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Cochlear Implantation Using Thin Film Array Electrodes
Oral Presentations
OBJECTIVE: For ten years, otolaryngology surgeons from Tripler Army Medical Center (TAMC) have been partnering with the Palau Ministry of Health to provide care for patients with ear, nose, and throat disorders. Here we present a ten year retrospective review of surgical cases, success rates, and disease incidence with regard to a unique Pacific island population. METHOD: A retrospective record review was performed of 402 operative cases over a ten year period between 1999 and 2009. Indices examined included age, sex, disease process, type of surgery performed, complication rate, and treatment outcomes. RESULTS: The average age in our surgical patient population was 16 with a 1.4 : 1 female to male ratio. Of 402 operative cases, 312 (78%) were primary otologic procedures addressing manifestations of endemic chronic otitis media (COM). Of these cases, 88 (28%) were placement of ear ventilation tubes while 194 (62%) tympanoplasties without mastoidectomy constituted the majority of otologic cases. Reported perforation closure rates were 75% for medial graft tympanoplasty and 78% for lateral graft tympanoplasty. Over ten years, only 11 cases (4% of otologic cases) involved primary or secondary cholesteatoma. The most common major complication encountered over this period was postoperative tonsillectomy bleeding reported as 6%. CONCLUSION: Within the Republic of Palau, complications of endemic COM represented a significant component of the population’s disease burden. In the Pacific region, this is a unique and relatively isolated island population, providing an opportunity for follow up and disease tracking. We present a ten year retrospective review on our surgical experience, highlighting the incidence and nature of COM as well as the efficacy of our treatment efforts. Cochlear Implant Outcomes in Anomalous Pediatric Inner Ears Barbara Herrmann, PhD (presenter); Hugh Curtin, MD; Jessica Van Beek-King, BS; Leila Mankarious, MD; Daniel Lee, MD OBJECTIVE: Up to 20% of cochlear implant (CI) candidates are found to have inner ear anomalies on preoperative computed tomography (CT) scan. We aim to describe the MEEI experience with CI outcomes in pediatric patients with congenital inner ear anomalies. Specifically, we will determine the impact of inner ear dysplasia on CI surgical difficulty and speech perception outcomes. METHOD: Retrospective review of 114 consecutive pediatric cochlear implant surgeries (age ⬍⫽18y) at the MEEI between 1995 and June 2009. 36 patients had temporal bone imaging available and of those 30 had outcome data available (n⫽30).
Mean follow-up time was 3.2 years. Operative notes and post-op plain films were reviewed for all patients. All CT images were directly reviewed by a neuroradiologist for identification of inner ear dysplasia. Anatomy was grouped as follows: normal, mild/moderate dysplasia (IP-II, LVA), and severe dysplasia (IP-1, hypoplastic cochlea). CNC testing was used to assess speech perception outcomes. This MEEI data will be presented in the context of a meta-analysis on inner ear dysplasia and CI outcomes. RESULTS: 7 patients (19%) had an inner ear anomaly, with 3 mild/moderate and 4 severe. 14 of 16 patients with normal-tomoderate anatomy were able to complete the CNC test by 2 years post-activation, whereas 0 of 2 with severe dysplasia could complete a CNC. CSF gusher was noted in two patients, both with severe anomaly. All 4 patients with severe dysplasia were confirmed to have full electrode insertion on post-op plain film. CONCLUSION: Patients with severe dysplasia were found to have increased rates of CSF gusher and relatively poor implant performance. There was no significant relationship between severity of dysplasia and depth of electrode insertion. Our incidence of inner ear anomalies among CI patients is consistent with those of previous studies. Cochlear Implantation Using Thin Film Array Electrodes Kenneth Iverson, MD (presenter); Pamela Bhatti, PhD; Jessica Falcone, BS; Brian McKinnon, MD, MBA OBJECTIVE: Current limitations in language perception may stem from an inability to provide high resolution sound input. Thin film array technology allows for a greater density of stimulating sites within the limited diameter of the scala tympani. This study examines the use of a flexible carrier to achieve adequate depth of insertion. METHOD: A prospective human cadaveric temporal bone insertion study was performed. A prototype thin film array electrode coupled with an Insertion Test Device (ITD) was manufactured and inserted into 10 human cadaveric temporal bones. As controls, two additional temporal bones were implanted with the ITD only and two were unimplanted. Radiologic and histologic data were collected. RESULTS: Ten thin film array electrodes were successfully implanted into 10 individual temporal bones via round window (5) and cochleostomy (5) approaches. 