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It is important for the surgeon to determine the position of the CI electrode array during and after its placement within the cochlea. Most preferably, this should be within the scala tympani to obtain the best audiological outcome. Thus, misplacement into the scala vestibuli or tip fold-over should be prevented. Since there are different ways to ensure proper positioning of the electrode array within the scala tympani (e.g., intraoperative radiography, electrophysiological recordings), our study was aimed at detecting intraoperative electrophysiologic characteristics to better understand the mechanisms of those electrode tip fold-overs. In a multi-centric, retrospective case–control series, patients with a postoperatively by radiography detected tip fold-over in perimodiolar electrodes were included. The point of fold-over (i.e., the electrode position) was determined and the intraoperative Auto-NRT recordings were analysed and evaluated. Four patients were found to have an electrode tip fold-over (out of 85 implantees). Significant changes of the Auto-NRT recordings were not detected. All tip fold-overs occurred in the most apical part of the electrodes. Cochlear implantation for hearing impaired patients plays a decisive role in modern auditory rehabilitation. Perimodiolar electrode arrays may fold over during the insertion and, hence, could have a negative impact on audiological outcome. Characteristic electrophysiologic changes to possibly predict this were not found in our series.

Benign paroxysmal positional vertigo (BPPV) is the most common type of vertigo, caused by otoconia falling from the utricle into a semicircular canal (SCC). After successful repositioning maneuvers residual dizziness (RD) has been described and several reasons are used to explain RD. It can last for only a few days or weeks, but also much longer. We present a patient with a severe traumatic loss of otoconia from both maculae utriculi and a persistent imbalance more than 9 years. We think that the loss of otoconia from the utricular and probably also saccular macula induced a sudden reduction of her ability to sense gravity thus logically explaining her symptoms. We show the vestibular test results also supporting our hypothesis and we extrapolate this support to other forms of so far unexplained dizziness especially increasing imbalance with aging. We also discuss the normal c- and oVEMP indicating intact haircell function and supporting our hypothesis of isolated otoconial loss as the major cause for imbalance.

To compare the standard T-Mic setting to UltraZoom and StereoZoom in 10 unilateral cochlear implant (CI) users, 10 bimodal device users and 10 bilateral CI users as well as a normal hearing (NH) reference group (n = 10).Speech reception thresholds were measured using the Oldenburg sentence test in noise. Speech was presented from the front at 0°, noise was presented from five loudspeakers spaced at ±60°, ±120°, 180° (setup A) or from four loudspeakers in the front hemisphere at ±30°, ±60° and one at 180° (setup B).There was a significant advantage for UltraZoom and StereoZoom for all groups in both setups. The largest advantage was for StereoZoom in the bilateral group (setup A, 5.2 dB, P 0.001 and B, 3.4 dB, P 0.001) There was a significant advantage for StereoZoom over UltraZoom in the bimodal group (setup A, P 0.01 and B, P 0.05) and in the bilateral group (P 0.01, setup B only). The bilateral group performed as well as the normally hearing group in both setups and the bimodal group performed as well in setup A. There was a significant benefit of 1.8 dB for ClearVoice over UltraZoom alone for the unilateral group.UltraZoom and StereoZoom provided a clinically and statistically significant benefit over the T-Mic condition. The largest gain was shown for StereoZoom in the bimodal and bilateral groups. The use of StereoZoom enabled the bilateral group to perform as well as the normally hearing group in both the challenging speaker setups. However, real life environments might provide an even greater challenge than the conditions tested here.

Objectives Patients with single-sided deafness can nowadays receive a cochlear implant. A majority of these patients are well adapted and benefit from the implant. The aim of this study was to evaluate the reasons for poor performance in a group of patients with single-sided deafness, who received a cochlear implant. Design A total of 65 patients were enrolled into a retrospective case series. Seven poor performers were present in the group. Freiburger monosyllabics, localization testing, and radiologic images were evaluated. Results Localization testing showed the absence of lateralization ability in three patients, whereas the Freiburger monosyllabic word scores improved in three patients. One patient had no speech perception after 1 year of rehabilitation. Findings of magnetic resonance imaging (MRI) revealed cerebral involvement in five patients. Conclusion Various factors influence the outcome in unilateral cochlear implantation in patients with single-sided deafness. These reasons may be preoperative, operative, or postoperative. Nevertheless, the majority of patients benefit from these implants.

Objective: To evaluate the long-term safety and performance of four different vibroplasty couplers (round window, oval window, CliP and Bell coupler) in combination with an active middle ear implant. Methods: This was a multicentre, prospective, long-term study including 5 German hospitals. Thirty adult subjects suffering from conductive or mixed hearing loss were initially enrolled for the study, 24 of these were included in the final analysis with up to 36 months of postsurgical follow-up data. Bone conduction and air conduction were measured pre- and postoperatively to evalu ate safety. Postoperative aided sound field thresholds and Freiburger monosyllable word recognition scores were compared to unaided pre-implantation results to confirm performance. Additional speech tests compared postoperative unaided with aided results. To determine patient satisfaction, an established quality-of-life questionnaire developed for conventional hearing aid usage was administered to all subjects. Results: Mean postoperative bone conduction thresholds remained stable throughout the whole study period. Mean functional gain for all couplers investigated was 38.5 ± 11.4 dB HL (12 months) and 38.8 ± 12.5 dB HL (36 months). Mean word recognition scores at 65 dB SPL increased from 2.9% in the unaided by 64.2% to 67.1% in the aided situation. The mean postoperative speech reception in quiet (or 50% understanding of words in sentences) shows a speech intelligibility improvement at 36 months of 17.8 ± 12.4 dB SPL over the unaided condition. The signal-to-noise ratio (SNR) improved by 5.9 ± 7.2 dB SNR over the unaided condition. High subjective device satisfaction was reflected by the International Inventory for Hearing Aids scored very positively. Conclusion: A significant improvement was seen with all couplers, and audiological performance did not significantly differ between 12 and 36 months after surgery.

