteointegrado fue una opción de tratamiento eficaz en estos pacientes, sin morbilidad o complicaciones significativas. El implante auditivo osteointegrado debe ser considerado un tratamiento de primera línea para niños con atresia congénita bilateral del CAE, ya que presenta buenos resultados funcionales y un alto nivel de satisfacción por parte de los pacientes.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 982 "Ancho" => 950 "Tamanyo" => 91603 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">CT image, transversal plane. EAC atresia (yellow arrows), with adequate morphology and topography of the middle ear and mastoid cells. Slight asymmetry of mastoid pneumatization.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 628 "Ancho" => 1500 "Tamanyo" => 93181 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CT image, transversal plane, right and left ear respectively. Bilateral EAC atresia of the bony portion, with the membranous portion of the EAC remaining permeable (yellow arrows).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1253 "Ancho" => 2167 "Tamanyo" => 122953 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Free field audiometric results without the osseointegrated hearing implant and audiometric gain with the osseointegrated hearing implant, in the 6 patients who underwent implantation.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Average hearing loss (SRT) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age at implantation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Implant side \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgery \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Time between stages \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up (from year of implantation) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reported complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55<span class="elsevierStyleHsp" style=""></span>dB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two-stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 years(2004–2020) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrent episodes of soft tissue inflammation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60<span class="elsevierStyleHsp" style=""></span>dB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One-stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 years(2017–2020) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrent episodes of soft tissue inflammation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45<span class="elsevierStyleHsp" style=""></span>dB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two-stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 years(2009–2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50<span class="elsevierStyleHsp" style=""></span>dB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One-stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 years(2016–2020) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55<span class="elsevierStyleHsp" style=""></span>dB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two-stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 years(2005–2016) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin overgrowth over abutment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40<span class="elsevierStyleHsp" style=""></span>dB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One-stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 years(2017–2020) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2686304.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Osseointegrated device implantation details.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BAHA in congenital aural 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Original article
Hearing rehabilitation with osseointegrated hearing implant in bilateral congenital external auditory canal atresia
Rehabilitación auditiva con implante auditivo osteointegrado en la atresia congénita bilateral del canal auditivo externo
Maria Jorge Casanova
, Sara Moreira Ferraz, Miguel Bebiano Coutinho, António Magalhães, Cecília Almeida e Sousa
Autor para correspondencia
Department of Otolaryngology and Head and Neck Surgery, Centro Hospitalar Universitário do Porto, Portugal