17 mm of insertion was noted for each device, with an average angular insertion depth of 392 by histologic sectioning. Distance of the electrode to the modiolus averaged 0.9 mm by CT and 0.63 mm by histologic measurements. Average percent trauma was 24% for the ITDbacked arrays, compared to 15% and 29% for ITD only and unimplanted temporal bones, respectively. CONCLUSION: Thin film array electrodes coupled with an ITD were successfully inserted into the human cochlea with
ORALS
Chronic Ear Disease in the Pacific: A 10 Year Review Jon Robitschek, MD (presenter)
P89
P90
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
limited trauma. With continued development and testing of this electrode design, the thin film array may improve the language perception achieved through cochlear implantation. Cochlear Implants Outcomes in Prelingually Deaf Children Jorge Humberto (presenter); Marisa Alves, BSc; Daniela Ramos; Luis Silva, MD; Carlos Ribeiro, MD OBJECTIVE: 1) Assess the audiological outcomes of cochlear implant in children with prelingual deafness. 2) Assess the language, speech and voice outcome of cochlear implant in children with prelingual deafness. METHOD: Prelingual deaf children with more than 5 years of aural rehabilitation with cochlear implant in a Portuguese Implant Centre (Centro Hospitalar de Coimbra), from 1992 to 2009, were submitted to tonal and vocal functional gain, discrimination tests adapted to the age of the individuals, auditory comprehension, speech and language. The monosyllables, numbers and sentences discrimination tests (Portuguese European Language tests) were presented in free field with recorded lists using SFS software through the audiometer at 65 dB SPL. The scales CAP and SIR, Portuguese test that evaluates language development (Compreenso de Estruturas Complexas) speech production (Teste de Articulao Verbal), vocal characteristics (Grelha de Avaliao das Caractersticas Vocais GACV) and a vowel discrimination test were also used. RESULTS: 142 individuals were evaluated with the monosyllables discrimination test; 78.1% achieved 50% discrimination; 41.5% achieved 70%; regarding phonemic discrimination, mean of 76.25 is achieved, median 81.40 and standard deviation 17.87 . 142 individuals were evaluated with the numbers discrimination test; 96.5% achieved 50% discrimination; 90% achieved 70%, regarding phonemic discrimination mean of 93 is achieved, median 98.85 and standard deviation 13.97. 142 individuals were evaluated with the sentences discrimination test; 76% achieved 50% discrimination; 51.9% achieved 70% discrimination. 133 individuals were evaluated with the vowel discrimination test; the results were an average of 97.42%, and standard deviations of 11.04. 190 individuals were evaluated with the SIR scale; 13.2% were scored on level 3, 16.8% on level 4, and 58.9% on level 5. 127 individuals were evaluated with the CAP scale; 28.3% were scored on level 4, 30.7% on level 5, 17.3% on level 6, and 22% on level 7. 209 individuals were evaluated with the GACV scale; 4.3% were scored on level 3, 34% on level 4 and 58.4% on level 5. Complex sentence comprehension test (Teste de Compreenso de Estruturas Complexas) (n⫽100) the results were an average of 61.67%, and standard deviations of 26.5. Speech production test (Teste de Articulao Verbal) (N⫽171) the results were an average of 77.6%, and standard deviations of 20.85. CONCLUSION: The results express a good performance in speech intelligibility, with a good articulation level and a good
