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Case Studies
Bilateral Cochlear Implantation – A Treat For The Deaf Ears & Music To The Surgeon
A 2-year-old child hailing from Bangalore presented to Bangalore Hearing and Implant Institute with complaints of hearing loss detected at 1 year and 3 months of age.
The child was born out of a 2nd degree consanguinous marriage with no family history of hearing loss. Antenatal and postnatal history were normal. There was no history of exanthematous fever during pregnancy or in childhood.
The mother was vaccinated during pregnancy. The child was born by normal vaginal delivery at term and did not have any history of ICU admissions.
The child did not have any syndromic manifestations and had achieved all developmental milestones as per date and was also vaccinated till date. The child was able to speak monosyllable words.
Clinical examination revealed a bilateral normal tympanic membrane. There was no evidence of syndromic signs. Audiological investigation showed absence of bilateral wave 5 absent at 100dBHL on BERA and absent OAE.
CT and MRI showed an essentially normal hearing pathway. The child was counselled for bilateral cochlear implantation under general anaesthesia.
Bilateral cochlear implantation was carried out by posterior tympanotomy technique. Bilateral CI 632 implant inserted. NRT and impedences were noted to be good. Ground electrode placed in zygoma site. Electrode placement was verified with a C-arm.
C-arm confirmed the presence of electrode in normal position. Facial nerve monitor used during the procedure revealed normal facial nerves.
Cochlear Implantation Is A Challenge In An Anomalous Temporal Bone: Hearing Is The Reward For Mastering The Challenge.
A 3-year-old child from Singapore was presented with reduced response to sounds at 6 to 8 months of age. There was no history of trauma and fever. She was able to speak bi-syllables. She also had snoring and recurrent rhinitis.
The child was a known case of hypothyroidism on regular medications. The prenatal, intranatal and postnasal history was normal. Child also had a maternal family history of hypothyroidism for which she was taking medications until 6 months of age.
On examination, EAC and tympanic membranes were normal on both the sides.
Audiological investigations revealed a bilateral severe to profound hearing loss on ASSR, absent wave V on BERA, and absent DPOAE.
MRI revealed a hypoplastic right internal auditory canal with a cochlear aperture measuring 1.5 mm. There was cystic dilation of the cochlea with absent modiolus and interscalar septum. There was evidence of hypoplastic vestibular and semicircular canals. There was the prominence of the sigmoid sinus on the right side. The cochlear nerve was absent on the right side.
The left internal auditory canal was narrow with absent inner ear structures. Petrous bone was formed with a hypoplastic left otic capsule. The left internal acoustic meatus was hypoplastic and there was an absence of left vestibular and cochlear nerves. There was complete labyrinthine aplasia on the left side.
The child was counseled for cochlear implantation on the right side and underwent right subtotal petrosectomy with blind sac closure and right cochlear implantation under general anaesthesia.
The challenges faced during the surgery were:
(1) Anomalous middle fossa dura with probable encephalocele communicating into the confines of the glenoid fossa
(2) Anteriorly lying sigmoid sinus
(3) Anomalous location of the vertical segment of the facial nerve
(4) Acute Miks angle
(5) Rudimentary round window niche and
(6) CSF gusher.
The procedure was completed with good NRT and impedence measurements for all electrodes.The switch on of the implant was completed and the child is undergoing AVT and doing extremely well.
Cochlear Implant – A life Created For A Deaf-Mute Child
A 3-year-old child presented to Bangalore Hearing and Implant Institute with history of hearing loss detected at 2 years of age. The child was born out of a non consanguinous marriage with no family history of hearing loss. There was no history of syndromic manifestations. Antenatal and post natal history. The child was born by normal vaginal route at full term with no neonatal ICU admission. The child was vaccinated to date and had achieved developmental milestones as per age. The child was using hearing aids since 2 years of age and was able to speak a few words.
On clinical examination, tympanic membranes were normal. BERA showed an absent fifth peak. OAE was absent in both ears.
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MRI showed an intact VII-VIII nerve complex upto the brainstem with no other radiological anomalies. HRCT of the temporal bone showed a high jugular bulb on the right side.
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The child underwent bilateral cochlear implantation(Cochlear CI-632) under general anaesthesia. Lazy S incision given on both sides. Musculoperiosteal flaps were raised. Cortical mastoidectomy with facial recess approach was done on both sides after identification of facial nerve with a nerve stimulator. Operculum was cleared after identifying the round window niche. Extended round window was created. Steroid flush was given prior to cochleostomy. Receiver stimulator bed was created posterosuperior to the mastoidectomy cavity.
