Indicazioni all'impianto cocleare - parte 2


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XIII Congresso Nazionale AOICO - Cava de’Tirreni (SA)
Seconda parte della Relazione tenuta dal dott. Antonio Della Volpe sulla indicazione all'impianto cocleare.

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  • Certain advantages of some electrode designsWe use perimodiolar electrodes: patient benefit primarily longer battery lifeWe like advance off stylette re likelihood of less trauma within the cochlea.Our recent fellow Arie Gordon showed improved speech perception outcomes with more recent electrodes and insertion techniques, which we think may be due to reduction in traumaShort for electro-acoustic stimulationSoft surgery, concentrating on scala tympani insertion may contribute to preservation of residual hearing, and here role of short arrays expanding – perhaps soon in children – thought have to consider the implications of progressive hearing loss and the potential difficulty of replacing with a longer array in the futureDouble array for ossificationWe may see other array designs in near futureNot always clear if one design is any better than another, but some scenarios where particular design is advantageous
  • Indicazioni all'impianto cocleare - parte 2

    1. 1. Round window /Cochleostomy
    2. 2. Device Positioning device away from processor receiver/stimulator oriented differently in infants
    3. 3. Displacement Force Calculation AL R P mg
    4. 4. Tie-down – Devices with and withouta Pedestal the bed the device tied in
    5. 5. Visualizing the Round Window key  to cochleostomy placement is finding landmarks every time  most important landmark is the round window
    6. 6. Visualizing the Round Window hand position differs on the left side care with stapes tendon
    7. 7. Round Window always present round window overhang relationship to oval window is constant jugular bulb stapes tendon Cavity Common Right Ear rolls away in jugular bulb anomalies
    8. 8. Round Window cochleostomy  direction  entry into the scala tympani
    9. 9. Cochleostomy vs. Round Window bone in round window steeper angle at first turn contact hard to pack/seal right ear bone in hook region
    10. 10. Cochleostomy vs. Round Window bone in round right ear window steeper angle at first turn contact hard to pack/seal
    11. 11. Cochleostomy vs. Round Window bone in round window steeper angle at first turn contact hard to pack/seal
    12. 12. Preparing the Cochleostomy anterior to the round window as inferior as possible look often
    13. 13. Cochleostomy with curved burs Curved HS Neurotology Burs Coolant Wrap
    14. 14. Opening the Cochlea pick used in “soft” technique hearing preservation
    15. 15. Drilling the Cochleostomy right ear target is scala tympani enter cochlea expand in anterior and inferior direction slow speed drilling
    16. 16. Drilling the Cochleostomy right ear target is scala tympani
    17. 17. Drilling the Cochleostomy slow speed drilling round off anterior and inferior edges (electrode is 0.8 mm) flush out bone dust
    18. 18. Ideal Cochlear Entry Point
    19. 19. Access into Scala Tympani scala vestibuli modiolus scala tympani Photo courtesy CRC for Cochlear Implant and Hearing Aid Innovation, MELBOURNE
    20. 20. CASISTICA CLINICAmarzo 2003 – dicembre 2011N° SEX AGE RANGE TYPE I.C. Cochlear312 148m 156f 11m. - 16aa Med- El AB MXM
    21. 21. Abnormal Cochleae 25% of anomalous cochleae have technical challenges at OR  gushers  anomalous VII n. anatomy  problematic exposure
    22. 22. Perilymph Gushers enlarged vestibular aqueduct (VAE)
    23. 23. Perilymph Gushers enlarged vestibular aqueduct (VAE) common cavity deformity
    24. 24. Perilymph Gushers enlarged vestibular aqueduct (VAE) common cavity deformity incomplete partition (IP-1)
    25. 25. Facial Nerve Anomalies common (14%) and associated with:  CC and HC  anomalous stapes  nerve can split proximally facial nerve monitor essential
    26. 26. Problematic Anatomyhypoplastic cochleaanteriorly displaced CN VIIprominent sinus pericrani
    27. 27. Re-implantation device failure device infection  (leave array in cochlea if possible)
    28. 28. Re-implantation tips  be prepared to drill around cochleostomy  insert new array immediately old array removed  straight array narrower but more flexible
    29. 29. Choice of electrode array IndicationsOptions general use, atraumatic Pre-curved AOS insertion incomplete partition Straight hearing preservation Short apical stimulation Long ossified cochleae Double or split
    30. 30. Conclusion keys to success are:  appropriate selection of the patient  fixation of the receiver stimulator  identification of landmarks for round window/cochleostomy  care with abnormal cochleae  appropriate selection of the electrode
    31. 31. CONCLUSIONS 2 CI is generally possible in cases with inner ear malformations Variable results (neural function) generally satisfactory results Facial nerve anomalies Surgical issues •surgical access Cochlear anomalies •CSF gusher (difficult to radiologically predict) •type of array •array placement misplacement in the IAC (++IP I, IP III, CC, CH) Programming difficulties / facial nerve electrical stimulation Fenestral CSF fistula (++)Higher risk of post-op. meningitis CSF fistula at cochleostomy site (--)
    32. 32.  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-vestibularnerve, but not a sure absence of the cochlear nerve (if the cochlear duct is present and thelabirynth 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
    33. 33. Azienda Ospedaliera di Rilievo Nazionale Santobono – Pausilipon NAPOLI Thank You !!!