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XIII Congresso Nazionale A.O.I.C.O. 20- 21 gennaio2012 Cava de’ Tirreni (SA) Attuali indicazioni chirurgiche in ORL L’Impianto Cocleare Antonio della Volpe SSD Chirurgia Protesica Sordità AORN Santobono-Pausilipon Napoli

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IC: non è solo inserire un elettrodo

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Patients SelectionIn pre-operative protocol we suggest to studynot only the ear and petrous mastoid region,but also the brain.In fact whole brain MRI can demonstrateanomalies also in children withoutneurological signs or symptoms and canexplain the wide variation of performanceacross individual cochlear implant users

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for an “optimal” outcomelook better into the ear

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Minimal Access Surgery

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Immunohistochemistry of human cochlea Neurofilament 160 Connexin 30 DAPI

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Connexins in human ear Connexin 30 Connexin 26 Merged DAPI

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Human gap junction Köling & Rask-Andersen 1983 Connexin 30 Connexin 26 Merge DAPI cap MC ES IC BC SLSEM - Human Confocal microscopy - Human

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Left Ear – Cadaver Temporal Bone Chorda Tympani Nerve (anterior border of FacialOsseous Spiral Lamina (OSL) /Basilar Recess Membrane – Under Bone Scala Vestibuli Anterior (Completely opened) Incus/stapedial jointScala Tympani(Completely opened to Short process of incus – notlateral wall, floor and True visible under ledgeosseous spiral lamina) RWM Antrum Mastoid Tip Incus Buttress Tegmen Facial Nerve (Posterior Cochleostomy Target Zone Lateral Semi-Circular Canal Border of Facial Recess) (“sweet” spot) Sigmoid Sinus Inferior

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Surgical Technique device position resistance to displacement cochleostomy/round window abnormal cochleae explant/replant electrode choice

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ApproachesTransmastoid TransmeatalApproach Approach

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Non-Mastoidectomy Approaches Pericanal Transmeatal Suprameatal Approach approach Approach R. Hausler (2001) – ( Minimal Access (SMA): - Post auricular skin Surgery)J. Kronenberg incision with K. Taibah (2005) (2001) - parietal extension - Post auricular- Post auricular skin incision. incision - Tympanomeatal flap - Tympanomeatal flap- Tympanomeatal flap - open tunnel in EAC - open tunnel in EAC- Groove lateral to chordi tympani with a groove for the - glass ionomer electrode.- Suprameatal closed cement and bone tunnel dust - Direct visualization- The dura of the middle cranial fossa is exposed.

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Skin Incisionright left