Orientation for cochlear implant surgery in cases with round window obstruction: a computer reconstruction study

In order to improve cochlear implant surgery in patients with obstructed round windows, surgical orientations of the round window and scala tympani relative to the stapes footplate were examined in ten normal temporal bones using a computer-aided, three-dimensional reconstruction and measurement technique. The round window was found to be exactly inferior to the midpoint of the inferior margin of the stapes footplate in most cases. An optimal point on the promontory wall for drilling to reach the bottom of the scala tympani of the basal turn was found to lie approximately 1.5 mm anterolateral or anterolateral inferior to a point 3 mm inferior to the midpoint of the inferior margin of the stapes footplate. A combination of the transmeatal and facial recess approaches made it possible to consistently reach the scala tympani, and demonstrated that this approach was also applicable to patients with obstructed round windows.     

Communication between the perilymphatic scalae and spiral ligament visualized by in vivo MRI

We evaluated the transport of Gadolinium-diethylenetriaminepentaacetate-bismethylamide (Gd-DTPA-BMA) through the round window (RW) membrane into the perilymphatic space with 4.7-T MRI in an animal study and 1.5-T MRI in humans. After administration of Gd-DTPA-BMA onto the intact RW membrane of guinea pig, Gd-DTPA-BMA uptake was observed in the basal turn and part of the second turn within 40 min. The scala tympani, scala vestibuli, the fibrous part of the spiral ligament and semicircular canal all showed uptake of Gd-DTPA-BMA. All turns of the cochlea were filled with Gd within 10 min in the perforated RW membrane administration group and within 30 min in the intravenous administration group. In patients who accepted middle ear injection of Gd-DTPA-BMA, uptake was observed within 2 h in the basal turn and semicircular canal. After 12 h the apex did still not show any uptake. Gd-DTPA-BMA is transported from the RW to the semicircular canal, the scala tympani and scala vestibuli without passing the helicotrema.     

Scalar localization of the electrode array after cochlear implantation: a cadaveric validation study comparing 64-slice multidetector computed tomography with microcomputed tomography.

HYPOTHESIS: Improved resolution available with 64-slice multidetector computed tomography (MDCT) could potentially be used clinically to localize the cochlear implant (CI) electrode array within the basal turn. BACKGROUND: In CI surgery, the electrode array should be inserted into and remain within the scala tympani to avoid injury to Reissner's membrane and the scala media. Correlating the position of the electrode in the basal turn with surgical technique and implant design could be helpful in improving outcomes. METHODS: After a standard left mastoid exposure of the round window niche through the facial recess performed on a cadaver head, an electrode array from a Nucleus Softip Contour CI was fully inserted through a cochleostomy. The head was then scanned axially on a 64-slice MDCT with 0.4-mm slice thickness and reconstructed into the oblique axial, oblique coronal, and oblique sagittal planes of the cochlea. The temporal bone was then harvested and imaged on a microcomputed tomographic scanner using 20-microm slice thickness. Identical reconstructions were made and compared with the 64-slice images to confirm exact location of the electrode array. RESULTS: The 64-slice MDCT accurately localized the electrode array to the scala tympani. This was best demonstrated in the oblique sagittal plane, identifying the electrode array in the posterior inferior portion of the basal turn, posterior to the spiral lamina. CONCLUSION: This ex vivo validation study suggests that 64-slice MDCT has the potential to allow accurate localization of the CI electrode array within the basal turn of the cochlea.     

Scala tympani cochleostomy II: topography and histology

OBJECTIVE: To assess intracochlear trauma using two different round window-related cochleostomy techniques in human temporal bones. METHODS: Twenty-eight human temporal bones were included in this study. In 21 specimens, cochleostomies were initiated inferior to the round window (RW) annulus. In seven bones, cochleostomies were drilled anterior-inferior to the RW annulus. Limited cochlear implant electrode insertions were performed in 19 bones. In each specimen, promontory anatomy and cochleostomy drilling were photographically documented. Basal cochlear damage was assessed histologically and electrode insertion properties were documented in implanted bones. RESULTS: All implanted specimens showed clear scala tympani electrode placements regardless of cochleostomy technique. All 21 inferior cochleostomies were atraumatic. Anterior-inferior cochleostomies resulted in various degrees of intracochlear trauma in all seven bones. CONCLUSION: For atraumatic opening of the scala tympani using a cochleostomy approach, initiation of drilling should proceed from inferior to the round window annulus, with gradual progression toward the undersurface of the lumen. While cochleostomies initiated anterior-inferior to the round window annulus resulted in scala tympani opening, many of these bones displayed varying degrees of intracochlear trauma that may result in hearing loss. When intracochlear drilling is avoided, the anterior bony margin of the cochleostomy remains a significant intracochlear impediment to in-line electrode insertion.     

