Biofilm prevention on cochlear implants.

OBJECTIVES: To examine the efficiency of a bacteria-resistant coating for the polydimethylsiloxane (PDMS) casing of cochlear implants. METHODS: The coatings are based on thin titania films that are made by liquid phase deposition or atomic layer deposition. The antibacterial activity of the coating was tested by two different detection assays: BCA protein and confocal microscopy. RESULTS: Coating the PDMS with thin films (10-40 nm) of titania significantly reduces the accumulation of bacteria. DISCUSSION: Thin oxide films made under conditions that do not undermine the integrity of polymeric materials can be used as anti-microbial coatings for soft polymers such as the PDMS that is used as a casing for cochlear implants or other medical devices.

[Mastoidectomy with reconstruction of the posterior canal wall and obliteration preventing postoperative morbidity].

INTRODUCTION: A cholesteatoma in the mastoid or in the middle ear presents a hazard to the well-being of patients. Commonly used surgical interventions are not an ideal solution as they bear with them postoperative morbidity such as the need for water precautions, a high rate of cholesteatoma recurrence and the inability to undergo hearing rehabilitation. METHODS: Forty-five patients underwent an innovative surgical procedure that enables complete removal of the cholesteatoma, preservation of ear anatomy and hearing restoration. Our series was divided into two groups. The first group comprised those in whom this innovative procedure was the first one and the posterior bony canal was preserved (primary surgery). The second group comprised those in whom the bony wall had been removed previously during surgery (secondary surgery). RESULTS: In the first group, which included 29 patients, the middle ear cavity was found to be aerated in 69% of the patients, the tympanic membrane was intact in 93% and the rate of cholesteatoma recurrence was 10.3%. In the second group, which included 16 patients, the middle ear cavity was found to be aerated in 56.2% of cases, the tympanic membrane was intact in 75% and the rate of cholesteatoma recurrence was 25%. DISCUSSION: Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO) was found to be an effective approach for completely removing a choLesteatoma and preventing cholesteatoma recurrence. It is water-safe and provides an excellent basis for hearing restoration. The use of the original posterior bony canal for middle ear reconstruction was found to be beneficial. The authors advise an MRI study 18 months after surgery for cholesteatoma detection.

Multicentre investigation on electrically evoked compound action potential and stapedius reflex: how do these objective measures relate to implant programming parameters?

OBJECTIVES: The aims of this study were to collect data on electrically evoked compound action potential (eCAP) and electrically evoked stapedius reflex thresholds (eSRT) in HiResolution(TM) cochlear implant (CI) users, and to explore the relationships between these objective measures and behavioural measures of comfort levels (M-levels). METHODS: A prospective study on newly implanted subjects was designed. The eCAP was measured intra-operatively and at first fitting through neural response imaging (NRI), using the SoundWave(TM) fitting software. The eSRT was measured intra-operatively by visual monitoring of the stapes, using both single-electrode stimulation and speech bursts (four electrodes stimulated at the same time). Measures of M-levels were performed according to standard clinical practice and collected at first fitting, 3 and 6 months of CI use. RESULTS: One hundred seventeen subjects from 14 centres, all implanted unilaterally with a HiResolution CII Bionic Ear(®) or HiRes 90K(®), were included in the study. Speech burst stimulation elicited a significantly higher eSRT success rate than single-electrode stimulation, 84 vs. 64% respectively. The NRI success rate was 81% intra-operatively, significantly increasing to 96% after 6 months. Fitting guidelines were defined on the basis of a single NRI measurement. Correlations, analysis of variance, and multiple regression analysis were applied to generate a predictive model for the M-levels. DISCUSSION: Useful insights were produced into the behaviour of objective measures according to time, electrode location, and fitting parameters. They may usefully assist in programming the CI when no reliable feedback is obtained through standard behavioural procedures.

Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO): preliminary results.

