Indications for and Outcomes of Mastoid Obliteration in Cochlear Implantation

Long-term clinical and radiological results for fat graft obliteration in subtotal petrosectomy and cochlear implant surgery: a retrospective clinical study

PURPOSE

The study aimed to evaluate the long-term clinical, radiological, and functional results for subtotal petrosectomy and cochlear implant surgery with closure of the external auditory canal and fat obliteration.

METHODS

We retrospectively included all consecutive cases of simultaneous subtotal petrosectomy and cochlear implant surgery performed at a tertiary referral center between 2009 and 2016 using the same surgical technique. All patients underwent postoperative high-resolution computed tomography (HRCT) and annual audiological assessments. A 5-year minimum clinical, radiological, and audiological follow-up was performed. The early and late postoperative results were compared. The main outcome measures were complications, postauricular retraction, fat graft reabsorption, and audiological outcomes.

RESULTS

Twenty-nine procedures performed in 23 patients (six bilateral) met the inclusion criteria. The mean age of the patients was 67 ± 13.4 years and mean follow-up duration was 7.5 ± 2 years. At follow-up, postauricular retraction was detected in 24 cases (82.8%), including five cases (17.1%) with subcutaneous protrusion of implant and array. Fat graft volume was significantly reduced at late-HRCT in terms of maximum diameter (2.24 ± 1.0 cm vs 3.69 ± 0.7 cm; p < 0.0005) and surface area (1.88 ± 1.2 vs 4.24 ± 1.6 cm2, p < 0.0005). Six patients had extracochlear electrodes at late-HRCT (3/6 had an increased number of extracochlear electrodes), with a lowering of this group's performance of - 15% (p < 0.005) in the follow-up speech comprehension test.

CONCLUSIONS

Subtotal petrosectomy with cochlear implantation is an effective long-term technique in selected cases. Fat grafts showed significant reabsorption at long-term follow-up with reaeration of the middle ear spaces. Prolonged clinical and radiological follow-up is recommended for monitoring implant performances and late complications.

Renewed Concept of Mastoid Cavity Obliteration with the Use of Temporoparietal Fascial Flap Injected by Injectable Platelet-Rich Fibrin after Subtotal Petrosectomy for Cochlear Implant Patients

Background: The subtotal petrosectomy procedure may be useful for cochlear implantation in selected patient groups. Although it is highly effective, complications can arise, which may have economic implications for the patient due to the high cost of the device. Therefore, several authors have attempted to identify the most effective concept for obliteration. Methods: We present a pilot descriptive study of application techniques for obliterating cavities after subtotal petrosectomy using a temporoparietal fascial flap (TPFF) modified with injectable platelet-rich fibrin (IPRF+) for three cochlear implant (CI) patients. Results: Our concept preserves important anatomical structures, such as the temporalis muscle, which covers the CI receiver-stimulator. Injection of IPRF+ also increases the available tissue volume for obliteration and enhances its anti-inflammatory and regenerative potential. Conclusions: To the best of our knowledge, the use of TPFF for filling the cavity has not been adopted for CI with SP and for blind sac closure. Our literature review and our experience with this small group of patients suggest that this procedure, when combined with IPRF+ injections, may reduce the risk of potential infection in the obliterated cavity, particularly when used with CI. This technique is applicable only in cases when the surgeons are convinced that the middle ear cavity is purged of cholesteatoma.

The use of a simultaneous fascia lata-free flap with cochlear implantation after radical Mastoidectomy

Patients undergoing cochlear implant after prior radical mastoidectomy are at increased risk of device infection requiring device explant. Various techniques including two-stage operations have been used. We report the novel technique with use of a vascularized fascia lata free flap for a patient undergoing cochlear implantation with radical mastoidectomy.

Materials used for mastoid obliteration and its complications: a systematic review

OBJECTIVE

The objectives of this review are to identify the types of materials with their associated complications and respective considerations when used to obliterate the mastoid cavity.

METHODS

A systematic search was performed across PubMed, Embase, Medline and Cochrane databases from January 2009 to January 2020 for randomized controlled trials and observational studies of patients that underwent mastoid obliteration. Studies that fulfilled the inclusion criteria were screened and scored according to the MINORS and relevance scores to determine final inclusion. Types of complications were grouped into minor and major complications based on the Clavien-Dindo classification.

RESULTS

Two thousand five hundred and seventy-eight ears were evaluated. There were a total of 165 (7.9%) minor and 142 (6.8%) major complications in the autologous group. Overall complication rate is 14.8%. The major complications were largely recurrent and residual disease requiring revision surgery. There were 10 (18.5%) minor complications and three (5.6%) major complications in the allogenic group. The cumulative complications risk is 24%. For the synthetic group, there were 39 (8.0%) minor and 34 (7.6%) major complications. The cumulative complication rate is 16.6%.

