Does Intraoperative Extracochlear Electrocochleography Correlate With Postoperative Audiometric Hearing Thresholds in Cochlear Implant Surgery? A Retrospective Analysis of Cochlear Monitoring.

In recent years, tools for early detection of irreversible trauma to the basilar membrane during hearing preservation cochlear implant (CI) surgery were established in several clinics. A link with the degree of postoperative hearing preservation in patients was investigated, but patient populations were usually small. Therefore, this study's aim was to analyze data from intraoperative extracochlear electrocochleography (ECochG) recordings for a larger group.During hearing preservation CI surgery, extracochlear recordings were made before, during, and after CI electrode insertion using a cotton wick electrode placed at the promontory. Before and after insertion, amplitudes and stimulus response thresholds were recorded at 250, 500, and 1000 Hz. During insertion, response amplitudes were recorded at one frequency and one stimulus level. Data from 121 patient ears were analyzed.The key benefit of extracochlear recordings is that they can be performed before, during, and after CI electrode insertion. However, extracochlear ECochG threshold changes before and after CI insertion were relatively small and did not independently correlate well with hearing preservation, although at 250 Hz they added some significant information. Some tendencies-although no significant relationships-were detected between amplitude behavior and hearing preservation. Rising amplitudes seem favorable and falling amplitudes disadvantageous, but constant amplitudes do not appear to allow stringent predictions.Extracochlear ECochG measurements seem to only partially realize expected benefits. The questions now are: do gains justify the effort, and do other procedures or possible combinations lead to greater benefits for patients?

Intracochlear Recording of Electrocochleography During and After Cochlear Implant Insertion Dependent on the Location in the Cochlea.

To preserve residual hearing during cochlear implant (CI) surgery it is desirable to use intraoperative monitoring of inner ear function (cochlear monitoring). A promising method is electrocochleography (ECochG). Within this project the relations between intracochlear ECochG recordings, position of the recording contact in the cochlea with respect to anatomy and frequency and preservation of residual hearing were investigated. The aim was to better understand the changes in ECochG signals and whether these are due to the electrode position in the cochlea or to trauma generated during insertion. During and after insertion of hearing preservation electrodes, intraoperative ECochG recordings were performed using the CI electrode (MED-EL). During insertion, the recordings were performed at discrete insertion steps on electrode contact 1. After insertion as well as postoperatively the recordings were performed at different electrode contacts. The electrode location in the cochlea during insertion was estimated by mathematical models using preoperative clinical imaging, the postoperative location was measured using postoperative clinical imaging. The recordings were analyzed from six adult CI recipients. In the four patients with good residual hearing in the low frequencies the signal amplitude rose with largest amplitudes being recorded closest to the generators of the stimulation frequency, while in both cases with severe pantonal hearing losses the amplitude initially rose and then dropped. This might be due to various reasons as discussed in the following. Our results indicate that this approach can provide valuable information for the interpretation of intracochlearly recorded ECochG signals.

[The value of HRCT in predicting cerebrospinal fluid gusher during cochlear implantation].

Objective:To investigate the predictive value of temporal bone high-resolution CT（HRCT） multiplanar reconstruction（MPR） for cerebrospinal fluid（CSF） gusher during cochlear implantation in patients with inner ear malformation. Methods:The clinical data of 33 patients（36 ears） with inner ear malformation who underwent cochlear implantation were retrospectively analyzed. The predictive value of HRCT for cerebrospinal fluid gusher during cochlear implantation was evaluated. Results:The width of the cochlear foramen（P=0.024, OR=1.735） and the diameter of the inner auditory meatus（P=0.022, OR=6.119） were independent risk factors for CSF gusher during cochlear implantation. The area under the curve（AUC） of cochlear foramen width in predicting intraoperative gusher was 0.851, the sensitivity was 93.33%, and the specificity was 61.90%. The AUC of the upper and lower diameter of the internal auditory canal for predicting intraoperative gusher was 0.848, the sensitivity was 80.00%, and the specificity was 80.95%. The AUC of cochlear foramen width combined with the upper and lower diameters of the internal auditory meatus for predicting intraoperative gusher was 0.930, the sensitivity was 80.00%, and the specificity was 95.24%. Conclusion:Based on temporal bone HRCT, the prediction model of cochlear foramen width combined with the upper and lower diameter of the internal auditory canal has crucial predictive value for the "gusher" during cochlear implantation in patients with inner ear malformation.

