What is the most appropriate option for hearing rehabilitation in a patient with profound Sensorineural Hearing Loss (SNHL) in one ear, a history of scalp psoriasis and skin infections, and inability to tolerate external hearing aids?

Cochlear Implant is the Most Appropriate Option

For a patient with profound unilateral SNHL who cannot tolerate external hearing aids and has scalp psoriasis/skin infections, cochlear implantation is the definitive choice for hearing rehabilitation, as it provides direct cochlear stimulation with significant improvements in sound localization, speech discrimination, and quality of life without requiring skin contact that would exacerbate dermatologic conditions. 1

Why Cochlear Implant is Superior in This Case

Direct Rehabilitation of the Affected Ear

• Cochlear implantation directly rehabilitates the profoundly deaf ear through electrical stimulation of the cochlea, bypassing the need for any external device contact with the scalp or ear canal 1
• In patients with unrecovered severe to profound SNHL, cochlear implants provide improvement in sound localization and speech discrimination, with 96% of patients experiencing tinnitus improvement if present 1
• The device provides both improved hearing and significant improvement in quality of life specifically for unilateral SNHL 1

Avoids Skin Contact Issues

• The internal receiver-stimulator is completely implanted beneath the scalp, with only the external processor sitting behind the ear without requiring tight contact or pressure on psoriatic skin 2
• This contrasts sharply with devices requiring skin-penetrating abutments or pressure on inflamed scalp tissue 3

Why Other Options Are Inappropriate

BAHA (Option b) - Contraindicated

• BAHA requires a skin-penetrating titanium abutment that would be absolutely contraindicated in a patient with active scalp psoriasis and recurrent skin infections 3, 4
• Adverse skin reactions around the skin penetration site are the most common BAHA complication, requiring antibiotics in many cases and surgical revision in 1-2% 4
• The device requires ongoing skin care and monitoring for infection at the abutment site, which would be impossible to maintain in a patient with baseline skin pathology 4, 5
• BAHA is designed for single-sided deafness where it transmits sound to the better-hearing ear via bone conduction, but this does not restore true binaural hearing 3

Conventional Hearing Aid (Option c) - Already Failed

• The patient explicitly cannot tolerate external hearing aids, making this option non-viable 6
• Conventional hearing aids require functional cochlear hair cells and would not provide adequate benefit for profound SNHL 3
• External aids would exacerbate scalp psoriasis through pressure and occlusion 6

Middle Ear Implant (Option d) - Wrong Indication

• Middle ear implants are designed for conductive or mixed hearing loss, not for complete sensorineural deafness 3
• These devices amplify sound but still require functional cochlear hair cells to transduce the signal, which are absent in profound SNHL 3

CROS Aids (Option e) - Non-Surgical but Suboptimal

• CROS aids represent a non-surgical alternative that transmits sound from the deaf ear to a speaker on the normal-hearing ear 1, 3
• However, this still requires wearing external devices that would contact the psoriatic scalp and ear canal 1
• CROS does not restore true binaural hearing or sound localization capabilities that cochlear implants provide 1
• Given the patient's intolerance to external aids, CROS would likely face the same compliance issues 1

Critical Implementation Considerations

Pre-Implantation Requirements

• Confirm intact cochlear nerve via CT or MRI imaging 2
• Document profound SNHL with audiometric testing showing minimal benefit from amplification 2
• Ensure realistic expectations through comprehensive counseling about outcomes 1

Dermatologic Coordination

• Optimize psoriasis control perioperatively to minimize surgical site complications
• The internal implant avoids the chronic skin-penetrating hardware required by BAHA 4
• Post-operative wound healing should be monitored closely given the history of skin infections

Expected Outcomes

• 96% likelihood of tinnitus improvement if present preoperatively 1, 2
• Significant improvement in sound localization and speech discrimination in the implanted ear 1
• Restoration of functional hearing without ongoing skin contact issues 1

Common Pitfall to Avoid

Do not select BAHA based solely on its indication for single-sided deafness without considering the absolute contraindication posed by active scalp psoriasis and recurrent skin infections. The skin-penetrating abutment would create a chronic portal for infection and inflammation in already compromised skin. 3, 4, 5