Otology & Neurotology 36:604Y609 Ó 2015, Otology & Neurotology, Inc.
Middle Ear and Mastoid Obliteration for Cochlear Implant in Adults: Indications and Anatomical Results *‡Daniele Bernardeschi, *†‡Yann Nguyen, *‡Mustapha Smail, *‡Didier Bouccara, *‡Bernard Meyer, *‡Evelyne Ferrary, *†‡Olivier Sterkers, and *‡Isabelle Mosnier *AP-HP, Groupe Hospitalier Pitie´-Salpeˆtrie`re, Unite´ Otologie, Implants auditifs et Chirurgie de la base du craˆne, Paris, France; ÞSorbonne Universite´s, UPMC Univ Paris 06, UMR-S 1159, ‘‘Re´habilitation chirurgicale mini-invasive et robotise´e de l’audition,’’ Paris, France; and þINSERM UMR-S 1159, ‘‘Re´habilitation chirurgicale mini-invasive et robotise´e de l’audition,’’ Paris, France
Aim of the Study: To review indications, anatomical results, and complications of cochlear implant (CI) surgery in adults for which middle ear and mastoid obliterations were performed. Patients and Methods: Thirty cases (26 patients, 4 bilaterally implanted) of 837 CI surgeries (3.5%) performed between January 2009 and December 2013 have been included in this retrospective study. The mean follow-up was 21 T 18 months (mean T SD, range 3Y58). There were 11 males and 15 females. The mean age was 59 T 19 years (range 35Y82). All surgeries were performed with a single-stage technique including a canal wall down mastoidectomy with external auditory canal closure and mastoid obliteration with fat. A postoperative CT scan was performed in all cases. Results: Etiologies of hearing loss were mainly chronic otitis with or without cholesteatoma in 24 cases. Other etiologies were meningitis with cochlear ossification in one case, progressive hearing loss in two cases, enlarged vestibular aqueduct in one case, temporal bone fracture with CSF leak in one case, and
congenital aural atresia in one case. Four of those 30 cases were revision CI surgery for electrode array misplacement (one case with cochlear ossification) or extrusion from an open cavity (one case) and recurrent cholesteatomas (two cases). All surgeries were uneventful and performed in a single stage. The electrode array was inserted in the basal turn (29 cases) or in the middle turn (one case) of the cochlea. No complications were observed. Two cases of postoperative abdominal hematoma were drained under local anesthesia. A major failure of the CI device occurred 5 months after surgery. Conclusion: CI with mastoid and middle ear obliteration is a safe and effective technique for selected cases of cochlear implantation. Mastoid obliteration prevents from recurrent disease and lowering the facial ridge allows more space to manage extensive cochlear ossification or malformation. Key Words: Chronic otitisVCochlear implantVMastoid obliterationV OssificationVSubtotal petrosectomy. Otol Neurotol 36:604Y609, 2015.
Cochlear implant (CI) surgery in adults is a wellestablished technique for the rehabilitation of severe to profound sensorineural hearing loss for many years (1); it encompasses a mastoidectomy with posterior tympanotomy to gain access to the middle ear and to insert the array through a cochleostomy or the round window membrane. It is a safe and simple procedure with low rate of complications. Nevertheless, some clinical circumstances make this classical approach difficult or contraindicated and led to modify the routine surgical procedure.
Cochlear implantation was previously contraindicated in case of chronic otitis (2). Then, a single (3Y7) or staged (5,8Y10) procedure was suggested in such circumstances. However, in case of cholesteatoma or active chronic otitis, tympanoplasty with or without CI could not prevent the recurrence of the pathology because middle ear spaces still exist and Eustachian tube dysfunction is often present. This is why mastoid obliteration has been also proposed in case of recurrent otitis media or after failure of myringotomy tube in children (5). In case of cochlear ossification, another difficult situation where the classical approach could be problematic, different surgical procedures have been proposed: drillout of the cochlea (11Y13), scala vestibuli insertion (14Y16), use of double-electrode array (17,18) and split array (19,20), and retrograde insertion via apical cochleostomy (21).
Address correspondence and reprint requests to Daniele Bernardeschi, M.D., Ph.D., Otology, Auditory Implants and Skull Base Surgery Department, Pitie´-Salpeˆtrie`re Hospital, 50/52 Bd Vincent Auriol, 75013 Paris, France; E-mail: [email protected] The authors disclose no conflicts of interest.
