Otology & Neurotology
39:e524–e531 ß 2018, Otology & Neurotology, Inc.
The Early Postoperative Effects of Cochlear Implantation
on Horizontal Semicircular Canal Function
William Graham Shute, Benjamin McOwan, yStephen John O’Leary,
and yDavid Szmulewicz
Department of Surgery (Otolaryngology) University of Melbourne; and yRoyal Victorian Eye and Ear Hospital,
Melbourne, Australia
Objectives: To use video head impulse testing to examine
the effect of cochlear implantation (CI) on horizontal SCC
Downloaded from http://journals.lww.com/otology-neurotology by BhDMf5ePHKbH4TTImqenVLeEdd5NVDXpaI5nvN0Ujkrp6zYHfasB2b4txOxNeBaAFAlPhuoE4Sg= on 07/13/2018
vestibulo-ocular reflex (VOR) gain early after surgery, and
to relate outcomes to subjective imbalance.
Study Design: Prospective cohort study.
Setting: Academic tertiary referral center.
Patients: Thirty-seven (23F:14M) adult cochlear implant
recipients (mean age, 55; age range, 20–80).
Intervention: Cochlear implantation.
Main Outcome Measure: The VOR of the horizontal
semicircular canal of both the operated and non-operated
ears was examined using video head impulse testing before
surgery and at days 1, 7, and 28 following surgery. VOR
gain, VOR gain asymmetry, and the change in VOR gain
from preoperative baseline where the primary outcome
measures. Subjective imbalance was assessed using a struc-
tured questionnaire.
Results: VOR gain value for the operated ear was
0.88  0.21. Mean VOR gain on day 1 postoperatively was
Imbalance in the early postoperative period following
cochlear implantation (CI) causes morbidity for patients
(1–3), but its etiology remains elusive (4,5). As the age of
CI implant recipients increases, and the indications are
broadened, preservation of inner ear sensory function,
and preventing imbalance after surgery, will become
increasingly important (6).
One reason why it has been difficult to elucidate the
cause(s) of imbalance following CI has been its transient
nature, and that classical vestibular function testing is
difficult for patients to tolerate in the early postoperative
period. The majority of studies of vestibular function
after CI surgery have been undertaken weeks to months
after surgery (2,7–10). Caloric thermal stimulation has
Address correspondence and reprint requests to Stephen John
O’Leary, Ph.D., Otolaryngology, Department of Surgery, The Univer-
sity of Melbourne, Australia. Level 2, Royal Victorian Eye and Ear
Hospital, 32 Gisbourne St, East Melbourne, VIC 3002, Australia;
E-mail: sjoleary@unimelb.edu.au
The authors disclose no conflicts of interest.
DOI: 10.1097/MAO.0000000000001840
e524
Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
0.86  0.19; on day 7, 0.87  0.17, and on day 30,
0.91  0.21. Before surgery median asymmetry was 5.50%,
on day 1 it was –5.30%, at day 7, 6.44%, and at day 30 it
was 2.61%. There was no significant difference between
these measures for the cohort across the four time points.
Thirteen of 37 (35%) of patients experienced imbalance in
the follow-up period, but this was not correlated to changes
in VOR gain.
Conclusion: Horizontal semicircular canal function is pre-
served in the immediate and early postoperative period. This
suggests that horizontal semicircular canal impairment is not
likely to be responsible for postoperative imbalance. Key
Words: Balance—Cochlear implantation—Dysequalibrium—
Oscillopsia—Vertigo—Vestibular function—Vestibular
rehabilitation—Video head impulse testing.