Cochlear implant electrode insertion: the round window revisited

OBJECTIVE: To examine aspects of round window (RW) anatomy that are relevant to its use as a portal for atraumatic insertion of cochlear implant electrodes. STUDY DESIGN: Anatomic study using human cadaveric temporal bones. METHODS: A series of 30 temporal bones was dissected to permit microscopic study of the RW region. RESULTS: The bony overhangs of the RW niche limit visibility of the RW membrane during surgery. Measurements of RW membrane area visible through a facial recess opening before and after drilling the overhangs in 15 temporal bones showed that RW membrane visibility is typically increased by a factor of 1.5 to 3 times after drilling and by as much as 13 times when the opening of the RW niche is relatively small. Observations from within the scala tympani in 15 cochlear dissections showed substantial variability in size of the RW opening available for electrode insertion. Area measurements of the portion of the RW covered by the vertical segment of the RW membrane ranged from 0.8 to 1.75 mm2 in these specimens. In addition, irregularities in contour of the RW margin may make insertion challenging, which may necessitate drilling the anterior-inferior margin of the RW. Drilling in this region should be approached with care because of the close proximity of the cochlear aqueduct opening. CONCLUSION: RW insertion can be performed in a manner that is potentially less traumatic than the standard cochleostomy insertion. It may therefore be advantageous in cases in which hearing preservation is the goal.     

Cochlear implant electrode insertion: Jacobson’s nerve, a useful anatomical landmark

The classical technique in approaching the scala tympani through the round window niche by way of facial recess has not always been successful. There have been recent reports on false insertion of the electrode array into the hypotympanic cells tracts or infralabrynithine cells tracts. In these cases the round window niche are situated posterior, or obliterated due to bony growth, or sclerosed at the basal turn of the cochlea. Therefore, successful intubation of the scala tympani much depends upon the position of the round window niche and patency of the basal turn of the cochlea. The present study was conducted in an attempt to elucidate factors that determine the ease of insertion of an electrode array, and to by-pass the initial turn of the basal cochlea (hook area). The jacobson’s nerve (JN) landmark was used to perform cochleostomy by drilling anteriorly or through the nerve. The inferior segment position of the basal turn of the cochlea studied in relation to the JN and successful intubation of the scala tympani was achieved. Also, critical anatomical measurements were made pertaining to this surgical technique.     

Local pO2- and pH2-measurements with needle electrodes for the examination of the hydrogen maintenance and microcirculation of the cochleae (author's transl)]

The local partial pressure of oxygen (pO2) and the rate of hydrogen elimination were measured in the three scalae of the basal turn of 28 Guinea-pig cochleae under conditions of normoxia, hyperoxia and hypercapnia and with acoustical stimulation with the needle electrodes developed by Baumg?rtl and Lübbers. In the scala tympani a pO2 decrease from the round window toward Corti's organ was registered and pO2 values of over 100 mm Hg were measured near the membrane of the round window and of 10-40 mm Hg near the basilar membrane depending on how deeply the electrode penetrated into the scala tympani. The pO2 profiles were changed or reversed when the animal breathed a mixture of 95% oxygen and 5% carbon dioxide and when the round window membrane was covered with agar-agar or paraffine and exteriorly flooded with nitrogen. Acoustical stimulation with a white noise of 85 dB caused a considerable pO2 drop in the perilymph of the scala tympani while in the endolymph of the scala media we observe only a slight decrease. Intravenous application of dextran of low viscosity leads to a pO2 increase when the original oxygen value in the scala tympani was low. The half-life of hydrogen in the scala tympani amounts to about 4 min. The results permit the conclusion that, in the area of the cochlear basis, Corti's organ receives its oxygen supply via the capillary system as well as via the membrane of the round window.     