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MIDDLE EAR AND MASTOID OBLITERATION Nevertheless, these procedures performed through a posterior tympanotomy are at risk of electrode misplacement because of the narrow space of the facial recess and prevent the safe identification of important structures and landmarks (internal carotid artery, facial nerve). Temporal bone fracture could lead to CSF leak and, if it involves the inner ear, fibrosis or ossification of cochlear scalae. Meningitis or the inability to introduce the array makes this situation an urgent otologic surgery, and CI should be performed as soon as possible in case of bilateral profound hearing loss to prevent fibrosis and/or ossification. Another similar clinical situation is the presence of inner ear malformation, where the risk of Gusher should prevent from using the classical facial recess technique because there would not be a safe suppression of the communication between the middle and the inner ear or subarachnoid spaces. The aim of this study was to review our cases of CI surgeries with middle ear and mastoid obliteration to define indications and to analyze complications and surgical results. PATIENTS AND METHODS Thirty cases (26 patients, 4 implanted bilaterally) of 837 CI surgeries in adults (3.5%) performed in our department between January 2009 and December 2013 were included in this retrospective study. All patients gave their consent to the use of personal clinical data. There were 11 males and 15 females. The mean age was 59 T 19 years (mean T SD, range 35Y82). There were 12 left-side and 18 right-side ears. The mean follow-up was 21 T 18 months (range 3Y58). All patients were operated on under general anesthesia with facial nerve monitoring (NIM 2 and 3; Medtronic, Jacksonville, FL). The case of congenital aural atresia was operated on with electromagnetic computer navigation system Digipointeur (Collin, Bagneux, France) (22) and a continuous facial nerve stimulating burr (Stimburgard; Medtronic) (23) for localization of the facial nerve in the malformed ear (this patient did not undergo any previous operation in that ear). Bacteriological scrub of external auditory canal (EAC), mastoid cavity, and/or otorrhea was obtained before antibioprophylaxis with amoxicillin-clavulanate in case of chronic otitis. Retroauricular incision with musculoperiosteal flap was performed whenever possible. Transection of EAC was performed at the level of transition cartilage/tympanic bone. An anterior cut in the tragal skin and cartilage was performed to have all the circumference of the EAC under vision. The lateral part of the skin of the anterior wall was elevated from the tragal cartilage and the sutured to the posterior wall of the transected EAC without everting the cutaneous edge with 4/0 resorbable sutures. The musculoperiosteal flap was then sutured with resorbable 3/0 sutures on the tragal cartilage. In case of large meatoplasty, the anterior skin flap was elevated more laterally and, if the musculoperiosteal flap was not available, a muscular temporalis flap was used as a second layer. The skin of the medial part of EAC was excised with tympanic drum remnant, malleus, and incus if present. Then, a canal wall down (CWD) mastoidectomy was performed, taking care to open all mastoid cells including tip, zygomatic process, retrosinusal, and infralabyrintine and hypotympanic cells. Drilling was stopped when healthy bone
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was reached without pathologic mucosa on it. In case of preoperative CWD mastoidectomy, all the skin of the posterior cavity and epitympanum was removed and the cavity was further drilled up to healthy bone. Also, all the hyperplasic mucosa of middle ear was removed. Obliteration of Eustachian tube with muscular graft and connective tissue was performed. In case of chronic otitis, the array was inserted through the round window membrane. In case of ossification, drilling of the basal turn of the cochlea was started in the region of the round window and continued toward the anatomical course of the basal turn. If there was a lumen in the basal turn of the cochlea, array was inserted in the scala tympani when possible or in the scala vestibuli. If no lumen was found in the basal turn, a cochleostomy was performed in the second turn just anterior to the oval windows (24). At the end of the procedure, the cavity was washed with antiseptic solution (povidone-iodine) and filled with abdominal fat. Closure was performed in two layers. Antibiotherapy was continued until the results of bacteriological test: if no bacteria were found, antibiotics were stopped. If the test was positive, antibiotics were adapted and delivered for 14 days, following the recommendations for meningitis (25). Postoperative CT scan was performed 1 day after surgery to all patients to check the correct positioning of the array. Six months after surgery, speech perception of disyllabic words in quiet without lipreading was tested.
RESULTS Etiology of hearing loss is described in Table 1. There were 24 cases (79%) of chronic otitis (three cases of cholesteatomas). Among them, there were four revision CI surgeries: two for recurrent cholesteatoma after tympanoplasty with cochlear implant insertion in the same time (Patient 12 and 15), one for misplacement (Patient 6), and one for extrusion of the array from a previous CWD mastoidectomy (Patient 23). Eight of the 24 cases suffering from chronic otitis (33%) had positive intraoperative bacteriological test (detailed in Table 1). Other etiologies encompassed two cases (6%) of progressive hearing loss (in which the obliteration was performed because of anterior sigmoid sinus with very small mastoid), one case (3%) of large vestibular aqueduct syndrome (small mastoid), one case (3%) of meningitis with cochlear ossification (3%), one case (3%) of temporal bone fracture with CSF leak, and one case (3%) of congenital aural atresia. Surgeries were uneventful and all performed in a single stage. The type of CI used is described in Table 1. In all but two cases, the array was inserted in the scala tympani of the basal turn of the cochlea through the round window membrane, and CT scan showed no misplacement of the array. In one case of ossification (Patient 11), the array was inserted in the scala tympani after drilling the basal turn of the cochlea. In another case (Patient 5), the array was inserted in the second turn of the cochlea through a cochleostomy performed anteriorly (24) to the oval window (Fig. 1). Two cases of abdominal subcutaneous hematomas were drained under local anesthesia 2 days after the first procedure. Patients were discharged 3 days after surgery, and cochlear implant was activated after Otology & Neurotology, Vol. 36, No. 4, 2015
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D. BERNARDESCHI ET AL. TABLE 1.