Hypothesis It was the aim of this study to establish normative data regarding intended changes in cochlear implants (CI) receiver positioning by one surgeon over time. Background With the increasing number of CI patients, the probability of needing magnetic resonance imaging (MRI) increases. The accessibility of cerebral structures is limited by MRI artifacts caused by CI. New studies show a dependence of the visibility of intracranial structures by the MRI sequences and the position of the CI receiver itself. Methods Retrospective and interindividual investigation of topograms with regard to the nasion-external auditory canal-internal magnet angle and the distance between the internal magnet and the external auditory canal. We evaluated scans of 150 CI recipients implanted from 2008 until 2015. Results The most common implant position in the years 2008 to 2015 was a nasion-external auditory canal-internal magnet angle between 121 and 140 degrees (mean, 127 degrees) and an internal magnet-external auditory canal distance between 61 and 80 mm (mean, 70 mm). Over time the nasion-external auditory canal-internal magnet angle increased and the internal magnet-external auditory canal distance decreased, both to a statistically significant degree. A difference between the manufacturers was not observed. Conclusion The CI receiver position is important for an artifact-free examination of the internal auditory canal and the cochlea. The realization of the position over a time course supports awareness of artifact-related visibility limitations.

Our present findings demonstrate that resealing to cover the electrode is an effective method to treat vertigo after CI. An insufficient cochleostomy sealing can be regarded as a cause of postoperatively newly occuring vertigo after CI. A transtympanic revision is a promising treatment option in cases of post-operative dizziness. Intoduction: A well-known and frequently reported complication after cochlear implantation is the appearance of postoperative vertigo symptoms. The aim of the present study was to observe if the postoperatively new occurrence of vertigo can be treated by resealing of the round window patch after cochlear implantation.A retrospective analysis revealed that 10 patients underwent revision surgery transtympanally. Vertigo was assessed preoperatively and directly postoperatively and after 6 month after revision surgery by using the Dizziness Handycap Inventory (DHI).The most common symptom was rotating vertigo. A spontanous nystagmus was seen in four cases. No nystagmus was found after the revision surgery. In three cases, the onset of dizziness was associated with an event (sneezing, otitis media, climbing a mountain). A preoperative CT showed insuspectible results in seven patients but revealed pathologies two patients. Vertigo was improved significantly in six patients, and three of them were symptom-free.

Objective To preserve residual hearing in cochlear implant surgery, the electrode design has been refined, and an atraumatic insertion has become one aspect of cochlear implant research. Previous studies have described the effect of insertion speed and opening of the round window membrane on intracochlear pressure changes. The aim of our current study was to observe intracochlear pressure changes due to different cochlear implant electrodes in an artificial cochlear model with stable surrounding factors. Study Design Prospective controlled study. Setting Tertiary referral center. Subjects and Methods The experiments were performed in an artificial cochlear model with a pressure sensor in the apical area. With straight and perimodiolar electrode arrays, 5 insertions with the same insertion speed and 5 insertions over the same time were performed. Results With the perimodiolar high-volume electrode, significantly greater intracochlear fluid pressure changes were observed than with the straight electrode. Compared with the straight electrode, the perimodiolar electrode induces significantly higher pressure peaks (1.12 ± 0.15 vs 0.86 ± 0.05 mm Hg, P = .006) and significantly higher amplitudes (0.38 ± 0.07 vs 0.09 ± 0.07 mm Hg, P.001). Conclusion The reliable preservation of residual hearing is an important multifactorial challenge in modern cochlear implant surgery. Insertion speed, handling, and electrode design are known to influence the preservation of residual hearing. In our artificial model experiments, we could prove objectively that the volume of the electrodes has a significant influence on the intracochlear pressure changes during cochlear implantation.

Objectives: An intraoperative neural response telemetry-ratio (NRT-ratio) was established, which can provide information about the intraoperative intracochlear electrode array position for perimodiolar electrodes. Methods: In a retrospective controlled study in 2 tertiary referral centers, the electrophysiological data sets of 50 patients with measured intraoperative auto-NRTs and postoperative radiological examinations were evaluated. All patients were implanted with Nucleus slim straight electrodes. The NRT-ratio was calculated by dividing the average auto-NRT data from electrodes 16 to 18 with the average from electrodes 5 to 7. Using a flat panel tomography system or a computed tomography, the position of the electrode array was certified radiological. Results: Radiologically, 2 out of 50 patients were identified with an electrode translocated from the scala tympani into the scala vestibuli. The radiologically estimated electrodes indicating a scalar change showed a regular NRT-ratio but nonspecific NRT-level changes at the localization of translocation.

BACKGROUND Dehiscence syndromes of the semicircular canals are a relatively new group of neurotological disorders. They have a variety of symptoms with hearing/balance involvement. Younger patients have clinically relevant symptoms in only about one third of cases. In addition to etiology and pathogenesis, the present paper describes diagnostic and therapeutic possibilities using a patient series of the authors. MATERIALS AND METHODS This nonrandomized prospective study included 52 patients with uni-/bilateral dehiscence syndromes of the superior and/or posterior canal (SCDS/PCDS), diagnosed with high-resolution computed tomography (HR-CT) of the petrous bone. Of 41 patients undergoing surgical therapy for severe symptoms-predominantly vertigo attacks (Meniere-like) and/or falls (Tumarkin crises)-31 received single-sided hearing implants. RESULTS Of the 41 patients with transmastoid superior and/or posterior canal occlusion, 30 showed a significant improvement of balance in the Dizziness Handicap Inventory (DHI); the dizzy spells ceased. A positive outcome was correlated with the severity of the preoperative disorder; a poor outcome (nonsignificant increase in DHI, recurrent vertigo of various qualities/frequencies) with the comorbidities vestibular migraine, Meniere's disease of the contralateral ear, and a dehiscence size exceeding 4 mm. CONCLUSION The more severe the vestibular symptoms, the better the outcome of surgical therapy. Auditory symptoms (nonspecific aural fullness, hyperacusis) do not generally respond well to surgical therapy. Cochlear implants have an additional beneficial effect; comorbidities should be considered as (relative) contraindications.