Cochlear hook anatomy: evaluation of the spatial relationship of the basal cochlear duct to middle ear landmarks

The cochlear hook is an important anatomical area for the otologist performing cochlear implants and other otological procedures, who requires knowledge of the basal cochlea. A total of 15 human temporal bones were dissected and the spatial relationship of the hook segment of the cochlear duct to the stapes, round window, cochleariform process and ductus reuniens were evaluated. Inter-individual variability was noted for widths of scala tympani (average width 1.36 +/- 0.25 mm) and scala vestibuli (average width 1.18 +/- 0.18 mm) in the region of typical cochlear implant placement, with the scala vestibuli occasionally being wider than the scala tympani. The cochlear duct was in closest proximity to the stapes at the midportion of the footplate, with an average distance of 1.23 mm at this narrowest width. A fibrous anchor, not previously described in otology literature, was identified securing the most basal end of the cochlear duct. Knowing the spatial relationship of the cochlear duct to the middle and inner ear structures could prevent damage to the basilar membrane in procedures around or involving the basal cochlear, such as cochlear implantation, stapedotomy, or implantable hearing devices.     

Current distributions in the cat cochlea: a modelling and electrophysiological study

The current distribution of bipolar electrodes implanted into the scala tympani of the cat cochlea was investigated using a two-electrode masking technique. Two electrode masking is a non-invasive technique which requires two electrically independent electrodes and relies upon the forward masking of the electrically evoked brainstem response to a probe stimulus by that of a preceding test stimulus. The technique was described in terms of a model, which enabled an approach for estimating the scala tympani length constant to be established. Model results have shown good agreement with electrophysiological results. Application of the model confirmed the scala tympani length constant within the basal turn of the cochlea to lie between 3 and 4 mm.     

Temporal bone investigations on landmarks for conventional or endosteal insertion of cochlear electrodes

CONCLUSION: Our anatomical findings place special emphasis on the requirement to follow an infero-anterior approach to the round window, to expose the scala tympani safely for 'normal' cochlear implantation. It is also known how easily the basilar membrane may be accidentally damaged, despite exercising considerable caution in the approach used. With regard to an 'endosteal electrode' it can be stated that there are no really specific indicators to locate the spiral ligament, or each of the scalae, on the lateral aspect of the tissue layer encasing the cochlea. For the concept of an endosteal electrode, however, the soft tissue layer of the lateral aspect of the cochlea is considered to be sufficiently thick to serve as a physical barrier between the electrode and the inner ear fluid. OBJECTIVES: To re-evaluate surgical techniques of gaining access to the scala tympani for cochlear implantation (cochleostomy, 'fenestration'). There are two reasons for this study. First, recent publications show that in a significant number of patients the electrode array was unintentionally inserted into the 'wrong' scala (sc. vestibuli). Second, dealing with an alternative concept proposed by Lehnhardt for patients with residual hearing ('endosteal electrode'), the anatomical site of the spiral ligament should be known. In a study on human temporal bones the topography of the middle and inner ear is revised with regard to the presence of anatomical or surgical landmarks that may guide the surgeon. MATERIALS AND METHODS: Anatomical examinations were performed on 10 temporal bones (5 fresh specimens and 5 fixed in formalin), in which the bone of the promontory was carefully milled. The consistency of identification and the relative location of specific surgical indicators or landmarks such as 'blue lines' and 'gray lines' were evaluated for 10 temporal bones. Furthermore, the projection of the lateral attachment of the basilar membrane on the promontory was determined with regard to round window anatomy. RESULTS: In all cases, a major blue line indicated the lateral aspect of the basal cochlear turn while milling the promontorial bone. In a limited number of cases (20%), an additional gray line potentially indicated the spiral ligament before the last shell of bone was removed. In 80% of the cases it was possible to remove the bony layer and leave the endosteum intact as a precondition for a potential endosteal electrode insertion. In addition, through the examination of these models, the relative anatomical location of structures, such as the scala vestibuli, scala tympani, spiral ligament, and basilar membrane, is reviewed.     