CONCLUSIONS: Our preliminary results indicate that mastoidectomy by reconstruction of the posterior wall and obliteration (MAPRO) avoided the disadvantages of a canal-wall-down mastoidectomy. MAPRO effectively prevented cholesteatoma recurrence, provided an excellent basis for hearing restoration, and was generally water-safe. OBJECTIVE: To evaluate the authors' experience with the MAPRO technique for eradication of cholesteatomas requiring canal-wall-down mastoidectomy. METHODS: The medical files of all the patients who underwent MAPRO for cholesteatoma between 2008 and 2011 at the Sheba Medical Center were retrospectively reviewed. RESULTS: This series included 49 patients (31 children and 18 adults). The index operation was the first procedure for 30 patients and repeat surgery for 19 patients. Eight patients underwent ossiculoplasty. The mean postoperative follow-up was 28 months. Water tolerance and absence of inflammation were achieved in 93.3% of the first-time group and in 73.7% of the repeat group. (Recurrent cholesteatoma was found on the postoperative non-echo planar base diffusion-weighted magnetic resonance imaging in six (12.2%) patients: three (10%) in the first-time group and three (15.8%) in the repeat group).

The insertion trajectory in cochlear implantation - comparison between two approaches.

CONCLUSION: The suprameatal approach (SMA) for cochlear implantation is a safe procedure and is at least comparable to the classic mastoidectomy-posterior tympanotomy approach (MPTA) regarding the possibility of reducing electrode insertion trauma. OBJECTIVES: To compare the trajectory in the SMA with insertion through cochleostomy, to the MPTA with round window insertion. METHODS: Nine temporal bones were implanted by both techniques, and the point of first contact of a precurved electrode was compared. RESULTS: With the SMA, in all bones, the point of first contact was the inferior wall of the scala tympani and insertion was into the scala tympani. In the MPTA, in five of the bones, the point of first contact was the modiolus, the osseous spiral lamina or the basilar membrane.

Telephone use among cochlear implanted children.

CONCLUSION: Telephone use among implanted children is significantly different from that of the normally hearing population of the same age. OBJECTIVE: To characterize the use of telephone in cochlear implanted children and compare it to that of age-matched normal-hearing children. METHODS: The study (n = 26) and control (n = 27) groups each consisted of children aged 5-17 years treated at a tertiary referral center. The study group included children who received a Med-El multichannel cochlear implant and had used it for at least 18 months. The control group comprised generally healthy children with normal hearing and no history of chronic ear disease or otologic surgery. The main outcome measures, evaluated through a questionnaire sent by mail, were comparison of telephone use and speech comprehension over the telephone between the study and control groups. RESULTS: The median age of the study and control groups was 9 and 7 years, respectively (p = 0.12). There was a significant difference between the two groups in the reported rate of telephone use (mean 128 and 244 min/week, respectively, p = 0.006) and speech comprehension of familiar persons and strangers, which was highly significant among teenagers. The reported sound quality was similar for the two groups.

Local tissue response to cochlear implant device housings.

OBJECTIVE: To determine whether cochlear device housing can be a source of local tissue response in human implant recipients. STUDY DESIGN: Prospective case series. METHODS: Connective tissue that covered and encapsulated cochlear implants was obtained during reimplantation procedure for electronic device failure and underwent histologic analysis. RESULTS: Fifteen devices were explanted in 10 male and 5 female subjects who had been between 15 months and 41 years of age (mean, 119.7 mo) at the time of the initial implantation. The interval between the initial and revision surgery ranged from 3 months to 11 years. Pseudocapsular formation with various degrees of chronic inflammatory reaction was present in all 15 specimens, and dystrophic microcalcifications were found in 3 of them. Foreign body birefringents were found in 9 of the 15 specimens, of which, 7 had a typical giant cell foreign body inflammatory reaction. The time between the initial and revision operations in these latter 7 patients ranged between 3 months and 8 years. All the specimens demonstrated similar histologic features in terms of pseudocapsular formation and microcalcifications, foreign body reaction, and birefringents independently of the manufacturer and type of device housing (silicone versus ceramic). CONCLUSION: Cochlear implants are artificial devices that can interact with the surrounding tissue in the recipient's skull. Even when the reaction to these foreign bodies is not clinically apparent, the implanted material is not absolutely innocent to the patients.