Patient
Age
Side
1VMF 2VMD 3VCM
70 56 52
Left Left Left
4VNJ
51
5VHM
Details of patients operated on with middle ear and mastoid obliteration
Etiology of hearing loss Progressive HL Chronic otitis Chronic otitis
FU Revision CI surgery (mo)
Complications
No No No
58 57 54
Right Chronic otitis
No
53
60
Right Chronic otitis
No
47
No
Sterile
60
Left
No
47
No
Sterile
6VDP
53 55
Right Chronic otitis Left Chronic otitis
No YesVmalposition
46 16
No No
7VFV
49
Right Chronic otitis
No
38
8VLJ
67
Right Chronic otitis
No
34
9VBP 10VBA 11VZF 12VRJ
76 73 77 67
Left Right Right Left
21 21 17 16
Abdominal hematoma Cochlear implant failure No No No No
Sterile Staphylococcus aureus Sterile
13VCE
43
14VDLP 15VMT
76 78
Chronic otitis
No No Abdominal hematoma No
Bacteriologic test
Cholesteatoma Chronic otitis Meningitis Chronic otitisVcholesteatoma Right Chronic otitis Left Chronic otitis
No No No YesVrecurrent cholesteatoma No No
16 3
No No
Right Large vestibular aqueduct Right Cholesteatoma
No 16 YesVextrusion of array 14 in the cavity No 14 No 13 No 12
No No
16VADFO 64 17VNS 67 18VTR 82
Right Progressive hearing loss Right Chronic otitis Right Chronic otitis
19VMN 20VGP 21VBMJ
35 45 78
Right Chronic otitis Left Chronic otitis Right Chronic otitis
No No No
11 11 5
No No No
22VLSM
56
Right Major aplasia
No
5
No
23VAY
59
Right Chronic otitis
3
No
24VMKI
40
Left
3
No
25VLF 26VAE
69 43
Left Left
3 3
No No
43
Right Chronic otitis
3
No
YesVextrusion array in the cavity Temporal bone fracture with No CSF leak Chronic otitis + meningitis No Chronic otitis No No
3 weeks. No post-auricular abscess or skin infection was observed in this series. One major device failure occurred 5 months after surgery (Patient 8, implanted with Cochlear CI512 device). For the 25 patients without cochlear ossification who were tested at 6 months, the speech perception of disyllabic words in quiet was 62 T 4.7% (mean T SEM), a value similar to that previously published in a similar population (61 T 6.8%, n = 46) (26).
DISCUSSION CI surgery has been well codified for many years. Classical facial recess technique allows inserting the array in the
No No No
Sterile Sterile Sterile
Pseudomonas aeruginosa Sterile Sterile Sterile Sterile Pseudomonas aeruginosa Sterile Sterile Staphylococcus aureus Sterile Sterile Pseudomonas aeruginosa Staphylococcus aureus
Cochlear implant Med-El Sonata Ti100 Cochlear CI24 Cochlear CI24 Advanced Bionics HiRes90k Advanced Bionics HiRes90k Advanced Bionics HiRes90k Neurelec Digisonic SP Neurelec Digisonic SP Cochlear CI512 Cochlear CI512 Cochlear CI24 Neurelec Digisonic SP Cochlear CI422 Cochlear CI24 Cochlear CI422 Cochlear CI422 Cochlear CI24 Cochlear CI24 Cochlear CI422 Cochlear CI422 Neurelec Digisonic SP Med-El Sonata Ti100 Neurelec Digisonic SP Cochlear CI24 Advanced Bionics HiRes90K Neurelec Digisonic SP Cochlear CI24
Sterile Staphylococcus aureus Aspergillus flavus
Cochlear CI422 Cochlear CI422 Cochlear CI422
majority of cases with very few complications. Nevertheless, there are some clinical circumstances where this classical technique could not be adapted for the insertion (Table 2). Chronic otitis with or without cholesteatoma was considered at the beginning of cochlear implantation (2) as a contraindication for CI because of the risk of meningitis, infection of the implant, and/or extrusion. Then, some authors started to treat these patients with two-staged procedures, which is a tympanoplasty for cholesteatoma removal and/or tympanic drum perforation repair followed by cochlear implantation after some months (8Y10). Other authors (3,4,27) advised to perform a single-staged procedure if there is no inflammatory active process in the implanted ear. In the presence of a previously performed open cavity, some authors advised to perform obliteration
Otology & Neurotology, Vol. 36, No. 4, 2015
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MIDDLE EAR AND MASTOID OBLITERATION
skin infection even in case of a positive perioperative bacteriological test (n = 8, Table 1). Another important consideration regarding chronic otitis is the possibility of labyrinthitis with cochlear ossification. Patient 6 suffered from bilateral chronic otitis since childhood. A first cochlear implant surgery was performed in the right side with mastoid and middle ear obliteration without any complication. The left side was implanted after 2 years by a young fellow, and a misplacement of the array in the hypotympanum was noted at the postoperative CT scan; analyzing the CT scan of the left side before operation of the right side and the CT scan after the unsuccessful left side, an ossification of the basal turn of the right cochlea occurred. So, another CT scan before a second surgery is mandatory in case of chronic otitis to detect ossification that could have been developed between the two operations. The question of residual cholesteatoma after obliteration and CI insertion has already been evaluated by other authors (33,34). MRI study in implanted patients is artifacted by the device. Therefore, clinical follow-up and eventually CT scan are mandatory for these patients (Table 2). The fat used for obliteration is different in density from residual cholesteatoma, so the latter could be identified in a routine CT scan (33). Ossification of the cochlea is another challenging situation for cochlear implant surgery. It could be expected after meningitis, otosclerosis, temporal bone fracture, and autoimmune inner ear diseases, and it usually starts at the basal turn of the cochlea near the cochlear aqueduct opening in the scala tympani. Placement of the array is performed in the scala tympani if a patent lumen is found (12,13) or in the scala vestibuli (14,15). In case of total ossification of the basal turn, insertion is attempted in the middle turn of the cochlea (17,20). Colletti (35) proposed in 1999 a middle cranial fossa cochleostomy in case of basal turn ossification. It is clear that lowering posterior canal wall and removing ossicular chain gives more space to perform drill-out procedures. Moreover, important structures could be damaged (internal carotid artery) if an unobstructed view is not obtained (Fig. 2). This is also the case of extremely procident sigmoid sinus with very small mastoid (Patient 1, 14, 16); CWD mastoidectomy is performed to be safer regarding the facial nerve
FIG. 1. Postoperative CT scan of Patient 6, showing the array in the second turn of the cochlea (left ear).
