http://www.aoico.it XIII Congresso Nazionale AOICO - Cava de’Tirreni (SA) Seconda parte della Relazione tenuta dal dott. Antonio Della Volpe sulla indicazione all'impianto cocleare.

2. Round window /
Cochleostomy

3. Device Positioning
 device away from
processor
 receiver/stimulator
oriented differently in
infants

4. Displacement Force Calculation
A
L R
P
mg

5. Tie-down – Devices with and without
a Pedestal
the bed the device tied in

6. Visualizing the Round Window
 key
 to cochleostomy
placement is finding
landmarks every time
 most important
landmark is the round
window

7. Visualizing the Round Window
 hand position differs
on the left side
 care with stapes
tendon

8. Round Window
 always present
round window
 overhang
 relationship to oval
window is constant
 jugular bulb
stapes tendon Cavity
Common
Right Ear
 rolls away in jugular bulb
anomalies

9. Round Window
 cochleostomy
 direction
 entry into the
scala tympani

10. Cochleostomy vs. Round Window
 bone in round
window
 steeper angle at
first turn contact
 hard to pack/seal right ear bone in hook region

11. Cochleostomy vs. Round Window
 bone in round right ear
window
 steeper angle at first
turn contact
 hard to pack/seal

12. Cochleostomy vs. Round Window
 bone in round window
 steeper angle at first
turn contact
 hard to pack/seal

13. Preparing the Cochleostomy
 anterior to the
round window
 as inferior as
possible
 look often

14. Cochleostomy with curved burs
Curved HS Neurotology Burs
Coolant Wrap

15. Opening the Cochlea
 pick used in “soft”
technique
 hearing
preservation

16. Drilling the Cochleostomy
right ear
 target is scala
tympani
 enter cochlea
 expand in anterior
and inferior
direction
 slow speed drilling

17. Drilling the Cochleostomy
right ear
 target is scala
tympani

18. Drilling the Cochleostomy
 slow speed drilling
 round off anterior
and inferior edges
(electrode is 0.8 mm)
 flush out bone dust

19. Ideal Cochlear Entry Point

20. Access into Scala Tympani
scala vestibuli
modiolus
scala tympani
Photo courtesy CRC for Cochlear Implant and Hearing Aid Innovation, MELBOURNE

21. CASISTICA CLINICA
marzo 2003 – dicembre 2011
N° SEX AGE RANGE TYPE I.C.
Cochlear
312 148m 156f 11m. - 16aa Med- El
AB
MXM

22. Abnormal Cochleae
 25% of anomalous cochleae have technical
challenges at OR
 gushers
 anomalous VII n. anatomy
 problematic exposure

23. Perilymph Gushers
 enlarged vestibular
aqueduct (VAE)

24. Perilymph Gushers
 enlarged vestibular
aqueduct (VAE)
 common cavity
deformity

25. Perilymph Gushers
 enlarged vestibular
aqueduct (VAE)
 common cavity
deformity
 incomplete partition
(IP-1)

26. Facial Nerve Anomalies
 common (14%) and
associated with:
 CC and HC
 anomalous stapes
 nerve can split proximally
 facial nerve monitor essential

27. Problematic Anatomy
hypoplastic cochlea
anteriorly displaced CN VII
prominent sinus pericrani

28. Re-implantation
 device failure
 device infection
 (leave array in cochlea if
possible)

29. Re-implantation
 tips
 be prepared to drill around
cochleostomy
 insert new array
immediately old array
removed
 straight array narrower but
more flexible

30. Choice of electrode array
Indications
Options
general use, atraumatic
 Pre-curved AOS insertion
incomplete partition
 Straight
hearing preservation
 Short
apical stimulation
 Long
ossified cochleae
 Double or split

31. Conclusion
 keys to success are:
 appropriate selection of the patient
 fixation of the receiver stimulator
 identification of landmarks for round
window/cochleostomy
 care with abnormal cochleae
 appropriate selection of the electrode

32. CONCLUSIONS 2
 CI is generally possible in cases with inner ear malformations
 Variable results (neural function) generally satisfactory results
Facial nerve anomalies
 Surgical issues •surgical access Cochlear anomalies
•CSF gusher (difficult to radiologically predict)
•type of array
•array placement misplacement in the IAC (++IP I, IP III, CC, CH)
 Programming difficulties / facial nerve electrical stimulation
Fenestral CSF fistula (++)
Higher risk of post-op. meningitis
CSF fistula at cochleostomy site (--)

33.  Cochlear nerve aplasia-hypoplasia is not uncommon(unilateral ++)
Cochlear nerve aplasia associated to a normal labirynth is possible
A severely narrowed IAC (2 mm) indicates a severe hypoplasia of the cochleo-vestibular
nerve, but not a sure absence of the cochlear nerve (if the cochlear duct is present and the
labirynth is malformed, the possibility of a functioning cochlear nerve is higher)
 A normal IAC does not garantee the presence of a normal cochleo-vestibular nerve
(unilateral cases, parasagittal reconstructions)
 The outcome after CI in pts with aplasia-hypoplasia of the cochlear n. are generally scarce

34. Azienda Ospedaliera di Rilievo
Nazionale
Santobono – Pausilipon
NAPOLI
Thank You !!!