[Bilateral cochlear implantation].

Cochlear implant surgery became the standard of care in hearing rehabilitation of patients with severe to profound sensorineural hearing loss. This procedure may alter the lives of children and adults enabling them to integrate with the hearing population. In the past, implantation was performed only in one ear, despite the fact that binaural hearing is superior to unilateral, especially in noisy conditions. Cochlear implantation may be performed sequentially or simultaneously. The "sensitive period" of time between hearing loss and implantation and between the two implantations, when performed sequentially, significantly influences the results. Shorter time spans between implantations improve the hearing results after implantation. Hearing success after implantation is highly dependent on the rehabilitation process which includes mapping, implant adjustments and hearing training. Bilateral cochlear implantation in children is recommended as the proposed procedure in spite of the additional financial burden.

Parotid mass as presenting symptom of lymphoma.

BACKGROUND: Lymphomas arising from the parotid gland are an uncommon entity, said to account for only 0.6-5% of tumors or tumor-like lesions of the parotid, and are therefore commonly overlooked. This misdiagnosis often leads to unnecessary diagnostic procedures, delaying the initiation of proper treatment. OBJECTIVES: To examine the clinical, diagnostic, therapeutic and survival data of patients with this disease. METHODS: We retrospectively reviewed our experience with patients diagnosed and treated for parotid lymphoma in our medical center during the period 1998-2008. RESULTS: The 13 patients in the series were aged 42-83. Twelve had non-Hodgkin's lymphoma and 1 had Hodgkin's lymphoma. In eight, parotid mass was the first manifestation of the disease, while in five who were in clinical remission its reoccurrence was first manifested in the parotid gland. Mean survival was 6.3 years CONCLUSIONS: Since parotid lymphoma is uncommon, it is often overlooked in the differential diagnosis. Methods of diagnosing and treating parotid lymphoma are different from those of other parotid pathologies. A high index of suspicion is warranted in order to provide a quick and efficient diagnosis and treatment without subjecting the patient to unnecessary tests and procedures.

Integration of cochlear-implanted children into the general Israeli community.

BACKGROUND: Severe hearing impairment can have devastating effects on social integration and vocational opportunities. OBJECTIVES: To investigate how well--or poorly--individuals who underwent cochlear implantation as children integrated into the general Israeli hearing community. METHOD: We sent a questionnaire to the 30 subjects > or = 18 years old who underwent cochlear implants in our department from 1990 to 2004 when they were < 18 years of age and had used their device for at least 3 years before replying. RESULTS: Eighteen implant users responded (14 males), yielding a 60% response rate. Their mean age was 13.3 +/- 7.0 years (range 6-17) at implantation and 21.1 +/- 3.6 years (range 18-34) when they filled in the questionnaire. Five were attending rabbinical school (yeshiva students), four were in regular military service, five were university students (three also held jobs), two were attending high school, one was employed (and had a university degree), and one had left the yeshiva and was unemployed when he returned the questionnaire. Fourteen respondents use the oral communication mode for conversation and the other 4 use both oral and sign languages. Longer daily implant use was significantly associated with coping with the difficulties in the setting in which they were currently active, with a higher level of satisfaction with their current lifestyle and with recognition of the implant's contribution to this satisfaction (P = 0.037, P = 0.019 and P = 0.001, respectively). CONCLUSIONS: Advances in cochlear implant technologies enable profoundly deaf implanted children to integrate well into the Israeli hearing society, albeit with a large intersubject variability.

Cochlear implant recipients' hearing sensation as manifested by their maps during pregnancy and postpartum.