CONCLUSION

Current evidence on materials for mastoid obliteration has been evolving. Each material has its strengths and limitations. The trend over the last decade favours the use of autologous materials. The principle of using a material remains being cautious of not reimplanting skin that can lead to the development of a cholesteatoma. The choice of materials is dependent on patient factors as well as the surgeons' preference and experience.

Subtotal Petrosectomy with Cochlear Implantation or Osseointegrated Hearing Rehabilitation: A Single Institutional Study

OBJECTIVE

To examine audiologic outcomes and operative considerations for patients undergoing subtotal petrosectomy (STP) followed by implantable hearing restoration.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary academic referral hospital.

PATIENTS

All patients who underwent STP and implantable hearing restoration from 2014 to 2020.

INTERVENTIONS

Single or staged STP with cochlear implantation (CI) or placement of an osseointegrated hearing implant (OHI).

MAIN OUTCOME MEASURES

Indications for STP and CI or OHI; postoperative complication and reoperation rates; audiologic outcomes through speech recognition thresholds, AzBio sentence scores, and consonant-nucleus-consonant scores.

RESULTS

Twenty-six adults (age 33-85) and six children (age 1-17) underwent 37 STP procedures with 33 CIs and four OHI. Thirty-one cases were planned single-stage, but six (16%) cases required revision surgery postoperatively due to refractory postauricular infection and breakdown of wound closure. Therefore, 25 cases were single procedures and 12 were staged. Indications for staged procedures included extensive cholesteatoma (n = 5, 42%), chronic middle ear inflammation (n = 5, 42%), and osteoradionecrosis (n = 2, 17%). No patients with OHI required revision surgery. For patients undergoing CI, the mean speech recognition thresholds improved from 80 ± 21 dB to 31 ± 9 dB (p < 0.001), mean aided AzBio scores improved from 11% to 43% (p = 0.002) and aided consonant-nucleus-consonant word scores improved from 6% to 47% (p < 0.001) in quiet.

CONCLUSIONS

Subtotal petrosectomy is effective for creating a safe, dry ear in patients with chronic inflammation or anatomically challenging ears. Rehabilitative hearing options following STP can be achieved safely, restoring hearing to an acceptable level with CI. Careful consideration should be undertaken to approach as a single or staged procedure.

Subtotal petrosectomy and cochlear implantation

Objective

The objective of this study is to analyse surgical outcomes in a series of patients who underwent subtotal petrosectomy in combination with cochlear implantation.

Methods

Retrospective chart review. Thirty patients (32 ears) underwent subtotal petrosectomy and cochlear implantation in one stage. Indications for subtotal petrosectomy included the following: cholesteatoma, chronic otitis media, previous canal wall-down, osteoradionecrosis, revision surgery for clinical reasons, inner ear malformations, middle ear anatomical variations and severe cochlear ossification.

Results

Follow-up ranged from 2 to 54 months. Only 2 complications related to the subtotal petrosectomy (1 subcutaneous abdominal haematoma and 1 subcutaneous abdominal seroma) occurred in this series. Complete electrode insertion was achieved in all but 4 cases.

Conclusions

Subtotal petrosectomy is a safe procedure and can offer technical advantages in some cases of complex cochlear implantation.

Cochlear Implantation in Chronic Otitis Media with and without Cholesteatoma: Surgical Considerations and Auditory Outcomes

INTRODUCTION

Cochlear implant (CI) surgery is a safe and standardized procedure in the presence of normal temporal bone anatomy. However, in the surgery of patients with chronic otitis media (COM), the surgeon may encounter several problems. The aim of this study was to evaluate the impact of COM with and without cholesteatoma on surgical and auditory outcomes of CIs.

METHODS

The study group consisted of 39 patients with COM who received CIs. Age- and gender-matched 38 standard CI patients served as controls. The surgical techniques and complications, pure tone audiometry (PTA) scores, speech discrimination scores (SDS), and the International Outcome Inventory for Hearing Aids (IOI-HA) questionnaire results of the groups were compared.

RESULTS

The presence of COM was associated with a higher rate of complication than controls. Staging the surgeries, presence or absence of cholesteatoma, and type of surgical technique were not associated with surgical outcomes and complications (p > 0.05). There was no significant difference between the groups in terms of postoperative PTA scores, SDS, and IOI-HA scores (p > 0.05).

CONCLUSION

Postoperative complications like device failure and skin breakdown are increased in cases of COM compared to standard CI surgeries. However, that increase is not associated with staging the surgeries, presence or absence of cholesteatoma, and type of ear surgery performed. It is advocated to close the external ear canal and eustachian tube without mastoid obliteration in the presence of a radical mastoidectomy cavity, which will decrease the postoperative complication rates and allow for radiological follow-up with computed tomography for the possibility of cholesteatoma recurrence. The auditory benefits of CI in patients with and without COM are comparable.

