OUR EXPERIENCE *Shruthi Gaddemane Shankar, **Harshita V Sabhahit, ***Sathish Kumar S., ****G Prabhakar,*****J M Hans Date of receipt of article -23-03-2016 Date of acceptance -2-5-2016 DOI-10.21176/ojolhns.2016.10.1.8 ABSTRACT As we are in the era of increased demand for cochlear implantation, the simplicity of procedure is the need of the day. We are presenting our experience of non mastoidectomy method of cochlear implantation, that is Veria technique in 16 patients during the period of 2012-2016. Out of which 13 were prelingual deaf children with age range of 2-5 yrs and 3 were postlingually deaf adults of 20-30 yrs range. We had ease of insertion of electrodes with this method in all patients except among 3 adults where we had partial ossification of cochlea. The deviation from classic method includes creating a transcanal direct tunnel by a special perforator, suprameatal well, cochleostomy endaurally and electrode insertion through special safety electrode forceps. The benefits of this procedure was less operative time of 30-45min, simple and safe method without any post operative complications. All our patients are doing well including adults leading a normal life. VERIA TECHNIQUE is a boon to all surgeons with its simpler non mastoidectomy way. Key words: Cochlear implantation, Veria technique.
Cochlear hair cells are vulnerable sensory link
between acoustic environment and central nervous system. Cochlear implants are the first true bionic sense organs. The history of cochlear implant (CI) goes way back to 1800 when Alessandro Volta found auditory sensation with electric stimulation. The first auditory prosthesis was in 1957 by work of Djourno and Eyries. Early cochlear implants were inplanted by William F Houses fruitful efforts. The first FDA approved implant was used in 1972. Since then continuous evolutions has led to multiple channels, miniaturized implants with improved speech perception and discrimination. With recent advances, new criteria of indications are laid like age of 12mts, hearing loss of 70dB, bilateral implantation and persons with multiple impairments. This has led to increased need for implantations and new modifications of procedure other than posterior tympanotomy like suprameatal approach, Veria, the pericanal electrode insertion, the transmastoid labyrinthotomy technique and middle cranial fossa approach.Veria technique is a simple
procedure without mastoidectomy, with less facial
nerve injury and less operative time. Here we are presenting our experience and outcome with this simple and safe technique. MATERIAL AND METHODS: In our institution we have performed Veria technique in 16 cases during the period of 2012-2016, out of which 13 patients were pre lingual deaf children of 2-5 yrs of age and 3 were post lingual deaf adults of 20-30 yrs of age. There was no significant history among children but the adult patients had previous history of meningitis which was bacterial and tubercular in origin. All had undergone hearing aid trial for at least 6 months. Affiliations: *,**,***,****. - Otorhinolaryngology Department, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India, *****Professor Emeritus, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India Address of Correspondence: Shruthi Gaddemane Shankar, MBBS,MS House no.302, Lalithya Olives apartment, BEML Layout, 4TH Main, 6TH Stage, Thubarahalli-560066, Bangalore,INDIA Email: gsshruthi@yahoo.com, Mobile no: 08884609524
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All patients were subjected for battery of tests like
pure tone audiometry, tympanometry, Speech audiometry, BERA, OAE, HRCT temporal bone, MRI with 3D reconstruction (Figure 1) and EEG. HRCT of adult patients showed partial ossification of basal turn of cochlea whereas all children had normal set of investigations. Immunization status was assessed and pneumococcal, meningococcal and Hib vaccine were administered. Patients were taken up for surgery after paediatric, neurology and anesthesia clearance. All three FDA approved cochlear implants like NUCLEUS, CLARION AND MED-EL were implanted.
Figure-2: Showing the incision line
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Figure 1: Showing MRI of middle and inner ear
with 3-D reconstruction Steps of surgery: Under general anaesthesia, with 2% lignocaine and adrenaline infiltration, endaural incision given from 12 - 6 o clock position and extended upto incisura terminalis . Implant template markings taken about 1cm above the auricle and incision given postero superiorly over squamous part of temporal bone joining the first incision (Figure 2). The skin flap was raised inferiorly and musculofacial flap superiorly, exposing bare bone. Tympanomeatal flap was elevated and promontory, round window niche identified and outer table of squamous temporal bone drilled to accommodate receiver / stimulator and suprameatal well created and tunnel was made connecting to bed (Figure-3) Using a special perforator in the transcanal wall direct tunnel was made in direction of round window between 10 and 11o clock position (Figure -4) 42
Figure -3: Showing suprameatal well and tunnel to
bed.
