International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

Contents lists available at SciVerse ScienceDirect

International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Review article

Endocochlear inammation in cochlear implant users: Case report and

literature review
Alice Benatti a,*, Alessandro Castiglione b, Patrizia Trevisi b, Roberto Bovo a, Monica Rosignoli c,
Renzo Manara d, Alessandro Martini e
a

Operative Unit of Otolaryngology and Otosurgery, Padua University, Via Giustiniani, 2, Padua, Italy
Department of Neurosciences, Padua University, Via Giustiniani, 2, Padua, Italy
ENT Department, Audiology Service, Ferrara University, Cso Giovecca 203, Ferrara, Italy
d
Neuroradiology, Padua University, Via Giustiniani 2, Padua, Italy
e
Department of Neurosciences, Operative Unit of Otolaryngology and Otosurgery, Padua University, Via Giustiniani, 2, Padua, Italy
b
c

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 7 January 2013
Received in revised form 7 March 2013
Accepted 10 March 2013
Available online 8 April 2013

Objectives: Cochlear implantation is a relatively safe procedure with a low complication rate. The overall
rate of complications among cochlear implant patients ranges from 6% to 20%. Major complications are
those that are life-threatening or require surgery, whereas minor complications are those that can be
medically treated. Nonetheless, certain complications, even if highly rare, may require specic
investigations and treatments. Among these rare complications are those with endocochlear
involvement, such as cochleitis or labyrinthitis, with brosis or ossication that could lead to
explantation. The aims of the present study were to report a particular case of post-operative cochleitis
and to review the rate of complications after cochlear implantation, emphasising those conditions with
proven endocochlear involvement.
Methods: We refer to the case of an eight-year-old Italian boy affected by the sudden onset of
headache, ipsilateral otalgia and facial paresis, who presented to our clinic for inexplicable
worsening of the performance of his implant and his residual hearing, six years after surgery. A
complete investigation including (clinical history, routine, autoimmune and serological blood
tests, electrophysiological measurements from the cochlear implant and neuroimaging) was
performed and is herein described. Additionally, a comprehensive review of the literature was
conducted using internet search engines; 274 papers were selected, 88 of which were best suited to
our purposes.
Results: In our case, the progression of the symptoms and the performance decrement required
explantation, followed by a complete recovery. Reviewing the literature revealed only three reports
concerning cases of proven endocochlear phlogosis that required revision surgery. Wound swelling/
infection and vertigo remain the two most common complications of cochlear implantation. Failure
of the device is the third most frequent complication (10.06% of all complications and 1.53% of
cochlear implantations). Other rare conditions (such as granulating labyrinthitis with cochlear
brosis, ossication and erosion, silicone allergy and the formation of a biolm around the internal
device) are possible and unpredictable. Although rare (approximately 1%), such cases may require
explantation.
Conclusions: Despite efforts by both surgeons and manufacturers, device-related and surgical
complications still occur. These and other rare conditions demand specic management, and their
frequency may be underestimated. Further studies are needed to assess more realistic rates of
complications and devise more efcient strategies for early diagnosis and treatment.
2013 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Cochleitis
Endocochlear phlogosis
Implant complications
Granulating labyrinthitis

* Corresponding author at: Operative Unit of Otolaryngology and Otosurgery, Giustiniani, 2, Padua 35128, Italy. Tel.: +39 339 6657486; fax: +39 049 821 1994.
E-mail addresses: alicebenatti@gmail.com (A. Benatti), alessandro.castiglione@unipd.it (A. Castiglione), patrizia.trevisi@unipd.it (P. Trevisi),
roberto.bovo@sanita.padova.it (R. Bovo), monica.rosignoli@unife.it (M. Rosignoli), renzo.manara@sanita.padova.it (R. Manara), alessandromartini@unipd.it (A. Martini).
0165-5876/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijporl.2013.03.016

A. Benatti et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

886

Contents
1.
2.

3.

4.
5.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .
Materials and methods . . . . . . . . . . . . . . . . . .
Clinical, audiological and genetic data .
2.1.
Neuroimaging . . . . . . . . . . . . . . . . . . . .
2.2.
Literature review . . . . . . . . . . . . . . . . .
2.3.
Case report . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical, audiological and genetic data .
3.1.
Neuroimaging . . . . . . . . . . . . . . . . . . . .
3.2.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction
Cochlear implantation has been established world-wide as a
safe and effective method of rehabilitating profoundly hearingimpaired adults or infants who derive insufcient benets from
hearing aids [1,2]. Medical, surgical and technological advances
in the eld of otology have led to expanding selection criteria and
increasing numbers of cochlear implantations in challenging
cases, with successful outcomes being achieved [36]. Despite

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886
887
887
888
888
888
888
889
889
891
891

efforts by both surgeons and manufacturers, device-related and

surgical complications still occur. Considering the total number
of implantations, the overall rate of complications reported in
most of the available studies ranges from 6 to 20%: the major
ones occur in 112% of patients, whereas the minor ones occur in
220% of patients (Table 1) [740]. The major complications are
those that are life-threatening or require surgery (including
explantation), whereas the minor complications are those that
can be treated medically. Wound swelling, technical/device

Table 1
Literature review of post-operative complications of cochlear implantation; device failures requiring surgery are considered major complications. The percentages refer to the
total number of cases for which data analysis was possible (studies with unspecied and/or unavailable data were excluded from the total number of cases). * = Complications
after surgery in patients with anomalous inner ears. ** = These results must be considered purely indicative because different authors adopted different classication criteria
for major and minor complications; for example, gusher is considered a major complication in some studies and a minor complication in others.
Study

No. of
Cases

No. of complications
(%)

Major complications
(%)

Brito et al. [7]

Ciorba et al. [43]
Ajalloueyan et al. [8]
Lescanne et al. [9]
Pirzadeh et al. [10]
Qiu J. et al. [11]
Achiques et al. [12]
Hansen et al. [13]
Hashemi et al. [14]
Lima Junior LR [16]
Loundon et al. [15]
McJunkin [17]
Ding et al. [18]
Ovesen et al. [19]
Ahn et al. [20]*
Venail et al. [41]
Dodson et al. [21]
Hopfenspirger et al. [22]
Postelmans et al. [23]
Kandogan et al. [24]
Migirov et al. [25]
Mosnier et al. [26]
Ramos et al. [44]
Stratigouleas et al. [27]
Dutt et al. [28]
Kandogan et al. [29]
Kubo et al. [25]
Bhatia et al. [42]
Green et al. [31]
Howard et al. [32]
Kim et al. [33]
Ray et al. [34]
Cervera-Paz et al. [35]
Kempf et al. [36]
Kempf et al. [37]
Proops et al. [38]
Luetje et al. [39]
Miyamoto et al. [40]
Total