Impact of occlusive material and cochlea-carotid artery relation on eustachian tube occlusion in subtotal petrosectomy

OBJECTIVE

To evaluate the success rate of eustachian tube (ET) occlusion in subtotal petrosectomy relative to the occlusive material used and to the varying protympanum anatomy, by means of standardized alignment of the cochlea-carotid artery relation on computed tomography images.

PATIENTS AND METHODS

All cases of subtotal petrosectomy carried out by the same surgeon at a tertiary care referral center were retrospectively evaluated. Only cases with available computed tomography prior to second stage cochlear or middle ear implantation were included. The occlusive material was either muscle tissue or oxidized regenerated cellulose in combination with bone wax. On 3D multiplanar image reconstruction, the varying topographic interrelation of the cochlea and the petrous carotid artery was measured and categorized into two groups: detachment or overlapping.

RESULTS

In 9 (31%) of the 29 included cases there was insufficient occlusion of the ET. In none of these cases was an infection of the fat filling in the obliterated cavity observed during the implantation procedure on second stage (average 10 months interval). The failure rate of both occlusion materials was almost the same (using muscle tissue, in 4 (33.3%) of 12 or oxidized regenerated cellulose, in 5 (29.4%) of 17 cases). It was also similar for both materials in each of the anatomic variation groups.

CONCLUSIONS

An incomplete occlusion of the ET alone does not appear to lead to an infection of the obliterated cavity. Autologous muscle tissue and oxidized regenerated cellulose had similar rates of ET occlusion failure. The topographical variance of the protympanum appears to have no direct influence on the success of the ET occlusion.

Surgical management of cochlear implant in chronic otitis media patients: safe and sound

INTRODUCTION

Cochlear implantation (CI) in cases with chronic otitis media (COM) was previously contraindicated but recent advances have made it possible.

OBJECTIVE

To review surgical and audiological outcomes of COM patients that underwent CI.

MATERIAL AND METHODS

Retrospective review of patients above 18 years old.

RESULTS

Ten patients with complete data were included. Patients were aged 24-69 years old. Tympanoplasty and mastoidectomy were performed before CI. Imaging was performed to rule out ossifications. Eight patients underwent a standard canal wall up with either cochleostomy or round window approach. One patient had additional canalplasty and tympanoplasty and another one had blind sac procedure respectively. Analysis of the hearing aided level with CI and hearing aid showed significant benefit provided by the CI (Z = 2.803, p = .005).

DISCUSSION

Creating a dry and safe ear is important prior to CI. Definite hearing improvement is seen in all our cases that helped them to become independent again in their daily life. Hearing aid usage pre-CI might not be important as the hearing aids may continue to cause discharging ears and the benefits of hearing aids in severe to profound hearing loss are very minimal.

CONCLUSIONS

Cochlear implant is safe and effective in COM patients.

Subtotal Petrosectomy and Cochlear Implantation: A Systematic Review and Meta-analysis

IMPORTANCE

Subtotal petrosectomy (STP) has been more frequently performed to prepare ears with unfavorable conditions for cochlear implantation.

OBJECTIVES

To provide an overview of indications for and complications of STP and cochlear implantation and to compare outcomes between single vs multistage procedures and between pediatric vs adult populations.

DATA SOURCES

A search of PubMed, Scopus, Ovid, and the Cochrane Library was performed from the databases' inception to January 23, 2020, for studies evaluating STP for cochlear implantation.

STUDY SELECTION

Studies with a minimum follow-up of 3 months and no missing data regarding postoperative outcomes were included. Of the initial 570 studies identified, 27 (4.7%) met selection criteria.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently assessed study eligibility according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines; discrepancies were resolved by a third reviewer. Extracted data included patient demographics, indications for STP, rates of complications, and cholesteatoma recidivism when applicable. Data were pooled using a random- or a fixed-effects model when appropriate.

MAIN OUTCOMES AND MEASURES

The primary study outcome was rate of global complications stratified by patient- and surgery-level characteristics.

RESULTS

Twenty-seven unique studies with 377 unique patients (54.2% male; mean age, 50.6 [range, 1-99] years) undergoing 397 STP procedures and cochlear implantation were included. Of these procedures, 299 of 394 cases with the information reported (75.9%) were single procedures and 95 (24.1%) were multistage procedures. Of the total 397 STP procedures, most common indications included chronic otitis media (220 cases [55.4%]), previous open mastoid cavity (141 [35.5%]), cholesteatoma (74 [18.6%]), and cochlear ossification (29 [7.3%]). The overall complication rate was 12.4% (95% CI, 9.4%-15.9%); overall cholesteatoma recidivism rate was 9.3% (95% CI, 4.3%-17.1%). Complication rates did not significantly differ based on stage or age of patients. Cases with cholesteatoma more often underwent multistage vs single-stage procedures (23 of 54 [42.6%] vs 35 of 174 [20.1%]).