voice quality, according to the results published by other international cochlear implant centers. Cochlear Microcirculation and Hearing Function After Noise Sebastian Strieth, MD (presenter); Martin Canis; Markus Suckfuell; Alexander Berghaus, MD; Warangkana Arpornchayanon OBJECTIVE: 1) Understand how microcirculatory disturbances are linked to hearing function of the inner ear after noise injury. 2) Establish a new standardized animal model for in vivo analysis of cochlear microcirculation and hearing function after noise injury. METHOD: In an experimental study using guinea pigs (n⫽6) normal hearing thresholds on both ears were verified (0 min) by evoked auditory brainstem responses (ABR). After application of loud noise (106 dB SPL) on both ears for 30 min the cochlea was surgically exposed on one side and in vivo fluorescence microscopy of stria vascularis capillaries was performed. In addition, simultaneous ABR measurements were derived from the contralateral ear. Animals without noise exposure served as controls (n⫽6). RESULTS: After noise exposure, red blood cell velocity decreased to 44.5 ⫹/- 3.4 % of baseline values at the end of observation period (210 min) in contrast to stable control measurements. With regard to unaffected vessel diameters in both groups a gradual decrease of segmental blood flow (38.1 ⫹/- 8.2 % of baseline values) became significant 150 min after noise exposure comparing with controls. Hearing thresholds shifted significantly from 20.0 ⫹/- 5.5 dB SPL (0 min) to 45.0 ⫹/- 4.5 dB SPL (210 min) only in animals exposed to loud noise. CONCLUSION: A new standardized model for inner ear microcirculatory disturbance and hearing threshold shift after acute loud noise was established. This method allows us to analyze in detail effects and kinetics of rheological treatments targeted on inner ear microcirculation with regard to the hearing function in vivo. Comparison of Muzzle Suppression and Ear-Level Protection Matthew Branch, MD (presenter) OBJECTIVE: To compare noise reduction of commercially available ear-level hearing protection (muffs/inserts) to that of firearm muzzle suppressors. METHOD: Multiple muzzle suppressors for two pistol and two rifle calibers were tested using B&K 2209 sound meter and B&K 4136 microphone calibrated with B&K Pistophone using Mil-Std 1474D placement protocol. Five shots were recorded unsuppressed and five shots suppressed under consistent environmental conditions. Sound reduction was then
OBJECTIVE: For ten years, otolaryngology surgeons from Tripler Army Medical Center (TAMC) have been partnering with the Palau Ministry of Health to provide care for patients with ear, nose, and throat disorders. Here we present a ten year retrospective review of surgical cases, success rates, and disease incidence with regard to a unique Pacific island population. METHOD: A retrospective record review was performed of 402 operative cases over a ten year period between 1999 and 2009. Indices examined included age, sex, disease process, type of surgery performed, complication rate, and treatment outcomes. RESULTS: The average age in our surgical patient population was 16 with a 1.4 : 1 female to male ratio. Of 402 operative cases, 312 (78%) were primary otologic procedures addressing manifestations of endemic chronic otitis media (COM). Of these cases, 88 (28%) were placement of ear ventilation tubes while 194 (62%) tympanoplasties without mastoidectomy constituted the majority of otologic cases. Reported perforation closure rates were 75% for medial graft tympanoplasty and 78% for lateral graft tympanoplasty. Over ten years, only 11 cases (4% of otologic cases) involved primary or secondary cholesteatoma. The most common major complication encountered over this period was postoperative tonsillectomy bleeding reported as 6%. CONCLUSION: Within the Republic of Palau, complications of endemic COM represented a significant component of the population’s disease burden. In the Pacific region, this is a unique and relatively isolated island population, providing an opportunity for follow up and disease tracking. We present a ten year retrospective review on our surgical experience, highlighting the incidence and nature of COM as well as the efficacy of our treatment efforts. Cochlear Implant Outcomes in Anomalous Pediatric Inner Ears Barbara Herrmann, PhD (presenter); Hugh Curtin, MD; Jessica Van Beek-King, BS; Leila Mankarious, MD; Daniel Lee, MD OBJECTIVE: Up to 20% of cochlear implant (CI) candidates are found to have inner ear anomalies on preoperative computed tomography (CT) scan. We aim to describe the MEEI experience with CI outcomes in pediatric patients with congenital inner ear anomalies. Specifically, we will determine the impact of inner ear dysplasia on CI surgical difficulty and speech perception outcomes. METHOD: Retrospective review of 114 consecutive pediatric cochlear implant surgeries (age ⬍⫽18y) at the MEEI between 1995 and June 2009. 36 patients had temporal bone imaging available and of those 30 had outcome data available (n⫽30).
