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Operative Techniques in Otolaryngology (2014) 25, 312–320

Techniques in cochlear implantation

Heather M. Weinreich, MD, MPH,a Howard W. Francis, MD,a
John K. Niparko, MD,b Wade W. Chien, MDa,c

From the aDepartment of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine,
Baltimore, Maryland; bDepartment of Otolaryngology-Head and Neck Surgery, Keck School of Medicine,
University of Southern California, Los Angeles, California; and the cNational Institute on Deafness and
Other Communication Disorders, National Institutes of Health, Bethesda, Maryland

KEYWORDS Since its clinical introduction 40 years ago, cochlear implantation surgery has continued to evolve.
Cochlear implant; Although the standard mastoidectomy with posterior tympanotomy has not changed, recent refinements
sensorineural hearing have focused on minimal incisions and implantation techniques designed to preserve hearing. Evidence
loss shows that smaller incisions with modest manipulation of soft tissue do not affect postoperative healing
outcomes. There has been a trend advocating “soft surgical” techniques in an attempt to preserve the
cochlear sensory epithelium. However, the literature is inconclusive as to the outcomes of “soft surgical”
over standard techniques for hearing preservation, including round window insertion and the use of
adjuvants with insertion. Cochlear implantation remains an important therapeutic option for hearing
loss, with new techniques and implant designs offering prospects for better outcomes using less invasive
r 2014 Elsevier Inc. All rights reserved.

Introduction implants for use in the United States (Cochlear Americas,

MED-EL Corp, and Advanced Bionics Corp). Here, we
Cochlear implants (CIs) convey sound information by provide a discussion of the most relevant techniques for
stimulating the auditory nerve and bypassing dysfunctional general implantation. Specific techniques for each device are
hair cell transducers within the cochlea. A typical CI not addressed.
consists of an external component (microphone and speech
processor) and an internal component (receiver-stimulator
and the stimulating electrodes) (Figure 1). Prior to 2008, Indications and contraindications
more than 172,000 CIs have been implanted worldwide.1
For more than 30 years, CIs have restored auditory Candidates for CIs include those with significant hearing
sensitivity in patients who are hearing impaired and loss that receive little to no benefit with hearing aids. In
provided access to speech and environmental sounds. general, severe-to-profound impairment of cochlear function
During this period, various surgical techniques have been in both the ears and anatomical preservation of the auditory
used and evolved. There are 3 Food and Drug Admin- nerve in the implanted ear are requirements for implantation.
istration (FDA)-approved device manufacturers providing CIs have been used for the management of cochlear
dysfunction owing to congenital or acquired causes
secondary to genetic, ototoxic, infectious, or autoimmune2
Address reprint requests and correspondence: Heather M. Weinreich,
MD, MPH. Johns Hopkins University, Department of Otolaryngology, 601
etiologies. CIs are also used for cases in which radiation
N. Caroline St., JHOC 6th floor, Baltimore, MD 21287. therapy or the surgical removal of a posterior fossa tumor
E-mail address: has led to hearing loss in the treated ear. Implantation of the
1043-1810/r 2014 Elsevier Inc. All rights reserved.
Weinreich et al. Cochlear Implantation 313

should understand that cochlear implantation is a commu-

nication tool and strategy and not a cure for deafness. It is
important to establish appropriate processes to ensure that
all patients are adequately immunized to minimize the risk
of pneumococcal meningitis following cochlear implanta-
Age, hearing loss etiology, unaided and aided hearing,
deafness duration, social support, and environment that
promote the development7 or restoration of spoken
language8 carry a predictive value. Duration of hearing
loss, speech perception, and duration of profound deafness
before implantation are significantly correlated with post-
implantation hearing outcome.9 Niparko et al7 found that
early implantation in infants and toddlers was associated
with accelerated spoken language learning with perform-
ance scores of early implanted children closer to scores of
normal hearing controls.
Although associated with lower outcomes, on an average,
a prolonged period of deafness does not rule out significant
speech understanding benefit with a CI, if basic foundations
of communicating through audition (eg, prior hearing aid
use and use of lip-reading) are in place.
A preoperative medical examination should be performed
to determine suitability for general anesthesia. A radiologic
evaluation of the temporal bone is performed to identify
structural changes that may affect the surgical approach and
the feasibility of a successful electrode placement. High-
resolution computed tomography (CT) scans of the temporal
bone can aid in surgical planning such awareness of a
displaced facial nerve, a low tegmen, or high-riding jugular
bulb. Especially in pediatric cases, assessing the convexity
of the cranium can assist in stable placement of the receiver-
stimulator device. Temporal bone surgical anatomy includ-
ing mastoid pneumatization, ossicular anatomy, position of
the facial nerve, caliber of the internal auditory canal (IAC),
cochlear malformation or ossifications, enlarged vestibular
Figure 1 A cochlear implant consists of an external component
(microphone and speech processor) and an internal component aquaduct presence, and labyrinthine anatomy can be
(receiver-stimulator and the stimulating electrodes). Reprinted with assessed.10 CT findings of cochlear patency generally
permission from Wade W. Chien et al, Schmidek and Sweet correlate with surgical findings,11 but discrepancies can
Operative Neurosurgical Techniques, 2012. (Color version of occur as a result of volume averaging.12,13
figure is available online.) Magnetic resonance imaging (MRI) may be a useful
adjunct to CT for assessment of implant candidacy by
contralateral ear that exhibits declining hearing, as in the imaging soft tissues such as the membranous labyrinth,
case of neurofibromatosis 2 (NF2), can provide auditory nerves in the IAC, and soft tissue within the cochlea.14-16
function for the patient.3 More recently, implantation in High-resolution T2-weighted magnetic resonance images
single-sided deafness has been described, particularly in are helpful for assessing cochlear patency by revealing the
cases of unilateral, profound hearing loss associated with presence or absence of fluid within the scalae. Specifically,
tinnitus.4 high-resolution T2-weighted fast spin-echo MRI can be
used to assess deficiency of the cochlear nerve.17 Special
consideration should be given to patients who need future
Candidacy assessment with MRI as the implanted magnet in the
internal device may be contraindicated. Baumgartner et al18
Comprehensive candidate assessment is essential to max- showed that in patients with CIs of different devices,
imize the chance of benefit, while minimizing the risks. undergoing MRI with 1 T did not cause implant malfunction
Audiologic, medical, surgical, developmental, cognitive, or patient injury. Our experience suggests that MRI with a
and psychosocial factors need to be addressed. As expect- 1.5-T magnet poses no significant threats, if the device is
ations largely shape postoperative satisfaction with any form immobilized using externally applied molding material and
of auditory rehabilitation,5 candidates and their families is firmly bound.19
314 Operative Techniques in Otolaryngology, Vol 25, No 4, December 2014

