Multichannel cochlear implantation in radical mastoidectomy cavities

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.

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.

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.

Middle Fossa Approach for Cochlear Implantation

OBJECTIVE

To present qualification criteria, surgery, and results of cochlear implantation via the middle fossa approach.

STUDY DESIGN

A retrospective analysis of medical charts of patients.

SETTING

Cochlear implant program in academic medical center.

PATIENTS

Six adults after middle ear surgery due to chronic otitis media with bilateral deafness or profound hearing loss.

INTERVENTION

Analysis aimed to identify patients qualified for cochlear implantation via middle fossa approach and to present surgery and result.

MAIN OUTCOME MEASURE

Qualification criteria, details of surgery and surgical, functional and audiological results.

RESULTS

Surgery was completed in four patients and in the remaining two it was stopped because of adhesions and bleeding from the dura. In three patients, there were no postoperative complications and in one individual intracranial hematoma occurred. Postoperative computed tomography showed the intracochlear position of the electrode in all the implanted patients. All of the patients use their implant for 14 to 16 hours daily. One year after the implantation, they had hearing thresholds in the sound-free field of between 25 and 45 dB sound pressure level, number recognition scores between 80 and 100% and monosyllabic words recognition between 30 and 90%.

CONCLUSION

Successful cochlear implantation via middle fossa approach results in satisfactory hearing, bringing deaf people into a hearing environment. However, this approach is technically difficult and provides the risk of intracranial complications. In our opinion this approach should be used in special cases only (e.g., postmeningitis or otosclerotis patients with obliteration of basal turn of cochlea). In analysed group it should not be considered the primary solution.

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.

Use of Pericranial Flap Coverage in Cochlear Implantation of the Radical Cavity

Cochlear implant (CI) surgery in the setting of an open mastoid cavity is evolving. Two strategies are commonly pursued: a staged approach, clearing the disease, closing the meatus or the external auditory canal (EAC), and reevaluating in 3 to 6 months prior to implantation, or a single-stage procedure with mastoid obliteration without EAC closure. Meatal closure is often employed in the setting of an open mastoid cavity to reduce the risk of electrode extrusion and infection. An open cavity offers the advantages of being a single-stage procedure, permitting direct surveillance for recurrent cholesteatoma, and reducing the need for repeat computed tomography scans. We describe an approach to the coverage of a CI within a dry, open mastoid cavity using an anteriorly-based postauricular pericranial flap.

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.

The role of subtotal petrosectomy in cochlear implant surgery--a report of 32 cases and review on indications

OBJECTIVE

To report and review 32 cases of subtotal petrosectomy (SP) in cochlear implant (CI) surgery and to define the indications and contraindications for this procedure.

STUDY DESIGN

Retrospective case review + case reports.

SETTING

Tertiary skull base center.

PATIENTS

Cochlear implant database: 32 subtotal petrosectomies in 31 patients.

INTERVENTIONS

Subtotal petrosectomy with blind sac closure of the external auditory canal, closure of Eustachian tube, and abdominal fat obliteration in combination with cochlear implantation.

RESULTS

Indications for SP in CI surgery were as follows: chronic otitis media (n = 4), previous radical cavity (n = 13), previous subtotal petrosectomy (n = 4), ossification of the cochlea (n = 5), malformation of the inner ear (n = 2), and temporal bone fracture (n = 4). One patient was simultaneously bilaterally implanted; 2 cases were revisions. All procedures were performed in 1 stage. In 2 cases, complications were encountered (6%), one of which lead to reoperation (3%). None of the patients was explanted.

CONCLUSION

Subtotal petrosectomy combined with cochlear implantation is a procedure required in specific situations and lowers the risk of repetitive ear infections, CSF leakage, and meningitis by closing off all connection with the external environment. Additionally, it gives excellent visibility and access in difficult anatomy or in drill-out procedures. The complication rate of 6% is comparable with normal cochlear implantation. Preservation of residual hearing can be considered the only absolute contraindication as an open external meatus is necessary for use of electroacoustic stimulation. Risks of the SP+CI procedure are infection of the abdominal fat, breakdown of the blind sac closure, and entrapped cholesteatoma. Follow-up with CT imaging is therefore mandatory.

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.

Cochlear implantation in patients with acute or chronic middle ear infectious disease: a review of the literature

Although in the past cochlear implantation was considered contraindicated in patients with acute (AOM) or chronic suppurative otitis media (CSOM) with or without middle ear cholesteatoma, recent developments now make it possible to perform cochlear implantation in these patients. Various procedures are available to make the ears of patients with either acute or CSOM suitable for cochlear implantation and to minimize the risk of recurrence of the disease, device extrusion, or intracranial complications. This review discusses these different approaches for optimizing implant survival and preventing complications related to otitis media. We performed a comprehensive literature search of the MEDLINE database. Cochlear implantation can be safely performed in patients with otitis media. However, the infection should be adequately controlled well before implantation, and all measures should be taken to prevent recurrent disease. Therefore, the procedure used should be tailored to individual clinical findings. This article provides a guideline to optimize the course of action in patients suffering from AOM, CSOM or their sequelae in preparation for cochlear implantation.

