Minimally invasive approach and fixation of cochlear and middle ear implants

Preliminary experience using a cochlear implant with a novel linear pedestal design

OBJECTIVE

To assess the safety and efficiency of cochlear implantation using a novel device with a linear silastic pedestal (2 mm wide, 2 mm deep, 10 mm long) on the flat undersurface.

METHODS

Operative times required to drill a linear groove (LG) for the new linear pedestal design were prospectively accrued for 46 implantations in 30 children (median age 3). Intra-operative safety was assessed during each case. Instances of dural exposure in the base of the LG were noted. Length of stay was also recorded as a secondary measure of efficiency.

RESULTS

Across all surgeons, the mean time needed to create the LG was 1.9 ± 1.5 min (±SD) with a median time of 1.5 min (95% Cl: 1-2 min). The range in time was 1-10 min. No intraoperative complications occurred. Intended device positioning was confirmed with on-table post-operative x-rays in all cases. 43% of patients were discharged on the day of surgery.

CONCLUSIONS

The novel linear pedestal design allows for deliberate device placement while adding little additional operative time and complexity, an improvement on our current standard of care.

Cochlear Implantation in Pediatric Patients: Comparison of Limited-Incision and Standard Cochlear Implantation

Today, cochlear implantation has become the standard procedure for rehabilitation of people with impaired sensory neural hearing. This procedure can be done through different techniques. The present study aimed to compare the standard technique (ST) with creation of "C" incision into the scalp with suture fixation and limited-incision technique (LIT) with creation of subperiosteal pocket without any fixation. The outcomes included operative time and complications. This retrospective study was conducted on 343 consecutive cochlear implantations. The patients received cochlear implants at our institution between 2004 and 2011. The complications were identified as "minor" or "major". All the complications and operation times were assessed for the two surgical techniques. The overall rates of complications were 4.4 % (11 out of 252) and 2.2 % (2 out of 91) for ST and LIT, respectively. The results revealed no significant difference between the two fixation techniques regarding the complications. The mean operation time was 150 ± 23.7 and 133 ± 23.12 min in ST and LIT, respectively, and the difference was statistically significant. Both ST and LIT are safe techniques with a relatively low complication rate. However, ST can be effectively replaced by LIT because of its shorter operative time.

Characterization of retentive capacity of the subpericranial pocket in cochlear implants with and without a pedestal

OBJECTIVES/HYPOTHESIS

To quantify the retentive capacity (RC) of the subpericranial pocket (SpP) in children undergoing cochlear implantation (CI) and measure improvements in RC with the addition of a pedestal to the device base. Retention of a CI in an SpP relies on the integrity of surrounding tissues to determine device position and resist movement from external forces. We hypothesize that device position can be controlled and resistance to movement can be improved with placement of a small pedestal on the base of the CI receiver stimulator.

STUDY DESIGN

Analysis of prospectively assembled data.

METHODS

Ninety-seven patients (145 devices) underwent CI (48 bilateral, 49 unilateral). Intraoperatively, a force gauge measured the displacement force on a template Nucleus 5 (Cochlear Corporation, Sydney, Australia) implant placed in an SpP prior to routine suture fixation of a standard device. In 47 patients (64 devices), displacement forces were also measured for a custom template Nucleus 5 implant with pedestal.

RESULTS

Average RC of the SpP for the standard device was 5.59 N ± 2.73 standard deviation (SD), which increased to 9.401 N ± 4.6267 SD with a pedestaled device. Resistance to displacement decreased significantly across trials in both groups (P <.0001). Retentive capacity of the SpP increased significantly with the addition of a pedestaled device (P < .0001). The interaction between device and trial was also found to be significant (P = .05).

CONCLUSIONS

The RC of the SpP in children and the ability to resist device migration in the absence of fixation may improve with the addition of a pedestal attached to the device.

LEVEL OF EVIDENCE

2b. Laryngoscope, 126:1175-1179, 2016.

A simplified fixation of the new thin cochlear implant receiver-stimulators in children: long term results with the "back-pocket" technique

OBJECTIVE

To describe a simple technique for pediatric cochlear implant receiver-stimulators (R/S) fixation and long term results with it.

