S u r g i c a l Tec h n i q u e s

in Cochlear Implants
Brannon Mangus, MDa,*, Alejandro Rivas, MDa, Betty S. Tsai, MDa,
David S. Haynes, MDa, J. Thomas Roland Jr, MDb

KEYWORDS
 Cochlear implants  Round window insertion  Cochleostomy

OVERVIEW OF SURGICAL TECHNIQUES FOR COCHLEAR IMPLANTS

The first report of auditory perception from an electrical stimulation occurred in 1790
when Alessandro Volta passed current across his own head using batteries. He expe-
rienced a “boom within his head” and the perceived a sound similar to “boiling, thick
soup.”1 The first cochlear implantation was performed by Djourno and Eyriès in Paris
in 1957. With this implant, the patient was able to discriminate between large changes
in frequencies and appreciate environmental noises and some words but had no
speech understanding. Dr William F. House collaborated with Dr James Doyle, a neuro-
surgeon, and Jack Urban, an engineer, to develop a practical and reliable means to
restore hearing through electrical stimulation and implanted two deaf volunteers in
1961 with some success of auditory stimulation, but both devices had to be removed
due to infections.2 By 1984, the cochlear implant had gained Food and Drug Adminis-
tration approval and multichannel implants were being developed. In 1988, the National
Institutes of Health released a statement that suggested multichannel implants would
be more effective than single-channel implants.3 At the same time, new processing
strategies were being developed, which ultimately led the National Institutes of Health
to conclude at their 1995 meeting that “a majority of those individuals with the latest
speech processors for their implants will score above 80% correct on high-context
sentences even without visual cues.”4 The success of the cochlear implant has pro-
gressed so much that in 2008, Gifford and colleagues5 reported the need for more diffi-
cult material to assess patient performance because more than 25% of cochlear
implant patients achieve 100% scores on standard sentence material. As of 2008,
more than 120,000 cochlear implants have been implanted worldwide.2

No disclosures.
David S Haynes is Consultant for Cochlear America, Zeiss.
a
Otology Group of Vanderbilt, Department of Otolaryngology–Head and Neck Surgery,
Vanderbilt Bill Wilkerson Center, Vanderbilt University, 1215 21st Avenue South, 7209 Medical
Center East, South Tower, Nashville, TN 37232, USA
b
Department of Otolaryngology, New York University Cochlear Implant Center, New York
University School of Medicine, 660 First Avenue, 7th Floor, New York, NY 10016, USA
* Corresponding author.
E-mail address: [email protected]

Otolaryngol Clin N Am 45 (2012) 69–80

doi:10.1016/j.otc.2011.08.017 oto.theclinics.com
0030-6665/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
70 Mangus et al

EVOLUTION OF INCISIONS

As the cochlear implant has evolved since its inception, so has the cochlear implant
incision.6 The original incisions were based on the concept that wide exposure of the
internal receiver stimulator (R/S) was necessary for placement and fixation. It was
also generally believed that the incision should not cross the implant or electrode array.
Because of these concepts, as well as the early practice of “thinning” the flap over the
magnet, initially the majority of cochlear implant complications were flap related, some-
times necessitating implant removal.7–9 Despite the evolution in incision design, the
underlying principles of the incision have remained the same and include the following:
1. Planned incision should not be near the internal R/S to prevent potential extrusion
or pain.
2. Blood supply must not be compromised.
3. Linea temporalis, mastoid tip, and spine of Henle should be accessible without
undue retraction.
The original, anteriorly based C-shaped postauricular incision worked well with
single-channel implants but had to be modified to a larger C-shaped incision when
multichannel devices came into use due to the increased size of the R/Ss. The larger
C-shaped incisions were associated with a high rate of device extrusion. The C-shaped
incisions preserved blood supply from branches of the superficial temporal artery but
transected occipital artery branches. Also, this incision was thought to be incompatible
with patients who had a pre-existing postauricular incision due to compromised blood
supply.10 In response to the complications associated with the C-shaped incision, an
extended endaural incision was developed and widely used in Europe due to its small
incision and lower risk. The endaural incision was abandoned, however, due to a high
incidence of skin breakdown at the external auditory meatus and scalp numbness. In
Australia, an inferiorly based inverted U-shaped incision was developed to replace
the C-shaped incision. The inverted U-shaped incision, which was later modified into
an inverted J-shaped incision, maximized the blood supply from both the superficial
temporal and occipital arteries but still had similar complications to the C-shaped inci-
sion, including scalp numbness. A benefit of the inverted J-shaped incision was that it
could incorporate a pre-existing postauricular incision.6,8,9,11–14 The inverted J-shaped
incision has been modified and shortened over time into the standard postauricular inci-
sion, which is the most commonly used incision at this time (Fig. 1). Many centers

Fig. 1. Skin incision and flap elevation. Left ear.