Otol Neurotol 39:e524–e531, 2018.
been the most studied testing modality (4,5,11). The
incidence of a reduction in caloric function varies
between studies, with 6 to 73% of patients having
deterioration in caloric response following surgery
(2,12–14). Furthermore, a recent meta-analysis deduced
a significant increase in relative risk of having a reduc-
tion in caloric responses following CI (5). Caloric irriga-
tion relies on changes in temperature in the external
auditory canal causing fluctuations in the density of
the endolymph within the horizontal semicircular canal
(hSCC). These alterations in density cause vortices of
endolymph which deviate the cupula in the ampulla of
the hSCC and alter the firing rate of the specialized
vestibular nerve endings, which in turn trigger eye
movement responses (15). However, changes in caloric
response may be confounded by CI surgery. The mas-
toidectomy component of CI surgery may alter heat
transfer to the hSCC (16). Moreover, it is uncertain what
exactly this test is assessing, as caloric irrigation tests the
horizontal vestibulo-ocular reflex (VOR) with a sub-
physiological stimulus (0.36–3.6 degrees/s) at which
the VOR contributes minimally to gaze stabilization
 THE EARLY POSTOPERATIVE EFFECTS OF COCHLEAR IMPLANTATION ON HSCC FUNCTION e525
(13). The development of the video head impulse test
(vHIT) represents an opportunity for reliable and non-
invasive examination of the VOR using high velocity
stimuli, i.e., in the physiologic range (17). Additionally,
at these higher velocities, other oculomotor reflexes such
as the cervico-ocular reflex contribute minimally to eye
movement responses (18).
The quantification of VOR gain early following surgery
may provide a novel insight into the sequalae of surgical
trauma to the inner ear, as it relates to imbalance. vHIT
provides a robust and accurate measurement of the VOR
gain, i.e., the ratio of eye-movement to head movement, as
the subject attempts to maintain forward gaze during a
series of rapid, unpredictable, high amplitude head
impulses (17). Unlike other similarly precise measures
of VOR gain (scleral search coil head impulse testing or
motorized head impulse testing) vHIT is easily undertaken
at the bedside. This allows for objective quantification of
VOR gain early in the postsurgical recovery period, when
patients would be unlikely to tolerate other investigative
modalities, and enables an assessment of whether transient
disturbance of the VOR contributes to the imbalance
experienced after surgery. Batuecas-Caletrio et al. (19)
recently demonstrated a reduction in hSCC VOR gain in
10 out of 30 patients on day 2 postoperatively using vHIT,
and found that these changes correlated with subjective
imbalance. However, this study did not analyze the mean
difference in hSCC VOR gain pre- and post-CI, because the
researchers argued that the magnitude of reduction in VOR
gain was less important than a drop to below a threshold
level of 0.8 (20,21). Furthermore, their study suggested that
there were differences in the catch-up saccades in the early
postoperative period associated with imbalance. These
results contrast with several other investigations using
longer-established methods of assessing the VOR that have
failed to demonstrate a lasting reduction in gain after CI
surgery, except in the occasional patient (8,22).
Although Batuecas-Caletrio’s study suggests that there
may indeed be a transient reduction in the VOR gain
associated with CI, there are several reasons for further
investigation. First, it is of interest to track the recovery
of the VOR over time. The second motivation is to
quantify the VOR in the postoperative period, rather than
relying on a categorical analysis. Therefore, we con-
ducted a prospective longitudinal cohort study of 37 CI
recipients using vHIT to examine the effect size of CI on
VOR gain. We undertook vHIT testing at four time
points. Baseline measurements were carried out before
CI (on the day of surgery) and outcome measurements
were taken at three points in the first month post-implan-
tation. These were on day 1, day 7, and day 30 post-
surgery. These time points were selected to approximate
and add to previous trials using hSCC function as a
primary end point, and those that described the paradigm
of imbalance early after CI (1,2,19,22–24). In addition,
we attempted to correlate the magnitude of changes in
VOR gain with subjective imbalance. We hypothesized
that hSCC function would be reduced in the early post-
operative period, as suggested by recent data (19,25). We
Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
also hypothesized that there would be a linear association
between subjective imbalance and the magnitude of
reduction in VOR gain as measured by vHIT,
owing to the previously demonstrated sensitivity of this
modality(4,20,26).
MATERIALS AND METHODS
Ethics
Ethics approval was obtained from the Royal Victorian Eye
and Ear Hospital’s Human Research and Ethics Committee
(10969H).