Indications for and Outcomes of Mastoid Obliteration in Cochlear Implantation

OBJECTIVE

To review the indications, efficacy, and long-term outcomes of mastoid obliteration in cochlear implant surgery.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Seventeen patients who underwent a mastoid obliteration procedure to facilitate the insertion of a cochlear implant between 1978 and 2005.

INTERVENTION

Mastoid obliteration procedure before cochlear implantation.

MAIN OUTCOME MEASURES

Revision rate of the mastoid obliteration and cochlear implantation, postoperative audiometric scores (consonant-nucleus-consonant words/phonemes, Central Institute for the Deaf sentences, City University New York sentences in quiet and in noise), and incidence of complications.

RESULTS

There were 17 patients with a median age of 60 years (range, 3-79 yr). Eight patients required mastoid obliteration for active chronic suppurative otitis media before cochlear implantation. Another 8 patients had existing mastoid cavities requiring obliteration (modified radical [n = 5] and fenestration cavities [n = 3]). A single patient with a sclerotic mastoid and an anterior sigmoid sinus underwent obliteration because of inadequate surgical access. The technique of obliteration was radical mastoidectomy with eustachian tube occlusion, blind sac closure of the external auditory canal, and cavity obliteration with either temporalis muscle flap (n = 15) or abdominal fat (n = 2). Cochlear implantation and mastoid obliteration were performed as a two-stage procedure in 10 patients and as a single-stage procedure in 7. Two patients required revision of the mastoid obliteration. At follow-up, all patients had stable obliterated cavities. Fifteen patients obtained significant improvement in speech discrimination scores, whereas 2 patients obtained some benefit from the cochlear implant through the perception of environmental sounds.

CONCLUSION

For patients with chronic suppurative otitis media or existing mastoid cavities, the obliteration with temporalis muscle or abdominal fat is an effective technique to facilitate safe cochlear implantation.

Cochlear implantation in a patient with eosinophilic otitis media

Eosinophilic otitis media is an intractable middle ear disease with gelatinous mucoid fluid containing eosinophils associated with bronchial asthma and nasal allergy that sometimes induces deterioration of sensorineural hearing loss. Here, we report a case of eosinophilic otitis media in a 50-year-old woman who received a Nucleus 22 multi-channel cochlear implant in the right ear at the age of 42 years. She had received treatment for bronchial asthma, chronic sinusitis with nasal allergy and otitis media with effusion since the age of 30 years and had noted bilateral sudden deafness and vertigo at the age of 35 years. Preoperative CT and MRI showed cochlear ossification in the left ear, in which mastoidectomy was performed as treatment of eosinophilic otitis media. Long-term follow-up revealed that cochlear implant is indicated for deafness induced by eosinophilic otitis media, and an early decision for cochlear implant surgery is necessary. Steroid administration was remarkably useful in controlling eosinophilic otitis media in patients with bronchial asthma and chronic sinusitis with nasal allergy.

Rescuing the imperiled cochlear implant: a report of four cases

OBJECTIVE

To report experience with exposed cochlear implants in patients with risk factors that may contribute to flap failure.

STUDY DESIGN

Retrospective review.

SETTING

University-based tertiary referral center.

PATIENTS

Four patients with exposed cochlear implants who presented with various risk factors that compromise healing.

INTERVENTION

After beginning antibiotic therapy, we took steps to correct the thyroid levels and blood glucose levels when indicated. We administered hyperbaric oxygen therapy in one case. At surgery, we debrided all devitalized and infected tissue. In one case, it was necessary to obliterate the mastoid bowl and relocate the device to a different site around the ear. In all four cases, we covered the implant with well-vascularized rotation flaps.

MAIN OUTCOME MEASURES

Wound healing, resolution of infection, and preservation of implant function.

RESULTS

In each case, the infection cleared and the implant covered. Nevertheless, one of the patients suffered implant failure 6 months after salvage surgery, and another suffered implant failure 3 years after salvage.

CONCLUSION

All exposed or infected implants need not be removed. By using sound wound handling technique and by optimizing the patient's medical status, many exposed implants can be salvaged.

Cochlear implants: indications in groups of patients with borderline indications. A review

Cochlear implants (CI) represent the current treatment for patients affected by profound sensorineural hearing loss (SNHL). Initially only deaf adult patients were considered to be candidates for a CI; however, the development of technology and matured experience have expanded the indications for cochlear implantation. Today, CIs are implanted in adults and children and broader indications are followed. There are, however, a number of patients who do not completely fulfill the current indications and who are potential candidates for CI. The duration of deafness and residual hearing represent prognostic indicators for CI performance; however, the candidacy of children with residual hearing and prelingually deafened adults are still under debate. Anatomical variants such as cochlear ossification, cochlear malformation and chronic otitis media represented and still represent for some surgeons a contraindication to CI. The otological experience of CI surgeons and the advent of auditory brainstem implants have changed the approach to these patients, who may still benefit from hearing rehabilitation. This paper briefly analyses and reviews the results obtained in these groups of patients, who were not, at least initially, considered to be candidates for cochlear implantation.