COCHLEAR IMPLANT
INTRODUCTION
Cochlear implants are first true bionic sense organs
Like human inner ear hair cells they convert mechanical sound energy into electrical impulses.
Cochlear implants are not hearing aids which merely amplify mechanical sound waves and increase
their energy content
Otter et al have shown that in the normal auditory nerve in young people there are approximately
35,000 nerve fibres; they concluded that a minimum of 10,000 spiral ganglion cells (SGC) are
required for preservation of speech recognition.
In most pathologies hair cells are damaged but ganglionic cells are intact which can be
electrically stimulated using cochlear implant.
PREOPERATIVE EVALUATION
Postlingually deafened adults tested using first PTA and speech discrimination testing.
Otological assessment for candidature should exclude active otological disease.
As in the medical domain the most important criterion should be the absence of major psychological
or psychiatric disorder.
HEARING TESTS
HINT (Hearing In Noise Test) and CNC word testing (Consonant Nucleus Consonant)
Other test includes ESP i.e. Early speech perception test
RADIOLOGICAL EVALUATION for any contraindications for implant procedure.
CT IS BEST FOR
Anatomy of facial nerve and facial canal
Enlarged Cochlear aqueduct
Defects of cribriform area of Cochlea
Presence of round and oval window
MRI BEST FOR
Morphology of cochlea and semicircular canals
Patency of cochlear duct
Status of cochlear nerve
Defect of modiolus
CNS Abnormalities
Most sensitive to identify early labrynthitis ossificans (before complete ossification) as fluid changes
within cochlea can be picked up by MRI early.
ASSOCIATED DEFECTS
CHARGE syndrome, (coloboma of iris, Heart defects, Coanal atresia, Retardation, Genital defects,
Ear anomalies), Pendred’s syndrome, Ushers syndrome
CANDIDATURE :
Individuals with < 50% HINT score and average PTA of 70 dB or greater are considered ideal
candidates for cochlear implant
It is widely accepted among all CI professionals (surgeons, audiologists and rehabilitation
professionals) that a period of trial of use of appropriate and well-fitted hearing aids should be given
before embarking on CI.
WHICH EAR TO IMPLANT :
Better hearing ear as ganglionic cell density is more and more chances of postop hearing
improvement (it is said implantation itself might damage residual hearing of poorer ear)
Least obstructed labyrinth if labrynthitis ossificans is there.
If any previous ear surgery, then the unoperated ear preferred eg canal wall down mastoidectomy in
one ear would make the C/L side more appealing as procedure wont require modification.
AGE OF IMPLANTATION
Now 1yr. Earlier thought that if implant placed early, electrodes might get displaced or implant
spontaneously extruded due to growth of skull which has been proved wrong.
Elderly are as likely to benefit from implants as young patients.
BILATERAL IMPLANTATION
Bilateral implantation benefits from “Head Shadow Effect” i.e. in normal listening environment
each ear receives different SNR (Signal to noise ratio)
Bilateral listeners can pick best SNR and enhance ability to speech understanding
Unilateral hearing makes sound localization almost impossible.
BENEFIT OF IMPLANTS IN AUDITORY NEUROPATHY
Auditory neuropathy is a condition in which Otoacoustic emissions are produced but BER waveforms
are absent as cochlear hair cells discharge dyssynchronously and thus are unable to generate action
potential.
Hearing loss in this condition is variable perhaps due to variable degree of dyssynchrony.
Cochlear implant bypasses dyssynchronous emissions and thus improves hearing.
ELECTROACOUSTIC or HYBRID IMPLANTS
Both cochlear implants and hearing aids.
For patients who retain hearing in lower frequencies but profound loss for higher frequencies.
DEVICE SELECTION
External and Internal Hardware
External Microphone, Speech processor, Transmission system.
Internal Receiver/Stimulator, electrode array
Speech processor converts sound into electrical impulses and transmits them across SKIN via radio
frequency transmission to the internal receiver / stimulator.
Receiver decodes signals and stimulates auditory nerve via electrodes
Signal then sent along auditory pathway ACSLIM to auditory cortex.
TYPES OF IMPLANTS AVAILABLE
Nucleus 22 channel cochlear implant
Clarion Cochlear implant system
MED EL (Medical electronic cochlear implant)
Ganglion cells reside in core of cochlear spiral, an area termed as Modiolus.
So electrodes placed closer to modiolus give better results. Known as the MODIOLUS HUGGING
ELECTRODES.
SURGICAL PROCEDURE
INCISION :
3 types
C shaped postaural incision as for mastoidectomy, significantly enlarged to avoid overlap
implanted stimulator / receiver. Incision line should not cross edges of device.
Inverted U shaped blood flow postaurally comes from below up so blood flow to flap is better.
Better if patient undergone previous mastoidectomy as C shaped incision is better avoided.
Inverted L or inverted J shaped incision Latest
Incision Flap elevated in 2 layers (Superficial layer and periosteum) thickness of flap overlying
the stimulator should not be more than 6mm as its diff for external device to be held to implanted
receiver (excess thinning may lead to flap necrosis) WELL (portion of skull as flat as possible
selected for placement of reciever) area drilled and contoured to create exact defect to fit in
receiver Mastoidectomy Cochleostomy (anterior lip of round window removed and electrodes
can be placed directly in Scala tympani) (Cochleostomy between 0.8 to 1.2mm diameter)
Monopolar cautery can damage device and thus use bipolar cautery ??????
Some introduce electrodes before fixing receiver and some after.
Electrode array tip should be directed inferiorly Cochleostomy sealed after entering arrays
FIXATION of stimulator if not done till now and held in place by sutures, now surgeons rely on tight
subperiosteal pocket to immobilize the stimulator/receiver
Closure done in three layers.
POSTOPERATIVE COMPLICATIONS
EARLY
Infection
Wound Dehiscence
Early device failure
CSF leak
Balance Disturbance
Meningitis
LATE
Pain
Displacement
Late device failure
Otitis media
Meninitis
Extrusion of device
LABRYNTHITIS OSSIFICANS
Bacterial Meningitis can lead to infection spreading via subarachnoid space to labyrinth via Cochlear
Aqueduct.
This Leads to labyrinthitis ossificans
Ossification occurs first and is worst at area where duct enters labyrinth i.e. at basal ends of scala
tympani close to round window.
According to Paperella labyrinthitis ossificans can be divided into three stages:
Acute stage – This stage is characterised by pus which fills up the perilymphatic spaces, sparing the
endolymphatic space. This is followed by the formation of serofibrinous exudate.
Stage of fibrosis – This stage is characterised by fibroblastic proliferation within the perilymphatic
spaces which usually begins two weeks after the onset of infection. This stage is also associated with
new bone formation (angiogenesis).
Stage of ossification – This stage is characterised by bone formation and is first observed at the basal
turn of the cochlea.Ossification occurs as early as 3 weeks following meningitis and may progress as
long as 9 months.
Fortunately auditory nerve preserved even in advanced ossification
Spiral ganglions decrease with increasing ossification
As MRI can detect fluid changes (ie absence of fluid within obstructed cochlear ductE) thus is more
sensitive to pick up early ossificans
If ossification limited to basal turns of cochlea simply keep drilling till u reach scala tympani for
electrode array placement.
If basal turns completely ossified then arrays are tried to insert in scala vestibule which is much
smaller
Scala tympani = combined cross sectional area of scala media and scala vestibule
Electrode arrays thus can be placed following sacrifice of reissners membrane.
