Revision Cochlear Implantation With Device Manufacturer Conversion: Surgical Outcomes and Speech Perception Performance.

OBJECTIVE: Describe the clinical profile of revision cochlear implantation (RCI) cases involving device manufacturer conversion (RCImc+), compare them to cases without manufacturer conversion (RCImc-), and classify the reasons for manufacturer conversion (MC). STUDY DESIGN: Retrospective case review. SETTING: Tertiary academic center. METHODS: Data on demographics, RCI indications, medical background, surgical details, and the reasons for MC were collected for all RCIs from 1989 to 2020. Post-RCI speech perception performance was categorized as unchanged, improved, or declined, according to clinically based criteria. RESULTS: Of 185 RCIs, 39 (21%) involved MC, mostly in pediatric patients (67%). The leading RCImc+ indications were device-related (59%) and medical (31%) failures. Initial implant manufacturers were Advanced Bionics (49%), Cochlear (25.5%), or Medel (25.5%). Most MC reasons were patient-driven (64%) versus CI team recommendations (36%). The RCImc+ group demonstrated a 3-fold higher rate of medical indications than RCImc- (31% vs 11.5%, P = .007). The time interval from symptom onset to RCI was longer in RCImc+ (43 vs 20.3 months, P = .001), and the rate of multiple revisions in the same ear was higher (25.6% vs 8.2%, P = .009). Complete reinsertion rates were high in both RCImc+ and RCImc- (94.8% vs 94.5%, P = 1) without any complications. Speech perception improved or remained unchanged in most (84%) cases, with no significant difference between the groups (P = .183). CONCLUSION: This retrospective study showed that RCI involving MC is safe and beneficial. Although RCImc+ patients exhibited distinct clinical characteristics, MC did not impact surgical or speech perception outcomes. This provides evidence-based data to support informed decision-making by CI teams and patients.

A Five-Decade Text Mining Analysis of Cochlear Implant Research: Where We Started and Where We Are Heading.

Background and Objectives: Since its invention in the 1970s, the cochlear implant (CI) has been substantially developed. We aimed to assess the trends in the published literature to characterize CI. Materials and Methods: We queried PubMed for all CI-related entries published during 1970-2022. The following data were extracted: year of publication, publishing journal, title, keywords, and abstract text. Search terms belonged to the patient's age group, etiology for hearing loss, indications for CI, and surgical methodological advancement. Annual trends of publications were plotted. The slopes of publication trends were calculated by fitting regression lines to the yearly number of publications. Results: Overall, 19,428 CIs articles were identified. Pediatric-related CI was the most dominant sub-population among the age groups, with the highest rate and slope during the years (slope 5.2 ± 0.3, p < 0.001), while elderly-related CIs had significantly fewer publications. Entries concerning hearing preservation showed the sharpest rise among the methods, from no entries in 1980 to 46 entries in 2021 (slope 1.7 ± 0.2, p < 0.001). Entries concerning robotic surgery emerged in 2000, with a sharp increase in recent years (slope 0.5 ± 0.1, p < 0.001). Drug-eluting electrodes and CI under local-anesthesia have been reported only in the past five years, with a gradual rise. Conclusions: Publications regarding CI among pediatrics outnumbered all other indications, supporting the rising, pivotal role of CI in the rehabilitation of children with sensorineural hearing loss. Hearing-preservation publications have recently rapidly risen, identified as the primary trend of the current era, followed by a sharp rise of robotic surgery that is evolving and could define the next revolution.

[SLEEP HABIT MODIFICATION AS A POSSIBLE PREVENTION OF RECURRENT BENIGN PAROXYSMAL POSITIONAL VERTIGO].

