小儿行为听力测试在人工耳蜗植入术前评估中的应用

目的 探讨小儿行为听力测试在人工耳蜗植入中的作用。方法和结果 在我院临床听力中心1996年至2001年4月就诊的1000科名6岁以下儿童中要求植入人工耳蜗的小儿,男30例,女26例,经系统的术前的医学和听力学评估（CT或MRI、ABR、40Hz-AERP、声阻抗、耳声发射、小儿行为听力评估包括裸耳听阈和助听听阈）,植入人工耳蜗45例,10例配以助听器,1例证实为蜗后病变而随访。结论 小儿行为听力测试在人工耳蜗植入术前听力学评估很重要,可以进行手术适应证的选择、指导术后测试,并可作为术前的听觉训练。     

人工耳蜗植入的手术技术

人工耳蜗的作用是刺激听神经，在大脑形成听觉信号。使用这种技术的前提是听觉神经的通路是完整的，已经失去功能的耳蜗用于安放刺激电极（图1，2）。     

脑白质异常小儿人工耳蜗植入手术适应证的讨论

目的讨论小儿人工耳蜗植入术前常规MRI检查中发现脑白质异常的手术适应证，为小儿人工耳蜗植入手术适应证选择的准确性提供依据。方法对2004年10月-2006年12月期间，351例年龄在0．9-3．0岁的重度或极重度感音性聋小儿，人工耳蜗植入术前进行常规影像学MRI检查，通过检查结果发现MRI形态有异常改变，对有脑白质异常的病例提出总结讨论，选择手术适应证，进行术后随访。结果351例患儿中选择了347例进行了人工耳蜗植入手术。351例患儿常规MRI检查提示：脑白质形态异常20例，占5．7％，其中轻、中度异常16例，进行了人工耳蜗植入手术，术后随访2年以上未见恶化趋势。严重异常4例，取消了人工耳蜗植入手术，进行长期随访。结论幼小儿人工耳蜗植入术前常规MRI检查不可忽视，通过术前的常规MRI检查可以了解患儿的脑形态和发育状况，从中发现听力障碍患儿伴有脑部罹患。轻度脑白质异常进行人工耳蜗植入手术未发现预后恶化，严重脑白质异常由于临床经验不足，采取MRI长期随访，如有明显影像学和症状的改善方可慎重考虑人工耳蜗植入手术。     

人工耳蜗植入手术远期并发症的临床处理

目的总结和分析人工耳蜗植入患者术后的远期并发症,探讨并发症的发生原因、临床处理方法和预后。方法对2002年3月~2016年11月在北京大学第三医院由作者潘滔完成人工耳蜗植入手术且随访资料完整的280例患者进行回顾性研究。结果在所有研究对象中,出现各类远期并发症(发生于术后3个月之后的并发症)共6例,总发生率为2.1%,并发症出现时间最早为术后4个月,最晚为术后5年。其中术后远期中耳炎合并植入体周围感染3例,发生率1.1%,经过抗生素及对症治疗后痊愈。植入体装置故障2例,发生率0.7%,行植入体取出及同侧再植入。皮瓣感染及坏死1例,发生率0.4%,先后4次行耳后清创、皮瓣转移术,仍不能控制感染,遂行植入体取出、乳突清创、皮瓣转移成形术并同期行对侧人工耳蜗植入,最终痊愈。以上出现远期并发症的患者经过上述治疗干预后均预后良好。结论即使人工耳蜗植入患者术后恢复良好,远期的并发症仍值得关注,及时的发现和处理可挽救或避免进一步的危害后果。     

小儿人工耳蜗植入手术切口选择及其相关并发症问题

目的探讨小儿人工耳蜗植入手术的切口选择。方法回顾性分析2001年6月～2007年7月开展的5岁以下患儿人工耳蜗植入手术589例,均设计小“S”切口。其中,行澳大利亚CI24M植入174例,切口长3.5cm;CI24CA植入137例,CI24K植入62例,切口均长3.0cm。行美国Bionics90K植入26例,切口长3.5cm。行奥地利MedelCombi40^＋植入190例,切口长6.0cm。均制备两个肌骨膜瓣,一个用于包裹植入体,另一个用于覆盖开放的乳突腔。术后随访6个月～6.5年,观察术后切口愈合状况以及与切口有关的并发症发生情况。结果植入的人工耳蜗均有听觉语言效果。12例于术后1～2年开始沿切口表面出现1.5～3.5mm的瘢痕隆起（2.0%）;4例于术后1～3年出现与皮下感染有关的植入体裸露（0.68%）。通过清除炎症及瘢痕组织、重新固定植入体、颞肌瓣转移覆盖均获痊愈,随访6个月～2.1年,未再出现植入体裸露。结论作者设计的小切口效果满意,可以减小皮肤切口瘢痕的范围,术后植入体裸露的发生率低。     