To preserve residual hearing in cochlear implant candidates, the atraumatic insertion of the cochlea electrode has become a focus of cochlea implant research. In a previous study, intracochlear pressure changes during the opening of the round window membrane were investigated. In the current study, intracochlear pressure changes during opening of the round window membrane under dry and transfluid conditions were investigated. Round window openings were performed in an artificial cochlear model. Intracochlear pressure changes were measured using a micro-optical pressure sensor, which was placed in the apex. Openings of the round window membrane were performed under dry and wet conditions using a cannula and a diode laser. Statistically significant differences in the intracochlear pressure changes were seen between the different methods used for opening of the round window membrane. Lower pressure changes were seen by opening the round window membrane with the diode laser than with the cannula. A significant difference was seen between the dry and wet conditions. The atraumatic approach to the cochlea is assumed to be essential for the preservation of residual hearing. Opening of the round window under wet conditions produce a significant advantage on intracochlear pressure changes in comparison to dry conditions by limiting negative outward pressure.

Objective Different aspects should be considered to achieve an atraumatic insertion of cochlear implant electrode arrays as an important surgical goal. Intracochlear pressure changes are known to influence the preservation of residual hearing. By using the intraoperative "pullback technique," an electrode position closer to the modiolus can be achieved than without the pullback. The aim of the present study was therefore to investigate to what extent the pullback technique can influence intracochlear pressure changes. Methods Insertions of cochlear implant electrodes were performed in an artificial cochlear model with two different perimodiolar arrays. Intracochlear pressure changes were recorded with a micro-optical pressure sensor positioned in the apical part of the cochlear. After complete insertion of the electrode array, a so-called pullback of the electrode was performed. Results Statistically significant pressure differences were measured if the electrode array was wet (ie, moisturized) during the pullback. Relative pressure changes in electrodes with smaller total volume are lower than pressure changes in larger electrodes. Conclusion The preservation of residual hearing and, thus, the resulting postoperative audiological outcome has a major impact on the quality of life of the patients and has become of utmost importance. Intracochlear pressure changes during the pullback manoeuver are small in absolute terms, but can even be still reduced statistically significantly by a moistening the electrode before insertion. Using the pullback technique in cases with residual hearing does not affect the probability of preservation of residual hearing but could lead to a better audiological outcome. Level of evidence NA.

Objective. Cerebral magnetic resonance imaging with the magnet of the cochlear implant receiver/stimulator in place causes artifacts and hinders evaluation of intracerebral structures. The aim of this study was to evaluate the internal auditory canal and the labyrinth in a 1.5T MRI with the magnet in place. Study Design. Observational study. Setting. Tertiary referral center. Subjects and Methods. The receiver/stimulator unit was placed and fixed onto the head of three volunteers at three different angles to the nasion–outer ear canal (90°–160°) and at three different distances from the outer ear canal (5–9 cm). T1 and T2 weighted sequences were conducted for each position. Results. Excellent visibility of the internal auditory canal and the labyrinth was seen in the T2 weighted sequences with 9 cm between the magnet and the outer ear canal at every nasion–outer ear canal angle. T1 sequences showed poorer visibility of the internal auditory canal and the labyrinth. Conclusion. Aftercare and visibility of intracerebral structures after cochlear implantation is becoming more important as cochlear implant indications are widened worldwide. With a distance of at least 9 cm from the outer ear canal the artifact induced by the magnet allows evaluation of the labyrinth and the internal auditory canal.

Das Cochlea-Implantat (CI) ist die Behandlung der Wahl bei schwerer bis hochgradiger Schallempfindungsschwerhorigkeit, sowie bei einseitiger Ertaubung. Bedingt durch das bei Magnetresonanztomographieuntersuchungen (Magnetresonanztomographie – MRT) bestehende Magnetfeld, waren MRT-Untersuchungen bei CI-Tragern uber viele Jahre kontraindiziert bzw. nur unter spezifischen Bedingungen durchfuhrbar. MRT-Untersuchungen bei CI-Tragern bergen die Gefahr von Komplikationen und bedurfen daher der Beachtung verschiedener praventiver Masnahmen. Ziel dieser Studie ist die Evaluation der Haufigkeit von MRT-Untersuchungen bei CI-Patienten und des Auftretens von Komplikationen durch das MRT-Magnetfeld, sowie die Erhebung der im radiologischen Alltag getroffenen Praventionsmasnahmen. Versand eines retrospektiven Fragebogens an 482 Patienten, die in den Jahren 1999–2013 mit einem CI versorgt wurden. Evaluiert wurden Daten zur MRT-Untersuchung sowie subjektive und objektive Vorkommnisse wahrend und nach der MRT-Untersuchung. Von 482 versendeten Fragebogen wurden 204 beantwortet (42,3 %). 20 Patienten (9,8 %) mit 23 CIs haben in der Summe 33 MRTs durchlaufen. 16 der Untersuchungen waren Kopf-MRTs (49 %). In 20 Fallen (61 %) wurden praventive Masnahmen in Form von Kopfwickeln getroffen. Die haufigste Komplikation waren Schmerzen in 23 Fallen (70 %) und die schwerwiegendste Komplikation war die Dislokation des internen Magneten in 3 Fallen (9 %). Die Anzahl der CI-Trager, welche mittels MRT untersucht werden, ist hoch. Mogliche Komplikationen und dementsprechende Vorsichtsmasnahmen finden in der alltaglichen radiologischen Routine zu wenig Beachtung.