Is the Position of the Basal-Most Electrode Depending on Electrode Array Design and Influencing Postoperative Speech Perception? A Retrospective Analysis of 495 Ears.

OBJECTIVE: The objective of this study is to examine the influence of electrode array design on the position of the basal-most electrode in cochlear implant (CI) surgery and therefore the stimulability of the basal cochlea. Specifically, we evaluated the angular insertion depth of the basal-most electrode in perimodiolar and straight electrode arrays in relation to postoperative speech perception. MATERIALS AND METHODS: We conducted a retrospective analysis of 495 patients between 2013 and 2018 using the Cochlear™ Contour Advance® (CA), Cochlear™ Slim Straight® (SSA), or Cochlear™ Slim Modiolar® (SMA) electrode arrays, as well as the MED-EL Flex24 (F24), MED-EL Flex28 (F28), and MED-EL FlexSoft (F31.5) electrode arrays. Cochlear size and the position of the basal-most electrode were measured using rotational tomography or cone beam computed tomography, and the results were compared with postoperative speech perception in monosyllables and numbers. RESULTS: The straight electrode arrays, specifically the F31.5 (31.5 mm length) and the F28 (28 mm length), exhibited a significantly greater angular insertion depth of the basal-most electrode. No significant correlation was found between cochlear morphology measurements and the position of the basal-most electrode artifact. Cochleostomy-inserted electrode arrays showed a significantly higher insertion depth of the basal-most electrode. Nevertheless, the position of the basal-most electrode did not have a significant impact on postoperative speech perception. CONCLUSION: Straight electrode arrays with longer lengths achieved deeper angular insertion depths of the basal-most electrode. Cochlear morphology does not have a substantial influence on the position of basal-most electrode. The study confirms that the basal area of the cochlea, responsible for high-frequency range during acoustic stimulation, is not the primary region for speech understanding via electrical stimulation with CI.

Towards inferring positioning of straight cochlear-implant electrode arrays during insertion using real-time impedance sensing.

BACKGROUND: Cochlear-implant electrode arrays (EAs) are currently inserted with limited feedback, and impedance sensing has recently shown promise for EA localisation. METHODS: We investigate the use of impedance sensing to infer the progression of an EA during insertion. RESULTS: We show that the access resistance component of bipolar impedance sensing can detect when a straight EA reaches key anatomical locations in a plastic cochlea and when each electrode contact enters/exits the cochlea. We also demonstrate that dual-sided electrode contacts can provide useful proximity information and show the real-time relationship between impedance and wall proximity in a cadaveric cochlea for the first time. CONCLUSION: The access resistance component of bipolar impedance sensing has high potential for estimating positioning information of EAs relative to anatomy during insertion. Main limitations of this work include using saline as a surrogate for human perilymph in ex vivo models and using only one type of EA.

Troubleshooting Cochlear Implant Malfunction Using Neural Response Telemetry and Normal Saline.

Cochlear implantation has become a standard of care for a child diagnosed with bilateral profound sensorineural hearing loss with a structured surgical standard operating procedure. A 3-year-old boy with bilateral profound prelingual sensorineural deafness underwent a Med-EL Sonata Ti100 implant. We faced a peculiar situation intraoperatively after inserting the electrodes and closing the wound. The impedance recording indicated high ground path impedance with short-circuiting of few electrodes. As a bionic implant, its electronic components may at times malfunction both intraoperatively and/or postoperatively; therefore, neural response telemetry (NRT) was invented to check it. By using NRT and a few milliliters of normal saline, we were able to diagnose as well as rectify the malfunctioning of the implant.

A scoping review on the clinical effectiveness of Trans-Impedance Matrix (TIM) measurements in detecting extracochlear electrodes and tip fold overs in Cochlear Ltd devices.