Figure -4: Showing transcanal wall direct tunnel
Cochleostomy was done anterosuperior to round
window niche and steroid wash given. Reciever/ stimulator was fixed and electrode array passed through transcanal tunnel and guided to cochleostomy by safety electrode forceps.Excess electrode was placed in suprameatal well and tympanomeatal flap repositioned, Neural response telemetry done after the repositioning. The flaps were sutured, followed by closure. We achieved complete insertion in all children. As we found ossification in adult patients cochleostomy was done till fluid filled lumen was accessed. One of the patients had round window niche obliteration and other two had part of inferior basal turn. Complete insertion of straight array was achieved in one patient and insertion of 18 and 20 electrodes in other two patients. With wide visibility of this method ossified cochlea was also managed effectively as other normal anatomy cases.Post operative check x-ray of skull (modified Stenvers view), confirmed the proper electrode placement in all patients. All patients had successful implant without any complications.Switching on and speech processor tuning was done 3 weeks after surgery. Mapping was done at periodic intervals like every 3 weekly interval and then monthly for 6months, followed by every 6months till a stable map was achieved. Periodical assessments of outcome were done with speech therapy in terms of environmental sound, open set speech, closed set speech and speech discrimination. All patients are doing well in open set speech except one adult patient who couldnt achieve speech discrimination. RESULTS: Out of 13 children 11 are attending regular schooling, performing well in their environment. Only one child who had ADHD-attention deficit hyperactive disorder, required aggressive speech therapy and 3 more months of follow up compared to other children. Two of recently operated patients are undergoing rehabilitation and are responding well. Adult patients have joined their job back except one patient where rehabilitation was challenging due to absence of literacy and lack of psychological and family support. DISCUSSION: Hearing loss is widely recognized as one of the most common human disorders. Guidelines for candidacy of cochlear implant have changed over time. New criteria of indication and selection of patients to
cochlear implant have been laid by Sampaio et al. These
changing trends of candidacy for CI has lead to increased need for cochlear implantation. At the same time the procedure of CI has also undergone continuous modifications other than standard mastoidectomy posterior tympanotomy technique described by House2. Appropriate training, ability and expertise of otologists is required for this commonly practiced facial recess approach to the middle ear. Since then many surgeons have come up with their modifications for a simpler and safer technique. Suprameatal approach was introduced by Kronenberg et al in 2001, in which mastoidectomy is avoided and the duration of the operation is reduced. This procedure is simpler and avoids damage to chorda tympani and facial nerve. Tunnel is drilled in the suprameatal bone region at 1 o clock position posterior-superiorly to external auditory meatus which goes superior to Henles spine. The electrode is introduced into the cochlea through this tunnel. The electrode enters the middle ear between incus and malleus 3. This technique is contraindicated in cases with low tegmen tympani as the space for the tunnel becomes restricted. Since this is a common finding in children there is a limitation for this procedure. Even though the classic technique of mastoidectomy and posterior tympanotomy has been very efficient in vast majority of cases, it has limited accessibility to cochlea and related structures and a lot of trauma 4. This lead to modifications by Kiratzidis to come up with his own surgical technique where a direct tunnel is drilled through posterior-superior bony canal wall to the facial recess and endaural approach to expose the middle ear structures and cochleostomy. Electrode placement is done through this tunnel, which is formed by a special perforator introduced by author. Here came the emergence of Veria technique. This was carried out in Cochlear Implant centre, General hospital of Veria, Greece from where the name veria has been derived 4. The standard posterior tympanotomy approach which has been successful in vast majority of cases still has its own disadvantages and complications. Facial paralysis due to narrow facial recess approach is reported in untrained hands as there is keyhole visibility and restricted accessibility. Healthy bone removal has an impact on growth of children. Misplacement, carotid injury, taste disturbances due to sacrifice of chorda tympani in narrow recess, dural injury or sigmoid 43
