T. Stöver

Hearing Conservation Surgery Using the Hybrid-L Electrode

Patients with high-frequency deafness and/or substantial residual hearing across frequencies might benefit from combined electro-acoustic stimulation. The Hybrid-L electrode was designed to address the issues of both hearing conservation and effective electrical stimulation in those recipients. The electrode with 22 contacts should be inserted through the round window membrane, and covers approximately 270° of the basal turn of the cochlear. This insertion length is equivalent to the one seen in many patients using the former Nucleus straight electrode. Twenty-four patients with low-frequency thresholds of 60 dB or better, up to 500 Hz, were implanted with a Hybrid-L device in a clinical trial at the Medical University of Hannover. Another group of 8 recipients with less residual hearing was included under extended inclusion criteria. Residual hearing was conserved in the majority of cases. One patient had a loss of more than 30 dB, but hearing partially recovered after 9 months. The median loss in all patients was 10 dB in both the Hybrid group and the extended group. Patients were able to use the residual hearing postoperatively to the same extent as preoperatively. In the Hybrid mode (cochlear implant + ipsilateral hearing aid), patients showed a significant improvement of 21% (p = 0.002) in speech understanding in quiet using the Freiburger Monosyllabic Word Test compared to the preoperative scores under aided conditions with their hearing aid. The Oldenburg Sentence Test in noise showed a remarkable average improvement of 10.2 dB (p < 0.001) compared to the preoperative hearing aid only mode. An additional improvement could be seen in the combined mode using an additional contralateral hearing aid. Recipients with a shorter duration of high-frequency hearing loss showed a larger benefit than those with a longer duration of hearing loss. Hearing conservation using the Hybrid-L electrode and a given surgical technique is possible with high probability in patients with high-frequency deafness or pantonal hearing loss. The use of the residual acoustic hearing offers specific advantages, especially for understanding speech in noise and for spatial hearing.

Temporal Bone Results and Hearing Preservation with a New Straight Electrode

Due to improved technology, cochlear implant (CI) candidacy has been widened towards patients with usable residual hearing in the low frequency range. These patients might benefit from additional acoustic amplification provided that residual hearing can be preserved with cochlear implantation. To provide a high probability of hearing preservation, a new electrode array was designed and developed at the Medizinische Hochschule Hannover. This ‘Hybrid-L’ electrode array has 22 electrodes spread over 15 mm with an overall insertion depth of 16 mm. The straight electrode with modiolus facing contacts is designed for a round window insertion. It shall provide the full range of the currently most advanced Nucleus CI system. A temporal bone study demonstrated the favorable insertion characteristics and minimized trauma to intracochlear structures. Compared to standard CI electrodes especially no basilar membrane perforation could be found. So far, 4 patients have been implanted and residual hearing could be preserved. One patient was fitted and showed a marked additional benefit from the electroacoustic stimulation compared to either acoustic or electrical stimulation alone. These results are very encouraging towards a concept of reliable hearing preservation with cochlear implantation.

Comparison of Round Window and Cochleostomy Approaches with a Prototype Hearing Preservation Electrode

Introduction: Preservation of residual hearing in cochlear implant recipients has been demonstrated to be possible and provides the potential benefit of combined electric and acoustic auditory stimulation. A prototype 16-mm multichannel array has been designed to facilitate placement of 22 electrodes without damage to intracochlear structures. The electrode array is suitable for insertion via the round window membrane (RWM) or a small cochleostomy. Aim: To evaluate the insertion trajectory and the presence of trauma to intracochlear structures with the prototype electrode inserted by either the RWM or a scala tympani cochleostomy. Materials and Methods: Eighteen fresh frozen human temporal bones were prepared for cochlear implantation using a standard transmastoid facial recess technique. Twelve electrodes were implanted at the University of Melbourne and 6 at the Medizinische Hochschule Hannover. In Melbourne fluoroscopy was used to monitor the insertions. Twelve prototype electrodes were inserted via the RWM. A further 6 electrodes were inserted via a small scala tympani cochleostomy. The cochleostomy was sited inferior to the RWM to avoid trauma to the basilar membrane and spiral ligament. Specimens were embedded and fixed with acrylic resin and the cochleae then examined histologically at 200-µm intervals using a grinding and polishing technique. Results: Full insertion of the electrode was achieved without significant resistance in all RWM and cochleostomy specimens. In two RWM specimens fold-over of the electrode tip occurred, and in one specimen the electrode penetrated the spiral ligament to lie in an ‘endosteal ‘position. In one cochleostomy specimen the electrode was rotated within the cochlea to face laterally rather than towards the modiolus. The final electrode position differed for the two groups, with the electrodes inserted via the RWM lying in a more perimodiolar position along the first part of the basal turn. The average depth of insertion was 240° for the RWM electrodes and 255° for the cochleostomy electrodes. Histologic examination showed no damage in any specimen to the modiolus, osseous spiral lamina or basilar membrane. Conclusions: A prototype hearing preservation electrode array was inserted by either a RWM or a scala tympani cochleostomy without evidence of significant intracochlear trauma.