BACKGROUND: Extrusion of electrodes outside the cochlea and tip fold overs may lead to suboptimal outcomes in cochlear implant (CI) recipients. Intraoperative measures such as Trans-Impedance Matrix (TIM) measurements may enable clinicians to identify electrode malposition and direct surgeons to correctly place the electrode array during surgery. OBJECTIVES: To assess the current literature on the effectiveness of TIM measurements in identifying extracochlear electrodes and tip fold overs. METHODS: A scoping review of studies on TIM-based measurements were carried out using the Databases-Medline/PubMed, AMED, EMBASE, CINAHL and the Cochrane Library following PRISMA guidelines. Eleven full texts articles met the inclusion criteria. Only human studies pertaining to TIM as a tool used in CI were included in the review. Further, patient characteristics, electrode design, and TIM measurement outcomes were reported. RESULTS: TIM measurements were available for 550 implanted ears with the subjects age ranged between 9 months to 89 years. Abnormal TIM measurements were reported for 6.55% (36). Tip fold over was detected in 3.64% (20) of the cases, extracochlear electrodes in 1.45% (8), and 1.45% (8) were reported as buckling. Slim-modiolar electrode array designs were more common (54.71%) than pre-curved (23.34%) or lateral wall (21.95%) electrode array. Abnormal cochlear anatomy was reported for five ears (0.89%), with normal cochlear anatomy for all other patients. CONCLUSION: TIM measurement is a promising tool for the intraoperative detection of electrode malposition. TIM measurement has a potential to replace intraoperative imaging in future. Though, TIM measurement is in its early stages of clinical utility, intuitive normative data sets coupled with standardised criteria for detection of abnormal electrode positioning would enhance its sensitivity.

Four-Point Impedance: A Potential Biomarker for Residual Hearing After Cochlear Implantation.

INTRODUCTION: Preservation of residual hearing after cochlear implantation allows for electroacoustic stimulation, which leads to better music appreciation, noise localization, and speech comprehension in noisy environments. Real-time intraoperative electrocochleography (rt-ECochG) monitoring has shown promise in improving residual hearing rates. Four-point impedance (4PI) is being explored as a potential biomarker in cochlear implantation that has been associated with fibrotic tissue response, hearing loss, and dizziness. In this study, we explore whether monitoring both rt-ECochG intraoperatively and postoperative 4PI improves predictions of the preservation of residual hearing. METHODS: This was a prospective cohort study. Adults with residual acoustic hearing underwent cochlear implantation with intraoperative intracochlear electrocochleography (ECochG) monitoring. The surgeon responded to a drop in ECochG signal amplitude of greater than 30% by a standardized manipulation of the electrode with the aim of restoring the ECochG. At the end of the procedure, the ECochG signal was categorized as being maintained or having dropped more than 30%. 4PI was measured on 1 day, 1 week, and 1 and 3 months after cochlear implantation. Residual hearing was measured by routine pure-tone audiogram at 3 months postoperatively. The ECochG category and 4PI impedance values were entered as factors in a multiple linear regression predicting the protection of residual hearing. RESULTS: Twenty-six patients were recruited. Rt-ECochG significantly predicted residual hearing at 3 months (t test; mean difference, 37.7%; p = 0.002). Inclusion of both 1-day or 3-month 4PI in a multiple linear regression with rt-ECochG markedly improved upon correlations with residual hearing compared with the rt-ECochG-only model (rt-ECochG and 1-d 4PI model, R2 = 0.67; rt-ECochG and 3-mo 4PI model, R2 = 0.72; rt-ECochG-only model, R2 = 0.33). CONCLUSIONS: Both rt-ECochG and 4PI predict preservation of residual hearing after cochlear implantation. These findings suggest that the biological response of the cochlea to implantation, as reflected in 4PI, is an important determinant of residual hearing, independent of the acute effects on hearing during implant surgery seen with rt-ECochG. We speculate that 4PI relates to inflammation 1 day after implantation and fibrosis at 3 months.

Preoperative Imaging in Cochlear Implants.

OBJECTIVE: To determine the utility of computed tomography (CT) and magnetic resonance imaging (MRI) in cochlear implant candidates. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral hospital. PATIENTS: A total of 207 cochlear implanted patients with CT and/or MRI. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Age versus abnormal radiologic findings, imaging abnormality versus postoperative outcomes, postoperative outcomes versus electrode design, Cambridge Cochlear Implant Protocol (CCIP) status for imaging abnormalities, sensitivity and specificity of CT and MRI for round-window/cochlear occlusion, and MRI for incomplete partitions. RESULTS: A total of 207 patients with CT, MRI, or both were reviewed retrospectively. Less than half (15.5%) of CT scans had findings that might affect surgical intervention compared with 5.9% of MRI. No significant difference was found between children and adults for relevant imaging abnormalities (grade 4 or higher) with either CT (p = 0.931) or MRI (p = 0.606). CCIP status correlated with cochlear abnormalities (p = 0.040); however, only 46.2% of radiographic abnormalities on CT would be identified by these criteria. For detecting cochlear occlusion requiring surgical intervention, the sensitivity and specificity for CT were 40% (4 of 10; 95% confidence interval [CI], 12.16-73.76) and 95.73% (95% CI, 91.40-98.27), respectively. For MRI, the sensitivity and specificity were 33.33% (1 of 3; 95% CI, 0.84-90.57) and 96.97% (63 of 65; 95% CI, 89.32-99.63), respectively. There was no difference for postoperative AzBio scores for higher-grade imaging abnormalities (p = 0.6012) or for electrode designs (p = 0.3699). CONCLUSIONS: Significant radiographic abnormalities were relatively uncommon in cochlear implant patients on either CT or MRI at our single-center institution. If present, abnormal imaging findings rarely translated to management changes. CCIP status does not reliably predict which patients are likely to have abnormalities. Both MRI and CT have low sensitivity for round-window or cochlear occlusion, but detection likely leads to changes in surgical management.