550
438
262
140
177
416
246
505
150
250
434
136
1237
313
80
500
345
268
112
105
300
134
346
176
122
227
315
300
240
158
430
844
135
697
366
100
56
100
11710

92
40
50
18
24
29
28
148
22
33
43
9
149
49
20
79
32

40
18

34
22
37
43

55
76
12
34

11
343
297
42
5
2
1936

49 (8.91%)
12 (2.74%)
1 (0.38%)
11 (7.86%)
8 (4.52%)
6 (1.44%)
21(8.54%)
9 (1.78%)
7 (4.67%)
13 (5.20%)
24 (5.53%)

130 (10.51%)
14 (4.47%)
5 (6.25%)
51 (10.20%)

22 (8.21%)
4 (3.57%)
4 (3.81%)
9 (3.00%)
1 (0.75%)

7 (3.98%)
15 (12.30%)
28 (12.33%)
33 (10.48%)
7 (2.33%)
15 (6.25%)
5 (3.16%)
9 (2.09%)
80 (9.48%)
5 (3.70%)
101 (14.49%)
83 (22.68%)
3 (3.00%)
5 (8.93%)
0
797 ** (7.32% of 10883)

(16.73%)
(9.13%)
(19.08%)
(12.86%)
(13.56%)
(6.97%)
(11.38%)
(29.31%)
(14.67%)
(13.20%)
(9.91%)
(6.62%)
(12.05%)
(15.65%)
(25.00%)
(15.80%)
(9.28%)
(35.71%)
(17.14%)

(9.83%)
(12.50%)
(30.33%)
(18.94%)
(18.3%)
(31.67%)
(7.59%)
(7.91%)
(8.15%)
(49.21%)
(81.15%)
(42.00%)
(8.93%)
(2.00%)
(19.66% of 9849)

Minor complications
(%)
43 (7.82%)
28 (6.39%)
49 (18.70%)
7 (5.00%)
16 (9.04%)
23(5.53%)
7 (2.85%)
139 (27.52%)
15 (10.00%)
20 (8.00%)
19 (4.38%)

19 (1.54%)
35 (11.18%)
15 (18.75%)
28 (5.60%)

36 (32.14%)
14 (13.33%)

15
22
15

48
61
7
25
6
242
214
39

2
1209

(8.52%)
(18.03%)
(6.61%)
(16.00%)
(25.42%)
(4.43%)
(5.81%)
(4.44%)
(34.72%)
(58.47%)
(39.00%)
(2.00%)
** (13.40% of 9022)

Children
(<18 years)

Adults
(>18 years)

19

18

28
45

22

3
6

5
2
157

21

103

9
3

136

(4.34%)
(12.86%)

(11.38%)
(8.91)

(6.62%)

(8.21)

(1.90%)
(1.40%)

(8.93%)
(2.00%)
(6.71% of 2341)

(4.79%)

(20.40%)

(5.70%)
(0.70%)

(8.88% of 1531)

A. Benatti et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

887

Table 2
Complications after/during cochlear implant surgery. The percentages refer to the total number of cases for which data analysis was possible (the studies with unspecied
and/or unavailable data were excluded from the total number of cases); % = percentage of total complications (1083, including unusual complications); %* percentages of total
cochlear implants (7132).
Type of complication

No.

% (of 1083 complications)

%* (of 7132 cochlear implants)

Wound complications
Infections, swelling, haematoma, suture rupture
Subcutaneous haematoma, seroma, emphysema
Keloid
Thin ap
Equilibrium disorders
Vertigo
Nystagmus
Neuritis, labyrinthitis
Device complications
Failure
Gain reduction, Absence of stimulation
Infections
Malpositioning, migration, kinking
Extrusion
Leaks
Gusher
Csf (cerebrospinal uid)
Fistula
Dural tear
Rhinoliquorrea
External, middle ear complications
External, media otitis, tympanic membrane perforation
Cholesteatoma
External auditory canal injury
Acute otomastoiditis
Pocket retraction
Peripheral nerve complications
Temporary facial nerve palsy
Permanent facial nerve palsy
Facial stimulation
Chorda tympani injury
Change in taste
Post-operative pain, transient neuralgia
Alteration in facial sensibility
Other
Worsening/increase/onset of tinnitus
Haemorrhage
Unspecied intraoperative complications
Cerebritis (1 case)/meningitis (7 cases)
Non user
Respiratory distress, laryngospasm
Ocular disorders
Hypertension
Burn
Tachycardia, hyperthermia
Abdominal distension
Unusual complications (Tab 3)
Total

223
153
57
11
2
113
111
1
1
311
109
57
4
102
39
90
62
14
9
4
1
92
58
13
6
14
1
115
46
12
20
20
3
10
4
63
16
13
13
8
5
3
2
1
1
1
1
76
1083

20.59
14.13
5.26
1.02
0.18
10.43
10.25
0.09
0.09
28.72
10.06
5.26
0.37
9.42
3.60
8.31
5.72
1.29
0.83
0.37
0.09
8.49
5.36
1.20
0.55
1.29
0.09
10.62
4.25
1.11
1.85
1.85
0.28
0.92
0.37
5.82
1.48
1.20
1.20
0.74
0.46
0.28
0.18
0.09
0.09
0.09
0.09
7.01
100

3.13
2.15
0.80
0.15
0.03
1.58
1.56
0.01
0.01
4.36
1.53
0.80
0.06
1.43
0.55
1.26
0.87
0.20
0.13
0.06
0.01
1.29
0.81
0.18
0.08
0.20
0.01
1.61
0.64
0.17
0.28
0.28
0.04
0.14
0.06
0.88
0.22
0.18
0.18
0.11
0.07
0.04
0.03
0.01
0.01
0.01
0.01
1.07
15.19

failure, dizziness/vertigo and infections represent the most

common complications (Table 2); however, certain complications may require specic investigations and treatments [6,41
44]. Such cases are very rare and not usually reported in case
studies; they include (Table 3) [10,4560]: cochleitis, granulating
labyrinthitis, pneumocoele, pneumolabyrinth, surgical emphysema, particular malpositioning or migration, biolm array
infections and allergic reactions to internal device [43,6174].
Although these are rare complications, they should be considered
as major complications because explantation may be required
[61,62]. As a consequence of pathological and inammatory
processes, cochlear erosion [75], brosis and/or ossication may
occur, leading to device malfunction, extrusion of electrodes or
displacement of the intracochlear array, with unpredictable
consequences for the patients health and the performance of the
implant [63,7680].
The aims of this study were to review the complication rate
after cochlear implantation and to investigate the causes of

unexpected clinical manifestations in an eight-year-old Italian boy

six years after cochlear implantation surgery, who was characterised by headache, ipsilateral otalgia and facial paresis and
worsening of his residual hearing and the performance of his
cochlear implant.
2. Materials and methods
2.1. Clinical, audiological and genetic data
A detailed family and clinical history was obtained from the
young patient and his parents. Acquired and environmental factors
that might be related to hearing loss were investigated. A complete
audiological evaluation was performed using micro-otoscopy,
pure-tone (2508000 Hz) audiometry to evaluate air and bone
conduction, speech audiometry to determine the speech recognition threshold and impedancemetry (tympanometry and acoustic
stapedial reexes). Other clinical data were collected, including

