Episode 29 Show Notes

(Read the episode transcript below)

On episode 29 of All Ears at Child’s Voice: A Hearing Loss Podcast, Tatum and Wendy are joined by Dr. Stephen Hoff. Dr. Stephen Hoff is a pediatric ear, nose and throat (ENT) doctor, with expertise in treating children with ear and hearing issues. As a pediatric otolaryngologist, he specializes in performing surgery of the ear, including cochlear implantation, to restore hearing for children and help them reach their maximum potential. He treats children with complex ear problems, such as cholesteatoma, congenital and acquired hearing loss, microtia and ear malformations, eardrum perforations and recurrent ear infections.

Dr. Hoff is a recognized leader in minimally invasive endoscopic ear surgery, which can provide excellent surgical outcomes for common and complex ear conditions, often with less incisions and an improved recovery. He is also the co-director for the Lurie Children’s Microtia Program and works with a comprehensive team to improve hearing and cosmetic outcomes for children born with malformed ears, including osseointegrated implants and other devices. As one of the two surgeons on the Lurie Children’s cochlear implant program, he treats infants, children and teenagers with sensorineural hearing loss, and truly enjoys taking an individualized approach for every family and their child.

Tatum and Wendy talk to Dr. Hoff about the surgical procedures related to microtia and other disorders. Dr. Hoff talks about his daily life as a surgeon as well as how things have changed in his practice since COVID-19 started as well as much more!

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Special thanks to John McCortney & Michael McCortney for their work recording All Ears at Child’s Voice episodes. Episodes of All Ears at Child’s Voice are graciously edited by John McCortney.

Disclaimer: Child’s Voice is a listening-and-spoken-language program for children with hearing loss. All Ears at Child’s Voice: A Hearing Loss Podcast is a resource provided by Child’s Voice. Reference to any specific product or entity does not constitute an endorsement or recommendation by Child’s Voice. The views expressed by guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent. Views and opinions expressed by Child’s Voice employees are those of the employees and do not necessarily reflect the view of Child’s Voice.

Tatum:

Hi everyone, this is your co-host, Tatum. I am so excited for you to listen to our conversation today with Dr. Hoff about his experience as an ENT working with children with hearing loss. But before we get to today’s episode, I wanted to share some personal news with all of our listeners. We recorded this conversation with Dr. Hoff back in December and shortly after I accepted a speech-language pathologist position at Lurie Children’s Hospital as part of the Aural Rehabilitation and cochlear implant team at Lurie Children’s. So I didn’t know it at the time of our recording but this is actually my last episode as co-host of All Ears at Child’s Voice. I will miss Child’s Voice and especially the podcast and my amazing co-host, Wendy Deters, so much. Having the opportunity to host the podcast with Wendy and with my first co-host Jessica Brock has been an amazing experience and such an interesting and exciting way to further my own development as a professional working in the hearing loss field. I know the podcast with Wendy and now Elise & Haley as the show’s newest hosts will continue to be an amazing resource for professionals and families. And I am so excited to continue to learn from the show as a listener. I want to thank my co-host, Wendy and, my first co-host, Jessica, all our amazing listeners, and Child’s Voice for giving me the opportunity to host the show and I also want to give a special thanks to the show’s amazing sound engineer, John McCortney, who was always been such a joy to work with and without whom the show could definitely not exist. I will always remember this unique and wonderful time in professional career getting to co-host this amazing shows. Thanks for listening!

Wendy:

Welcome to another episode of all ears. At child’s voice, we aim to connect parents of children with hearing loss, with the professionals who serve them.

Tatum:

And I’m Tatum Fritz. Our guest today is Dr. Stephen Hoff. Dr. Hoff is a pediatric ear nose and throat surgeon at Lurie children’s hospital. And he specializes in the treatment of infants, children and adolescents with hearing loss and ear anomalies. He completed his training at Stanford University and is currently an associate professor at Northwestern University at Lurie children’s. He is the director of the microtia clinic in a surgeon on the cochlear implant team. He also started the minimally invasive endoscopic ear surgery program at Lurie children’s. Dr. Hoff, thank you for being here. We are excited to learn from you.

Dr. Hoff:

Thank you for Having me, this is exciting.

Tatum:

If you haven’t listened to the show before, usually before we jump into the main discussion, we like to ask our guests for like a funny story from the past week, or it’s not necessarily funny, but for a story from the past week, it could be something cute, something funny, something heartwarming. Does anything come to mind?

Dr. Hoff:

It does. So this was Thanksgiving week and 2020 is such a different year. That Thanksgiving looked a little different than usual this year. So instead of the big family get together, of course we did just this, which is like a zoom call and then had dinner with just my family. So I have three kids, 10, 8, and 5, and that’s a little different than our usual thing. So the big thing this year was all of my family and the cousins got together online to play this video game called among us, which is basically like an app where you’re kind of like in a space capsule and you try to find out who’s the bad guy. And so the entire Thanksgiving, instead of this big group, get together, was my kids basically running around the house in different colored sweatshirts, because among us, you go by color. So it’s like red or versus blue and things like that. And the entire time was just my kids kind of looking at each other and saying that they looked suspicious or “sus.” And so like a totally surreal experience instead of the big family thing, it was just kind of kids kind of like hiding from each other and saying, you look suspicious. And so it was just kind of summed up 2020 right there,

Wendy :

My seven and a half year old plays it. And he told my husband that he’s playing it. And now my husband is jealous and he wants to play too.

Dr. Hoff:

It’s pretty fun. It doesn’t require a lot of thought, but it’s definitely fun.

