Round and Oval Window Reinforcement for the Treatment of Hyperacusis

[TheDanishGirl]

Congratulations on the surgery @GoatSheep! You are very brave. Did you have pain hyperacusis? How much does the surgey cost?

 

[GoatSheep]

Congratulations on the surgery @GoatSheep! You are very brave. Did you have pain hyperacusis? How much does the surgey cost?

I apologize for the confusion where I posted about surgery in this thread. My surgery was for removal of an internal auditory canal osteoma in hopes of it relieving my tinnitus. It did not work.

I didn't have the hyperacusis surgery. I do have pain hyperacusis though.

 

[Lucifer]

From reading some posts on here SCDS is similar to the Round and Oval reinforcement surgery.

What type of specialists deal with SCDS are they ENTs?

What are the main differences between SCDS and Round oval reinforcement surgery?

 

[Daniel Lion]

From reading some posts on here SCDS is similar to the Round and Oval reinforcement surgery.

What type of specialists deal with SCDS are they ENTs?

What are the main differences between SCDS and Round oval reinforcement surgery?

Sorry, what's SCDS?

 

[Lucifer]

Sorry, what's SCDS?

Superior canal dehiscence syndrome

 

[Backpacker]

Superior canal dehiscence syndrome

From what I read so far I noticed that some symptoms of PLF and SCDS (other abbreviations SCD, SCCD, SCCDS) overlap. But not all of them. PLF is caused by a traumatic event which made a sudden change of pressure in the head (starting from typical examples like scuba diving or flight barotrauma, excessive straining, to literally blowing your nose too hard) while SCDS can be congenital. Both conditions are tricky to diagnose and "regular" ENTs do not know about them. On the other hand, (exploratory) surgery for PLF is similar or same as oval and round window reinforcement surgery for hyperacusis, but I think it is different from the surgery for SCDS. I am trying to figure out the differences between all of these, too.

 

[Lucifer]

From what I read so far I noticed that some symptoms of PLF and SCDS (other abbreviations SCD, SCCD, SCCDS) overlap. But not all of them. PLF is caused by a traumatic event which made a sudden change of pressure in the head (starting from typical examples like scuba diving or flight barotrauma, excessive straining, to literally blowing your nose too hard) while SCDS can be congenital. Both conditions are tricky to diagnose and "regular" ENTs do not know about them. On the other hand, (exploratory) surgery for PLF is similar or same as oval and round window reinforcement surgery for hyperacusis, but I think it is different from the surgery for SCDS. I am trying to figure out the differences between all of these, too.

I didn't realise PLF was similar to round and oval window reinforcement surgery. I thought SCDS would be similar to it.

What does PLF stand for?

 

[Backpacker]

What does PLF stand for?

Perilymphatic fistula is a tear of oval or/and round window membrane on one or both ears (but more common only one). Symptoms include Sudden Hearing Loss, ear fullness, subjective dizziness without nystagmus/ or objective vertigo with nystagmus, tinnitus, brain fog, even unspecific problems with eyes like blurry vision or weird focus, sometimes gets misdiagnosed with vestibular migrene, sometimes with mental disorders by "regular" ents and neurologists who claim "it would be visible on MRI or CT" (no, but some doctors use high resolution CT of temporal bone to rule out SCCD).

 

[Labyrinthine]

New research article published by Silverstein (2020) pertaining the old and new, improved surgical procedure.

"Objective: A minimally invasive surgery developed by the senior author has previously been reported to significantly improve sound tolerance after surgery. This report compares the new versus original surgical technique used and long-term results of all patients who have undergone minimally invasive surgery for hyperacusis."

"Results: 80% of subjects who underwent the new surgical technique had improvement in hyperacusis symptoms after surgery compared to 60% of subjects who underwent the original technique. Long term follow-up showed sustained results with both techniques with a mean follow-up of 2 years after surgery."

