In-Depth Interview With Dr. David M. Kaylie

None — David M. Kaylie, M.D, from Duke University, explains how a new procedure can change somebody's life.

Who is Mark Andrews? What was his issue and what do you do for him here that he can't get anywhere else?

Dr. Kaylie: He was born with a condition called microtia and atresia. His outer ear just didn't form right, he just had a small little nubbin of an ear and he had no ear canal at all, so he couldn't hear from that side. He had a big cosmetic deformity, just not having an ear at all didn't look right, and so as a child, they did reconstructive surgery to try and build him a new ear. They took rib cartilage and tried to build him a new ear, but they just never looked right, and it became more of a problem for him. He just didn't like the way it looked, so he had the whole thing removed, and had a prosthetic ear made. The problem with the prosthetic ear is that even though they looked very real, there's not a good way to have them stay on. You have to use adhesives and glues, and those can cause skin reactions and infections, and it just became really irritating. It got to the point where he couldn't even wear that, so he had no ear and couldn't hear on that side. There's a new technology where you can implant into the bone, titanium posts, that are super-pure titanium, so that when it gets implanted into bone, the bone can grow into it and anchor it fully into the bone, and they come up through the skin. They can put clips onto the anchors, and have the ear clip onto it, so there's no adhesives, and it's a much more secure fit.

What's the jaw drop factor on the fact that they're able to take this titanium, implant it, and then use it as a way to anchor a prosthetic?

Dr. Kaylie: The thing that's really great for him is that not only does it give him an ear, but he has no ear canal, so we also implanted a third one for a hearing aid, so he can hear from that side for the first time in his life, as well as have a normal-looking ear.

Beforehand, what were the options for something like this?

Dr. Kaylie: They'd have to do this reconstruction, this four or five stage reconstruction that you have to do as a child, and they take your own rib cartilage and there's all kinds of risks with that. It's extremely painful, and it just never looks right, it just looks like a fake ear on the side of your head. Then in order to re-create the hearing, that's a whole another set of surgeries where you have to rebuild an ear canal, and the hearing results are really pretty poor with that. After having gone three or four surgeries to reconstruct the ear, then it's another three or four surgeries to try and reconstruct the ear canal and middle ear, which gives very poor hearing results. This is a single-stage surgery where we get implanted, and he gets a normal ear and can hear.

How long does the process take?

Dr. Kaylie: The whole surgery takes about an hour, and then it takes three months for the bone to fully grow in and anchor into the titanium. Then we put on the hearing device right then, and he hears, and that takes a couple weeks.

How many titanium screws are we talking about? Does it vary, or do you have a set number?

Dr. Kaylie: Three. One is for the hearing aid, and two are for the ear. The ear itself is made out of silicone and all kinds of plastics and modeling equipment.

What has Mark Andrew's reaction been so far?

Dr. Kaylie: He's amazed. When I put the hearing aid onto the first prosthesis, he'd never heard from that side in his life, and he was blown away. He couldn't believe the things he could hear, he could tell where sounds were coming from. The little things you take for granted. If you hear a siren, you know if it's coming from the left or the right, he could never do that. If you put your cell phone down and it rings, you don't know where it is because you can't localize it, he could do that for the first time in his life.

Did he vocalize his frustration beforehand?

Dr. Kaylie: Absolutely. The skin would get infected, you'd get blisters, he'd have to wear them for parties, he does children's shows, and so he'd have to wear it for that, but by the end of the day it'd be flaming red and in pain, and he'd be miserable. He'd have to leave it off for several days, and it was a huge inconvenience for him, but also a lot of work. He needed to look right.

How new is this titanium technology?

Dr. Kaylie: It's only in the last five or six years that it's become common in the U.S., particularly for the hearing aid part. The Baja, they've been around since the 70's in Europe, but it really took a long time for it to get over to the US to really make inroads, and a lot of it has to do with insurance coverage for it. That's been the big problem particularly with prosthetics, the hearing parts are getting covered pretty nicely but the prosthetic for ears or for the eyes or for noses, insurance is really lagging behind and not paying for it. Now they're really picking up the slack, and so within the last year or so it's really become something that can be done.