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is effectively treated with a variety of repositioning maneuvers but one-third to one-half of patients experience recurrence, usually within 2 years after the first attack. OBJECTIVES: The aim of this study was to investigate possible prevention of recurrent BPPV by sleep habit modification. METHODS: Patients diagnosed with posterior semicircular canal BPPV (p-BPPV) were asked their preferred lying side during nocturnal sleep. Following Epley maneuver they were recommended to change their head lying side at least every 2 hours during nocturnal sleep and to come back in case of recurrence. RESULTS: A total of 266 patients were diagnosed with p-BPPV. The mean patient's age was 57 years (range 14-87 years). There were 167 patients with right p-BPPV and 99 patients with left p-BPPV; 134 (50%) patients habitually slept on the right side. Of those, 112 (84%) were diagnosed with right p-BPPV (P= 0.0006); 87 patients (33%) habitually slept on the left side; 56 of them (64%) were diagnosed with left p-BPPV (P <0.0001). Among the 45 patients (17%) who expressed no preference concerning their sleeping positions, the right versus left p-BPPV was nearly even. During the follow-up period (1-80 months, mean 41) 11 patients (4%) were diagnosed with recurrent p-BPPV. Of those, 9 had a recurrence in the same posterior semicircular canal and 2 in the contralateral one. All of them reported that they had not modified their sleep habits. CONCLUSIONS: The results of our study can shed some light on the etiology of BPPV and may be helpful in preventing recurrent BPPV by changing sleep-position habits.

Current demographic and auditory profiles of adult cochlear implant candidates and factors affecting uptake.

OBJECTIVES: Despite growth of CI and widening of implantation criteria, penetration rates remain low and the clinical profile of adult CI candidates has not substantially changed. This study evaluated the demographic and auditory profiles of current adult CI candidates and identified factors affecting CI uptake. DESIGN: Preoperative data from patients who underwent CI candidacy evaluation between 2016-2018 were retrospectively reviewed. Data included demographics, medical reports, audiological results, and reasons for not pursuing implantation. Comparisons between candidates who pursued implantation and those who did not were performed. STUDY SAMPLE: Ninety-five candidates (54 females), average age 52 years. RESULTS: Most candidates exhibited post-lingual bilateral hearing loss with mean unaided PTA4 of 105dBHL and monosyllabic word score of 26%. Forty-nine candidates were implanted, and the main reason for not pursuing CI was candidates' reluctance. Candidates that pursued CI were mostly younger females with poorer unaided PTA4. Age was the only significant predictor of CI uptake. CONCLUSIONS: While current candidates demonstrated greater demographic diversity and better speech perception compared to previous findings, unaided thresholds are still within the profound range. Our findings indicate that eligible candidates face barriers to the utilisation of CI, some of which are modifiable by means of updated candidacy protocols.

Rates, Indications, and Speech Perception Outcomes of Revision Cochlear Implantations.

Revision cochlear implant (RCI) is a growing burden on cochlear implant programs. While reports on RCI rate are frequent, outcome measures are limited. The objectives of the current study were to: (1) evaluate RCI rate, (2) classify indications, (3) delineate the pre-RCI clinical course, and (4) measure surgical and speech perception outcomes, in a large cohort of patients implanted in a tertiary referral center between 1989-2018. Retrospective data review was performed and included patient demographics, medical records, and audiologic outcomes. Results indicated that RCI rate was 11.7% (172/1465), with a trend of increased RCI load over the years. The main indications for RCI were device-related failures (soft-45.4%, hard-23.8%), medical failure (14%), trauma (8.1%), and surgical failure (6.4%). Success rate was 98.8%. Children comprised 78% (134) of the cohort and were more likely than adults to undergo RCI. Most (70%) of the RCIs were performed within 10 years from primary implantation. Speech perception outcome analysis revealed unchanged or improved performance in 85% of the cases and declined performance in 15%. Current findings confirm that RCI is a safe with high clinical efficacy; however, the non-negligible percentage of patients that exhibited declined performance post-RCI should be considered in decision-making processes regarding RCI. Routine follow-up during their first years post-implantation is warranted.

Trans-canal endoscopic ear surgery and canal wall-up tympano-mastoidectomy for pediatric middle ear cholesteatoma.