蜗内直流电对耳蜗基底膜振动的影响

目的探讨外加直流电流后对耳蜗基底膜振动的影响.方法在豚鼠耳蜗底回距圆窗龛缘2.4mm处开一直径约0.4mm小孔,作为测量活体基底膜的振动速度测试窗.在测试窗上、下缘的鼓阶、前庭阶各开一小孔,将铂-铱电极置入鼓阶、前庭阶作为跨蜗管的电刺激电极.用激光多普勒干涉测速仪观察直流电流对纯音诱发的基底膜振动速度的影响.结果当外加电流前庭阶极性为正,鼓阶极性为负时,可以看到基底膜振动速度显著增大,给相反极性电流时,基底膜振动速度减小.结论生理状态下的正内淋巴电位是耳蜗将声音能量转变为神经冲动的必要条件.适当提高外毛细胞顶端正电位,有助于提高耳蜗放大器的增益.外加负电位则严重影响耳蜗放大器的增益.     

Temporal bone characterization and cochlear implant feasibility in the common marmoset (Callithrix jacchus)

The marmoset (Callithrix jacchus) is a valuable non-human primate model for studying behavioral and neural mechanisms related to vocal communication. It is also well suited for investigating neural mechanisms related to cochlear implants. The purpose of this study was to characterize marmoset temporal bone anatomy and investigate the feasibility of implanting a multi-channel intracochlear electrode into the marmoset scala tympani. Micro computed tomography (microCT) was used to create high-resolution images of marmoset temporal bones. Cochlear fluid spaces, middle ear ossicles, semicircular canals and the surrounding temporal bone were reconstructed in three-dimensional space. Our results show that the marmoset cochlea is ～16.5?mm in length and has ～2.8 turns. The cross-sectional area of the scala tympani is greatest (～0.8?mm(2)) at ～1.75?mm from the base of the scala, reduces to ～0.4?mm(2) at 5?mm from the base, and decreases at a constant rate for the remaining length. Interestingly, this length-area profile, when scaled 2.5 times, is similar to the scala tympani of the human cochlea. Given these dimensions, a compatible multi-channel implant electrode was identified. In a cadaveric specimen, this electrode was inserted ? turn into the scala tympani through a cochleostomy at ～1?mm apical to the round window. The depth of the most apical electrode band was ～8?mm. Our study provides detailed structural anatomy data for the middle and inner ear of the marmoset, and suggests the potential of the marmoset as a new non-human primate model for cochlear implant research.     

Scala vestibuli cochlear implantation in patients with partially ossified cochleas

Partial cochlear obstruction is a relatively common finding in candidates for cochlear implants and frequently involves the inferior segment of the scala tympani in the basal turn of the cochlea. In such patients, the scala vestibuli is often patent and offers an alternative site for implantation. The current report describes two patients with such partial obstruction of the inferior segment of the basal cochlear turn, caused in one case by systemic vasculitis (Takayasu's disease) and in the other by obliterative otosclerosis. A scala vestibuli implantation allowed for complete insertion of the electrode array. No problems were encountered during the surgical procedures and the good post-operative hearing and communicative outcomes achieved were similar to those reported in patients without cochlear ossification. The importance of accurate pre-operative radiological study of the inner ear is underscored, to disclose the presence and define the features of the cochlear ossification and ultimately to properly plan the surgical approach.     

The inferior cochlear vein: surgical aspects in cochlear implantation

The patency of the inferior cochlear vein (ICV) may be challenged in cochlear implantation (CI) due to its location near the round window (RW). This may be essential to consider during selection of different trajectories for electrode insertion aiming at preserving residual hearing. Venous blood from the human cochlea is drained through the ICV. The vein also drains blood from the modiolus containing the spiral ganglion neurons. Surgical interference with this vein could cause neural damage influencing CI outcome. We analyzed the topographical relationship between the RW and ICV bony channel and cochlear aqueduct (CA) from a surgical standpoint. Archival human temporal bones were further microdissected to visualize the CA and its accessory canals (AC1 and AC2). This was combined with examinations of plastic and silicone molds of the human labyrinth. Metric analyses were made using photo stereomicroscopy documenting the proximal portion of the AC1, the internal aperture of the CA and the RW. The mean distance between the AC1 and the anterior rim of the RW was 0.81 mm in bone specimens and 0.67 mm assessed in corrosion casts. The AC1 runs from the floor of the scala tympani through the otic capsule passing parallel to the CA to the posterior cranial fossa. The mean distance between the CA and AC1 canal was 0.31 and 0.25 mm, respectively.     