with different materials (28Y30), whereas others protected the electrode array with cartilage in the cavity (31) or reconstruction of the posterior canal wall with bone chips (32). Basavaraj et al. (6) described five cases of chronic otitis and cochlear implantation in a single-stage procedure. More recently, Free et al. (33), in a series of 32 cases of subtotal petrosectomy with CI surgery in the same time, described four cases affected by chronic otitis, 13 by previously performed open technique, and four cases of previously performed subtotal petrosectomy. We stopped performing staged procedure or, in case of open cavity, the covering of the array with some materials. Three of our four cases of revision were a result of recurrent cholesteatoma after tympanoplasty with CI surgery (Patient 12) or extrusion of the array in a previously performed open cavity (Patient 15 and 23). We have to keep in mind that chronic otitis is an active, evolving disease and recurrence may be experienced many years after tympanoplasty. Consequently, tympanoplasty performed before or in the same time of a cochlear implantation should not be considered as a safe procedure in a long-term follow-up. Even in case of active chronic otitis, there is no need to stage the procedure if the surgery is correctly performed and adapted antibiotherapy is given in the peri- and postoperative period. We did not experience any post-auricular abscess or TABLE 2. Author Issing et al. 1988 Bendet et al. 1998 Gray et al. 1999 Pasanisi et al. 2002 Basaravaj et al. 2005 Leung et al. 2007 Free et al. 2013 Vincenti et al. 2013 Baranano et al. 2013 Wong et al. 2014 Present study
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Cochlear implantation with middle ear and mastoid obliteration
Cases adults/ children
Chronic otitis
13/1 5/1 17/0 6/0 3/0 17 (ND) 28/4 12/0 23/16 19/0 30/0
14 2 17 6 3 16 21 12 33 19 24
Ossification Malformation 0 0 0 0 0 0 5 0 0 0 1
0 0 0 0 0 0 2 0 0 0 1
Temporal bone fracture
Other etiologies
0 2 0 0 0 0 4 0 0 0 1
0 2 0 0 0 1 0 0 6 0 3
One stage/ two stage Complications 10/4 5/1 1/16 6/0 3/0 7/10 28/4 9/3 10/29 7/12 30/0
4 1 4 0 0 3 2 2 6 3 3
ND, not detailed. Otology & Neurotology, Vol. 36, No. 4, 2015
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D. BERNARDESCHI ET AL.
FIG. 2. Right ear after canal wall down mastoidectomy and basal turn drill-out. Scala tympani (black arrow) and scala vestibuli (white arrow) are seen. Note the close relationship between the basal turn of the cochlea and the internal carotid artery (white star) and the surgical field with unobstructed view of middle ear structures.
and to allow an easier and more appropriate way to insert the array than through posterior tympanotomy (10,36). Moreover, the axis of insertion is more ‘‘anatomic’’ than with a suprameatal (37) or transcanal approach (38) with less risk of misplacement of the array. Temporal bone fracture involving the inner ear could undergo cochlear ossification as the result of intracochlear hemorrhage and labyrinthitis ossificans (39). This may complicate the insertion of the array; furthermore, temporal bone fracture could be complicated with CSF leak (Patient 23), which could expose the patient to life-threatening meningitis (40,41). In the literature, cochlear implantation after temporal bone fracture has been performed with obliteration technique by few authors (29,33). Regarding the patient with aural atresia, only one case of cochlear implantation in such malformation has already been described in children by Lin et al. (42); they performed a cochlear implantation on a 2-year-old child suffering from microtia and aural atresia. It is clear that in such a difficult situation, extensive drilling of the malformed ear to identify surgical landmarks is mandatory. We used electromagnetic computer-assisted navigation and a stimulating burr to be safer in such challenging case. We do not observe in our series inner ear malformation requiring obliteration, probably because in our center only adult patients can be treated. Free et al. (33) had described this procedure in two cases, and the rationale is to avoid CSF leak that could occur in inner ear malformation. In conclusion, middle ear and mastoid obliteration is a safe and effective technique for cochlear implant surgery in adults. To our knowledge, this is the largest series of adult cases implanted with this technique. It allows a safe insertion in difficult and challenging situations.
