REVIEW: Round and Oval Window Reinforcement Surgery for Hyperacusis — The Silverstein Institute

Hi everyone - I’m excited to share my experience with the Round and Oval Window Reinforcement surgery for hyperacusis offered by the Silverstein Institute in Sarasota, Florida, USA. I willing share this information to help those considering this surgery and to those in the early stages in their hyperacusis journey. I will spare no detail and I know many are eager to know specifics. I will do my very best to answer as many questions as I am able to across platforms.

TL;DR: - Surgery success! 15-22 dB increase. Side effects being monitored over the coming months. LDL’s and hearing test results attached.

INTRODUCTION
A little background on my condition: I developed severe bilateral hyperacusis and reactive tinnitus as a result of acoustic trauma (loud live music for a prolonged duration) suffered in June of 2018. From this onset, I had a feeling of fullness and discomfort for the first 8-10 months throughout my ears and nerves on the sides of my head. This was the most uncomfortable part of my acute symptoms. The hyperacusis also developed immediately, but I didn’t know how to manage it so I had a series of rather serious setbacks within the first year from onset. The tinnitus came on gradually and became increasingly louder, but has since more or less stabilized with almost daily reactivity still (flutters/spikes).

When I first had my LDL’s (Loudness Discomfort Level) tested in November 2018, it showed between 55-65 dB over a range of frequencies. I have no discernible or clinically significant hearing loss across all frequencies prior to surgery.

From November 2018 - May 2021, I did Tinnitus Retraining Therapy (TRT) with the hope of increasing my LDL’s and habituating to the tinnitus. For this therapy, I wore pink noise generators 8 hours per day in both ears. The device I use is called Amplisound Quell - looks like a simple hearing aid with an open canal design. In conjunction, I also did CBT (cognitive behavioral therapy) to help my mental state. In May 2021, after over two years of TRT, my LDL test disappointingly showed no improvement - still ranging between 55-65.

I honestly love wearing the pink noise generators as they are very soothing and relaxing to wear. I do not regret trying TRT as I feel I have made minor improvements - the feelings of fullness in my ears have largely disappeared, my hyperacusis seemed to have slightly improved (but not according to the testing), and my tinnitus continues to become more stable as time goes on (less spikes and flutters).

In my research, the surgery seemed to be low risk, high reward. I contacted the Silverstein Institute and had two separate one-on-one video calls with Dr. Herbert Silverstein and Dr. Neil Nayak. After discussing my case, they each recommended me as a good candidate for the surgery. To my surprise, Dr. Silverstein even mentioned that those in the acute stage should just get the surgery and not waste time or money on treatments such as TRT. Again, I don’t regret doing TRT at all, but that was interesting to hear from the big man himself after previously reading that this surgery is recommended for those with stabilized symptoms, 1-2+ years. I went forward with scheduling the surgery for mid-June 2021.

LOGISTICS/SCHEDULE

• Sunday: Travel day, fly in. Flight was difficult coming from the Pacific Northwest, but made it ok.
  
• Monday: Morning physical with Dr. Nayak. Sign consent and risk forms. Talked about surgery details. Quick appt. Front desk very helpful in breaking down insurance/costs/deductibles etc. CT scan requested to be completed locally before travel and sent to clinic.
  
• Tuesday: Morning hearing test (eardrum, hair cells, LDL’s, tinnitus pitch matching, speech recognition) and meet Dr. Silverstein.
  
• Wednesday: Surgery day. More on this below.
• Wednesday afternoon through the following Tuesday: Rest at hotel. Very helpful to have a family member/friend care for you during this time - I had my brother there the whole time. If not, I was told you can hire a nurse to get you back to the hotel and look after you until anesthesia wears off within the day.
• Wednesday: Morning meeting with Dr. Silverstein to remove packing from ear. Followed by all the same pre-op testing in the afternoon.
• Thursday: Travel day, fly home.