Das Auftreten einer Osteoradionekrose nach Bestrahlung im Kopf-Hals-Bereich ist eine seltene, aber gefurchtete Spatkomplikation im Rahmen einer Radiotherapie. Die Lokalisation der Osteoradionekrose im Sternoklavikulargelenk wurde bisher selten beschrieben. Es handelt sich um eine retrospektive Studie unter Einbezug aller Patienten, welche in den letzten 5 Jahren an der Klinik der Autoren aufgrund einer Osteoradionekrose des Sternoklavikulargelenks behandelt wurden. Therapie und Ergebnisse wurden ausgewertet und mit der Literatur verglichen. In den letzten 5 Jahren wurden 2 Patienten aufgrund einer Osteoradionekrose des Sternoklavikulargelenks behandelt. Beide Patienten wurden aufgrund eines Tumors im Hals- und Brustbereich adjuvant bestrahlt und stellten sich mit einer Veranderung in Hohe des Sternoklavikulargelenks vor. Nach Ausschluss eines lokalen Rezidivs konnte bildmorphologisch und histologisch eine Entzundung gesichert werden. Nach Resektion der Entzundung mit Anteilen der Klavikula und des Sternums erfolgte in beiden Fallen die Defektdeckung mittels Pektoralislappen. Eine Osteoradionekrose betrifft sowohl den Knochen als auch das umliegende Weichgewebe. Aufgrund der Vorbehandlung und der damit verbundenen Veranderungen muss der Knochen und das Weichgewebe vollstandig reseziert und mit von der Entzundung unabhangig versorgtem Gewebe (Lappenplastik) gedeckt werden. Dann ist die Prognose der Erkrankung gut.

Objective: To investigate whether a previous established neural response telemetry (NRT) ratio corresponds with the scalar position of the CI electrode. Study Design: Retrospective blinded controlled study. Setting: Tertiary referral center. Patients: The electrophysiological data sets of 85 patients with measured intraoperative NRTs were evaluated. All patients were implanted with the same CI system. Using a flat panel tomography system, the position of the electrode array was confirmed radiologically. Interventions: The radiological results were blindly compared with the intraoperatively obtained electrophysiological data (NRT ratio) and statistically evaluated. In a second step, irregularities between the NRT ratios and the radiologically confirmed electrode positions were determined and the entire study material was investigated deeper. Main Outcome Measures: Correlation of the NRT ratio with the intracochlear position of the CI electrode. Results: By electrophysiological evaluation only, 69 patients were detected without a scalar change at first. In 16 patients, a scalar change was probable. A significant correlation between the radiological results and the NRT ratios was found. Secondly, additional patient characteristics were identified which influences the electrode’s position. Excluding those patients, the selectivity and specificity of the NRT ratio could be increased to a higher level. Conclusion: Evidenced by a blinded group of patients, we are able to show that the electrode array position within the cochlea could be predicted using the NRT ratio. Key Words: CIVFlat panel tomographyVNRTVScalar position. Otol Neurotol 00:00Y00, 2015.

OBJECTIVE The position of cochlear implant (CI) electrodes in the cochlea is fundamental for the interaction between the implant and the neurons of the spiral ganglion. The scalar position of the electrode in the cochlea is assumed to be an important parameter for the clinical outcome. In our study, the intraoperative electrophysiologic characteristics in dependence of the position of CI electrodes in the scala tympani or in the scala vestibuli after scalar change should be determined. MATERIALS AND METHODS The intraoperative impedances and neural response telemetry (NRT) data of 23 patients implanted with a Nucleus Advance Contour (Cochlear Pty, Sydney, Australia) electrode were recorded. One CI surgeon and two radiologists evaluated the electrode array's position independently radiologically by flat-panel tomography. Results from 17 patients with the electrode positioned in the scala tympani and six patients with the electrode changing intraoperatively from the tympanic into the vestibular scala were retrospectively analyzed. RESULTS We found a statistically significant difference with an NRT threshold-based ratio for the groups. An estimation of the (radiologically confirmed) scalar position based on the NRT ratio was possible retrospectively. CONCLUSION The evaluation of specific intraoperative electrophysiologic data allowed separating between a regular and an irregular (i.e., scalar changing) position of CI electrodes. This noninvasive methodology can support the postoperative radiologic evaluation of the CI electrode array position.

Background: Patients with a superior canal dehiscence syndrome display symptoms of the vestibular disorder except that of hearing loss. Therefore, any type of surgery should treat those symptoms without affecting the hearing threshold. The aim of this study was to evaluate the extent to which the hearing threshold has been affected; the evaluation process was carried out by a transmastoid plugging of the superior canal. Another aim was to estimate the risk in loss of hearing due to this surgery. Material and Methods: In a retrospective study, 31 patients with dehiscence of the superior canal, who underwent a transmastoid plugging, were included. Additionally, 8 of them with the clinical symptoms of the Menière’s disease received an endolymphatic sac surgery. A b-c threshold at 0.25, 0.5, 1, 2, and 4 kHz was observed in all patients pre and postoperatively as well as in the long-term follow-up. Results: After a mean interval of 149 days, a change in the b-c threshold of 5.9 dB was detected. After 149 days, in the patient group comprising those who underwent an additional endolymphatic sac surgery, a b-c threshold change of 17.18 dB was detected. Conclusion: The transmastoid plugging of the superior semicircular canal can be performed with an acceptable risk of hearing affection. If the surgery was combined with other techniques, (e.g. endolymphatic sac surgery) then the risk increases.

