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

Pneumatocoele after cochlear implantation with lateral petrosectomy: A minor complication?

OBJECTIVE

To illustrate the clinical features and management of pneumatocoele presenting with a trap-valve mechanism after cochlear implantation with lateral petrosectomy (LP) in comparison with literature.

INTRODUCTION

Pneumatocoele is a rare complication of cochlear implant (CI) surgery, generally managed with conservative treatments.

METHODS

We describe a progressively increasing pneumatocoele with a trap-valve mechanism occurring one year after CI with LP, successfully managed with revision surgery. Literature review was performed on this topic.

RESULTS

Our case was the second ever reported in literature. It appeared consequently to forceful nose-blowing in a patient with refractory nasal polyposis. Unlike the pneumatocoeles reported after standard CI, we advised revision surgery as well as in the case of pneumatocoele after staged LP and CI. In both the patients subcutaneous air collection occurred as a late complication and an insufficient Eustachian tube closure was disclosed, which is considered a complication of LP itself. Surgical management was necessary in consideration of the risk of ascending infections associated with Eustachian tube patency in LP with CI.

CONCLUSION

We consider surgical treatment mandatory in pneumatocoele after CI with LP, it is indeed the sentinel of the restoration of Eustachian tube patency and the potential prelude to major complications.

Cochlear Implantation After Head and Neck Radiation: A Case Series, Systematic Review, and Meta-analysis

OBJECTIVE

To determine if cochlear implant (CI) is safe and effective in patients with radiation therapy (XRT)-induced sensorineural hearing loss and to discuss considerations in this population through a retrospective cohort review, systematic review, and meta-analysis.

DATABASES REVIEWED

PubMed, Cochrane Library, and Embase.

METHODS

We retrospectively reviewed all CI cases after head and neck (HN) XRT at our institution, noting intraoperative findings, postoperative complications, and hearing outcomes. Change in speech discrimination scores (SDSs) was the primary outcome measure. Systematic review was performed to identify all cases of CI after HNXRT. A meta-analysis was performed to assess SDS change.

RESULTS

The retrospective cohort review identified 12 patients who underwent CI after HNXRT. One patient with HN cancer (HNC) and one with central nervous system pathology (CNSP) received bilateral implants. Six had HNC, three had CNSP, and one had Langerhans cell histiocytosis. Eleven had abnormal findings during CI. There were no postoperative complications. Twenty articles with an additional 97 patients were suitable for systematic review inclusion. Of the 109 patients, 67 (61.5%) had HNC and 18 (16.5%) had CNSP. Abnormal intraoperative findings were common (30.3%), most frequently in the mastoid (66.7%). Postoperative complications, including wound dehiscence and infection with some requiring explantation, occurred in 10.1% of patients. Sixty-six patients were included in the meta-analysis. All demonstrated SDS improvement (mean increase, 56.2%).

CONCLUSION

Patients with prior HNXRT benefit from CI. Paying careful attention to surgical planning and technique, postoperative care, and patient expectations is imperative, as complications are not uncommon.

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.

Subtotal Petrosectomy: Pictorial Review of Clinical Indications and Surgical Approach

Subtotal petrosectomy (STP) is characterized by obliteration of the middle ear and occlusion of the external auditory canal. The advent of the endoscope has allowed a reduction in morbidity for some conditions such as cholesteatoma and other middle ear disorders, but STP still plays an important role. A retrospective review of medical records and videos of patients who had undergone STP was performed. Perioperative data and images were collected from various clinical cases who had undergone subtotal petrosectomy at our tertiary referral university hospital in Verona. We confronted our experience with a review of the literature to present the main indications for this type of procedure. STP allows a variety of diseases to be managed effectively as it offers the possibility of a definitive healing with radical clearance of temporal bone. Moreover, it can be safely combined with other procedures with a very low complication rate. Although the endoscope represents a revolution in ear surgery, STP, when indicated, is nowadays a surgical option that should be included in the otosurgeon's portfolio.

Current trends on subtotal petrosectomy with cochlear implantation in recalcitrant chronic middle ear disorders

Objective

To establish the safety and effectiveness of subtotal petrosectomy with cochlear implantation in patients affected by chronic middle ear disorders to refractory to previous surgical treatments.

Methods

A multicentre, retrospective study was conducted on patients affected by recalcitrant chronic middle ear disorders who underwent cochlear implantation in combination with subtotal petrosectomy. Patients' details were collected from databases of 11 Italian tertiary referral centres. Additionally, a review of the most updated literature was carried out.