I consider it to be unacceptable that Silverstein - not once - acknowledged the distinct types of H, and clustered it together thoughtlessly. Perhaps he had his reasons, but I'd love to know the efficacy of the surgery in patients with loudness H as opposed to pain H. He's omitting crucial information here, in my opinion... Based on the reviews I've read in the hyperacusis surgery Facebook group, I'd say it is probably more effective for loudness H. Would've been great to have that conjecture confirmed scientifically, though.

 

[Samir]

Prior studies have identified superior semicircular canal dehiscence, peri-lymphatic fistulas, and third window involving lesions as other potential causes for hyperacusis. Stapes hypermobility has been postulated as a possible etiology of hyperacusis in a previous publication by the senior author.

What is this "third window"? Is there another term for that? I never heard of third window... I know about two windows: round and oval window.

Also, what does "stapes hypermobility" mean?

 

[Labyrinthine]

What is this "third window"?

Third window abnormalities are defects in the integrity of the bone structure of the inner ear. Various conditions can lead to such defects, Superior Semicircular Canal Dehiscence Syndrome (SSCDS) being a well-known example. In the case of SSCDS, head trauma, for instance, can lead to an opening or "dehiscence" in the temporal bone covering the vestibular organ. We already have two windows you pointed out, hence the name third window. The third window allows sound and pressure through, causing a myriad of symptoms (hyperacusis, tinnitus, balance issues, among others).

Also, what does "stapes hypermobility" mean?

Stapes hypermobility, as the name suggests, is a hyper mobile, or 'loose', stapes bone. As far as I know, ENT surgeons can confirm this by "wiggling" the stapes bone with surgical instruments. Presumably, a hypermobile stapes can move more freely, consequently hitting the oval window with more impact, which ultimately leads to pain or discomfort (Silverstein doesn't actually elaborate on this in his paper; this is my theory).

 

[Samir]

Various conditions can lead to such defects, Semicircular Canal Dehiscence Syndrome (SSCDS) being a well-known example. In the case of SSCDS, the vestibular organ isn't completely covered by bone, and a third window ("dehiscence") emerges in the semicircular canal.

How is this diagnosed? Can these defects be seen on a CT scan of the temporal bone?

I have never heard of a third window. Can you have more than three?

They appear on the semicircular canals? Like in the picture below?

 

[Samir]

At least this is where it appears in case of SSCDS. Here is another picture... (I think SSCC means Superior SemiCircular Canal.)

 

[Samir]

Stapes hypermobility, as the name suggests, is a hyper mobile, or 'loose', stapes bone. As far as I know, ENT surgeons can confirm this by "wiggling" the stapes bone with surgical instruments. Presumably, a hypermobile stapes can move more freely, consequently hitting the oval window with more impact, which ultimately leads to pain or discomfort.

That's interesting. I seem to have a problem with one or both of the little bones in my left ear. I sometimes hear a click sound. It sometimes happens randomly but I can trigger it by swallowing sometimes. An older/senior ("experienced") doctor I once met at a university hospital here in Sweden told me that it could be due to the Eustachian tube opening and closing. I did not believe him for a second! He didn't even do a tympanometric test. I did not have this problem until my tinnitus started, and that only started after the acoustic trauma. I wonder if these clicks could be a case of "hypermobile stapes" bone. It's either that or a hyperactive nerve pulling on the little muscle to stiffen up the bone in order to protect my ear.

 

[Labyrinthine]

How is this diagnosed? Can these defects be seen on a CT scan of the temporal bone?

A CT-scan of the superior semicircular canal, in combination with an anamnesis, is employed for the diagnosis of SSCDS. The diagnosis might be different for other third window abnormalities, though. To clarify: a third window can emerge elsewhere in the inner ear, as well; it's more of an umbrella term. Other inner ear conditions that can create a third window are: enlargement of the opening of the vestibular aqueduct, dehiscence of the scala vestibuli side of the cochlea, and abnormal bony thinning between the cochlea and vascular channels - again, these are third windows in different parts of the inner ear.

I have never heard of a third window. Can you have more than three?