A. Benatti et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

888

Table 3
Unusual post-operative complications of cochlear implantation. The number of cases should be considered an underestimate.? = unavailable or unspecied data.
Unusual post-operative
complications
Cochlear complications
Pneumolabyrinth
Oesteolisys/erosion

Chronic granulating labyrinthitis

Fibrosis/oesteogenesis
Silicone allergy/foreign
body reaction

Bacterial/fungal biolm
formation
Pneumocoele
Epidural/subdural haematoma
Misplacement into the
carotid canal
Total (%)

No. of
cases

Explantation

3
5

None
4/5

3
19
25

3/3
19/19
14/25

Children
(<18 years)

Adults
(>18 years)

1
3

4/5

4
4

None
None

2
1

8/8

52/76 (68.42% of 76)

4 (?)

76

routine, autoimmune and serological blood tests, evaluation of the

thyroid and renal functions, electrophysiological measurements
from the cochlear implant and neuroimaging of the temporal bone.
Behavioral audiometry and auditory brainstem response (ABR)
testing were useful to dene the clinical indications for a cochlear
implant at the age of 2 years, when he underwent the rst
implantation surgery (2006). Direct sequencing of the GJB2 gene
was also performed to investigate the genetic cause of his hearing
loss.
2.2. Neuroimaging
Axial and coronal imaging with a high resolution computed
tomography (HRCT) scanner and a 1.5-tesla magnetic resonance
imaging (MRI) system was repeated during this young patients
life. In 2006, the patient underwent preoperative HRCT and MRI
scans for diagnostic and surgical purposes. In 2012, due to the
onset and progression of his symptoms, two temporal bone HRCT
scans were conducted, one month apart. He also underwent an MRI
of the temporal bone 24 h after explantation surgery for diagnostic
and prognostic purposes.
2.3. Literature review
A complete review of the literature was conducted using
computer search engines and internet databases; the search terms
brosis, ossication, cochlear implant, complications, cochleitis and labyrinthitis were combined as follows: (brosis or
ossication) and (cochlear implant), (cochleitis or labyrinthitis)
and (cochlear implant and/or complications). A second search was
performed using a combination of the search terms cochlear
implant and complications. The English, Italian, Spanish, German
or French language articles were retrieved and included in the
review they reported cases of particular interest or research
published between 1996 and 2012.
3. Case report
3.1. Clinical, audiological and genetic data
The patient is an 8-year-old Italian boy affected by profound
congenital bilateral sensorineural hearing loss of unknown origin.

References

Rother et al. [65]; Ott et al. [69]; Hempel et al. [45]

Neilan et al. [46]; Ho et al. [71]; Cervera-Paz &
Linthicum [75]; Doherty & Linthicum [84];
personal observation (2012, unpublished data)
Levi et al. [63]; Ho et al. [62]; Bertuleit et al. [61]
Cote et al. [47]
Ciorba et al. [43]; Lim et al. [68]; Pirzadeh et al. [10];
Liu et al. [48]; Kunda et al. [70]; Migirov et al. [25];
Puri et al. [49]; personal observation (2012,
unpublished data)
Neelam et al. [50]; Ruellan et al. [51]; Pawlowski et al. [52];
Cristobal et al. [53]; Makarem et al. [74]
Qiu S. et al. [64];
Gosepath et al. [54]; Sunkaraneni et al. [55]; Dodson et al. [21];
Stamatiou et al. [56]
Nevoux et al. [66]; Son et al. [57]; Tange et al. [58];
Gastman et al., [59]; Jain & Mukherji [60]; personal observation
(2012, unpublished data)

12 (?)

Born at term after a normal pregnancy from unrelated parents with

no familial hearing loss, he underwent a left cochlear implantation
(Nucleus Freedom Contour, CI24RE) at the age of two years (2006).
Pre-operative click-evoked ABRs for bilateral ear stimuli at a level
of 95 dB nHL (normal Hearing Level) were absent. No GJB2
mutations were found.
The operation was uneventful and all of the electrodes were
properly inserted through the cochleostomy, achieving good
impedance values. The electrically evoked compound action
potential (ECAP) thresholds were measured intraoperatively using
the neural response telemetry (NRT) capabilities of Cochlear
Corporations (Cochlear1, Lane Cove, New South Wales, Australia)
CI24RE-CA device. The correct array position was documented by
postoperative skull radiography. He obtained good results and he
was followed-up regularly without problems until December
2011, when the device was tested and all of the electrodes were
found to have low impedance values and normal NRT thresholds.
At that time, the pure-tone and speech audiometry (with cochlear
implant) results were within normal ranges. The pure tone average
(PTA0.5,1,2 kHz), the average of the pure-tone thresholds at 500 Hz,
1 kHz, and 2 kHz, was 25 dB nHL and speech recognition at 30 dB
SPL (sound pressure level) was 80% of the words in an open set
(Fig. 1).
In February 2012, six years after the surgery, he presented to
our tertiary care hospital complaining of ipsilateral otalgia,
headache and cochlear implant discomfort. No potential causes
were identied in the rst examination; no signs of infection,
extrusion, migration, neuritis or vestibular concerns were found.
The results of micro-otoscopy and tympanometry were normal;
the acoustic reex was absent as expected, due to the pre-existing
conditions. Nevertheless, a temporal bone CT scan was ordered and
steroid treatment (with partial symptom remission) was prescribed. Technical analysis of the device was conducted, revealing
impedance variations of three electrodes and undetectable NRT
thresholds. The pure-tone audiometry results were still acceptable
with the cochlear implant (PTA = 32 dB nHL) but the young boy
presented severe tone-speech dissociation (Fig. 1). When providing a history, the patient and his parents did not refer to any
particular event, except for a violent head injury on the right side
that occurred three weeks before and a minor head injury on the
left side (the implanted side) that occurred a few days later. After
one month, he returned to the clinic for clinical aggravation with

