2nd Timisoara International Course on Microsurgery of

the Middle Ear with Temporal Bone Dissection

May 26th-28th 2010

COCHLEAR IMPLANT

Prof. Dr. S. Cotulbea MD PhD

ENT Department
University of Timisoara
 Cochlear implant
Cochlear implantation represents one of the
greatest advances in the management of
children with severe to profound sensorineural
hearing loss (HL).
Thanks to the implementation of universal
newborn hearing screening, deafness is most
often diagnosed and intervention services
initiated as early as the first few months of life
The proportion of profoundly deaf children
implanted at or before age 2 has increased
considerably (*,**)
* McConkey Robbins A, Koch DB, Osberger MJ, et al. Effect of age at cochlear implantation on
auditory skill development in infants and toddlers. Arch Otolaryngol Head Neck Surg 2004; 130:570-4
* * Nikolopoulos TP, O‘Donoughue GM, Archbold S. Age at implantation: its importance in pediatric
cochlear implantation. Laryngoscope 1999;109:595-9
 Cochlear implant

The age at witch children with severe to

profound HL can be implanted has also
been significantly lowered based on the
premise that the earlier auditory input is
provided, the greater the benefit will be to
the child (*).

*Yoshinaga-Itano C, Sedey AL, Coulter DK, et al. Language of early- and later-identified
children with hearing loss. Pediatrics 1998;102:1161-71.
 Cochlear implant

Central auditory plasticity and the existence of a

sensitive or “critical” period in the maturation
of the central auditory system have been well
demonstrated with animal studies and clinical
experience with feral children (*,**,***).

*Kral A, Hartmann R, Tillein J, et al. Hearing after congenital deafness: central auditory plasticity and
sensory deprivation. Cereb Cortex 2002;12:797-807
**Kral A, Tillein J, Heid S, et al. Cochlear implants: cortical plasticity in congenital deprivation. Prog
Brain Res 2006;157:283-313
***Ruben RJ. A time frame of critical/sensitive periods of language development. Acta Otolaryngol
1997;117:202-5
 Cochlear implant

Children who are deprived of a sufficient

quantity and/or quality of language in their
earliest years are at high risk for failure in
language and academic endeavors later in
childhood (*).
Poor language skills and/or limited parent-child
communication interactions early in life are
associated with socio-emotional and
behavioral problems (**).

*Hart B, Risley T. Meaningful Differences in the Everyday Experience of Young Deaf American
Children. Baltimore: Paul H. Brookes, 1995
**Baltaxe C. Emotional, behavioral and other psychiatric disorders of childhood, associated with
communications disorders. In: Layton TL, Crais E, Watson LR, eds.2001
 Cochlear implant

It is now widely recognized that age at

implantation is an important factor in the
successful development of spoken language.
Many studies demonstrated that early
cochlear implantation is associated with
improved speech perception and production
outcomes (*,**).

*Geers AE. Speech, language, and reading skills after early cochlear implantation. Arch Otolaryngol
Head Neck Surg 2004;130:634-8
*Tait M, Lutman ME, Robinson K. Preimplant measures of preverbal communicative behavior as
predictors of cochlear implant outcomes in children. Ear Hear 200;21:18-24
Cochlear implant
5 years later
Cochlear implant
5 years later
 Cochlear implant

Restoring hearing at an earlier age gives these

children the potential to develop at a near
normal rate (*) and is particulary important
in minimizing language delay with respect to
normally hearing children.
Ideally, cochlear implantation should occur not
only early enough for normal language
development to be achieved but also before
the child has begun to lag behind his age
group (**).

* Geers AE. Speech, language, and reading skills after early cochlear implantation. Arch Otolaryngol
Head Neck Surg 2004;130:634-8
**Svirsky MA, Teoh SW, Neuburger H. Development of language and speech perception in
congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol Neurootol
2004;9:224-33
 Cochlear implant

An additional argument for early cochlear

implantation is to develop an auditory
feedback mechanism to facilitate preverbal
auditory and vocal skill development.
These essential precursors of aural/oral
communication (*,**) are developed through
important early mother-child interactions.

*Tait M, Lutman ME, Robinson K. Preimplant measures of preverbal communicative behavior as

predictors of cochlear implant outcomes in children. Ear Hear 200;21:18-24
**Tait ME, Nikolopoulos TP, Lutman ME. Age at implantation and development of vocal and auditory
preverbal skills in implanted deaf children. Int J Pediatr Otorhinolaryngol 2007;71:603-10
 Cochlear implant

Other parameters, such as duration of cochlear

implant use, age of hearing aid fitting,
chronological age, and preoperative hearing
levels, may also play an important role in the
development of speech perception and
production (*,**)

* Nikolopoulos TP, O‘Donoughue GM, Archbold S. Age at implantation: its importance in pediatric
cochlear implantation. Laryngoscope 1999;109:595-9
**Svirsky MA, Teoh SW, Neuburger H. Development of language and speech perception in
congenitally, profoundly deaf children as a function of age at cochlear implantation. Audiol Neurootol
2004;9:224-33
 Cochlear implant

In recent ears, the trend to implant both adults

and children bilaterally has gained
momentum, and many studies have
demonstrated that implanted bilaterally have
improved speech understanding in noise (*,**)
and improved sound localization (*,**,***)

*Laszig R, Aschendorff A, Stecker M, et al.Benefits of bilateral electrical stimulation with Nucleus

cochlear implant in adults: 6 month postoperative results. Otol Neurotol 2004;25:958-68.
**Litovsky R, Parkinson A, Arcaroli J, Sammeth C. Simultaneous bilateral cochlear implantation in
adults: a multicenter clinical study. Ear Hear 2006;27:714-31.
*** Litovsky R, Parkinson A, Arcaroli J, et al. Bilateral cochlear implants in adults and children. Arch
Otolaryngol Head Neck Surg 2004;130:648-55.
 Cochlear implant
Approaches in cochlear implantation

Classique approach with Mastoidectomy –

WF House 1976
Alternative approaches without
Mastoidectomy
– Endomeatal Approach – Chouard 1976;
Hausler 2003
– Middle Fossa Approach – Coletti 1998
– Veria Operation (transcanal wall) –
Kiratzidis 2000
– SMA (suprameatal approach) –
Kronenberg 2001
– Transepitympanic approach – Nahler 2002
 Cochlear implant

CLASSIC APPROACH
A. Implant bed
B. Mastoidectomy
C. Facial recess approach
D. Cochleostomy technique.

* Oliver Adunka, Craig Buchman, University of North Carolina, 2003

 SURGICAL TECHNIQUES
Drill mastoidectomy and tympanotomy
SURGICAL TECHNIQUES
Drill cochleostomy
SURGICAL TECHNIQUES
Insert electrode array
 Cochlear implant
Since January 2003, a number of 66
cochlear implants have been performed –
78% children under the age of 6
Postlingual deafness – 5 cases
Prelingual deafness - 61 cases
– 62 MedEl
28 COMBI 40+
34 PULSAR CI 100
– 1 Cochlear - Nucleus 24 K
– 3 Advanced Bionics – Hi – Res 90
Classic technique in all cases using both
the large and the minimal incision
 Cochlear implant

In our ENT Department the technique

used in selected cases was performed
through minimal incision approach and
cochlear implant fixation using periosteal
sutures * - 21 cases

* Oliver Adunka, Craig Buchman, University of North Carolina, 2003

Cochlear implant

THANK YOU !