Mean follow-up time was 3.2 years. Operative notes and post-op plain films were reviewed for all patients. All CT images were directly reviewed by a neuroradiologist for identification of inner ear dysplasia. Anatomy was grouped as follows: normal, mild/moderate dysplasia (IP-II, LVA), and severe dysplasia (IP-1, hypoplastic cochlea). CNC testing was used to assess speech perception outcomes. This MEEI data will be presented in the context of a meta-analysis on inner ear dysplasia and CI outcomes. RESULTS: 7 patients (19%) had an inner ear anomaly, with 3 mild/moderate and 4 severe. 14 of 16 patients with normal-tomoderate anatomy were able to complete the CNC test by 2 years post-activation, whereas 0 of 2 with severe dysplasia could complete a CNC. CSF gusher was noted in two patients, both with severe anomaly. All 4 patients with severe dysplasia were confirmed to have full electrode insertion on post-op plain film. CONCLUSION: Patients with severe dysplasia were found to have increased rates of CSF gusher and relatively poor implant performance. There was no significant relationship between severity of dysplasia and depth of electrode insertion. Our incidence of inner ear anomalies among CI patients is consistent with those of previous studies. Cochlear Implantation Using Thin Film Array Electrodes Kenneth Iverson, MD (presenter); Pamela Bhatti, PhD; Jessica Falcone, BS; Brian McKinnon, MD, MBA OBJECTIVE: Current limitations in language perception may stem from an inability to provide high resolution sound input. Thin film array technology allows for a greater density of stimulating sites within the limited diameter of the scala tympani. This study examines the use of a flexible carrier to achieve adequate depth of insertion. METHOD: A prospective human cadaveric temporal bone insertion study was performed. A prototype thin film array electrode coupled with an Insertion Test Device (ITD) was manufactured and inserted into 10 human cadaveric temporal bones. As controls, two additional temporal bones were implanted with the ITD only and two were unimplanted. Radiologic and histologic data were collected. RESULTS: Ten thin film array electrodes were successfully implanted into 10 individual temporal bones via round window (5) and cochleostomy (5) approaches. 17 mm of insertion was noted for each device, with an average angular insertion depth of 392 by histologic sectioning. Distance of the electrode to the modiolus averaged 0.9 mm by CT and 0.63 mm by histologic measurements. Average percent trauma was 24% for the ITDbacked arrays, compared to 15% and 29% for ITD only and unimplanted temporal bones, respectively. CONCLUSION: Thin film array electrodes coupled with an ITD were successfully inserted into the human cochlea with
ORALS
Chronic Ear Disease in the Pacific: A 10 Year Review Jon Robitschek, MD (presenter)
P89
P90
Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010
limited trauma. With continued development and testing of this electrode design, the thin film array may improve the language perception achieved through cochlear implantation. Cochlear Implants Outcomes in Prelingually Deaf Children Jorge Humberto (presenter); Marisa Alves, BSc; Daniela Ramos; Luis Silva, MD; Carlos Ribeiro, MD OBJECTIVE: 1) Assess the audiological outcomes of cochlear implant in children with prelingual deafness. 2) Assess the language, speech and voice outcome of cochlear implant in children with prelingual deafness. METHOD: Prelingual deaf children with more than 5 years of aural rehabilitation with cochlear implant in a Portuguese Implant Centre (Centro Hospitalar de Coimbra), from 1992 to 2009, were submitted to tonal and vocal functional gain, discrimination tests adapted to the age of the individuals, auditory comprehension, speech and language. The monosyllables, numbers and sentences discrimination tests (Portuguese European Language tests) were presented in free field with recorded lists using SFS software through the audiometer at 65 dB SPL. The scales CAP and SIR, Portuguese test that evaluates language development (Compreenso de Estruturas Complexas) speech production (Teste de Articulao Verbal), vocal characteristics (Grelha de Avaliao das Caractersticas Vocais GACV) and a vowel discrimination test were also used. RESULTS: 142 individuals were evaluated with the monosyllables discrimination test; 78.1% achieved 50% discrimination; 41.5% achieved 70%; regarding phonemic discrimination, mean of 76.25 is achieved, median 81.40 and standard deviation 17.87 . 