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After completion of the cochleostomy, CI 632 Implant was inserted. A steroid flush was given around the cochleostomy site. The periosteum was used to secure the electrodes. NRT and impedences were excellent intraoperatively. A ground electrode placed in zygoma site. Electrode placement verified with a C-arm. Closure of wound was completed 3 layers.
Mastoid dressing was applied on both sides.
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After completion of the cochleostomy, CI 632 Implant was inserted. Steroid flush given around the cochleostomy site. Periosteum was used to secure the electrodes. NRT and impedences were excellent intraoperatively. Ground electrode placed in zygoma site. Electrode placement verified with a C-arm. Closure of wound was completed 3 layers.
AN INTERESTING CASE OF COCHLEAR IMPLANT AND MAGNET CHANGE
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Despite the more recent and advanced cochlear implants being quite compatible with MRI, it is not unusual to come across complications during scanning such as partial or complete depolarization of the magnet, displacement of the implant electrode and pain, where the scan needs to be abandoned. Nevertheless, the disrupted implant needs to be addressed to put the implant back to its function.
Here we have an experience to share, where a child, having previously undergone cochlear implantation for her right ear, at a private center, was planned for left ear cochlear implantation at our center. Owing to the dilemma of the patient not being offered a simultaneous bilateral cochlear implantation during the first time, and lack of any previous medical reports, radiological images, the patient again had to be worked up. During the 1.5 tesla MRI scan, the child complained of severe, lancinating pain over her right temporal region during the scan. Following this, the processor was found to be dysfunctional and wouldn’t sustain in place, suggesting either magnet displacement or depolarization which rendered the child bilaterally deaf. One of the options was to install a reverse polarized magnet in the processor. Since the arrival of the magnet would have taken more than a couple of weeks, the child was planned for cochlear implantation on the left side without delay, along with exploration of the receiver stimulator bed of the existing implant on the right side.
The receiver stimulator bed on the right was approached a little posteriorly lest not to end up damaging the receiver while dissecting the soft tissue. The button magnet of the stimulator was found flipped over its belly, which was retrieved from its pocket. The magnet was also weak, suggesting depolarization, hence a new magnet was replaced in its place, and wound closed in layers. The cochlear implantation was completed uneventfully on the opposite side as planned.
OSIA IMPLANTATION
Osia, the world’s first Osseointegrated steady state implant, is a piezoelectric mechanism, unlike a conventional BAHA implant, giving the nearest possible experience of natural hearing. With all its components- the bone anchoring implant, the actuator and the electromagnetic coil placed underneath the skin, unlike as it is in a conventional BAHA, where the bone implant with its abutment fixture needs to be punctured out through the skin and the processor unit exteriorized completely, Osia is much concise yet sophisticated.
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This week, we have a middle-aged male, who was earlier diagnosed with right otosclerosis and underwent a stapedotomy with Teflon piston insertion, with some improvement in his hearing. No sooner than 3 months after surgery, he developed acute severe mixed hearing loss, on the operated side without any other significant medical history. The patient underwent a revision stapedectomy again 7 months later, without any improvement in his hearing.
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The patient was operated at Bangalore Skull Base Institute - Bangalore Hearing and Implant Institute by Team Dr. Sampath Chandra Prasad Rao and he underwent Osia ‘Cochlear OSI200’ implantation under general anesthesia, in a post auricular approach with extension if the skin incision into the suboccipital area. The conical guide drill is placed on the identified area of the skull which is relatively flat behind the ear, and the hole is widened with countersink drill bits. The bone bed is then levelled and prepared with a bone bed indicator. The implant with the coil and actuator is then positioned and secured over the ‘Cochlear BI300’ implant with the fixation screw. Hemostasis is then secured and wound closed in layers
Bilateral Cochlear Implantation
Proven and agreed upon are the advantages of an early bilateral cochlear implant over being done on only one side, specifically for the better speech and language learning capabilities and unarguably better binaural sound perception, not to mention the enhanced brain and intellectual development of a born deaf individual. With an incidence of nearly 5700 cases for every million newborn children, congenital deafness bears a significant impact on our developing society, be it both economically and emotionally. This week's case of a week is about a one and a half year old baby born with bilateral severe to profound hearing loss, who underwent a successful simultaneous bilateral cochlear implantation.
The psychomotor evaluation of the child preoperatively was satisfactory for her age. The radiological- HRCT temporal bones showed favorable anatomy and MRI was suggestive of bilateral normal morphology.