Impact of Low-Frequency Hearing

Today, cochlear implantation is the treatment of choice in the case of severe to profound hearing loss, but the speech perception abilities of many recipients in noisy conditions are still poor and the overall sound quality and ease of listening still require improvement. Residual low-frequency hearing has been associated with improved hearing performance in cochlear implant patients, especially in difficult listening environments (i.e. cocktail party effect). It seems that low-frequency information can enhance the segregation of competing voices, which leads to better speech understanding in noise. We investigated the effect of low-frequency hearing on speech perception performance in a group of subjects being implanted with the Nucleus Hybrid-L device. The Hybrid-L device is a modified Nucleus Freedom implant, which instead of the standard electrode carries a very delicate electrode array that allows preservation of residual hearing to a great extent. Sentence test results from 22 subjects are presented here. Additionally, for 8 subjects, the acoustically presented frequency range was limited to 300, 500 and 700 Hz, and speech perception tests with a single competing talker were conducted. The Hybrid-L study group achieved a speech reception threshold of 15.9 dB in the hearing aid alone condition, 10.8 dB in the cochlear implant alone condition, and 3.9 dB when using the combination of cochlear implant and hearing aid. Differences between the 3 conditions are statistically significant. Results from the additional experiment on the acoustically presented frequency range suggest that very limited residual hearing below 500 Hz is already sufficient to produce a significant improvement in speech perception performance in conjunction with a cochlear implant.

Dual-Energy CT Applications in Head and Neck Imaging

OBJECTIVE Dual-energy scanning is a breakthrough in CT technology that has several applications in chest and abdominal imaging. Dual-energy CT also has potential for head and neck imaging. This review describes the role of dual-energy CT in head and neck imaging. CONCLUSION As with other body regions, both image fusion and material characterization dual-energy applications can be used for head and neck imaging. Early results are promising, and further research is encouraged.

Stress induces transient auditory hypersensitivity in rats

Exposure to harsh environment induces stress reactions that increase probability of survival. Stress influences the endocrine, nervous and immune systems and affects the functioning of a variety of organs. Numerous researchers demonstrated that a 24-h exposure to an acoustic rodent repellent provokes stress reaction in exposed animals. In addition to the activated hypothalamic-pituitary-adrenal (HPA) axis, exposed animals had pathological reactions in the reproductive organs, bronchia and skin. Here, we examined the effect of above stress model on the auditory system of Wistar rats. We found that 24-h stress decreases the thresholds and increases the amplitudes of auditory brainstem responses and distortion product otoacoustic emissions. Resultant auditory hypersensitivity was transient and most pronounced between 3 and 6h post-stress, returning to control levels one week later. The concentration of corticosterone and tumor necrosis factor alpha was systemically elevated in stressed animals between 3 and 6h post-stress, confirming the activation of the HPA axis. In addition, expression of the HPA-axis-associated genes: glucocorticoid receptor (GR) and hypoxia-inducible factor 1 alpha (Hif1a) was modulated in the auditory tissues. In detail, in the inferior colliculus, we found an up-regulation of GR mRNA 3h post-stress and continuous up-regulation of Hif1a up to 24h post-stress. In the spiral ganglion, we found no differences in gene expression between stressed and control animals. In the organ of Corti, expression of GR mRNA remained stable, whereas that of Hif1a was significantly down-regulated one week after stress. In addition, the expression of an outer hair cell marker prestin was significantly up-regulated 6h post-stress. We conclude that 24-h stress induces transient hypersensitivity of the auditory system and modulates gene expression in a tissue-specific manner. Stress-induced auditory hypersensitivity could have evolutionary consequence by giving animals an advantage of hearing better under stress conditions.

Neurite outgrowth on cultured spiral ganglion neurons induced by erythropoietin

The morphological correlate of deafness is the loss of hair cells with subsequent degeneration of spiral ganglion neurons (SGN). Neurotrophic factors have a neuroprotective effect, and especially brain-derived neurotrophic factor (BDNF) has been demonstrated to protect SGN in vitro and after ototoxic trauma in vivo. Erythropoietin (EPO) attenuates hair cell loss in rat cochlea explants that were treated with gentamycin. Recently, it has also been shown that EPO reduces the apoptose rate in hippocampal neurons. Therefore, the aim of the study was to examine the effects of EPO on SGN in vitro. Spiral ganglion cells were isolated from neonatal rats and cultured for 48 h in serum-free medium supplemented with EPO and/or BDNF. Results showed that survival rates of SGN were not significantly improved when cultivated with EPO alone. Also, EPO did not further increase BDNF-induced survival of SGN. However, significant elongation of neurites was determined when SGN were cultivated with EPO alone. Even though a less than additive effect was observed, combined treatment with BDNF and EPO led to a significant elongation of neurites when compared to individual treatment with BDNF or EPO. It can be concluded that EPO induces neurite outgrowth rather than promoting survival. Thus, EPO presents as an interesting candidate to enhance and modulate the regenerative effect of BDNF on SGN.