Migration of a cochlear implant electrode is a hitherto uncommon complication. So far, array migration has only been observed in lateral wall electrodes. Between 1999 and 2014, a total of 27 patients received bilateral perimodiolar electrode arrays at our institution. The insertion depth angle was estimated on the initial postoperative scans and compared with the insertion depth angle of the postoperative scans performed after contralateral cochlear implantation. Seven (25.93%) patients were found to have an electrode array migration of more than 15°. Electrode migration in perimodiolar electrodes seems to be less frequent and to occur to a lower extent than in lateral wall electrodes. Electrode migration was clinically asymptomatic in all cases.

Hintergrund Die Positionierung des B-FMT der Vibrant Bonebridge kann aufgrund der anatomischen Verhaltnisse des Mastoids und der Grose des Aktuators ohne eine vorherige Beurteilung der individuellen Computertomographie (CT) des Felsenbeins problematisch sein. Die Entwicklung eines einfach zu bedienenden Viewers, welcher eine Positionierung des B-FMT im Felsenbeinmodell ermoglicht und hier auf individuelle potenzielle anatomische Konflikte hinweist sowie Losungsmoglichkeiten anbietet, kann ein hilfreiches Werkzeug zur praoperativen Positionierung sein.

Nowadays, specific and reproducible side-separated neurotologic testing of all vestibular receptors is possible. Assessment of saccular function by measuring cervical vestibular-evoked myogenic potentials (cVEMP) is well established. Reliable screening tests exist for the isolated assessment of utricular function. These tests can be performed even in less well-equipped surroundings to generate information regarding a possible partial dysfunction of the otolith organs. Apart from assessing the functionality of the semicircular canals by caloric irrigation and the head impulse test, screening for otolith disorders should be part of a comprehensive modern vestibular examination. Neurofeedbacktraining is an effective therapy in the treatment of otholith disorders.

Objective To investigate safety and efficacy of a new transcutaneous bone conduction hearing implant, over a 3-month follow-up period. Study design Prospective, single-subject repeated-measures design in which each subject serves as his/her own control. Setting Departments of Otolaryngology at 4 hospitals in Germany and Austria. Patients Subjects were 12 German-speaking adults who suffered from conductive or mixed hearing loss. The upper bone conduction threshold limit was set to 45 dB HL at frequencies between 500 Hz and 4 kHz. Intervention Implantation of a transcutaneous bone conduction hearing implant. Main outcome measures Subjects' speech perception (word recognition scores and SRT 50%) and audiometric thresholds (air conduction, bone conduction and sound field at frequencies 500 Hz to 8 kHz) were assessed preoperatively, 1 month postoperatively and 3 months postoperatively. The subjects were monitored for adverse events and given a questionnaire to assess their satisfaction levels. Results Speech perception as measured by word recognition scores and SRT 50% improved on average about 78.8% and 25 dB HL, respectively, 3 months after implantation. Aided thresholds also improved postoperatively at all tested frequencies and continued to improve from 1 to 3 months postoperatively. Air conduction and bone conduction thresholds showed no significant changes, confirming that subjects' residual unaided hearing was not deteriorated by the treatment. Only minor adverse events were reported and resolved by the end of the study. Conclusion The new transcutaneous bone conduction implant was demonstrated to be safe and effective in adults up to 3 months of device use.

The position of the cochlear-implant electrode is important to audiological outcomes after cochlear implantation. The common technique to evaluate the intracochlear electrode’s position involves the use of ionized radiation in MSCT, DVT, or flat-panel tomography (FPT). Recent advances in knowledge regarding the handling of MRI artifacts in cochlear implantees indicate that estimating the intracochlear electrode’s position with an MRI could be possible. This study’s aim was to evaluate the ipsilaterally position of electrodes using MRI at 1.5 T. In a retrospective study of 10 implantees with postoperative need for MRI scanning, we evaluated the intrascalar electrode’s position using a T2-weighted sequence at 1.5 T. We compared the resulting estimate of the intracochlear position with the estimates from the postoperative FPT scan and the intraoperative NRT ratio. For each ear, the MRI-estimated scalar position corresponded with the estimated positions from the FPT and NRT ratio. For eight ears, a scala tympani’s position was observed in the MRI. In one case, an electrode scalar translocation was found. In one case, the scala vestibuli’s position was observed. Thus, MRI-based estimation of the scalar position of a cochlear-implant electrode is possible. Limitations to this method include implant-specific magnet and fixation configurations, which can cause complications.

The aims of this study were to collect data on electrically evoked compound action potential (eCAP) and electrically evoked stapedius reflex thresholds (eSRT) in HiResolution(TM) cochlear implant (CI) users, and to explore the relationships between these objective measures and behavioural measures of comfort levels (M-levels).A prospective study on newly implanted subjects was designed. The eCAP was measured intra-operatively and at first fitting through neural response imaging (NRI), using the SoundWave(TM) fitting software. The eSRT was measured intra-operatively by visual monitoring of the stapes, using both single-electrode stimulation and speech bursts (four electrodes stimulated at the same time). Measures of M-levels were performed according to standard clinical practice and collected at first fitting, 3 and 6 months of CI use.One hundred seventeen subjects from 14 centres, all implanted unilaterally with a HiResolution CII Bionic Ear(®) or HiRes 90K(®), were included in the study. Speech burst stimulation elicited a significantly higher eSRT success rate than single-electrode stimulation, 84 vs. 64% respectively. The NRI success rate was 81% intra-operatively, significantly increasing to 96% after 6 months. Fitting guidelines were defined on the basis of a single NRI measurement. Correlations, analysis of variance, and multiple regression analysis were applied to generate a predictive model for the M-levels.Useful insights were produced into the behaviour of objective measures according to time, electrode location, and fitting parameters. They may usefully assist in programming the CI when no reliable feedback is obtained through standard behavioural procedures.