Subjects
Thirty-seven adult CI recipients with a mean age of 55
(range, 20–84) were enrolled in the study, with a sex ratio
of 14M:23F. Of these, 35 had completed hSCC VOR measures
at all four time points. One subject was unable to tolerate testing
on day 1 postoperatively due to pain and one subject failed to
attend their 1-week follow up appointment. Eight surgeons
completed CI with one of two electrode arrays (the pre-curved
ContourTM in a CI512 implant, or the Thin Straight lateral wall
electrode on CI422/CI522 implants from Cochlear Limited
Sydney, NSW, Australia). Subjects under the age of 18 years
or with significant visual impairment (e.g., unable to clearly
discern a fixation dot without corrective eyewear at a distance
of 1 m) were excluded from the study. Patients did not receive
reimbursement for their participation. Demographic data col-
lected included patient, age, hearing loss aetiology, side of
operated ear, and electrode type.
Equipment
Assessment of horizontal VOR gain was made using the ‘‘ICS
Impulse System’’ manufactured by GN Otometrics (Otometrics
A/S, Taastrup, Denmark). The ICS Impulse is a lightweight
monocular infrared video goggle that records right eye move-
ments with respect to head movements. Nine gyroscopes
mounted within the body of the goggles records the velocity
of the head impulse stimulus while a high resolution 250 Hz
infrared camera records the response of the right eye. Data were
recorded, saved, and displayed using the ‘‘OTOsuite Vestibular’’
software version 2.0 (Otometrics A/S, Taastrup, Denmark). The
software calculates VOR gain and highlights corrective saccades
that occur during the head impulse and in the 380 ms following.
Study Protocol
Assessment of Subjective Imbalance
At each of the four time points where VOR gain data were
gathered, the subjects completed a structured questionnaire as
previously described by Enticott et al. (7). This questionnaire
elicited symptoms of vertigo, oscillopsia, and disequilibrium in
keeping with previous studies using questionnaires pertaining to
imbalance post-CI (27). Patients were deemed to have imbal-
ance as a consequence of surgery if they described any episodes
of imbalance, which represented deterioration when referenced
with the results of their preoperative questionnaire. Imbalance
was further characterized as vertigo (the visual illusion of
rotation), oscillopsia (instability or oscillation of objects in
space), or disequilibrium (a sensation of unsteadiness).
Assessment of the VOR
Two investigators performed all vHIT assessment (W.S. and
B.M.). vHIT assessment comprised 20 technically acceptable
Otology & Neurotology, Vol. 39, No. 7, 2018
e526 W. G. SHUTE ET AL.
impulses per side. The amplitude of each impulse was approxi-
mately 15 to 20 degrees and velocity was in the range of 100 to
250 degrees/s. Qualitative examination for the emergence of
new overt or covert saccades following surgery was performed
by investigators Stephen O’Leary and David Szmulewicz.
Analysis
Head impulses data limited by technical artifact or peak head
velocity below 100 degrees/s were excluded before analysis
(17). Four parameters were examined in this study: 1) the
absolute VOR gain at each time point, 2) the alteration in
VOR gain from preoperative baseline (D gain) at day 1, day 7,
and day 30 postoperatively, 3) the VOR gain asymmetry
between the implanted and non-implanted ear at each time
point, and 4) the alteration in asymmetry (D asymmetry) from
baseline at day 1, day 7, and day 30. D gain was determined by
subtracting the preoperative gain from the gain measured at a
given time point. VOR gain asymmetry between the implanted
(ipsilateral) ear and the non-implanted (contralateral) ear was
calculated using the following formula:
 
contralateral gain
Asymmetryð%Þ ¼ 1 
ipsilateral gain
 100
Positive asymmetry values reflect higher VOR gain in the
implanted ear while negative values reflect lower VOR gain in
the implanted ear. D asymmetry was calculated by subtracting
the preoperative asymmetry value from the asymmetry mea-
sured at the time point of interest.