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injury is not uncommon. In complicated anatomic
situations like- sclerotic mastoid, prominent sinus, anatomic variations of cochlea and low placed dura it is a cumbersome procedure 5,6,7 . The advantages of Veria technique over classical technique are1. No mastoidectomy; 2. Healthy bone of mastoid retained, anatomy of air cell system is not hampered ;3. Easy access to middle ear by endaural approach ;4. Wider visibility and accessibility ;5. Convenient for anatomic variations and malformations of cochlea ;6. Easy access to second turn and apex of cochlea in obliteration cases ; 7. No impact on growth of children ;8. Suitable for hypoplastic mastoid cavity and 9. Safe and simple technique with a short learning curve7,8 . In our experience patients with partial ossification of cochlea , ossification is never a contraindication. Studies have shown that patients with partial ossification do as well as patients with patent cochlea 9. Hartrampf showed that benefits can be obtained from cochlear implantation independent of the depth of electrode insertion. He suggested that significant improvement in performance may be expected in users with as few as 7 inserted electrodes 10 .Kirtazidis et al 7 in their study of surgical results in 101 cases, have successfully implanted in 23 revision cases by Veria technique without complications which signifies the efficiency of this technique. Out of their revision cases they found that in 13 cases electrode was misplaced and 5 cases implantation was not completed in the previous limited exposure of posterior tympanotomy approach.Various studies have proved efficiency of this techinique in the difficult situations like revision cases, malformations, cochlear ossifications and poor mastoid development 11 . It is suitable for very young children, where the mastoid has not yet been sufficiently developed. As the drilling depth and direction is under control by the special guarded perforator it is safe for the facial nerve.There is no surgery without complications. Creation of tunnel without direct visualization of mastoid anatomical references in absence of mastoidectomy requires some expertise. As posterior tympanotomy is technically more demanding, Veria technique may be suitable for a surgeon having limited experience of posterior tympanotomy technique. CONCLUSION : As various studies including ours have less complication in this surgeon friendly technique, more 44
and more trained surgeons are to be encouraged to
incorporate this method to meet the increased demand and have a disability free world. DISCLOSURES (a) Competing interests/Interests of Conflict- None (b) Sponsorships - None (c) Funding - None (d) No financial disclosures REFERENCES: 1. Sampaio ALL, Arajo MFS, ACP. New Criteria of Indication and Selection of Patients to Cochlear Implant. International Journal of Otolaryngology 2011: Article ID 573968; 13 pages 2. House, W.F. Cochlear implants. Ann Otol Rhinol Laryngol. 1976; 85: 193 3. Kronenberg J, Migirsov L, Dagan T. Suprameatal approach: new surgical approach for cochlear implantation. J Laryngol Otol.2001; 115(4):283-5. 4. Kiratzidis T. Veria operation: cochlear implantation without a mastoidectomy and a posterior tympanotomy. Adv ORL 2000; 57:127-30. 5. Fayad N, Wanna GB, Micheletto JN, Parisier SC. Facial nerve paralysis following cochlear implant surgery, The Laryngoscope 2003: 113 (8);1344 1346 6. Kubo T, Matsuura S, Iwaki T, Complications of cochlear implant surgery, Operative Techniques in Otolaryngology: Head and Neck Surgery 2005:16 (2); 154158, 2005 7. Trifon kirtazidis, Theophilos Iliades,Wolfgang Arnold, Veria operation1.Surgical results from 101 casesORL2002;64:413-416 8. Colletti V,Florino FG,Carner M,et al.New approach for cochlear implantation:Cochleostomy through the middle fossa.Otolaryngol Head Neck Surg.2000;123:467-74. 9. Balkany TJ, Gantz B, Nadol JB: Multichannel cochlear implants in partially ossified cochleas. Ann Otol Rhinol Laryngol 97:3-7, 1988 10. Hartrampf R, Dahon MC, Battmer RD. Insertion depth of the Nucleus electrode array and relative performance. Ann Otal Rhino Laryngol 1955; 104: 277-80. 11. Kiratzidis T, Arnold W, Iliades T. Veria operation updated. I. The trans-canal wall cochlear implantationORL J Otorhinolaryngol Relat Spec. 2002 Nov-Dec; 64(6):406-12.