Inter-rater Reliability and Validity of Holgers Scores for the Assessment of Bone-anchored Hearing Implant Images

Abstract

Objectives: This study aims to review the utility and interassessor reliability of Holgers classification by simultaneously testing various professionals of the bone-anchored implant team for their impression of a series of randomized images. Study Design: Retrospective review of a randomized series of bone-anchored implant fixture clinical photographs from the database at a tertiary referral university hospital. Raters were blinded to the contemporaneous Holgers grading assigned by the Clinical Nurse Specialist at initial assessment. Multivariate analysis was performed for correlation between scores for assessors and between grades of assessor. Setting: Queen Elizabeth Hospital, Birmingham, UK a tertiary center for BAHIs. Patients: Patients implanted from May 2012 until November 2014. Main Outcome Measure: Photographs of fixture sites of adult patients were taken following bone-anchored hearing implant surgery using either a tissue reduction (a split skin graft or linear incision technique was used) or tissue preservation approach, at 1 week, 6 months, and 12 months postoperatively. On a single occasion 263 images were reviewed by 10 assessors (2 consultants, 2 higher surgical trainees, 3 junior doctors, and 3 audiologists). Images were displayed at 10-second intervals and were scored by each assessor. Assessors were blinded to patient identity, time points and to each other's scores. Results were then compared against the real-time scoring of Holgers grades done by the BAHI specialist nurse to compare scores. Results: Overall 227 (86.2%) images were with tissue reduction technique of which 110 (41.8%) were with linear incision and 117 (44.4%) were with a split skin graft (SSG); and 36 (13.6%) were with tissue preservation technique. Of these 263 images, 104 were at 1 week (39.5%), 70 were at 6 months (26.6%), and 89 were at 12 months (33.9%). The cumulative scores for each grade scored by blinding the time points were: 0 = 1132 (43.04%), total 1 = 995 (37.83%), total 2 = 346 (13.15%), total 3 = 141 (5.36%), total 4 = 16 (0.6%). 2630 data points had a variance of only 0.6415 for each nominal. Multivariate correlation between all assessors was r =0.7230 (Pearson's R). Correlations between consultants r=0.6317, higher surgical trainees r=0.7351, junior doctors r=0.7599, and audiologists r=0.7981. There is a good correlation (r=0.89) with no statistically significant differences between the SSG and linear incision groups (p>0.05), possibly suggesting Holgers score is comparable within both these tissue reduction techniques. There is a moderate correlation (r=0.58) with statistically significant differences between tissue preservation versus tissue reduction groups (p<0.05), possibly suggesting tissue preservation gives better results with lower Holgers scores than tissue reduction. Conclusion: Holgers scoring system is a reliable tool with respect to inter-rater variability across all levels of experience. Correlation was closer with audiologists and lesser experienced assessors.

Surgical and audiological results of bone-anchored hearing aids: comparison of two surgical techniques

“…Regarding the surgical complications, we found that skin complications (Holgers ≥ 1) 10 , 11 were present in both surgical techniques, that is, in the linear incision technique in 9 of 20 individuals undergoing surgery (45%) and in the MIPS technique, in 10 individuals of 22 submitted to surgery (45%). In addition to these skin complications that occurred in up to 6 months of postoperative follow-up (which were resolved in their entirety), we found a description of intraoperative bleeding in 1 patient undergoing each of the surgical techniques, that is, 5% in the linear incision technique and 4.5% in the MIPS technique.…”

“…To assess skin complications, the classification proposed by Holgers et al was used 10 , 11 : Grade 0 = no adverse reactions; Grade 1 = skin with erythema; Grade 2 = skin with erythema and secretion; Grade 3 = granulation tissue; and Grade 4 = inflammation or infection that resulted in the removal of the abutment. Skin complications were divided into minor (Grade 1 and 2) and major (Grade 3 and 4) complications.…”

Reliability of Postsurgical Soft Tissue Reaction Grading Scales for Bone-anchored Hearing Implants

“…Similar concerns were the reason for the development of the Tullamore Classification, which was presented during the International Congress on Bone Conduction Hearing and Related Technologies (2017, Nijmegen, the Netherlands) as a more suitable classification scale in 2017 (15). A reliable classification system is essential to producing a standardized evaluation of the severity of postoperative skin reactions aimed at improving quality of the care and scientific investigation (26). To observe an optimal/ reliable gradual improvement of the inflammatory site, it is important to be able to compare different timings of follow-up.…”

“…A reliable classification system is essential to producing a standardized evaluation of the severity of postoperative skin reactions aimed at improving quality of the care and scientific investigation (26). To observe an optimal/reliable gradual improvement of the inflammatory site, it is important to be able to compare different timings of follow-up.…”

Tobacco Use and Skin Reactivity in Patients With Percutaneous Auditory Osseointegrated Implants

“…Standard postoperative care includes one postoperative visit 1 week after surgery and processor loading approximately 6 weeks after implantation. The primary outcome of skin reactivity was reported using the Holgers score, a widely used and validated tool to analyze soft tissue reactions for pOAIs (Table 1) (4,5). For visits without a Holgers score, a score was retrospectively assigned based on the physical examination description of the surgical site.…”