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889

Fig. 1. Audiological data before explantation surgery. Tonal and speech audiometry showed the constant decline of implant benets compared to the good performance
demonstrated at the end of 2011; (a) tonal audiometry results with the left cochlear implant (open set) and residual hearing without the cochlear implant (headphones); (b)
speech audiometry results with the left cochlear implant, using an open set of words, revealed an SRT equal to 25 dB SPL before the onset of symptoms, with worsening
performance in subsequent tests, so that there was a severe discrepancy between the tonal and speech audiometric results (SRT = Speech Recognition Threshold, the lowest
level at which the speech signal can be correctly identied 50% of the time).

fever (38.5 8C) and hyperemia of the external auditory canal and
cheeks. The patient was treated with the oral nonsteroidal antiinammatory drugs cephalosporin and betamethasone for 7 days,
but they produced only a modest and transient benet.
Given the uctuating course of the symptoms, the patient
continued steroid therapy, 30 mg of Deazacort per day, and
experienced partial improvement, but the hearing threshold of his
implant gradually worsened (Fig. 1).
After approximately one month, the patient had thinning or
disruption of the posterior wall of the external auditory canal with
reacutisation of symptoms, likely due to contact with a part of the
internal device array causing a granuloma of approximately
2 mm in diameter in the posterior wall of the external auditory
canal, near the annulus.
A few days later, the patient developed acute left facial nerve
paralysis (grade III on the House-Brackmann scale).
Technical analysis of the device revealed high impedance of 3
apical electrodes (20, 21 and 22) and basal electrode 1. The
external device functioned normally. Subsequently, an integrity
test on the CI24RE cochlear implant was performed by Cochlear
Italia SRL and it was concluded that the receiverstimulator and all
of the electrodes were functioning within the specications
(Normal Device Function) according to the European consensus
statement on cochlear implant failures and explantations [81].
The results of the blood tests were all within the normal ranges
with the exception of the serum biochemistry, which showed an
increase in acute-phase reactants and the presence of IgM and IgG
specic for paramyxovirus type 1 that became negative to
subsequent one month control, exception for (obviously) IgG.
The worsening of his clinical condition, with left facial paralysis
grade IV, fever and persistent tone-speech dissociation, led to
hospitalisation for the removal of the internal device.
The presence of a small granuloma, most likely due to the array
having rotated, was conrmed intraoperatively; the inammatory
reaction was essentially limited to the external auditory canal,
with no evidence of middle ear involvement.
After surgery and antibiotic therapy, complete regression of the
symptoms was achieved. A temporal bone MRI was performed 24 h
after the explantation to evaluate the inner ear and the VII/VIII

nerve complex. Histological examination conrmed the presence

of brotic tissue around the array. Two months later, the patient
underwent a right cochlear implantation without complications.
3.2. Neuroimaging
Temporal bone MRI and CT scans conducted in 2006, before the
rst cochlear implantation, were normal with the exception of
mild plagiocephaly that was clinically insignicant. In 2012, two
months after the onset of symptoms, the patient underwent
another CT scan of the temporal bone, without contrast, which
showed the following: (1) normal post-surgical anatomy and
correct array positioning; (2) presence of phlogistic material in the
left mastoid air-cells with preservation of the trabecular bone
microarchitecture and (3) presence of a granuloma in the posterior
wall of the external auditory canal, near the tympanic membrane,
with partial bone erosion (Fig. 2). No other signicant alterations
were observed. Because his clinical condition worsened and his
facial nerve paralysis was aggravated, with both refractory to the
usual therapy, a HRCT exam was repeated one month later,
conrming the previous ndings and showing a slight improvement of the radiologic inammatory signs. However, the HRCT
scans revealed hyperdensity in the left cochlea, likely attributable
to the initial brosis/ossication of the basal and apical turns
(Fig. 3).
The post-explantation MRI revealed (Fig. 4) left cochlear
ossication and brosis with partial involvement of the internal
auditory canal. The VII/VIII nerve complex was not clearly visible in
the distal portion of the internal auditory canal.
4. Discussion
A total of 274 reports were including in our metanalysis, 88 of
which best matched our purposes. Most of them referred to the
common or predictable (even if rare) complications of cochlear
implant surgery (Tables 1 and 2) and lacked insight into the
aetiology and management of particular cases because they
focused on the occurrence and classication of major and minor
complications [6,4143]. The collective data conrmed the

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A. Benatti et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

Fig. 2. Axial temporal bone HRCT scans showing the array position and the
phlogistic ndings in the mastoid and external auditory canal. (A and B) There is no
evidence of electrode extrusion or migration; (C) a granuloma and adjacent eroded
bone (white arrow) are present in the posterior wall of the external auditory canal,
near the tympanic membrane; (D) the mastoid air-cells are full of phlogistic
material.

complications rates reported in single studies. Device failure

remains the third most frequent complication (10.06% of the total
complications and 1.53% of the complications of cochlear
implantation) after wound-related complications and vertigo
(Table 2). However, these last two complications (vertigo and
wound involvement) are usually temporary and medically
treatable, whereas device failure necessitates surgical revision. It
can be deduced that device failure is the principal cause of
explantation/reimplantation (Table 1). Vertigo is most likely due to
surgical trauma to the vestibular labyrinth: its residual function
causes equilibrium disorders, which generally are self-limited and
resolve within a few weeks, as occurs in other vestibular disorders.
Permanent facial palsy is a very rare complication (0.17%), most
likely due to intraoperative monitoring of the intratympanic and

Fig. 3. The second temporal bone HRCT scan showed: (A and B) slight improvement
of the radiologic inammatory signs and (C and D) hyperdensity of the cochlea
likely attributable to the initial brosis/ossication of the basal and apical turns.