A general linear model using the Wilks’ Lambda test of
significance was used in SPSS software version 22.0 (IBM corp,
Armonk, NY) to examine the effect of CI on VOR gain, D gain,
and gain asymmetry across the study period. We used an
independent t test assuming equal variance to compare the
differences in gain, D gain, gain asymmetry, and D asymmetry
between patients who experienced imbalance and those who did
not, at a given time point. Finally, we examined preoperative
gain and asymmetry to determine if they were predictive of
experiencing imbalance at any point during the follow-up
period. Type I error rates were set at 0.05.
RESULTS
Thirty seven patients were enrolled into the study.
Twelve patients received Cochlear Limited’s Thin
Straight Electrode (Model CI422 or 522) and 22 received
Cochlear Limited’s perimodiolar Contour Advance elec-
trode (Model CI512).
Imbalance
In total, 13 of 37 (35%) subjects experienced imbal-
ance at some point during the follow-up period that the
subject perceived to be of greater magnitude than any
preoperative symptoms. Eight subjects described par-
oxysms of vertigo on day 1 postsurgery. Three of these
eight subjects continued to have vertigo at day 7 and
day 30, with two of these describing an exacerbation of
their preoperative symptoms (one with a pre-existing
diagnosis of Menière’s disease and the other with
persistent disequilibrium since suffering a sudden
Otology & Neurotology, Vol. 39, No. 7, 2018
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sensorineural hearing loss before surgery). The third
subject who experienced vertigo on day 1, described
paroxysmal oscillopsia at day 7, this persisted at day
30. Another patient described episodes of vertigo at
day 7 postoperatively, however this subject did not
report any imbalance at day 1, and symptoms did not
persist at day 30. Four patients described disequilib-
rium at day 7; this had resolved in three by day 30, but
persisted in one.
Objective Impairment
Of the 37 patients who completed this study, the
mean preoperative VOR gain value for the operated ear
was 0.88  0.21. Mean VOR gain on day 1 postopera-
tively was 0.86  0.19; on day 7, 0.87  0.17, and on
day 30, 0.91  0.21. There was no significant differ-
ence between these measures for the cohort across the
four time points. Likewise, the non-implanted ear
showed no significant alteration in VOR gain across
the four time points (0.94  0.15, 0.93  0.13,
0.92  0.11, 0.92  0.15). VOR gain asymmetry is
plotted in Figure 1. Note that these data had similar
variability across time points, but with marked outliers
in the operated ear indicative of significant preopera-
tive asymmetries in two patients, that persisted after
implantation. In light of the outliers, central tendencies
for asymmetry were evaluated non-parametrically,
arriving at a median asymmetry of 5.50%, on
day 1 it was 5.30%, at day 7, 6.44%, and at day
30 it was 2.61%.
Difference between the preoperative and postoperative
VOR gain (D gain) were centered around zero in both the
operated (Fig. 2A) and the unoperated ears (Fig. 2B), and
most values were within 0.3 of the preoperative assess-
ment. However, in the operated ear at 1 week after
surgery, three patients had VOR gains that had reduced
by a greater amount (0.4, 0.5, and 0.6, Fig. 2A). No other
differences in the distribution of D gain were found
between the three postoperative time points.
There was no significant difference in either the VOR
gain, D gain, or D asymmetry of subjects with and with-
out the subjective experience of imbalance, at any time
point in this study. Indicative data are presented in
Figure 3, where D gain (as measured at day 7) is plotted
for subjects with and without dizziness, at any time
during the first postoperative week. Note that the dis-
tributions are similar irrespective of imbalance. Neither
subject age, nor implant type had a significant effect upon
these estimates of VOR gain. When comparing changes
in VOR gain between those subjects who received the
straight CI522 electrode and those who received the
precurved CI512 contour advance electrode, no changes
were observed at day 1 ( p ¼ 0.4773), day 7 ( p ¼ 0.8462),
or day 30 ( p ¼ 0.5196).
