Assessment of Angular Insertion-Depth of Bilateral Cochlear Implants Using Plain X-ray Scans

Angular Insertion Depth in Inner Ear Malformations, Relationship to Cochlear Size, and Implications for Electrode Selection

OBJECTIVE

The objectives were to determine the interrater agreement of the Skull AP X-ray in measuring angular insertion depth (AID), to provide descriptive information about the insertion depths of different electrodes used in inner ear malformations (IEMs), to investigate the effect of cochlear size and electrode length on AID, and to guide clinicians in electrode selection in IEMs.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

A total of 198 IEMs (n = 169 patients) and 60 cochleae with normal anatomy (n = 60 patients) were selected from patients with severe mixed or sensorineural hearing loss who presented to our clinic and underwent cochlear implantation (CI) between January 2010 and December 2022.

INTERVENTIONS

Three neurotologists independently measured AID on Skull AP X-rays. Basal turn length of the cochlea was measured in axial and coronal oblique reformatted sections on HRCT images.

MAIN OUTCOME MEASURES

Interrater reliability (ICC) of the AID measurements on Skull AP X-ray, determining the impact of cochlea size and electrode length on AID measurements.

RESULTS

The interrater reliability (ICC) test showed a high level of consistency in measuring AID in the Skull AP X-ray ( R = 0.906, p < 0.001). In the control group, a negative correlation was observed between the AID and the basal turn length of the cochlea, while a positive correlation was found between electrode length and AID ( R = 0.947, p < 0.001).

CONCLUSIONS

The Skull AP X-ray appears to be a dependable tool for measuring AID. In cases of IEMs, it is important to select an electrode of appropriate length, considering the dimensions of the cochlea.

Lateralization of interaural time differences with mixed rates of stimulation in bilateral cochlear implant listeners

While listeners with bilateral cochlear implants (BiCIs) are able to access information in both ears, they still struggle to perform well on spatial hearing tasks when compared to normal hearing listeners. This performance gap could be attributed to the high stimulation rates used for speech representation in clinical processors. Prior work has shown that spatial cues, such as interaural time differences (ITDs), are best conveyed at low rates. Further, BiCI listeners are sensitive to ITDs with a mixture of high and low rates. However, it remains unclear whether mixed-rate stimuli are perceived as unitary percepts and spatially mapped to intracranial locations. Here, electrical pulse trains were presented on five, interaurally pitch-matched electrode pairs using research processors, at either uniformly high rates, low rates, or mixed rates. Eight post-lingually deafened adults were tested on perceived intracranial lateralization of ITDs ranging from 50 to 1600 μs. Extent of lateralization depended on the location of low-rate stimulation along the electrode array: greatest in the low- and mixed-rate configurations, and smallest in the high-rate configuration. All but one listener perceived a unitary auditory object. These findings suggest that a mixed-rate processing strategy can result in good lateralization and convey a unitary auditory object with ITDs.

The Relationship Between Interaural Insertion-Depth Differences, Scalar Location, and Interaural Time-Difference Processing in Adult Bilateral Cochlear-Implant Listeners

Sensitivity to interaural time differences (ITDs) in acoustic hearing involves comparison of interaurally frequency-matched inputs. Bilateral cochlear-implant arrays are, however, only approximately aligned in angular insertion depth and scalar location across the cochleae. Interaural place-of-stimulation mismatch therefore has the potential to impact binaural perception. ITD left-right discrimination thresholds were examined in 23 postlingually-deafened adult bilateral cochlear-implant listeners, using low-rate constant-amplitude pulse trains presented via direct stimulation to single electrodes in each ear. Angular insertion depth and scalar location measured from computed-tomography (CT) scans were used to quantify interaural mismatch, and their association with binaural performance was assessed. Number-matched electrodes displayed a median interaural insertion-depth mismatch of 18° and generally yielded best or near-best ITD discrimination thresholds. Two listeners whose discrimination thresholds did not show this pattern were confirmed via CT to have atypical array placement. Listeners with more number-matched electrode pairs located in the scala tympani displayed better thresholds than listeners with fewer such pairs. ITD tuning curves as a function of interaural electrode separation were broad; bandwidths at twice the threshold minimum averaged 10.5 electrodes (equivalent to 5.9 mm for a Cochlear-brand pre-curved array). Larger angular insertion-depth differences were associated with wider bandwidths. Wide ITD tuning curve bandwidths appear to be a product of both monopolar stimulation and angular insertion-depth mismatch. Cases of good ITD sensitivity with very wide bandwidths suggest that precise matching of insertion depth is not critical for discrimination thresholds. Further prioritizing scala tympani location at implantation should, however, benefit ITD sensitivity.

Computed-Tomography Estimates of Interaural Mismatch in Insertion Depth and Scalar Location in Bilateral Cochlear-Implant Users

HYPOTHESIS

Bilateral cochlear-implant (BI-CI) users will have a range of interaural insertion-depth mismatch because of different array placement or characteristics. Mismatch will be larger for electrodes located near the apex or outside scala tympani, or for arrays that are a mix of precurved and straight types.

BACKGROUND

Brainstem superior olivary-complex neurons are exquisitely sensitive to interaural-difference cues for sound localization. Because these neurons rely on interaurally place-of-stimulation-matched inputs, interaural insertion-depth or scalar-location differences for BI-CI users could cause interaural place-of-stimulation mismatch that impairs binaural abilities.

METHODS

Insertion depths and scalar locations were calculated from temporal-bone computed-tomography scans for 107 BI-CI users (27 Advanced Bionics, 62 Cochlear, 18 MED-EL).

RESULTS

Median interaural insertion-depth mismatch was 23.4 degrees or 1.3 mm. Mismatch in the estimated clinically relevant range expected to impair binaural processing (>75 degrees or 3 mm) occurred for 13 to 19% of electrode pairs overall, and for at least three electrode pairs for 23 to 37% of subjects. There was a significant three-way interaction between insertion depth, scalar location, and array type. Interaural insertion-depth mismatch was largest for apical electrodes, for electrode pairs in two different scala, and for arrays that were both-precurved.

CONCLUSION

Average BI-CI interaural insertion-depth mismatch was small; however, large interaural insertion-depth mismatch-with the potential to degrade spatial hearing-occurred frequently enough to warrant attention. For new BICI users, improved surgical techniques to avoid interaural insertion-depth and scalar mismatch are recommended. For existing BI-CI users with interaural insertion-depth mismatch, interaural alignment of clinical frequency tables might reduce negative spatial-hearing consequences.