142 individuals were evaluated with the numbers discrimination test; 96.5% achieved 50% discrimination; 90% achieved 70%, regarding phonemic discrimination mean of 93 is achieved, median 98.85 and standard deviation 13.97. 142 individuals were evaluated with the sentences discrimination test; 76% achieved 50% discrimination; 51.9% achieved 70% discrimination. 133 individuals were evaluated with the vowel discrimination test; the results were an average of 97.42%, and standard deviations of 11.04. 190 individuals were evaluated with the SIR scale; 13.2% were scored on level 3, 16.8% on level 4, and 58.9% on level 5. 127 individuals were evaluated with the CAP scale; 28.3% were scored on level 4, 30.7% on level 5, 17.3% on level 6, and 22% on level 7. 209 individuals were evaluated with the GACV scale; 4.3% were scored on level 3, 34% on level 4 and 58.4% on level 5. Complex sentence comprehension test (Teste de Compreenso de Estruturas Complexas) (n⫽100) the results were an average of 61.67%, and standard deviations of 26.5. Speech production test (Teste de Articulao Verbal) (N⫽171) the results were an average of 77.6%, and standard deviations of 20.85. CONCLUSION: The results express a good performance in speech intelligibility, with a good articulation level and a good
voice quality, according to the results published by other international cochlear implant centers. Cochlear Microcirculation and Hearing Function After Noise Sebastian Strieth, MD (presenter); Martin Canis; Markus Suckfuell; Alexander Berghaus, MD; Warangkana Arpornchayanon OBJECTIVE: 1) Understand how microcirculatory disturbances are linked to hearing function of the inner ear after noise injury. 2) Establish a new standardized animal model for in vivo analysis of cochlear microcirculation and hearing function after noise injury. METHOD: In an experimental study using guinea pigs (n⫽6) normal hearing thresholds on both ears were verified (0 min) by evoked auditory brainstem responses (ABR). After application of loud noise (106 dB SPL) on both ears for 30 min the cochlea was surgically exposed on one side and in vivo fluorescence microscopy of stria vascularis capillaries was performed. In addition, simultaneous ABR measurements were derived from the contralateral ear. Animals without noise exposure served as controls (n⫽6). RESULTS: After noise exposure, red blood cell velocity decreased to 44.5 ⫹/- 3.4 % of baseline values at the end of observation period (210 min) in contrast to stable control measurements. With regard to unaffected vessel diameters in both groups a gradual decrease of segmental blood flow (38.1 ⫹/- 8.2 % of baseline values) became significant 150 min after noise exposure comparing with controls. Hearing thresholds shifted significantly from 20.0 ⫹/- 5.5 dB SPL (0 min) to 45.0 ⫹/- 4.5 dB SPL (210 min) only in animals exposed to loud noise. CONCLUSION: A new standardized model for inner ear microcirculatory disturbance and hearing threshold shift after acute loud noise was established. This method allows us to analyze in detail effects and kinetics of rheological treatments targeted on inner ear microcirculation with regard to the hearing function in vivo. Comparison of Muzzle Suppression and Ear-Level Protection Matthew Branch, MD (presenter) OBJECTIVE: To compare noise reduction of commercially available ear-level hearing protection (muffs/inserts) to that of firearm muzzle suppressors. METHOD: Multiple muzzle suppressors for two pistol and two rifle calibers were tested using B&K 2209 sound meter and B&K 4136 microphone calibrated with B&K Pistophone using Mil-Std 1474D placement protocol. Five shots were recorded unsuppressed and five shots suppressed under consistent environmental conditions. Sound reduction was then