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
techniques.
r 2014 Elsevier Inc. All rights reserved.

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

Cochlear implants (CIs) convey sound information by
stimulating the auditory nerve and bypassing dysfunctional
hair cell transducers within the cochlea. A typical CI
consists of an external component (microphone and speech
processor) and an internal component (receiver-stimulator
and the stimulating electrodes) (Figure 1). Prior to 2008,
more than 172,000 CIs have been implanted worldwide.1
For more than 30 years, CIs have restored auditory
sensitivity in patients who are hearing impaired and
provided access to speech and environmental sounds.
During this period, various surgical techniques have been
used and evolved. There are 3 Food and Drug Admin-
istration (FDA)-approved device manufacturers providing
Address reprint requests and correspondence: Heather M. Weinreich,
MD, MPH. Johns Hopkins University, Department of Otolaryngology, 601
N. Caroline St., JHOC 6th floor, Baltimore, MD 21287.
E-mail address: hweinre1@jhmi.edu
http://dx.doi.org/10.1016/j.otot.2014.09.002
1043-1810/r 2014 Elsevier Inc. All rights reserved.
MED-EL Corp, and Advanced Bionics Corp). Here, we
provide a discussion of the most relevant techniques for
general implantation. Specific techniques for each device are
not addressed.
Indications and contraindications
Candidates for CIs include those with significant hearing
loss that receive little to no benefit with hearing aids. In
general, severe-to-profound impairment of cochlear function
in both the ears and anatomical preservation of the auditory
nerve in the implanted ear are requirements for implantation.
CIs have been used for the management of cochlear
dysfunction owing to congenital or acquired causes
secondary to genetic, ototoxic, infectious, or autoimmune2
etiologies. CIs are also used for cases in which radiation
therapy or the surgical removal of a posterior fossa tumor
has led to hearing loss in the treated ear. Implantation of the
Weinreich et al. Cochlear Implantation
Figure 1 A cochlear implant consists of an external component
(microphone and speech processor) and an internal component
(receiver-stimulator and the stimulating electrodes). Reprinted with
permission from Wade W. Chien et al, Schmidek and Sweet
Operative Neurosurgical Techniques, 2012. (Color version of
figure is available online.)
contralateral ear that exhibits declining hearing, as in the
case of neurofibromatosis 2 (NF2), can provide auditory
function for the patient.3 More recently, implantation in
single-sided deafness has been described, particularly in
cases of unilateral, profound hearing loss associated with
tinnitus.4
Candidacy
Comprehensive candidate assessment is essential to max-
imize the chance of benefit, while minimizing the risks.
Audiologic, medical, surgical, developmental, cognitive,
and psychosocial factors need to be addressed. As expect-
ations largely shape postoperative satisfaction with any form
of auditory rehabilitation,5 candidates and their families
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-
tion.6
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
aquaduct presence, and labyrinthine anatomy can be
assessed.10 CT findings of cochlear patency generally
correlate with surgical findings,11 but discrepancies can
occur as a result of volume averaging.12,13
Magnetic resonance imaging (MRI) may be a useful
adjunct to CT for assessment of implant candidacy by
imaging soft tissues such as the membranous labyrinth,
nerves in the IAC, and soft tissue within the cochlea.14-16
High-resolution T2-weighted magnetic resonance images
are helpful for assessing cochlear patency by revealing the
presence or absence of fluid within the scalae. Specifically,
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
assessment with MRI as the implanted magnet in the
internal device may be contraindicated. Baumgartner et al18
showed that in patients with CIs of different devices,
undergoing MRI with 1 T did not cause implant malfunction
or patient injury. Our experience suggests that MRI with a
1.5-T magnet poses no significant threats, if the device is
immobilized using externally applied molding material and
is firmly bound.19
314 Operative Techniques in Otolaryngology, Vol 25, No 4, December 2014
Adult candidates
Adult candidates typically have unaided thresholds in the
severe-to-profound hearing loss range defined as a pure-tone
average hearing loss of 70 dB or greater in both the ears.