Tatum:

It’s really funny. So I’ve seen lots of talk about among us online and I have like a very vague understanding of what it is. That in animal crossing. That’s another thing I wanted to try over 2020. Anyways I realized we jumped to the funny story, but didn’t ask you to share a little bit about your role at Lurie before we go on. Maybe just kind of talk about like what your day to day life looks like, what you do there, and then we’ll get more into it in the main discussion.

Dr. Hoff:

Yeah, absolutely. As you said, I’m a pediatric otolaryngologist. So I see kids with issues and their ear, nose and throat. I mostly see kids with ear issues, which I think is really both interesting, but also kind of fun because you get to follow kids very much over time. So you kind of see how they grow and how they progress and how they’re doing. And it’s kind of fun to watch them grow up. So to speak. At Lurie, I spend about half my time in the operating room and about half the time seeing kids in clinic, both at our downtown campus and then a couple of the suburban sites and the West suburbs. And it’s been really fun coming to work and seeing all these kids every day and seeing the same kids and just doing just that, like talking about what video games they’re into and what superhero movies they’re watching and just kind of interacting with them on that level. And then also all their hearing problems.

Wendy :

How long have you been at Lurie?

Dr. Hoff:

I joined in 2011, so almost 10 years.

Wendy :

Wow. Congratulations.

Dr. Hoff:

Which went by in just a flash. I mean, 2020 is one of those years where time is hard to keep track of it, both dilates and contracts at the same time, but yeah, almost 10 years now.

Wendy :

So before that, how did you come to the decision to specialize in otolaryngology? And what was your career like before you came to Lurie?

Dr. Hoff:

It’s kind of funny. A patient’s parent was actually just asking me that in my clinic, they’re usually lying down on a table so I can look at the ears with a microscope. And I think I was cleaning out ear wax, which is nothing glamorous, but needs to be done for a lot of these kids. And one of the parents just asked, how did you end up here? And I just looked up, it was like a very profound, like, how did I end up here? I think like anything else, it’s just a series of decisions you make in life. My first interaction with Laurie Children’s, which was Children’s Memorial at the time in Lincoln park, in Chicago in college, I actually volunteered on a cancer ward to my entire role as a volunteer was just to entertain the kids. So we just played games and distract them, so to speak that kind of got me interested in medicine because I would see how these kids were doing with their treatment. And I didn’t really know a lot about it at the time, but it got me interested. Then I went to med school here in Chicago, did my residency in Chicago as well, and then went to California for my pediatric training, pediatric ENT fellowship, and then came back. And so, you know, with ENT, you kind of do everything in the head and neck that involves all the small holes in the head. So the ears, the nose and the throat, but most of it’s fairly hidden. We do see kids with big neck masses and more obvious issues, but most of it is kind of hidden in the throat or in the nose and the ears, especially. And it’s just As time went on, it just kind of was drawn to the incredibly detailed anatomy and complexity that’s inside the ear and how it works and how much hearing and hearing issues impact these kids and have like a profound change in their life, whether or not they can hear and how well they’re interacting, particularly with other people. So other kids and their families and things like that. So just a series of decisions where I ended up cleaning ear wax, but it’s been very fun so far.

Wendy :

So aside from removing earwax and microsurgery, what are the other main interests in the field of ENT? What other kinds of procedures do you do?

Dr. Hoff:

Yeah, the middle ear, which is the area behind your eardrum is a really small cavity. So, you know, the entire volume would be maybe one of the cubes of a Rubik’s cube, one of those small cubes, and there’s just incredibly detailed anatomy and physiology in there controlling the little bones for hearing the ossicles, the nerves that are controlling your face and taste. And some of the surgeries we do take five, six hours and you’re in that tiny space the entire time. And it’s just very intricate. And I think that’s what I enjoy about it. It’s just the kind of the detail work. It’s not just the work. It’s kind of like how much it changes for these kids. How much of impact you can have. I do enjoy that the detailed work in med school, you go through different rotations and there’s different types of surgery. Of course, orthopedic surgery was another kind of option and that’s more involving large hammers and chisels, which was fun. But ENT tends to be more microscopic detail work where you’re spending hours doing tiny little movements with your hands. And, and I enjoy that. I think video games really helped to train for that.

Wendy :

I’ve heard that a lot, a lot of doctors are into video games.

Dr. Hoff:

I think it’s true. I still play with my kids and played growing up. I don’t know if it’s true or not. There have been actually some studies trying to look at that and maybe some evidence, some soft evidence on that, but I think it does help with that fine muscle movement and find muscle memory that you can have, especially translating that into what I do, which requires very small muscle movements in the hand.

Speaker 1:

So aside from removing earwax and microsurgery, what are the other main interests in the field of ENT, what other kinds of procedures do you do?

Dr. Hoff:

Ear things. So that’s kids who were born with or develop hearing loss. The main surgeries are cochlear implant surgery for the kids with hearing loss, but also anything that’s causing difficulty and transmission from the sound waves all the way from the outer ear to the inner ear. So a lot of that is issues with the eardrum holes in the eardrum or the little ossicle bones behind the eardrum. And actually what we’re doing now is approaching them in that minimally invasive way. So using the endoscopes to go through the natural ear canal and really this is that that technology has just gotten better and smaller so that the majority of the surgery now can be done just through the ear canal. And so there’s no visible incision on the outside and just be able to fix whatever problem might be in there, be it a hole in the eardrum or replacing one of those tiny little replacing one of those tiny little ossicles which are kind of the smallest bones in your body using these telescopes and then putting everything back together. So there’s no visible scar or visible surgery site. So that’s been really fun. Then another big thing I’m into is the microtia clinic, which is kids who have small ears or born without an ear. And usually that means without an ear canal, which is usually a bit of a shock for the parents at first. And so there’s a lot that goes into that and it has been really rewarding.