小儿人工耳蜗植入术前准备与围手术期护理流程

目的讨论小儿人工耳蜗植入术前准备与围手术期护理的效果,为达到提高手术质量、手术效率和手术安全性提供临床经验,为制定小儿人工耳蜗植入围手术期护理标准提供参考。方法2007年4月-2008年10月,我院共接受台湾捐赠项目的人工耳蜗植入患儿106例,术前制定了围手术期的流程,包括患者与家长的心理准备、临床中的术前检查、术前准备、手术流程、麻醉方法、术后并发症的防范及注意事项各项流程,按流程进行澳大利亚Cochlear CA型号人工耳蜗植入手术。结果106例人工耳蜗植入手术全部一次成功,手术当日起使用头孢类抗生素2周,术后6天拆除包扎出院,未见围手术期并发症。结论术前认真严格制定围手术期流程,为规范人工耳蜗植入手术围手术期护理提供了科学的方法,提高了护理质量和水平。     

乙状窦前移小儿人工耳蜗手术方法的探讨

目的:探讨乙状窦前移小儿人工耳蜗植入术式的选择和术中处理的方法,为特殊情况下的人工耳蜗植入手术的顺利完成提供经验。方法:538例行人工耳蜗植入手术的听力障碍患儿,术前进行的常规听力学与影像学检查,术前通过高分辨率CT判断乙状窦是否前移,行人工耳蜗植入手术中证实分为显著前移和轻度前移。结果:538例通过常规术式进行人工耳蜗植入患儿中,乙状窦轻度前移64例,占11.9%,对常规人工耳蜗植入手术无影响。4例患儿乙状窦显著前移,对常规人工耳蜗植入手术带来困难,占0.74%,通过处理骨性外耳道后壁和切除砧骨顺利完成手术。结论:小儿人工耳蜗植入手术患儿中,乙状窦轻度前移者对手术无影响,显著前移者经过适当手术处理,亦能成功进行手术。     

1448例人工耳蜗植入手术中疑难问题的总结

目的通过对1448例人工耳蜗植入手术的总结,讨论人工耳蜗植入术中疑难问题,为提高人工耳蜗植入手术的成功率提供参考。方法1448例人工耳蜗植入手术病例资料来源于1998年1月～2009年3月。术前信息年龄8．5个月～51．2岁,平均年龄为4．57。全部为双耳重度和极重度感音神经性聋,其中语前聋患者1430例、成人语后聋患者18例。术前进行常规检查包括：①听力学检查、影像学检查、小儿肢体智力发育评估。②全麻常规检查。手术方法：①按常规面神经隐窝入路自耳蜗底转鼓阶植入耳蜗电极。②自乳突入路从耳蜗与前庭共同腔后下植入耳蜗电极。③在开放式乳突腔内埋藏电极线后仍于圆窗入路植入耳蜗电极。手术疑难判断方法：①无法按常规面隐窝入路手术者。②由于乙状窦、天盖、外耳道壁等解剖问题不能顺利完成乳突轮廓化者。③由干面神经、鼓索神经、外耳道骨壁的解剖问题使开放面隐窝的空间狭小导致暴露圆窗困难者。④耳蜗或圆窗等骨化或畸形等问题不能按常规自圆窗口部顺利植入耳蜗电极者。结果①手术成功率：1448例人工耳蜗植入手术均～期成功,成功率为100％。②术中疑难问题：术中疑难问题共241例（耳）,占16．64％,其中非常规手术入路10例,乙状窦前移影响手术入路4例,面神经垂直部高位并前移使与鼓素神经或外耳道壁的距离狭小影响圆窗的暴露179例,耳蜗底转骨化影响打开耳蜗鼓阶23例,圆窗骨化无法以圆窗为标记打开耳蜗鼓阶15例,耳蜗海绵状改变判断鼓阶正确位置困难5例,耳蜗与内听道共同腔耳蜗电极在共同腔内正确摆放困难5例。结论对1448例人工耳蜗植入手术总结体会认为,人工耳蜗植入手术中的疑难问题主要表现为：①面神经垂直部过度前移影响圆窗的暴露。②耳蜗骨化或海绵状改变影响开放耳蜗     