CONCLUSIONS AND RELEVANCE

Across all age groups, STP has been shown to be an effective surgical operation in preparing an ear with unfavorable conditions for cochlear implantation. The potential indications for which cochlear implantation can be performed have expanded with the use of STP. Presence of cholesteatoma might indicate that a multistage procedure should be performed. Lastly, with complication rates comparable to those in adult patients, STP can be considered in children requiring cochlear implantation to minimize ear-related issues and allow benefit from cochlear implantation.

Subtotal Petrosectomy in Cochlear Implant Surgery: Our Experience

Aims

Subtotal petrosectomy (SP) with cochlear implant (CI) is required in certain specific situations in the management of patients who are candidates for cochlear implants. To study and review the indications, surgical issues, and complications of this procedure.

Materials and Methods

Retrospective review of all patients who underwent subtotal petrosectomy with cochlear implant during the period January 2010-December 2016 at a tertiary care and referral centre.

Results

19 patients underwent 20 subtotal petrosectomy with cochlear implant during this period. One patient had simultaneous bilateral implantation. The indications were previous mastoid cavity in 7 patients, 5 patients had chronic otitis media, inner ear malformations in 3,ossified cochlea in 3 and unfavourable anatomy in 2 patients. Fat or musculoperiosteal flaps were used to obliterate the cavity. Ninety percent of patients underwent single stage surgery and ten percent underwent two stage procedure.Complications were seen in three patients (15%).

Conclusion

SP helps in isolating the cavity from external environment after removal of disease, improves the exposure and access, reduces risk of infection and cerebrospinal fluid (CSF) leaks and facilitates CI. Meticulous surgical technique will reduce the complications and long term follow up is needed to detect entrapped cholesteatoma. Subtotal petrosectomy with blind sac closure of external ear canal is required in certain specific situations. It is a safe and effective surgery with acceptable rate of complications.

Cochlear implantation and mastoid obliteration in a patient with Alström Syndrome

OBJECTIVES

To describe the outcomes of cochlear implantation with mastoid obliteration in a patient with Alström Syndrome and chronic otorrhea.

METHODS

This is a single case discussion of a patient with Alström Syndrome and chronic otorrhea who underwent unilateral cochlear implantation and mastoid obliteration in January 2019. Subsequent contralateral procedure was performed 4 months later. Implantation was pursued due to the progressive sensorineural hearing-loss that is characteristic of Alström Syndrome. Serial Audiograms were obtained before and after procedure.

RESULTS

Following implantation, audiological reports improved to near normal thresholds from the previous 60-85 dB sloping hearing loss. The patient's language skills rapidly improved as well as the ability to express her personality. Mastoid obliteration effectively resolved the chronic otorrhea that further complicated this case.

CONCLUSION

Cochlear implantation with mastoid obliteration was successful in improving hearing thresholds and resolving chronic otorrhea in a patient with Alström Syndrome.

Cochlear Implantation in Chronic Otitis Media: Investigation of Long-term Speech Comprehension and Rate of Complications

OBJECTIVE

To analyze the long-term speech comprehension and rate of complications of cochlear implantation in chronic otitis media.

STUDY DESIGN

Retrospective data analysis.

SETTING

Tertiary referral center with a large cochlear implant program.

MAIN OUTCOME MEASURE

Speech perception scores in quiet and background noise and rate of complications.

PATIENTS

Forty ears from a total of 38 patients with a mean age of 63.28 ± 2.16 years at the time of implantation were included.

RESULTS

Patients with a history of multiple ear surgeries, with no alternative option for hearing restoration than a cochlear implant, were implanted with satisfactory results in regard to speech comprehension. Preoperative bone conduction PTA4 correlated to postoperative speech comprehension scores in background noise. The rate of complications was low, but higher than in cases of cochlear implantation in normal middle ears.

CONCLUSION

Cochlear implantation in chronic otitis media can be a satisfactory and safe procedure, if the surgery technique and aftercare is appropriate to the altered anatomy.

Cochlear implantation in patients with canal wall down mastoidectomy cavities

BACKGROUND

Safe cochlear implantation (CI) is challenging in patients with a canal wall down (CWD) mastoidectomy cavity.

OBJECTIVES

We reviewed the outcomes of CI and proposed surgical management principles according to the presentation status of CWD mastoidectomy cavity.

MATERIAL AND METHODS

The cases of eight patients (nine ears) with CWD mastoidectomy cavity who underwent CI were retrospectively reviewed. The basis of the surgical decision, postoperative complications, and postimplant auditory performance were analysed.

RESULTS

In seven patients (eight ears), implantation was performed in a single stage; in six ears, the external auditory canal (EAC) was oversewn. In two patients with ossification, the electrode array was inserted into the scala tympani by drilling of the basal turn or in the second turn of the cochlea through a drill-out procedure. Seven patients had a follow-up of 12-50 months and one patient was lost to follow-up. None of the followed-up seven patients suffered complications.