I guess, in theory, more than three windows can be present, but that goes beyond the scope of my knowledge.

They appear on the semicircular canals? Like in the picture below?

In the case of SSCDS, yes.

 

[Lane]

I seem to have a problem with one or both of the little bones in my left ear.

To chime in briefly, once I heard that some tinnitus is caused by the "misalignment" of these tiny little bones and how they intereact with each other (apparently usually age-related), it became apparent to me that I should do literally everything possible to maintain the health of those bones, as well as the other bones (and teeth) in my body.

My top priorities at this time are to 1) Regularly consume bone broth; 2) Regulary take diatomaceous earth, which besides being antiparasitic, has large amounts of silica (without which bone regeneration is not possible); 3) Supplement with Taurine; 4) Eat plenty of foods like liver, butter, and other healthy saturated fats (per the Westin Price diet; 5) Supplement with Boron (which I get from borax); and 6) Blend egg shells finely, and use them when making grain dishes and bone broth (bone broth actually has relatively small amounts of calcium). -- I also regularly do use self-acupuncture around my ears, to help support healthy energy and nerve flow around those fragile areas.

 

[Bartoli]

Excuse me if I come across as uneducated on the subject, but I only just read about this. How come there aren't more people with bothersome hyperacusis that get this procedure done?
It seems hearing acuity doesn't suffer from it. How can that be? From what I can father, it's a reinforcement of the round and oval window so they become stiffer and less effective at transmitting sound. Would the quieter sounds not be the first to suffer from such a procedure? Though I don't have as bad hyperacusis as some people, it would definitely benefit my quality of life. But... because of my tinnitus it's very hard wearing earplugs as it makes my tinnitus even more intrusive. I need background sound to retain some sanity so I'm wondering if that's going to be a problem? It's as if I'm caught between 2 acts. I'm sure many must be in the same situation I guess. Any help would be much appreciated.

Thanks!

 

[Marko Nakovski]

I had the surgery 6 weeks ago. So far no improvement but I remain optimistic that maybe it's still too early. Maybe the new tissue still needs time to scar and connect with the windows and stapes.

 

[Daniel Lion]

I had the surgery 6 weeks ago. So far no improvement but I remain optimistic that maybe it's still too early. Maybe the new tissue still needs time to scar and connect with the windows and stapes.

Hi Marko,
You are very brave. Thank you for reporting in to the community.

Where did you get the surgery? What type of hyperacusis do you suffer from, pain or noise, or both?

I hope the surgery works and you feel better in time.
Take care and thanks again for sharing.

Daniel

 

[Marko Nakovski]

Hi Marko,
You are very brave. Thank you for reporting in to the community.

Where did you get the surgery? What type of hyperacusis do you suffer from, pain or noise, or both?

I hope the surgery works and you feel better in time.
Take care and thanks again for sharing.

Daniel

I had the surgery in Croatia. Doctor Djuric performed the surgery for the first time. He had no experience before with round and oval window reinforcement. However, he has performed so many different procedures and he has great experience with plastic and middle ear surgeries. The name of the clinic is Sinteza.

He told me that is willing to perform the surgery but he cannot promise me that the surgery will benefit my hyperacusis. I told him that is totally fine. I just wanted to make sure that he will perform the surgery exactly like Dr Silverstein.

During the surgery he have seen that my stapes are hypermobile and very tiny. The hypermobility wasn't so severe but anyway he decided to reinforce the stapes and he was right. He made good decision even if he didn't know that even mild hypermobility requires tissue placement. It was his personal decision. Dr Silverstein recommend that even if the hypermobility is mild it should be reinforced. I assume that they were very tiny and weak since I was born. Maybe because of that they were predisposed to suffer damage...

I have both pain hyperacusis, loudness and some sort of neuralgia irritability. I think that I have every possible symptom of hyperacusis like - stabbing, fullness, pressure, burning, aching, fluttering, ice pick and some sort of electrical shocks.

