Surgery


Round and Oval Window Reinforcement Surgery
Heavy Grommet Surgery

Round and Oval Window Reinforcement Surgery

The following surgery is being studied as an option for those with hyperacusis where the cause is unknown and the usual medical therapies have failed. Mainstream clinical researchers continue to recommend less invasive treatments such as sound therapy and counseling.

OvalvsRoundWindowSimple

The technique being studied is the surgical reinforcement of the round and oval windows of the inner ear. This surgery has now been performed on more than 50 hyperacusis patients. Details about their methodology and results can be found reading this article, authored by Dr. Silverstein and published in a 2020 issue of the Journal of Otolaryngology.

The oval window is where the stapes bone displaces fluid in the cochlea toward the round window. As cochlear fluid is incompressible, the round window must be flexible so the fluid can move.

The details of the round and oval window reinforcement surgery were described by Silverstein et al. The authors originally developed the surgery in 2009 and found success with this surgery in superior semicircular canal dehiscence (SSCD) patients. This surgery has since been attempted on hyperacusis patients without evidence of SSCD. The surgery is 45 minutes and “minimally invasive.”

Data for 40 patients are included in the 2020 publication (see references). Hyperacusis questionnaire, Loudness discomfort levels, and hearing loss measurements were taken before and after surgery. For the questionnaire, the score can be interpreted as follows (Herraiz 2006):

Survey ScoreDegree of Incapacity
26-45Very Severely Incapacitated
18-25Severely Incapacitated
11-17Moderately Incapacitated
1-10Slightly Incapacitated

Treatment Outcomes

The 2020 publication shows the average LDLs before and after treatment improved 13 dB. The averages of the hyperacusis questionnaire scores reduced by 14.8 suggesting functionality improved as well. The plot below shows the hyperacusis questionnaire (HQ) results for the 20 patients who had a long-term follow up.

Data interpreted from Figure 4 of Silverstein et al. 2020

Older patients seemed to show better outcomes than younger patients, on average. Patient testimonials of those who improved enthusiastically expressed that the surgery had a life-changing impact. As with most treatments, not all patients improved and some had adverse reactions.

Adverse Reactions

A complete list of potential adverse reactions should be provided by the surgeon. The list of rare adverse reactions is quite long for such an ear surgery but should be disclosed by your doctor. However, a more common side effect of this surgery appears to be some loss in hearing ability. Details of this impact of the surgery should be discussed as well.

Earlier studies showed that hearing loss after surgery increased 10db-20dB above 4kHz, but this loss in hearing ability was not noticeable to the patients. The latest study of 40 participants reports an average of roughly 5 dB hearing loss when measuring frequencies up to 2kHz. This hearing loss was not found to be statistically significant. Hearing loss above 2kHz was not reported in the latest publication. As a result, we cannot see how much the surgery introduces high-frequency hearing loss.

Links

Videos of patient testimonials can be found here.

Surgeries are performed by the Silverstein Institute in Florida. They provide more information about the surgery on their website.

Heavy Grommet Surgery

A less invasive surgery is described by Dr. Timothy Hain on his clinic’s hyperacusis information webpage. His surgery involves inserting heavy, gold grommets (custom tympanostomy tubes) into the eardrum to dampen incoming sound. Dr. Hain reports a larger than expected increase in loudness tolerance relative to the high frequency hearing loss that is intentionally introduced by the grommet. Unfortunately, this surgery lacks the sample size to assess the expected treatment outcomes and adverse reactions relative to other treatments.

Data Interpreted from Dr. Hain’s Website

Grommet insertion into the eardrum is regularly performed using plastic grommets/tubes by ENTs throughout the world. This is done when a particular medical condition needs to be resolved by creating an opening between the middle ear and outer ear. While the application for hyperacusis is different, the heavy grommet surgery appears to be easier to perform and easier to reverse than the round and oval window reinforcement surgery. However, without more research, the heavy grommet surgery should be considered experimental and unproven.

Click to Show: Extreme Surgeries for Patients with Unilateral Hearing Loss

Hyperacusis Surgeries for Patients with Unilateral Hearing Loss

The following are examples of more extreme surgeries that have been performed on hyperacusis patients with significant hearing loss in one ear. With these patients, the ear without hearing loss is untouched while drastic changes are made to the ear that already presented significant hearing loss. None of the surgeries listed below are common or recommended. They are listed to provide an understanding of what has been tried in the unique case of hyperacusis induced by unilateral hearing loss.

Cochlear Implant

There is a study that shows both tinnitus and hyperacusis can be alleviated by cochlear implants in those with unilateral hearing loss. Cochlear implants will only be implanted in ears with significant hearing loss. Before describing the details of the study, it is important to understand what a cochlear implant does and does not do. A cochlear implant does not restore normal hearing or swap in a fresh new cochlea. Instead, it is a string of electrodes inserted into the cochlea that electrically stimulates the nerves that would normally be stimulated by hair cells. This gives the person a useful representation of sound and helps them understand speech. General information on cochlear implants can be found on the NIH website here. A more detailed description with pictures of the surgery can be found on the Brown University website here.