Results

55 patients were included with a mean follow-up time of 44 months. Cholesteatoma was the most common middle ear recurrent pathology and 50.9% of patients had an open cavity. 80% of patients underwent a single stage surgery. One case of explantation for device failure was reported among the 7 patients with post-operative complications.

Conclusions

Subtotal petrosectomy with cochlear implantation is a benchmark for management of patients with recalcitrant chronic middle ear disorders. A single stage procedure is the most recommended strategy. Optimal follow-up is still debated. Further studies are required to investigate the role of this surgery in paediatric patients.

[Emphysema after cochlear implantation - risk factors and therapeutic options]

OBJECTIVE

In case of cochlear implantation seroma, hematoma, local wound infections or vertigo are rare but typical complications. In contrast, emphysema is seldom reported. They can occur after cochlear implantation both in the postoperative healing phase and years later. A therapeutic algorithm does not yet exist.

METHODS

We report on 3 patients with subcutaneous emphysema in the area of the receiver-stimulator. An unsystematic review of the literature of cases with emphysema after cochlear implantation highlights possible risk factors and the therapeutic options.

RESULTS

The 3 cases developed subcutaneous emphysema 2-11 month after cochlear implantation due to nose blowing or CPAP therapy in obstructive sleep apnea. The current literature reports another 35 cases of emphysema after cochlear implantation. Air insufflation via the Eustachian tube is the most frequently described cause. Diseases of the nose and sinuses, tube dysfunction and obstructive sleep apnea are potential risk factors. Pressure bandage, puncture, tympanic tubes, and surgical revision are common treatments.

CONCLUSIONS

Most emphysema can be controlled by conservative methods such as pressure bandaging and behavioral instruction. Punctures should be avoided due to the risk of upcoming infections. The prophylactic use of antibiotics seems dispensable. Surgical revision should be considered especially in cases of pneumocephalus with suspected leakage in the dura. The coverage of the mastoidectomy by a bony cap can be precautious and beneficial in cases with risk factors.

Subtotal Petrosectomy (SP) in Cochlear Implantation (CI): A Report of 92 Cases

In most cases, cochlear implantation is a straightforward procedure. Nevertheless, there are clinical situations in which the presence of the middle ear may compromise access and/or the outcome in terms of complications. This article includes a series of patients for whom we eliminated the middle ear to facilitate placement of the electrode array of the implant and/or reduce potential complications. A total of 92 cases in 83 patients, managed by the senior author, are included in this series. Different indications are outlined that justify associating a subtotal petrosectomy technique with cochlear implantation. The steps of the technique are described. We include complications from this series that compare favorably with standard techniques.

Posterior Tympanotomy Versus Subtotal Petrosectomy: A Comparison of Complications in Cochlear Implantation

OBJECTIVE

To compare the postoperative complications between posterior tympanotomy cochlear implantation (PTCI) and subtotal petrosectomy cochlear implantation (SPCI).

STUDY DESIGN

A retrospective cohort study.

SETTING

Two tertiary referral centers.

PATIENTS

Two hundred ninety-eight patients who underwent PTCI and 33 who underwent SPCI.

INTERVENTIONS

Cochlear implantation using either posterior tympanotomy or subtotal petrosectomy.

MAIN OUTCOME MEASURES

Postoperative complications between the two groups were compared after categorization into minor complications (requiring conservative management) and major complications (requiring surgical revision or hospitalization treatment).

RESULTS

Dizziness was the most common complication in both groups. The major complication rate in the SPCI group was significantly higher than in the PTCI group (12.1% [4 of 33] versus 1.3% [4 of 298], p = 0.004), while the minor complication rate was similar between the two groups. Among the major complications, device migration was significantly more common when SPCI was performed (9.1% [3 of 33] versus 0.3% [1 of 298], p = 0.003).

CONCLUSIONS

Major complication rate of SPCI was higher than that of PTCI; particularly, device migration was more commonly observed after SPCI than PTCI. Therefore, special attention should be paid to device placement and fixation during SPCI.

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.

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.

Surgical outcomes of simultaneous cochlear implantation with subtotal petrosectomy

OBJECTIVE

To evaluate the surgical outcomes of simultaneous cochlear implantation (CI) with subtotal petrosectomy (SP).