The current U.S. FDA guidelines require speech recognition
on sentence test material at normal conversational levels
(50- or 60-dB sound pressure level) in best aided condition
of less than 60% in the better hearing ear and less than 50%
in the ear to be implanted.20 Centers for Medicare &
Medicaid Services (CMS) guidelines are stricter than the
FDA guidelines. Since 2005, CMS requires a score of less
than 40% on sentence test material. If the patient is enrolled
in an FDA-approved category B investigational device–
exemption clinical trial, implantation may be covered with
hearing test scores of greater than 40% and less than or
equal to 60%.21
A retrospective study of patients meeting new extended
criteria reveals superior and more consistent results when
compared with traditional candidates. Patients who are 60
years of age or older with pre-CI speech testing scores of
40%-60% had higher post-CI scores at 1 year as compared
with candidates who scored less than 40% even after
controlling for age of implantation and age of hearing loss.22
More importantly, Lin et al22 showed that older adult CI
candidates who are younger at time of implantation may
derive the greatest benefit from a CI as demonstrated on
pretesting and posttesting. The current CMS guidelines may
prevent some individuals from using CIs to their fullest
potential.
Pediatric candidates
Children with bilateral severe-to-profound sensorineural
hearing loss (assessed by pure-tone average) who have
demonstrated limited or no functional benefit from hearing
amplification, and lack of progress in auditory skills are
considered CI candidates. The FDA has approved implan-
tation 12 months of age onward. Hearing loss should be
confirmed by acoustic reflex data and auditory brainstem
responses to both clicks and tonal stimuli when appropriate.
Many children with congenital deafness exhibit cochlear
malformation such as cochlear hypoplasia or a common
cavity.23 A hypoplastic cochlea is associated with poor
definition of cochlear turns and partitions between the
modiolus and IAC and relatively low spiral ganglion cell
populations.24 However, if an auditory nerve is present on
high-resolution T2-weighted fast spin-echo MRI, implanta-
tion can be attempted, even though the hearing outcome
may not be as good as patients without cochlear
malformation. CT confirmation of a modiolus or foramen
for innervation of the cochlea is helpful.
Bilateral CIs
Bilateral cochlear implantation, either sequential or
simultaneous, has been described for individuals with
bilateral severe-to-profound hearing loss who do not receive
adequate benefit with a hearing aid in the better hearing ear.
The potential benefit of bilateral implantation relies on
increased auditory sensitivity owing to summation effects,
improved sound source localization, and improved speech
recognition in noise.25 Improved hearing in noise has been
demonstrated in postlingual adults who have undergone
simultaneous bilateral implantation, whereas bilateral im-
plantation in children is currently favored to optimize access
to spoken language in background noise.26 Moreover,
children who receive bilateral implants have significantly
faster rates of vocabulary and language development
when compared with children with unilateral implants.27
The benefit and cost savings of the first device is likely to
exceed that of the placement of the second; however,
data do suggest that bilateral implantation may be a cost-
effective use of resources when examining overall quality
of life.28
The timing between implants is an area of research. The
research done by Gordon et al29 has shown that children
with sequential implantation exhibit mismatches in timing in
auditory activity as shown on auditory brainstem responses
and cortical responses. Children who received their second
implant within 12 months of the initial implantation have
resolution of this mismatch by 9 months with consistent
with bilateral CI use. By contrast, children who received
their second implant after longer than 2 years continue to
show mismatch. The authors further conclude that children
that receive simultaneous bilateral CI implantation have the
best chances to develop bilateral auditory pathways capable
of processing binaural cues.
Taking this into account, the potential effects of a
prolonged simultaneous surgery in an infant must be
weighed against the risks and costs of a second (sequential)
surgery within 6-12 months. The health of the child, wishes
of the parents, anticipated difficulty of the surgery, and
comfort of the surgeon and anesthesia team must be taken
into consideration. In adult populations, bilateral implanta-
tion is less common because of a lack of insurance coverage
or a lack of motivation to proceed with another surgery and
rehabilitation efforts.
Neurofibromatosis 2
Preservation of auditory nerve integrity should be
strongly considered in all NF2 cases irrespective of whether
the contralateral ear has already demonstrated hearing loss.
