Cochlear Implantation in Advanced Otosclerosis: Pitfalls and Successes

Purpose of Review This review will highlight recent outcome-based evidence guiding decision making for cochlear implantation in advanced otosclerosis, related complications, and technical surgical considerations in otosclerosis and the obstructed cochlea. Recent Findings Cochlear implantation in advanced otosclerosis results in consistent, excellent auditory outcomes with improvement in both objective speech recognition scores and subjective quality of life measures. Facial nerve stimulation may occur at higher rates in otosclerosis cochlear implant recipients. Cochlear implantation in the setting of luminal obstruction in osteosclerotic patients may be managed with altered surgical technique to achieve successful auditory improvements. Pre-operative imaging with high resolution CT or MRI may help anticipate intraoperative challenges and post-operative complications in cochlear implantation. Summary Cochlear implantation is an established, successful treatment for profound hearing loss in advanced otosclerosis. Surgeon knowledge of outcomes, complications, and potential surgical challenges is important to appropriately counsel patients regarding auditory rehabilitation options in advanced otosclerosis.

Severe and persistent facial nerve stimulation after cochlear implantation in a patient with cochlear–facial dehiscence: a case report

Generally, cochlear implants (CIs) are effective in helping patients improve their hearing performance; however, some patients have poor hearing performance owing to facial nerve stimulation (FNS), which is often associated with cochlear anomalies. We report a case with a normal cochlea and severe and persistent FNS owing to cochlear–facial dehiscence (CFD) that affected the CI outcomes. Preoperatively, a careful review of the computed tomography images before CI surgery is necessary not only for patients with otosclerosis and inner ear malformations but also for patients with normal cochlear structures because facial nerve anomalies could be present.

Postoperative radiological assessment of the mastoid facial canal in cochlear implant patients in correlation with facial nerve stimulation

Objectives To correlate the radiological assessment of the mastoid facial canal in postoperative cochlear implant (CI) cone-beam CT (CBCT) and other possible contributing clinical or implant-related factors with postoperative facial nerve stimulation (FNS) occurrence. Methods Two experienced radiologists evaluated retrospectively 215 postoperative post-CI CBCT examinations. The mastoid facial canal diameter, wall thickness, distance between the electrode cable and mastoid facial canal, and facial-chorda tympani angle were assessed. Additionally, the intracochlear position and the insertion angle and depth of electrodes were evaluated. Clinical data were analyzed for postoperative FNS within 1.5-year follow-up, CI type, onset, and causes for hearing loss such as otosclerosis, meningitis, and history of previous ear surgeries. Postoperative FNS was correlated with the measurements and clinical data using logistic regression. Results Within the study population (mean age: 56 ± 18 years), ten patients presented with FNS. The correlations between FNS and facial canal diameter (p = 0.09), wall thickness (p = 0.27), distance to CI cable (p = 0.44), and angle with chorda tympani (p = 0.75) were statistically non-significant. There were statistical significances for previous history of meningitis/encephalitis (p = 0.001), extracochlear-electrode-contacts (p = 0.002), scala-vestibuli position (p = 0.02), younger patients’ age (p = 0.03), lateral-wall-electrode type (p = 0.04), and early/childhood onset hearing loss (p = 0.04). Histories of meningitis/encephalitis and extracochlear-electrode-contacts were included in the first two steps of the multivariate logistic regression. Conclusion The mastoid-facial canal radiological assessment and the positional relationship with the CI electrode provide no predictor of postoperative FNS. Histories of meningitis/encephalitis and extracochlear-electrode-contacts are important risk factors. Key Points • Post-operative radiological assessment of the mastoid facial canal and the positional relationship with the CI electrode provide no predictor of post-cochlear implant facial nerve stimulation. • Radiological detection of extracochlear electrode contacts and the previous clinical history of meningitis/encephalitis are two important risk factors for postoperative facial nerve stimulation in cochlear implant patients. • The presence of scala vestibuli electrode insertion as well as the lateral wall electrode type, the younger patient’s age, and early onset of SNHL can play important role in the prediction of post-cochlear implant facial nerve stimulation.