METHODS

Medical records of thirty-one patients (31 ears) who underwent simultaneous CI with SP in two tertiary referral centers for management of profound hearing loss secondary to chronic suppurative otitis media, cholesteatoma, previous open cavity, temporal bone fracture, and temporal bone irradiation were retrospectively analyzed. Pre and postoperative speech performances and related complications requiring surgical correction were evaluated.

RESULTS

Significant improvement in postoperative speech performance was observed in all 31 patients compared to preoperative result. Of the 31 patients, complications occurred in three patients (9.6%). One patient exhibited the breakdown of blind sac closure of the external auditory canal and two others exhibited the migration of the receiver-stimulator cochlear implant. The migrations occurred despite tie-down fixation of the device to the skull. The migrated devices were repositioned using revision surgery.

CONCLUSIONS

Simultaneous CI with SP is an effective and safe surgical method with relatively low complication incidence. However, particular attention should be paid to prevent certain complications. The receiver-stimulator may be predisposed to migrate to abnormal position because it can be placed with lack of tight subperiosteal support at a more superior or posterior location of the skull where the skull curvature changes abruptly than can conventional CI using limited mastoidectomy and posterior tympanotomy approach.

Evaluation of Subtotal Petrosectomy Technique in Difficult Cases of Cochlear Implantation

OBJECTIVES

To assess the validity of the subtotal petrosectomy (STP) technique in problematic cases of cochlear implant (CI) surgery, and review indications, outcomes, and related controversies.

STUDY DESIGN

This is a retrospective review of data from a private quaternary referral center of otology and skull base surgery.

PATIENTS AND METHODS

A review of patients who underwent CI with STP (STP-CI) as the leading approach was performed. Demographics, indications, surgical details, and main outcomes were evaluated. The surgeries performed were usually single-stage procedures encompassing a comprehensive mastoidectomy, blind sac closure of the external auditory canal (EAC), and mastoid obliteration with autologous fat.

RESULTS

A total of 107 cases were included. Mean follow-up was 7.1 years (range 1-13 years). The most frequent indication for STP-CI was chronic otitis media with/without cholesteatoma (32.7%), followed by open mastoid cavity (26.1%), and cochlear ossification (17.7%). Other difficult conditions where STP facilitates successful implantation include inner-ear malformations, temporal-bone trauma, unfavorable anatomic conditions, and revision surgery. A planned staged procedure was performed in 3 cases. The rate of major complications was 5.6% (n = 6). Three patients developed postauricular wound dehiscence which eventually resulted in device extrusion. No cases of recurrent/entrapped cholesteatoma, EAC breakdown, or meningitis were encountered. This is the largest single-center series of STP-CI reported in the literature.

CONCLUSIONS

When CI is intended in technically challenging cases or associated with a high risk of complications, STP is effective and reliable. Safe implantation and excellent long-term outcomes can be achieved provided surgical steps are properly followed. Single-stage procedures can be performed in most cases, even when there is active middle-ear disease.

Alternative techniques in cochlear implant surgery: Subtotal petrosectomy

OBJECTIVES

To report and analyze three cases of subtotal petrosectomy (SP) in cochlear implant surgery at our institution, and establish the indications, surgical technique and complications encountered.

MATERIALS AND METHOD

A retrospective descriptive study is proposed, analyzing a series of three clinical cases of subtotal petrosectomy as surgical technique for cochlear implant surgery at San Ignacio University Hospital (Bogotá, Colombia) from year 2004 to 2019.

RESULTS

A total of three cases of subtotal petrosectomy as surgical technique in cochlear implant candidates were analyzed. The indications were the presence of a wide mastoid cavity after canal wall down mastoidectomy, extrusion of the electrode into the external auditory canal with a wide mastoid cavity and erosion of the posterior wall of the ear canal, and the presence of cholesteatoma in a cophotic ear with previous surgery. The ear canal was defunctionalized in all three cases; in two of them with obliteration of the Eustachian tube and in none of the cases the mastoid was obliterated. There was a single complication associated with the procedure corresponding to a small retention cholesteatoma in the skin of the obliterated duct sac, that didn't required surgical intervention.

CONCLUSION

Subtotal petrosectomy is a surgical alternative for cochlear implant surgery in patients with chronic ear pathology, wide cavities or cochlear implant extrusion, not associated to significant complications.

Initial surgical and clinical experience with the Nucleus CI532 slim modiolar electrode in the UK

OBJECTIVE

The goal of this work is to describe the first experience in the UK with the slim pre-curved perimodiolar electrode Nucleus CI532 in a continuous series of patients in terms of surgical and clinical reliability and early performance outcomes.