Adult candidates bilateral severe-to-profound hearing loss who do not receive

adequate benefit with a hearing aid in the better hearing ear.
Adult candidates typically have unaided thresholds in the The potential benefit of bilateral implantation relies on
severe-to-profound hearing loss range defined as a pure-tone increased auditory sensitivity owing to summation effects,
average hearing loss of 70 dB or greater in both the ears. improved sound source localization, and improved speech
The current U.S. FDA guidelines require speech recognition recognition in noise.25 Improved hearing in noise has been
on sentence test material at normal conversational levels demonstrated in postlingual adults who have undergone
(50- or 60-dB sound pressure level) in best aided condition simultaneous bilateral implantation, whereas bilateral im-
of less than 60% in the better hearing ear and less than 50% plantation in children is currently favored to optimize access
in the ear to be implanted.20 Centers for Medicare & to spoken language in background noise.26 Moreover,
Medicaid Services (CMS) guidelines are stricter than the children who receive bilateral implants have significantly
FDA guidelines. Since 2005, CMS requires a score of less faster rates of vocabulary and language development
than 40% on sentence test material. If the patient is enrolled when compared with children with unilateral implants.27
in an FDA-approved category B investigational device– The benefit and cost savings of the first device is likely to
exemption clinical trial, implantation may be covered with exceed that of the placement of the second; however,
hearing test scores of greater than 40% and less than or data do suggest that bilateral implantation may be a cost-
equal to 60%.21 effective use of resources when examining overall quality
A retrospective study of patients meeting new extended of life.28
criteria reveals superior and more consistent results when The timing between implants is an area of research. The
compared with traditional candidates. Patients who are 60 research done by Gordon et al29 has shown that children
years of age or older with pre-CI speech testing scores of with sequential implantation exhibit mismatches in timing in
40%-60% had higher post-CI scores at 1 year as compared auditory activity as shown on auditory brainstem responses
with candidates who scored less than 40% even after and cortical responses. Children who received their second
controlling for age of implantation and age of hearing loss.22 implant within 12 months of the initial implantation have
More importantly, Lin et al22 showed that older adult CI resolution of this mismatch by 9 months with consistent
candidates who are younger at time of implantation may with bilateral CI use. By contrast, children who received
derive the greatest benefit from a CI as demonstrated on their second implant after longer than 2 years continue to
pretesting and posttesting. The current CMS guidelines may show mismatch. The authors further conclude that children
prevent some individuals from using CIs to their fullest that receive simultaneous bilateral CI implantation have the
potential. best chances to develop bilateral auditory pathways capable
of processing binaural cues.
Taking this into account, the potential effects of a
Pediatric candidates
prolonged simultaneous surgery in an infant must be
weighed against the risks and costs of a second (sequential)
Children with bilateral severe-to-profound sensorineural
surgery within 6-12 months. The health of the child, wishes
hearing loss (assessed by pure-tone average) who have
of the parents, anticipated difficulty of the surgery, and
demonstrated limited or no functional benefit from hearing
comfort of the surgeon and anesthesia team must be taken
amplification, and lack of progress in auditory skills are
into consideration. In adult populations, bilateral implanta-
considered CI candidates. The FDA has approved implan-
tion is less common because of a lack of insurance coverage
tation 12 months of age onward. Hearing loss should be
or a lack of motivation to proceed with another surgery and
confirmed by acoustic reflex data and auditory brainstem
rehabilitation efforts.
responses to both clicks and tonal stimuli when appropriate.
Many children with congenital deafness exhibit cochlear
malformation such as cochlear hypoplasia or a common
Neurofibromatosis 2
cavity.23 A hypoplastic cochlea is associated with poor
definition of cochlear turns and partitions between the
Preservation of auditory nerve integrity should be
modiolus and IAC and relatively low spiral ganglion cell
strongly considered in all NF2 cases irrespective of whether
populations.24 However, if an auditory nerve is present on
the contralateral ear has already demonstrated hearing loss.
high-resolution T2-weighted fast spin-echo MRI, implanta-
If the contralateral nonoperated tumor ear continues to
tion can be attempted, even though the hearing outcome
benefit from a hearing aid but is undergoing measurable
may not be as good as patients without cochlear
decline in function, early implantation provides an oppor-
malformation. CT confirmation of a modiolus or foramen
tunity for continued nerve stimulation as hearing dimin-
for innervation of the cochlea is helpful.
ishes. Lustig et al3 examined 7 NF2 patients who were
implanted following surgical resection with nerve preserva-
Bilateral CIs tion or stereotactic radiation of vestibular schwannomas.
Hearing acuity and awareness of environmental sound were
Bilateral cochlear implantation, either sequential or achieved in all cases; however, there was variability in
simultaneous, has been described for individuals with speech understanding.
Weinreich et al. Cochlear Implantation 315