Anatomy of the middle-turn cochleostomy

Objective: Middle‐turn cochleostomies are occasionally used for cochlear implant electrode placement in patients with labyrinthitis ossificans. This study evaluates the anatomic characteristics of the middle‐turn cochleostomy and its suitability for placement of implant electrodes. Methods: Ten cadaveric human temporal bones were dissected using a facial recess approach. A middle‐turn cochleostomy was drilled 2 mm anterior to the oval window and just inferior to the cochleariform process. The preparations were then stained with osmium tetroxide and microdissections were performed. The location of the cochleostomy on the cochlear spiral and its path through the various cochlear compartments were evaluated in all 10 specimens. A Cochlear Corporation depth gauge was inserted in five of the specimens and insertion trauma, number of contact rings, and depth of insertion were recorded. Results: Eight of the 10 cochleostomies were placed at approximately 360° on the cochlear spiral, near the transition between the basal and middle turns. In one case, the cochleostomy was found to enter the cochlear apex and in another it entered scala vestibuli of the proximal basal turn. The cochleostomy entered scala media in six bones and scala vestibuli in four specimens. A depth gauge was inserted in five specimens. The number of contacts placed within the cochlear lumen ranged from four to nine. There was evidence of insertional trauma to the lateral wall of the cochlear duct, basilar membrane, and Reissner's membrane, but no evidence of fractures to the osseous spiral lamina or modiolus. Conclusion: This study demonstrates that electrodes inserted via a middle‐turn cochleostomy are likely to enter scala vestibuli and have access to the middle‐ and apical‐cochlear turns. It is also possible that the electrode could be directed into the descending portion of the basal turn depending on cochleostomy orientation. Middle‐turn cochleostomy seems to be a viable alternative for electrode placement when preservation of residual hearing is not a concern.     

蜗内直流电对耳蜗基底膜振动的影响

目的：探讨外加直流电流后对耳蜗基底膜振动的影响。方法：在豚鼠耳蜗底回距圆窗龛缘2．4mm处开一直径约0．4mm小孔，作为测量活体基底膜的振动速度测试窗，在测试窗上，下缘的鼓阶，前庭阶各开一小孔，将铂－铱电极置入鼓阶，前庭阶作为跨蜗管的电刺激电极，用激光多普勒干涉测速仪观察直流电流对纯音诱发的基底膜振动速度的影响。结果：当外加电流前庭阶极性为正，鼓阶极性为负时，可以看到基底膜振动速度显著增大，给相反极性电流时，基底膜振动速度减小。结论：生理状态下的正内淋巴电位是耳蜗将声音能量转变为神经冲动的必要条件，适当提高外毛细胞顶端正电位，有助于提高耳蜗放大器的增益，外加负电位则严重影响耳蜗放大器的增益。     

Electrical impedance measurements of cochlear structures using the four-electrode reflection-coefficient technique

In individuals with severe-to-profound hearing loss, cochlear implants (CIs) bypass normal inner ear function by applying electrical current directly into the cochlea, thereby stimulating surviving auditory nerve fibers. Although cochlear implants are able to restore some auditory sensation, they are far from providing normal hearing. It has been estimated that up to 75% of the current injected via a CI is shunted along scala tympani and is not available to stimulate auditory neurons. The path of the injected current and the consequent population of stimulated spiral ganglion cells are dependent upon the positions of the electrode contacts within the cochlea and the impedances of cochlear structures. However, characterization of the current path remains one of the most critical, yet least understood, aspects of cochlear implantation. In particular, the impedances of cochlear structures, including the modiolus, are either unknown or based upon estimates derived from circuit models. Impedance values for many cochlear structures have never been measured. By combining the hemicochlea preparation, a cochlea cut in half along its mid-modiolar plane, and the four-electrode reflection-coefficient technique, impedances can be measured for cochlear tissues in a cochlear cross section including the modiolus. Advantages and disadvantages of the method are discussed in detail and electrical impedance measurements obtained in the gerbil hemicochlea are presented. The resistivity values for the cochlear wall in Ωcm are, 528 (range: 432–708) for scala media 3rd turn, 502 (range: 421–616) for scala tympani 3rd turn and scala vestibuli 2nd turn, 627 (range: 531–759) for scala media 2nd turn, 434 (range: 353–555) for scala tympani 2nd turn and scala vestibuli basal turn, 434 (range: 373–514) for scala media basal turn, and 590 (range: 546–643) for scala tympani basal turn. The resistivity was 455 Ωcm (range: 426–487) for the modiolus.     