The corrective saccades produced by the head
impulses were analyzed qualitatively, by inspection of
the raw traces in each subject over time. We did not
observe any systematic difference in the incidence of
saccades in postoperative vHIT recordings.
 THE EARLY POSTOPERATIVE EFFECTS OF COCHLEAR IMPLANTATION ON HSCC FUNCTION e527
FIG. 1. Mean VOR gain asymmetry with 95% confidence intervals and outliers across all time points. VOR indicates vestibulo-ocular reflex.
DISCUSSION
Insertion of a cochlear implant electrode array can
have adverse effects on a patients’ subjective balance
function. In this study, 35% of subjects experienced
imbalance in the early postoperative period, which is
consistent with previous reports. Enticott et al. (28) make
the observation that there is a one in three risk of a patient
developing transient imbalance after surgery, although
the reported incidence of imbalance varies remarkably
between studies (0–75%) (2,7–10).
Five previous studies have suggested that early, par-
oxysmal vertigo is the most common clinical presenta-
tion of imbalance following CI (1,9,23,24,29). Long-
term follow up in these studies has shown that symptoms
rarely persist beyond 1-month after surgery (24,29), and
our results support these findings. The present study did
not reveal a significant correlation between subjective
imbalance and the magnitude of change in absolute VOR
gain or VOR gain asymmetry early after surgery. This
suggests that dizziness after CI surgery is not due to a
transient dysfunction of the horizontal semicircular canal
at moderate to high stimulus velocities, which is the main
outcome of this paper. A recent study approached the
question of vestibular dysfunction after CI in a different
manner. A reduction in VOR gain to below 0.8 on vHIT
and/or new onset corrective saccades were associated
with an increase in dizziness handicap inventory (DHI)
score on day 2 following CI (19). We were not able to
Copyright © 2018 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
replicate these findings. Pertinently, we did not observe
any new onset saccades postoperatively. Another impor-
tant observation is that we did not find many patients in
whom the VOR gain dropped to below 0.8 in the early
postoperative period. Ten patients in this study had a
VOR gain of less than 0.8 before surgery, and nine
patients had gains less than 0.8 on the first postoperative
day. Of these, only one had had a gain of more than 0.8
before surgery; this individual exhibited a gain of 1.0
before surgery, 0.79 at day 1, and more than 0.9 thereaf-
ter. Therefore, we did not find a trend whereby VOR gain
reduced below 0.8 shortly after surgery, as has been
described by Batuecas-Caletrio et al. (19). In summary,
we observed neither of the hallmarks described by
Batuecas-Caletrio as potentially explaining imbalance
early after CI surgery. It is difficult to explain why a
change in catch-up saccades was observed by Batuecas-
Caletrio, but not in the present investigation. One possi-
bility is that the head impulses may have differed
between the studies; there is evidence that head impulses
were of lower velocity in the postoperative data, from
Figure 2 in that publication (19). A second possibility is
that the surgeries that Batuecas-Caletrio and colleagues
studied were more traumatic than those of the patients
that we studied, resulting in greater vestibular trauma and
a greater number of subjects with reduced postoperative
VOR gain. Finally, it is worth noting that the inclusion
criteria differed between the two studies. For inclusion in
Batuecas-Caletrio’s study, the VOR gain had to be
Otology & Neurotology, Vol. 39, No. 7, 2018
e528 W. G. SHUTE ET AL.

FIG. 2. A, Distribution of changes in VOR gain from preoperative baseline (D gain) in the operated ear. Positive values reflect reduction in
VOR gain from baseline. B, Distribution of changes in VOR gain from preoperative baseline (D gain) in the non-operated ear. Positive values
reflect reduction in VOR gain from baseline. VOR indicates vestibulo-ocular reflex.

Otology & Neurotology, Vol. 39, No. 7, 2018

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 THE EARLY POSTOPERATIVE EFFECTS OF COCHLEAR IMPLANTATION ON HSCC FUNCTION e529

FIG. 3. Indicative data comparing the differences in D gain at day 7 postoperatively in patients who were dizzy at any time point and those
that were not.