人工耳蜗电极植入耳蜗入口的定位

目的 :确定人工耳蜗电极植入耳蜗入口的位置。方法 :对 2 5具尸头 50耳标本进行人工耳蜗植入手术有关的解剖数据测量。结果 :人工耳蜗电极植入耳蜗鼓阶入口与前庭窗最近距离为 2 .77mm。结论 :该解剖参数为蜗窗难以找到的人工耳蜗植入病例提供了定位参考     

术中圆窗耳蜗电图对人工耳蜗植入电极安全性评估

目的：分析人工耳蜗电极植入前后圆窗耳蜗电图（R W EcochG）中耳蜗微音电位（CM）阈值的变化,以客观评估人工耳蜗植入手术是否对耳蜗基底膜造成损伤。方法：对40例拟行人工耳蜗植入术的患者在全身麻醉下行R W EcochG测试,分析植入电极前后CM阈值的变化。结果：40例人工耳蜗植入患者中,39例电极植入前后CM阈值相近,且在个别频率植入电极后CM阈值减小5dB;仅有1例患者电极植入后CM阈值比植入前明显增加,术中植入电极时有阻力感。结论：术中RWEcochG测试可以客观评估人工耳蜗植入手术本身是否对耳蜗基底膜造成损伤。     

儿童人工耳蜗植入术后音乐能力发育研究

目的：探讨儿童人工耳蜗植入术后音乐能力的发展趋势,为人工耳蜗植入儿童音乐能力评估提供临床资料。方法：26例人工耳蜗植入儿童,手术年龄为11～68个月,平均35．6个月;以76例1～24月龄的听力正常婴幼儿作为对照组,平均月龄6．1个月。使用小龄人工耳蜗儿童音乐能力等级量表进行评估。人工耳蜗植入儿童评估分别在开机时,开机后1、3、6、9、12及24个月时进行;听力正常婴幼儿评估分别在1、3、6、9、12及24月龄时进行。结果：人工耳蜗植入儿童的音乐能力得分随人工耳蜗使用时间的延长而显著提高（P〈O．05）,听力正常婴幼儿的音乐能力得分亦随年龄的增长而显著提高（P〈O．05）。经两样本比较的秩和检验,人工耳蜗植入儿童与听力正常婴幼儿在听力年龄为1、3、6、9、12个月时音乐能力得分的差异无统计学意义（P〉O．05）,在听力年龄为24个月时音乐能力得分的差异有统计学意义（P〈O．05）。结论：人工耳蜗植入儿童开机后音乐能力随人工耳蜗使用时间的延长而显著提高,并在开机12个月内呈现快速增长趋势。     

Orbital sequelae of rhinosinusitis after cochlear implantation in children

OBJECTIVES: The objectives of this retrospective case review were to describe orbital complications in children after cochlear implantation, to define rhinosinusitis as a possible preoperative risk factor, and to suggest a possible pathophysiological mechanism for this previously unreported occurrence. METHODS: Records of children undergoing cochlear implantation over a 7-year period at a tertiary academic medical center were reviewed. Four children who experienced postoperative orbital sequelae were identified. We describe the demographics, clinical course, and radiologic findings in these children. RESULTS: The records of 91 children who underwent cochlear implantation were reviewed. The mean age was 6.0 years (range, 0.9-16.9 years). Forty-nine children (54%) were female and 51 (56%) were white. Four children developed postoperative orbital complications on the ipsilateral side to implantation. Orbital complications were characterized by periorbital edema and preseptal cellulitis necessitating prolonged hospitalization in all four children (mean length of stay, 3.3 days). Each child's orbital complication resolved with medical therapy that included intravenous antibiotics and nasal saline. Temporal bone images before implantation showed evidence of rhinosinusitis in all four cases. Of 76 available preoperative scans from the unaffected children, only 11 (14%) studies showed evidence of rhinosinusitis. CONCLUSIONS: Children with preoperative radiologic evidence of rhinosinusitis may be at risk of orbital sequelae after cochlear implantation. Positioning of the patient during surgery, length of surgery, and minor trauma to the lamina papyracea during drilling of the mastoid may be important etiologic factors. A careful review of medical history and computed tomography imaging before implantation may identify at-risk children.     