Transimpedance Matrix Can Be Used to Estimate Electrode Positions Intraoperatively and to Monitor Their Positional Changes Postoperatively in Cochlear Implant Patients.

OBJECTIVE: Accurate positioning of the electrode array during cochlear implant (CI) surgery is crucial for achieving optimal hearing outcomes. Traditionally, postoperative radiological imaging has been used to assess electrode position. Transimpedance matrix (TIM) measurements have also emerged as a promising method for assessing electrode position. This involves utilizing electric field imaging to create an electric distance matrix by analyzing voltage variations among adjacent electrodes. This study aimed to investigate the feasibility of using intraoperative TIM measurements to estimate electrode position and monitor postoperative changes. STUDY DESIGN: Retrospective cohort study. SETTING: University Medical center, tertiary academic referral center. PATIENTS: Patients undergoing CI (CI622) surgery between January 2019 and June 2022. INTERVENTION: CI electrode positions and maximal angular insertion depths (maxAID) were determined using X-ray imaging according to Stenvers' projection. The mean gradient phase (MGP) was extracted from the TIM, and a correlation between the MGP and maxAID was examined. A model was then built to estimate the maxAID using the MGP, and changes in electrode location over time were assessed using this model. MAIN OUTCOME MEASURES: Twenty-four patients were included in this study. A positive correlation between the maxAID and the MGP ( R = 0.7, p = 0.0001) was found. The established model was able to predict the maxAID with an accuracy of 27.7 ± 4.4°. Comparing intraoperative and postoperative TIM measurements, a decrease of 24.1° ± 10.7° in maxAID over time was observed. CONCLUSION: TIM measurements are useful for estimating the insertion depth of the electrode and monitoring changes in the electrode's position over time.

Uncovering Vulnerable Phases in Cochlear Implant Electrode Array Insertion: Insights from an In Vitro Model.

OBJECTIVES: The aim of this study is to improve our understanding of the mechanics involved in the insertion of lateral wall cochlear implant electrode arrays. DESIGN: A series of 30 insertion experiments were conducted by three experienced surgeons. The experiments were carried out in a previously validated artificial temporal bone model according to established soft surgery guidelines. The use of an in vitro setup enabled us to comprehensively evaluate relevant parameters, such as insertion force, intracochlear pressure, and exact electrode array position in a controlled and repeatable environment. RESULTS: Our findings reveal that strong intracochlear pressure transients are more frequently caused during the second half of the insertion, and that regrasping the electrode array is a significant factor in this phenomenon. For choosing an optimal insertion speed, we show that it is crucial to balance slow movement to limit intracochlear stress with short duration to limit tremor-induced pressure spikes, challenging the common assumption that a slower insertion is inherently better. Furthermore, we found that intracochlear stress is affected by the order of execution of postinsertion steps, namely sealing the round window and posterior tympanotomy with autologous tissue and routing of the excess cable into the mastoid cavity. Finally, surgeons' subjective estimates of physical parameters such as speed, smoothness, and resistance did not correlate with objectively assessed measures, highlighting that a thorough understanding of intracochlear mechanics is essential for an atraumatic implantation. CONCLUSION: The results presented in this article allow us to formulate evidence-based surgical recommendations that may ultimately help to improve surgical outcome and hearing preservation in cochlear implant patients.

Evaluation of a Radiological Tool for Semiautomatic Scalar Translocation Detection After Cochlear Implantation.