Electrically evoked otoacoustic emissions from apical and basal perilymphatic electrode positions in the guinea pig cochlea

Stimulation of the cochlea with sinusoidal current results in the production of an otoacoustic emission at the primary frequency of the stimulus current. In this study we test the hypothesis that the wide frequency response from round window (RW) stimulation is due to the involvement of a relatively large spatial segment of the organ of Corti. Tonotopically organized group delays would be evident from perilymphatic electrode locations that restrict the spatial extent of hair cell stimulation. Monopolar and bipolar-paired stimulus electrodes were placed in perilymphatic areas of the first or third cochlear turns and the electrically evoked otoacoustic emissions (EEOAE) produced by these electrodes were compared to that from the RW monopolar electrode in the anesthetized guinea pig. Current stimuli of 35 microA RMS were swept across the frequency range between 60 Hz and 100 kHz. The EEOAE was measured using a microphone coupled to the ear canal. It was found that the bandwidth of EEOAEs from RW stimulation extended to at least 40 kHz and was a relatively insensitive to electrode location on the RW. The group delay of the EEOAE from stimulation at the RW membrane (corrected to stapes motion) was about 53 micros. First and third turn stimulations from electrode placements in perilymph near the bony wall of cochlea yielded narrower band EEOAE magnitude spectra but which had the same short group delays as for RW stimulation. A confined current (from a bipolar electrode pair) applied close to the basilar membrane (BM) in the first turn produced the narrowest frequency-band magnitude emissions and a mean corrected group delay of 176 micros for a location approximately 3 mm from the high frequency end of the BM (corresponding to about the 18 kHz best frequency location). Bipolar electrodes in the third turn scala tympani produced low pass EEOAE magnitude functions with corrected group delays ranging between approximately 0.3 and 1 ms. The average phase slopes did not change with altered cochlear sensitivity and postmortem. These data indicate that the EEOAE from RW stimulation is the summed response from a wide-tonotopic distribution of outer hair cells. A preliminary model study indicates that short time delayed emissions are the result of a large spatial distribution of current applied to perilymphatic locations possibly giving rise to "wave-fixed" emissions.     

Direct Entry of Gadolinium into the Vestibule Following Intratympanic Applications in Guinea Pigs and the Influence of Cochlear Implantation

Although intratympanic (IT) administration of drugs has gained wide clinical acceptance, the distribution of drugs in the inner ear following IT administration is not well established. Gadolinium (Gd) has been previously used as a marker in conjunction with magnetic resonance imaging (MRI) to visualize distribution in inner ear fluids in a qualitative manner. In the present study, we applied gadolinium chelated with diethylenetriamine penta-acetic acid (Gd-DTPA) to the round window niche of 12 guinea pigs using Seprapack^TM (carboxlmethylcellulose-hyaluronic acid) pledgets which stabilized the fluid volume in the round window niche. Gd-DTPA distribution was monitored sequentially with time following application. Distribution in normal, unperforated ears was compared with ears that had undergone a cochleostomy in the basal turn of scala tympani and implantation with a silastic electrode. Results were quantified using image analysis software. In all animals, Gd-DTPA was seen in the lower basal scala tympani (ST), scala vestibuli (SV), and throughout the vestibule and semi-circular canals by 1 h after application. Although Gd-DTPA levels in ST were higher than those in the vestibule in a few ears, the majority showed higher Gd-DTPA levels in the vestibule than ST at both early and later time points. Quantitative computer simulations of the experiment, taking into account the larger volume of the vestibule compared to scala tympani, suggest most Gd-DTPA (up to 90%) entered the vestibule directly in the vicinity of the stapes rather than indirectly through the round window membrane and ST. Gd-DTPA levels were minimally affected by the implantation procedure after 1 h. Gd-DTPA levels in the basal turn of scala tympani were lower in implanted animals, but the difference compared to non-implanted ears did not reach statistical significance.