Surgical technique included poor positioning and migration of the device. Of

the 2 reported devices that migrated in the study, one
CI surgery is performed in the supine position using an occurred after trauma and the other was attributed to the
operating microscope and a rotating drill. Prophylactic technique. In either case, the internal receiver was secured
antibiotics are administered to provide coverage for the only in a subperiosteal pocket. Advocacy for a minimal
placement of a prosthetic device. Implantation is performed access incision includes decreased operative time leading to
under general anesthesia with the intent to discharge on the decreased time under anesthesia and decreased costs. In the
day of surgery or the following day. In our center, facial study conducted by Prager et al,32 mean operative time was
nerve monitoring is routinely used during cochlear implan- reduced from 45 down to 28 minutes (P o 0.0001).
tation. Perioperative steroids are administered to minimize
postoperative nausea and mitigate any cochlear injury
associated with electrode insertion. Mastoidectomy and facial recess

Design of the flap or soft tissue work Once the incision has been made, the mastoid cortex and
the surrounding squamous portion of the temporal bone are
exposed by raising a pedicled anteroinferior “flap” of the
Supralabyrinthine approaches to cochlear implantation
mastoid periosteum. Incision within the periosteum can vary
have not found wide acceptance due to technical limitations
from a standard “T” or “7” design. A mastoidectomy with
with exposure of the scala tympani and postoperative
posterior tympanotomy is performed to access the middle ear.
healing. Thus, standard mastoidectomy techniques are
During the simple mastoidectomy, some advocate preserving
typically used.
a slight overhang at the superior (middle fossa tegmen) and
The mastoidectomy incision design and device place-
posterior (sigmoid sinus) cortical margins to facilitate
ment are critical for prevention of complications. Wound
retention of the connecting leads. After adequate thinning of
complications have been associated with a delay in
the bony ear canal and opening of the antrum, the short
activation.30 The following 3 principles guide the placement
process of the incus and horizontal canal are identified.33
of the incision: (1) it should not be placed such that it will
Once this is performed, the facial recess (between chorda
overlay the internal receiver, (2) it should not compromise
tympani nerve and the vertical segment of the facial nerve)
the blood supply of the scalp, and (3) it should provide
is opened to identify the incudostapedial joint and cochlear
exposure for a standard mastoidectomy.31 Additionally, the
promontory. The facial nerve and the chorda tympani nerve
location of the incision should be positioned posterior
are identified by “blue-lining” these structures using a large
enough to enable placement of the internal device
diamond burr. This allows the surgeon to use the landmarks
sufficiently away from the pinna to accommodate an ear-
of the chorda tympani, facial nerve, and buttress to enter the
level external processor. Consideration must be made of the
facial recess using a small diamond burr (Figure 2).
curvature of the skull, as stable placement is optimal on a
Adequate thinning of the posterior external auditory canal
flat surface, which requires variable orientation of the
bone and thinning of the bone anterior to the vertical
device; more vertical placement in young children is
segment of the facial nerve can improve and maximize
common owing to the underdeveloped and convex shape
visualization of the round window niche via the facial
of the postauricular region. Punctate marks on the
periosteum using microinjections of methylene blue can
also assist more precise placement of the bony well. Owing
to migration after incisions and flap elevation, dependence
on skin markings along can lead to inappropriate placement
of the internal device.
The typical approach incorporates a postauricular
incision similar to that used in mastoidectomy surgery.
The incision may be made further posterior from the
postauricular sulcus and be extended superiorly to provide
exposure for the location of the well for the internal
receiver-stimulator. In the past, an inverted J-shaped
incision was used, as it was based on a posterior-inferior
arterial supply and allowed incorporation of prior postaur-
icular scars, if the patient had undergone previous otologic
surgery. Over time this incision has been shortened, with
some institutions using a minimal access design with a Figure 2 Location of the facial recess. Landmarks include the
straight incision of 2-4 cm.31 In a comparative study of a chorda tympani, facial nerve, and buttress. A small diamond burr is
standard CI incision versus a minimal access technique, an used to enter the facial recess. Reprinted with permission from
overall complication rate of 18.4% vs 11.0% was noted, Wade W. Chien et al, Schmidek and Sweet Operative Neuro-
respectively.32 This difference was not statistically signifi- surgical Techniques, 2012. (Color version of figure is available
cant. Minor complications of the minimal access technique online.)
316 Operative Techniques in Otolaryngology, Vol 25, No 4, December 2014