The objective of this study was to investigate the occurrence of vestibular receptor deficiency and taste disorders after bilateral cochlear implantation in postlingually deafened patients and to find out whether the risk for these complications is higher for the second implantation. In a retrospective cohort study, we examined 20 patients (11-58 years, mean age 41.5 years), implanted sequentially between 2000 and 2007 (mean period between cochlear implantation 32.9 ± 25 months). Pre- and postoperative vestibular testing was performed by subjective rating [Dizziness Handicap Inventory (DHI)], caloric irrigation [vestibuloocular reflex (VOR)] and by vestibular-evoked myogenic potential (VEMP) recordings for saccular function. The sense of taste was evaluated pre- and postoperatively by a questionnaire and testing (sour/sweet/bitter/salty bilaterally on the tongue). DHI evaluation showed a moderate not significant mean increase by 2.7 ± 7.7 SD points after the first and a significant increase by 9.4 ± 16.6 SD points after the second implantation. Ipsilateral VEMP responses disappeared in three ears (27.3%) after the first and in two ears (18.2%) after the second operation. VOR disappeared only once (5.9%) after the first implantation. One (5%) patient complained of a persisting disturbance of taste in the questionnaire after unilateral and 3 (15%) after bilateral implantation. Specific testing showed in one case (5%) a unilateral taste disorder after ipsilateral cochlear implantation. Our data show that there is a higher risk for subjective vertigo after the second implantation. The occurrence of unilateral and/or bilateral vestibular dysfunction and the potential risk of taste disorder should be included in the risk counseling before bilateral cochlear implantation to increase patients' and medicolegal safety in the decision-making process.

BACKGROUND For the functional outcome after cochlear implant surgery, the electrode position is of essential importance. Therefore, radiological techniques to localize the electrode within the cochlea are becoming increasingly important. In our study, we used multi-slice computed tomography (CT) to find radiological criteria to allocate the electrode within the cochlea. METHODS Ten Nucleus 24 RCA electrodes were implanted into isolated human temporal bones using an extended cochleostomy and the Advance Off-Stylet technique. Five electrodes were implanted into the scala tympani and five into the scala vestibuli. After implantation, the temporal bones were blinded to the radiologist, and 64-slice CT scans were performed and analysed. RESULTS AND CONCLUSIONS In all 10 cases, the surgical positioning of the electrode was equal to the radiological analysis of the CT scans. Radiological criteria were found that permit correct identification of the electrode within the cochlea. We think that this technique is sufficient for most questions concerning quality control and is widely available.

Verletzungen des Larynx und der Trachea sind selten. Aufgrund ihrer Lokalisation konnen sie jedoch fur den Patienten erhebliche Konsequenzen haben. Eine fruhzeitige Diagnostik und die Sicherung der Atemwege sind fur das Uberleben der Patienten von entscheidender Bedeutung. In einer Ubersicht werden die Anatomie, die Pathomechanismen und die Klassifizierungen der Verletzungen mit ihren Therapieoptionen dargestellt.

Cochlear implant surgery has become a successful procedure for deaf patients to restore their hearing again. Some of the patients, however, complain of persisting dizziness after the surgery which can have a major impact on their quality of life. Neurotological tests of the vestibular system were applied in a total of 18 cochlear implantees pre- and postoperatively. In addition, vestibular evoked myogenic potentials were evoked intraoperatively to investigate possible interferences of the electrically stimulated cochlear implant electrode (eVEMP) with vestibular receptor cells of the saccule in more detail. After cochlear implantation, the saccular function was impaired in the majority of the patients. However, eVEMPs could be recorded intraoperatively in all patients by intracochlear, high-level electrical stimulation via the cochlear implant electrode. In essence, acute, short-term dizziness after cochlear implantation seems to result primarily from a transient vestibular deficit of various origins. In contrast to this, chronic, persisting dizziness after cochlear implant surgery is largely based on a dysfunction of the saccular macula which is an integral component of the otolith system. This saccular impairment is induced most likely by the insertion trauma of the cochlear implant electrode when advancing it into the inner ear. A possible coactivation of the inferior vestibular nerve by the electrical stimulation might play an additional role in the pathogenesis of the persisting postsurgical dizziness.

Cochlear implants (CI) are the preferred method of treatment for patients with severe to profound bilateral sensorineural hearing loss and unilateral deafness. For many years, because of the magnetic field applied during magnetic resonance imaging (MRI) examinations, MRI examinations were contraindicated for CI patients or feasible only under specific circumstances. MRI examinations of CI recipients entail complications and therefore preventive measures have to be considered. The aim of this study was to evaluate the prevalence of MRI scans in CI recipients and the occurrence of complications and furthermore to investigate the preventive measures taken in radiological daily routine. A retrospective questionnaire was sent to 482 patients that received CIs from 1999–2013. Details of the MRI examination and subjective and objective incidents during and after the MRI scan were evaluated. A total of 204 CI recipients answered the retrospective questionnaire (42.3 %). Twenty patients (9.8 %) with 23 implants underwent a total of 33 MRI scans with their cochlear implant in place. In 16 cases the scanned region was the head (49 %). Preventive measures in the form of head bandages were taken in 20 cases (61 %). The most common complication was pain in 23 cases (70 %) and the most serious complication was the dislocation of the internal magnet in 3 cases (9 %). The number of CI recipients undergoing MRI scans is high. Possible complications and preventive measures attract too little attention in radiological daily routine.

