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With great interest we read the recently published article by Bianchin et al. describing a case report of a child with Van Maldergem Syndrome causing severe craniofacial dysmor-phism and bilateral congenital conductive hearing loss due to microtia and external auditory canal atresia [1]. Auditory restoration with a conventional skin-drive bone-conduction device, attached to a steel spring headband, was not optimal causing a speech development delay. Therefore, it was decided to implant Vibrant Soundbridge. The workup to this decision and postoperative outcomes are being discussed. We agree to the statement of the author that the best solution should be provided after careful multidisciplinary assessment about risk and benefits of all possible treatments. But with this letter we would like to express our concerns regarding the incomplete considerations about the BAHA, further described as bone implant (BI), and Vibrant Soundbridge made in the article especially in such a young child with complex needs. In the case report, clinical evaluation at five years of age showed a speech development delay, despite the application of traditional bone-conduction hearing aids from the age of twenty-two months. During preoperative pure-tone audiom-etry, good functional gain with hearing aids was detected, but good compliance was lacking and the device was not used correctly. This can be explained by the fact that steel spring headband was being used. Zarowski et al. stated that this type of head band should not be used for more than 1-2 hours, because of unpleasant pressure and pain caused by the tight fitting [2]. To solve this problem elastic softband was introduced in 2003, exerting significantly less pressure on the skull, increasing comfort, without affecting audiological results [3–5]. This softband is currently the treatment of choice and advised to be used from 3 months of age, especially in bilateral cases. This can be used until the age of 4 years. This article describes a minimum age of implantation of 5 years, which applies to the VSB. The BAHA consensus statement from 2005 recommends pediatric implantation after the age of 3 years [6]. Without proper comfort during testing, the conventional skin-drive bone-conduction device is not representative for a percutaneous BI. Therefore, using steel spring headband for prolonged period, that is, longer than a few days or maximum 2-3 weeks of preoperative testing phase requires, is considered obsolete. Skin dampening must also be considered during patient counseling. Differences in audiometric threshold and speech reception thresholds (SRT) …

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