recess. The round window niche and adjacent hypotympa- produce no negative effects on utricular, saccular, and
num should be visualized before cochleostomy. semicircular channel function. In this technique, the round
window membrane is visualized by drilling away the bony
overhangs of the niche as well as bone anterior to the
Cochleostomy descending segment of the facial nerve. Factors that
influence the appropriateness of a round window insertion
A cochleostomy is created in the scala tympani, either include the diameter of the electrode relative to the width of
indirectly through the promontory, anteroinferior to the the round window, the angle of the round window relative to
center of the round window niche, or directly through the the facial recess approach, and angle of the round window
round window membrane. The preferred approach is relative to the curvature of the basal turn. The final point
debatable. The priority should be to access the scala affects the ease with which the electrode can enter and travel
tympani for adequate access for unimpeded insertion of along the basal turn without traumatizing the perimodiolar
the electrode array, while not creating barotrauma through bone. If the membrane is fully visualized and other
suctioning of perilymph or inducing direct injury to the conditions are favorable, Healon can be placed over the
basilar membrane.34 The round window membrane should window. The window is then opened with a straight pick
be exposed by drilling away the bony overhangs of the and the electrode is inserted.
niche.35 If the round window niche is obliterated with bone A third technique that combines both the approaches is
and difficult to identify, a round window drill out can be the extended round window technique. With this approach,
made by drilling approximately 2 mm from the inferior an anterior extension of the round window is made to allow
margin of the oval window or approximately 1-1.5 mm a more favorable anterior angulation of the electrode into the
inferior to the stapes tendon to enter the scala tympani.36 scala tympani. The anterior inferior bone of the round
When drilling the cochleostomy, a technique of “soft window is drilled away allowing enlargement of the round
surgery” implantation has been proposed. Principles include window opening.
minimizing trauma upon opening the cochlea, avoiding The debate between the approaches centers on adequate
entrance of foreign material (eg, blood and bone dust) into placement of the electrode and hearing-preservation strat-
the cochlea, and limiting injury upon insertion of the egies, especially in light of the development of softer,
electrode. Before entering the cochlea, a topical hemostatic shorter, or hybrid arrays for patients with residual low-
agent such as a cotton ball soaked in 1:1,000 epinephrine frequency hearing. Wanna et al,39 in evaluation of post-
can be placed on the promontory to minimize bleeding, operative imaging, demonstrated that the round window and
while entering the cochlea. A cotton pledget placed in the extended round window approaches had higher rates of
antrum can minimize blood from entering the middle ear.37 complete scala tympani insertion.
Traditionally, the cochleostomy is placed through the Regarding hearing-preservation methods, Friedland and
ventral aspect of the promontory anteroinferior to the round Runge-Samuelson37 provide a review of the “soft surgical”
window membrane using a small diamond burr. The technique and implications. New bone formation at the
placement of the cochleostomy is critical to avoiding cochleostomy site is more pronounced in the traditional
inadvertent insertion into scala vestibule or the osseous cochleostomy compared with round window insertion; however,
spiral lamina. The endosteum should be exposed but not implications for hearing preservation are unknown. Havenith
penetrated, as this exposes the inner ear to barotrauma. Care et al40 performed a systematic review to determine whether there
should be taken to prevent bone dust from entering the inner was a difference in postoperative residual hearing. There was no
ear. At our institution, sodium hyaluronate (Healon) is clear benefit of one approach over the other.
applied to the round window or cochleostomy to provide a One of the most recent published case series showed
clear window for visualization as the scala tympani is comparable postoperative speech perception scores at up to
opened with a straight pick. This helps to remove and 48 months follow-up; however, the study did not examine
prevent bone dust and blood from entering the cochlea, as hearing-preservation rates.41 Wanna et al39 found that
well as to lubricate the electrode upon insertion. Evidence patients with full scala tympani insertions had statistically
supports that bone dust can create a source for intracochlear significantly better consonant nucleus consonant test word
bone formation, whereas the implication of blood within the scores leading the study authors to conclude that round
middle ear, limited to animal studies, suggests an increased window and extended round window techniques to be
low-frequency hearing loss.37 A straight pick is used to open associated with superior audiological outcomes.
the endosteum through a drop of Healon, and care should be Unfortunately, literature is limited to case series and
taken to avoid the use of suction until the electrode is fully cohort designs with no published randomized controlled
inserted. studies. It is nevertheless the responsibility of the surgeon to
Some otologic surgeons favor CI insertion directly wherever possible, minimize harm of the intervention. Other
through the round window membrane. The technique may than the appropriate selection of patients for the round
reduce damage to the cochlea by providing an ideal window approach, the principles of soft surgery have
insertion angle and permits correct electrode position.38 minimal risk and are gaining acceptance as reasonable
Round window insertion has been shown to provide technical standards with the goal of preserving intracochlear
preservation of residual low-frequency hearing38 and structure and when possible, preserving native function.
Weinreich et al. Cochlear Implantation 317

