DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.

VERIA TECHNIQUE OF COCHLEAR IMPLANTATION:

OUR EXPERIENCE
*Shruthi Gaddemane Shankar, **Harshita V Sabhahit, ***Sathish Kumar S., ****G Prabhakar,*****J M Hans
Date of receipt of article -23-03-2016
Date of acceptance -2-5-2016
DOI-10.21176/ojolhns.2016.10.1.8
ABSTRACT
As we are in the era of increased demand for cochlear implantation, the simplicity of procedure is the need of the
day. We are presenting our experience of non mastoidectomy method of cochlear implantation, that is Veria
technique in 16 patients during the period of 2012-2016. Out of which 13 were prelingual deaf children with age
range of 2-5 yrs and 3 were postlingually deaf adults of 20-30 yrs range. We had ease of insertion of electrodes
with this method in all patients except among 3 adults where we had partial ossification of cochlea. The deviation
from classic method includes creating a transcanal direct tunnel by a special perforator, suprameatal well,
cochleostomy endaurally and electrode insertion through special safety electrode forceps. The benefits of this
procedure was less operative time of 30-45min, simple and safe method without any post operative complications.
All our patients are doing well including adults leading a normal life. VERIA TECHNIQUE is a boon to all
surgeons with its simpler non mastoidectomy way.
Key words: Cochlear implantation, Veria technique.

Cochlear hair cells are vulnerable sensory link

between acoustic environment and central nervous
system. Cochlear implants are the first true bionic sense
organs. The history of cochlear implant (CI) goes way
back to 1800 when Alessandro Volta found auditory
sensation with electric stimulation. The first auditory
prosthesis was in 1957 by work of Djourno and Eyries.
Early cochlear implants were inplanted by William F
Houses fruitful efforts. The first FDA approved
implant was used in 1972. Since then continuous
evolutions has led to multiple channels, miniaturized
implants with improved speech perception and
discrimination. With recent advances, new criteria of
indications are laid like age of 12mts, hearing loss of
70dB, bilateral implantation and persons with multiple
impairments.
This has led to increased need for implantations
and new modifications of procedure other than
posterior tympanotomy like suprameatal approach,
Veria, the pericanal electrode insertion, the
transmastoid labyrinthotomy technique and middle
cranial fossa approach.Veria technique is a simple

procedure without mastoidectomy, with less facial

nerve injury and less operative time. Here we are
presenting our experience and outcome with this simple
and safe technique.
MATERIAL AND METHODS:
In our institution we have performed Veria
technique in 16 cases during the period of 2012-2016,
out of which 13 patients were pre lingual deaf children
of 2-5 yrs of age and 3 were post lingual deaf adults of
20-30 yrs of age. There was no significant history
among children but the adult patients had previous
history of meningitis which was bacterial and
tubercular in origin. All had undergone hearing aid
trial for at least 6 months.
Affiliations:
*,**,***,****. - Otorhinolaryngology Department, Vydehi Institute of
Medical Sciences and Research Centre, Bangalore, India, *****Professor
Emeritus, Vydehi Institute of Medical Sciences and Research Centre,
Bangalore, India
Address of Correspondence:
Shruthi Gaddemane Shankar, MBBS,MS
House no.302, Lalithya Olives apartment, BEML Layout, 4TH Main, 6TH
Stage, Thubarahalli-560066, Bangalore,INDIA
Email: gsshruthi@yahoo.com, Mobile no: 08884609524

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INTRODUCTION

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

All patients were subjected for battery of tests like

pure tone audiometry, tympanometry, Speech
audiometry, BERA, OAE, HRCT temporal bone,
MRI with 3D reconstruction (Figure 1) and EEG.
HRCT of adult patients showed partial ossification of
basal turn of cochlea whereas all children had normal
set of investigations. Immunization status was assessed
and pneumococcal, meningococcal and Hib vaccine
were administered. Patients were taken up for surgery
after paediatric, neurology and anesthesia clearance. All
three FDA approved cochlear implants like
NUCLEUS, CLARION AND MED-EL were
implanted.

Figure-2: Showing the incision line

Vol.-10, Issue-I, Jan-June - 2016

Figure 1: Showing MRI of middle and inner ear

with 3-D reconstruction
Steps of surgery:
Under general anaesthesia, with 2% lignocaine and
adrenaline infiltration, endaural incision given from 12
- 6 o clock position and extended upto incisura
terminalis . Implant template markings taken about 1cm
above the auricle and incision given postero superiorly
over squamous part of temporal bone joining the first
incision (Figure 2). The skin flap was raised inferiorly
and musculofacial flap superiorly, exposing bare bone.
Tympanomeatal flap was elevated and promontory,
round window niche identified and outer table of
squamous temporal bone drilled to accommodate
receiver / stimulator and suprameatal well created and
tunnel was made connecting to bed (Figure-3)
Using a special perforator in the transcanal wall
direct tunnel was made in direction of round window
between 10 and 11o clock position (Figure -4)
42

Figure -3: Showing suprameatal well and tunnel to

bed.