METHOD

In this retrospective review we describe the complication rate (including electrode array tip fold-over), NRT thresholds, hearing preservation, power efficiency and CI performance outcomes in a continuous series of 40 cochlear implants CI532 performed between October 2016 and November 2017 in 17 adults and 13 children with severe to profound hearing loss.

RESULTS

Preliminary data from these groups reveals some low-frequency hearing preservation in the CI532 group although none of the patients were conventional hearing preservation candidates. NRT thresholds, power efficiency, and BKB sentences in quiet were measured at 3 and 6 months post activation. There were no significant differences in these results. The average BKB score in quiet increases from 22% pre-operatively to 58% at 3 months and 70% at 6 months. In addition, although hearing preservation was not an objective, low-frequency thresholds were preserved in 20% of cases at 3 and 6 months post-operatively. Complications were observed in 5 cases, one case with non-device related aerocoele and four related to the device array: two cases of tip roll over, one case of the electrode array being placed extra-cochlea, and one case with the electrode buckling into the middle ear. The last 2 cases were dealt with per-operatively.

DISCUSSION

Our preliminary results with the CI532 implant indicate that it may be reliably placed with standard surgical techniques but care is needed during the deployment of the electrode. Further initial data suggest that switch on and early electrophysiological measures are comparable to the existing CI 512 device. However whilst preliminary, our data suggest that it may be possible to use this electrode for hearing preservation. However, further studies are required to determine its definitive advantage over other electrode designs.

CONCLUSION

CI532 is a reliable device offering good initial results and could be an option for hearing preservation although further studies are required.

Cochlear Implantation in Chronic Otitis Media With Cholesteatoma and Open Cavities: Long-term Surgical Outcomes

OBJECTIVES

To evaluate the long-term surgical outcomes of cochlear implantation (CI) in chronic otitis media (COM) with cholesteatoma and open cavities using subtotal petrosectomy (STP). To review device explantation (DE) patients and reimplantation considerations.

STUDY DESIGN

Retrospective review.

SETTING

Otology and skull base center.

PATIENTS AND METHODS

Charts of 35 patients (36 ears) with COM with cholesteatoma, including open cavities, who underwent CI were reviewed for surgical outcomes and DE. Patient demographics, pathologies, previous surgeries, staging of implantation, salient intraoperative findings at the time of implantation and follow-up were evaluated. Details of patients with DE were evaluated for cause, operative findings, and reimplantation considerations.

RESULTS

Mean age of patients was 65.94 years. Nineteen open cavities, 11 primary cholesteatomas, 3 petrous bone cholesteatomas, and 3 atelectatic middle ears represented the pathologies with 31 patients of CI with concurrent STP and 5 patients where implantation was staged. The mean follow-up was 7.16 years ranging from 2 to 13 years. Four patients (11%) had DE due to extrusion and cavity infection with three reimplanted in same or contralateral ear. All explantations occurred within 24 months of primary implantation. No residual or recurrent cholesteatoma was observed in any of the patients during follow-up.

CONCLUSION

CI is feasible in COM with cholesteatoma and open cavities with the use of STP and single-stage implantation can be performed in the absence of purulence. Despite low risk of residual cholesteatoma post meticulous disease removal, risk of DE remains, particularly in open cavity patients, and is higher than standard implantation. Reimplantation is often possible with careful considerations.

The Use of Temporoparietal Fascial Flap to Eliminate Wound Breakdown in Subtotal Petrosectomy for Chronic Discharging Ears

OBJECTIVE

To find out if the use of the vascularized temporo-parietal fascial flap (TPFF) reduces postoperative infection or wound breakdown in subtotal petrosectomy for chronic discharging ears.

PATIENTS

A retrospective review on 26 subtotal petrosectomies with blind pit closures on chronic discharging ears performed by a single surgeon between 2000 and 2015 was performed. All patients had a minimum follow-up period of 6 months.

INTERVENTION

Eleven mastoid cavities were obliterated with abdominal fat, and 15 cavities were obliterated with TPFF. There was no concomitant cochlear implant or middle ear implant.

MAIN OUTCOME MEASURE(S)

All postoperative wound infections or delay in wound healing were recorded into a database. The complication rates of the fat obliteration group were compared using Fisher's exact test with those for the TPFF obliteration group.