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Middle Ear and Mastoid Obliteration for Cochlear Implant in Adults: Indications and Anatomical Results *‡Daniele Bernardeschi, *†‡Yann Nguyen, *‡Mustapha Smail, *‡Didier Bouccara, *‡Bernard Meyer, *‡Evelyne Ferrary, *†‡Olivier Sterkers, and *‡Isabelle Mosnier *AP-HP, Groupe Hospitalier Pitie´-Salpeˆtrie`re, Unite´ Otologie, Implants auditifs et Chirurgie de la base du craˆne, Paris, France; ÞSorbonne Universite´s, UPMC Univ Paris 06, UMR-S 1159, ‘‘Re´habilitation chirurgicale mini-invasive et robotise´e de l’audition,’’ Paris, France; and þINSERM UMR-S 1159, ‘‘Re´habilitation chirurgicale mini-invasive et robotise´e de l’audition,’’ Paris, France
Aim of the Study: To review indications, anatomical results, and complications of cochlear implant (CI) surgery in adults for which middle ear and mastoid obliterations were performed. Patients and Methods: Thirty cases (26 patients, 4 bilaterally implanted) of 837 CI surgeries (3.5%) performed between January 2009 and December 2013 have been included in this retrospective study. The mean follow-up was 21 T 18 months (mean T SD, range 3Y58). There were 11 males and 15 females. The mean age was 59 T 19 years (range 35Y82). All surgeries were performed with a single-stage technique including a canal wall down mastoidectomy with external auditory canal closure and mastoid obliteration with fat. A postoperative CT scan was performed in all cases. Results: Etiologies of hearing loss were mainly chronic otitis with or without cholesteatoma in 24 cases. Other etiologies were meningitis with cochlear ossification in one case, progressive hearing loss in two cases, enlarged vestibular aqueduct in one case, temporal bone fracture with CSF leak in one case, and
congenital aural atresia in one case. Four of those 30 cases were revision CI surgery for electrode array misplacement (one case with cochlear ossification) or extrusion from an open cavity (one case) and recurrent cholesteatomas (two cases). All surgeries were uneventful and performed in a single stage. The electrode array was inserted in the basal turn (29 cases) or in the middle turn (one case) of the cochlea. No complications were observed. Two cases of postoperative abdominal hematoma were drained under local anesthesia. A major failure of the CI device occurred 5 months after surgery. Conclusion: CI with mastoid and middle ear obliteration is a safe and effective technique for selected cases of cochlear implantation. Mastoid obliteration prevents from recurrent disease and lowering the facial ridge allows more space to manage extensive cochlear ossification or malformation. Key Words: Chronic otitisVCochlear implantVMastoid obliterationV OssificationVSubtotal petrosectomy. Otol Neurotol 36:604Y609, 2015.
Cochlear implant (CI) surgery in adults is a wellestablished technique for the rehabilitation of severe to profound sensorineural hearing loss for many years (1); it encompasses a mastoidectomy with posterior tympanotomy to gain access to the middle ear and to insert the array through a cochleostomy or the round window membrane. It is a safe and simple procedure with low rate of complications. Nevertheless, some clinical circumstances make this classical approach difficult or contraindicated and led to modify the routine surgical procedure.
Cochlear implantation was previously contraindicated in case of chronic otitis (2). Then, a single (3Y7) or staged (5,8Y10) procedure was suggested in such circumstances. However, in case of cholesteatoma or active chronic otitis, tympanoplasty with or without CI could not prevent the recurrence of the pathology because middle ear spaces still exist and Eustachian tube dysfunction is often present. This is why mastoid obliteration has been also proposed in case of recurrent otitis media or after failure of myringotomy tube in children (5). In case of cochlear ossification, another difficult situation where the classical approach could be problematic, different surgical procedures have been proposed: drillout of the cochlea (11Y13), scala vestibuli insertion (14Y16), use of double-electrode array (17,18) and split array (19,20), and retrograde insertion via apical cochleostomy (21).
Address correspondence and reprint requests to Daniele Bernardeschi, M.D., Ph.D., Otology, Auditory Implants and Skull Base Surgery Department, Pitie´-Salpeˆtrie`re Hospital, 50/52 Bd Vincent Auriol, 75013 Paris, France; E-mail: [email protected] The authors disclose no conflicts of interest.
