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Cochlear implantation leading to successful stapedectomy in the contralateral only-hearing ear.

Abstract

Cochlear implants have recently begun to be offered to patients with single-sided deafness (SSD). Implantation in these patients has led to good results in suppressing ipsilateral tinnitus and in providing audiologic benefits in terms of speech perception in noise and localization. One previously unreported benefit of cochlear implantation in patients with SSD is the restoration of functional hearing in the previously deaf ear, which may allow for surgical opportunities in the contralateral hearing ear. We report a case in which cochlear implantation in the deaf left ear of a 50-year-old man allowed for surgical intervention in the previously only-hearing right ear, which in turn led to the restoration of normal middle ear function. Further studies may be warranted to consider the surgical candidacy of the contralateral only-hearing ear as another potential indication for cochlear implantation inpatients with SSD.

Introduction

Approximately 1 % of adults will experience single-sided deafness (SSD) during the course of their lifetime. (1) Treatment of SSD has traditionally involved a hearing aid with contralateral routing of signals or an osseointegrated hearing device (OHD). Recently, the indications for cochlear implantation were expanded to include patients with SSD, although this is still considered an off-label indication by the federal Food and Drug Administration. (2) For patients with SSD, cochlear implantation has been effective in suppressing ipsilateral tinnitus, and it has provided audiologic benefits in terms of speech perception in noise and localization. (3-5)

A previously unreported benefit of cochlear implantation in patients with SSD is that the restoration of functional hearing in the previously deaf ear may provide surgical opportunities in the contralateral hearing ear; previously, such surgery was contraindicated.

We report an instance in which cochlear implantation in a deaf ear allowed for surgical intervention in the contralateral hearing ear, which resulted in a successful stapedectomy and restoration of normal middle ear function.

Case report

A 50-year-old man presented to us with a history of bilateral otosclerosis and moderate to severe conductive hearing loss. The patient had undergone several otologic surgical interventions during the previous decade (table):

Left stapedectomy. In 2003, the patient had undergone a left stapedectomy, which was complicated by deafness in the operated ear several weeks after surgery.

OHD placement. In 2006, an OHD was placed on the left side, which the patient used in conjunction with a behind-the-ear hearing aid on the right. He experienced some relief of the acoustic "head shadow" with the left-sided OHD, but he desired bilateral hearing and alleviation of tinnitus in the deaf left ear. More important, he expressed interest in the possibility of surgical treatment of the otosclerosis in his right ear, which would be possible only if he gained sufficient hearing in his deaf left ear to accept the small risk of deafness associated with stapedectomy surgery in his right hearing ear.

Cochlear implantation. In August 2012, the patient received a left cochlear implant (Nucleus CI422; Cochlear; Sydney, Australia), which was placed via cochleostomy without difficulty. However, the body of the implant could not be placed in the usual postauricular position because of the previous placement of the OHD (figure 1, A). Instead, the device was positioned anterosuperiorly in a nearly vertical position (figure 1, B). The limited length of the implant lead wire between the body of the processor and the electrode array increased the difficulty of this unorthodox placement.

Four weeks postoperatively, the patient presented to an emergency department for wound dehiscence. He reported that during an airplane flight, he had performed the Valsalva maneuver and felt air under his surgical wound. It was later found that the incision had dehisced.

The patient was evaluated by the otolaryngology staff on call in the emergency department, and he was treated with oral cephalexin and topical bacitracin ointment. The wound was left open. Three days later, the patient returned to the otolaryngology clinic for reevaluation of the wound dehiscence, and he was admitted for intravenous clindamycin treatment for wound infection.

Cochlear implant revision. In September 2012, 6 weeks after cochlear implantation, the patient presented for activation of the implant. However, it was found that the implant had slipped interiorly from its original position, and it was now visible through the dehisced wound. The patient was immediately taken back to the operating room for revision. The internal device was repositioned slightly posterior to its previous position. During the procedure, the electrode array was displaced, and it required reinsertion through the cochleostomy.

[FIGURE 1 OMITTED]

Intraoperatively, all 22 electrodes were verified to be intact, and there were no short or open circuits. Also, a well-formed neural response was obtained from the basal, middle, and apical electrodes. The incision healed without complication, and the implant was activated 10 days postoperatively.

After activation, the patient used the left cochlear implant full-time, and he discontinued use ofthe left OHD. On a difficult speech recognition task (AzBio presented in quiet at 60 dB SPL with appropriate masking in the contralateral right ear), he scored 87%. With the success of the left cochlear implant, the right otosclerotic ear was no longer the only-hearing ear, and the patient was offered a right stapedectomy, to which he agreed.

Right stapedectomy. Prestapedectomy audiometry confirmed a significant conductive hearing loss in the right ear (figure 2, A). An uncomplicated right stapedectomy and placement of a prosthesis was performed in April 2013, about 7 months after the revision of his left cochlear implant surgery. On postoperative day 9, the patient experienced improvement in the right ear, with significant closure of the air-bone gap (figure 2, B). Eight months poststapedectomy, he exhibited normal audiometric thresholds and an air-bone gap of 15 dB or less at frequencies up to 3 kHz in the operated ear (figure 2, C). He was able to communicate satisfactorily without the use of amplification or the cochlear implant.