CONCLUSIONS

CI is safe and effective in patients with profound hearing loss after radical mastoidectomy. In patients with CWD mastoidectomy cavity, CI does not cause a higher rate of postoperative complications relative to standard CI procedures. The outcome is excellent and comparable to that in the general CI population.

Middle Ear Obliteration with Blind-Sac Closure of the External Auditory Canal for Spontaneous CSF Otorrhea

Outcome Objectives To (1) identify unique features of patients who underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal for spontaneous cerebrospinal fluid (CSF) otorrhea and (2) explore outcomes. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Adults treated for spontaneous cerebrospinal fluid otorrhea from 2007 through 2015 were reviewed and stratified into 2 groups based on the surgery performed: (1) 11 patients underwent middle ear/mastoid obliteration with blind-sac closure of the external auditory canal and (2) 26 patients underwent other procedures. Demographics, body mass index, revised cardiac risk index, Duke Activity Status Index scores, and anticoagulation use were documented. Audiologic data were gathered from pre- and postoperative visits. The primary outcome measure was leak recurrence. Complications were tabulated. Results Poor preoperative hearing was a relative indication for obliteration. Obliteration patients had higher body mass index (43.2 vs 34.9 kg/m2; P < .05), incidence of super-morbid obesity (45% vs 7.6%; P = .015), anticoagulation usage (36% vs 0%; P = .004), cardiac risk scores (1.2 vs 0.1 dB; P < .0004), and Duke Activity Status Index scores. There was 1 leak recurrence (9%). Major and minor complication rates were 9% and 36%, respectively. Mean follow-up was 30.8 ± 8.6 months. Conclusion Middle ear and mastoid obliteration with blind-sac closure of the external auditory canal is effective for treating spontaneous CSF otorrhea. The small cohort reviewed did not experience any major perioperative morbidity. The technique may be best suited for patients with poor hearing, the infirm, and those in whom craniotomy is contraindicated.

The role of subtotal petrosectomy in cochlear implantation

Background:

Subtotal petrosectomy combined with cochlear implantation is a procedure required in specific situations.

Methods:

A retrospective review of all cases of subtotal petrosectomy in cochlear implant surgery over a five-year period was performed. The indications, complications and outcomes for this procedure are outlined.

Results:

Sixteen patients underwent cochlear implantation in combination with subtotal petrosectomy and blind sac closure of the external auditory meatus from 2008 to 2013. Seventy-five per cent of these were completed as a two-stage procedure and 25 per cent as a single-stage procedure. The most common indications for the procedure were chronic otitis media, previous radical cavity, and for surgical access in challenging anatomy or in drill-out procedures. Mastoids were obliterated with fat or musculoperiosteal flaps. The complication rate relating to blind sac closure was 6 per cent. Cochlear implants were successfully placed in all cases and there was no incidence of device failure.

Conclusion:

For patients with chronic suppurative otitis media or existing mastoid cavities, subtotal petrosectomy with blind sac closure of the external auditory canal, closure of the eustachian tube, and cavity obliteration is an effective technique to facilitate safe cochlear implantation.

Systematic Review and Meta-analysis of Surgical Complications following Cochlear Implantation in Canal Wall Down Mastoid Cavities

Objective

We sought to assess the complication rates following cochlear implantation in canal wall down mastoid cavities in adults and children.

Data Sources

A systematic review of English articles from PubMed, Web of Science, EMBASE, and the Cochrane Library. Additional studies were identified by reviewing the reference lists of the originally identified studies.

Review Methods

Studies were included that reported on surgical outcomes following cochlear implantation in canal wall down mastoid cavities. Two authors, using predefined data fields, independently reviewed all articles while tabulating study quality indicators. A meta-analysis of proportions was conducted on select cohorts to determine weighted complication rates.

Results

Forty-two articles were included that accounted for 424 patients and described surgical outcomes following cochlear implantation in canal wall down mastoid cavities. In a comparison of the postoperative complication rates, overclosing the external auditory meatus had significantly fewer global complications than did maintaining a canal wall down mastoid cavity ( P = .027). In a comparison of the complication rates (1) between staging the cochlear implantation and performing external auditory meatus overclosure simultaneously with cochlear implantation and (2) between pediatric and adult cochlear implantation recipients with external auditory meatus overclosure, there were no significant differences ( P = .085 and P = .92, respectively).

Conclusion

Overclosing the external auditory meatus at the same time of cochlear implantation leads to significantly fewer complications when compared with maintaining a canal wall down mastoid cavity with soft tissue coverage of the electrode array.