After scheduling the surgery day, I was regularly contacted by the medical staff at Sarasota Memorial Hospital for various electronic registration requirements and necessary paperwork. Everyone I interested with has been very friendly and their process is well-organized.

COST
I’ve heard of numbers between $8,000-9,000 USD if paying out-of-pocket. I was elated to be notified by the hospital staff prior to scheduling that my insurance covers the surgery so my total out-of-pocket for office visits, anesthesia, surgery, etc. was only about $1,300. Most of this was simply a factor of hitting my deductible so everyone will be different depending on their insurance policy.

SURGERY DAY
Dr. Nayak does the majority of procedures nowadays while Dr. Silverstein supervises and Dr. Kim there as well. This surgery only allows for one ear to be operated on at a time because they have noticed that the non-operated ear also improves but they do not know exactly why. My guess is that it has to do with the brain trying to equalize your neurological equilibrium so it tells your other ear it’s okay to increase its tolerance. I elected to have my right ear operated on as it has always had the worse symptoms of hyperacusis and tinnitus. After waiting 6 months after the first surgery, some patients return to have the other ear operated on as well.

I was the first operation of the day and arrived at 5:45 am for my 7:00-9:00 am operating room block. I was taken back by the nurse to change, take vitals, install IV, and set me up on the rollaway cart. This takes a little bit of time to get fully prepared. Dr. Kim, the OR nurse, and the anesthesiologist all paid me a visit to chat before heading into the OR. I wore earplugs during this time (and glad I did) because this prep area has many staff and patients around with medical machines beeping frequently as well. I kept these plugs in until just before anesthesia in the operating room. Once in the operating room, I was positioned on the OR table and given oxygen. That is my final memory before going under and waking up two hours later in the recovery area and greeted by my brother. At this point I was offered snacks and drinks while the nurse was monitoring my pain levels and providing me with pain pills. The only period in this whole surgery where I had pain was the first 45 minutes in recovery upon waking up. I wouldn’t even describe it as real pain, but just enough pain where you’re slightly uncomfortable. The pain pills kicked in and brought me back to a comfortable state. Surprisingly, the external skin tissue extraction wound was more the source of discomfort than the operated inner ear itself. After my pain levels were stabilized, I was able to walk myself out of the building and into the awaiting Uber back to the hotel. From waking up in recovery to morning of the next day, there is a cup over the operated ear secured with a velcro headband. Under this is gauze patches, then a cotton ball on the outer ear, and finally the plug deep in the ear canal. Back at the hotel, I rested in an elevated position for pretty much the rest of the day. Throughout my trip, I tried to eat soft foods to not disturb the inner ear with crunchy vibrations and also food that doesn’t require opening your mouth too wide as the whole side of your head has been freshly operated on. All pain had subsided by the next morning. I was given a prescription prior to surgery for pain if needed but only took one tablet in the 24 hours following surgery.

RECOVERY
The dull but extremely important part of the trip. Sit and do nothing for a whole week. Eat, sleep, repeat. My brother was key in keeping me comfortable and fed. Directions were given to change out the cotton ball from the outer ear as it catches blood and drippings. I changed the cotton ball every couple days and the bleeding had for the most part stopped around day 3 or 4 after surgery. I also gently, and I mean very gently, cleaned some of the blood out of my ear with my fingertip under a tissue from the visible outer ear canal. I stayed at a hotel downtown on the 7th floor. It was a comfortable stay being high enough away from the road. The downtown area really isn’t loud if you can get into a high up room. The Silverstein Institute was only 2.5 miles away and Uber’s were easy to catch. I prescheduled my Uber to the early morning surgery to ensure my arrival.

The following Wednesday after the long week of rest, I met with Dr. Silverstein to remove the earplug I had in all week. Immediately following this removal, it was time to test my new ears to see how we did!

RESULTS
My pre-op LDL’s tested the day before surgery showed better than my previous testing done at the clinic I did TRT through. My belief is that the testing method involving multiple rounds per ear provided the confidence to really try hard to get good numbers. My LDL’s in both ears averaged mid to high 60’s with some frequencies in a given round topping 70 dB. These LDL’s felt more along the lines of what my ears felt like they’re at so I was happy to see that.