Tatum:

Yeah. We definitely want to ask you more about the microtia clinic. We’ve talked some about microta on the show. Well we did dedicate an episode to it, but most of our show has focused on implants and hearing aids So we definitely want to talk more about that.

Wendy :

I think with that episode, we talked a lot about function, like language and listening development. So we’re looking forward to talking more about the surgery and technology. So we’re really excited to talk to you about these conditions from a medical perspective.

Dr. Hoff:

Yeah. And it’s kind of, you know, as far as surgeries go there’s obviously there’s different types of different complexities, but I’d say as far as cochlear implants are probably the most rewarding, so to speak, just because you are taking somebody who has not had any hearing typically or has lost it and you’re bringing that back, but really the endoscopic ear surgery is kind of the most fun, like the video game style surgery, where you have a very small field and you’re working in that. But really for my microtia the most technically demanding kind of on-point surgery is that the rebuilding of the ear so that, you know, like actually using cartilage from the ribs and then literally sculpting it into an ear to match the other side. So that there’s kind of different categories of surgery, to kind of rewarding, fun and, and demanding. And some are all three in, but there’s certain, each day is a little different. And that’s, that’s part of the fun,

Tatum:

I know you mentioned you’re in clinic, you’re in surgeries, but what does a day look like? Do you start in surgery then go to clinic ?

Dr. Hoff:

Sometimes? it tends to be, I either do all day of surgery or all day of clinic, but some are kind of half and half. But I will typically come in pretty early. I think it’s a trend in medicine to just kind of get here as early as you can. My typical day we’ll either have one or two kind of what we’d call bigger ear surgeries, which are, you know, multi hour, one say maybe like four hour or even more. And kind of the shorter surgery. So ear tubes, are a very quick procedure. And we see a lot of kids who need ear tubes. So you may have a day where you happen to see 10 kids who need ear tubes and kind of just do all those in one day. I’m over in clinic. And I work with, I I’m lucky enough to work with a pretty consistent team in clinic. And so we have a great time, you know, it’s, it’s, you know, You see some of the same kids over and over, I work with Armando Morales, who is a nursing specialist here and he and I are, are just great friends and we’ll work different clinics together. So it it’s clinic itself can be, I don’t know, just a fun place to be. And then we tend to have impromptu almost round-table discussions about different issues that come up or one of our trainees will come in with something that they never heard of. And so we have a quick discussion about it, or we look it up on Google or something like that, but it tends to be a little bit more relaxed, but either way, either being in the clinic or in the, OR it’s very much, you’re pretty mobile. I kind of like that. Like, there’s always, you’re always on the move. You’re always kind of moving from one room to the next or in the operating room. Your movie, you know, During the surgery, obviously you’re kind of in one spot, but it’s always this kind of flow of moving from pre-op to post-op and kind of interacting with this team of people that you see every day. It’s a very fun place. The operating room is a unique place where there’s, you know, there’s a lot of procedures and people counting things cause you don’t want to lose anything obviously. But it’s, it’s just a very unique place to be that, once you get the flow it’s pretty fun.

Wendy :

We had the opportunity last summer to observe a cochlear implant surgery and it is just absolutely fascinating and there really does seem to be a flow. And you can tell that everyone in the room has this great relationship with one another and you have sort of your own language that you have in there. It’s really incredible.

Dr. Hoff:

Yeah. That’s, you know, everybody has their own role. Everybody has their own role and they all just interact. And like you said, people are people just kind of know, it’s almost like a choreographed. I don’t wanna say dance, but it’s just a choreograph session where people are just moving and flowing and obviously all have the same end goal in mind, but are doing different parts of that team. And so it’s a fun place to be. I think most surgeons would agree that clinic is an interesting part of the job, but really the operating room is where you want to be. That’s where, that’s where you can. Just kinda that’s where you can interact with the entire team. That’s where you can just kind of do your craft and that’s where you feel the most comfortable.

Tatum:

Yeah. That’s kinda nice too, that each person in the room is like, especially skilled at like whatever they need to be doing.

Tatum:

Yeah, exactly. Even if it’s counting, which is a very, I don’t know if you saw that in your observation, but you know, you’re constantly getting a count. And there’s just so much going on in the background while at the same time you’re staying completely focused and that’s part of the that’s part of how it works, I guess, is that like, I can stay completely focused on what I’m doing and yet, and, and the anesthesiologist is completely focused on what they’re doing. But at the same time, everybody’s doing their own role in taking care of each thing that needs to happen. And it’s, it’s a great place to be. And like I was saying before you can you kind of interact with the same people each time. So it’s, I don’t know, if I compare it to like a sports team or maybe a space shuttle thing where it’s just, everybody has their exact role and you know exactly where people should be. It’s, it’s it’s a great place to be.

Wendy :

I find that really comforting. As a parent to know that there are so many highly skilled professionals who are all working together to take care of my child,

Dr. Hoff:

You know, just the thought of having your child go under anesthesia is, is anxiety provoking and terrifying, frankly, for a lot of parents. And so, you know, we talk to them about how it goes, but also just taking care of the kid. Like a lot of it is not just, you know, who’s going to move the equipment around the room. It’s who’s who’s the one turning the music on and asking like each kid gets like pick a song or like we interact. We have iPads that we come back with. We actually have child life specialists whose entire job it is to frankly just distract the kids and blow bubbles and like make it a fun environment. So they’re, they’re not worried. And the parents aren’t either. And we all kind of do all of everything. I mean half the time, I’m the one picking the cartoon to watch, or like asking the kid about, you know, all the different characters in whatever show they’re in. I try to keep up with most, most of the current shows, so I can just ask them all the Paw Patrol characters or whoever it happens to be just so they, so they don’t feel like they’re in a terrifying place and they just feel like, yeah, it’s just something that’s going to happen and we’re going to have fun and then it’s over. And then they have a Popsicle in their hand.