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MIDDLE EAR AND MASTOID OBLITERATION Nevertheless, these procedures performed through a posterior tympanotomy are at risk of electrode misplacement because of the narrow space of the facial recess and prevent the safe identification of important structures and landmarks (internal carotid artery, facial nerve). Temporal bone fracture could lead to CSF leak and, if it involves the inner ear, fibrosis or ossification of cochlear scalae. Meningitis or the inability to introduce the array makes this situation an urgent otologic surgery, and CI should be performed as soon as possible in case of bilateral profound hearing loss to prevent fibrosis and/or ossification. Another similar clinical situation is the presence of inner ear malformation, where the risk of Gusher should prevent from using the classical facial recess technique because there would not be a safe suppression of the communication between the middle and the inner ear or subarachnoid spaces. The aim of this study was to review our cases of CI surgeries with middle ear and mastoid obliteration to define indications and to analyze complications and surgical results. PATIENTS AND METHODS Thirty cases (26 patients, 4 implanted bilaterally) of 837 CI surgeries in adults (3.5%) performed in our department between January 2009 and December 2013 were included in this retrospective study. All patients gave their consent to the use of personal clinical data. There were 11 males and 15 females. The mean age was 59 T 19 years (mean T SD, range 35Y82). There were 12 left-side and 18 right-side ears. The mean follow-up was 21 T 18 months (range 3Y58). All patients were operated on under general anesthesia with facial nerve monitoring (NIM 2 and 3; Medtronic, Jacksonville, FL). The case of congenital aural atresia was operated on with electromagnetic computer navigation system Digipointeur (Collin, Bagneux, France) (22) and a continuous facial nerve stimulating burr (Stimburgard; Medtronic) (23) for localization of the facial nerve in the malformed ear (this patient did not undergo any previous operation in that ear). Bacteriological scrub of external auditory canal (EAC), mastoid cavity, and/or otorrhea was obtained before antibioprophylaxis with amoxicillin-clavulanate in case of chronic otitis. Retroauricular incision with musculoperiosteal flap was performed whenever possible. Transection of EAC was performed at the level of transition cartilage/tympanic bone. An anterior cut in the tragal skin and cartilage was performed to have all the circumference of the EAC under vision. The lateral part of the skin of the anterior wall was elevated from the tragal cartilage and the sutured to the posterior wall of the transected EAC without everting the cutaneous edge with 4/0 resorbable sutures. The musculoperiosteal flap was then sutured with resorbable 3/0 sutures on the tragal cartilage. In case of large meatoplasty, the anterior skin flap was elevated more laterally and, if the musculoperiosteal flap was not available, a muscular temporalis flap was used as a second layer. The skin of the medial part of EAC was excised with tympanic drum remnant, malleus, and incus if present. Then, a canal wall down (CWD) mastoidectomy was performed, taking care to open all mastoid cells including tip, zygomatic process, retrosinusal, and infralabyrintine and hypotympanic cells. Drilling was stopped when healthy bone
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was reached without pathologic mucosa on it. In case of preoperative CWD mastoidectomy, all the skin of the posterior cavity and epitympanum was removed and the cavity was further drilled up to healthy bone. Also, all the hyperplasic mucosa of middle ear was removed. Obliteration of Eustachian tube with muscular graft and connective tissue was performed. In case of chronic otitis, the array was inserted through the round window membrane. In case of ossification, drilling of the basal turn of the cochlea was started in the region of the round window and continued toward the anatomical course of the basal turn. If there was a lumen in the basal turn of the cochlea, array was inserted in the scala tympani when possible or in the scala vestibuli. If no lumen was found in the basal turn, a cochleostomy was performed in the second turn just anterior to the oval windows (24). At the end of the procedure, the cavity was washed with antiseptic solution (povidone-iodine) and filled with abdominal fat. Closure was performed in two layers. Antibiotherapy was continued until the results of bacteriological test: if no bacteria were found, antibiotics were stopped. If the test was positive, antibiotics were adapted and delivered for 14 days, following the recommendations for meningitis (25). Postoperative CT scan was performed 1 day after surgery to all patients to check the correct positioning of the array. Six months after surgery, speech perception of disyllabic words in quiet without lipreading was tested.
RESULTS Etiology of hearing loss is described in Table 1. There were 24 cases (79%) of chronic otitis (three cases of cholesteatomas). Among them, there were four revision CI surgeries: two for recurrent cholesteatoma after tympanoplasty with cochlear implant insertion in the same time (Patient 12 and 15), one for misplacement (Patient 6), and one for extrusion of the array from a previous CWD mastoidectomy (Patient 23). Eight of the 24 cases suffering from chronic otitis (33%) had positive intraoperative bacteriological test (detailed in Table 1). Other etiologies encompassed two cases (6%) of progressive hearing loss (in which the obliteration was performed because of anterior sigmoid sinus with very small mastoid), one case (3%) of large vestibular aqueduct syndrome (small mastoid), one case (3%) of meningitis with cochlear ossification (3%), one case (3%) of temporal bone fracture with CSF leak, and one case (3%) of congenital aural atresia. Surgeries were uneventful and all performed in a single stage. The type of CI used is described in Table 1. In all but two cases, the array was inserted in the scala tympani of the basal turn of the cochlea through the round window membrane, and CT scan showed no misplacement of the array. In one case of ossification (Patient 11), the array was inserted in the scala tympani after drilling the basal turn of the cochlea. In another case (Patient 5), the array was inserted in the second turn of the cochlea through a cochleostomy performed anteriorly (24) to the oval window (Fig. 1). Two cases of abdominal subcutaneous hematomas were drained under local anesthesia 2 days after the first procedure. Patients were discharged 3 days after surgery, and cochlear implant was activated after Otology & Neurotology, Vol. 36, No. 4, 2015
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D. BERNARDESCHI ET AL. TABLE 1.