PURPOSE: To evaluate clinical parameters, outcomes and complications of transcanal endoscopic ear surgeries (EES) and canal wall-up tympano-mastoidectomy (CWU) for middle ear cholesteatoma in children and to compare between the two surgical approaches. METHODS: A retrospective chart review of all children (< 16 years) who underwent surgery for cholesteatoma involving the middle ear only with a minimal follow-up period of 12 months. Demographic features, site and extent of disease, outcome and complications were reviewed and compared between the groups. RESULTS: Thirty EES and 19 CWU were included. The overall disease relapse rates in the EES and CWU groups were 20% (n = 6, residual rate = 10%, recurrence rate = 10%) and 47% (n = 9, residual rate = 11%, recurrence rate = 37%), respectively (p = 0.04), with mean duration of follow-up of 32.6 and 37.2 months, respectively. In the EES and CWU groups, the most common site of residual disease was the mastoid cavity/antrum (n = 2, 66% and n = 2, 100%, respectively). Most recurrences involved the epitympanum and extended into the tympanic cavity (n = 2, 66%) in the EES group and into the tympanic cavity, posterior mesotympanum and mastoid cavity/antrum (n = 3, 43%, each) in the CWU group. The overall complication rates in the EES and CWU groups were 10% (n = 3) and 11% (n = 2), respectively (p = 0.61). CONCLUSIONS: Endoscopic ear surgeries in children were found to be an acceptable and safe technique for the treatment of cholesteatoma limited to the middle ear cavity. A better overall success rate and a similar complication rate were found in the EES group when compared to CWU.

Traumatic Perforation of the Tympanic Membrane: A Review of 80 Cases.

BACKGROUND: Traumatic perforation of the tympanic membrane (TPTM) is often encountered in primary care or in the emergency department (ED). Several therapeutic interventions have been described, but conservative follow-up until spontaneous complete recovery is the most common choice. OBJECTIVE: Our goal was to analyze the trauma mechanism, perforation characteristics, and outcome of patients with TPTM. METHODS: The study included patients examined in the ED of a tertiary, university-affiliated medical center because of TPTM between 2012 and 2016. Their medical records were retrospectively reviewed for demographics, trauma mechanism, clinical characteristics, and outcome. A phone survey was performed to obtain the missing information of all the patients who did not continue their follow-up in our outpatient clinic. RESULTS: We reviewed the histories of 80 patients with a mean age of 26.7 ± 14.6 years (20 children; 25%). TPTM was caused by blunt trauma in 45 patients (56%) and penetrating trauma in 35 patients (44%). Thirty-five patients (44%) completed their follow-up in the hospital outpatient clinic, with a mean duration of 6.2 weeks. Twenty-five patients (38%) completed their follow-up in a community-based otolaryngology clinic, 6 patients (9%) chose not to complete their follow-up, and 14 patients were lost to follow-up. Of the 60 patients who completed follow-up, 56 patients recovered spontaneously, 3 patients underwent successful tympanoplasty, and 1 patient was referred to surgery but was lost to follow-up. All children healed spontaneously. CONCLUSION: TPTM was more common in young males with main mechanisms of blunt trauma (an assault) or cleaning the ear canal. All children demonstrated complete spontaneous recovery.

Transcanal Endoscopic Ear Surgery for Middle Ear Cholesteatoma.

OBJECTIVE: To evaluate the clinical parameters, outcomes, and complications of transcanal endoscopic ear surgeries for middle ear cholesteatoma. STUDY DESIGN: Retrospective study. SETTING: Tertiary university-affiliated medical center. PATIENTS: Adult patients (age >18) who underwent transcanal endoscopic ear surgeries for cholesteatoma, between March 2009 and March 2015. INTERVENTION: Transcanal endoscopic surgery was indicated when the cholesteatoma did not extend posterior to the anterior limb of the lateral semicircular canal. Rigid endoscopes 4 and 2.7 mm in diameter, 0, 30, 45, and 70 degrees were used with angled picks, suction, and forceps.Preoperative assessment included high-resolution computed tomography of the temporal bones and/or non echo-planar diffusion-weighted magnetic resonance imaging and pure-tone audiometry. MAIN OUTCOME MEASURES: Residual or recurrent disease was diagnosed by clinical examination and/or magnetic resonance imaging findings consistent with cholesteatoma. Intra- and postoperative complications, pre- and postoperative audiometric results were recorded. RESULTS: Sixty operations (56 patients, mean age = 43.6) were included.Six operations (10%) were performed under local anesthesia. The most common sites of cholesteatoma involvement were: posterior epitympanum (n = 51, 91%), anterior epitympanum (n = 19, 33.9%), posterior mesotympanum (n = 13, 23.2%), and sinus tympani (n = 11, 19.6%). Intraoperative ossicular chain reconstruction was performed in 18 (30%) cases.Our overall residual and recurrence rates were 10% (n = 6) and 8.3% (n = 5), respectively, with mean duration of follow up of 35 months. The most common sites of residual disease were the mastoid cavity/antrum (n = 3, 50%), tympanic cavity, and posterior mesotympanum. Overall minor and major complication rates were 16.6 and 6%, respectively. CONCLUSIONS: Transcanal endoscopic ear surgery was found to be an acceptable and safe technique for the exposure and eradication of middle ear and/or attic cholesteatoma.