I took the LDL test a week after surgery to discover that I responded tremendously well to the surgery. My average LDL dB increase in my right (operated) ear was 22 dB from 67 dB to 89 dB. My left (non-operated) also showed a healthy increase averaging 15 dB from 68 dB to 83 dB. I believe most of the success was due to my stapes being hypermobile and that being one of the main areas targeted for reinforcement. I was blown away and emotionally taken back. After everything that has happened the last 3 years in my life from these disorders I finally felt extreme joy. Later in the same day I met again with Dr. Silverstein and Dr. Nayak and both were very happy with the results.

SIDE EFFECTS

• Hearing loss - My operated right ear lost some hearing in the higher frequencies to the point just considered minor hearing loss. Dr. Nayak said I probably won’t even notice it after I’ve fully healed.
• Fullness - Immediately upon Dr. Silverstein removing the plug after the week of rest, a feeling of fullness consumed my operated ear. It was shocking at first, but justifiably different after a surgical operation. Both doctors said this would subside in about 4-6 weeks.
• Taste - A very minor but still to be noted side effect was a change in taste. This change in taste will last roughly two months. It was described to me as a “metallic” taste and I personally would describe it as a slightly burnt tongue. When you bit into something or drink something that was too hot and a few taste buds on your tongue feel numb or dead is the closest feeling I could equate it to. This is not major though and you will still be able to enjoy food.

CURRENT STATE/GOING FORWARD
Writing this post, I am nine days post-op. My main concern is the feeling of fullness subsiding on schedule in the coming weeks. I will update as my symptoms improve. Secondly, I am closely monitoring my tinnitus levels and reactivity. Overall, the surgery has not affected the tinnitus one way or another although I may be perceiving it slightly different due to the fullness in my right ear.

 

@Mrkbek, was it loudness hyperacusis or pain hyperacusis?

Like do you get burning pain in and around the ears?

 

Loudness hyperacusis. Although I’ve had many various feelings of discomfort, I wouldn’t describe it as real pain. In the acute stage I believe I had some burning feelings but those memories don’t stick with me too much.

 

So this surgery is useless for pain hyperacusis.

 

Thanks for posting your experience. I really appreciate it!

I have been looking at this for a while. I might go in for testing to see if I’m a candidate.

 

I have not read many successful stories about pain hyperacusis, either. Because it's the hardest to treat, unfortunately.

 

Really awesome write-up, thanks a lot for this. I’m strongly considering the Silverstein procedure if I don’t show any improvement over the next year. I think I have pain hyperacusis (loud sounds feel like I’m being stabbed in the ear), so hopefully I’ll be able to report back on whether that improves.

Also remember to take it easy and go slow when reintroducing loud sounds. There’s a guy who had the procedure and got the same huge improvements. Apparently he got cocky and overexposed himself to noise and within a couple of months after the procedure he was right back to square one.

 

I live about a 20 minute drive from The Silverstein Institute. In fact, he's the guy who diagnosed my mother with Meniere's Disease.

Happy to hear a positive testimonial about it. I've been considering trying to get the surgery done, but my hyperacusis is probably nowhere near bad enough to qualify.

 

@Mrkbek, do you have any updates about your reactive tinnitus?

After my latest noise trauma about 8 months ago, my hyperacusis is way worse and any noise above conversation level has my left ear distort/react with a ”shhh” -sound, matching the duration of the external sound (i.e reactive tinnitus).

Is this what you were/are experiencing, and did this in any way improve post op?

 

@Mrkbek, I'd love an update. How are you doing? Hopefully that fullness sensation is subsiding. I called Silverstein yesterday and left a message but haven't heard from them. I am very interested in the procedure. I have otosclerosis and am wondering if that disqualifies me, I hope not!