人工耳蜗植入术后改良耳蜗位平片的探讨

目的 探讨改良后耳蜗位平片摄影位的临床应用价值。方法 21例人工耳蜗植入术后患儿(年龄30d～4岁)分别摄许氏提倡的耳蜗位平片摄影位和我们改良后的许氏耳蜗位平片摄影位,用Cohen(c)方法测出蜗管内电极数,将术中得数与2种片所得共3组数据行统计处理t检验。结果 2种平片均能清晰地显示蜗管内电极的位置和形态,2组X片结果与手术结果基本吻合,3组数据比较差异无统计学意义。结论 改良后耳蜗位平片摄影位方法简便,易使4岁以下患儿接受,且能满足了解人工耳蜗植入术后精确状态的需要。     

Partial deafness cochlear implantation in children

OBJECTIVE: Partial deafness cochlear implantation and electric-acoustic stimulation have proven to be a useful method of treating adults with a ski-slope type hearing loss. Good hearing preservation and speech perception outcomes have been reported. This study aims to assess partial deafness cochlear implantation in children. METHOD: Nine children, ranging in age from 4.2 to 12 years, received a cochlear implant following the round window surgical technique for partial deafness cochlear implantation. Hearing preservation was assessed by pure-tone audiometry and speech perception outcomes were measured using monosyllable word tests in quiet and noise. Data are available for most children up to a period of 1 year. RESULTS: Hearing could be preserved partially in all cases, however, one child does not have sufficient preservation to make use of electric-acoustic stimulation. The eight children with sufficiently preserved hearing either use the natural low frequency hearing in combination with a cochlear implant to hear or use the DUET combined hearing system. Speech perception tests showed improvement in quiet and noise over time. CONCLUSION: Results suggest that partial deafness cochlear implantation is a viable treatment method in children. However, surgery should only be conducted by an experienced surgeon and parents need to be carefully counselled about the risks and benefits of partial deafness cochlear implantation.     

HRCT多平面重组耳蜗形态测量在人工耳蜗植入术的应用

目的：运用颞骨高分辨率CT（HRCT）多平面重组（MPR）技术测量人工耳蜗植入患者的耳蜗形态,探讨其在人工耳蜗植入术前评估中的应用价值。方法：收集符合入组标准的80例人工耳蜗植入患者资料,根据患者的性别、年龄及有无内耳畸形进行分组;对患者术前颞骨CT进行MPR,在标准方位图像下分别测量耳蜗长径A、宽径B及底转角度7,对测量的数据进行可重复性评价及对不同组间的结果进行比较。结果：各组测量参数值在测量者自身和测量者之间的一致性较好;内耳正常组男性耳蜗长径A[（8．79士0．34）mm]及宽径B[（6．58士0．28）mm]均大于女性耳蜗长径A[（8．534士0．47）mm]和宽径B[（6．22±0．43）mm],差异均有统计学意义（P〈O．05）,但底转角度7无性别差异（P〉0．05）;耳蜗长径A及宽径B不随年龄的增长而变化（P〉O．05）,但底转角度7随着年龄的增长呈逐渐减小趋势（r=-0．25,P〈0．05）;内耳畸形组患者耳蜗宽径B较耳蜗正常组小（P〈0．01）,但两组的耳蜗长径A及底转角度7差异无统计学意义（P〉O．05）。结论：术前应用HRCTMPR技术测量耳蜗形态方法简单可行、重复性好,可用于指导手术及为设计个性化电极提供客观依据,值得临床推广。     

Usefulness of radiological findings for predicting cochlear implantation outcomes in children with cochlear nerve deficiency: a pilot study

Conclusion: Children with CND received limited benefits from CIs and their results varied. The size of the vestibulocochlear nerve relative to the facial nerve could potentially be used as a predicator for CI outcomes in children with CND.

Objective: This study aimed to (1) retrospectively review the outcomes of cochlear implants (CIs) in children with cochlear nerve deficiency (CND) and (2) evaluate the clinical usefulness of radiological findings as predictors for post-implantation outcomes.