Tatum:

I want to go into more about the microtia part. So Wendy and I work in early intervention. So most of our kids that we see are under three, we see a couple of kids over three, but so most of our kids have soft bands. And then I really just because of that, like where I’ve worked since graduating from grad school, I haven’t really been through the process of families, like choosing an implantable device if that’s indicated or going with reconstruction of the pinna or the outer ear. Can you walk us through that?

Dr. Hoff:

Yeah. And it really has changed recently, I mean, you know, I’ve been with Lurie children’s almost 10 years and within that time almost everything has changed. So you’re right. So, first typically with microtia will have a small ear or an ear remnant, so something there, but it doesn’t necessarily look like an ear and they typically don’t also have that ear canal. So they have a conductive hearing loss and the sound can’t get through to the inner ear as well. So very muffled hearing. And so the you know, I’m fortunate to work with a team of audiologists and plastic surgeons and everybody who we all kind of work together, but we try to identify these kids really early and get them diagnostic, hearing testing, so know exactly what their hearing status is. And just keep following them over time with hearing testing but also treat that hearing loss at each stage. So you’re right. Typically the young kids are offered the soft band, which is that headband that has the bone conduction aid, which then vibrates and vibrates the school itself on the back of the head. And that vibration is then sent directly to the inner ear to the cochlea. And so then they perceive that as sound. So it completely bypasses that missing ear canal. And the soft band is a great option and a lot of kids will just wear that up until they’re around five, which is kind of usually the next decision point. And some kids will just keep wearing it because it works great. And in fact, we have a kid that I follow whose parents wrote a book about her daughter’s microtia and daughter’s soft band. And they they call it Rebecca’s superpower. So her BAHA device is her superpower, because it’s working so well, but there are other options. And part of the process is showing those to the families and to the kids. Now there’s an adhesive one that goes behind the ear called the ADHEAR, where they wear basically a sticker behind the ear and then click the device on and off the sticker. So it’s a little less visible. It’s not a headband going across the head. And then when they’re older, there are other non-invasive options. There’s one that goes behind the head called the Sound Arc, which also uses the BAHA device. Then there’s kind of a headband that looks more like a hair, a headband as well. They can use. Here’ve been other devices previously that would be like almost like a denture that they can put in and hear that way. Cause if it vibrates any bone in the head will work that wasn’t particularly popular with the kids, I don’t think. Then around age five, u, typically do a little bit more diagnostic testing and then testing with, and without the devices to see if they’re interested in just keeping the one they have or even doing a surgically implanted one. And that typically involves the  audiologist. We mainly work with Colleen Ittner. She is an audiology specialist for these kids with microtia where they go and do diagnostic testing, but also simulated noise. So they’ll test the kids with, and without these devices, ad then with, and without noisy environments, t frankly see how well they do and how much improved their speech perception is, and then how much they like it, because most of these kids do pretty well. When they only have microtia on one side, you know, is they can still hear well with the other side. And so they can usually get by in daily life when things get noisy. So like a restaurant or cafeteria, that’s when they really start to struggle. And so that’s the environment we’re trying to simulate in the sound booth and see if one of these other devices would work.

Wendy :

If the family does decide that they want to surgically implant the device. Does that go along with the reconstruction? Like, did those happen at the same time? That is something that Tatum and I don’t have as much experience with the reconstruction since we work with young children and mostly with sensorineural

Dr. Hoff:

You’re correct. We could do both of those at the same time or separate, and they are very we’re treating the same problem, but kind of two aspects of it. So it is very separate. The hearing device is obviously bringing back the hearing with that goal. And then the rebuilding of the ear is much more of a cosmetic psychological procedure, but it doesn’t have function as far as hearing. So typically the reconstruction of the ear is done around age 10, or at least after age 10. There are some techniques that can provide a reconstructed ear earlier one of the cartilage techniques tended to, but this is the kind of thing where when you’re using cartilage from your own body, which is currently the go-to technique because it’s tissue from your own body. So it doesn’t get rejected and your body accepts that. And it is the kind of thing where you can make it look like the the normal or a native ear, so to speak. Kids don’t really have enough to work with until they’re around 10, but that’s also an age where they can participate much more in the decision-making, it’s a really big procedure. And it also requires a lot of care afterwards, like wound care and, you know, little kids just aren’t really ready to take care of it. And they, frankly just don’t really understand the process. Whereas somebody who is 10 or a lot of times, we’ll see teenagers for the first time who really want to decide what, what they want to do. And so we give them all the options. I mean, they can, as far as the reconstruction of the ear, they can certainly just keep what they have and that’s fine if they’re doing fine, it’s some of them feel like it’s almost like a confidence thing. Like this is what I was born with, and this is what I’m going to have and great, totally fine. Some kids want the reconstruction and we can offer them that. But of course we kind of take them through the process of that. And then there are some other options such as a prosthetic ear where you implant some magnets and then they have an anaplastologist creates an ear that looks just like their real one and airbrushes it. And they kind of click that on and off which looks very realistic, but a lot of them don’t necessarily feel comfortable with that process of taking it on and off. And then there is another way to reconstruct with something called MEDPOR, which is kind of like a plastic internal implant, but that’s covered with natural tissue and that one typically can be done at a younger age. But the risk there is that if anything ever hits that ear, that plastic can actually come out and not that then it wouldn’t look good at all because there would just be a big scar there. So in our opinion, the cartilage is best because it you know, it’s, it’s your own tissue and you can do sports and things like that. But yeah, you really have to be after 10.

Wendy :

What part of the body does the cartilage come from?