What kinds of centers across the country are doing the same thing?

Dr. Kaylie: First of all you need an incredibly talented doctor who can build the ear. You have to have a surgery center that's familiar with the technology and it takes a lot of experience to do the prosthetics. It takes a lot more experience than the Baja, the hearing part, because for that, the whole, you just put it anywhere and it'll work, but for the ear or for any other prosthetic part on the face, nose or eyes, the posts have to be put in a very specific way and in a very specific spot. It requires a tremendous amount of pre-operative planning and work between the surgeon and the patient to get it right, and so a lot of these people have also had a lot of other surgeries that have failed, so there's a lot of scarring, and so there's a lot of planning and manipulation of the tissue that needs to be done.

Is there a certain place on the head where you place these screws?

Dr. Kaylie: It's in the temporal bone behind the ear, but the problem with the temporal bone is the thickness of the bone can vary, and there's parts that are loaded with air cells and parts that are more thick. These screws need four millimeters of bone to anchor and if it's not put in the right spot, they won't integrate, and they'll just fall out, and it won't work. The surgeon has to plan where the screws can go, because the clips can't go just anywhere on the prosthetic also, they have to be hidden well, and they have to be on thicker parts. It requires a lot of planning in the design of the prosthetic and the placement of the screw so everything works right, so they do integrate and it will be hidden properly on the prosthesis.

How long are these screws, exactly?

Dr. Kaylie: The internal part in the bone is four millimeters, and then there's an external part, that depends on how thick the skin is, but generally about five to seven millimeters. The under-surface of the ear has bars that clip onto it, and they're beveled out in the inside, so it sits flush on the ear and on the head. It clips on, so you've got to rotate it off. Some of them are also held on by magnets.

Are the titanium screws growing inside the person's head?

Dr. Kaylie: The bone has grown into it and anchored it. The external part can actually be unscrewed from the integrated bone and then the skin would just close over it, so it is reversible.

Is the confidence of this patient growing?

Dr. Kaylie: Absolutely. Just imagine not having an ear, is a huge cosmetic deformity. There's no way of not noticing it, and your whole life, everywhere you go, people notice if you don't have an ear. For women to be able to wear your hair up, it's a huge thing. The quality of the prosthetics are absolutely astounding, they're indistinguishable from the real ear, they're really not able to tell the difference unless you were right up close, just studying it. It gives you this whole new confidence that. It's hard to imagine what it would be like to not have an ear, but having worked with these patients to actually hear their stories and what things they go through is pretty amazing. It may not seem like a big deal, but for a woman to be able to say I can actually wear my hair up now if I want to is pretty good.

The cosmetics and the prosthetics, that's the icing isn't it? You could still not have the ear but still hear couldn't you?

Dr. Kaylie: That's possible. It's because there's no ear canal, so his inner ear, the cochlear, the part where the cochlear nerve senses hearing worked, but there was no way for sound to get through because he didn't have an ear canal, the ear drum and the hearing bones. This implantable hearing aid bypasses all of that and stimulates the inner ear directly, so you can do it without putting on the prosthetic ear also, but the two together, it's a wonderful combination.

Does the titanium affect your actual hearing?

Dr. Kaylie: What happens is that for the hearing part, the hearing aid that you wear doesn't amplify sound like a normal hearing aid, which picks up sound and then has an output that's louder. What this hearing aid does is it picks up sound and it vibrates, and it snaps onto the titanium post and it vibrates the skull at very specific frequencies, which then stimulates the inner ear directly, and gives remarkable hearing. Just like the ear snaps onto two of the posts to be anchored on, the hearing aid snaps onto the third post to be anchored on, and that is what gives the hearing improvement. We do those a lot for all kinds of reasons for people who are deaf in one ear. We do the Baja prosthetic for single-sided deafness, so people can hear from their deaf side. The microphone will pick up sound from the deaf side, and send it to their other ear.

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