Fig. 4. A temporal bone MRI performed 24 h after explantation revealed: (AC)

cochlear ossication and brosis with partial involvement of the internal auditory
canal (white arrowheads); (C and D) reactive tissue formation in the mastoid with
air-uid levels in the surgical cavity (white asterisk). The integrity of the explanted
device was tested by the manufacturer and it was reported to be normal.

mastoid portions of the facial nerve. In addition, the non-users (the

implant recipients who do not use them) are very rare (0.07%),
underlining the benet and usefulness of cochlear implant, even if
it is possible that they are not always included in case studies on
post-operative complications. Cerebritis (1 case) and meningitis (7
cases) have an occurrence rate of 0.01% and 0.10%, respectively
(Table 2); nevertheless, the risk of meningitis among implanted
patients (100/100,000) is higher than that of the general
population (1.38/100,000) [82].
The particular cases reported in single papers range from simple
wound infection to meningeal involvement without distinction
being made between endocochlear or extracochlear complications
[43,6474]. Pneumolabyrinth, pneumocoele and epidural or
subdural haematoma appear to not require explantation
(Table 3). Only three reports [6163] discovered in our literature
search involved proven endocochlear phlogosis in cochlear
implant users that resulted in explantation, of which two
[61,62] concerned brotic and oesteogenic processes (Tables 2
and 3). It is interesting that endocochlear involvement was usually
preceded or accompanied by bone erosion in the external auditory
canal [6163].
In summary, our case report describes a late post-operative
complication leading to explantation because of extensive
cochlear involvement with brosis and ossication and, consequently, malfunction of the implant. The clinical, neuroimaging
and surgical ndings suggested a secondary inammation process
of unknown origin with endocochlear and internal auditory canal
phlogosis. Consequently, granulating formations in the middle
and inner ear gave rise to partial erosion of the cochlea and
massive brosis/ossication of the basal and apical turns.
Contralateral cochlear implantation (Nucleus Freedom Contour)
was performed 2 months after the explantation (5 months after
the onset of symptoms). This operation was uneventful and all of
the electrodes were properly inserted through the promontorial
cochleostomy, achieving good impedance values and NRT thresholds. Subsequently control showed a quick recovery to implant
benets (Fig. 5). The correct array position was documented by
postoperative skull radiography.
Fibrotic and oesteogenic processes subsequent to inammation
of the labyrinth are well known events occurring after meningitis

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891

Fig. 5. Audiological data after reimplantation surgery in July 2012. Tonal and speech audiometry showed a rapid increase of implant benets reaching the performances of
previous contralateral implanted ear; (a) tonal audiometry with right cochlear implant (open set) and residual hearing without cochlear implant (headphones); (b) the speech
audiometry with right cochlear implant, in an open set words, revealed a SRT equal to 45 dB SPL after 5 months from revision surgery (SRT = Speech Recognition Threshold is
the lowest level at which the speech signal can be correctly identied 50% of the time).

or during otosclerosis [7679]. It is well known that brotic

phenomena occur near the array, but the cochlear abnormalities
induced by an implant are mainly of little clinical signicance and
do not compromise the devices functions [80,8386]. While
middle ear infections can lead to meningitis, in this case, the
patient never showed the pathognomonic symptoms of meningitis
or mastoiditis. Therefore, his endocochlear involvement seems
more likely to be due to (unpredictable) reactive processes that are
very similar to a foreign body reaction, which was initiated and
sustained by traumatic events [75]. In our case, a manufacturers
report to rule out direct damage of the device causing its failure
was obtained from Cochlear Italia SRL. Furthermore, his paramyxovirus infection may have provoked phlogistic activity
resembling an autoimmune cross-reaction [87,88], which would
explain all of the early and late symptoms. It is also possible that
those events can be attributed to predisposing conditions.
The impedance of the most apical and basal electrodes was
high, which mimics in implanted patients [85] the evolution of the
oesteodystrophic process in patients affected by otosclerosis [89
93]. It is important to note that if predisposing conditions are
identied, they should be investigated prior to surgery.
5. Conclusions
Cochlear implantation is a relatively safe procedure with a
complication rate of 620%. The frequency of complications has
consistently declined over the last 15 years settling and, to date, is
approximately 15% among cochlear implant patients. Reviewing
the literature (Tables 2 and 3) revealed that the majority of
complications are minor ones that do not affect the nal outcome;
however, the classication criteria used to dene minor and major
complications may be different. Furthermore, inner ear malformations or comorbidity may increase the risk of complications (such
as meningitis or gusher) [20], and the length of the follow-up
period may inuence the reported occurrence rates. For these
reasons, the reported percentages of complications can vary widely
among the studies.
Unusual complications are rare and unpredictable situations
that must be considered major complications because they usually

require revision surgery (Table 3). Although massive brosis and

ossication of the cochlear lumen is a rare complication after
cochlear implantation, explantation may be required in such cases,
with specic treatment being administered to counteract the
pathophysiological process and reduce the overall symptoms.
The pathophysiological mechanisms underlying acquired or
congenital factors that constitute, in selected cases, a contraindication to bilateral cochlear implantation need to be identied.
Further studies are necessary to manage the events similar to those
of the case presented here, which may have resulted from
predisposing conditions, and to rene diagnostic procedures and
treatment options.
Consent
Written informed consent was obtained from the family
according to current national rules and laws for publication of
this case and any accompanying images.
Competing interests
The authors declare that they have no competing interests.
References
[1] J.T. Roland, Complication of cochlear implant surgery, in: S.B. Waltzman, N.L.
Cohen (Eds.), Thieme, Cochlear Implants, New York, 1997, pp. 171175.
[2] A.A. Lassig, T.A. Zwolan, S.A. Telian, Cochlear implant failures and revision, Otol.
Neurotol. 26 (4) (2005) 624634.
[3] Y. Bajaj, N. Gibbins, K. Fawkes, B. Hartley, C. Jephson, N. Jonas, et al., Surgical
aspects of cochlear implantation in syndromic children, Cochlear Implants Int. 13
(3) (2012) 163167.
[4] R. Bovo, A. Ciorba, P. Trevisi, C. Aimoni, L. Cappiello, A. Castiglione, et al., Cochlear
implant in cogan syndrome, Acta Otolaryngol. 131 (5) (2011) 494497.
[5] A. Ciorba, R. Bovo, P. Trevisi, C. Bianchini, R. Arboretti, A. Martini, Rehabilitation
and outcome of severe profound deafness in a group of 16 infants affected by
congenital cytomegalovirus infection, Eur. Arch. Otorhinolaryngol. 266 (10)
(2009) 15391546.
[6] M. Palmieri, S. Berrettini, F. Forli, P. Trevisi, E. Genovese, A.M. Chilosi, et al.,
Evaluating benets of cochlear implantation in deaf children with additional
disabilities, Ear Hear. 33 (6) (2012) 721730.