Dr. Hoff:

From the ribs actually. So the sternum or breast bone in the middle of your rib cage is bone, but then the part of the ribs that is between the sternum and then kind of the side of the chest is all cartilage. And then the ribs going back to the spine are bone. So the lower ribs are not really doing much as far as keeping the rib cage intact and you’re able to take out actually portions of four of them. And then, so in sculpt to those four together to make it look like an ear, you tuck it into a little pocket that you create, and then you actually use these kind of suctions to suction the skin down. And that’s always, actually a, a great moment in the operating room, because up until that point, it looks like what we call a scaffold. So it looks roughly like an ear. But you can’t really, it doesn’t have, it’s not covered with the skin. So when you tuck it under the skin and then turn the vacuum on the little suction drains, it brings the skin down to the scaffold. And at that moment it suddenly looks like they have an ear and everybody in the operating room kind of gasps. It’s like, wow, it, it like it worked. Yeah. And so that’s always like a really fun moment in the operating room.

Tatum:

That’s really cool. It sounds rewarding. I have a lot of followup questions. First question. So the kids, that’s interesting you think about so the kids are older and part of the decision making process, and it sounds like it does sound like a big decision. Is social work involved in that or like some type of counselor or do you bring in other specialists to help with that conversation?

Dr. Hoff:

Yeah, absolutely. As far as the surgery itself I was doing most of that here at Lurie. Now I’m doing, I’m so busy with the hearing stuff we’ve brought in the plastic surgeons and so Dr. Akira Amata from plastic surgery, that’s his specialty. So he’ll be doing the actual reconstructions now. He’s taken over that portion, but yeah, we, in our actual microtia clinic where patients come in, they’ll meet with myself with plastic surgery with audiology. And then in addition to that, we have social workers, psychologists, genetics specialists, speech therapists, who will also work with these patients and these kids to help them make decisions and ask questions. It tends to be for my microtia kids, don’t really become what we call self-aware until around age five or six, where they don’t even really realize, or they don’t really care that their ear looks different. But then around that age, they start to notice that that ear looks different and other kids of course do too. And kids aren’t always nice in elementary school. So, hat’s when we really want to bring in the whole, you know, like, are you being bullied? Just type of thing to make sure that they are, okay. To develop resilience and make sure that they have all the resources they need to get through.

Tatum:

And then my other follow up question is on the opposite. It’s not related to that, but since it is kind of a cosmetic surgery, is there ever an issue with like insurance approval for it?

Dr. Hoff:

Usually not because this is considered reconstructive, so it’s basically a congenital, so they were born with it reconstructive surgery. So it would be similar to a cleft palate or cleft lip, or orthopedic surgery, like a club foot type of thing, where there was a congenital malformation that that is amenable to being fixed. Whereas it’s not, it’s less so than just a cosmetic make me look good on Instagram type of, ear or nose surgery. Yeah.

Wendy :

How often do kids with microtia/ atresia have other cranial facial differences?

Dr. Hoff:

Sometimes is the short answer. Usually they don’t. And usually it’s just the microtia. It happens to be usually on the right side. So usually it’s just one side and more often on the right. But about 30% of the kids will have some other cranial facial anomalies. Sometimes it’s just that their jaw is a little short on that side. Sometimes they have some extra kind of dimples or pits on the face or neck. And then there’s a huge spectrum all the way to known syndromes with microtia. So Treacher Collins syndrome is probably the most well-known, which is also the movie and book Wonder that child has Treacher Collins syndrome. There’s Goldenhar syndrome, or OAVS as it’s known. And so there’s several syndromes that are well known to have, microtia associated with them, but then also other issues with typically the jaw, the spine, the heart, and, other anomalies that need treatment, But they have a big part of that too, is their hearing treatment. I didn’t even get into the whole, to your actual question on, when do we, when do I do the hearing implant? I’m too busy talking.

Tatum:

And this is all stuff that Wendy and I are less familiar with.

Dr. Hoff:

To get back to that, the reconstruction of the outer ear, any, so anytime after 10 is the general rule but the reconstruction of the hearing really depends on age too, because it used to be the soft band was their option and it worked great. Still does. But now there’s other non reconstructive options. The, the that I mentioned the adhesive one and the headband. Now as far as implantable ones, there’s of course the implantable, what we call the percutaneous BAHA, which is the one that has the metal post coming out of the head. And then there are the implantable magnetic BAHA, which is called the Attract, which kids can get as young as age five. So usually that’s the point where we start thinking about, you know, if the soft band is going really well, but they don’t want to wear the headband or they do want it so they have a more permanent implant. Then after age five, we start having a discussion about that particular device. And actually we started, we switched over from the posts to the magnet to the Attract around 2013 when it first came out and it’s been a huge difference, but now even better now, there’s even more devices that have come out recently one of which is the same company that makes the BAHA. So, Cochlear Americas, and then another one by a company Med El both of which make cochlear implants, of course. And those devices are the Cochlear Osia or the Med El Bone Bridge. And they do a similar thing in that they take over for the bone conduction and send that sound directly to the cochlea, but they do it in an even more efficient manner, so to speak. And they’re just really great options. And they’re both fairly new to the market. I mean, they’ve been well tested and everything, but they’re just, haven’t been available in the United States quite as long. But kids are eligible for those currently at age 12. So there’s all these kinds of decision points at which we kind of restart the conversation, or if somebody is 11 and really wants one, we’re like, okay, well, you know, we’ll just keep using the soft band and maybe come back next year. Or we’ll, we’ll kind of push for doing it a little earlier, but you’re right in that it depends on when we’re going to do that. Typically we’ll try to do the hearing part either fully before or fully after the reconstruction, just to save them from some surgical time. And we’re both using kind of different areas and we wouldn’t want to be operating in too many different areas at the same time and kind of cross contaminate there. So I’d say the typical thing is we’ll do the hearing, usually the hearing is first, but sometimes, sometimes after, but they tend to be separated.