The procedure was posterior tympanotomy facial recess approach with extended cochleostomy on both the sides, the implants used were 'Nucleus profile plus with slim modular electrode CI632', the insertion of the electrode arrays complete and smooth. The procedures on both sides were uneventful. The post operative HRCT temporal bones done on POD-I confirmed the position of the implants.
A tale of epistaxis : case of capillary hemangioma of temporal bone
A 48-year-old male patient from Bangladesh presented with epistaxis. Multiple investigations including endoscopy and radiological evaluation confirmed the primary source of bleed as a mass lesion involving the left temporal bone and eustachian tube. His Pure Tone Audiometry revealed hearing sensitivity within normal limits in the right ear and moderate mixed hearing loss in the left ear.
The patient underwent Subtotal Petrosectomy with blind sac closure with ipsilateral BI 300 4mm implant with abutment. Post-operative recovery was uneventful. Histopathology revealed the lesion to be a capillary hemangioma. Four weeks after the surgery the patient was fitted with Baha 5 Power processor.
Bilateral Cochlear Implantation
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A 14-month-old baby boy from Bangalore was diagnosed with congenital bilateral sensorineural hearing loss. BERA revealed bilateral severe-to-profound hearing loss. Baby was fitted with hearing aids on both the sides and was given auditory verbal therapy for a period of 3 months. There were no benefits seen using the same. Hence, he was recommended to undergo bilateral cochlear implant surgery. CT & MRI revealed no anatomical abnormality on both the sides. Bilateral Cochlear Implantation was performed with Cochlear Nucleus CI632 Implant. Intra-operative monitoring revealed Impedance and Neural response telemetry within normal limits (NRT).
Translabyrinthine approach for Giant Vestibular schwannoma with simultaneous Ipsilateral Osia implantation for hearing restoration
A 51-year-old male patient presented with a one-year long history of nausea, vomiting and imbalance. The episode got precipitated following a minor RTA, and was associated with gradual loss of hearing with poor speech discrimination and tinnitus in the left side. MRI revealed a heterogeneously enhancing solid tumor of 3.69cmX2.99cmX3.52cm size with cystic areas in the left CPA. The tumor was seen widening the fundus of left IAM, which is a feature highly suggestive of vestibular schwannoma. A Translabyrinthine approach for excision of giant Vestibular Schwannoma was performed with simultaneous ipsilateral OSIA Implantation for hearing restoration. Post-surgery patient recovered well with a HB grade II facial paralysis. Upon switch on of the OSIA implant, the patient was able to hear normally with good speech discrimination, in both quiet and noisy environment.
Skull Base Osteomyelitis with ipsilateral Cochlear Implantation
Skull base osteomyelitis due to impacted foreign body in the petrous bone: Subtotal petrosectomy with facial nerve decompression with simultaneous ipsilateral cochlear implantation for hearing restoration
A 56 year old lady presented with right ear pain, ear discharge, bleeding and facial deviation for 1 month. Patient had a past history of severe hearing loss for several years and was offered hearing aid. During the trial, ear mould was inserted deep inside the EAC following which she developed symptoms. A week later she developed facial paralysis, following which a local ENT surgeon removed ear mould debris from the EAC and referred the patient to our center. Otoendoscopy revealed large central perforation with mucopurulent discharge and granulations in the EAC. Patient had HB Grade V facial nerve paralysis. Pure tone audiometry revealed profound hearing loss 90dB in the right ear and 75dB severe SNHL in the left ear. HRCT temporal bone revealed soft tissue density in the middle ear and EAC with demineralization of the tympanic segment of the facial nerve with ? foreign body along the horizontal petrous carotid and eustachian tube. Patient underwent Subtotal petrosectomy with facial nerve decompression with simultaneous ipsilateral cochlear implantation for hearing restoration. The foreign body which was an ear mould material was removed completely. Post surgery, recovery was uneventful. She was put on long term antibiotics as per our SBO antibiotic protocol. The CI switch on was done after 3 weeks, following which the patient’s hearing has been restored successfully. Over 3 months, her facial nerve function has marginally improved and it is expected to improve further.
CPA Epidermoid with ipsilateral BI300 implant
22 years old male patient presented with intermittent episodes of giddiness and tinnitus left ear with left ear block since six months. Otoendoscopy revealed intact TM. VII, IX, X, XI, XII cranial nerve examination was normal. Pure tone audiometry revealed bilateral hearing sensitivity within normal limits. MRI Brain and temporal bone with contrast showed well defined non-enhancing T1 hypointense and T2 predominant hyperintense diffusion restricting lesion in the left CPA suggestive...