OBJECTIVE: To investigate possible changes in hearing sensation as manifested in the maps' psychoacoustic parameters, threshold (T), and most comfortable (C/M) levels among cochlear implant (CI) female recipients during pregnancy and after delivery. SETTING: University-affiliated tertiary referral center. DESIGN: : Retrospective study. METHOD: Two MedEl device and 3 Nucleus device users' medical records were reviewed for age at the time of implantation, cause of deafness, type of anesthesia used during delivery, and maps' parameters (T and C/M levels) during pregnancy and after childbirth. RESULTS: Two CI recipients underwent uncomplicated cesarean deliveries under spinal anesthesia, and 3 others had natural delivery without anesthesia. There were no changes in map values during pregnancy, delivery, and the postpartum period in 4 of 5 CI recipients. Only 1 CI recipient showed significant increase in T levels that was resolved after she completed breastfeeding 3 months postdelivery. CONCLUSION: The elevation in T levels might indicate that pregnancy and delivery can result in some temporary reversible changes in hearing sensation manifested by map levels of CI users.

Suprameatal approach for cochlear implantation in children: our experience with 320 cases.

OBJECTIVE: To summarize our experience with the 320 children who underwent cochlear implantation by the suprameatal approach (SMA). METHOD: The SMA involves entering the middle ear by retroauricular tympanotomy. After drilling of the cochleostomy and of the suprameatal tunnel, the electrode is passed through the suprameatal tunnel underneath to the chorda tympani and lateral to the incus into the cochleostomy. RESULTS: The following implant-related complications required explantation with subsequent reimplantation: foreign body reaction (0.6%), allergy to implant (0.3%), and protrusion of the positioner (0.3%). Post-traumatically displaced magnets were reinserted in 3 (0.9%) children. All the vestibular (5.3%) and wound (3.1%) problems were considered as being patient-related and resolved spontaneously or were managed conservatively. There were no surgery-related complications and no cases of mastoiditis developed among the children implanted with the SMA. CONCLUSIONS: The SMA enables a decreasing the rate of surgery-related complications and safe electrode insertion.

Cochlear implantation in elderly patients: surgical and audiological outcome.

BACKGROUND: Deteriorated hearing affects speech perception and speech production, and negatively impacts on social interaction, employment, income, and, as a result, the quality of life of the elderly population. Lack of satisfaction with conventional hearing aids motivated part of them to turn to more sophisticated cochlear device systems. OBJECTIVE: To investigate the outcome of cochlear implantation (CI) among elderly cochlear implant recipients. METHODS: The medical records of 20 postlingual patients aged >65 years at the time of CI, who were followed up for a period of at least 12 months were retrospectively reviewed for age at the time of CI, the cause and duration of deafness, hearing aid experience, comorbidities, complications of the procedure and audiological outcome. Pre- and post-CI speech perception performance was tested using a battery of speech perception tests. RESULTS: In addition to bilateral severe to profound hearing loss, all 20 patients had some comorbidities and 13 had more than 2 pathologies that are associated with hearing impairment. Major complications such as facial nerve paralysis and foreign body reaction were rare (n = 2). Minor complications such as disequilibrium (n = 5) and wound problems (n = 5) resolved spontaneously or were successfully managed conservatively. There were no complications associated with general anesthesia used during the CI procedure. Statistical analysis using the Wilcoxon Signed Rank Test showed significant differences (p < 0.01) between the pre- and postspeech perception categories. No significant correlations were found between the background data: unaided thresholds, aided thresholds, duration of profound deafness, duration of hearing aid use prior to CI, speech perception before CI and speech perception performance after CI using Pearson correlations. CONCLUSION: CI was found to be associated with significant hearing benefit in elderly candidates. However, every CI candidate must be informed about possible complications associated with the procedure, especially related to the vestibular system. At the same time, it should be made clear that life-threatening conditions are rare and that the surgery is usually safe.

Factors affecting choice of device by cochlear implant candidates.