Methods: Study participants included 10 children with bilateral CND and profound sensorineural hearing loss. The preoperative magnetic resonance imaging and temporal bone computed tomography scans were evaluated. Auditory processing capability and speech perception performance were measured with Categories of Auditory Performance (CAP) and Speech Intelligibility Rating (SIR) scales. Aided hearing thresholds with CI were measured. The relationships between CI outcomes and the sizes of vestibulocochlear nerve and cochlear nerve canal (CNC) were analysed.

Results: Although post-operative CAP scores and hearing thresholds significantly improved in children with CND, their results were worse than those measured in implanted children with normal cochlear nerve. No significant correlation was found between the CI outcomes and the vestibulocochlear nerve diameters or the CNC diameters in children with CND. However, children with larger vestibulocochlear-nerve-to-facial-nerve-ratios got better results.     

Hearing benefits of second-side cochlear implantation in two groups of children

OBJECTIVE: To investigate the additional bilateral benefits of a second cochlear implant (CI) in a group of young children (<6 years of age) and a group of older children (>6 years of age). METHOD: This is a Belgian tertiary multi-centre study in which 33 CI-children with a second implant between the age of 2 and 12 participated. Assessments took place pre-second implant and at several time intervals post-fitting on pure tone audiometry and speech recognition in quiet and noise (+10 dBSNR). Testing was done with the first and second implant alone and bilaterally. Results were analysed separately for children younger and older than 6 years at the time of implantation of the 2nd CI. RESULTS: After 18 months of bilateral implant use all children obtained significantly higher hearing thresholds in the bilateral condition in comparison to both the unilateral conditions (p(CI1)=0.035/p(CI2)=0.042 for the younger children and p(CI1)=0.021/p(CI2)=0.007 for the older children). The speech recognition scores in quiet were for all children superior in the bilateral condition (p(CI2)=0.011 for the younger children and p(CI1)=0.016/p(CI2)=0.003 for the older children). In the noisy condition only significant bilateral better results were obtained in the group of younger children (p(CI1)=0.028/p(CI2)=0.034). CONCLUSIONS: Bilateral cochlear implantation offers advantages to all children. Even for the children who received a second implant after the age of 6 a progress is determined after 18 months. However, the data appear to show a beneficial performance for those children who received their second implant before the age of 6, especially in the more challenging conditions.     

A cost-utility analysis of pediatric cochlear implantation

OBJECTIVE/HYPOTHESIS: The aim of this study was to explore the cost-utility of pediatric cochlear implantation, incorporating savings associated with education into the analysis. METHODS: The costs of pediatric cochlear implantation were based on the full costs levied to purchasers, inclusive of complications and maintenance, by a large pediatric cochlear implant program in the United Kingdom. After implantation, profoundly hearing-impaired children have been found to develop hearing threshold levels equivalent to severely hearing-impaired children who wear hearing aids. An independent study calculated the educational costs for severely hearing-impaired and profoundly hearing-impaired children. From this study, savings in educational costs that would result from enabling the profoundly hearing-impaired to function as severely hearing-impaired were determined. Cost-utility was established conservatively by applying to children the known gains in utility reported by adults with cochlear implants. RESULTS: The discounted costs of creating a pediatric cochlear implant user and of maintaining the child over the first 12 years were 48,757 pound silver($78,011). The discounted difference in education costs associated with a profoundly hearing-impaired child (HL >95 dB) as compared with a severely hearing-impaired child (HL 70-95 dB) over the same period was 26,781 pound silver($42,850). These represent the potential savings in educational costs associated with pediatric cochlear implantation. Assuming implantation at age 4 years, the discounted net average cost of pediatric cochlear implantation over compulsory school years (ages 4-16) was 21,976 pound silver ($35,162). Cochlear implants have been shown to improve the quality of life in adults by 0.23 points per annum (where quality of life is rated on a scale from 0 to 1). Applying this weight to children receiving implantation at age 4 years, and assuming a life expectancy of 74 years, the quality-adjusted life-year (QALY) gain is calculated to be 16.33. The cost per undiscounted QALY gain was estimated to be 1,345.70 pound silver ($2153.12) and per discounted QALY gain to be 10,341 pound silver ($16,545.60). CONCLUSION: This study provides evidence, based on conservative assumptions, to support the view that pediatric cochlear implantation is a cost-effective health care intervention in profoundly hearing-impaired young children.