Insertion The most recent work by Rajan et al45 compliments the

aforementioned study by examining the effect different
The electrode array is advanced under direct visualization insertion speeds have on hearing preservation and vestibular
along a trajectory tangential to the basal turn of the scala symptoms after implantation. Average hearing loss post-
tympani (Figure 3). For a round window insertion, the insertion and subjective postoperative imbalance was less
electrode is inserted at an oblique or an anterior angle. when insertion speed was decreased from 60 down to
Resistance to array insertion can produce buckling of the 15 mm/min. Additionally, a greater rate of complete
carrier array, leading to spiral ligament and basilar insertion was noted in the 15-mm/min group. The findings
membrane injury, and neural loss. Aggressive insertion were attributed to a slow electrode insertion allowing for
should be avoided as damage occurs when the electrode is pressure equalization within the intracochlear space, leading
inserted past the point where resistance is first detected. to a net reduction of intracochlear volume displacement,
Cochlear trauma with array placement is associated with ultimately causing less mechanical effects and trauma to the
poorer outcomes in clinical trials of adults and children.42,43 basilar membrane.
Current electrode carriers are typically inserted over a After insertion of the array, the cochleostomy should be
distance of up to 25-30 mm which places array adjacent to sealed gently with a fascia graft. In a round window
fibers of the auditory nerve that normally subserve the entire insertion, the electrode itself can seal the incision or a small
range of speech frequencies. “Soft surgical” techniques amount of muscle or periosteum can be used to further seal
when used with shorter electrodes focus on a depth of the opening. The connecting lead should be stabilized within
17-20 mm to preserve low-frequency thresholds within the facial recess to reduce the likelihood of the array
35 dB of preoperative hearing.37 These techniques can also extruding from the cochlea. Balkany and Telischi46 describe
be used for full-length electrodes. However, deeper a technique that includes drilling a notch in the incus
insertions may result in mechanical damage, leading to buttress that provides a slot in which the array lead can be
further deterioration of residual hearing.37 stabilized. The electrode should be coiled into the mastoid
A slow, uninterrupted insertion technique has been cavity.
advocated to minimize trauma. Kontorinis et al44 analyzed
the effect of insertion speed of 4 different electrodes on
insertion forces within the cochlea. Progressive increase in Special situations
insertion speed between 40 mm/min and 200 mm/min was
proportional to increased force within the scala tympani Diseases such as otosclerosis or meningitis can lead to
with average measurements ranging from 0.131-0.185 N. labyrinthitis ossificans. Labyrinthitis ossificans results in the
Additionally, interrupted insertions were associated with formation of fibrous tissue and possible calcifications
force peaks. In monitoring human insertions, the average deposited in the scalae, leading to obstruction of the scalae.
insertion speed was 95.2 mm/min with surgeon experience The scala tympani, especially in the basal turn, is the most
and type of device affecting speed. More experience and common site of fibrous tissue and new bone growth,
insertion of a hybrid style electrode was associated with regardless of the etiology. As many patients with cochlear
slower insertion speed. ossification receive only partially inserted electrode arrays,
performance may suffer because of either smaller numbers
of available channels or spiral ganglion cell depletion.
A study conducted by Francis et al30 showed that a
significantly smaller proportion of electrodes were initially
activated in children with a history of meningitis. This
proportion remained stable at 12 and 24 months post-
implantation. The need for additional cochleostomy drilling
was also noted to have lower proportion of activated

Securing the device

Before placement of the electrode array, a subperiosteal

flap is elevated deep to the temporalis. The pocket should be
elevated to fit the device and minimize movement. A well is
drilled for the internal receiver. In general, the receiver
Figure 3 Insertion of the electrode. The electrode array is should be placed posterior to the incision and at 451,
advanced under direct visualization along a trajectory tangential to avoiding overlap with the external processor. More vertical
the basal turn of the scala tympani. Reprinted with permission placement may be needed in young children owing to
from Wade W. Chien et al, Schmidek and Sweet Operative achieve stable placement on a flat segment of the cranium.
Neurosurgical Techniques, 2012. The well should be drilled to accommodate the device.
318 Operative Techniques in Otolaryngology, Vol 25, No 4, December 2014

When the skull is thick enough, a deep well with anterior device without direct anchors to the bone. Closure includes
counter-well allows the device to lay flush against the skull. approximation of the periosteum, dermal layer, and
In the past, it has been advocated that for children or adults epidermis with suture. Our institution uses 3-0 chromic
with thinner bone, the well should be drilled until the dura with gut suture for the periosteum and dermis, whereas 5-0 fast-
or without a floating island of bone to decrease the profile of absorbing plain gut suture is used for the skin. Antibiotic
the internal receiver. Complications to this technique can ointment is applied to the incision, followed by antibiotic
occur. In a retrospective study involving both children and impregnated petroleum dressing (Xeroform) and a mastoid
adults, a well drilling complication rate of o1% was published dressing.
with injuries to the dura resulting in cerebrospinal fluid (CSF)
leaks and in another case, a subdural hematoma.47 The authors
concluded by advocating for no or minimal dural exposure.47
Indeed the trend among surgeons is to avoid dural exposure. In
a survey of otolaryngologists, only 35.1% usually or always Results in adults
expose the dura, whereas even fewer surgeons create a bony
island (25%).48 Implanted adults with 6 months of experience have been
In light of concerns about the depth of the well, device found to receive an average score of 40% correct on word
migration is considered a potential development of infection or testing with a range of 0%-100%.51 Sentence testing on
extrusion leading to methods for securing the internal receiver. patients results in an average of 75% correct, with a wide
Titanium screws with nylon suture, mesh or GORE-TEX, and range of scores from 0%-100%. In adults, especially the
isomeric bone cement are proposed options.31 More recent elderly, it has been suggested that cochlear implantation
research has supported that the receiver-stimulator is stabilized slows age-related cognitive decline and can improve quality
to the bony cortex by virtue of a tight-fit to the pericranium and of life among the elderly.8
deep fascia of the temporalis muscle also known as the
temporalis pocket technique.49 In a study conducted by Prager
et al,32 comparison of a minimal access technique that included Results in children
creation of a tight-fitting pocket without drilling a well resulted
in migration of one device after head trauma and a second There is a wide variability in the speech perception
incidence of an electrode migrating into the vestibule, which outcomes in children owing to differences in residual
had a major complication rate of 2.7%. This number was not hearing, age of implantation, mode of communication,
statistically different when compared with the standard family support, and length of deafness. Miyamoto et al52
techniques. For children, a minimal access technique should found that in children between 1 and 4 years of age after
still include a method of fixation given a thinner soft tissue implantation, roughly half achieved at least some open-set
envelope and frequency of head trauma in this population.50 speech recognition. Furthermore, earlier implantation in
It is, however, the perspective of these authors that children results in better outcomes and is important in
thoughtful placement and securing of the internal receiver in predicting language abilities. A study by Niparko et al7
children needs to be performed to avoid 2 potential found that children who were implanted before 18 months
problems: migration of the device and tenting of the skin of age showed significantly higher rates of language
by the “fantail” of the electrode where it inserts into the comprehension and expression than those implanted at a
internal device. Failure to do so can result in breakdown of later age, and the trajectory of language acquisition was on
the overlying skin or incision or both. Avoidance of these par with that of the normal hearing controls.
issues can be addressed by first selecting the least convex
location on the skull. In patients with a previously placed
implant, favoring a flatter profile should outweigh the Complications
esthetics of symmetric placement of the second implant.
For shallow wells secondary to thin skulls, skulls with Cochlear implantation entails risks inherent with mastoid
curvature such that the fantail will tent the overlying skin, or surgery and those associated with the implanted device.
situations where the device may easily spring out of the well Cohen et al53 characterized implant-related complications as
with mild trauma, we advocate tying the device down. This major if they required revision surgery and minor if they
can be accomplished using suture on screws or holes made resolved with minimal or no treatment. Major complications
in the bone. include facial nerve paralysis and implant exposure due to
flap loss. In several surveys of implant operations, major
complication rates ranged from 8%-13.7%, whereas minor-
Closing complication rates ranged from 4.3%-13.7%.53-55 Facial
nerve injury is uncommon and, when recognized promptly,
As the incision is closed, the implanted device is covered is unlikely to produce permanent paralysis. Otologic
completely. Care should be taken to ensure that the surgeons should not solely rely on the facial nerve monitor
periosteum is closed over the electrode. This step may be for locating the facial nerve and should maintain a keen
the only and most effective means of immobilizing the understanding of the anatomical course of facial nerve.
Weinreich et al. Cochlear Implantation 319