Patient
Age
Side
1VMF 2VMD 3VCM
70 56 52
Left Left Left
4VNJ
51
5VHM
Details of patients operated on with middle ear and mastoid obliteration
Etiology of hearing loss Progressive HL Chronic otitis Chronic otitis
FU Revision CI surgery (mo)
Complications
No No No
58 57 54
Right Chronic otitis
No
53
60
Right Chronic otitis
No
47
No
Sterile
60
Left
No
47
No
Sterile
6VDP
53 55
Right Chronic otitis Left Chronic otitis
No YesVmalposition
46 16
No No
7VFV
49
Right Chronic otitis
No
38
8VLJ
67
Right Chronic otitis
No
34
9VBP 10VBA 11VZF 12VRJ
76 73 77 67
Left Right Right Left
21 21 17 16
Abdominal hematoma Cochlear implant failure No No No No
Sterile Staphylococcus aureus Sterile
13VCE
43
14VDLP 15VMT
76 78
Chronic otitis
No No Abdominal hematoma No
Bacteriologic test
Cholesteatoma Chronic otitis Meningitis Chronic otitisVcholesteatoma Right Chronic otitis Left Chronic otitis
No No No YesVrecurrent cholesteatoma No No
16 3
No No
Right Large vestibular aqueduct Right Cholesteatoma
No 16 YesVextrusion of array 14 in the cavity No 14 No 13 No 12
No No
16VADFO 64 17VNS 67 18VTR 82
Right Progressive hearing loss Right Chronic otitis Right Chronic otitis
19VMN 20VGP 21VBMJ
35 45 78
Right Chronic otitis Left Chronic otitis Right Chronic otitis
No No No
11 11 5
No No No
22VLSM
56
Right Major aplasia
No
5
No
23VAY
59
Right Chronic otitis
3
No
24VMKI
40
Left
3
No
25VLF 26VAE
69 43
Left Left
3 3
No No
43
Right Chronic otitis
3
No
YesVextrusion array in the cavity Temporal bone fracture with No CSF leak Chronic otitis + meningitis No Chronic otitis No No
3 weeks. No post-auricular abscess or skin infection was observed in this series. One major device failure occurred 5 months after surgery (Patient 8, implanted with Cochlear CI512 device). For the 25 patients without cochlear ossification who were tested at 6 months, the speech perception of disyllabic words in quiet was 62 T 4.7% (mean T SEM), a value similar to that previously published in a similar population (61 T 6.8%, n = 46) (26).
DISCUSSION CI surgery has been well codified for many years. Classical facial recess technique allows inserting the array in the
No No No
Sterile Sterile Sterile
Pseudomonas aeruginosa Sterile Sterile Sterile Sterile Pseudomonas aeruginosa Sterile Sterile Staphylococcus aureus Sterile Sterile Pseudomonas aeruginosa Staphylococcus aureus
Cochlear implant Med-El Sonata Ti100 Cochlear CI24 Cochlear CI24 Advanced Bionics HiRes90k Advanced Bionics HiRes90k Advanced Bionics HiRes90k Neurelec Digisonic SP Neurelec Digisonic SP Cochlear CI512 Cochlear CI512 Cochlear CI24 Neurelec Digisonic SP Cochlear CI422 Cochlear CI24 Cochlear CI422 Cochlear CI422 Cochlear CI24 Cochlear CI24 Cochlear CI422 Cochlear CI422 Neurelec Digisonic SP Med-El Sonata Ti100 Neurelec Digisonic SP Cochlear CI24 Advanced Bionics HiRes90K Neurelec Digisonic SP Cochlear CI24
Sterile Staphylococcus aureus Aspergillus flavus
Cochlear CI422 Cochlear CI422 Cochlear CI422
majority of cases with very few complications. Nevertheless, there are some clinical circumstances where this classical technique could not be adapted for the insertion (Table 2). Chronic otitis with or without cholesteatoma was considered at the beginning of cochlear implantation (2) as a contraindication for CI because of the risk of meningitis, infection of the implant, and/or extrusion. Then, some authors started to treat these patients with two-staged procedures, which is a tympanoplasty for cholesteatoma removal and/or tympanic drum perforation repair followed by cochlear implantation after some months (8Y10). Other authors (3,4,27) advised to perform a single-staged procedure if there is no inflammatory active process in the implanted ear. In the presence of a previously performed open cavity, some authors advised to perform obliteration
Otology & Neurotology, Vol. 36, No. 4, 2015
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MIDDLE EAR AND MASTOID OBLITERATION
skin infection even in case of a positive perioperative bacteriological test (n = 8, Table 1). Another important consideration regarding chronic otitis is the possibility of labyrinthitis with cochlear ossification. Patient 6 suffered from bilateral chronic otitis since childhood. A first cochlear implant surgery was performed in the right side with mastoid and middle ear obliteration without any complication. The left side was implanted after 2 years by a young fellow, and a misplacement of the array in the hypotympanum was noted at the postoperative CT scan; analyzing the CT scan of the left side before operation of the right side and the CT scan after the unsuccessful left side, an ossification of the basal turn of the right cochlea occurred. So, another CT scan before a second surgery is mandatory in case of chronic otitis to detect ossification that could have been developed between the two operations. The question of residual cholesteatoma after obliteration and CI insertion has already been evaluated by other authors (33,34). MRI study in implanted patients is artifacted by the device. Therefore, clinical follow-up and eventually CT scan are mandatory for these patients (Table 2). The fat used for obliteration is different in density from residual cholesteatoma, so the latter could be identified in a routine CT scan (33). Ossification of the cochlea is another challenging situation for cochlear implant surgery. It could be expected after meningitis, otosclerosis, temporal bone fracture, and autoimmune inner ear diseases, and it usually starts at the basal turn of the cochlea near the cochlear aqueduct opening in the scala tympani. Placement of the array is performed in the scala tympani if a patent lumen is found (12,13) or in the scala vestibuli (14,15). In case of total ossification of the basal turn, insertion is attempted in the middle turn of the cochlea (17,20). Colletti (35) proposed in 1999 a middle cranial fossa cochleostomy in case of basal turn ossification. It is clear that lowering posterior canal wall and removing ossicular chain gives more space to perform drill-out procedures. Moreover, important structures could be damaged (internal carotid artery) if an unobstructed view is not obtained (Fig. 2). This is also the case of extremely procident sigmoid sinus with very small mastoid (Patient 1, 14, 16); CWD mastoidectomy is performed to be safer regarding the facial nerve
FIG. 1. Postoperative CT scan of Patient 6, showing the array in the second turn of the cochlea (left ear).