OBJECTIVE: To investigate the ways the various cochlear devices are chosen by candidates/surrogates and analyze the factors that influenced their decisions. SETTING: University-affiliated tertiary referral center. METHOD: : A questionnaire that included general items and questions on device's aesthetics, technical considerations, and quality was sent to 429 patients who underwent cochlear implantation between June 1997 and December 2006 in our department. RESULTS: One hundred eighty-four questionnaires were returned, yielding a response rate of 42.9%. Some patients did not receive the questionnaires because of the postal address changes. In addition, recently implanted patients/their surrogates were more ready to answer on the questionnaire on decision-making process compared with those who received their devices before 2001. The Nucleus users were more influenced by the questions pertaining to the quality/reliability of the device than the aesthetic and technical aspects. The ABC users were more influenced by the aesthetic aspects, and the MED-EL users were generally influenced by all the groups of questions equally. Females used the Internet as the source of information on the devices significantly more than males, and their decisions were more influenced by their families than those of the males. In addition, the females were more influenced by the quality of a device's function compared with males. Pediatric candidates (aged 1-16 yr) were significantly more influenced by the experience of other implant users, the medical staff, and religious considerations than adults. Adults arrived at decisions more easily than children or their surrogates. The adults and older children were more influenced by the ease of the device's functioning compared with the young children. CONCLUSION: Choosing the type of cochlear implant device is a highly individualized process that depends on various personal, social and cultural factors, and factors linked directly to the device itself.

Ear trauma caused by a yucca plant leaf spine.

Three uncommon cases of ear trauma caused by a yucca plant leaf spine are presented. One patient presented with tympanic perforation and the second with mixed hearing loss after spontaneous closure. The third patient probably had a perilymphatic fistula with subsequent labyrinthitis and hearing loss. Although the yucca is a ubiquitous plant, to the best of our knowledge, such incidents have not been previously reported.

Self-reported listening habits and enjoyment of music among adult cochlear implant recipients.

OBJECTIVES: We sought to assess the associations between self-reported listening habits and enjoyment of music, and the following variables: age at implantation, gender, prelingual versus postlingual deafness, duration of deafness, duration of cochlear implant (CI) use, type of CI, speech coding strategy, and speech perception abilities. METHODS: A questionnaire on listening habits and enjoyment of music before the onset of deafness and after implantation was sent to 85 adult CI recipients who had been using the devices for at least 6 months. RESULTS: Of the 53 responders, 39 (73.6%) listened to music after implantation. Listening to music was not significantly related to age at implantation, gender, duration of deafness, duration of CI use, type of CI device, speech coding strategy, or open-set speech perception abilities. The 14 nonlisteners were postlingually deafened. The ratings of enjoyment were the same for 22.6% of patients, improved for 26.4%, and worse for 50.9%. Only 2 of 13 patients who played a musical instrument and 14 of 24 patients who sang before the onset of deafness resumed their musical activities. CONCLUSIONS: Despite the decline in listening habits and in the enjoyment of music after cochlear implantation, most patients do listen to music. The changes in listening habits and enjoyment were not related to the selected background variables.

MRI, not CT, to rule out recurrent cholesteatoma and avoid unnecessary second-look mastoidectomy.

BACKGROUND: Aural cholesteatoma is an epidermal cyst of the middle ear or mastoid that can be eradicated only by surgical resection. It is usually managed with radical or modified radical mastoidectomy. Clinical diagnosis of recurrent cholesteatoma in a closed postoperative cavity is difficult. Thus, the accepted protocol in most otologic centers for suspected recurrence consists of second-look procedures performed approximately 1 year after the initial surgery. Brain herniation into a post-mastoidectomy cavity is not rare and can be radiologically confused with cholesteatoma on the high resolution computed tomographic images of temporal bones that are carried out before second-look surgery. OBJECTIVES: To present our experience with meningoceles that were confused with recurrent disease in patients who had undergone primary mastoidectomy for cholesteatoma and to support the use of magnetic resonance imaging as more suitable than CT in postoperative follow-up protocols for cholesteatoma. METHODS: We conducted a retrospective chart review of four patients. RESULTS: Axial CT sections demonstrated a soft tissue mass in the middle ear and mastoid in all four patients. Coronal reconstructions of CT scans showed a tympanic tegmen defect in two patients. CT failed to exclude cholesteatoma in any patient. Each underwent a second-look mastoidectomy and the only finding at surgery was meningocele in all four patients. CONCLUSIONS: Echo-planar diffusion-weighted MRI can differentiate between brain tissue and cholesteatoma more accurately than CT. We recommend that otolaryngologists avoid unnecessary revision procedures by using the newest imaging modalities for more precise diagnosis of patients who had undergone mastoidectomy for cholesteatoma in the past.