Device failure is attributed to either flaws in manufactur- 56% of pediatric CI recipients were immunized.63 The
ing or trauma. Device failure as a result of loss of electrical determination of vaccination status is paramount for the CI
function in the external processor commonly produces a surgeon and requires the establishment of procedures that
sudden loss of function and, therefore, hearing. External will ensure that appropriate immunization precedes CI
processor function may be lost with direct trauma, exposure surgery and is updated as recommended by the Centers for
to water, and, most frequently, normal wear and tear. An Disease Control and Prevention.6
internal device failure typically presents as either an
immediate cessation of hearing or intermittent hearing loss
associated with reduced quality of sound and a period of
diminishing function over days to weeks. Conclusion
Revision implant surgery is indicated with device Cochlear implantation surgery has evolved over the past 30
malfunction, infection, electrode migration, facial stimula- years. Implantation criteria have expanded where younger
tion, and upgrades from single-channel to multiple-channel candidates have shown improved outcomes. Although the
CIs. At our institution, there was a 1.3% annual risk of approach has not changed, recent techniques have focused on
revision surgery in adults and 4% in children.56,57 In adults, smaller incisions and hearing-preservation methods that
device failure (65%) was the most common indication of minimize trauma to the cochlear. Complications continue to
reimplantation. A third of patients presented with complete remain low secondary to careful patient selection, meticulous
cessation of device function, and two-thirds experienced less surgical technique, and diligence in ensuring vaccination status.
dramatic declines in function. Other indications included
infection (12%), electrode extrusion (15%), and facial nerve
stimulation (8%).57 In children, the most common reasons
for revision surgery included hard failure (42%), suspected Referenecs
device failure (29%), and extracochlear electrodes (16%).56
Risk of meningitis remains low in cochlear implantation. 1. Peters BR, Wyss J, Manrique M: Worldwide trends in bilateral
cochlear implantation. Laryngoscope 120:S17-S44 (suppl 2), 2010
In animal studies, inoculation of streptococci resulted in
2. Malik MU, Pandian V, Masood H, et al: Spectrum of immune-
inflammation of the round window niche; however, cochlear mediated inner ear disease and cochlear implant results. Laryngoscope
inflammation was absent possibly owing to the barrier that 122:2557-2562, 2012
the electrode created.58,59 More than 10 years ago, an 3. Lustig LR, Yeagle J, Driscoll CL, et al: Cochlear implantation in
increased risk of meningitis was associated with a particular patients with neurofibromatosis type 2 and bilateral vestibular
device design (positioner) of which the manufacturer schwannoma. Otol Neurotol 27:512-518, 2006
4. Punte AK, Vermeire K, Hofkens A, et al: Cochlear implantation as a
ultimately recalled. Children appeared to be particularly durable tinnitus treatment in single-sided deafness. Cochlear Implants
affected: of the 52 cases originally reported by the FDA, 33 Int 12:S26-S29 (suppl 1), 2011
(63%) were younger than 7 years. Reefhuis et al60 5. Ross MLH: Consumer satisfaction is not enough: Hearing aids are still
conducted a study on 4,264 children implanted between about hearing. Semin Hear 18:11, 1997
6. Carpenter RM, Limb CJ, Francis HW, et al: Programmatic challenges
1997 and 2002 and found 29 cases of bacterial meningitis in
in obtaining and confirming the pneumococcal vaccination status of
26 children. The rate of meningitis among children with the cochlear implant recipients. Otol Neurotol 31:1334-1336, 2010
positioner was 30 times the incidence in the general 7. Niparko JK, Tobey EA, Thal DJ, et al: Spoken language development
population, whereas in children implanted without the in children following cochlear implantation. J Am Med Assoc
positioner, the rate was 16 times higher than the general 303:1498-1506, 2010
8. Clark JH, Yeagle J, Arbaje AI, et al: Cochlear implant rehabilitation in
population. Risk factors included a history of placement of a
older adults: Literature review and proposal of a conceptual framework.
ventriculoperitoneal CSF shunt, a history of otitis media J Am Geriatr Soc 60:1936-1945, 2012
before implantation, the presence of CSF leaks alone or 9. Tyler RS, Summerfield AQ: Cochlear implantation: Relationships with
inner-ear malformations with CSF leak, signs of middle-ear research on auditory deprivation and acclimatization. Ear Hear
inflammation at the time of implantation, and exposure to 17:38S-50S, 1996
smoking in the household. 10. Woolley AL, Oser AB, Lusk RP, et al: Preoperative temporal bone
computed tomography scan and its use in evaluating the pediatric
Since this study, the incidence of meningitis has cochlear implant candidate. Laryngoscope 107:1100-1106, 1997
decreased but likely depends on assurance of vaccination 11. Langman AW, Quigley SM: Accuracy of high-resolution computed
against Streptococcus pneumoniae, evaluation of preoper- tomography in cochlear implantation. Otolaryngol Head Neck Surg
ative imaging for cochlear anatomy that may place patient at 114:38-43, 1996
12. Wiet RJ, Pyle GM, O'Connor CA, et al: Computed tomography: How
risk for CSF leak, aggressive treatment of otitis media, and
accurate a predictor for cochlear implantation? Laryngoscope
surgical techniques used to seal cochleostomy.61 Pneumo- 100:687-692, 1990
coccal vaccination schedules now include both pneumo- 13. Frau GN, Luxford WM, Lo WW, et al: High-resolution computed
coccal conjugate vaccine 13 (eg, Prevnar 13) and tomography in evaluation of cochlear patency in implant candidates:
pneumococcal polysaccharides vaccine 23 (eg, Pneumovax A comparison with surgical findings. J Laryngol Otol 108:743-748, 1994
14. Harnsberger HR, Dart DJ, Parkin JL, et al: Cochlear implant candidates:
23). Specific immunization schedules are published by the
Assessment with CT and MR imaging. Radiology 164:53-57, 1987
Centers for Disease Control and Prevention.62 Although the 15. Casselman JW, Kuhweide R, Deimling M, et al: Constructive
schedules have been published, many children are still not interference in steady state-3DFT MR imaging of the inner ear and
vaccinated. In a study of a state-maintained registry, only cerebellopontine angle. Am J Neuroradiol 14:47-57, 1993
320 Operative Techniques in Otolaryngology, Vol 25, No 4, December 2014