Cochlear implants have already been found to alleviate tinnitus symptoms in bilaterally deaf patients. A recent study led by Angel Macias analyzed the impact of cochlear implant surgery on 16 patients who had unilateral hearing loss and severe tinnitus. All patients presented hyperacusis symptoms before the surgery. 7 patients have had their 12 month follow up visit that included filling out a hyperacusis questionnaire to assess post-operation hyperacusis. Comparing Pre and post op results show all patients with a fully inserted cochlear implant reported a reduction in hyperacusis symptoms. For hyperacusis and crippling tinnitus caused by sudden unilateral deafness,  cochlear implants might provide a last resort solution.

The full paper can be found here.

Cochlear destruction

A musician who had sudden hearing loss due to an acoustic trauma from a gunshot presented hyperacusis and diplacusis symptoms 40 years later. Work was becoming intolerable as symbol sounds were “distressingly unpleasant and distorted.” As there was significant hearing loss in the effected side already, a labyrinthectomy was suggested to abolish the residual hearing and consequently abolish the hyperacusis and diplacusis. A labyrinthectomy is a surgical procedure to destroy the cochlea that was more commonly done in very severe cases of unilateral Meniere’s disease with intractable vertigo. After the operation, the hyperacusis patient was relieved of his hyperacusis and diplacusis symptoms. However, since this procedure destroys the vestibular function of the inner ear, the patient was left with a persistent feeling of unsteadiness.

The paper can be read with purchase or subscription here.

Disconnection of Middle Ear Bones

A 1991 report by Peter Prinsely and Nicholas Frootko describes a woman who experienced progressive deafness in one ear over a two year span. This deafness resulted in hyperacusis and distortion from sounds. The patient pleaded for anything to be done so the doctors suggested the disarticulation of the ossicular chain. This would effectively disconnect the middle ear bones and worsen the deafness in the effected ear. Before surgery hearing thresholds were 50dB-60dB in the bad ear. After surgery, the hearing thresholds changed to 100dB-120dB. The patient reported complete relief from hyperacusis and distortion symptoms.

This surgery is the functional equivalent of adding a super ear plug into the ear (with 50+dB attenuation) and appears to work in cases where hearing loss is already significant in one ear. Any thought to have this surgery performed in two normal hearing ears should be disregarded for many reasons. First, hyperacusis would likely not be completely relieved with only 50 dB attenuation and could very well be exacerbated over time (the patients in each of the surgeries above developed hyperacusis as a result of sudden hearing loss). Second, tinnitus would develop or worsen as a result of the hearing loss. Third, losing the sense of hearing without the option of a hearing aid would have a negative impact on the quality of life.

Next: Other


Have ideas on how to make this article better? Please contact [email protected].

References

Cherry J, Brown M. Relief of severe hyperacusis and diplacusis in a deafened ear by cochlear labyrinthectomy. Journal of Laryngology and Otology 1996:110:57-58.

Hain, T https://dizziness-and-balance.com/disorders/hearing/hyperacusis.htm

Herraiz C, Santos G, Diges I, Diez R, Aparicio J.M.. Assessment of Hyperacusis: The Self-Rating Questionnaire of Hypersensitivity to Sound. Acta Otorrinolaringol Esp 2006:57(7):303-306.

Macias A, Gonzalez J, Manrique M, Morera C, Gacia-Ibanez L, Cenjor C, Coudert-Koall C, Killian M. Cochlear Implants as a Treatment Option for Unilateral Hearing Loss, Severe Tinnitus and Hyperacusis. Audiol Neurotol 2015:20:60-66.

Nikkar-Esfahani A, Whelan D, Banerjee A. Occlusion of the round window: a novel way to treat hyperacusis symptoms in superior semicircular canal dehiscence syndrome. Journal of Laryngology and Otology 2013:127(7):705-707.

Prinsley P.R., Frootko N. Disarticulation of the Ossicular Chain for Severe Recruitment. Ear Nose & Throat Journal 1991:70:115-117.

Silverstein H, Wu Y, Hagan S. Round and Oval Window Reinforcement for the Treatment of Hyperacusis. American Journal of Otolaryngology 2015:36:158-162.

Silverstein H, Ojo R, Daugherty J, Nazarian R, Wazen J. Minimally Invasive Surgery for the Treatment of Hyperacusis. Otolaryngology & Neurotology 2016:37:1482-1488.

Silverstein H, Smith J, Kellermeyer B.  Stapes Hypermobility as a Possible Cause of Hyperacusis. American Journal of Otolaryngology 2019:40: 247- 252.

Silverstein H, Kellermeyer B, Martinez U.  Minimally invasive surgery for the treatment of hyperacusis: New technique and long term results. American Journal of Otolaryngology 2020:41:102319.