If the contralateral nonoperated tumor ear continues to
benefit from a hearing aid but is undergoing measurable
decline in function, early implantation provides an oppor-
tunity for continued nerve stimulation as hearing dimin-
ishes. Lustig et al3 examined 7 NF2 patients who were
implanted following surgical resection with nerve preserva-
tion or stereotactic radiation of vestibular schwannomas.
Hearing acuity and awareness of environmental sound were
achieved in all cases; however, there was variability in
speech understanding.
Weinreich et al. Cochlear Implantation 315

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

CI surgery is performed in the supine position using an
operating microscope and a rotating drill. Prophylactic
antibiotics are administered to provide coverage for the
placement of a prosthetic device. Implantation is performed
under general anesthesia with the intent to discharge on the
day of surgery or the following day. In our center, facial
nerve monitoring is routinely used during cochlear implan-
tation. Perioperative steroids are administered to minimize
postoperative nausea and mitigate any cochlear injury
associated with electrode insertion.
the 2 reported devices that migrated in the study, one
occurred after trauma and the other was attributed to the
technique. In either case, the internal receiver was secured
only in a subperiosteal pocket. Advocacy for a minimal
access incision includes decreased operative time leading to
decreased time under anesthesia and decreased costs. In the
study conducted by Prager et al,32 mean operative time was
reduced from 45 down to 28 minutes (P o 0.0001).
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-
num should be visualized before cochleostomy.
Cochleostomy
A cochleostomy is created in the scala tympani, either
indirectly through the promontory, anteroinferior to the
center of the round window niche, or directly through the
round window membrane. The preferred approach is
debatable. The priority should be to access the scala
tympani for adequate access for unimpeded insertion of
the electrode array, while not creating barotrauma through
suctioning of perilymph or inducing direct injury to the
basilar membrane.34 The round window membrane should
be exposed by drilling away the bony overhangs of the
niche.35 If the round window niche is obliterated with bone
and difficult to identify, a round window drill out can be
made by drilling approximately 2 mm from the inferior
margin of the oval window or approximately 1-1.5 mm
inferior to the stapes tendon to enter the scala tympani.36
When drilling the cochleostomy, a technique of “soft
surgery” implantation has been proposed. Principles include
minimizing trauma upon opening the cochlea, avoiding
entrance of foreign material (eg, blood and bone dust) into
the cochlea, and limiting injury upon insertion of the
electrode. Before entering the cochlea, a topical hemostatic
agent such as a cotton ball soaked in 1:1,000 epinephrine
can be placed on the promontory to minimize bleeding,
while entering the cochlea. A cotton pledget placed in the
antrum can minimize blood from entering the middle ear.37
Traditionally, the cochleostomy is placed through the
ventral aspect of the promontory anteroinferior to the round
window membrane using a small diamond burr. The
placement of the cochleostomy is critical to avoiding
inadvertent insertion into scala vestibule or the osseous
spiral lamina. The endosteum should be exposed but not
penetrated, as this exposes the inner ear to barotrauma. Care
should be taken to prevent bone dust from entering the inner
ear. At our institution, sodium hyaluronate (Healon) is
applied to the round window or cochleostomy to provide a
clear window for visualization as the scala tympani is
opened with a straight pick. This helps to remove and
prevent bone dust and blood from entering the cochlea, as
well as to lubricate the electrode upon insertion. Evidence
supports that bone dust can create a source for intracochlear
bone formation, whereas the implication of blood within the
middle ear, limited to animal studies, suggests an increased
low-frequency hearing loss.37 A straight pick is used to open
the endosteum through a drop of Healon, and care should be
taken to avoid the use of suction until the electrode is fully
inserted.
Some otologic surgeons favor CI insertion directly
through the round window membrane. The technique may
reduce damage to the cochlea by providing an ideal
insertion angle and permits correct electrode position.38
Round window insertion has been shown to provide
preservation of residual low-frequency hearing38 and
produce no negative effects on utricular, saccular, and
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
descending segment of the facial nerve. Factors that
influence the appropriateness of a round window insertion
include the diameter of the electrode relative to the width of
the round window, the angle of the round window relative to
the facial recess approach, and angle of the round window
relative to the curvature of the basal turn. The final point
affects the ease with which the electrode can enter and travel
along the basal turn without traumatizing the perimodiolar
bone. If the membrane is fully visualized and other
conditions are favorable, Healon can be placed over the
window. The window is then opened with a straight pick
and the electrode is inserted.