Tatum:

It sounds like it can vary a little.

Wendy :

Would it be possible for a child to have say a BAHA surgery around five years old and then get the other surgery at a later time? Like, does the post from the BAHA surgery, is that able to be removed or does it become sort of integrated into the body?

Dr. Hoff:

The PO yeah, The post itself can be removed. And so the post for decades was, and still is a good option as far as like the hearing is excellent with the post. So the percutaneous BAHA, because they click that directly onto the post and the post is connected directly to the bone and then it sends a signal in. But the problem is the post has a lot of issues with the skin around the post chronically gets infected or overgrows and makes it so you can’t even click the device on. So a lot of those kids up to 70, to 100% of those kids have chronic skin issues and need further surgeries just to try to fix that post. And it becomes a real pain. And then I got to say the nobody’s particularly enthusiastic child or parent about having a metal post sticking out of their head. So that’s where the magnets really have come in. So I will see kids that have had the post and we will convert them over to the magnet one, so that can actually be removed. The implant itself, that’s attached to the bone really stays there, but that part is kind of flush with the bone. And so the outer post is removed and then that can be replaced with a magnet on the BAHA attract and the magnet, the internal magnet is about the size of a quarter, and that just sits on top of bone. And then the skin covers that, such that from the outside, you’d never see that there’s anything there unless they’re wearing their actual device, but there’s nothing sticking through the skin. And then even for these newer devices for that particular one, the Cochlear brand, the Osia uses that same bone implant. So theoretically they could use that same bone implant to even get the latest and greatest device, the Osia. The only thing that determines there is whether the location will be the same, because, you know, you don’t want to, the Osia is a little, just positioned a little differently. You wouldn’t want it to end up in a funny position that you’d like on top of their head or something like that. So sometimes you may just have to move that back.

Wendy :

It looks like the single unit cochlear implant, right?

Dr. Hoff:

Yeah. And that’s a real advantage. The, so the newer two. So these are what we call the transcutaneous active piezoelectric bone conduction implants. That’s just that there’s a part implanted into the bone and then the signal is being sent in, and transmitting the sound. But both of them, the Osia and the Bone Bridge transmit the sound even better than the BAHA Attract. And that’s particularly true for high frequencies. So higher pitch sounds in which the BAHA Attract doesn’t do a great job of transmitting those and that’s important for our kids because like F and S are an example of a higher pitch sound that they should know the difference between and so their sound transmission is better, but you’re right. It’s a very, it’s a much lower profile. It looks very similar to external cochlear implant the button device and it also doesn’t vibrate, which is a big step up as far as the bone conduction AIDS go because the BAHA and the Ad Hear or any bone conduction aid typically works by vibrating and it vibrates and sends that signal in. But the problem is kids get feedback with that. So if they sit too close to their chair or they’re wearing a hat, the device will start vibrating and cause an an audible feedback sound that everybody around them can hear. Whereas these devices don’t do that at all. They send this signal in and the internal portion vibrates using a piezoelectric signal. So they’ll use kind of a ceramic on the inside a little bit electrical charge, which is, you know, incredibly small charge, but that makes it actually vibrate. And so there, the outside part doesn’t vibrate at all, and they don’t feel the inside part vibrating either, but it’s, it’s a big improvement because it’s lower profile and it doesn’t cause that feedback and actually causes better sound transmission. So that’s why we’re really excited about these, the Osia and Bone Bridge is kind of the active transcutaneous devices. These are the next thing

Tatum:

That’s so cool. So you said those kids are eligible to get them by 12. Is there a reason for that? Is it just like FDA approval?

Dr. Hoff:

FDA

Tatum:

Could you explain that for our listeners?

Dr. Hoff:

Sure. I’m not entirely sure if that’s just because that’s the age that the companies applied for or the FDA, I don’t believe they had a particular opinion about it. One of those With both of them, you need a certain thickness of bone there. So certainly very young kids really wouldn’t be eligible, but with both of those devices you know, we do it’s very similar to the surgery that we do for the attract at age five. So like anything including like cochlear implants up until very recently, cochlear implants, weren’t FDA approved until age one, but we certainly did them many times under age one is probably a similar thing where people across the country and world will be doing it off-label. Knowing that it’s a safe surgery and knowing that it’s something that will work well for these children, just like we knew and do know that cochlear implants work well for children under one, whether the FDA you know, officially approves that or not. So as long as we know it’s safe and appropriate I think we’ll see a bit of of a gray zone there.

Tatum:

Yeah. I kind of thought it might be kind of a combination.

Dr. Hoff:

Yeah. It does add a little bit of a tricky part of the conversation because, you know, between age 5 to 12, we have to make some decisions as to hold off for one of these newer ones or not. And obviously every patient is very different and has different needs and wants. And so But that’s a whole part of the conversation that really wasn’t didn’t come into play until very recently.

Tatum:

So say a kid got another option at like age 5, like the Attract or something that has been implanted. And then they want to switch over to the Osia or something like that at 12. Is there an insurance, could there be an insurance difficulty there where an insurance company might say like, well, you already have a working device.

Dr. Hoff:

There could be. And it totally depends on not only the child’s kind of auditory situation, so what their need is. But also their insurance company. And frankly, it seems like part of that is up to whoever at that insurance company happens to be, you know, stamping approval or denial that day. Which is to say we don’t give up easy. So, you know, if we tend to you’re right, if you just got one device, it’s unlikely that they’ll approve another one immediately after that’s totally kind of serving the same purpose and within that window, but typically if a child did have say a BAHA Attract or the percutaneous BAHA we’re switching them over, typically after an interval of about three years they’ll get approval for another one or if we do get a denial letter, then usually we just need to be a little more specific about why what’s necessary or what we think is appropriate for this particular child. And they’re pretty reasonable with that. And we have had a lot of success with switching kids, taking a kid who already had the BAHA post, the percutaneous BAHA and so taking that out and directly switching them over to the Attract device and typically they’ll get a new pro if they’re due for a new processor. So currently the BAHA is in version five but a lot of these kids have been using older ones. If they’re due for a new one, they’ll get a new one at that time, too.

