Jan Kiefer

Hearing preservation in cochlear implantation for electric acoustic stimulation

Objective To evaluate the possibility of preservation of low-frequency hearing in atraumatic cochlear implant electrode insertion procedures for combined, ipsilateral electric and acoustic stimulation. Material and Methods A total of 21 patients were implanted with a MED EL C40+ cochlear implant using an atraumatic electrode insertion technique to preserve residual low-frequency hearing. Pure-tone audiometric thresholds were measured pre- and postoperatively to evaluate the degree of preserved hearing. Speech discrimination tests in quiet and with background noise were performed in a patient with successful hearing preservation. Results Using the atraumatic electrode insertion procedure with an insertion depth of 360° (18–24 mm), hearing preservation could be achieved in 18/21 patients (85.7%). Three patients (14.3%) lost their residual low-frequency hearing after the implantation. Residual hearing was preserved completely in 13 patients (61.9%) and partial hearing preservation was possible in 5 (23.8%). Preliminary speech discrimination tests showed a dramatic benefit for the combined electric and acoustic stimulation mode compared to cochlear implantation alone. Conclusion Preservation of low-frequency hearing in cochlear implantation is possible in patients implanted because of profound high-frequency deafness. With the development of new, more atraumatic electrode designs, preservation of residual hearing should be further improved.

Cochlear Implantation Via the Round Window Membrane Minimizes Trauma to Cochlear Structures: A Histologically Controlled Insertion Study

Objective To evaluate cochlear implant trauma to intracochlear structures when inserting the electrode via the round window membrane. Material and methods Eight fresh human temporal bones were evaluated histologically after insertion using two types of cochlear implant array. Bones underwent a special fixation and embedding procedure that allowed sectioning of undecalcified bone with the electrode in situ. Insertions depths were evaluated radiologically and histologically. Results All arrays were found in the scala tympani of the cochlea. Basal trauma could be avoided in all but one specimen. The mean depth of insertion was 382.5°. Apically, only one implanted bone showed cochlear trauma exceeding lifting of the basilar membrane. Conclusion Insertions through the round window membrane were shown to be atraumatic, even in basal cochlear regions. This route of insertion might be very effective for combined electric and acoustic stimulation of the auditory system.

Development and evaluation of an improved cochlear implant electrode design for electric acoustic stimulation

Objective: The objective of this study was to assess the intracochlear position and the extent of trauma to cochlear structures using a new prototype electrode carrier (Flex EAS). Special emphasis was placed on the practicality for combined electric and acoustic stimulation of the auditory system.

Impact of electrode insertion depth on intracochlear trauma

Objective To assess the effect of cochlear implant (CI) insertion depth and surgical technique on intracochlear trauma. Study Design and Setting Twenty one fresh human temporal bones were implanted with CI electrodes and underwent histologie processing and evaluation. Specimens were grouped into 3 categories: 1) soft implantation technique and standard electrode; 2) soft implantation technique and flexible prototype array; 3) forceful implantations and standard electrode. Based on the grading system (1 to 4), 2 numeric values were calculated indicating the overall severity of cochlear damage (trauma indices). Results Mean trauma index values were 13.8, 36.3, and 59.2 for group 1, 2, and 3, respectively. Differences in cochlear trauma (trauma index) were nonsignificant between specimens in groups 1 and 2 but were significant between groups 1 and 3. Conclusion This study gives evidence that intracochlear trauma increases with deep insertions. Thus, in cases where cochlear integrity might be important, limited insertions should be achieved. Conclusion This study gives evidence that intracochlear trauma increases with deep insertions. Thus, in cases where cochlear integrity might be important, limited insertions should be achieved.

Evaluation of Performance with the COMBI 40 Cochlear Implant in Adults: A Multicentric Clinical Study

The present multicentric clinical study involves 19 centres, 16 of them in German-speaking countries, 1 British, 1 Polish and 1 Hungarian. 60 postlingually deafened adults with a mean age of 47.5 years (20-70) and mean duration of deafness of 5.3 years (0.5-20) have been evaluated with the MED-EL COMBI 40 cochlear implant which implements a high-rate continuous-interleaved-sampling strategy with 8 channels. Safety and effectiveness data have been collected. Speech perception tests include a 16-consonant, an 8-vowel, a sentence and a monosyllabic-word test in all languages and a 2-digit figure test in all languages but English. Test intervals are 1, 3, 6 months and 1 year after first fitting. 41 of the 60 postlingually deafened adult study patients have completed their 6-month evaluation. While their pre-operative monosyllabic-word score was 0%, their mean monosyllabic-word score 6 months after first fitting was 48% (8-90) with a median of 50%. The mean sentence understanding was 84% (24-100) with a median of 90%. The respective values for the 1-year evaluations with 25 patients are a mean of 50% (5-85), with a median of 60% for the monosyllables and a mean of 89% (30-100), with a median of 97%, for the sentences.