16. Bettman R, Beek E, Van Olphen A, et al: MRI versus CT in assessment 41. Kang BJ, Kim AH: Comparison of cochlear implant performance after
of cochlear patency in cochlear implant candidates. Acta Otolaryngol round window electrode insertion compared with traditional cochle-
124:577-581, 2004 ostomy. Otolaryngol Head Neck Surg 148:822-826, 2013
17. Glastonbury CM, Davidson HC, Harnsberger HR, et al: Imaging 42. Lenarz T, Kuzma J, Weber BP, et al: New Clarion electrode with
findings of cochlear nerve deficiency. Am J Neuroradiol 23:635-643, positioner: Insertion studies. Ann Otol Rhinol Laryngol Suppl
2002 185:16-18, 2000
18. Baumgartner WD, Youssefzadeh S, Hamzavi J, et al: Clinical 43. Geers AE, Nicholas J, Tye-Murray N, et al: Effects of communication
application of magnetic resonance imaging in 30 cochlear implant mode on skills of long-term cochlear implant users. Ann Otol Rhinol
patients. Otol Neurotol 22:818-822, 2001 Laryngol Suppl 185:89-92, 2000
19. Crane BT, Gottschalk B, Kraut M, et al: Magnetic resonance imaging 44. Kontorinis G, Lenarz T, Stover T, et al: Impact of the insertion speed of
at 1.5 T after cochlear implantation. Otol Neurotol 31:1215-1220, 2010 cochlear implant electrodes on the insertion forces. Otol Neurotol
20. American Speech-Language-Hearing Association: Cochlear implants 32:565-570, 2011
[Technical Report], 2004. Available at: Accessed 45. Rajan GP, Kontorinis G, Kuthubutheen J: The effects of insertion speed
December 11, 2013. on inner ear function during cochlear implantation: A comparison study.
21. Centers for Medicare and Medicaid Services: Cochlear implantation, Audiol Neurootol 18:17-22, 2013
2012. Available at: 46. Balkany T, Telischi FF: Fixation of the electrode cable during cochlear
age-with-Evidence-Development/Cochlear-Implantation-.html. Accessed implantation: The split bridge technique. Laryngoscope 105:217-218,
December 9, 2013. 1995
22. Lin FR, Chien WW, Li L, et al: Cochlear implantation in older adults. 47. Dodson KM, Maiberger PG, Sismanis A: Intracranial complications of
Medicine (Baltimore) 91:229-241, 2012 cochlear implantation. Otol Neurotol 28:459-462, 2007
23. Jackler RK, Luxford WM, House WF: Congenital malformations of the 48. Yoshikawa N, Hirsch B, Telischi FF: Cochlear implant fixation and
inner ear: A classification based on embryogenesis. Laryngoscope dura exposure. Otol Neurotol 31:1211-1214, 2010
97:2-14, 1987 49. Balkany TJ, Whitley M, Shapira Y, et al: The temporalis pocket
24. Schmidt JM: Cochlear neuronal populations in developmental defects technique for cochlear implantation: An anatomic and clinical study.
of the inner ear. Implications for cochlear implantation. Acta Otol Neurotol 30:903-907, 2009
Otolaryngol 99:14-20, 1985 50. Davids T, Ramsden JD, Gordon KA, et al: Soft tissue complications
25. Tyler RS, Dunn CC, Witt SA, et al: Update on bilateral cochlear after small incision pediatric cochlear implantation. Laryngoscope
implantation. Curr Opin Otolaryngol Head Neck Surg 11:388-393, 2003 119:980-983, 2009
26. Litovsky R, Parkinson A, Arcaroli J, et al: Simultaneous bilateral 51. Rubinstein JT, Parkinson WS, Tyler RS, et al: Residual speech
cochlear implantation in adults: A multicenter clinical study. Ear Hear recognition and cochlear implant performance: Effects of implantation
27:714-731, 2006 criteria. Am J Otol 20:445-452, 1999
27. Sarant J, Harris D, Bennet L, et al: Bilateral versus unilateral cochlear 52. Miyamoto RT, Osberger MJ, Robbins AM, et al: Prelingually deafened
implants in children: A study of spoken language outcomes. Ear Hear children's performance with the nucleus multichannel cochlear implant.
35:396-409, 2014 Am J Otol 14:437-445, 1993
28. Summerfield AQ, Lovett RE, Bellenger H, et al: Estimates of the cost- 53. Cohen NL, Hoffman RA, Stroschein M: Medical or surgical