COMPARISON OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION AND NEUROMUSCULAR RE-EDUCATION WITH CONVENTIONAL TREATMENT AND HOME BASED EXERCISE PLAN ALONG WITH FACIAL NERVE STIMULATION FOR REDUCING FACIAL DISABILITY IN PATIENTS WITH BELL’S PALSY

The purpose of the present study was to compare the proprioceptive neuromuscular facilitation and neuromuscular re-education with conventional treatment and home based exercise plan along with facial nerve stimulation for reducing facial disability in patients with Bell’s Palsy. In the present study, purposively selected 20 patients (both male and female) with Bell’s palsy with age group 20-70 years were considered. Further, the patients were allocated equally into two treatment groups. In Group-A, patients were treated with Proprioceptive Neuromuscular Facilitation (PNF) and Neuromuscular Re-Education (NRE) along with interrupted galvanic stimulation, facial massage and home based exercises. In Group-B, patients received the treatment of interrupted galvanic stimulation and manual facial massage along with home based facial exercises program in front of mirror. The outcome measures included Facial Disability Index-Physical Function (FDI-PF), Facial Disability Index-Social Function (FDI-SF), Synkinesis Assessment Questionnaire (SAQ) and Sunnybrook Facial Grading Scale (SFGS). In results. it was found that in pre-intervention condition, no significant differences were noted in FDI-PF, FDI-SF, SAQ and SFGS between these two groups. However, significant differences (p<0.001) were observed in FDI-PF, FDI-SF and SFGS in post intervention condition between the patients treated in Group-A and Group-B. Statistically significant increase (p<0.001) was found in FDI-PF and SFGS and significant decrease (p<0.013-0.001) was found in FDI-SF and SAQ between pre- and post-intervention in Group-A. Statistically significant decrease (p<0.003-0.001) was found in FDI-PF, FDI-SF, SAQ and SFGS between pre- and post-intervention in patients treated in Group-B. From the findings of the study it could be concluded the treatment protocol comprised of PNF and NRE along with interrupted galvanic stimulation, facial massage and home based exercises was more effective than only interrupted galvanic stimulation, facial massage and home based exercises in improving facial symmetry and reducing facial disability in patients with Bell’s palsy. Keywords: Proprioceptive neuromuscular technique, Neuromuscular re-education technique, Interrupted galvanic stimulation, Facial massage, Home based exercises, Bell’s palsy, Facial disability, Synkinesis.

Hearing Preservation Surgery in the Sitting Position for Grade 3B Hannover Classification Vestibular Schwannoma: 3-Dimensional Operative Video

Surgical treatment of large vestibular schwannomas is challenging. Both facial and cochlear nerves should be preserved in patients who have no neurological deficit preoperatively. In this 3-dimensional video, we present a 35-yr-old patient who presented with documented increase in the size of a known vestibular schwannoma over the span of 3 yr. Surgery was favored among all treatment options due to his young age and the tumor size. Informed consent was obtained. Semisitting surgery allowed for bimanual microdissection of the tumor capsule from the surrounding arachnoid and cranial nerves with 2 micro dissectors. The precision of microdissection is enhanced in the sitting position. Facial nerve stimulation remained stable at 0.05 mA. The auditory evoked potential remained unchanged during the surgery. Complete resection of the tumor and preservation of facial and cochlear nerves was achieved. The patient had a stable hearing grade B and a normal facial nerve function at 3-mo follow-up.

Possibilities of triphasic stimulation in patients with cochlear implants

The rationale for the use of three-phase stimulation for programming the processor of the cochlear implantation system (CI) in patients with deafness is presented. To study the possibilities of using a new type of stimulation, we selected patients with deafness after cochlear implantation, in whom signs of facial nerve stimulation (FNS) were established in the postoperative period. All subjects were previously installed in the CI processor with individual listening maps based on traditional biphasic stimulation. The use of three-phase stimulation to prevent SOS phenomena is caused by the geometry of the electric current pulse, which allows to reduce the penetrating power of the charge in the tissues and eliminate the effect on the facial nerve, without resorting to reducing the levels of stimulation necessary to create a dynamic range of sound perception. Comparative data of the parameters and the results of audiological testing in 21 patients with symptoms of SLE with traditional (two-phase) and three-phase electrical impulses in the stimulation algorithm of the CI system are presented. The positive effect of three-phase stimulation has been established. The results of the study show a significant increase in sound perception indicators when switching to a three-phase stimulation algorithm.