OBJECTIVE: To evaluate the clinical applicability of a semiautomatic radiological tool for scalar translocation detection. STUDY DESIGN: Retrospective study. SETTING: Tertiary care academic center. PATIENTS: We included 104 patients implanted with 116 HiFocus Mid-Scala electrode arrays between January 2013 and September 2016. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: The tool's scalar position assessments were compared with manual ones by calculating intraclass coefficient (ICC) for individual contacts and sensitivity and specificity for translocation detection of the whole array. In addition, ICC was calculated for diameters A and B, ratio A/B, and angular insertion depth (AID). RESULTS: Nine-one percent of cases could be processed, which took 5 to 10 minutes per case. Comparison of manual and semiautomatic scalar position showed for individual contacts an ICC of 0.89 and for the whole array a sensitivity of 97% and a specificity of 96%. ICCs for A, B, and A/B were 0.82, 0.74, and 0.39 respectively. For AID, ICC of each of the 16 contacts was 0.95 or higher. CONCLUSIONS: The semiautomatic radiological tool could analyze most cases and showed good to excellent agreement with manual assessments for translocation detection, diameter A, diameter B, and AID. The variability between semiautomatic and manual measurements is comparable to interobserver variability, indicating that clinical implementation of the tool is feasible.

Correlation of Scalar Cochlear Volume and Hearing Preservation in Cochlear Implant Recipients with Residual Hearing.

OBJECTIVE: Preservation of residual hearing is one of the main goals in cochlear implantation. There are many factors that can influence hearing preservation after cochlear implantation. The purpose of the present study was to develop an algorithm for validated preoperative cochlear volume analysis and to elucidate the role of cochlear volume in preservation of residual hearing preservation after atraumatic cochlear implantation. STUDY DESIGN: Retrospective analysis. SETTING: Tertiary referral center. PATIENTS: A total of 166 cochlear implant recipients were analyzed. All patients were implanted with either a MED-EL (Innsbruck, Austria) FLEXSOFT (n = 3), FLEX28 (n = 72), FLEX26 (n = 1), FLEX24 (n = 41), FLEX20 (n = 38), or FLEX16 (n = 11, custom made device) electrode array through a round window approach. Main outcome measures: Cochlear volume as assessed after manual segmentation of cochlear cross-sections in cone beam computed tomography, and preservation of residual hearing 6 months after implantation were analyzed. The association between residual hearing preservation and cochlear volume was then assessed statistically. RESULTS: Rapid and valid cochlear volume analysis was possible using the individual cross-sections and a newly developed and validated algorithm. Cochlear volume had the tendency to be larger in patients with hearing preservation than in those with hearing loss. Significant correlations with hearing preservation could be observed for the basal width and length of the basal turn. CONCLUSIONS: Preservation of residual hearing after cochlear implantation may depend on cochlear volume but appears to be influenced more strongly by other cochlear dimensions.

Variability in Manual Segmentation of Temporal Bone Structures in Cone Beam CT Images.

PURPOSE: Manual segmentation of anatomical structures is the accepted "gold standard" for labeling structures in clinical images. However, the variability in manual segmentation of temporal bone structures in CBCT images of the temporal bone has not been systematically evaluated using multiple reviewers. Therefore, we evaluated the intravariability and intervariability of manual segmentation of inner ear structures in CBCT images of the temporal bone. METHODS: Preoperative CBCTs scans of the inner ear were obtained from 10 patients who had undergone cochlear implant surgery. The cochlea, facial nerve, chorda tympani, mid-modiolar (MM) axis, and round window (RW) were manually segmented by five reviewers in two separate sessions that were at least 1 month apart. Interreviewer and intrareviewer variabilities were assessed using the Dice coefficient (DICE), volume similarity, mean Hausdorff Distance metrics, and visual review. RESULTS: Manual segmentation of the cochlea was the most consistent within and across reviewers with a mean DICE of 0.91 (SD = 0.02) and 0.89 (SD = 0.01) respectively, followed by the facial nerve with a mean DICE of 0.83 (SD = 0.02) and 0.80 (SD = 0.03), respectively. The chorda tympani had the greatest amount of reviewer variability due to its thin size, and the location of the centroid of the RW and the MM axis were also quite variable between and within reviewers. CONCLUSIONS: We observed significant variability in manual segmentation of some of the temporal bone structures across reviewers. This variability needs to be considered when interpreting the results in studies using one manual reviewer.

The impact of the size and angle of the cochlear basal turn on translocation of a pre-curved mid-scala cochlear implant electrode.