Cochlear Implantation through the Middle Fossa Approach: A Review of Related Temporal Bone Studies and Reported Cases

Introduction Middle fossa approach has been suggested as an alternative for patients in whom other routes of electrode insertion are contraindicated. Even though there are temporal bone studies about the feasibility of introducing the cochlear implant through the middle fossa, until now, very few studies have described results when cochlear implant surgery is done through this approach. Objective The objective of this study is to review a series of temporal bone studies related to cochlear implantation through the middle fossa and the results obtained by different surgical groups after cochlear implantation through this approach. Data Sources PubMed, MD consult and Ovid-SP databases. Data Synthesis A total of 8 human cadaveric temporal bone studies and 6 studies reporting cochlear implant surgery through the middle fossa approach met the inclusion criteria. Temporal bone studies show that it is feasible to perform cochlear implantation through this route. So far, only two surgical groups have performed cochlear implantation through the middle fossa with a total of 15 implanted patients. One group entered the cochlea in the most upper part of the basal turn, inserting the implant in the direction of the middle and apical turns; meanwhile, the other group inserted the implant in the apical turn directed in a retrograde fashion to the middle and basal turns. Results obtained in both groups were similar. Conclusions The middle fossa approach is a good alternative for cochlear implantation when other routes of electrode insertion are contraindicated.

Cochlear Implantation in Canal Wall Down Mastoid Cavities

Cochlear implantation in canal wall down mastoid (CWD) cavities is fraught with the issue of how best to manage the mastoid cavity. Decision points include whether the external auditory meatus should be overclosed, whether the implantation should be staged, or even if the eustachian tube should be plugged. Given these options, we sought to describe our experience of cochlear implantation in CWD cavities. Among evaluation of subjects ≥18 years of age, 9 had cochlear implants placed in CWD mastoid cavities, 7 of which had the external auditory meatus overclosed, while 2 maintained open cavities following implantation. With an average follow-up of 36.7 months (median, 22.8 months), 2 subjects who had overclosure developed meatal dehiscences requiring further intervention, while no complications were observed in the 2 patients who maintained open cavities.

Subtotal Petrosectomy for Cochlear Implantation

Objectives:

The purpose of this study was to review the indications for subtotal petrosectomy for cochlear implantation, report our management of complications, as well as review those technical factors that are critical for successful implantation.

Methods:

Patients (n = 104) that underwent subtotal petrosectomy with closure of the external auditory canal and obliteration of the cavity with abdominal fat in combination with cochlear implantation were analyzed.

Results:

The most frequent indication for subtotal petrosectomy was the existence of a previous canal wall down technique. Postoperative complications occurred in 13 patients (11.83%). Extrusion of the device took place in 5 cases (4.55%).

Conclusions:

Subtotal petrosectomy in cochlear implantation permits obtaining a cavity isolated from the external environment, and when needed, it improves the access and visibility during the surgical procedure. Subtotal petrosectomy is a safe technique, with a low rate of complications.

A case report: the first successful cochlear implant in Uganda

Hearing impairment is a significant disability. According to the World Health Organization (WHO), more than 80% of the world's approximately 120 million people with hearing impairment live in developing countries. Cochlear implant is the only therapeutic intervention for those with severe-profound sensorineural hearing loss. We are reporting an interesting case of the very first cochlear implant operation carried out in Uganda. The patient was a 23 year old male whose presenting complaint was inability to hear in the left ear for three and a half years and in the right ear for one year. He had been treated for TB(Tuberculosis) mastoiditis. After the 8 months of treatment, the otorrhea persisted and he underwent a tympanomastoidectomy on the same ear. He reported no familial history of hearing loss. On examination, ENT examination revealed a small pars flaccida retration pocket of the right tympanic membrane with cholesteatoma. The left ear had an intact tympanic membrane. Pure tone audiometry revealed profound sensorineural hearing loss in both ears (see attached PTA results), CT scan of the temporal bone showed normal inner ear anatomy bilaterally and mild sclerotic changes in both mastoid bones. He then had surgery on his right ear which included cochlear implantation. The cochlear implant (CI) was activated on the first postoperative day remotely via internet with the help of the cochlear implant team at New York University Cochlear Implant Center and the patient was immediately able to appreciate some sounds. He received a pneumococcal vaccine on the first postoperative day and was discharged the following day.

Cochlear implantation in patients with chronic suppurative otitis media

OBJECTIVE

To determine the safety, efficacy, and outcomes of cochlear implantation in patients with chronic suppurative otitis media (CSOM).

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center with large cochlear implant program.

PATIENTS

Nineteen patients with CSOM who underwent cochlear implantation were identified. Case history, timing of surgical procedures, complications, infections, and postimplant audiometric scores (Hearing in Noise Test [HINT], City University of New York Sentences [CUNY], and Central Institute for the Deaf Sentences [CID]) were evaluated.

MAIN OUTCOME MEASURES

Rates of postoperative infections and complications as well as postimplant auditory performance.