Tatum:

Yeah. I was wondering how that might play in the decision-making at five families would be worried about like, well then we can’t do this at 12.

Dr. Hoff:

No, not typically, just cause that gap is so large.

Tatum:

It’s a lot. Yeah. That makes sense.

Dr. Hoff:

You know, like anything with technology, like I’ll use an iPhone as an example, of course you want the latest and greatest but it’s always getting better. So cochlear implants are another thing, very similar to these bone conduction devices where you always wonder, well, if I hold off for the latest, the next generation, will it be better? And possibly some things will be better, but then you’re kinda missing out on that window of what you could be hearing up until that point. And a lot of things that are getting better with these devices as you guys know, is, are, are more like external capability. So compatibility with smartphones and Bluetooth and water and things that are an advantage, but not necessarily an advantage for hearing. So I don’t know, I think all the current devices are, are great and that’s one of the advantages. And one of the big things that’s changed over the last 10 years is it really used to be a more linear path of, well, here’s your device and take, you know we’ll see if you want this per this one, but now there’s, I think there’s five of the non-surgical and four of the surgical. So it it’s more of just kind of a big tree, like a decision tree there that is a lot more fun. And we kind of have a whole session where they, they see each device and kind of hold them and each one has different color skins that you can put on. And so that’s kind of part of the whole selection process where they get to pick some, some will want it to be their hair color to kind of make it blend in. And some of them want the neon green one and just make it stand out and just like, Oh, totally own it. So that’s kind of fun to see.

Tatum:

Yeah. It’s so cool how many options there are.

Dr. Hoff:

That was one of the fun things about living in Silicon Valley for a while was all the new tech companies. I mean, which is everything out there wanting to try out all their new, they wanted to show off what they had at Stanford. And so you got, you just saw so many interesting options including that sound bite one, which was the one where you just chomp down on to hear which they’re using now in the military. There’s just so many creative technology options. It’s fun.

Tatum:

This has been really fascinating to hear about everything that you do. And I feel like I’ve already learned a ton that I had like a vague sense of knowledge about when it comes to microtia but not as detailed as you just were able to provide. So that’s gonna immediately like, make me more confident in talking to parents about this. So I’m glad we’ve had you on I’m curious you’ve been, we’ve referred to 2020 a couple of times in the episode already, how has COVID 19 kind of affected your practice and like day to day life? What changes have you thinks has Lurie like gone through?

Dr. Hoff:

Yeah, I mean, and obviously like everybody, everything has changed, but you know, initially back in March and April, it was almost a total shutdown because just like everywhere nobody knew what was happening and the hospitals seem to be filling up fast. And we actually kind of designed Lurie to be almost like an overflow hospital if needed, which fortunately it wasn’t needed. But there was really a hold on what, you know, what we could do, you know, we were holding off on almost all surgeries. But starting around may and up till now, we’re as far as procedures, we’re almost back to, I wouldn’t say back to normal because nothing’s normal, but a lot of the stuff just shouldn’t wait. So kids are still being born with hearing loss. And a big part of what I do is taking cholesteatoma which are like a skin cyst within the ear which behave in some ways like a tumor in that they just keep growing over time and it can be very destructive. So those are the kinds of things you don’t wait for. And so there’s a lot that still needs to be done. And so what we’re really just trying to do is take precautions. So I, you know, universal masking everybody before getting a procedure, gets a COVID tests to make sure that they’re not exposing our staff. And it really does feel very safe and has been safe. We’ve done, you know, hundreds and hundreds of procedures in the summer and fall of 2020. And it’s been a very safe environment but we’re all really optimistic for the vaccine and kind of hopefully getting back to kind of normal. And if anything’s been good to come out of it, it’s really kind of forced our hand into doing much more creative telemedicine and things that have always been around and we’ve dabbled with, but when you can’t see somebody in person, then you do a telemedicine. So we’ve all become very facile with Zoom and, and Star Leaf and other telemedicine apps that we can do, which I think is actually pretty great and something that’ll will last well beyond COVID, especially for our families that are coming from really far away. So it’s a great way to see them,

Tatum:

I think, yeah, in the beginning it was so like, everything felt so scary and obviously like things are still, there’s still reasons to be safe and we’re not in the clear, and I’m not trying to downplay like the way things are now, but my husband works in a hospital in the beginning It just felt like scary, like sending him off to work every day and then like the procedures to stay safe they work and now I feel like very comfortable with him going to his job at the hospital and more worried when he like goes to the grocery store.

Dr. Hoff:

And at first, you know, we, nobody really knew, you know, can you get it by touching a table and things like that. And now we just, we know more and we know how to stay safer. Like I had a change of clothes in my car and like, it was all this you got to immediately jumped in the shower and it was just, it was a pretty frightening time. And certainly we’re not through it yet, but it feels there’s less just daily anxiety, I think. So that, that has made it, so it really does feel pretty safe. And so the hospital just, you know, needs to be here. So we just keep coming in.

Wendy :

Another COVID related question that is coming up in schools and with some of our families of children with hearing loss, how are you at the hospital working with kids who need visual cues when everyone has masks on, do you have clear masks? What, are you guys doing?