The authors mention the occurrence of specific balance disorders in the elderly (for example, Meniere’s disease, which has a prevalence of 0.1% in the general population) (1), but they do not sufficiently explain the sequential degeneration of the vestibular receptor (hair) cells (in that order: semicircular canal receptors → saccule → utricle) (2), which determines the clinical picture of vestibular disorders in the elderly—which the Berlin Aging Study (3) has demonstrated for the first time over a time period of 30 years (first longitudinal study so far). This study also showed that the determinants correlating the most with psychosocial well-being, social interactions, and cognitive-motor functions are primarily the sensory systems hearing and balance/equilibrium. Since falls usually occur out of a movement, the tests for balance assessment suggested by the authors (Romberg’s test, for instance, has a sensitivity of only 30% for detecting vestibular deficits) are possibly suitable for screening, but not to determine the extent and quality of a vestibular deficit and/or the need for therapy. Modern posturographic approaches (4) using standardized standing and walking tests that reflect the everyday life conditions of the elderly can be quickly and easily used to assess the postural stability and the risk of falls, which in turn can then be used to decide on a specific intervention (for example, the so-called neurofeedback balance training). A further important aspect is optimizing a patient ’s hearing by means of hearing aids/implants, because fewer falls occur in those with good spatio-temporal orientation as supported by optimized hearing. Substituting all sensory functions is of crucial importance for a self-sustained life at old age—which the authors explicitly stressed for vision.

The position of the cochlear electrode array within the scala tympani is essential for an optimal hearing benefit. An intraoperative NRT-ratio was established, which can provide information about the intraoperative intracochlear electrode array position for perimodiolar electrodes. The aims of this study were to verify the longterm reliability for the NRT-ratio in perimodiolar electrodes. In a retrospective controlled study in a Tertiary Referral Center the electrophysiological data sets of 123 patients with implanted Nucleus Contour Advance electrodes were enclosed. Intraoperative and up to 1 year follow-up Auto-NRTs were evaluated. A NRT-ratio was calculated by dividing the average Auto-NRT data from electrode 16 to 18 with the average from electrode 5 to 7. Using a flat panel tomography system, the position of the electrode array was certified radiological. 31 patients with perimodiolar electrodes with 1 year follow-up data were included in the study. Eleven patients showed regular follow-up NRT-ratio with a correlated and radiologically confirmed electrode position. 20 patients showed mismatches between the NRT-ratio and the radiological position. These patients were highly variable in terms of duration of deafness and neural spectrum disorders. The NRT-ratio can be used to determine the intracochlear position of the electrode array for perimodiolar electrodes. Intraoperatively the NRT-ratio predicts the array position within the cochlea highly reliable for perimodiolar electrodes. We showed that after 6 months and a year, the NRT-ratio remains unchanged in most of the cases and shows a good correlation to the radiological determined position of the array. Nevertheless, the condition of the neural structures is highly important for reproducible responses. Limited validity is given in patients with degenerative and structural neural disorders.

Knochenverankerte Horgerate bieten bei Schallleitungsschwerhorigkeit und kombinierter Schwerhorigkeit eine Moglichkeit der Horrehabilitation. Beisstab und Testbugel bieten dem Patienten praoperativ die Moglichkeit, einen Eindruck des postoperativen Horens zu gewinnen. Ziel der Studie war es, praoperative Testmoglichkeiten zu evaluieren und pradiktive audiometrische Werte zu ermitteln. Bei 16 bereits mit einem BAHA-Compact-System versorgten Patienten wurden Ton- und Sprachaudiogramme mit verankertem BAHA-Gerat, mit Testbugel und mit interdentalem Beisstab ermittelt. Bei allen Patienten konnte durch den Schluss der Knochen-Luft-Leitungsdifferenz sowohl mit dem verankerten BAHA-System als auch mit den Testapparaturen eine deutliche Anhebung der Horschwelle und des Sprachverstandnisses erreicht werden. Hierbei fand sich eine im Mittel 9 dB bessere Horschwelle mit dem verankerten BAHA als mit den Testapparaturen. Die Untersuchung des Sprachverstandnisses ergab einen mittleren Vorteil des verankerten BAHA gegenuber den Testapparaturen bei der Messung des Einsilberverstandnisses von 14% bzw. 20%. Die praoperative Testung vor einer BAHA-Versorgung eignet sich zur zuverlassigen Vorhersage des zu erwartendem Horvermogen und Sprachverstandnis.

Objective: To evaluate the safety and effectiveness of round window (RW), oval window (OW), CliP and Bell couplers for use with an active middle ear implant. Methods: This is a multicenter, long-term, prospective trial with consecutive enrollment, involving 6 university hospitals in Germany. Bone conduction, air conduction, implant-aided warble-tone thresholds and Freiburger monosyllable word recognition scores were compared with unaided preimplantation results in 28 moderate-to-profound hearing-impaired patients after 12 months of follow-up. All patients had previously undergone failed reconstruction surgeries (up to 5 or more). In a subset of patients, additional speech tests at 12 months postoperatively were used to compare the aided with the unaided condition after implantation with the processor switched off. An established quality-of-life questionnaire for hearing aids was used to determine patient satisfaction. Results: Postoperative bone conduction remained stable. Mean functional gain for all couplers was 37 dB HL (RW = 42 dB, OW = 35 dB, Bell = 38 dB, CliP = 27 dB). The mean postoperative Freiburger monosyllable score was 71% at 65 dB SPL. The postimplantation mean SRT50 (speech reception in quiet for 50% understanding of words in sentences) improved on average by 23 dB over unaided testing and signal-to-noise ratios also improved in all patients. The International Outcome Inventory for Hearing Aids (IOI-HA)quality-of-life questionnaire was scored very positively by all patients. Conclusion: A significant improvement was seen with all couplers, and patients were satisfied with the device at 12 months postoperatively. These results demonstrate that an active implant is an advantage in achieving good hearing benefit in patients with prior failed reconstruction surgery.