[FIGURE 2 OMITTED]

OHD abutment removal. Because the successful surgery obviated the possibility that the patient might require the left OHD to overcome a conductive loss in the right ear, the OHD abutment was removed in December 2013.

The patient continues to use the cochlear implant to alleviate tinnitus in the deaf ear and to enhance spatial auditory perception.

Discussion

Initially, patients with SSD receive a cochlear implant to ameliorate tinnitus, and most experience significant relief. (6-8) Moreover, studies have documented enhanced speech recognition in noise after cochlear implantation in patients with SSD. (4,5,9,10) SSD is now recognized as an off-label indication for cochlear implantation. (2)

This report suggests an additional benefit of cochlear implantation for SSD patients in that it allows the contralateral ear with otologic pathology to be considered a candidate for surgical intervention. Prior to the left cochlear implantation, our patient's right ear was his only-hearing ear, despite the significant conductive hearing loss secondary to otosclerosis, and the right ear was not a surgical candidate because of the risk that stapedectomy might cause a complete sensorineural hearing loss. However, following placement of the cochlear implant in the formerly anacusic left ear, the patient regained functional hearing. As a result, the right ear could be considered a candidate for stapedectomy.

The improvement in right-sided hearing following stapedectomy was so great that the patient no longer required amplification for his daily communication activities. This case illustrates the utility of the cochlear implant in restoring hearing capacity in an anacusic ear to the extent that the contralateral ear can be considered a surgical candidate.

Based on our experience, we believe that potential surgical intervention in an only-hearing ear may be a viable indication for cochlear implantation in the deaf ear for patients with SSD. Future studies may be useful in assessing the prevalence of this surgical indication for cochlear implantation in SSD patients.

References

(1.) Baguley DM, Bird J, Humphriss RL, Prevost AT. The evidence base for the application of contralateral bone anchored hearing aids in acquired unilateral sensorineural hearing loss in adults. Clin Otolaryngol 2006;31(1):6-14.

(2.) Arnoldner C, Lin VY. Expanded selection criteria in adult cochlear implantation. Cochlear Implants Int 2013;14(Suppl 4):10-13.

(3.) Vermeire K, Van de Heyning P. Binaural hearing after cochlear implantation in subjects with unilateral sensorineural deafness and tinnitus. Audiol Neurootol 2009;14(3):163-71.

(4.) Arndt S, Aschendorff A, Laszig R, et al. Comparison of pseudobinaural hearing to real binaural hearing rehabilitation after cochlear implantation in patients with unilateral deafness and tinnitus. Otol Neurotol 2011;32(1):39-47.

(5.) Firszt JB, Holden LK, Reeder RM, et al. Auditory abilities after cochlear implantation in adults with unilateral deafness: A pilot study. Otol Neurotol 2012;33(8):1339-46.

(6.) Ito J, Sakakihara J. Suppression of tinnitus by cochlear implantation. Am J Otolaryngol 1994;15(2):145-8.

(7.) Mo B, Harris S, Lindbaek M. Tinnitus in cochlear implant patients-a comparison with other hearing-impaired patients. Int I Audiol 2002;41(8):527-34.

(8.) Van de Heyning P, Vermeire K, Diebl M, et al. Incapacitating unilateral tinnitus in single-sided deafness treated by cochlear implantation. Ann Otol Rhinol Laryngol 2008;117(9):645-52.

(9.) Hassepass F, Schild C, Aschendorff A, et al. Clinical outcome after cochlear implantation in patients with unilateral hearing loss due to labyrinthitis ossificans. Otol Neurotol 2013;34(7):1278-83.

(10.) Tavora-Vieira D, Marino R, Krishnaswamy J, et al. Cochlear implantation for unilateral deafness with and without tinnitus: A case series. Laryngoscope 2013;123(5):1251-5.

Samantha J. Mikals, MD; Gerald I. Schuchman, PhD; Joshua G.W. Bernstein, PhD; Arnaldo L. Rivera, MD

From the Department of Otolaryngology-Head and Neck Surgery (Dr. Mikals and Dr. Rivera) and the National Military Audiology and Speech Pathology Center (Dr. Schuchman and Dr. Bernstein), Walter Reed National Military Medical Center, Bethesda, Md.

Corresponding author: Samantha J. Mikals, MD, Department of Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889. Email: Samantha.Mikals@gmail.com
Table. Summary of our patient's surgical interventions

Date         Intervention        Ear     Outcome

2003         Stapedectomy        Left    Deafness in the operated ear

2006         Osseointegrated     Left    Successful; some relief of
             hearing device              acoustic "head shadow"
             (OHD)

Aug.2012     Cochlear            Left    Infection and displaced
             implantation (CI)           device 4 wk postoperatively

Sept. 2012   CI revision         Left    Successful; 87% AzBio
                                         sentence recognition

Apr. 2013    Stapedectomy        Right   Successful; air-bone gap
                                         reduced to [less than or
                                         equal to]15 dB 8 mo
                                         postoperatively

Dec. 2013    OHD abutment        Left    Successful
             removal
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Title Annotation:ORIGINAL ARTICLE
Author:Mikals, Samantha J.; Schuchman, Gerald I.; Bernstein, Joshua G.W.; Rivera, Arnaldo L.
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Mar 1, 2015
Words:1711
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