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Objective: To examine the number of magnetic resonance imaging (MRI) examinations performed in patients with hearing implants and to quantify side effects or complications related to this procedure., Study Design: Questionnaire., Setting: Tertiary referral center, academic hospital., Patients: One thousand four hundred sixty-onepatients with an implanted hearing system., Intervention: Patients were asked to complete a questionnaire either during a visit to the clinic (304) or by mail contact (1,157) between February 2018 and March 2019., Main Outcome Measures: Number of examinations by means of MRI per patient and number of side effects or complications., Results: A total of 711 questionnaires were returned. After excluding nonvalid information on the questionnaire, 12.8% of patients were identified who had undergone an MRI after having received their hearing implant. Within this group of 91 patients, the most common precaution undertaken was a head bandage (69%). Side effects were mainly pain (37%), followed by anxiety (15%) and tinnitus (9%). The MRI had to be aborted in 14% and dislocation of the magnet occurred in 7% of examinations., Conclusions: Our data indicate that patients undergoing hearing implant surgery need better information about the limitations and requirements of MRI. The occurrence of side effects is likely as only half of the patients in our study group were completely free of symptoms. Dislocation of the implant magnet was observed in several cases, hence patients and physicians need to be educated about this potential complication., Competing Interests: The authors disclose no funding and conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Hypothesis: The risk of electrode migration in cochlear implant (CI) surgery can be reduced by securing the electrode lead in a bone groove in the chorda-facial angle., Background: Electrode migration is an important complication in CI surgery, which affects hearing performance, may induce pain and facial nerve stimulation, and requires surgical revision. A potential method to secure the electrode is to use a bone groove created in the facial recess to fixate the electrode lead. This surgical measure is a standard procedure for lateral wall electrodes (LWE) in our clinic since 2013., Methods: Retrospective analysis of consecutive CI cases of a tertiary referral center from 2006 to 2016 and comparison of incidence rates between group A (without bone groove, years 2006-2012) and group B (with bone groove fixation, years 2013-2016). Clinical cases were reviewed with respect to electrode type, migration length, time interval to migration, and findings during revision surgery., Results: Seventeen cases of electrode migration were found in a total of 1,603 cochlear implantations. Only LWE designs were affected by migration. The cumulative incidence for LWE in group B (0.5%) was significantly lower than in group A (3.7%, p < 0.01). The two migration cases in group B revealed insufficient geometric design of the bone grooves. Only one patient experienced a remigration after revision surgery., Conclusion: The fixation in a bone groove in the chorda-facial angle is an effective measure against migration of LWE. Proper surgical execution is mandatory to ensure a tight and enduring fit.

Objective: Incidence and clinical presentation of tip foldover during cochlear implantation (CI)., Study Design: Retrospective case review., Setting: Tertiary referral university hospital., Patients: One thousand three hundred twenty CI recipients who underwent postoperative Stenvers view, digital computed tomography (CT), or digital volume tomography (DVT)., Main Outcome Measure: Tip foldover rates were evaluated with regard to perimodiolar (PM), lateral wall (LW), and mid-scalar (MS) electrode carriers; the electrode insertion angle was estimated and postoperative complications and the necessity for revisions were described., Results: One thousand three hundred twenty CI recipients (1,722 ears) had detailed surgery reports and postoperative imaging available for review. Tip foldover occurred in 15 ears (0.87%) with the highest rate (1.67%) for PM electrodes. In three patients tip foldover was accompanied by costimulation of the facial nerve and one patient reported vertigo. Eleven patients underwent revision surgery. In two of them revision was performed in the same surgical intervention due to abnormality in spread of excitation measurement. In four patients no revision was conducted due to uncompromised aided speech perception., Conclusion: In a large academic center with experienced surgeons, tip foldover verified by CT/DVT arose at a rate of 0.87%. PM electrode carriers inherited the highest risk for this electrode malposition. Revision surgery was feasible in these cases.