normal (defined as >0.8), while we accepted any patient
with a recordable vHIT gain. However, if we examine the
data on the 27 patients in our study who had a preopera-
tive VOR gain of more than 0.8 (comparable numbers to
those in the Batuecas-Caletrio study) then we are still
unable to replicate that study’s findings.
The finding that mean VOR gain was unaffected by CI
is in keeping with previous data (8,22). However, our
study is the first to elucidate this finding in the early
postoperative period. These studies tested semicircular
canal function with stimulus velocities similar to those in
our study, and these are within the range known to be
sensitive for detecting abnormalities in patients with
acute imbalance (17). However, more recent data have
suggested that higher stimulus velocities (from 250 to
300 degres/s) can unmask more subtle defects (30). None-
theless, our data when combined with previous studies
suggest that the function of the hSCC at moderate to high
stimulus velocities is preserved following CI (8,22). This
is contrary to caloric irrigation data. Caloric electronys-
tagmography data have elucidated changes in hSCC func-
tion at low stimulus velocities (0.36–3.6 degrees/s) at
which vHIT is not validated. The incidences of caloric
deficits following cochlear implantation vary from 6 to
77% (11). A review of the literature spanning from 1995 to
2004 found that 71 of 186 patients (38%) had a modified
caloric response following cochlear implantation (11).
However, when comparing postoperative vertiginous with
postoperative non-vertiginous patients, these studies
failed to demonstrate a significant difference in caloric
responses (31). O’Neil (16) in 1995 also raised the possi-
bility that anatomical anomalies such as previous mas-
toidectomy (a component of CI surgery) may alter heat
transfer dynamics across the middle ear and therefore
reduce the reliability of caloric irrigation testing.
When examining VOR gain asymmetry, we found there
was no increase in asymmetry between the implanted and
non-implanted ears. A key consideration when examining
asymmetry using vHIT is that there is a certain degree of
asymmetry is considered to be within normal limits (15).
Some authors have reported that monocular testing modal-
ities may produce up to 15.3% asymmetry in healthy
controls (32). This discrepancy has been attributed to
synaptic delay between the ipsilateral abducens nucleus
and the contralateral lateral rectus muscle (33), or alterna-
tively the relative differences in excitability of the medial

Otology & Neurotology, Vol. 39, No. 7, 2018

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e530 W. G. SHUTE ET AL.
and lateral rectus muscles (34). The vHIT modality exam-
ines right eye movements only and, as such, may tend to
produce lower VOR gain values when stimulating the left
hSCC. However in our population the side of CI did not
affect either the D gain or gain asymmetry. Furthermore,
when comparing results between right and left CI the
differences in gain were not significant. Therefore, despite
the limitations of monocular testing, it is unlikely that the
asymmetries seen in our study (<7% across all time points)
are clinically important.
We have found no evidence that subjective imbalance
early after CI surgery is related to dysfunction of the
lateral semicircular canal at moderate to high stimulus
velocities. The cause of early-postoperative imbalance
remains poorly understood. Given that a reduction
cVEMP responses is the most frequently reported finding
several months after CI surgery (12,35,36) otolithic
dysfunction remains a possibility. To study the possibil-
ity of an association between saccular dysfunction and
subjective dizziness would require early postoperative
testing. This would be difficult to achieve using cVEMP
measurement given the incidence of postoperative neck
discomfort. Another possible approach may be to study
the subjective visual vertical, which is thought to reflect
utricular function (36–38).
We confirmed that imbalance is a common cause of
morbidity in the first 30 days following CI, occurring in
35% of subjects. Despite this, objective hSCC function
(as measured by vHIT) was preserved. At moderate to
high stimulus levels (100–200 degrees/s) VOR gain was
unchanged by CI in the first 30 days following CI
surgery. In our cohort subjective imbalance was not
correlated with reductions in VOR gain. It remains
possible, that if post-CI imbalance is of a vestibular
etiology, then the underlying lesion may be isolated to
the other vestibular end organs; the vertical canals or
otolith organs.
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