RESULTS

In the fat obliteration group, 4 out of 11 patients had documented postoperative complications. Three had wound breakdown with exposure of the fat that required revision surgery. Another patient had postauricular abscess without the wound actually broken down. On the other hand, all the ears in the TPFF obliteration group (100%) were completely free of wound infection, wound breakdown, or any complication. The difference between the two groups was statistically significant (p = 0.022).

CONCLUSION

Many authors have encountered postoperative infection or wound breakdown in subtotal petrosectomy with fat obliteration in the treatment of chronic otitis media. Using a richly vascularized temporo-temporal fascial flap to protect the blind pit closure in such patients reduces postoperative infection and wound breakdown.

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 in a subject with a narrow facial recess: Importance of preoperative radiological findings

OBJECTIVE

This case report aims to emphasize the importance of preoperative computed tomography to evaluate the anatomy of the facial recess (FR) in order to prevent complications during cochlear implantation (CI) and to discuss alternative surgical approaches for the management of a narrow FR. Failure to notice this anomaly may result in facial nerve (FN) injury or inability to complete CI.

CASE PRESENTATION

A 50-year-old female with bilateral sensorineural hearing loss presented for CI. High-resolution CT (HRCT) demonstrated a narrow FR; specifically the space between the vertical segment of the FN and external auditory canal (EAC) was narrow. A section of the EAC was removed to obtain adequate exposure and was repaired with a cartilage graft following CI.

CONCLUSION

CI surgery may be difficult in patients with a narrow FR. Such surgical difficulty could be avoided if cochlear implant surgeons have adequate preoperative radiological imaging to evaluate the anatomy of the temporal bone. HRCT is the only modality that can detect this abnormality preoperatively. If the surgeon identifies this abnormality on preoperative HRCT, an alternative surgical technique could be used.

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.

Management of chronic otitis media by subtotal petrosectomy

INTRODUCTION AND OBJECTIVES

Subtotal petrosectomy is the complete exenteration of all air cell tracts of the temporal bone. The isthmus of the Eustachian tube is obliterated and the external auditory canal is closed. The aim of this study was to describe the use of this technique in the management of certain cases of chronic otitis media.

MATERIAL AND METHODS

We conducted a retrospective revision of the patients treated in our Institution with this technique for chronic otitis media in a 5-year period (2008-2012). All charts were reviewed and data from the otomicroscopy, audiometry, radiology, surgical findings, postoperative complications and follow-up (including diffusion magnetic resonance imaging, MRI) of a minimum of 24 months were collected.

RESULTS

In this period petrosectomy was performed on 28 patients for chronic otitis media. We treated 13 cases as primary cases, while 15 cases were secondary (patients that had already undergone another procedure in that ear). Fifteen cases had no serviceable hearing. Only 1 case had an immediate postoperative complication (infection); during the posterior follow-up, 2 cases had to be reoperated for diffusion restriction in the mastoid area revealed in the MRI 2 years after surgery.

CONCLUSIONS

A subtotal petrosectomy is rarely performed for the treatment of chronic otitis media. However, it is a technique that we have to keep in mind for the treatment of certain cases where there is recurrence and deep hearing loss, as well as in cases with good cochlear reserve if the disease coexists with other complications.

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.

Subtotal petrosectomy and Codacs™: new possibilities in ears with chronic infection

Subtotal petrosectomy combined with obliteration of the tympanomastoid is a standard procedure to treat temporal bones in patients with radical cavity and chronic infections. Currently, patients with profound-to-severe sensorineural hearing loss are often fitted with cochlear implants. In the case of profound mixed hearing loss, active middle ear implants have been used successfully. The new Codacs™ system provides an effective treatment for patients with severe-to-profound mixed hearing loss; however, only aerated middle ears have been treated with this device. The question arises whether the Codacs™ can be implanted in patients with radical cavity or ears with chronic otorrhea. Of the 41 patients who were implanted with the Codacs™ at the department, 4 received the device after subtotal petrosectomy and obliteration with abdominal fat. Clinical and audiological results were assessed. The device was implanted without any complications in the obliterated subtotal petrosectomy. The preliminary results of the first two patients showed stable bone conduction thresholds and indicated improved speech intelligibility in quiet and noise. Implanting the Codacs™ device after subtotal petrosectomy and obliteration with abdominal fat has been proven to be a feasible and suitable procedure for patients with radical cavity or chronic otorrhea. The speech intelligibility outcome directly after activation was comparable to patients with aerated middle ears.