Download - Indicazioni all'impianto cocleare - parte 2
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Round window /Cochleostomy
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Device Positioningdevice away from
processor
receiver/stimulator oriented differently in infants
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Displacement Force CalculationA
P
L R
mg
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the bed the device tied in
Tie-down – Devices with and without a Pedestal
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Visualizing the Round Windowkey
to cochleostomy placement is finding landmarks every time
most important landmark is the round window
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Visualizing the Round Windowhand position differs
on the left side
care with stapes tendon
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Round Windowalways presentoverhangrelationship to oval
window is constant jugular bulbrolls away in
anomalies
round window
stapes tendon
jugular bulb
Common Cavity Right Ear
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Round Window
cochleostomydirectionentry into the
scala tympani
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Cochleostomy vs. Round Windowbone in round
window
steeper angle at first turn contact
hard to pack/seal right ear bone in hook region
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Cochleostomy vs. Round Windowbone in round
window
steeper angle at first turn contact
hard to pack/seal
right ear
coch
leos
tom
yroun
d w
indo
w
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Cochleostomy vs. Round Window bone in round window
steeper angle at first turn contact
hard to pack/seal
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Preparing the Cochleostomy anterior to the
round window
as inferior as possible
look often
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Cochleostomy with curved burs
Curved HS Neurotology Burs Coolant Wrap
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Opening the Cochlea pick used in “soft”
technique
hearing preservation
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Drilling the Cochleostomyright ear
target is scala tympani
enter cochlea expand in anterior
and inferior direction
slow speed drilling
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Drilling the Cochleostomy target is scala
tympani
right ear
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Drilling the Cochleostomy slow speed drilling
round off anterior and inferior edges (electrode is 0.8 mm)
flush out bone dust
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Ideal Cochlear Entry Point
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Photo courtesy CRC for Cochlear Implant and Hearing Aid Innovation, MELBOURNE
Access into Scala Tympani
scala tympani
scala vestibuli
modiolus
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SEXN° AGE RANGE TYPE I.C.
148m 156f312 11m. - 16aa
Cochlear
Med- El
AB
MXM
CASISTICA CLINICAmarzo 2003 – dicembre 2011
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Abnormal Cochleae
25% of anomalous cochleae have technical challenges at ORgushersanomalous VII n. anatomyproblematic exposure
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Perilymph Gushers enlarged vestibular
aqueduct (VAE)
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Perilymph Gushers enlarged vestibular
aqueduct (VAE)
common cavity deformity
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Perilymph Gushers enlarged vestibular
aqueduct (VAE)
common cavity deformity
incomplete partition (IP-1)
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Facial Nerve Anomalies common (14%) and
associated with: CC and HC anomalous stapes nerve can split proximally
facial nerve monitor essential
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Problematic Anatomy
anteriorly displaced CN VII
prominent sinus pericrani
hypoplastic cochlea
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Re-implantation device failure device infection
(leave array in cochlea if possible)
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Re-implantation tips
be prepared to drill around cochleostomy
insert new array immediately old array removed
straight array narrower but more flexible
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Choice of electrode array
Options
Pre-curved
Straight
Short
Long
Double or split
Indications
general use, atraumatic AOS insertion
incomplete partition
hearing preservation
apical stimulation
ossified cochleae
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Conclusion
keys to success are:appropriate selection of the patientfixation of the receiver stimulatoridentification of landmarks for round
window/cochleostomycare with abnormal cochleaeappropriate selection of the electrode
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CI is generally possible in cases with inner ear
malformations
Variable results (neural function) generally
satisfactory results
Surgical issues
Programming difficulties / facial nerve electrical
stimulation
Higher risk of post-op. meningitis
CONCLUSIONS 2
• surgical access
• CSF gusher (difficult to radiologically predict)• type of array • array placement misplacement in the IAC (++IP I, IP III, CC, CH)
Fenestral CSF fistula (++)CSF fistula at cochleostomy site (--)
Facial nerve anomaliesCochlear anomalies
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Cochlear nerve aplasia-hypoplasia is not uncommon(unilateral ++)
Cochlear nerve aplasia associated to a normal labirynth is possible
A severely narrowed IAC (2 mm) indicates a severe hypoplasia of the
cochleo-vestibular nerve, but not a sure absence of the cochlear
nerve (if the cochlear duct is present and the labirynth is
malformed, the possibility of a functioning cochlear nerve is higher)
A normal IAC does not garantee the presence of a normal cochleo-
vestibular nerve (unilateral cases, parasagittal reconstructions)
The outcome after CI in pts with aplasia-hypoplasia of the cochlear
n. are generally scarce
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Thank You !!!
Azienda Ospedaliera di Rilievo Nazionale
Santobono – Pausilipon NAPOLI