Benno P. Weber

Preservation of residual hearing with cochlear implantation: how and why.

Conclusions Hearing may be conserved in adults after implantation with the Nucleus Contour Advance perimodiolar electrode array. The degree of hearing preservation and the maximum insertion depth of the electrode array can vary considerably despite a defined surgical protocol. Residual hearing combined with electrical stimulation in the same ear can provide additional benefits even for conventional candidates for cochlear implantation. Objectives We present preliminary results from a prospective multicentre study investigating the conservation of residual hearing after implantation with a standard-length Nucleus Contour Advance perimodiolar electrode array and the benefits of combined electrical and acoustic stimulation. Material and methods The subjects were 12 adult candidates for cochlear implantation recruited according to national selection criteria. A “soft” surgery protocol was defined, as follows: 1–1.2-mm cochleostomy hole anterior and inferior to the round window; Nucleus Contour Advance electrode array inserted using the “Advance-off-stylet” technique; and insertion depth controlled by means of three square marker ribs left outside the cochleostomy hole. These procedures had been shown to reduce insertion forces in temporal bone preparations. Variations in surgical techniques were monitored using a questionnaire. Pure-tone thresholds were measured pre- and postoperatively. Patients who still retained thresholds <90 dB HL for frequencies up to 500 Hz were re-fitted with an in-the-ear (ITE) hearing aid. Word recognition was tested in quiet and sentence perception in noise for the cochlear implant alone and in combination with an ipsilateral hearing aid. Results Hearing threshold level data were available for 12 patients recruited from 6 of the centres. Median increases in hearing threshold levels were 23, 27 and 33 dB for the frequencies 125, 250 and 500 Hz, respectively. These median increases include the data for two patients who had total loss of residual hearing due to difficulties encountered during surgery. “Cochlear view” X-ray images indicated that the depth of insertion varied between 300 and 430°, despite modest variations in the length of the electrode inserted (17–19 mm). The insertion angle had some influence on the preservation of residual hearing at frequencies of 250–500 Hz. Six of the 12 patients retained sufficient hearing for effective use of an ipsilateral ITE hearing aid (≤80 dB HL at 125 and 250 Hz; ≤90 dB HL at 500 Hz). Word recognition scores in quiet were improved from 10% to 30% with the cochlear implant plus ipsilateral hearing aid in 3 patients who had at least 3 months postoperative experience. Signal:noise ratio thresholds for sentence recognition were improved by up to 3 dB. Patients reported that they experienced greatly improved sound quality and preferred to use the two devices together.

Benefits of bilateral electrical stimulation with the nucleus cochlear implant in adults: 6-month postoperative results.