A third technique that combines both the approaches is
the extended round window technique. With this approach,
an anterior extension of the round window is made to allow
a more favorable anterior angulation of the electrode into the
scala tympani. The anterior inferior bone of the round
window is drilled away allowing enlargement of the round
window opening.
The debate between the approaches centers on adequate
placement of the electrode and hearing-preservation strat-
egies, especially in light of the development of softer,
shorter, or hybrid arrays for patients with residual low-
frequency hearing. Wanna et al,39 in evaluation of post-
operative imaging, demonstrated that the round window and
extended round window approaches had higher rates of
complete scala tympani insertion.
Regarding hearing-preservation methods, Friedland and
Runge-Samuelson37 provide a review of the “soft surgical”
technique and implications. New bone formation at the
cochleostomy site is more pronounced in the traditional
cochleostomy compared with round window insertion; however,
implications for hearing preservation are unknown. Havenith
et al40 performed a systematic review to determine whether there
was a difference in postoperative residual hearing. There was no
clear benefit of one approach over the other.
One of the most recent published case series showed
comparable postoperative speech perception scores at up to
48 months follow-up; however, the study did not examine
hearing-preservation rates.41 Wanna et al39 found that
patients with full scala tympani insertions had statistically
significantly better consonant nucleus consonant test word
scores leading the study authors to conclude that round
window and extended round window techniques to be
associated with superior audiological outcomes.
Unfortunately, literature is limited to case series and
cohort designs with no published randomized controlled
studies. It is nevertheless the responsibility of the surgeon to
wherever possible, minimize harm of the intervention. Other
than the appropriate selection of patients for the round
window approach, the principles of soft surgery have
minimal risk and are gaining acceptance as reasonable
technical standards with the goal of preserving intracochlear
structure and when possible, preserving native function.
Weinreich et al. Cochlear Implantation
Insertion
The electrode array is advanced under direct visualization
along a trajectory tangential to the basal turn of the scala
tympani (Figure 3). For a round window insertion, the
electrode is inserted at an oblique or an anterior angle.
Resistance to array insertion can produce buckling of the
carrier array, leading to spiral ligament and basilar
membrane injury, and neural loss. Aggressive insertion
should be avoided as damage occurs when the electrode is
inserted past the point where resistance is first detected.
Cochlear trauma with array placement is associated with
poorer outcomes in clinical trials of adults and children.42,43
Current electrode carriers are typically inserted over a
distance of up to 25-30 mm which places array adjacent to
fibers of the auditory nerve that normally subserve the entire
range of speech frequencies. “Soft surgical” techniques
when used with shorter electrodes focus on a depth of
17-20 mm to preserve low-frequency thresholds within
35 dB of preoperative hearing.37 These techniques can also
be used for full-length electrodes. However, deeper
insertions may result in mechanical damage, leading to
further deterioration of residual hearing.37
A slow, uninterrupted insertion technique has been
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
insertion speed between 40 mm/min and 200 mm/min was
proportional to increased force within the scala tympani
with average measurements ranging from 0.131-0.185 N.
Additionally, interrupted insertions were associated with
force peaks. In monitoring human insertions, the average
insertion speed was 95.2 mm/min with surgeon experience
and type of device affecting speed. More experience and
insertion of a hybrid style electrode was associated with
slower insertion speed.
Figure 3 Insertion of the electrode. The electrode array is
advanced under direct visualization along a trajectory tangential to
the basal turn of the scala tympani. Reprinted with permission
from Wade W. Chien et al, Schmidek and Sweet Operative
Neurosurgical Techniques, 2012.
317
The most recent work by Rajan et al45 compliments the
aforementioned study by examining the effect different
insertion speeds have on hearing preservation and vestibular
symptoms after implantation. Average hearing loss post-
insertion and subjective postoperative imbalance was less
when insertion speed was decreased from 60 down to
15 mm/min. Additionally, a greater rate of complete
insertion was noted in the 15-mm/min group. The findings
were attributed to a slow electrode insertion allowing for
pressure equalization within the intracochlear space, leading
to a net reduction of intracochlear volume displacement,
ultimately causing less mechanical effects and trauma to the
basilar membrane.