RESULTS

Twelve patients underwent a staged procedure involving canal wall down mastoidectomy or radical revision mastoidectomy with middle ear and mastoid obliteration and closure of the external auditory canal followed by cochlear implantation approximately 5 months later. Seven patients were implanted in a single procedure. There were no infections or medical complications after implantation. On average, patients had excellent audiometric scores at 1 year postimplantation (mean sentence test, 79%; SD, 14), and these scores were comparable to our general population (mean sentence test, 71%; SD, 32).

CONCLUSION

Cochlear implant patients with CSOM have no increased risk of postoperative infections or complications. These patients have excellent outcomes with audiometric scores comparable to the general cochlear implant population. Cochlear implantation is a safe and effective treatment for patients with profound hearing loss secondary to CSOM.

Long-term outcome of cochlear implant in patients with chronic otitis media: one-stage surgery is equivalent to two-stage surgery

This study compared long-term speech performance after cochlear implantation (CI) between surgical strategies in patients with chronic otitis media (COM). Thirty patients with available open-set sentence scores measured more than 2 yr postoperatively were included: 17 who received one-stage surgeries (One-stage group), and the other 13 underwent two-stage surgeries (Two-stage group). Preoperative inflammatory status, intraoperative procedures, postoperative outcomes were compared. Among 17 patients in One-stage group, 12 underwent CI accompanied with the eradication of inflammation; CI without eradicating inflammation was performed on 3 patients; 2 underwent CIs via the transcanal approach. Thirteen patients in Two-stage group received the complete eradication of inflammation as first-stage surgery, and CI was performed as second-stage surgery after a mean interval of 8.2 months. Additional control of inflammation was performed in 2 patients at second-stage surgery for cavity problem and cholesteatoma, respectively. There were 2 cases of electrode exposure as postoperative complication in the two-stage group; new electrode arrays were inserted and covered by local flaps. The open-set sentence scores of Two-stage group were not significantly higher than those of One-stage group at 1, 2, 3, and 5 yr postoperatively. Postoperative long-term speech performance is equivalent when either of two surgical strategies is used to treat appropriately selected candidates.

Management options for cochlear implantation in patients with chronic otitis media

OBJECTIVE

Patients with chronic otitis media with/without cholesteatoma present a significant challenge to safe cochlear implantation (CI). The aim of our study is to describe our experience and propose management options for CI in patients with chronic otitis media.

STUDY DESIGN

Retrospective case study.

SETTING

Tertiary academic center.

SUBJECT AND METHODS

We enrolled the 9 ears of 8 subjects who received CI in the ear with chronic otitis media from 2006 to 2013 by a single surgeon. CI was performed as a single-stage or staged operation with mastoid surgery according to the activity of ear infection.

RESULTS

Six patients had bilateral chronic otitis media and 2 patients had long history of sensorineural hearing loss at contralateral ear. CI was performed with simultaneous radical mastoidectomy with closure of the EAC as a single-stage in 3 ears with a history of previous open cavity mastoidectomy and no active discharge. Staged CI was performed in 6 ears, after radical mastoidectomy with closure of the EAC in 3 ears and after intact canal wall mastoidectomy in 3 ears, due to active inflammation or complications related to otitis media. In one patient, wound infection had occurred, and implant was removed along with implantation at contralateral ear. Other subjects showed no evidence of recurrence.

CONCLUSION

Decision whether implantation as a single-stage or staged operation depends on the presence of active inflammation. Single-stage CI with proper mastoid surgery can be performed in patients without active inflammation. Staged procedure need to be done in ears with active inflammation. Proper application of mastoid surgery leads to safe CI for patients with chronic otitis media.

Subtotal petrosectomy and mastoid obliteration in adult and pediatric cochlear implant recipients

OBJECTIVE

To investigate the effect of subtotal petrosectomy and mastoid obliteration (SPMO) on the overall success of adult and pediatric cochlear implant (CI) recipients.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care referral center.

PATIENTS

Thirty-nine ears in 36 patients (23 adults and 13 children) received both surgeries between 1990 and 2012.

INTERVENTION

CI candidates underwent SPMO to permit implantation and minimize the risks of infectious complications in the recipient ear. SPMO was performed before (69.3%), at the time of (25.6%), and after CI (5.13%). Mastoids were obliterated with fat (30.8%), muscle (66.7%), and bone pate (2.56%).

MAIN OUTCOME MEASURE

Feasibility, complications, and success of SPMO and CI were assessed with standard statistical analysis and Fisher's exact test with 2-sided p values.

RESULTS

Ear disease was definitively managed, and CI was successfully placed in all but one case. Complications including abscess (n = 3), subcutaneous emphysema (n = 1), ear canal granulation formation (n = 1), and electrode extrusion (n = 1) occurred in 15.4% of patients. Predisposing syndromes were present in children more often than adults (43.8% versus 13.0%, p = 0.0598). Adults more often than children had previous mastoid surgery for middle ear disease (30.4% versus 0.0%, p = 0.0288). CIs were placed under local anesthetic and sedation (n= 3) and after radiation treatment for nasopharyngeal cancer (n = 2) in adult ears.