Development of a specially tailored local drug delivery system for the prevention of fibrosis after insertion of cochlear implants into the inner ear

A cochlear implant (CI)-associated local drug delivery system based on dexamethasone (DMS) was developed with the purpose to inhibit the growth of fibrotic tissue which influences the signal transmission from the CI to the neurons of the inner ear. For the realization of a targeted DMS delivery the following concepts were combined: modification of the silicone-based electrode carrier by incorporation of DMS and a DMS-containing polymeric coating chemically attached on the surface of the electrode carrier. It was demonstrated that the coated CI showed a high coating stability in a simulated implantation procedure. The in vitro drug release studies in a quasi-stationary model revealed a faster DMS release in the initial phase originating from the DMS-containing coatings and then a lower and sustained DMS release originating from the DMS-loaded silicone carrier. The performed in vitro biocompatibility study confirmed that the released DMS was non-toxic for cultured spiral ganglion cells.

Substance distribution in a cochlea model using different pump rates for cochlear implant drug delivery electrode prototypes

Several studies using animals have shown the protective effects of neurotrophic factors (NF) on spiral ganglion cells (SGC). This is of particular importance since the number of SGCs is considered to be among the factors defining the efficacy of cochlear implants. A device for local inner ear treatment is therefore of great interest. As described previously, we modified a Contour(TM) cochlear implant electrode, to examine the inbuilt canal to be used for fluid release [Paasche, G., Gibson, P., Averbeck, T., Becker, H., Lenarz, T., Stöver, T., 2003. Technical report: modification of a cochlear implant electrode for drug delivery to the inner ear. Otol. Neurotol. 24, 222-227]. In the present study, three different electrode prototypes with openings of the delivery channel at various locations along the electrode array were examined to determine distribution of dye in a cochlea model over time. We compared dye delivery with: (a) release of the dye at the tip, (b) release of the dye at the tip and the side of the electrode, and (c) release of the dye only at the side of the electrode (6 mm from the tip). A mechanical pump was used to drive the system at pump rates of 100, 10, and 1 microl/h. Dye concentration changes along the length of the whole cochlea were investigated. Mean values for all experimental conditions show that the distribution along the array is fastest with two outlets whereas the distribution via a single outlet at the side of the electrode array is not considered to be sufficient. The established experimental setup provides the possibility of investigating prototypes of a fluid based drug delivery system for the treatment of inner ear pathologies in combination with electrical stimulation.

Development and evaluation of the modiolar research array – multi-centre collaborative study in human temporal bones

Abstract Objective Multi-centre collaborative study to develop and refine the design of a prototype thin perimodiolar cochlear implant electrode array and to assess feasibility for use in human subjects. Study Design Multi-centre temporal bone insertion studies. Materials and Methods The modiolar research array (MRA) is a thin pre-curved electrode that is held straight for initial insertion with an external sheath rather than an internal stylet. Between November 2006 and February 2009, six iterations of electrode design were studied in 21 separate insertion studies in which 140 electrode insertions were performed in 85 human temporal bones by 12 surgeons. These studies aimed at addressing four fundamental questions related to the electrode concept, being: (1) Could a sheath result in additional intra-cochlear trauma? (2) Could a sheath accommodate variations in cochlea size and anatomies? (3) Could a sheath be inserted via the round window? and (4) Could a sheath be safely removed once the electrode had been inserted? These questions were investigated within these studies using a number of evaluation techniques, including X-ray and microfluoroscopy, acrylic fixation and temporal bone histologic sectioning, temporal bone microdissection of cochlear structures with electrode visualization, rotational tomography, and insertion force analysis. Results Frequent examples of electrode rotation and tip fold-over were demonstrated with the initial designs. This was typically caused by excessive curvature of the electrode tip, and also difficulty in handling of the electrode and sheath. The degree of tip curvature was progressively relaxed in subsequent versions with a corresponding reduction in the frequency of tip fold-over. Modifications to the sheath facilitated electrode insertion and sheath removal. Insertion studies with the final MRA design demonstrated minimal trauma, excellent perimodiolar placement, and very small electrode dimensions within scala tympani. Force measurements in temporal bones demonstrated negligible force on cochlear structures with angular insertion depths of between 390 and 450°. Conclusion The MRA is a novel, very thin perimodiolar prototype electrode array that has been developed using a systematic collaborative approach. The different evaluation techniques employed by the investigators contributed to the early identification of issues and generation of solutions. Regarding the four fundamental questions related to the electrode concept, the studies demonstrated that (1) the sheath did not result in additional intra-cochlear trauma; (2) the sheath could accommodate variations in cochlea size and anatomies; (3) the sheath was more successfully inserted via a cochleostomy than via the round window; and (4) the sheath could be safely removed once the electrode had been inserted.