Figure -4: Showing transcanal wall direct tunnel

Cochleostomy was done anterosuperior to round

window niche and steroid wash given. Reciever/
stimulator was fixed and electrode array passed through
transcanal tunnel and guided to cochleostomy by safety
electrode forceps.Excess electrode was placed in
suprameatal well and tympanomeatal flap repositioned,
Neural response telemetry done after the repositioning.
The flaps were sutured, followed by closure.
We achieved complete insertion in all children.
As we found ossification in adult patients cochleostomy
was done till fluid filled lumen was accessed. One of
the patients had round window niche obliteration and
other two had part of inferior basal turn. Complete
insertion of straight array was achieved in one patient
and insertion of 18 and 20 electrodes in other two
patients. With wide visibility of this method ossified
cochlea was also managed effectively as other normal
anatomy cases.Post operative check x-ray of skull
(modified Stenvers view), confirmed the proper
electrode placement in all patients. All patients had
successful implant without any complications.Switching
on and speech processor tuning was done 3 weeks after
surgery. Mapping was done at periodic intervals like
every 3 weekly interval and then monthly for 6months,
followed by every 6months till a stable map was
achieved. Periodical assessments of outcome were done
with speech therapy in terms of environmental sound,
open set speech, closed set speech and speech
discrimination. All patients are doing well in open set
speech except one adult patient who couldnt achieve
speech discrimination.
RESULTS:
Out of 13 children 11 are attending regular
schooling, performing well in their environment. Only
one child who had ADHD-attention deficit hyperactive
disorder, required aggressive speech therapy and 3 more
months of follow up compared to other children. Two
of recently operated patients are undergoing
rehabilitation and are responding well.
Adult patients have joined their job back except
one patient where rehabilitation was challenging due
to absence of literacy and lack of psychological and
family support.
DISCUSSION:
Hearing loss is widely recognized as one of the
most common human disorders. Guidelines for
candidacy of cochlear implant have changed over time.
New criteria of indication and selection of patients to

cochlear implant have been laid by Sampaio et al. These

changing trends of candidacy for CI has lead to increased
need for cochlear implantation. At the same time the
procedure of CI has also undergone continuous
modifications other than standard mastoidectomy
posterior tympanotomy technique described by
House2. Appropriate training, ability and expertise of
otologists is required for this commonly practiced facial
recess approach to the middle ear. Since then many
surgeons have come up with their modifications for a
simpler and safer technique. Suprameatal approach was
introduced by Kronenberg et al in 2001, in which
mastoidectomy is avoided and the duration of the
operation is reduced. This procedure is simpler and
avoids damage to chorda tympani and facial nerve.
Tunnel is drilled in the suprameatal bone region at 1 o
clock position posterior-superiorly to external auditory
meatus which goes superior to Henles spine. The
electrode is introduced into the cochlea through this
tunnel. The electrode enters the middle ear between
incus and malleus 3. This technique is contraindicated
in cases with low tegmen tympani as the space for the
tunnel becomes restricted. Since this is a common
finding in children there is a limitation for this
procedure.
Even though the classic technique of
mastoidectomy and posterior tympanotomy has been
very efficient in vast majority of cases, it has limited
accessibility to cochlea and related structures and a lot
of trauma 4. This lead to modifications by Kiratzidis
to come up with his own surgical technique where a
direct tunnel is drilled through posterior-superior bony
canal wall to the facial recess and endaural approach to
expose the middle ear structures and cochleostomy.
Electrode placement is done through this tunnel, which
is formed by a special perforator introduced by
author. Here came the emergence of Veria technique.
This was carried out in Cochlear Implant centre,
General hospital of Veria, Greece from where the name
veria has been derived 4.
The standard posterior tympanotomy approach
which has been successful in vast majority of cases still
has its own disadvantages and complications. Facial
paralysis due to narrow facial recess approach is reported
in untrained hands as there is keyhole visibility and
restricted accessibility. Healthy bone removal has an
impact on growth of children. Misplacement, carotid
injury, taste disturbances due to sacrifice of chorda
tympani in narrow recess, dural injury or sigmoid
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injury is not uncommon. In complicated anatomic

situations like- sclerotic mastoid, prominent sinus,
anatomic variations of cochlea and low placed dura it
is a cumbersome procedure 5,6,7 .
The advantages of Veria technique over classical
technique are1. No mastoidectomy; 2. Healthy bone of
mastoid retained, anatomy of air cell system is not
hampered ;3. Easy access to middle ear by endaural
approach ;4. Wider visibility and accessibility ;5.
Convenient for anatomic variations and malformations
of cochlea ;6. Easy access to second turn and apex of
cochlea in obliteration cases ; 7. No impact on growth
of children ;8. Suitable for hypoplastic mastoid cavity
and 9. Safe and simple technique with a short learning
curve7,8 .
In our experience patients with partial ossification
of cochlea , ossification is never a contraindication.
Studies have shown that patients with partial
ossification do as well as patients with patent cochlea 9.
Hartrampf showed that benefits can be obtained from
cochlear implantation independent of the depth of
electrode insertion. He suggested that significant
improvement in performance may be expected in users
with as few as 7 inserted electrodes 10 .Kirtazidis et al 7
in their study of surgical results in 101 cases, have
successfully implanted in 23 revision cases by Veria
technique without complications which signifies the
efficiency of this technique. Out of their revision cases
they found that in 13 cases electrode was misplaced and
5 cases implantation was not completed in the previous
limited exposure of posterior tympanotomy
approach.Various studies have proved efficiency of this
techinique in the difficult situations like revision cases,
malformations, cochlear ossifications and poor mastoid
development 11 . It is suitable for very young children,
where the mastoid has not yet been sufficiently
developed. As the drilling depth and direction is under
control by the special guarded perforator it is safe for
the facial nerve.There is no surgery without
complications. Creation of tunnel without direct
visualization of mastoid anatomical references in absence
of mastoidectomy requires some expertise. As posterior
tympanotomy is technically more demanding, Veria
technique may be suitable for a surgeon having limited
experience of posterior tympanotomy technique.
CONCLUSION :
As various studies including ours have less
complication in this surgeon friendly technique, more
44

and more trained surgeons are to be encouraged to

incorporate this method to meet the increased demand
and have a disability free world.
DISCLOSURES
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) No financial disclosures
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