Necrotizing otitis externa: diagnosis, treatment, and outcome in a case series.

We reviewed 25 cases of patients diagnosed with necrotizing otitis externa in our tertiary university-affiliated medical center between 2009 and 2015. Mean overall hospitalization duration was 14.52days, 95% of the patients showed specific seasonal incidence. Mean duration of symptoms prior to hospitalization was 6weeks and the duration correlated with outcome. Only 8% of the patients presented with cranial neuropathies; however, this presentation correlated with adverse outcome. Pseudomonas aeruginosa was the main causative organism (50%), with a 30% multidrug-resistance rate. A high rate (35%) of fungal pathogens was noted. Seventeen patients (68%) were eventually operated; however, only 5 patients needed extensive surgery under general anesthesia. Computed tomography (CT) evidence of adjacent structures' involvement correlated with adverse outcome. Eighty percent of our patients improved clinically. The overall death rate was 12% and the disease-related mortality rate was 8%. Our findings state the importance of limited surgical intervention and microbiologic cultures in disease treatment. This is particularly important in patients with cranial neuropathies and CT finding of adjacent structural involvement that correlate with adverse prognosis. A rising pseudomonal antibiotic resistance and fungal infections may challenge antibiotic treatment in the future.

Myringoplasty in children.

BACKGROUND: Tympanic membrane perforation (TMP) may be caused by acute and chronic otitis media, trauma and iatrogenic reasons. The goal of myringoplasty is to achieve a dry, self-cleansing ear with intact TM while preserving hearing. Literature review of myringoplasty outcome demonstrates results with different success rates and affecting factors. OBJECTIVES: The aim of this study was to evaluate TMP closure (TMPC) rate and hearing improvement and to assess the effect of clinical and surgical parameters on residual and recurrent perforation. MATERIALS AND METHODS: Retrospective chart analysis of pediatric patients who underwent myringoplasty between the years 2000-2015. Closure success rate and hearing improvement were evaluated. The influence of age and clinical and surgical variables over TMPC rate and recurrent perforation were examined. RESULTS: Our study cohort consisted of 165 myringoplasties in 151 children, with a mean age of 11.7 years (R = 4.8-17.9, Me = 12.0). At one month follow-up (FU) TMPC rate was 88% (145/165). Among patients with successful TMPC a mean improvement of air bone gap (ABG) and speech reception threshold (SRT) were 9.9 dB, p < 0.001 and 9.4 dB, p < 0.001, respectively. 58/145 (40%) patients with initial closure had a minimum FU of 6 months (Me = 12.0), during which time 8/58(13.8%) had a recurrent perforation. Surgery before 9 years of age was the only factor correlated with failed initial closure (p = 0.03) and recurrent perforation (p = 0.02). CONCLUSIONS: Pediatric myringoplasty is associated with high TMPC rate. Hearing improvement is to be expected in most hearing impaired patients. Age under 9 years is associated with significantly higher rates of persistent and recurrent perforation.

Pain in cochlear implant recipients: an uncommon, yet serious, consequence of cochlear implantation.

OBJECTIVES/HYPOTHESIS: We describe pain around the receiver/stimulator [RS] presenting months to years after implantation. STUDY DESIGN: A retrospective chart review. METHODS: We performed a retrospective review of all cochlear implant recipients complaining of pain around their RS through the years 2009 through 2013, with a follow-up of at least 6 months. Excluded from the study were patients with an identifiable cause for their pain such as trauma, local infection, or skin breakdown. The therapy regimen and outcomes were reviewed. RESULTS: Thirty patients complained of delayed pain over their RS, representing 2.8% of 1,044 implantations performed at the Sheba Medical Center, Tel Hashomer, Israel, as of 2013. The time from implantation to the presentation of pain ranged from 3 months to 12 years. The pain was perceptible even when the external magnet and processor were not used, and was usually most obvious in specific points around the RS. Seventy-seven percent of our patients responded well to conservative therapy. Fifteen (50%) responded to prolonged antibiotic treatment. Five patients (17%) responded to antiinflammatories alone. One patient (3%) responded to deactivation of two electrodes. Six patients (20%) required reimplantation, after which the pain resolved in all. At explantation, no signs of infection, foreign body reaction, or obvious device damage were found. CONCLUSION: Delayed pain around the RS that is unrelated to use is a serious consequence of cochlear implantation, and in some cases, those necessitating reimplantation, should be considered a major complication. LEVEL OF EVIDENCE: 4.