Perimodiolar Electrodes in Cochlear Implant Surgery

Perimodiolar-positioned cochlear implant electrodes have been developed in order to bring the electrode contacts as close as possible to the spiral ganglion cells, which are the target of electrostimulation. This results in lower electrical thresholds, higher dynamic ranges and less channel interaction when compared with normal implant electrodes which are usually located peripherally within the scala tympani. In this study we evaluated 4 different types of perimodiolar electrode: the Clarion Preformed electrode, the Clarion Preformed electrode with positioner, the Nucleus Contour electrode and the Med-El Perimodiolar Combi 40 electrode. These devices require different approaches to achieve a perimodiolar electrode position. The electrodes were inserted in fresh human temporal bones. After processing these bones with the electrodes in situ by employing a sawing, grinding and polishing technique, the inner ear structures as well as the electrode positions could be evaluated in detail. All electrode types studied had a more or less perimodiolar position; however, each type produced a certain amount of trauma to cochlear structures which is discussed in relation to mechanical properties. Further human temporal bone studies with improved perimodiolar cochlear implant electrodes are necessary in order to find an optimized type of electrode.Perimodiolar-positioned cochlear implant electrodes have been developed in order to bring the electrode contacts as close as possible to the spiral ganglion cells, which are the target of electrostimulation. This results in lower electrical thresholds, higher dynamic ranges and less channel interaction when compared with normal implant electrodes which are usually located peripherally within the scala tympani. In this study we evaluated 4 different types of perimodiolar electrode: the Clarion Preformed electrode, the Clarion Preformed electrode with positioner, the Nucleus Contour electrode and the Med-El Perimodiolar Combi 40 electrode. These devices require different approaches to achieve a perimodiolar electrode position. The electrodes were inserted in fresh human temporal bones. After processing these bones with the electrodes in situ by employing a sawing, grinding and polishing technique, the inner ear structures as well as the electrode positions could be evaluated in detail. All electrode types studied had a more or less perimodiolar position; however, each type produced a certain amount of trauma to cochlear structures which is discussed in relation to mechanical properties. Further human temporal bone studies with improved perimodiolar cochlear implant electrodes are necessary in order to find an optimized type of electrode.

Optimized speech understanding with the continuous interleaved sampling speech coding strategy in patients with cochlear implants : Effect of variations in stimulation rate and number of channels

The purpose of this study was to investigate the effect of systematic variations in stimulation rate and number of channels on speech understanding in 13 patients with cochlear implants who used the continuous interleaved sampling speech coding strategy. Reducing the stimulation rate from 1,515 to 1,730 pulses per second per channel to 600 pulses per second per channel resulted in decreased overall performance; the understanding of monosyllables and consonants was more affected than the understanding of vowels. Reducing the number of active channels below 7 or 8 channels decreased speech understanding; the identification of vowels and monosyllables was most affected. We conclude that vowel recognition with the continuous interleaved sampling strategy relies on spectral cues more than on temporal cues, increasing with the number of active channels, whereas consonant recognition is more dependent on temporal cues and stimulation rate.

Speech understanding in quiet and in noise with the CIS speech coding strategy (MED-EL combi-40) compared to the multipeak and spectral peak strategies (nucleus)

This study compares sentence understanding in quiet and in noise with 3 different speech coding strategies for cochlear implants. The results show that the spectral-peak (SPEAK) and continuous-interleaved-sampling (CIS) coding strategies, based on spectral signal analysis, allow for better speech understanding in quiet as well as in noise, than the multipeak (MPEAK) coding strategy, which relys on speech feature extraction. In the intrasubject comparison of the MPEAK and SPEAK strategies, the SPEAK coding strategy provided a considerable improvement in quiet and in noise for the majority of patients using the Nucleus 22 Mini-implant. In the intersubject comparisons, the mean results in noise with the CIS strategy were superior to both the MPEAK and the SPEAK strategies. The difference was greatest for the most difficult tests in noise. Understanding in noise was least reduced for the CIS strategy. Understanding in quiet was not significantly different between the CIS and the SPEAK strategies; both strategies were significantly better than the MPEAK strategy in quiet. These results are still preliminary, due to the relatively small number of patients and the great inherent intersubject variability of results.

Scala vestibuli Insertion in Cochlear Implantation: A Valuable Alternative for Cases with Obstructed Scala tympani

Insertion of a sufficient number of electrodes is important for a successful use of cochlear implants. We investigated the results of scala vestibuli insertion for cochlear implantation in cases of obstructed scala tympani. In a series of 200 cochlear implantations, scala vestibuli insertion was successfully performed in 4 cases with obstruction of the scala tympani. Etiologies included a temporal bone fracture, severe otosclerosis and malformations of the cochlea. The maximum insertion depth obtained via the scala vestibuli was 30 mm. Postoperative results were comparable to patients in whom conventional scala tympani insertion was performed. No adverse effects related to the site of insertion were observed. Scala vestibuli insertion offers a valuable alternative in cases of obstructed scala tympani that can be employed for a variety of etiologies.

A Novel Technetium-99M Labeled Monoclonal Antibody (174H.64) For Staging Head and Neck Cancer by Immuno-Spect

A novel murine monoclonal antibody (MAb 174H.64) was labeled with 99mTc by a direct method. MAb 174H.64 detects a cytokeratin-associated antigen which is expressed by over 90% of all squamous cell carcinomas. Panendoscopy, sonography and computerized tomography scan were performed in all cases as well as magnetic resonance imaging (in selected patients). Pre-operative immunoscintigraphy was performed in 21 patients with histologically proven primary carcinomas (18 with remaining primary tumors and 3 with lymph node recurrences). Scintigraphic images were obtained 4-6 h after injection of 1.1 GBq of the 99mTc-labeled antibody (2 mg). Late images were acquired 18 to 24 h after injection. Single-Photon-Emission-Computed Tomography (SPECT) of the head and thorax was performed in all patients. The primary tumors were immunoscintigraphically visualized in all 18 patients with remaining primary tumor. Fifteen of 18 loco-regional lymph node metastases were visualized by immunoscintigraphy (the smallest lesions had a diameter of < 1 cm), in one patient lymph node metastases were detected by immunoscan only. Two metastatically involved lymph nodes were identified by histology only (micrometastases). Distant metastases were present in 3 patients, of which two were identified by immunoscintigraphy. Immuno-SPECT according to this method was a sensitive and specific imaging modality for preoperative staging of patients with squamous cell carcinoma of the head and neck and detected lymph node metastases with higher accuracy than conventional clinical and imaging modalities.