The position of the cochlear electrode array within the scala tympani is essential for optimal hearing benefit. An intraoperative neural response telemetry ratio (NRT ratio; a threshold ratio of pairs of apical and basal electrodes) has been established, which can provide information about the intracochlear electrode array position. Out of a previous collective of 85 patients, the 6-month follow-up electrophysiological NRT data of 37 patients have been included in this study. Comparing the intraoperatively estimated NRT ratio with the 6-month follow-up NRT ratio, it remained unchanged intraindividually in 92% of cases. Within this group the NRT ratio and the intracochlear position of the electrode array matched in all cases. There were two newly occurring mismatches and one new match was observed. After a period of 6 months the NRT ratio remained unchanged in most cases and showed a good correlation with the intracochlear position of the electrode array.

Vestibular evoked myogenic potentials (VEMPs) can be recorded from sternocleidomastoid muscle (SCM) in clinical practice. The aim of the present study was to investigate VEMPs upon direct electrical stimulation of the human inferior vestibular nerve to evidence the vestibulocollic reflex arch and their saccular origin, respectively. Seven subjects were stimulated at the inferior (IVN) and superior (SVN) vestibular nerve. The EMG signals of the SCM were recorded. These recordings were compared to air- and bone-conduction evoked VEMPs with respect to latency and shape. All subjects showed normal VEMPs upon acoustic stimulation with a latency of 12.8 ± 1.4 ms for P13, and 22.7 ± 2.0 ms for the N23 pre-operatively. Upon direct electrical stimulation of the IVN, the mean latency of the positive peak was 9.1 ± 2.2 and 13.2 ± 2.3 ms for the negative one. No contralateral SCM response was found. Electrical stimulation of the SVN did not result in any EMG response of the SCM. The study shows experimental evidence of the vestibulocollic reflex by direct electrical stimulation of the human IVN for the first time. The method can be utilized to map VIIIth nerve subdivisions and to intraoperatively monitor IVN integrity in a real-time mode.

Manual medicine aims at diagnosing and treating different disorders of the musculoskeletal system. It is a multidisciplinary approach with special emphasis on reversible disorders of the joints, muscles and ligaments. The treatment conception includes chirotherapy, physical therapy and drug treatment. The spine, and in particular the cervical spine, is treated primarily for joint disorders characterized by a variety of symptoms (e.g. headache, vertigo, dizziness, blurred vision). Manual medicine should be an integral part of modern clinical otolaryngology.

Fur die Rekonstruktion des Zungengrundes nach Tumorresektionen stehen eine Vielzahl von Verfahren zur Verfugung. Neben der direkten Naht bei kleinen Defekten stehen verschiedene gestielte Transplantate zur Verfugung. Es wird ein mikrovaskular gestieltes Zungentransplantat fur die Rekonstruktion mittlerer Zungengrunddefekte vorgestellt. Zwischen 1999 und 2002 wurden am Unfallkrankenhaus Berlin 6 Patienten mit einem Karzinom des Zungengrundes mit einem modifizierten Set-back-Zungenlappen versorgt. Die Defektgrose umfasste die Halfte bis 3/4 des Zungengrundes. Es kam in einem Fall zu einer postoperativen Nachblutung. Mit der Nahrungsaufnahme konnte im Durchschnitt nach 7,5 (4–12) Tagen begonnen werden. Noch wahrend des stationaren Aufenthalts konnte in allen Fallen das Tracheostoma nach 16,2 (12–22) Tagen verschlossen werden. Der gesamte stationare Aufenthalt betrug im Mittel 20,3 (15–27) Tage. Der modifizierte Set-back-Zungenlappen stellt eine Alternative in der Versorgung von Defekten der Halfte bis 3/4 des Zungengrundes dar. Die einfache Handhabung und guten Ergebnisse des neurovaskularen Transplantates in der Restitution des Schluckvorgangs erweisen sich als Vorteil.

Anamnese Wir berichten uber eine 49-jahrige Patientin die sich mit einer seit circa 1,5 Jahren bestehenden Dysphagie fur flussige und feste Kost vorstellte. Zusatzlich traten seit einem Jahr beim Verzehr von fester Nahrung Ohnmachtsanfalle auf. Die Beschwerden waren begleitet von einem Globusgefuhl und Regurgitationen.

The position of the cochlear implant electrode array within the scala tympani is essential for an optimal postoperative hearing benefit. If the electrode array changes in between the scalae intracochlearly (i.e., from scala tympani to scala vestibuli), a reduced auditory performance can be assumed. We established a neural response telemetry-ratio (NRT-ratio) which corresponds with the scalar position of the electrodes but shows within its limits a variability. The aim of this study was to determine if insertion depth angle or cochlea size influences the NRT-ratio. The intraoperative electrophysiological NRT data of 26 patients were evaluated. Using a flat panel tomography system, the position of the electrode array was evaluated radiologically. The insertion depth angle of the electrode, the cochlea size, and the NRT-ratio were calculated postoperatively. The radiological results were compared with the intraoperatively obtained electrophysiological data (NRT-ratio) and statistically evaluated. In all patients the NRT-ratio, the insertion depth angle, and the cochlea size could be determined. A significant correlation between insertional depth, cochlear size, and the NRT-ratio was not found. The NRT-ratio is a reliable electrophysiological tool to determine the scalar position of a perimodiolar electrode array. The NRT-ratio can be applied independent from insertion depth and cochlear size.