Objective: To evaluate the benefits of bilateral electrical stimulation for hearing-impaired adult subjects using the Nucleus 24 cochlear implant in a multicenter study, and to compare and quantify performance on speech perception measures in quiet and in noise and localization ability for unilateral and bilateral cochlear implant use. Design: Repeated single subject measures were carried out for each subject, with each subject serving as their own control. Assessment of unilateral and bilateral listening conditions for performance on tests of speech comprehension and sound localization were performed. Speech comprehension measures were performed in quiet at 0 degree azimuth and in the presence of background noise simultaneously presented from the same speaker and spatially separated by 90 degrees, at S+45°N45° and at S−45°N+45°. Test materials included Freiburger monosyllabic words, Oldenburger sentences, and the Hochmair-Schulz-Moser sentences. Tests of localization were performed in the horizontal plane with 12 speaker locations 30 degrees apart using a shortened sentence stimulus from the Hochmair-Schulz-Moser sentences at two possible presentation levels of 55 and 70 dB sound pressure level for assessment of directionality. The binaural advantage provided by bilateral stimulation was calculated with respect to each ear separately, classified as either the better or poorer performing ear for each speech material in quiet and in noise test conditions. For localization of sound, the binaural advantage was compared with left and right ears separately. Paired comparisons for performance data in all conditions were carried out by considering measurements for each subject in different conditions as paired observations and applying the Student’s t test to determine the statistical difference between the data sets. Setting: Tertiary referral centers with a cochlear implant program. Patients: Thirty-seven profoundly hearing-impaired adults were enrolled in the study, 22 simultaneously and 15 sequentially bilaterally implanted. All patients received the Nucleus 24 cochlear implant and used the Nucleus SPrint or ESPrit 3G speech processor, with the vast majority using the ACE speech coding strategy. Results: For spatially separated speech in noise conditions, an interaural performance advantage for the ear closest to the speech source (i.e., with a superior signal to noise ratio) compared with that for the ear closest to the noise source (i.e., with an inferior signal to noise ratio) is consistently demonstrated regardless of whether it is the better or poorer performing ear closest to the speech signal. This is referred to as a significant binaural head-shadow benefit, resulting in a mean improvement between −10 dB and −11.4 dB in the critical signal to noise ratio required for 50% speech comprehension for the Olden-burger sentences and a mean improvement in the maximum score of 42% to 55% for the ear closest to the speech signal over the ear farthest away for the Hochmair-Schulz-Moser sentences. Bilateral stimulation is always observed to provide a performance advantage over the unilateral listening condition for either ear when ipsilateral to the noise source. In addition, as demonstrated by approximately half the subjects tested in noise with the Hochmair-Schulz-Moser sentences, a performance advantage of bilateral stimulation may be observed over the better ear alone when positioned ipsilateral to the speech signal, which is referred to as a binaural squelch effect. On average, for the group, this resulted in a statistically significant improvement in speech comprehension scores of 8% in the bilateral listening condition compared with the scores for the better ear alone. Through assessment of comprehension of coincidental speech in noise and speech in quiet, a significant benefit of binaural redundancy was noted for the group for Oldenburger sentence scores in noise and in quiet compared with unilateral scores for either ear and for the Freiburger monosyllabic words in quiet in comparison with the better ear alone scores. Binaural stimulation also led to a significant improvement in localization ability over either monaural condition, with the root mean square degrees of error reduced by 38 degrees compared with that observed for unilateral stimulation. Conclusion: Similar to what has been observed for bilateral acoustic stimulation in the past, bilateral electrical stimulation provides the foundation for the potential advantages of the head-shadow effect, providing a binaural head-shadow benefit and binaural auditory processing such as binaural redundancy and binaural squelch effects, all of which combine to lead to improved speech comprehension over unilateral listening conditions. The combination of improved speech comprehension and improved localization ability made available through bilateral electrical stimulation provides the necessary foundation to further assist the hearing-impaired listener to better cope with communication in the everyday listening situation both in noise and in quiet.

Clinical experience with the Vibrant Soundbridge implant device.

Objective To evaluate the full degree and range of benefits provided by the Vibrant Soundbridge (VSB; Symphonix Devices, Inc., San Jose, CA, U.S.A.) and analyze pre-and postoperative results of audiologic tests. Study Design Single-subject study with each subject serving as his or her own control. Setting Multicenter clinical study conducted at 10 centers in Europe. Patients 47 patients who met the selection criteria for participation in the study. Interventions Implantation of the VSB direct-drive middle ear hearing device. Main Outcome Measures Average change in unaided thresholds with the patient wearing headphones at each frequency pre-and postsurgery was measured. A mean threshold change less than 5 dB across all frequencies was considered clinically nonsignificant. Results 47 patients had successful surgery for implantation and fitting with the VSB device. Conclusion The VSB is a new middle ear implant device that can be used safely in the treatment of patients with moderate to severe sensorineural hearing loss.

Congenital malformations of the inner ear and the vestibulocochlear nerve in children with sensorineural hearing loss: evaluation with CT and MRI.