with different materials (28Y30), whereas others protected the electrode array with cartilage in the cavity (31) or reconstruction of the posterior canal wall with bone chips (32). Basavaraj et al. (6) described five cases of chronic otitis and cochlear implantation in a single-stage procedure. More recently, Free et al. (33), in a series of 32 cases of subtotal petrosectomy with CI surgery in the same time, described four cases affected by chronic otitis, 13 by previously performed open technique, and four cases of previously performed subtotal petrosectomy. We stopped performing staged procedure or, in case of open cavity, the covering of the array with some materials. Three of our four cases of revision were a result of recurrent cholesteatoma after tympanoplasty with CI surgery (Patient 12) or extrusion of the array in a previously performed open cavity (Patient 15 and 23). We have to keep in mind that chronic otitis is an active, evolving disease and recurrence may be experienced many years after tympanoplasty. Consequently, tympanoplasty performed before or in the same time of a cochlear implantation should not be considered as a safe procedure in a long-term follow-up. Even in case of active chronic otitis, there is no need to stage the procedure if the surgery is correctly performed and adapted antibiotherapy is given in the peri- and postoperative period. We did not experience any post-auricular abscess or TABLE 2. Author Issing et al. 1988 Bendet et al. 1998 Gray et al. 1999 Pasanisi et al. 2002 Basaravaj et al. 2005 Leung et al. 2007 Free et al. 2013 Vincenti et al. 2013 Baranano et al. 2013 Wong et al. 2014 Present study
607
Cochlear implantation with middle ear and mastoid obliteration
Cases adults/ children
Chronic otitis
13/1 5/1 17/0 6/0 3/0 17 (ND) 28/4 12/0 23/16 19/0 30/0
14 2 17 6 3 16 21 12 33 19 24
Ossification Malformation 0 0 0 0 0 0 5 0 0 0 1
0 0 0 0 0 0 2 0 0 0 1
Temporal bone fracture
Other etiologies
0 2 0 0 0 0 4 0 0 0 1
0 2 0 0 0 1 0 0 6 0 3
One stage/ two stage Complications 10/4 5/1 1/16 6/0 3/0 7/10 28/4 9/3 10/29 7/12 30/0
4 1 4 0 0 3 2 2 6 3 3
ND, not detailed. Otology & Neurotology, Vol. 36, No. 4, 2015
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D. BERNARDESCHI ET AL.
FIG. 2. Right ear after canal wall down mastoidectomy and basal turn drill-out. Scala tympani (black arrow) and scala vestibuli (white arrow) are seen. Note the close relationship between the basal turn of the cochlea and the internal carotid artery (white star) and the surgical field with unobstructed view of middle ear structures.
and to allow an easier and more appropriate way to insert the array than through posterior tympanotomy (10,36). Moreover, the axis of insertion is more ‘‘anatomic’’ than with a suprameatal (37) or transcanal approach (38) with less risk of misplacement of the array. Temporal bone fracture involving the inner ear could undergo cochlear ossification as the result of intracochlear hemorrhage and labyrinthitis ossificans (39). This may complicate the insertion of the array; furthermore, temporal bone fracture could be complicated with CSF leak (Patient 23), which could expose the patient to life-threatening meningitis (40,41). In the literature, cochlear implantation after temporal bone fracture has been performed with obliteration technique by few authors (29,33). Regarding the patient with aural atresia, only one case of cochlear implantation in such malformation has already been described in children by Lin et al. (42); they performed a cochlear implantation on a 2-year-old child suffering from microtia and aural atresia. It is clear that in such a difficult situation, extensive drilling of the malformed ear to identify surgical landmarks is mandatory. We used electromagnetic computer-assisted navigation and a stimulating burr to be safer in such challenging case. We do not observe in our series inner ear malformation requiring obliteration, probably because in our center only adult patients can be treated. Free et al. (33) had described this procedure in two cases, and the rationale is to avoid CSF leak that could occur in inner ear malformation. In conclusion, middle ear and mastoid obliteration is a safe and effective technique for cochlear implant surgery in adults. To our knowledge, this is the largest series of adult cases implanted with this technique. It allows a safe insertion in difficult and challenging situations.
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