22 years old male patient presented with intermittent episodes of giddiness and tinnitus left ear with left ear block since six months. Otoendoscopy revealed intact TM. VII, IX, X, XI, XII cranial nerve examination was normal. Pure tone audiometry revealed bilateral hearing sensitivity within normal limits. MRI Brain and temporal bone with contrast showed well defined non-enhancing T1 hypointense and T2 predominant hyperintense diffusion restricting lesion in the left CPA suggestive....
A 22 years old male patient presented with intermittent episodes of giddiness, tinnitus and blockage in the left ear for six months. Otoendoscopy revealed intact TM. VII, IX, X, XI, XII cranial nerve examination was normal. Pure tone audiometry revealed bilateral hearing sensitivity within normal limits. MRI Brain and temporal bone with contrast showed well defined non-enhancing T1 hypointense and T2 predominant hyperintense diffusion restricting lesion in the left CPA, suggestive of an epidermoid (22x27x22mm). Translabyrinthine approach for the excision of the CPA epidermoid with blind sac closure and BI300 4mm implant was placed on the mastoid occipital region. Postoperatively, the patient had HB grade II facial nerve paralysis with no intracranial complications. Histopathology was consistent with epidermoid.
Temporal Bone Squamous Cell Carcinoma with ipsilateral BI300 implant
A 74 year male, known diabetic, presented from Mysore, with blood tinged left ear discharge and ear pain since one month. Patient had a long standing history of bilateral ear discharge, decreased hearing left ear more than the right and occasional giddiness on and off since 20 years. There was no history of facial nerve paralysis. He was on oral antibiotics, analgesics on and off for the same. Otoendoscopy revealed left EAC aural polyp obscuring the view of Tympanic membrane, right ear showed...
A 74 year male, known diabetic, presented from Mysore, with blood tinged left ear discharge and ear pain since one month. Patient had a long standing history of bilateral ear discharge, decreased hearing left ear more than the right and occasional giddiness on and off since 20 years. There was no history of facial nerve paralysis. He was on oral antibiotics, analgesics on and off for the same. Otoendoscopy revealed left EAC aural polyp obscuring the view of Tympanic membrane, right ear showed...
A 74 year male, known diabetic, presented from Mysore, with blood tinged left ear discharge and ear pain since one month. Patient had a long standing history of bilateral ear discharge, decreased hearing left ear more than the right and occasional giddiness on and off since 20 years. There was no history of facial nerve paralysis. He was on oral antibiotics, analgesics on and off for the same. Otoendoscopy revealed left EAC aural polyp obscuring the view of Tympanic membrane, right ear showed...
A 74 year male, known diabetic, presented from Mysore, with blood tinged left ear discharge and ear pain since one month. Patient had a long standing history of bilateral ear discharge, decreased hearing left ear more than the right and occasional giddiness on and off since 20 years. There was no history of facial nerve paralysis. He was on oral antibiotics, analgesics on and off for the same. Otoendoscopy revealed left EAC aural polyp obscuring the view of Tympanic membrane, right ear showed...
A 74 year male, known diabetic, presented with blood tinged left ear discharge and ear pain since one month. Patient had a long standing history of bilateral ear discharge, decreased hearing left ear more than the right and occasional giddiness on and off since 20 years. There was no history of facial nerve paralysis. He was on oral antibiotics, analgesics on and off for the same. Otoendoscopy revealed left EAC aural polyp obscuring the view of Tympanic membrane, right ear showed subtotal perforation with edematous middle ear mucosa. There were no palpable neck nodes. Cranial nerve examination including Facial Nerve was found to be normal. Biopsy of the aural polyp revealed moderately differentiated squamous cell carcinoma. PTA showed profound hearing loss in the left ear (>90 dB) and severe sloping mixed hearing loss in the right ear (85dB). Subtotal temporal bone resection with selective (level V, IIA, IIB) neck dissection and partial parotidectomy with blind sac closure was performed. BI300 4mm implant with cover screw placed on the mastoid occipital bone. Post op Facial nerve status was HB Grade II. Patient is planned for radiotherapy.
Contact Us
Bangalore Hearing & Implant Institute
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'Kalpavriksha' No 14, 1st Cross, 5th Block
17th A Main Road, Koramangala, Bangalore 560095
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