Objective: This study reviewed outcomes of hearing preservation (HP) surgery depending on the angle of insertion (AOI) in a cochlear implant (CI) patient population who used electric stimulation (ES) or combined electric-acoustic stimulation (EAS)., Study Design: Retrospective case review., Setting: Tertiary referral university hospital., Patients: Ninety-one patients with different degrees of preoperative low-frequency residual hearing who underwent HP surgery with a free-fitting lateral-wall electrode array (MED-EL Flex) with lengths ranging from 20.0 to 31.5 mm., Intervention: Cochlear implantation using HP surgery technique and subsequent fitting with CI speech processor for ES, or combined CI and hearing aid speech processor for EAS., Main Outcome Measures: Individual AOI were estimated using modified Stenvers' projection. Freiburg monosyllable test in quiet (free-field presentation at 65 dB SPL) and pure-tone averages for low frequencies (125, 250, and 500 Hz; PTAlow) were evaluated during a follow-up period of 12 months after implantation., Results: Estimated AOIs showed bimodal distribution: shallow insertion (SI) with mean AOI of 377 degrees and deep insertion (DI) with mean AOI of 608 degrees. Speech test scores after 12 months were comparable between AOI groups, however, they were significantly different between stimulation types with better scores for EAS. Only ES showed a positive correlation (r = 0.293) between speech test score and AOI. When HP was possible, both SI and DI showed significant postoperative PTAlow shifts with mean of 17.8 and 21.6 dB, respectively. These were comparable between AOI groups and no significant shifts were observed in follow-up intervals. Audiometric indication for HP and subsequent EAS is proposed up to 65 dB HL at 500 Hz, and up to 87 dB HL for HP., Conclusions: CI candidates can benefit from HP surgery with deep insertion when only using ES due to insufficient residual hearing. Conversely, candidates with preoperative threshold up to 65 dB HL at 500 Hz could perform significantly better with EAS which requires shallow insertion.

Purpose of Review: In the era of increasing antibiotic resistance worldwide, this review highlights the advantages of revival of old antibiotics for treatment of uncomplicated urinary tract infections (uUTIs)., Recent Findings: Recent studies have shown that these four oral old antibiotics, fosfomycin trometamol, nitrofurantoin, nitroxoline and pivmecillinam, show no increasing antibiotic resistance against uropathogens causing uUTI, are still effective for the treatment of uUTI and exhibit only minimal or no collateral damage as compared with fluoroquinolones or third-generation cephalosporines., Summary: According to the principles of antibiotic stewardship, the prudent use of antibiotics is needed. Therefore, recent international and national guidelines already favour these old oral antibiotics as first-choice treatment of uUTI. Unfortunately, implementation of these guidelines is still suboptimal.

Objective: The present study reviewed a cochlear implant (CI) patient population after surgery, which received a free-fitting electrode carrier designed for hearing preservation. The aim was to determine the rate of electrode migration of the CI electrodes and present clinical and surgical implications., Study Design: Retrospective patient review., Setting: Tertiary referral university hospital., Patients: Two hundred seventy-eight patients implanted uni- or bilaterally with lateral wall electrodes designed for hearing preservation (358 implants). The control group was 323 patients implanted uni- or bilaterally with preformed perimodiolar electrodes (468 implants)., Interventions: Determination of CI electrode migration was conducted according to a clinical test protocol. Revision surgery was offered in confirmed patients of electrode migration. A bone groove was considered to improve the fixation of the electrode., Main Outcome Measures: Audiological testing including speech audiometry, subjective sound quality rating, and bilateral pitch comparison in bilateral patients, as well as radiological examinations, were conducted., Results: Electrode migration was observed solely in patients implanted with lateral wall electrodes; 10 of 358 patients with free-fitting electrodes (2.8%) had electrode migration, which was successfully confirmed by the proposed clinical test protocol. Nine of the 10 confirmed patients underwent reinsertion surgery. Mean perception score decreased from 75.0% to 62.1% after electrode migration and recovered completely after reinsertion surgery. A flowchart to detect electrode migration was designed for clinical practice., Conclusion: Although electrode migration is a rare complication in CI surgery, long-term follow-up diagnostics should include a test protocol to detect electrode shifts of lateral wall electrode arrays. A reinsertion surgery should be conducted in confirmed patients to recover speech perception.

Objective: This study reviewed outcomes of hearing preservation (HP) surgery in a cochlear implant patient population, with clinical follow-up results up to 11 years after implantation., Study Design: Retrospective case review., Setting: Tertiary referral university hospital., Patients: Ninety six patients (103 ears) with partial deafness who underwent HP surgery at the University Hospital Frankfurt since 1999 were included. Electrode carriers were Cochlear Slim Straight, MED-EL Standard, Medium, Flex, and Flex., Intervention: Cochlear implantation using the HP surgery technique with either the cochleostomy or round window approach., Main Outcome Measures: Pure-tone averages for low frequencies (125 Hz, 250 Hz, 500 Hz, PTAlow) and speech perception scores of the Freiburg monosyllable and number tests in quiet. PTAlow shifts were used to evaluate HP as complete for ≤10 dB, partial between 10 and 30 dB, and minimal for ≥30 dB. Time intervals were: preoperative, postoperative, after 12 months, and long-term (>24 months, mean 51.4 months, range 2-11 years). Impacts of electrode design and surgical approach were analyzed., Results: Postoperatively (n = 103), HP was complete in 32 (31.1%), partial in 49 (47.6%), minimal in 14 (13.6%), and loss of hearing occurred in 8 cases (7.8%). After 12 months (n = 81), HP was complete in 22 (27.2%), partial in 33 (40.7%), minimal in 11 (13.6%), and loss of hearing occurred in 7 additional cases. For long-term outcomes (n = 62) HP was complete in 7 (11.3%), partial in 24 (38.7%), minimal in 9 (14.5%), and loss of hearing occurred in 7 additional cases (total 22/103, 21.4%). Cases with residual hearing who could utilize acoustic amplification (i.e., PTAlow < 80 dB HL) were 82/95 (85.3%) postoperatively, 58/66 (87.9%) after 12 months, and 38/40 (95.0%) for long-term outcomes., Conclusions: Long-term HP is feasible in a subset of patients. Patients with sufficient long-term residual hearing had the prerequisite to benefit from additional acoustic stimulation. No correlation of total hearing loss with etiology, electrode design, or surgical approach was evident. Apart from individual effects of structural damage or inflammation, genetic factors are suggested to influence HP. Cases with total hearing loss still demonstrated successful speech perception in long-term monosyllable recognition scores.