Scalar translocation is a severe form of intra-cochlear trauma during cochlear implant (CI) electrode insertion. This study explored the hypothesis that the dimensions of the cochlear basal turn and orientation of its inferior segment relative to surgically relevant anatomical structures influence the scalar translocation rates of a pre-curved CI electrode. In a cohort of 40 patients implanted with the Advanced Bionics Mid-Scala electrode array, the scalar translocation group (40%) had a significantly smaller mean distance A of the cochlear basal turn (p < 0.001) and wider horizontal angle between the inferior segment of the cochlear basal turn and the mastoid facial nerve (p = 0.040). A logistic regression model incorporating distance A (p = 0.003) and horizontal facial nerve angle (p = 0.017) explained 44.0-59.9% of the variance in scalar translocation and correctly classified 82.5% of cases. Every 1mm decrease in distance A was associated with a 99.2% increase in odds of translocation [95% confidence interval 80.3%, 100%], whilst every 1-degree increase in the horizontal facial nerve angle was associated with an 18.1% increase in odds of translocation [95% CI 3.0%, 35.5%]. The study findings provide an evidence-based argument for the development of a navigation system for optimal angulation of electrode insertion during CI surgery to reduce intra-cochlear trauma.

Intracochlear Trauma and Local Ossification Patterns Differ Between Straight and Precurved Cochlear Implant Electrodes.

HYPOTHESIS: Trauma to the osseous spiral lamina (OSL) or spiral ligament (SL) during cochlear implant (CI) insertion segregates with electrode type and induces localized intracochlear ossification and fibrosis. BACKGROUND: The goal of atraumatic CI insertion is to preserve intracochlear structures, limit reactive intracochlear tissue formation, and preserve residual hearing. Previous qualitative studies hypothesized a localized effect of trauma on intracochlear tissue formation; however, quantitative studies failed to confirm this. METHODS: Insertional trauma beyond the immediate insertion site was histologically assessed in 21 human temporal bones with a CI. Three-dimensional reconstructions were generated and virtually resectioned perpendicular to the cochlear spiral at high resolution. The cochlear volume occupied by ossification or fibrosis was determined at the midpoint of the trauma and compared with regions proximal and distal to this point. RESULTS: Seven cases, all implanted with precurved electrodes, showed an OSL fracture beyond the immediate insertion site. Significantly more intracochlear ossification was observed at the midpoint of the OSL fracture, compared with the -26 to -18 degrees proximal and 28 to 56 degrees distal to the center. No such pattern was observed for fibrosis. In the 12 cases with a perforation of the SL (9 straight and 3 precurved electrodes), no localized pattern of ossification or fibrosis was observed around these perforations. CONCLUSION: OSL fractures were observed exclusively with precurved electrodes in this study and may serve as a nidus for localized intracochlear ossification. Perforation of the SL, in contrast, predominantly occurred with straight electrodes and was not associated with localized ossification.

Morphologic Analysis of the Scala Tympani Using Synchrotron: Implications for Cochlear Implantation.

OBJECTIVES: To use synchrotron radiation phase-contrast imaging (SR-PCI) to visualize and measure the morphology of the entire cochlear scala tympani (ST) and assess cochlear implant (CI) electrode trajectories. METHODS: SR-PCI images were used to obtain geometric measurements of the cochlear scalar diameter and area at 5-degree increments in 35 unimplanted and three implanted fixed human cadaveric cochleae. RESULTS: The cross-sectional diameter and area of the cochlea were found to decrease from the base to the apex. This study represents a wide variability in cochlear morphology and suggests that even in the smallest cochlea, the ST can accommodate a 0.4 mm diameter electrode up to 720°. Additionally, all lateral wall array trajectories were within the anatomically accommodating insertion zone. CONCLUSION: This is the first study to use SR-PCI to visualize and quantify the entire ST morphology, from the round window to the apical tip, and assess the post-operative trajectory of electrodes. These high-resolution anatomical measurements can be used to inform the angular insertion depth that can be accommodated in CI patients, accounting for anatomical variability. LEVEL OF EVIDENCE: N/A. Laryngoscope, 134:2889-2897, 2024.

Landmark-based registration of a cochlear model to a human cochlea using conventional CT scans.