effectiveness of pediatric bilateral cochlear implantation. Ear Hear complications related to the Nucleus multichannel cochlear implant.
31:611-624, 2010 Ann Otol Rhinol Laryngol Suppl 135:8-13, 1988
29. Gordon KA, Jiwani S, Papsin BC: What is the optimal timing for 54. Webb RL, Lehnhardt E, Clark GM, et al: Surgical complications with
bilateral cochlear implantation in children? Cochlear Implants Int 12: the cochlear multiple-channel intracochlear implant: Experience at
S8-S14 (suppl 2), 2011 Hannover and Melbourne. Ann Otol Rhinol Laryngol 100:131-136,
30. Francis HW, Buchman CA, Visaya JM, et al: Surgical factors in 1991
pediatric cochlear implantation and their early effects on electrode 55. Hoffman RA, Cohen NL: Surgical pitfalls in cochlear implantation.
activation and functional outcomes. Otol Neurotol 29:502-508, 2008 Laryngoscope 103:741-744, 1993
31. Mangus B, Rivas A, Tsai BS, et al: Surgical techniques in cochlear 56. Marlowe AL, Chinnici JE, Rivas A, et al: Revision cochlear implant
implants. Otolaryngol Clin North Am 45:69-80, 2012 surgery in children: The Johns Hopkins experience. Otol Neurotol
32. Prager JD, Neidich MJ, Perkins JN, et al: Minimal access and standard 31:74-82, 2010
cochlear implantation: A comparative study. Int J Pediatr Otorhinolar- 57. Rivas A, Marlowe AL, Chinnici JE, et al: Revision cochlear
yngol 76:1102-1106, 2012 implantation surgery in adults: Indications and results. Otol Neurotol
33. Francis HW, Niparko JK: Temporal Bone Dissection Guide. (ed 2) 29:639-648, 2008
New York, NY: Thieme Medical Publishers, Inc; 2011 58. Franz BK, Clark GM, Bloom DM: Effect of experimentally induced
34. Adunka O, Gstoettner W, Hambek M, et al: Preservation of basal inner otitis media on cochlear implants. Ann Otol Rhinol Laryngol
ear structures in cochlear implantation. ORL J Otorhinolaryngol Relat 96:174-177, 1987
Spec 66:306-312, 2004 59. Antonelli PJ, Lee JC, Burne RA: Bacterial biofilms may contribute to
35. Proctor B, Bollobas B, Niparko JK: Anatomy of the round window persistent cochlear implant infection. Otol Neurotol 25:953-957, 2004
niche. Ann Otol Rhinol Laryngol 95:444-446, 1986 60. Reefhuis J, Honein MA, Whitney CG, et al: Risk of bacterial
36. Balkany TJ, Brown KD, Ganz BJ: Cochlear implantation. In: Flint PW, meningitis in children with cochlear implants. N Engl J Med
Haughey BH, Lund, VJ, editors. Cummings Otolaryngology Head & 349:435-445, 2003
Neck Surgery. ed 5. Philadelphia: Mosby Elsevier, p. 2234-2242, 2010. 61. Lalwani AK, Cohen NL: Does meningitis after cochlear implantation
37. Friedland DR, Runge-Samuelson C: Soft cochlear implantation: remain a concern in 2011? Otol Neurotol 33:93-95, 2012
Rationale for the surgical approach. Trends Amplif 13:124-138, 2009 62. Bennett NM, Pilishvili T, Whitney CG, et al: Use of 13-valent
38. Roland PS, Wright CG, Isaacson B: Cochlear implant electrode insertion: pneumococcal conjugate vaccine and 23-valent pneumococcal poly-
The round window revisited. Laryngoscope 117:1397-1402, 2007 saccharide vaccine among children aged 6-18 years with immunocom-
39. Wanna GB, Noble JH, Carlson ML, et al: Impact of electrode design promising conditions: Recommendations of the Advisory Committee
and surgical approach on scalar location and cochlear implant on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep
outcomes. Laryngoscope Volume 124; Supplement 6; S1-7, 2014 62:521-524, 2013
40. Havenith S, Lammers MJ, Tange RA, et al: Hearing preservation 63. Ou H, Cleary P, Sie K: Assessing the immunization status of pediatric
surgery: Cochleostomy or round window approach? A systematic cochlear implant recipients using a state-maintained immunization
review Otol Neurotol 34:667-674, 2013 registry. Otolaryngol Head Neck Surg 143:487-491, 2010