Objective: The present study aimed to determine the extent of hearing preservation retrospectively after atraumatic cochlear implant (CI) surgery using a specialized surgical technique and specially designed flexible electrode to minimize cochlear trauma., Study Design: Retrospective study., Setting: Academic tertiary care center., Patients: A consecutive series of 34 patients who had some preoperative residual hearing were included in this study., Intervention: Patients underwent CI surgery with a flexible 28-mm electrode using a round window insertion technique., Main Outcome Measures: All patients had at least 6 months of postoperative follow-up including audiometric testing and speech perception determined using the Freiburg monosyllable word test and the Oldenburger Sentence Test in noise. Audiometric testing served as a proxy for the evaluation of cochlear trauma and hearing preservation., Results: Hearing was preserved to within 20 dB of preoperative low-frequency pure-tone audiometry (PTA) in 40.7% of patients. Hearing was preserved to within 20 dB of preoperative high-frequency PTA in 35.7% of patients. Overall, a deterioration in hearing thresholds was observed between preoperative assessment and first fitting. Speech perception improved significantly over time after surgery., Conclusion: Using appropriate surgical techniques, and electrodes specially designed to minimize cochlear trauma, hearing preservation can be achieved.

Objective: The combination of electrical and acoustical hearing (EAS) is the aim of successful hearing preservation in patients with low-frequency residual hearing who receive a cochlear implant. With adequate surgical treatment and electrode arrays designed for hearing preservation, partial hearing preservation can nowadays be achieved in the majority of patients. Over recent years, the number of patients with EAS has increased, and device failures within this group are a problem that will need to be addressed. It remains unclear how reliably hearing can be preserved during revision surgery. The outcome of 3 subjects requiring cochlear reimplantation after surgery for hearing preservation is presented and discussed. Our aim was to investigate the influence of electrode reinsertion on hearing preservation., Patients: Three patients with measurable residual hearing were implanted with a flexible, free-fitting electrode array in 3 different centers., Interventions: Two subjects received a 31.5-mm array inserted 24 mm into the cochlea, whereas a third was treated with a 24-mm array, which was inserted 21 mm into the cochlea. In all cases, hearing was preserved at the initial operation. All of these subjects subsequently represented with device problems, and reimplantation was performed., Main Outcome Measures: Hearing preservation was measured using preoperative and postoperative pure tone audiograms. In addition, speech perception with the implant was evaluated before and after reimplantation surgery., Results: Reimplantation was feasible in all subjects also in cases where a slightly deeper reinsertion was performed. Speech understanding scores after reimplantation were comparable to those seen after the first intervention., Conclusion: Revision surgery in patients with preserved hearing after cochlear implantation does not necessarily lead to loss of natural residual hearing, and patients can continue to benefit from the combination of electric and acoustic hearing. Even deeper insertion is possible without hearing loss within residual frequencies.

Objectives: This study aimed to evaluate the possibility of predicting radiologically the scalar localization of a 31.5-mm-long, free-fitting electrode carrier for cochlear implantation, using conventional planar computed tomography., Study Design: A cross-sectional human temporal bone study was conducted., Setting: Twenty human temporal bones were acquired postmortem and implanted with 31.5-mm-long electrode carriers. Ten of these were implanted into the scala tympani using the round window approach, whereas the other 10 electrodes were inserted into the scala vestibuli by cochleostomy. Computed tomography was then performed, and 2 experienced blinded radiologists evaluated the intracochlear position of the array., Main Outcome Measure: The estimated position of the electrode carrier was described using a 5-point scale. After sectioning and histologic investigation, the results of the radiologic and histologic investigations were compared., Results: In 17 of 20 cases, it was possible to estimate the correct position of the electrode carrier within the basal turn of the cochlea by means of computed tomography. As the insertion angles widened beyond 360 degrees, it became increasing difficult for the radiologists to correctly determine the position of the electrode carrier., Conclusion: The comparison of our temporal bone experiment results with the computed tomography results revealed the difficulty of assessing the correct position of intracochlear electrodes. Scalar localization of deeply inserted electrode carriers cannot be precisely determined by means of computed tomography.