892

A. Benatti et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

[7] R. Brito, T.A. Monteiro, A.F. Leal, R.K. Tsuji, M.H. Pinna, R.F. Bento, Surgical
complications in 550 consecutive cochlear implantation, Braz. J. Otorhinolaryngol. 78 (3) (2012) 8085.
[8] M. Ajalloueyan, S. Amirsalari, J. Youse, M.A. Raeessi, S. Radfar, M. Hassanalifard, A
repot of surgical complications in a series of 262 consecutive pediatric cochlear
implantations in Iran, Iran J. Pediatr. 21 (4) (2011) 455460.
[9] E. Lescanne, M. Al Zahrani, D. Bakhos, A. Robier, S. Morinie`re, Revision surgeries
and medical interventions in young cochlear implant recipients, Int. J. Pediatr.
Otorhinolaryngol. 75 (10) (2011) 12211224.
[10] A. Pirzadeh, M. Khorsandi, M.A. Mohammadi, A. Pirzadeh, Complications related
to cochlear implants: experience in Tehran, J. Pak. Med. Assoc. 61 (7) (2011)
622624.
[11] J. Qiu, Y. Chen, P. Tan, J. Chen, Y. Han, L. Gao, et al., Complications and clinical
analysis of 416 consecutive cochlear implantations, Int. J. Pediatr. Otorhinolaryngol. 75 (9) (2011) 11431146.
[12] M.T. Achiques, A. Morant, N. Munoz, J. Marco, I. Llopez, E. Latorre, et al., Cochlear
implant complications and failure, Acta Otorrinolaringol. Esp. 61 (6) (2010)
412417.
[13] S. Hansen, K. Anthonsen, S.E. Stangerup, J.H. Jensen, J. Thomsen, P. Caye-Thomasen, Unexpected ndings and surgical complications in 505 consecutive cochlear
implantations: a proposal for reporting consensus, Acta Otolaryngol. 130 (5)
(2010) 540549.
[14] B. Hashemi, A. Bayat, T. Kazemei, Surgical complications of cochlear implantation,
Iran J. Med. Sci. 35 (1) (2010) 5356.
[15] N. Loundon, M. Blanchard, G. Roger, F. Denoyelle, E.N. Garabedian, Medical and
surgical complications in pediatric cochlear implantation, Arch. Otolaryngol.
Head Neck Surg. 136 (1) (2010) 1215.
[16] L.R. Lima Junior, A. Rodrigues Junior Fde, C.M. Calhau, A.C. Calhau, C.T. Palhano,
Postoperative complications in implanted patients in the cochlear implant program of Rio Grande do Norte-Brazil, Braz. J. Otorhinolaryngol. 76 (4) (2010)
517521.
[17] J. McJunkin, A. Jeyakumar, Complications in pediatric cochlear implants, Am. J.
Otolaryngol. 31 (2) (2010) 110113.
[18] X. Ding, H. Tian, W. Wang, D. Zhang, Cochlear implantation in China: review of
1,237 cases with an emphasis on complications, ORL J. Otorhinolaryngol. Relat.
Spec. 71 (4) (2009) 192195.
[19] T. Ovesen, L.V. Johansen, Post-operative problems and complications in 313
consecutive cochlear implantations, J. Laryngol. Otol. 123 (5) (2009) 492496.
[20] J.H. Ahn, J.W. Chung, K.S. Lee, Complications following cochlear implantation in
patients with anomalous inner ears: experiences in Asan medical center, Acta
Otolaryngol. 128 (1) (2008) 3842.
[21] K.M. Dodson, P.G. Maiberger, A. Sismanis, Intracranial complications of cochlear
implantation, Otol. Neurotol. 28 (4) (2007) 459462.
[22] M.T. Hopfenspirger, S.C. Levine, F.L. Rimell, Infectious complications in pediatric
cochlear implants, Laryngoscope 117 (10) (2007) 18251829.
[23] J.T. Postelmans, B. Cleffken, R.J. Stokroos, Post-operative complications of cochlear
implantation in adults and children: ve years experience in Maastricht, J.
Laryngol. Otol. 121 (4) (2007) 318323.
[24] T. Kandogan, L. Olgun, G. Gultekin, Complications of cochlear implantation in
adults, KBB-Forum 5 (2) (2006) 7376.
[25] L. Migirov, C. Muchnik, R. Kaplan-Neeman, J. Kronenberg, Surgical and medical
complications in paediatric cochlear implantation: a review of 300 cases, Cochlear Implants Int. 7 (4) (2006) 194201.
[26] I. Mosnier, E. Ambert-Dahan, M. Smadja, E. Ferrary, D. Bouccara, A. Bozorg-Grayeli,
et al., Performances and complications of cochlear implant in 134 adult patients
implanted since 1990, Ann. Otolaryngol. Chir. Cervicofac. 123 (2) (2006) 7178.
[27] E.D. Stratigouleas, B.P. Perry, S.M. King, C.A. Syms 3rd., Complication rate of
minimally invasive cochlear implantation, Otolaryngol. Head Neck Surg. 135 (3)
(2006) 383386.
[28] S.N. Dutt, J. Ray, E. Hadjihannas, H. Cooper, I. Donaldson, D.W. Proops, Medical and
surgical complications of the second 100 adult cochlear implant patients in
Birmingham, J. Laryngol. Otol. 119 (10) (2005) 759764.
[29] T. Kandogan, O. Levent, G. Gurol, Complications of paediatric cochlear implantation: experience in Izmir, J. Laryngol. Otol. 119 (8) (2005) 606610.
[30] T. Kubo, S. Matsuura, T. Iwaki, Complications of cochlear implant surgery, Oper.
Tech. Otolaryngol. 16 (2005) 154158.
[31] K.M. Green, Y.M. Bhatt, S.R. Saeed, R.T. Ramsden, Complications following adult
cochlear implantation: experience in Manchester, J. Laryngol. Otol. 118 (6) (2004)
417420.
[32] N.S. Howard, P.J. Antonelli, Complications of cochlear implant placement with
minimal hair shave, Am. J. Otolaryngol. 25 (2) (2004) 8487.
[33] C.S. Kim, S.O. Chang, S.H. Oh, H.J. Lee, Complications in cochlear implantation, Int.
Congress Series 1273 (2004) 145148.
[34] J. Ray, W. Gibson, H. Sanli, Surgical complications of 844 consecutive cochlear
implantations and observations on large versus small incisions, Cochlear
Implants Int. 5 (3) (2004) 8795.
[35] F.J. Cervera-Paz, M. Manrique, A. Huarte, F.J. Garca, R. Garca-Tapia, Study of
surgical complications and technical failures (correction of technical defects) of
cochlear implants, Acta Otorrinolaringol. Esp. 50 (7) (1999) 519524.
[36] H.G. Kempf, S. Tempel, K. Johann, T. Lenarz, Complications of cochlear implant
surgery in children and adults, Laryngorhinootologie 78 (10) (1999) 529537.
[37] H.G. Kempf, K. Johann, T. Lenarz, Complications in pediatric cochlear implant
surgery, Eur. Arch. Otorhinolaryngol. 256 (3) (1999) 128132.
[38] D.W. Proops, R.L. Stoddart, I. Donaldson, Medical, surgical and audiological
complications of the rst 100 adult cochlear implant patients in Birmingham,
J. Laryngol. Otol. 24 (Suppl.) (1999) 1417.