The feasibility of endoscopic transcanal approach for insertion of various cochlear electrodes: a pilot study.

To determine the feasibility of inserting various types of electrode arrays using an endoscopic transcanal approach into the cochlea via the round window membrane (RWM). All the procedures were performed by the first author and started with a cortical mastoidectomy. A six o'clock vertical incision was made in the meatal skin, and a posterior tympano-meatal flap was elevated transmeatally to expose the middle ear cavity using a rigid 0° endoscope (diameter 3 mm, length 14 cm). The chorda tympani nerve (CTN) and body of the incus were exposed. The RWM was incised, and the electrodes were passed through the tunnel from the mastoid to the epitympanum, medial to the CTN and lateral to the incus into the round window (RW) in seven procedures. In the other six cases, an open groove had been drilled, starting superiorly and laterally to the CTN and ending in the mastoid region. After electrodes insertion, the groove was filled with bone dust and covered with a large piece of fascia prior to repositioning of the tympano-meatal flap. Complete electrode insertion (7 Nucleus Contour Advance, 5 Concerto and 1 HiRes90K) via the RW was achieved in all 13 cases. Endoscopic CI was more feasible for insertion of concerto electrode followed by HiRes90K and Nucleus. An assistance of another surgeon was required for removal of stylet in the "off-the-stylet technique" utilized for implantation of nucleus electrode. Endoscopic transcanal implantation of different cochlear electrodes through the RW is feasible in both children and adults and can be used as first surgical option or as a complementary to the traditional posterior tympanotomy approach.

Evidence for a right cochlear implant advantage in simultaneous bilateral cochlear implantation.

OBJECTIVES/HYPOTHESIS: To compare speech perception performance with right versus left cochlear implants (CIs) in children with bilateral CIs implanted simultaneously. STUDY DESIGN: Prospective case series of patients undergoing simultaneous bilateral cochlear implantation. METHODS: Speech perception performance was tested in 10, right-handed children who received bilateral CIs simultaneously between 11 and 36 months (mean, 21 months), had at least 18 months of bilateral CI use, and were 5.3 years of age during testing. All children exhibited bilateral symmetrical severe-to-profound hearing loss prior to implantation and did not benefit from hearing aids. Speech perception performance was evaluated with the right CI and the left CI by means of an open-set monosyllabic word test in quiet presented at 45 dB HL in a sound field. RESULTS: All children exhibited higher performance with the right CI compared to the left CI. Group mean performance with the right CI was 66.5% compared to 52% with the left CI (P = .002), yielding a 14.5% difference. With increasing duration of bilateral CI use and age at evaluation, the right-left difference increased (r = 0.72, P = .019 and r = 0.74, P = .014, respectively). CONCLUSIONS: Current preliminary data indicate that children with bilateral CIs implanted simultaneously exhibit a significant right ear advantage for speech. Similarly to reports on normal-hearing children, right ear preference for speech increased with increasing age and auditory-linguistic experience. Thus, simultaneous bilateral cochlear implantation may lead to normal development of auditory pathways and may be an important contributor to the superior auditory, language, and communication skills reported in children with bilateral versus unilateral CIs.

Cytoplasmic mislocalization of POU3F4 due to novel mutations leads to deafness in humans and mice.