Hypothesis: To evaluate histologically the risk of trauma to intracochlear structures after sequential insertion of an intracochlear catheter and an electrode array., Background: A previous computed tomographic scan-based study demonstrated that introduction of a flexible disposable intracochlear catheter for drug delivery to a distance of up to 15 mm was feasible and showed no radiologic evidence of basilar membrane trauma., Methods: Fifteen fresh human temporal bones were prepared for cochlear implantation. We sequentially performed the introduction of the catheter, the injection of 15 µl of an iodine solution into the scala tympani via the catheter, and the removal of the catheter in 14 temporal bones, and finally, 2 types of electrode array (Flex EAS and Flex Soft) from MED-EL, were inserted into 10 temporal bones. The bones were fixed and embedded in methylmethacrylate to cut the undecalcified temporal bones parallel to the modiolus axis with the electrode array in place, and each histologic section was photographed to document the location and extent of trauma in the cochlea., Results: No specific damage (Grade 0 trauma) to cochlear structures occurred in 12 temporal bones, and elevation of basilar membrane (Grade 1 trauma) occurred in 2 cases. The electrode array was positioned in the scala tympani under the basilar membrane in all temporal bones, with one exception, in which the Flex Soft electrode array deviated behind the spiral ligament and into the scala vestibuli apically (Grade 3 trauma)., Conclusion: The infusion of an iodine solution within an intracochlear catheter and the subsequent insertion of an electrode array was shown to be feasible and often atraumatic.

Objectives: To demonstrate the possibility of atraumatic insertion with the free-fitting FLEX electrode by evaluating the degree of hearing preservation postoperatively., Design: Retrospective study., Setting: Academic tertiary care center., Participants: Twenty-two severely to profoundly hearing impaired subjects with measurable residual hearing preoperatively., Intervention: Atraumatic implantation with the 31.5-mm-long, free-fitting, and highly flexible FLEX electrode using either the round window approach or a cochleostomy technique., Main Outcome Measures: Subjects were tested preoperatively in unaided condition and at varying intervals postoperatively. Preoperative and postoperative low-frequency pure-tone average (PTA) and PTA shifts were calculated. Speech perception was measured preoperatively and postoperatively using the Freiburger monosyllabic word test in quiet., Results: Preoperative low-frequency hearing could be preserved to a certain degree in 77.3% of subjects (17/22) after insertion of the FLEX electrode up to the point of first resistance. Complete loss of residual hearing was observed in 22.7% of subjects (5/22). In 18.2% of the subjects (4/22), the preoperative PTA was preserved within 10 dB. Pure-tone average results between preoperative and most recent testing showed statistically significant differences (p < 0.001 to p = 0.031) for almost all loudness levels ranging from 125 Hz to 1.5 kHz. The maximum threshold shift was 40 dB at 250 Hz for the lower frequencies up to 1 kHz. Monosyllable testing in quiet demonstrated significant improvement over time (p < 0.001)., Conclusion: This study showed that preservation of residual hearing is possible in a high number of subjects when a flexible electrode and atraumatic surgical techniques are used.

Objectives: This study aimed to evaluate an atraumatic prototype electrode carrier for cochlear implantation, the FLEX electrode. This electrode is designed to preserve hearing and to achieve a 360-degree insertion., Study Design: A cross-sectional human temporal bone study was conducted., Setting: Preliminarily, the prototype electrode was inserted in a scala tympani model to measure the insertion force. Thirteen human temporal bones were acquired postmortem and implanted with the new device using the round window approach. Three of them were implanted under radiologic control to demonstrate the insertion path. After embedding, the remaining 10 temporal bones were sectioned undecalcified and examined macroscopically and histologically., Main Outcome Measures: The insertion force was measured to determine intracochlear resistance peaks. The insertion angle was measured, and the degree of intracochlear trauma was determined., Results: The round window approach caused cochlear trauma in 1 of 10 specimens. An exact 360-degree insertion was achieved in 7 of 10 specimens (mean overall insertion angle, 360 degrees). Radiologic examination and insertion force measurements revealed the smooth and atraumatic insertion., Conclusion: The new prototype electrode carrier is suitable for clinical application. It can be handled easily and allows atraumatic 360-degree insertion of all electrode contacts. Therefore, this electrode concept allows good coverage of the cochlea for electrical and additional acoustic stimulation., (© 2011, Otology & Neurotology, Inc.)