After insertion of the array, the cochleostomy should be
sealed gently with a fascia graft. In a round window
insertion, the electrode itself can seal the incision or a small
amount of muscle or periosteum can be used to further seal
the opening. The connecting lead should be stabilized within
the facial recess to reduce the likelihood of the array
extruding from the cochlea. Balkany and Telischi46 describe
a technique that includes drilling a notch in the incus
buttress that provides a slot in which the array lead can be
stabilized. The electrode should be coiled into the mastoid
cavity.
Special situations
Diseases such as otosclerosis or meningitis can lead to
labyrinthitis ossificans. Labyrinthitis ossificans results in the
formation of fibrous tissue and possible calcifications
deposited in the scalae, leading to obstruction of the scalae.
The scala tympani, especially in the basal turn, is the most
common site of fibrous tissue and new bone growth,
regardless of the etiology. As many patients with cochlear
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
electrodes.
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
should be placed posterior to the incision and at 451,
avoiding overlap with the external processor. More vertical
placement may be needed in young children owing to
achieve stable placement on a flat segment of the cranium.
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
counter-well allows the device to lay flush against the skull.
In the past, it has been advocated that for children or adults
with thinner bone, the well should be drilled until the dura with
or without a floating island of bone to decrease the profile of
the internal receiver. Complications to this technique can
occur. In a retrospective study involving both children and
adults, a well drilling complication rate of o1% was published
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
expose the dura, whereas even fewer surgeons create a bony
island (25%).48
In light of concerns about the depth of the well, device
migration is considered a potential development of infection or
extrusion leading to methods for securing the internal receiver.
Titanium screws with nylon suture, mesh or GORE-TEX, and
isomeric bone cement are proposed options.31 More recent
research has supported that the receiver-stimulator is stabilized
to the bony cortex by virtue of a tight-fit to the pericranium and
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
creation of a tight-fitting pocket without drilling a well resulted
in migration of one device after head trauma and a second
incidence of an electrode migrating into the vestibule, which
had a major complication rate of 2.7%. This number was not
statistically different when compared with the standard
techniques. For children, a minimal access technique should
still include a method of fixation given a thinner soft tissue
envelope and frequency of head trauma in this population.50
It is, however, the perspective of these authors that
thoughtful placement and securing of the internal receiver in
children needs to be performed to avoid 2 potential
problems: migration of the device and tenting of the skin
by the “fantail” of the electrode where it inserts into the
internal device. Failure to do so can result in breakdown of
the overlying skin or incision or both. Avoidance of these
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
esthetics of symmetric placement of the second implant.
For shallow wells secondary to thin skulls, skulls with
curvature such that the fantail will tent the overlying skin, or
situations where the device may easily spring out of the well
with mild trauma, we advocate tying the device down. This
can be accomplished using suture on screws or holes made
in the bone.
Closing
As the incision is closed, the implanted device is covered
completely. Care should be taken to ensure that the
periosteum is closed over the electrode. This step may be
the only and most effective means of immobilizing the
device without direct anchors to the bone. Closure includes
approximation of the periosteum, dermal layer, and
epidermis with suture. Our institution uses 3-0 chromic
gut suture for the periosteum and dermis, whereas 5-0 fast-
absorbing plain gut suture is used for the skin. Antibiotic
ointment is applied to the incision, followed by antibiotic
impregnated petroleum dressing (Xeroform) and a mastoid
dressing.
Outcomes
Results in adults
Implanted adults with 6 months of experience have been
found to receive an average score of 40% correct on word
testing with a range of 0%-100%.51 Sentence testing on
patients results in an average of 75% correct, with a wide
range of scores from 0%-100%. In adults, especially the
elderly, it has been suggested that cochlear implantation
slows age-related cognitive decline and can improve quality
of life among the elderly.8
Results in children
There is a wide variability in the speech perception
outcomes in children owing to differences in residual
hearing, age of implantation, mode of communication,
family support, and length of deafness. Miyamoto et al52
found that in children between 1 and 4 years of age after
implantation, roughly half achieved at least some open-set
speech recognition. Furthermore, earlier implantation in
children results in better outcomes and is important in
predicting language abilities. A study by Niparko et al7
found that children who were implanted before 18 months
of age showed significantly higher rates of language
comprehension and expression than those implanted at a
later age, and the trajectory of language acquisition was on
par with that of the normal hearing controls.