Purpose The purpose of this work was to study the diagnostic value of CT and MRI in children with sensorineural hearing loss and to analyze anatomic abnormalities of the inner ear and the vestibulocochlear nerve in this patient group. Method We evaluated 42 inner ears in 21 children with congenital deafness who had congenital inner ear malformations and who were candidates for cochlear implants. All patients were studied with high resolution MR and helical CT examinations. The MR study included a T2-weighted 3D fast SE sequence. We describe and tabulate the anatomic abnormalities. Special attention was given to abnormalities of the vestibulocochlear nerve. The field of view in the plane according to the length axis of the internal auditory canal (IAC) was 4 cm. Additional continuous parasagittal reformations perpendicular to the length axis of the IAC were studied with a field of view of 3 cm. Results CT and MRI allowed accurate identification of malformations of the inner ear in children with congenital deafness. We identified 99 malformations, with a majority of patients demonstrating multiple abnormalities. Common imaging findings were Mondini abnormality and Mondini variants (12/42) and fusion of the lateral or superior semicircular canal with the vestibule (12/42). MRI demonstrated in 9 of 21 patients a rudimentary or absent vestibulocochlear nerve in the auditory canal. Conclusion CT and MRI are important modalities to analyze the inner ear in children who are candidates for cochlear implants. MRI with an extremely small field of view should be used to study possible abnormalities of the vestibulocochlear nerves. This may alter clinical care and allow cochlear implant placement in patients whose electrodiagnostic studies suggest that the implant should not be performed. The detailed analysis of abnormalities of the inner ear might establish prognostic factors.

Virtual endoscopy of the middle ear: experimental and clinical results of a standardised approach using multi-slice helical computed tomography.

Abstract. Virtual endoscopy (VE) enables non-invasive 3D endoluminal imaging of the middle ear by post-processing of CT data. To optimise the clinical application a standardised approach was evaluated in normal and pathologic cases. Data acquisition was performed using multi-slice helical CT in 20 normal patients and 15 patients with malformation or trauma. Virtual endoscopy of the tympanic cavity and 3D images of the ossicles were generated using surface and volume rendering. Qualitative assessment of the representation of anatomical structures was performed in normal patients. In 15 pathological cases the diagnostic benefit was evaluated by comparing the 3D images to the 2D images and intra-operative findings. In all 35 cases 3D imaging was possible using the standardised approach. The ossicular chain as well as the bony and soft tissue structures of the tympanic cavity were visualised in 20 normal patients. In 7 of 8 patients with malformation and 1 of 7 patients with trauma the original diagnosis was changed by 3D imaging. Standardisation and evaluation of the method in normal patients is essential as it enhances the diagnostic reliability. Virtual endoscopy facilitates understanding of the complex anatomy of the middle ear. In cases of suspected malformation and confirmed trauma it is helpful for diagnosis and surgical planning.

New Clarion electrode with positioner: insertion studies.

A new straight thin electrode array (universal electrode) was designed to be used together with a positioner, which will place the electrode array at the medial wall (modiolus) of the cochlea. The study objectives were to demonstrate safety and ease of insertion, tissue trauma, electrode position, and depth for universal and standard electrodes in human temporal bones; to test functional properties in cats; and to determine the surgical procedure and electrophysiological benefits in a clinical study. The cadaver study demonstrated the ease of insertion for the universal electrode and the positioner without tissue damage. An average gain of insertion depth of 180° was achieved with the positioner. Animal studies demonstrated a reduction in threshold of 6 dB for the electrical auditory brain stem response (EABR). Neither additional cochlear damage nor additional connective tissue formation was found. The intraoperative human study findings showed a marked reduction of threshold for both EABR and stapedius reflex thresholds. Impedances were increased. Plain x-rays demonstrated modiolus proximity of the electrode with the positioner. The new Clarion electrode with positioner is a relatively safe design for providing modiolus proximity. The electrophysiological benefits include reduction of threshold and power consumption.

Performance and preference for ACE stimulation rates obtained with nucleus RP 8 and freedom system.

Cochlear recently released the Nucleus® Freedom™ System which has been based on the Nucleus® Research Platform 8. Both systems make use of the same implant, the CI24RE, which includes expanded total stimulation rates up to 32 kHz. In this study the performance of the ACE strategy at 500, 1200 and 3500 pps/channel was investigated using an ABC-CBA design. At the end of each period speech tests were performed. In the CBA phase the patients completed a comparative questionnaire to determine the subjective rate preference. Preliminary results in 13 recipients indicate no differences in for the ACE strategy at rates ranging from 500 pps to 3500 pps/channel.