 

@Philip83, my reactive tinnitus was generally activated by bothersome noise. If one ear had too much it would flutter or spike letting me know that it’s time to rest or quit doing whatever I’m doing. I can’t tell any immediate difference post-op but I’m really hoping it improves with time. I’ll of course post any updates if things change or don’t after awhile. Sorry to hear about your latest noise trauma.

 

@Mary97, I’m just over two weeks post-op and I can feel the fullness starting to fade so that’s a good sign. Also it seems that the taste side effect has disappeared. Other than that the tinnitus seems unchanged. I’ll continue to rest the next two weeks or so to hit the one month mark of rest suggested by Dr. Nayak of keeping my ear canal dry and before returning to physical activity.

 

I contacted them yesterday and they called me today. I had a long talk with one of the guys. I’m going to go in for testing next week to try and find out what caused the distortions and weird problems I got from deadlifting. If we don’t find anything, I’m going to go ahead and do the procedure. I will keep everybody posted.

 

@Brian Newman, I so hope that Silverstein Institute thinks their procedure will help you. Definitely keep us posted.

@Philip83, did you end up having a Zoom appointment with Silverstein? How did it go? Any updates?

 

UPDATE, One-Month Post-Op:

Hi all,

As requested by The Silverstein Institute, I just had my one month post operation LDL test. This was the same LDL test I previously used in recent years showing 55-65 dB before getting the surgery. This test was slightly modified to match the testing method (dB range with multiple rounds) done by The Silverstein Institute. My right (operated) ear maxed out the LDL test at 90 dB meaning the test simply does not test higher than that level because that is the lower threshold of what’s considered normal tolerance levels. My left (non-operated) ear also showed great results hovering around 80 dB and similar to the Silverstein results.

As previously mentioned, the taste disturbance side effect is long gone and the fullness in the right ear has largely faded. I can definitely tell there is a little higher frequency hearing loss as measured on the hearing test but nothing that has interfered with my ability to hear everyday noises.

Overall, this surgery experience could not have gone better for me. I am ecstatic with these results and the progress of my healing only one month later. I would probably like to get the left ear done someday to maximize my benefits but that decision is for another day.

 

Thx for the update man! I’m going in this Thursday to get evaluated.

 

Thanks for the update, mrbek!

 

I went to Silverstein to get some answers yesterday. Not gonna lie, I was not impressed at all. Yes, his hyperacusis surgery is very helpful, has a good success rate, but that is it.

Do not expect anything else from him.

You would think if this was a hyperacusis specialist, the best in the world, this facility would be a little more accommodating. Loud noise every corner, construction drills going off my entire visit, people slamming doors, the audiologist jamming pieces in my ears for the pressure test. For all their knowledge on hyperacusis, they did not seem to express like they knew a whole lot about it.

If anybody is having trouble with long term hyperacusis, this surgery will most likely help, especially with all the people saying it helped them. All the staff were very nice, along with Silverstein himself, but I still got the normal, I have no idea what’s wrong with your ears response. He did offer his surgery and said I could benefit; I said I will give him a call if I decide to do it.

A lot of people do think I have a possible PLF and that’s why my symptoms are so strange and confusing, but Silverstein kinda shrugged when I mentioned it. His surgery will actually be a 2 in 1 if I choose to do it which is good. The reinforcement will patch up any holes I have in the round or oval window and will also reinforce the stapes. I think I could greatly benefit from this, but he did not want to do any PLF testing or try to figure out what else is going on. Kind of a bummer. I assumed he would be like Brian, we’re gonna figure this out and keep running tests but it was pretty much me getting my expensive hearing test, saying I have perfect hearing, with my LDLs in the 50-60s which I predicted. Then just meeting him to discuss the surgery and that’s it.

I think I come off as an intimidating person to ear doctors because 95% of the time they know that I know everything they could possibly already tell me. They say I’m very well informed and it is what it is, to save themselves the time and effort. Maybe I’m being too optimistic thinking the best specialists in the world would maybe try something? Anything?