Cochlear implants can provide an advanced treatment option to restore hearing. In standard pre-implant procedures, many factors are already considered, but it seems that not all underlying factors have been identified yet. One reason is the low quality of the conventional computed tomography images taken before implantation, making it difficult to assess these parameters. A novel method is presented that uses the Pietsch Model, a well-established model of the human cochlea, as well as landmark-based registration to address these challenges. Different landmark numbers and placements are investigated by visually comparing the mean error per landmark and the registrations' results. The landmarks on the first cochlear turn and the apex are difficult to discern on a low-resolution CT scan. It was possible to achieve a mean error markedly smaller than the image resolution while achieving a good visual fit on a cochlear segment and directly in the conventional computed tomography image. The employed cochlear model adjusts image resolution problems, while the effort of setting landmarks is markedly less than the segmentation of the whole cochlea. As a next step, the specific parameters of the patient could be extracted from the adapted model, which enables a more personalized implantation with a presumably better outcome.

Combining Intraoperative Electrocochleography with Robotics-Assisted Electrode Array Insertion.

OBJECTIVE: To describe the use of robotics-assisted electrode array (EA) insertion combined with intraoperative electrocochleography (ECochG) in hearing preservation cochlear implant surgery. STUDY DESIGN: Prospective, single-arm, open-label study. SETTING: All procedures and data collection were performed at a single tertiary referral center. PATIENTS: Twenty-one postlingually deaf adult subjects meeting Food and Drug Administration indication criteria for cochlear implantation with residual acoustic hearing defined as thresholds no worse than 65 dB at 125, 250, and 500 Hz. INTERVENTION: All patients underwent standard-of-care unilateral cochlear implant surgery using a single-use robotics-assisted EA insertion device and concurrent intraoperative ECochG. MAIN OUTCOME MEASURES: Postoperative pure-tone average over 125, 250, and 500 Hz measured at initial activation and subsequent intervals up to 1 year afterward. RESULTS: Twenty-two EAs were implanted with a single-use robotics-assisted insertion device and simultaneous intraoperative ECochG. Fine control over robotic insertion kinetics could be applied in response to changes in ECochG signal. Patients had stable pure-tone averages after activation with normal impedance and neural telemetry responses. CONCLUSIONS: Combining robotics-assisted EA insertion with intraoperative ECochG is a feasible technique when performing hearing preservation implant surgery. This combined approach may provide the surgeon a means to overcome the limitations of manual insertion and respond to cochlear feedback in real-time.

The Effect of Electrode Position on Behavioral and Electrophysiologic Measurements in Perimodiolar Cochlear Implants.

BACKGROUND: The shape and position of cochlear implant electrodes could potentially influence speech perception, as this determines the proximity of implant electrodes to the spiral ganglion. However, the literature to date reveals no consistent association between speech perception and either the proximity of electrode to the medial cochlear wall or the depth of insertion. These relationships were explored in a group of implant recipients receiving the same precurved electrode. METHODS: This was a retrospective study of adults who underwent cochlear implantation with Cochlear Ltd.'s Slim Perimodiolar electrode at the Royal Victorian Eye and Ear Hospital between 2015 and 2018 (n = 52). Postoperative images were obtained using cone beam computed tomography (CBCT) and analyzed by multi-planar reconstruction to identify the position of the electrode contacts within the cochlea, including estimates of the proximity of the electrodes to the medial cochlear wall or modiolus and the angular depth of insertion. Consonant-vowel-consonant (CVC) monosyllabic phonemes were determined preoperatively, and at 3 and 12 months postoperatively. Electrically evoked compound action potential (ECAP) thresholds and impedance were measured from the implant array immediately after implantation. The relationships between electrode position and speech perception, electrode impedance, and ECAP threshold were an analyzed by Pearson correlation. RESULTS: Age had a negative impact on speech perception at 3 months but not 12 months. None of the electrode-wide measures of proximity between electrode contacts and the modiolus, nor measures of proximity to the medial cochlear wall, nor the angular depth of insertion of the most apical electrode correlated with speech perception. However, there was a moderate correlation between speech perception and the position of the most basal electrode contacts; poorer speech perception was associated with a greater distance to the modiolus. ECAP thresholds were inversely related to the distance between electrode contacts and the modiolus, but there was no clear association between this distance and impedance. CONCLUSIONS: Speech perception was significantly affected by the proximity of the most basal electrodes to the modiolus, suggesting that positioning of these electrodes may be important for optimizing speech perception. ECAP thresholds might provide an indication of this proximity, allowing for its optimization during surgery.