[39] C.M. Luetje, K. Jackson, Cochlear implants in children: what constitutes a complication? Otolaryngol. Head. Neck. Surg. 117 (3 Pt 1) (1997) 243247.
[40] R.T. Miyamoto, M. Young, W.A. Myres, K. Kessler, K. Wolfert, K.I. Kirk, Complications of pediatric cochlear implantation, Eur. Arch. Otorhinolaryngol. 253 (1/2)
(1996) 14.
[41] F. Venail, M. Sicard, J.P. Piron, A. Levi, F. Artieres, A. Uziel, et al., Reliability and
complications of 500 consecutive cochlear implantations, Arch. Otolaryngol.
Head Neck Surg. 134 (12) (2008) 12761281.
[42] K. Bhatia, K.P. Gibbin, T.P. Nikolopoulos, G.M. ODonoghue, Surgical complications
and their management in a series of 300 consecutive pediatric cochlear implantations, Otol. Neurotol. 25 (5) (2004) 730739.
[43] A. Ciorba, R. Bovo, P. Trevisi, M. Rosignoli, C. Aimoni, A. Castiglione, et al.,
Postoperative complications in cochlear implants: a retrospective analysis
of 438 consecutive cases, Eur. Arch. Otorhinolaryngol. 269 (6) (2012)
15991603.
[44] A. Ramos, R. Charlone, I. de Miguel, A. Valdivielso, J.M. Cuyas, D. Perez, et al.,
Complications in cochlear implantation, Acta Otorrinolaringol. Esp. 57 (3) (2006)
122125.
[45] J.M. Hempel, L. Jager, U. Baumann, E. Krause, G. Rasp, Labyrinth dysfunction 8
months after cochlear implantation: a case report, Otol. Neurotol. 25 (5) (2004)
727729.
[46] R.E. Neilan, K. Pawlowski, B. Isaacson, P.S. Roland, Cochlear implant device failure
secondary to cholesterol granuloma-mediated cochlear erosion, Otol. Neurotol.
33 (5) (2012) 733735.
[47] M. Cote, P. Ferron, F. Bergeron, R. Bussie`res, Cochlear reimplantation: causes of
failure, outcomes, and audiologic performance, Laryngoscope 117 (7) (2007)
12251235.
[48] Y.Z. Liu, K.L. Cao, Y. Wang, C.G. Wei, L.J. Yang, Local response caused by implant
after cochlear implantation, Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 43 (6)
(2008) 409413.
[49] S. Puri, J.L. Dornhoffer, P.E. North, Contact dermatitis to silicone after cochlear
implantation, Laryngoscope 115 (10) (2005) 17601762.
[50] V. Neelam, V. Sanjay, M. Manoj, Case report biolm infection of a cochlear
implant, Cochlear Implants Int. 14 (2) (2012) 117120.
[51] K. Ruellan, J.H. Frijns, G.V. Bloemberg, C. Hautefort, T. Van den Abbeele, G.E.
Lamers, et al., Detection of bacterial biolm on cochlear implants removed
because of device failure, without evidence of infection, Otol. Neurotol. 31 (8)
(2010) 13201324.
[52] K.S. Pawlowski, D. Wawro, P.S. Roland, Bacterial biolm formation on a human
cochlear implant, Otol. Neurotol. 26 (5) (2005) 972975.
[53] R. Cristobal, C.E. Edmiston Jr., C.L. Runge-Samuelson, H.A. Owen, J.B. Firszt, P.A.
Wackym, Fungal biolm formation on cochlear implant hardware after antibiotic-induced fungal overgrowth within the middle ear, Pediatr. Infect. Dis. J. 23 (8)
(2004) 774778.
[54] J. Gosepath, J. Maurer, W.J. Mann, Epidural hematoma after cochlear implantation
in a 2.5-year-old boy, Otol. Neurotol. 26 (2) (2005) 202204.
[55] V.S. Sunkaraneni, A. Banerjee, R.F. Gray, Subdural haematoma: a complication of
cochlear implantation, Laryngol. Otol. 118 (12) (2004) 980982.
[56] G.A. Stamatiou, E. Kyrodimos, A. Sismanis, Complications of cochlear implantation in adults, Ann. Otol. Rhinol. Laryngol. 120 (7) (2011) 428432.
[57] E.J. Son, S.C. Kim, J.Y. Choi, Cochlear implant electrode misplaced in the carotid
canal, Arch. Otolaryngol. Head Neck Surg. 133 (8) (2007) 827829.
[58] R.A. Tange, W. Grolman, A. Maat, Intracochlear misdirected implantation of a
cochlear implant, Acta Otolaryngol. 126 (6) (2006) 650652.
[59] B.R. Gastman, B.E. Hirsch, I. Sando, M.B. Fukui, M.L. Wargo, The potential risk of
carotid injury in cochlear implant surgery, Laryngoscope 112 (2) (2002) 262266.
[60] R. Jain, S.K. Mukherji, Cochlear implant failure: imaging evaluation of the electrode course, Clin. Radiol. 58 (2003) 288293.
[61] H. Bertuleit, C. Groden, H.J. Schafer, R. Leuwer, Removal of a cochlea implant with
chronic granulation labyrinthitis and foreign body reaction, Laryngorhinootologie
78 (6) (1999) 304306.
[62] E.C. Ho, C. Dunn, D. Proops, A. Wareld, Case report: explantation of a cochlear
implant secondary to chronic granulating labyrinthitis, Cochlear Implants Int. 4
(4) (2003) 191195.
[63] J. Levi, L. Looney, R. Murray, Y. Inverso, R. OReilly, T. Morlet, Auditory
nerve function following cochleitis, Int. J. Pediatr. Otorhinolaryngol. 76 (2012)
16961701.
[64] S. Qiu, R.F. Gray, S. Kumar, P. Axon, Pneumocoele after cochlear implantation,
Cochlear Implants Int. 13 (3) (2012) 188192.
[65] T. Rother, C. Albrecht, P.R. Issing, Pneumolabyrinth after cochlear implantation in
large vestibular aqueduct syndrome: a case report, Am. J. Otolaryngol. 32 (5)
(2011) 430432.
[66] J. Nevoux, N. Loundon, N. Leboulanger, G. Roger, H. Ducou Le Pointe, et al.,
Cochlear implant in the carotid canal. Case report and literature review, Int. J.
Pediatr. Otorhinolaryngol. 74 (6) (2010) 701703.
[67] C. Arnoldner, S. Helbig, J. Wagenblast, W. Gstoettner, Cochlear implant reference
electrode migration to dura mater, Otol. Neurotol. 30 (7) (2009) 10131014.
[68] H.J. Lim, E.S. Lee, H.Y. Park, K. Park, Y.H. Choung, Foreign body reaction
after cochlear implantation, Int. J. Pediatr. Otorhinolaryngol. 75 (11) (2011)
14551458.
[69] I.O. Ott, B. Schwab, H. Becker, P.R. Issing, Pneumolabyrinth after cochlear implantation in large vestibular aqueduct syndrome, Otol. Neurotol. 29 (7) (2008) 1037
1038.
[70] L.D. Kunda, K.R. Stidham, M.M. Inserra, P.S. Roland, D. Franklin, J.B. Roberson Jr.,
Silicone allergy: a new cause for cochlear implant extrusion and its management,
Otol. Neurotol. 27 (8) (2006) 10781082.