Dr. Hoff:

And you’re right. I mean, these kids with hearing loss, losing that ability to see lips is a big deal. So we do have the clear masks we don’t use. I don’t use them for every patient. The audiologists are much more likely to, cause they’re doing much longer sessions with our kids with hearing loss. But those have really helped where it’s a clear kind of plastic shield and so that you can still see the visual cues for hearing. So that has really helped. These kids. And then yeah, I guess that’s, you know, Telemedicine is a little harder there that, but it tends to be a good way to do kind of the entire counseling session, which a lot of my life in clinic is just talking. And so I can talk on a zoom call just as well as I can talk in the clinic room. And so that I think is really nice for families to be able to kind of get that visit without the burden of, or risk, I guess, of kind of coming into a hospital environment.

Tatum:

Yeah. I agree that the one, like a positive of everything that has been going on is just like, we’ve also like delved into like telemedicine. Now I have teletherapy skills I didn’t have like 8 months ago. And it’s like strengthened my skills as a clinician, I think.

Dr. Hoff:

Yeah. It’s like a whole new set. Yeah.

Wendy :

When I was in school parent coaching, wasn’t the way that I was taught. But with teletherapy that to be how it is. So for me, it’s made my parent coaching skills so much stronger.

Tatum:

So we’re going to start trying to wrap things up. It’s been really nice having you on the show. Before we wrap up, do you have any are you involved with any research at Lurie children’s that you’d like to share about?

Dr. Hoff:

I am, we always have a lot of projects going on both related with cochlear implants, especially implanting really to fix hearing loss that way. But one of the kind of related things to this as we have a project going on with the collaboration, with some of our bioengineers to do biocompatible, 3D printing of kids with microtia. So you can kind of, the idea would be to take a scan of their good or normal ear, or just a kind of a template of one and then be able to print out a biocompatible material and then implant that instead of using the cartilage. So whether that becomes the future or something similar, I think that’s kind of the next big step. And so we’re trying to participate in that too. It’s been fun.

Wendy :

That is really cool. And I would imagine the recovery from where you take the cartilage is pretty extensive. Right?

Dr. Hoff:

Right. They that’s where they, you know, the post-operative care and kind of pain tends to be from that site. Which currently still is the best option, but I’m sure just like anything a hundred years from now, they’ll probably think that was a barbaric thing to do because they’ll just be able to print out whatever they need to, but we got to get there.

Wendy :

What else do you see happening over the next 10 years in the field of ENT?

Dr. Hoff:

I think it really is related to technology. I mean, the surgeries will stay relatively similar, but most of it has to do with making smaller and smaller optics to get to smaller and smaller places and cameras that go into the cochlea itself. And a lot of what people are working on is using virtual and augmented reality in the operating room more before to where, you know, i get a CAT scan and then have a virtual reality where the surgeon can wear kind of VR goggles and then do almost like a fly through of that ear before surgery. So you can know based on the CAT scan, what to predict and kind of like move around and in 3D real time. And, and I mean, those things already exist, but they’re going to get better and better or using an augmented reality overlay in the operating room to show anatomical structures that you can’t see because they’re hidden or using 3D goggles in glasses and optics in the operating room. And these are all already starting, but it’s going to be really exciting to see where they go over the next 10 years. And I think it’s mostly going to be technology driven.

Tatum:

That’s really fascinating. I think when I was in grad school, they were doing research on using CAT scan to like help with like, or like to reconstruct like image of the cochlea to help with like the placement of the electrode array.

Dr. Hoff:

Yeah, exactly. And there’s some groups that are doing that particularly out of North Carolina and Vanderbilt that you can predict where the array should sit and, and that will help program the array so that you can get that tonotopic organization. So you can predict where in the cochlea, certain frequencies should go and kind of where their natural placements should be. I think all that’s going to be just amazing to see you know, what, what people come up with.

Tatum:

So cool. And then the last question we like to ask guests before we wrap is just for any advice for our audience. So most of the people who listen to the show are either parents are professionals, so it could either be geared towards both or one of those, whatever you have to share

Dr. Hoff:

Medical advice, I’d mostly just say well, I guess it’s medical and and just wellness advice, just take care of your ears. So protect your ears from noises that are too loud, but really what I mean is just treat your ears to some good sounds like good music. Like there’s nothing I like more than just turning on some good music, whether you have protective or or sound noise-canceling headphones or not, or like what I do with my family, we just have the Alexa crank up some dance music in the kitchen and we all just dance around. So I’d say, obviously protect your ears from music and other sources of, of trauma that can damage them, but really just more treat your ears to some good music and some good sounds that I personally think that you know, music is almost art in time and there’s nothing more important to wellness and than hearing and music.

Wendy :

Thank you. That was good advice.

Tatum:

This has been so fun. So thank you, Dr. Hoff for joining the show today, this has been really interesting and I know I personally learned a lot. Do you have any contact information for where our listeners can find you?

Dr. Hoff:

Absolutely. So on that Lurie children’s our main contact number direct line is (312) 227-6230. And that will get you directly in contact with our office and all of the kind of all of the email and contact info that somebody would be able to get ahold of us.

Tatum:

Well, thank you for joining us for another episode of all ears at Child’s Voice, be sure to join us for our next we release episodes once monthly.

Wendy :

If you’d like to reach out to us. You can find us on Twitter and Instagram. I’m @wendydetersslp and Tatum is @tatumfritzslp.

Tatum:

You can also email us at podcast at child’s voice.org, and you can find episodes, show notes and archived episodes of our episode show notes and episode transcripts at our child’s voice website, child’s voice.org.

Wendy :

If you’re interested in learning more about child’s voice. You can find us on Facebook and Instagram with the handle @childs_voice

Tatum:

Voice. We’ll see you next time.

Wendy :

Bye.

Tatum:

Bye.