CONCLUSION

SPMO is an effective and safe procedure for definitively managing middle ear disease and implanting adult and pediatric CI candidates.

The feasibility of endoscopic transcanal approach for insertion of various cochlear electrodes: a pilot study

To determine the feasibility of inserting various types of electrode arrays using an endoscopic transcanal approach into the cochlea via the round window membrane (RWM). All the procedures were performed by the first author and started with a cortical mastoidectomy. A six o'clock vertical incision was made in the meatal skin, and a posterior tympano-meatal flap was elevated transmeatally to expose the middle ear cavity using a rigid 0° endoscope (diameter 3 mm, length 14 cm). The chorda tympani nerve (CTN) and body of the incus were exposed. The RWM was incised, and the electrodes were passed through the tunnel from the mastoid to the epitympanum, medial to the CTN and lateral to the incus into the round window (RW) in seven procedures. In the other six cases, an open groove had been drilled, starting superiorly and laterally to the CTN and ending in the mastoid region. After electrodes insertion, the groove was filled with bone dust and covered with a large piece of fascia prior to repositioning of the tympano-meatal flap. Complete electrode insertion (7 Nucleus Contour Advance, 5 Concerto and 1 HiRes90K) via the RW was achieved in all 13 cases. Endoscopic CI was more feasible for insertion of concerto electrode followed by HiRes90K and Nucleus. An assistance of another surgeon was required for removal of stylet in the "off-the-stylet technique" utilized for implantation of nucleus electrode. Endoscopic transcanal implantation of different cochlear electrodes through the RW is feasible in both children and adults and can be used as first surgical option or as a complementary to the traditional posterior tympanotomy approach.

Cochlear implantation through the middle cranial fossa: a novel approach to access the basal turn of the cochlea

The classic approach for cochlear implant surgery includes mastoidectomy and posterior tympanotomy. The middle cranial fossa approach is a proven alternative, but it has been used only sporadically and inconsistently in cochlear implantation.

OBJECTIVE

To describe a new approach to expose the basal turn of the cochlea in cochlear implant surgery through the middle cranial fossa.

METHOD

Fifty temporal bones were dissected in this anatomic study of the temporal bone. Cochleostomies were performed through the middle cranial fossa approach in the most superficial portion of the basal turn of the cochlea, using the meatal plane and the superior petrous sinus as landmarks. The lateral wall of the internal acoustic canal was dissected after the petrous apex had been drilled and stripped. The dissected wall of the inner acoustic canal was followed longitudinally to the cochleostomy.

RESULTS

Only the superficial portion of the basal turn of the cochlea was opened in the fifty temporal bones included in this study. The exposure of the basal turn of the cochlea allowed the visualization of the scala tympani and the scala vestibuli, which enabled the array to be easily inserted through the scala tympani.

CONCLUSION

The proposed approach is simple to use and provides sufficient exposure of the basal turn of the cochlea.

Long-term results of external auditory canal closure and mastoid obliteration in cochlear implantation after radical mastoidectomy: a clinical and radiological study

Cochlear implant candidates with mastoid cavity present a significant challenge to safe cochlear implantation because of possible spread of infection to the inner ear as well as an increased risk of electrode array extrusion. Closure of the external auditory canal is one of the several surgical techniques utilized to block the potential entry routes for infection and to protect the implanted device. The main concern after external auditory canal closure is the risk of developing a cholesteatoma, which can lead to an asymptomatic erosion of the temporal bone and/or cochlear implant failure. In this study we present the results of very long-term (mean 12 years) clinical and radiological follow-up in 12 patients who underwent external auditory canal closure associated with mastoid and Eustachian tube obliteration to facilitate cochlear implantation. To date, with a mean ± SD follow-up of 12 ± 4.7 years (range 5-21 years), the only complication experienced was the breakdown of the EAC closure in one patient, successfully treated by performing a rotation skin flap. The results of this study confirmed that external auditory canal closure is a reliable technique in cochlear implantation after radical mastoidectomy provided that a rigorous surgical technique is performed. A right balance between the need to reduce costs and to avoid unnecessary doses of radiation to patients and the task of a radiological surveillance may be represented by performing computed tomography 12-18 months postoperatively and then, only if clinically warranted.

Single-Stage BAHA and Mastoid Obliteration

A single-stage fitting of a bone-anchored hearing aid (BAHA) implant and abutment with mastoid obliteration both obviates the need for two separate procedures and utilises the BAHA soft tissue reduction in the mastoid obliteration. Such a procedure has good outcomes in terms of osseointegration and achieving a dry ear. We present a 6-patient case series report highlighting the technique of combined BAHA insertion and mastoid obliteration in six patients. All patients at twelve-month followup have a good degree of sound localisation and hearing thresholds with their BAHA and are free from the social stigma associated with a foul smelling discharging ear.