Just giving out advice to anybody who’s interested in going there... Wear earplugs around this whole place lmao. And be aggressive with the audiologist to be careful with your ears, because they will not treat you different. If your LDLs are under 60, you will qualify for this surgery for sure.

 

Jesus Brian, what a disappointment. I'm sorry you went through that. They sound like a bunch of aholes.

 

Yeah, I’m pretty annoyed! I expected it deep town to be honest. I have been completely losing faith in the medical world over these past 7 months. I tried to be hopeful but deep down I knew not to get my hopes up. My advice to anybody dealing with hyperacusis is give it time and stop trying everything like I am, I keep getting worse because I am failing to accept that my life is gone and I will have to live like a hermit. The medical world cannot help us, we must help ourselves and each other because that’s all we got.

Anybody else reading this, remember you can always get worse. Before you try anything at all, you must assess and say, can I live with it if things get worse? Can I handle it? If that’s a no, lay low, and let time work it’s magic

 

They never got back to me about the meeting actually, and I've been just super busy with work these last months. I'm going to follow up with them later this fall. I'll make a post as soon as I do.

 

@Mrkbek - So you operated your right ear, where you had a 30-40 dB hearing loss around 8 kHz pre-op, but you said you still felt as if there were even more high frequency loss after? Did you do an audiogram lately to follow up, and/or do you think this loss is above 8 kHz?

Thanks!

 

Tbh, I don't really understand the difference between loudness and pain hyperacusis and I feel it might just be semantics between people with different severity of hyperacusis.

I mean, even before hyperacusis, if something was too loud it "hurt", at least for me. And how can you get a result of 50-60 dB on an LDL test if you're not hurting when it becomes too loud? Is it pure phonophobia then? Or is pain hyperacusis when the pain is lingering after loud noises?

 

It takes a long time for a hearing condition to evolve. My severe hyperacusis did not heal but morphed into tinnitus, a bit of hearing loss and still less bad hyperacusis... but I can do more things nowadays, as not every sound cuts like a knife through earplugs plus earmuffs... so it's a matter of finding a balance, and trying to live as best as you can with this condition..

 

Loudness is like you get a remote control and turn up your TV volume point by point of volume, and suddenly at one moment, when you go above a decibel level, the sound just booms real loud. So the perception of decibel increase is felt like progressive until you reach your threshold and the sound just seems incredibly loud. When the sound stops it is more or less ok... to me that's loudness hyperacusis.

Pain hyperacusis means you go out for a walk with earplugs and earmuffs on top, and there is someone using a power saw like 200 metres from you, for 30 seconds... and that gives you pain, muffled hearing, extreme pressure, and triggers tension in neck, shoulders, jaw etc for like 3 weeks... that's the difference...

 

I believe this is called recruitment.

https://en.wikipedia.org/wiki/Recruitment_(medicine)

I experience a similar thing at high frequencies, all of a sudden the sound starts crackling and just feels too loud.

 

Loudness for me is like I’ve been given super hearing ability. Earmuffs + plugs don’t even work because I can still hear well through them mainly when sound is coming behind me. My ears pick up sounds from far distances as well, like ambulance sirens. My ears also can feel the vibrating and sonic booms produced by a plane/helicopter. Plus sound sensitivity to certain sounds like silverware clanking, doors closing, etc.

 

@Philip83, the 30-40 dB hearing loss I reported in my right ear was POST-op as a result of the surgery. The only loss that had shown in previous pre-op Audiograms was all less than 10 dB, which is not considered hearing loss. I posted an updated LDL test 30 days post-op but did not do a hearing test alongside it.

 

Do you get pain afterwards?

 

So you lost about 20 dB in hearing from the surgery? Man that makes me want to think more. But you said your tinnitus is the same? I want to do it but I have way more than just tinnitus and hyperacusis. The distortions are complete hell and I don’t want them to get worse.

I am still considering the surgery because I think I might have a fistula in my ear so I think it’ll help with both the hole and the sensitivity.