Complications
Cochlear implantation entails risks inherent with mastoid
surgery and those associated with the implanted device.
Cohen et al53 characterized implant-related complications as
major if they required revision surgery and minor if they
resolved with minimal or no treatment. Major complications
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-
complication rates ranged from 4.3%-13.7%.53-55 Facial
nerve injury is uncommon and, when recognized promptly,
is unlikely to produce permanent paralysis. Otologic
surgeons should not solely rely on the facial nerve monitor
for locating the facial nerve and should maintain a keen
understanding of the anatomical course of facial nerve.
Weinreich et al. Cochlear Implantation
Device failure is attributed to either flaws in manufactur-
ing or trauma. Device failure as a result of loss of electrical
function in the external processor commonly produces a
sudden loss of function and, therefore, hearing. External
processor function may be lost with direct trauma, exposure
to water, and, most frequently, normal wear and tear. An
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.
Revision implant surgery is indicated with device
malfunction, infection, electrode migration, facial stimula-
tion, and upgrades from single-channel to multiple-channel
CIs. At our institution, there was a 1.3% annual risk of
revision surgery in adults and 4% in children.56,57 In adults,
device failure (65%) was the most common indication of
reimplantation. A third of patients presented with complete
cessation of device function, and two-thirds experienced less
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
device failure (29%), and extracochlear electrodes (16%).56
Risk of meningitis remains low in cochlear implantation.
In animal studies, inoculation of streptococci resulted in
inflammation of the round window niche; however, cochlear
inflammation was absent possibly owing to the barrier that
the electrode created.58,59 More than 10 years ago, an
increased risk of meningitis was associated with a particular
device design (positioner) of which the manufacturer
ultimately recalled. Children appeared to be particularly
affected: of the 52 cases originally reported by the FDA, 33
(63%) were younger than 7 years. Reefhuis et al60
conducted a study on 4,264 children implanted between
1997 and 2002 and found 29 cases of bacterial meningitis in
26 children. The rate of meningitis among children with the
positioner was 30 times the incidence in the general
population, whereas in children implanted without the
positioner, the rate was 16 times higher than the general
population. Risk factors included a history of placement of a
ventriculoperitoneal CSF shunt, a history of otitis media
before implantation, the presence of CSF leaks alone or
inner-ear malformations with CSF leak, signs of middle-ear
inflammation at the time of implantation, and exposure to
smoking in the household.
Since this study, the incidence of meningitis has
decreased but likely depends on assurance of vaccination
against Streptococcus pneumoniae, evaluation of preoper-
ative imaging for cochlear anatomy that may place patient at
risk for CSF leak, aggressive treatment of otitis media, and
surgical techniques used to seal cochleostomy.61 Pneumo-
coccal vaccination schedules now include both pneumo-
coccal conjugate vaccine 13 (eg, Prevnar 13) and
pneumococcal polysaccharides vaccine 23 (eg, Pneumovax
23). Specific immunization schedules are published by the
Centers for Disease Control and Prevention.62 Although the
schedules have been published, many children are still not
vaccinated. In a study of a state-maintained registry, only
319
56% of pediatric CI recipients were immunized.63 The
determination of vaccination status is paramount for the CI
surgeon and requires the establishment of procedures that
will ensure that appropriate immunization precedes CI
surgery and is updated as recommended by the Centers for
Disease Control and Prevention.6
Conclusion
Cochlear implantation surgery has evolved over the past 30
years. Implantation criteria have expanded where younger
candidates have shown improved outcomes. Although the
approach has not changed, recent techniques have focused on
smaller incisions and hearing-preservation methods that
minimize trauma to the cochlear. Complications continue to
remain low secondary to careful patient selection, meticulous
surgical technique, and diligence in ensuring vaccination status.
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