A. Benatti et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 885893

[71] E.C. Ho, D. Proops, P. Andrews, J. Graham, Unexpected exit of a cochlear implant
electrode through the wall of the basal turn of the cochlea a report on two
patients, Cochlear Implants Int. 8 (3) (2007) 162171.
[72] M.M. Khatwa, A. Khan, J. Osborne, Surgical emphysema: a rare complication
following cochlear implantation, Cochlear Implants Int. 8 (3) (2007) 158161.
[73] H. Staecker, H. Chow, J.B. Nadol Jr., Osteomyelitis, lateral sinus thrombosis, and
temporal lobe infarction caused by infection of a percutaneous cochlear implant,
Am. J. Otol. 20 (6) (1999) 726728.
[74] A.O. Makarem, C. Schaudinn, P. Webster, F.H. Linthicum, Possible role of biolm in
fulminant meningitis related to cochlear implantation of dysplastic inner ear, Rev.
Laryngol. Otol. Rhinol. (Bord) 129 (45) (2008) 245248.
[75] F.J. Cervera-Paz, F.H. Linthicum Jr., Cochlear wall erosion after cochlear implantation, Ann. Otol. Rhinol. Laryngol. 114 (7) (2005) 543546.
[76] H.X. Xu, S.S. Joglekar, M.M. Paparella, Labyrinthitis ossicans, Otol. Neurotol. 30
(4) (2009) 579580.
[77] B. Isaacson, T. Booth, J.W. Kutz Jr., K.H. Lee, P.S. Roland, Labyrinthitis ossicans:
how accurate is MRI in predicting cochlear obstruction? Otolaryngol. Head Neck
Surg. 140 (5) (2009) 692696.
[78] M. Durisin, S. Bartling, C. Arnoldner, M. Ende, J. Prokein, A. Lesinski-Schiedat, et al.,
Cochlear osteoneogenesis after meningitis in cochlear implant patients: a retrospective analysis, Otol. Neurotol. 31 (7) (2010) 10721078.
[79] M. Sainz, J. Garcia-Valdecasas, J.M. Ballesteros, Complications and pitfalls of
cochlear implantation in otosclerosis: a 6-year follow-up cohort study, Otol.
Neurotol. 30 (8) (2009) 10441048.
[80] C.H. Choi, J.S. Oghalai, Predicting the effect of post-implant cochlear brosis on
residual hearing, Hear. Res. 205 (12) (2005) 193200.
[81] European consensus statement on cochlear implant failures and explantations,
Otol. Neurotol. 26 (6) (2005) 10971099.
[82] M.C. Thigpen, C.G. Whitney, N.E. Messonnier, E.R. Zell, R. Lyneld, J.L. Hadler, et al.,
Bacterial meningitis in the United States, 19982007, N. Engl. J. Med. 364 (21)
(2011) 20162025.

893

[83] F.H. Linthicum Jr., F.R. Galey, Histologic evaluation of temporal bones with
cochlear implants, Ann. Otol. Rhinol. Laryngol. 92 (6 Pt 1) (1983) 610613.
[84] J.K. Doherty, F.H. Linthicum Jr., Cochlear endosteal erosion with focal
osteomyelitis induced by cochlear implantation, Otol. Neurotol. 25 (6)
(2004) 10291030.
[85] J.N. Fayad, A.O. Makarem, F.H. Linthicum Jr., Histopathologic assessment of
brosis and new bone formation in implanted human temporal bones using
3D reconstruction, Otolaryngol. Head Neck Surg. 141 (2) (2009) 247252.
[86] J.B. Nadol Jr., D.K. Eddington, Histologic evaluation of the tissue seal and biologic
response around cochlear implant electrodes in the human, Otol. Neurotol. 25 (3)
(2004) 257262.
[87] M.D. Eaton, Autoimmunity induced by syngeneic splenocyte membranes
carrying irreversibly adsorbed paramyxovirus, Infect. Immun. 27 (3) (1980)
855861.
[88] N.S. Asfandiyarova, Cell-mediated immunity to insulin: a new criterion for
differentiation of diabetes mellitus? Med. Hypotheses 78 (3) (2012) 402406.
[89] M. Polak, S.A. Ulubil, A.V. Hodges, T.J. Balkany, Revision cochlear implantation for
facial nerve stimulation in otosclerosis, Arch. Otolaryngol. Head Neck Surg. 132
(4) (2006) 398404.
[90] J.S. Toung, T. Zwolan, T.R. Spooner, S.A. Telian, Late failure of cochlear implantation resulting from advanced cochlear otosclerosis: surgical and programming
challenges, Otol. Neurotol. 25 (5) (2004) 723726.
[91] L.J. Rotteveel, D.W. Proops, R.T. Ramsden, S.R. Saeed, A.F. van Olphen, E.A.
Mylanus, Cochlear implantation in 53 patients with otosclerosis: demographics,
computed tomographic scanning, surgery, and complications, Otol. Neurotol. 25
(6) (2004) 943952.
[92] T.S. Huang, P.T. Yen, S.Y. Liu, Cochlear implantation in a patient with osteogenesis
imperfecta and otospongiosis, Am. J. Otolaryngol. 19 (3) (1998) 209212.
[93] S.A. Telian, S. Zimmerman-Phillips, P.R. Kileny, Successful revision of failed
cochlear implants in severe labyrinthitis ossicans, Am. J. Otol. 17 (1) (1996)
5360.