Hearing loss, commonly known as deafness, is often characterized by a lack of ability to hear and recognize sounds, and as a result, people with hearing loss experience difficulties in interpersonal communication, which can have a negative impact on their work and life. Hearing loss can be caused by a variety of pathologies. For congenital hearing loss, the common causes are genetic disorders, infections during pregnancy, and birth abnormalities. Acquired hearing loss can be caused by infections, ototoxic drug use, trauma, noise exposure, sudden deafness causative factors, and aging of the auditory system. Depending on the site of attack, hearing loss is often categorized as sensorineural, conductive, or mixed; and according to the degree of hearing impairment, it can be classified as mild, moderate, moderately severe, profound, or profoundly deaf. Usually, mild deafness has little impact on the patient’s work and life; we focus on the surgical treatment options for patients with more than moderate deafness. For such patients, there are more implantation options available clinically – artificial auditory ossicles, cochlear implants, electroacoustic co-stimulation, BAHA, vibroacoustic bridges and bone bridges. So how do you choose the right treatment option for your patient? Sensorineural Deafness Cases To be precise, we are discussing sensorineural deafness cases, i.e. cases where the lesion is in the cochlea. In these cases, if the hearing loss is moderate or less (i.e. not more than 55 decibels), good hearing recovery can be achieved with the use of hearing aids. When the patient is moderately deaf (i.e., hearing loss exceeds 55 decibels), some patients do not do well with hearing aids. If the patient has a steeply falling hearing loss, i.e., good low-frequency hearing (500 Hz hearing loss of no more than 45 dB), and poor middle and high-frequency hearing (but middle and high-frequency hearing loss of no more than 70 dB), then the implantation of the artificial middle ear is feasible. The artificial middle ear approved for clinical use in China is the vibrating sound bridge. If the patient has a steeply descending hearing loss, but the degree is more severe than in the above case: i.e., low frequency hearing (500 Hz) does not exceed 65 dB, and the mid- and high-frequency hearing loss exceeds 80 dB. In this case, electroacoustic co-stimulation implantation is possible: Hybrid by Cochlear and EAS by MED-EL. The characteristic of this type of implantation is that after the electrodes are implanted into the cochlea, the hearing in the low-frequency region must be preserved, so that the patient can use his or her own low-frequency hearing after the implantation, and then combined with the electroacoustic stimulation to rebuild the sense of hearing – through the “combination” of the two types of auditory stimulation, hearing and speech rehabilitation can be realized. Hearing and speech rehabilitation is achieved through the “combination” of the two types of auditory stimulation. If the patient has severe or profound hearing loss, i.e., hearing loss of more than 70 decibels in all frequencies, a cochlear implant is necessary. Cochlear implantation has been practiced in China for 15 years, and the patient population is familiar with the program. There is another group of patients with normal cochlear function and abnormal auditory nerve function, i.e., patients with auditory neuropathy. In this group of patients, the degree of hearing loss varies, but they all have speech recognition difficulties that do not match the hearing loss: they can hear, but they cannot understand. Cochlear implantation may be considered in these patients when auditory nerve dysplasia is excluded. Conductive deafness cases The common clinical causes of conductive deafness requiring surgical treatment are as follows: congenital atresia of the external auditory canal, malformations of the middle ear, chronic otitis media, cholesteatoma, otosclerosis and trauma. We do not describe these causes here, but only discuss the surgical treatment options. Cases of congenital atresia of the external auditory canal were scored using the Jahrsdoerfer system. If the score is 7 or more, external auditory canal reconstruction is recommended to restore hearing. If the score is 7 or less, at this point restenosis/atresia is more likely after ear canal reconstruction and an artificial hearing implant is recommended. The options available at this time include BAHA from Cochlear, Vibroacoustic Bridge and Bone Bridge from MED-EL. Of these three options, the BAHA and Bone Bridge utilize the patient’s bone conduction to reconstruct hearing, while the Vibroacoustic Bridge essentially reconstructs the air conduction, which is closer to natural hearing. In cases of middle ear malformations, auditory ossicular chain reconstruction surgery is preferred except