POU3F4 is a POU domain transcription factor that is required for hearing. In the ear, POU3F4 is essential for mesenchymal remodeling of the bony labyrinth and is the causative gene for DFNX2 human nonsyndromic deafness. Ear abnormalities underlie this form of deafness, characterized previously in multiple spontaneous, radiation-induced and transgenic mouse mutants. Here, we report three novel mutations in the POU3F4 gene that result in profound hearing loss in both humans and mice. A p.Gln79* mutation was identified in a child from an Israeli family, revealed by massively parallel sequencing (MPS). This strategy demonstrates the strength of MPS for diagnosis with only one affected individual. A second mutation, p.Ile285Argfs*43, was identified by Sanger sequencing. A p.Cys300* mutation was found in an ENU-induced mutant mouse, schwindel (sdl), by positional cloning. The mutation leads to a predicted truncated protein, similar to the human mutations, providing a relevant mouse model. The p.Ile285Argfs*43 and p.Cys300* mutations lead to a shift of Pou3f4 nuclear localization to the cytoplasm, demonstrated in cellular localization studies and in the inner ears of the mutant mice. The discovery of these mutations facilitates a deeper comprehension of the molecular basis of inner ear defects due to mutations in the POU3F4 transcription factor.

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.

The perceived angle of the round window affects electrode insertion trauma in round window insertion - an anatomical study.

CONCLUSION: In this study round window (RW) insertion of cochlear implant was performed with a lower degree of trauma in 86.6% of cases. Therefore RW insertion is a valid option to be considered in selected cochlear implant patients, especially when hearing preservation is a goal. In most cases drilling of the overhangs is required. OBJECTIVES: To systematically examine the potential for minimizing electrode insertion trauma with RW insertion. METHODS: Fifteen temporal bones were inserted with a 0.5 mm electrode analog in an anterior or antero-inferior vector from a reference point along the facial recess. Surface preparation of the inferior segment of the basal turn was performed and the point of first contact was analyzed using computerized morphometric software. The same software was used to measure the RW dimensions before and after drill down of the bony overhangs. An insertion was considered 'traumatic' if the point of first contact was the medial wall of the scala, whereas 'less traumatic' was an insertion in which the point of first contact was the inferior or posterior wall of the scala. RESULTS: Less traumatic insertion was achieved in 13 of the 15 bones, and in these the mean RW angle, as observed from a surgical point of view, was 137°. The mean RW angle in the traumatic insertion group was 147°. The difference was statistically significant.

The temporalis pocket technique for cochlear implantation: an anatomic and clinical study.

OBJECTIVE: To describe the surgical anatomy and clinical outcomes of a technique for securing cochlear implant receiver/stimulators (R/S). Receiver/stimulators are generally secured by drilling a custom-fit seat and suture-retaining holes in the skull. However, rare intracranial complications and R/S migration have been reported with this standard method. Newer R/S designs feature a low profile and larger, rigid flat bottoms in which drilling a seat may be less appropriate. We report a technique for securing the R/S without drilling bone. STUDY DESIGN: Anatomic: Forty-eight half-heads were studied. Digital photography and morphometric analysis demonstrated anatomic boundaries of the subpericranial pocket (t-pocket). Clinical: Retrospective series of 227 consecutive Cochlear implant recipients implanted during a 2-year period using either the t-pocket or standard technique. The main outcome measures were rates of R/S migration and intracranial complications. Minimum follow-up was 12 months. RESULTS: The t-pocket is limited anteriorly by dense condensations of pericranium anteriorly at the temporal-parietal suture, posteroinferiorly at the lamdoid suture, and anteroinferiorly by the bony ridge of the squamous suture. One hundred seventy-one subjects were implanted using the t-pocket technique and 56 using the standard technique, with a minimum follow-up of 12 months. There were no cases of migration or intracranial complications in either group. CONCLUSION: The t-pocket secures the R/S with anatomically consistent strong points of fixation while precluding dural complications. There were no cases of migration or intracranial complication noted. Further trials and device-specific training with this technique are necessary before it is widely adopted.

Tympanic membrane breakdown after intratympanic injection of steroids in irradiated ears.

OBJECTIVE: To describe a rare complication of intratympanic injection of steroids in susceptible ears. PATIENTS: We present two patients with a history of irradiation involving the injected ear. INTERVENTION: Therapeutic. MAIN OUTCOME MEASURE: Tympanic membrane condition after intratympanic injection of steroids. RESULTS: Total or near-total breakdown of the irradiated tympanic membrane. CONCLUSION: Tympanic membranes with an impaired wound-healing ability, together with exposure to intratympanic steroids, may be at risk for total or near-total breakdown.