1

LITERATURE READING

Oke Kadarullah




Department of Otorhinolaryngology-Head and Neck Surgery
Hasan Sadikin Hospital
Medical Faculty Padjadjaran University
2012
INTRODUCTION
Hearing loss poses a monumental obstacle of
effective communication skills.
The perception and the production of speech are
highly dependent on the ability to process
auditory information.
Early identification
An appropriate sensory aid recommended.
Conventional amplification is initial choice.
cochlear implants or other implantable hearing
aids.
2
Anatomy & Physology of Hearing
3
Preview animasi
History Cochlear Implant
Djourno and Eyries direct excitation of the
auditory nerve in 1957.
1964 Simmons et al. electrical stimulation of the
intracranial portion of the auditory nerve.
1971 Michaelson : stimulation of the cochlea .
1976 Dr. William House first introduced the
cochlear implant.
Single electrode multiple electrode/multi
channel
4
Component CI system
Microphone.
Speech processor.
Electrode array.

5
Role of The Cochlea
Preview animasi
6
The Cochlea (Spiral Ganglion)
7
Otte et al : We Need
10.000 ganglion
cells with 3.000
apically to have a
good speech
discrimination
How CI Works
8
Preview animasi
Implant Selection

Nucleus
Clarion/Bionic
MedEl


9
Selection & Evaluation of Patients
Adults
18 years old and older (no limitation by age)
Bilateral severe-to-profound sensorineural hearing
loss (70 dB hearing loss or greater with little or no
benefit from hearing aids for 6 months)
Psychologically suitable
No anatomic contraindications
Medically not contraindicated


10
Selection & Evaluation of Patients
Children
12 months or older
Bilateral severe-to-profound sensorineural hearing
loss with PTA of 90 dB or greater in better ear
No appreciable benefit with hearing aids (parent
survey when <5 yo or 30% or less on sentence
recognition when >5 yo)
Must be able to tolerate wearing hearing aids and
show some aided ability
Enrolled in aural/oral education program
No medical or anatomic contraindications
Motivated parents


11
Contraindications
Incomplete hearing loss
Neurofibromatosis II, mental retardation, psychosis,
organic brain dysfunction, unrealistic expectations
Active middle ear disease
CT findings of cochlear agenesis (Michel deformity) or
small IAC (CN8 atresia)
Dysplasia not necessarily a contraindication, but
informed consent is a must
H/O CWD mastoidectomy
Labyrinthitis ossificansfollow scans
Advanced otosclerosis

12
Classification of Cochlear Implant Recipients
1. Postlingually deafened adults and children:
deaf at or after age 5 years
High level of success

2. Congenitally or early deafened children:
most frequently encountered type of profound SNHL
variable results

3. Congenitally or early deafened adolescents and adults:
patient who has had little or no experience with sound
low level of success
13
General Workup
Audiologic exam with binaural amplification
CT scan/MRI of temporal bones
Trial of high-powered hearing aids
Psychological evaluation
Medical evaluation
Any necessary tests to discover etiology of hearing
loss
14
Surgical Anatomy
15
Mastoidectomy
16
Posterior Tympanotomy
17
Cochleostomy
18
SURGICAL IMPLANTATION
19
SURGICAL IMPLANTATION
20
SURGICAL IMPLANTATION
21
SURGICAL IMPLANTATION
22
23
SURGICAL IMPLANTATION
Step by step surgery
24
Preview film
Special Circumstances
Cochlear Ossification
Cochlear Malformation
Bilateral Implantation

25
Postoperative Management
Initial Stimulation & Device Programming
Post operative Rehabilitation
26
Complication
Infrequent
Wound infection
Facial nerve injury
Tinnitus
Infected foreign body
Electronic malfuction
Delayed mastoiditis postauricular abscess.
Meningitis
Further degeneration of the central auditory
system
27
Result
Wide range of outcomes
(subjective & objective measurements)

Adult outcome

Pediatric outcome
Spoken word recognition
Speech production and language outcomes


28
Other Implantable Hearing Devices
Implantable Hearing Devices (IHDs) that couple with the
ossicular chain in the middle ear

Advantages of IHDs :
(1)elimination of acoustic feedback
(2)a wider frequency response
(3)elimination of a tight-fitting external ear canal mold
(4)improved perception of the auditory signal.

Devices :
Vibrant Soundbridge
Direct System


29
Vibrant Soundbridge
30
Components:
(1)A surgically implanted internal receiver that
includes the floating mass transducer, which is
crimped onto the long process of the incus
(2)External processor, which picks up sound from
the environment and transmits the signal to
the implanted receiver. The implant is
positioned through a mastoid-facial recess
approach


Vibrant Soundbridge
Appropriate for moderate sensorineural hearing loss
Not appropriate for conductive hearing loss or
retrocochlear hearing loss
Speech discrimination must be at least 50%.
A stable middle ear should be present and the tympanic
membrane must be intact.
Average functional gain of 10 to 15 dB across the
frequency spectrum
Aided speech recognition scores comparable with
conventional hearing aids
31
Direct System
consists of :
a neodymium-iron-boron (Nd-Fe-Bo) magnet
implanted at the incudostapedial joint via a transcanal
procedure
An external processor produces an electromagnetic field
that sets the implanted magnet into motion.
Average functional gain of 10 to 15 dB for all tested
frequencies lower than 6 Hz.
There was no significant change in average residual hearing

32

HIGHLIGHTS

Cochlear implants (multichannel design)
sound information : intensity, timing, and
frequency.

Postlinguistically deafened adults the
most predictable beneficiaries of cochlear
implants.

Ossified or congenitally deformed cochleas
(i.e., Mondini deformity) do not
contraindicate cochlear implantation.

33
HIGHLIGHTS
A detailed hearing-aid trial with training is
required to compare hearing-aid performance
with that expected with a cochlear implant.

The standard surgical approach is through the
mastoid and facial recess, providing access to
the round window.

Detailed longitudinal studies are now clearly
demonstrating improvements in speech
perception and speech production.

34
THANK YOU
35
Cumming otolaryngology HNS 4
th
ed Elsevier 2007
Bailey BJ, Head & Neck Surgery - Otolaryngology, 4th Edition
Lippincott Williams & Wilkins 2006
Snow, JB., Ballenger JJ, Otorhinolaryngology Head and Neck
Surgery, sixteenth Edition, BC Decker 2003
Dhingra PL, Diseases of Ear, Nose and Throat, 4
th
edition,
Elsevier, 2005
Moller, A.R, Cochlear and Brainstem Implants, Karger, 2006
Ulug T., Atlas of Temporal Bone Surgery, 1
st
edition,Thieme, 2010
Niparko J.K, CochlearImplants: Principles and Practice, 2
nd
,
Lippincott, 2009