for vestibular window atresia. Intraoperatively, the use of PORP or TORP was chosen to accomplish the auditory ossicular chain reconstruction, depending on the situation. For cases of congenital vestibular window atresia, an artificial auditory implant option is recommended because of the high rate of reattachment after manual window opening. Options include BAHA, acoustic bridge and bone bridge. In cases of chronic otitis media, auditory ossicle-tubular reconstruction is performed after intraoperative cleaning of the tympanic and mastoid lesions. Depending on the extent of the lesion and the damage to the auditory chain, the specific surgical procedure and the selection of the appropriate artificial auditory ossicles are determined intraoperatively. In such cases, auditory chain-tubular reconstruction usually results in better hearing reconstruction and therefore rarely involves the implantation of an artificial hearing solution. Cholesteatoma cases. In principle, hearing reconstruction in such cases should be staged. One-stage surgery is performed to clean the epithelial tissue in the tympanic chamber and mastoid process; second-stage surgery is performed 6-12 months later, and after review to confirm that the cholesteatoma has not recurred, the hearing reconstruction plan is decided on the basis of the residual auditory ossicular chain and the status of the operative cavity in the middle ear. If the stapes base plate is still movable and the conditions for reconstruction of the tympanic chamber are still available, artificial auditory ossicles should be preferred to reconstruct hearing; if only the root canal is left and it is difficult to reconstruct the auditory ossicle chain, implantation of BAHA or vibrating acoustic bridge is recommended. In otosclerosis cases, after stapedectomy, the stapes base plate is opened and a Piston implanted, which usually results in good hearing reconstruction. Trauma-induced conductive deafness is most often due to rupture of the tympanic membrane or disruption of the auditory ossicular chain. Auditory chain-tubular reconstruction is preferred, with intraoperative use of artificial auditory ossicles as appropriate. Mixed deafness cases The following conditions are common clinical causes of mixed deafness: chronic otitis media, cholesteatoma and otosclerosis. If an infection persists within the tympanic cavity, toxins produced by the pathogen and the diseased tissue can leak into the inner ear through the membranes or blood vessels penetrating the tympanic capsule, damaging the inner ear and causing a loss of sound perception – this is why cases of chronic otitis media and cholesteatoma can lead to Mixed Deafness. In addition, the repeated use of otologic drills after multiple middle ear surgeries in some cases may also lead to a loss of hearing in the inner ear, resulting in mixed deafness. For some otosclerosis cases, cochlear otosclerosis may develop as the disease progresses, at which point mixed deafness develops. In cases of mixed deafness, surgical procedures (acoustic chain-tubular reconstruction) can only address the conductive part of the deafness, but have no curative effect on the decline in inner ear function. In such cases, where the decrease in inner ear function (bone conduction) is relatively mild (no more than 30 dB), relatively satisfactory hearing reconstruction can be achieved after successful auditory ossicular-chamber-temporal reconstruction surgery. We therefore discuss the surgical options for mixed deafness cases with a bilateral decrease in inner ear function (bone conduction) of more than 35 dB. Chronic otitis media cases. Preoperative CT of the temporal bone is performed, and based on the extent of the lesion and the anatomy, if it is predicted that after tympanic chamber reconstruction, the relatively intact morphology of the external auditory canal can be preserved, then it is feasible to remove the lesion and perform auditory ossicles-temporal chamber reconstruction, with postoperative dry ear, and the patient then wears a hearing aid; if it is predicted that the posterior wall of the external ear canal can’t be preserved preoperatively or if the patient requests to keep the canal open postoperatively (due to eczema or inflammation of the external auditory canal), then the option of an artificial auditory implantation can be considered at this time: BAHA, bone bridge and acoustic bridge are all options if the bone conduction threshold is between 35-45 dB; if the bone conduction threshold is between 45-60 dB, implantation of a vibrating acoustic bridge is recommended. Cholesteatoma cases. The management principles for such cases are the same as those described above for chronic otitis media cases. Exceptionally, cochlear implantation is also feasible in cases of severe or profound mixed deafness with bilateral residual root cavities.