METHODS

Clinical sample include thirty-two children with severe-to-profound or profound hearing loss candidate for cochlear implantation. Low-profile devices were used (Med El Concerto and Nucleus CI512). The R/S was housed into a tight subperiosteal pocket carefully dissected behind the mastoidectomy. The pocket was closed with a single periosteal to bone suture around the posterior edge of mastoidectomy. No skull drilling was required for housing the device.

RESULTS

No intraoperative complications have been observed. 20% of operating time was saved. No migration of R/S over time was apparent at follow up.

CONCLUSIONS

The back-pocket technique seems effective in retaining the CI package and in optimizing surgical time and safety in pediatric cochlear implantation. It seems particularly suitable with new generation low profile CI devices.

A surgical technique for implantation of the vibrant soundbridge middle ear implant in dogs

OBJECTIVE

To report a surgical implantation of the Vibrant Soundbridge (VSB) middle ear implant in dogs.

STUDY DESIGN

Pilot study.

ANIMALS

Dogs (n=3).

METHODS

A lateral approach to the tympanic bulla was used to insert the floating mass transducer of the VSB into the tympanic bulla. Using microscopic guidance the transducer was moved to and inserted into the round window niche by manipulation through the acoustic bony meatus, after reflection of the tympanic membrane. VSB position was confirmed by computed tomography (CT) imaging.

RESULTS

No intraoperative complications occurred and CT images confirmed correct placement of the VSB.

CONCLUSIONS

A VSB can be safely implanted in the middle of dogs.

An illuminated retractor for minimal access surgery in cochlear implantation: How we do it

CONCLUSION

Use of a Langenback retractor with an Ultrathin™ Lightmat(®) light source can adequately illuminate the entire surgical field inside the subperiosteal pocket and facilitate ease of surgery and safer drilling.

OBJECTIVES

Minimal access surgery for cochlear implantation has become widely accepted as it reduces surgical time and morbidity. Adequate illumination is required when drilling a bony recess for the receiver-stimulator package within a subperiosteal pocket.

METHODS

An Ultrathin™ Lightmat(®) adhesive strip was attached to the Langenback retractor used for retraction of the wound.

RESULTS

No adverse effects or surgical complications associated with the use of the Lightmat(®) occurred. It was particularly helpful in the bony dissection to the dura often needed in paediatric cochlear implantation.

Cochlear Implant Fixation in Children Using Periosteal Sutures

OBJECTIVE

To describe a simple technique for implant receiver/stimulator (ICS) fixation that uses a seat for the device and suture fixation through the native cranial periosteum. This technique has been used through minimal-access surgical techniques in children since 2003.

PATIENTS

One hundred sixty pediatric cochlear implant recipients.

INTERVENTION

Implantation using the described technique for ICS fixation.

MAIN OUTCOME MEASURE

Postoperative complications related to ICS fixation.

RESULTS

No complications have been observed.

CONCLUSION

This report describes a simple and effective technique to secure the ICS package for pediatric cochlear implant surgery.

Mini-Incision for Pediatric Cochlear Implantation with a MED-EL Device

OBJECTIVE

Minimal invasive approaches have been described for cochlear implantation. However, the number of reports about minimal invasive approaches for MED-EL devices is sparse. In this technical note, we describe our pediatric cochlear implantation and incision techniques for MED-EL devices.

METHODS

Among 92 cochlear implantations performed between November 2002 and November 2006, there were 32 consecutive pediatric cochlear implantations with MED-EL devices which were performed between July 2005 and October 2006. In our technique, standard posterior tympanotomy and cochleostomy were performed after 4- to 5-cm mini-incisions in the postauricular region. However, suture fixations were not used for the implant receiver nor its electrode.

RESULTS

There were 14 girls and 18 boys with a mean age of 3.9 years. The mean follow-up duration was 5.8 months. No flap necrosis, hematoma or infection, nor implant migration, extrusion or breakdown were encountered. Revision surgery was performed in 3 patients due to cochlear ossification, perilymph leakage and extracochlear implantation.

CONCLUSION

MED-EL implantation can be performed using small incisions without suture fixation of the receiver and its electrode.