I was skeptical about the surgery because of 2 reasons. I was his first patient for this kind of surgery and second thing was that my ears get irritated from physical contact like shower, earplugs inside my ears, touch, press on pillow and etc. I have had constant aching pain for 1 year but from physical contact and sound it becomes even worse. I have read a lot about this and found out that the windows don't have any pain receptors so it shouldn't create pain from placing a tissue inside them.

So far no changes in LDL. Maybe it's still early? It's hard to tell.

Thank you a lot. Do you consider the surgery?

 

[Daniel Lion]

Hi @Marko Nakovski,

Yes I have been considering the surgery and have communicated with Silverstein's team in Florida.

Doing interviews and case history etc.
your doctor sounds very competent. I do hope it helps you with your hyperacusis.
You deserve relief Marko, hoping you get some ASAP.

Thanks again for sharing your story,
Daniel

 

[Marko Nakovski]

@Daniel Lion Thanks a lot.

What is the cause of your hyperacusis? Do you have both pain and loudness hyperacusis?

 

[100Hz]

In the event you needed to rely on the round window membrane to absorb a medication via intratympanic injection (say fx-322 in future for example), would that still be possible after this operation or would the round window become impenetrable. And if that's the case is this surgery reversible to the point of giving the round window back its original semi-permeable properties?

 

[Lucifer]

In the event you needed to rely on the round window membrane to absorb a medication via intratympanic injection (say fx-322 in future for example), would that still be possible after this operation or would the round window become impenetrable. And if that's the case is this surgery reversible?

The surgery is reversible so if FX-322 ends up resolving your hyperacusis you can undo the surgery then also get the shot as well. It will be way easier to get the shot when they have to open the eardrum to remove the tissue.

 

[100Hz]

The surgery is reversible so if FX-322 ends up resolving your hyperacusis you can undo the surgery then also get the shot as well. It will be way easier to get the shot when they have to open the eardrum to remove the tissue.

Thanks, yes I thought that as well. It would hopefully make the delivery of FX-322 very accurate.

I have seen it mentioned that its reversible but only on a patient testimony as a quote from a UK based journal, but not in any of the detailed Silverstein procedural papers I've read.

The part of the reinforcement procedure that concerns me is this - 'The mucosa of the round window niche and the stapes footplate was scraped with a micro pick to facilitate tissue welding.'

That sounds to me like at worst the reinforcement material could totally fuse to the membrane, or, could be removed leaving some kind of impenetrable scar tissue behind, or at best be removed leaving the membrane in its original state. So if the surgery is reversible which it sounds like it is, what state does it leave the membrane in?

What I would really like to know is if it matters at all and that the reinforced window would allow the diffusion as normal (saving the need for the reversal op at all).

 

[Marko Nakovski]

I just wanted to inform everyone that my left ear was operated too and beside both windows my stapes were reinforced too, same as my right ear 3 months ago...

 

[weab00]

I just wanted to inform everyone that my left ear was operated too and beside both windows my stapes were reinforced too, same as my right ear 3 months ago...

Any improvement so far?

 

[Marko Nakovski]

@weab00 Unfortunately, this surgery isn't working for me. From my observations, I believe that this surgery mostly help people in category 3 rather than category 4.

 

[weab00]

@weab00 Unfortunately, this surgery isn't working for me. From my observations, I believe that this surgery mostly help people in category 3 rather than category 4.

I believe I saw your post in the Facebook surgery group, I'm sorry to hear that man. Silverstein surgery only seems to have a 60% success rate and is just putting a bandaid on the real issue.

 

[aot]

Something just occured to me:

If this surgery (by all accounts) is successful in treating hyperacusis, then could it also help prevent tinnitus spikes as well? Since it's more or less extra protection.

I am aware that tinnitus is perceived to be louder afterwards, similar to when one is wearing earplugs.

(On a side note, I live in Sarasota and am within driving distance of The Silverstein Institute. It was Dr. Silverstein himself who diagnosed both my mother and my therapist in Meniere's.)