Petromastoid canal and cochlear aqueduct in cochlear implant candidates.

OBJECTIVE: To present temporal bone fine channels in cochlear implantation candidates. METHODS: Review of the axial sections of 108 temporal bone CTs. In type I, the petromastoid canal (PMC) was invisible but appeared as channels in type II and type III, <0.5 and 0.5-1 mm wide, respectively, and in type IV was >1 mm wide. The cochlear aqueduct (CA) was visualized up to the vestibule in type 1, the medial two thirds in type 2, the external aperture and/or the medial third in type 3, and was undetectable in type 4. RESULTS: The PMC size and shape differed significantly between the young (aged <5 years) and older (aged 5-16 years) children and between the young children and adults. A wide PMC (>2 mm) was found in only children younger than 2 years. Children up to 2 years of age and those aged 2 to 5 years demonstrated similar findings. The CA types differed among the pediatric and adult CI candidates, with the main difference appearing after the age of 16 years. There was no correlation between CA and PMC types. CONCLUSIONS: It is likely that the age-related changes in CA and PMC are attributable to the developmental or age-related changes in skull base growth.

Surgical and medical complications in different cochlear implant devices.

CONCLUSION: There were no surgery-related complications among the patients in the current study. Positioner and removable magnets have been associated with postoperative problems, and the silicone devices were the only ones found by us to cause foreign body and allergic reactions. OBJECTIVES: To evaluate the complication rate in patients who were implanted with cochlear devices manufactured by different companies. PATIENTS AND METHODS: This retrospective study included all the patients who underwent cochlear implantation (138 Nucleus, 105 Med-El and 14 Clarion devices) via the suprameatal approach in our department during 2001-2007 and followed up for at least 18 months. Complications such as magnet displacement, foreign body reaction and protrusion of the positioner were considered as being implant-related. Allergy to implant, cholesteatoma, perforated tympanic membrane, intraoperative cerebrospinal fluid (CSF) leakage, wound breakdown, haematoma or seroma, and vestibular disturbances were considered to be patient-related. RESULTS: Vestibular and wound problems emerged as the most common complications, but there were no significant differences in their rate of occurrence among the various devices. Explantation of the device was required in one case of foreign body reaction, one case of allergy to implant and one case of extrusion of the positioner followed by device failure.

Cholesteatoma invasion into the internal auditory canal.

Cholesteatoma invasion into the internal auditory canal (IAC) is rare and usually results in irreversible, complete hearing loss and facial paralysis on the affected side. This retrospective study examines the clinical characteristics of seven patients with cholesteatoma invading the IAC, analyzes possible routes of the cholesteatoma's extension and describes the surgical approaches used and patient outcome. Extension to the IAC was via the supralabyrinthine route in most patients. A subtotal petrosectomy, a translabyrinthine approach or a middle cranial fossa approach combined with radical mastoidectomy were required for the complete removal of the cholesteatoma. All seven patients presented with some preoperative facial nerve palsy. The facial nerve was decompressed in four patients and facial nerve repair was performed in three others, two by hypoglossal-facial anastomosis and one by a greater auricular nerve interposition grafting. All patients ended up with total deafness in the operate ear. At 1 year following surgery, the facial nerve function was House-Brackmann grade III in six cases and grade II in one. In conclusion, cholesteatoma invading the IAC is a separate entity with characteristic clinical presentations, require a unique surgical approach, and result in significant morbidity, such as total deafness in the operated ear and impaired facial movement.