Clinical results of the CLARION® magnetless Cochlear Implant

This paper reports initial results for the CLARION® Multi-Strategy™ Cochlear Implant, presently under investigational study in Europe. A magnetless implantable cochlear stimulator (ICS) with an ear-mold—supported headpiece was designed in response to an increasing demand for a magnetic resonance imaging (MRI)–compatible cochlear implant. Surgical technique, accompanying magnetless headpiece, and MRI compatibility were evaluated in 11 deaf patients (ages 6 to 62 years) who were implanted with a magnetless Clarion implant. Because of the headset mechanics, the ICS was implanted closer behind the ear than a magnet-containing ICS. The ICS-MRI compatibility was investigated with 1.5- and 0.3-T MRI. Results showed that the surgery was relatively safe and easy to learn. The headset was stable and reliable. The MRI compatibility tests indicate that the ICS poses no contraindication for patients needing MRI. Overall, the results suggest that the Clarion magnetless cochlear implant is relatively safe and easy to implant, is MRI-compatible, and functions well with the ear-mold—supported headpiece.

Clinical relevance of the distance between the cochlea and the facial nerve in cochlear implantation.

Hypothesis To elucidate possible mechanisms of facial nerve costimulation after cochlear implantation that are supposed to result from the close cochlea to facial nerve contact. Background One of the postoperative complications of cochlear implantation is facial muscle twitching, which has preferentially been found in otosclerotic patients. It impairs hearing benefits because of deactivation of electrodes and can still not be adequately prevented. Methods A total of 13 temporal bones were dissected to quantify where the labyrinthine portion of the facial nerve is closest to the scala tympani, the placement site of the cochlear implantation electrode array. After the typical operative procedures to find out the number of electrodes lying closest to the facial nerve were performed, a cochlear implantation array was inserted into four specimens. The clinical records of 14 otosclerotic patients were investigated to correlate these results with the position of in vivo deactivated electrodes. Results The closest distance between the scala tympani and the nerve was only 0.33 mm (±0.14). On average, after insertion of 23 electrode resp. marking rings, the facial nerve was reached. This is clinically the position of most frequently deactivated electrodes to prevent postoperative facial nerve costimulation. Conclusions These investigations support the hypothesis that a direct current spread at the site of the facial nerve crossing the cochlear basal turn is most likely the reason for postoperative facial muscle twitching facilitated in otospongiotic bone. Prevention could therefore be achieved by cochlear implantation designs and surgical techniques that take into consideration the site of closest contact.

Computertomographische Untersuchungstechnik und Anatomie des Felsenbeins

ZusammenfassungStandarduntersuchung des Felsenbeins unter besonderer Berücksichtigung der Innenohrstrukturen ist die hochauflösende Spiral-Computertomographie (-CT) mit niedriger Dosis. Im Vergleich von Standard- und Spiraltechnik zeigt sich lediglich ein minimaler Qualitätsverlust. Die knöchernen Begrenzungen der Kochlea kommen mit der Standardtechnik geringgradig schärfer zur Darstellung, wodurch die diagnostische Aussagekraft der Spiraltechnik jedoch nicht beeinflußt wird. Bei regelrechtem Befund ermöglichen die originalen Schichtbilder mit hinreichender Sicherheit eine Beurteilung der Strukturen. In Zweifelsfällen oder bei ungünstig angeschnittenen Strukturen ist es jedoch nicht immer möglich, exakt zwischen pathologischem und regelrechtem Befund zu differenzieren. Mittels der optimierten Sekundärreformationen aus dem Spiraldatensatz lassen sich alle Strukturen in ihrem Verlauf darstellen und optimal beurteilen.AbstractLow-dose spiral-CT has gained standard in the preoperative examination of cochlea-implant patients. There is only a minimal loss of quality from spiral-CT when compared with standard-CT, which is not relevant for the diagnosis. In cases when all structures seem to be regular, the axial sections are sufficient for the diagnosis. In cases of doubt or complex pathology two-dimensional reformations are an important tool for the diagnosis. Multiplanar reformats provide the presentation of all interesting structures in their whole extension and thus enable an exact diagnosis.