 Surgical Techniques in Cochlear 71

(including New York University [NYU] and Vanderbilt University) now use a minimal
access incision, which is a 2-cm to 4-cm, oblique, straight postauricular incision. The
advantages of this incision are that there is minimal hair shaving, less tissue eleva-
tion/manipulation, shorter operative times, faster healing, less swelling, and the poten-
tial for earlier activation. Disadvantages include decreased visibility, need for more skin
retraction, and limited access for drilling the bony well for the implant.6,14 (For an illus-
tration of the evolution of the skin incision, see Fig. 2.)

SECURING THE COCHLEAR IMPLANT

Because device migration can lead to infection, extrusion, and the need for revision
surgery, different methods of securing the internal R/S and the cochlear implant elec-
trode have been proposed.15,16
Traditionally, the R/S has been secured using tie-down sutures that were passed
through monocortically drilled holes on each side of the R/S.17 Other techniques for
securing the R/S include
 Drilling two 4-mm titanium screws on either side of the well and connecting them
with a 3-0 nylon suture18
 Applying polypropylene mesh over the R/S and securing the mesh with titanium
screws19
 Cementing the R/S with ionomeric bone cement20
 Securing the proximal portion of the electrode by placing it in a drilled-out groove
connecting the well and mastoid, thus eliminating the need for fixation of any
type21
 Sewing the periosteum together over the implant.22

Fig. 2. The evolution of the cochlear implantation incision. The original C-shaped incision
evolved into the large C-shaped incision to accommodate the larger multichannel implant.
Due to the high complication rate of the C-shaped incision, the endaural incision was adop-
ted in Europe and widely used. The U-shaped incision, however, which evolved into the
J-shaped incision, was widely used in Australia and the United States. The J-shaped incision
was able to accommodate a pre-existing postauricular incision and eventually was modified
to become the standard postauricular incision most commonly used today. (From Flint P,
editor. Cummings otolaryngology—head and neck surgery. 5th edition. Philadelphia:
Mosby: Elsevier; 2010; with permission of Elsevier.)
72 Mangus et al

In 2009, Balkany and colleagues23 described the temporalis pocket technique obvi-
ating drilling a well or fixation of any type. The theory behind this technique is based on
the anatomic limitations of the temporalis pocket, which is bounded “anteriorly by
dense condensations of pericranium anteriorly at the temporal-parietal suture, poster-
oinferiorly at the lamboid suture, and anteroinferiorly by the bony ridge of the squa-
mous suture.”
Electrode migration is reported to be second only to device failure as a cause of
reimplantation.24,25 To prevent electrode migration, Balkany and Telischi26 described
the split bridge technique. This technique uses the incus buttress as a fixation point
for the electrode changing the force vector of extrusion by 90 . Cohen and Kuzma
also took advantage of the incus buttress by securing the electrode to the buttress
with a titanium clip.27 Several other techniques have been developed to minimize
electrode migration, including tightly packing the cochleostomy with tissue, placing
a coil of electrode against the tegmen mastoideum, and using precurved electrode
arrays.25
At Vanderbilt University and NYU, no effort is made to fix the electrode at the fantail
or at the facial recess. Attempts are made to coil the redundant electrode array in the
mastoid cavity, usually securing the coil in against the tegmen (Fig. 3). A tight pocket
technique for securing the R/S, snugged up with or without periosteal sutures, is
currently preferred (Fig. 4). This technique has shortened operative times, eliminating
the need for (potentially biofilm-forming) additional foreign material. No significant R/S
migrations have occurred at either center.

MINIMALLY INVASIVE TECHNIQUES

Mastoidectomy with Posterior Tympanotomy Approach
In 1961, Dr House introduced the mastoidectomy with posterior tympanotomy
approach (MPTA) for cochlear implantation.28 Since then, the MPTA has stood the
test of time and become the most commonly used approach. As the name implies,
a mastoidectomy is performed followed by a posterior tympanotomy, which opens
the facial recess exposing the round window. Several techniques have been devel-
oped and explored to try to minimize the extent of surgery needed to place the implant
and the risk to the facial nerve and chorda tympani associated with the MPTA.

Fig. 3. Electrode in cochleostomy (arrow) with excess electrode coiled in mastoid cavity
(arrow head). Left ear.
 Surgical Techniques in Cochlear 73

Fig. 4. Placing the R/S into the periosteal pocket. Left ear.

Suprameatal Route
In 1999, Kronenberg and colleagues29,30 developed a technique that avoids a mastoid-
ectomy altogether and introduces the electrode into the middle ear via a suprameatal
route. This suprameatal approach is based on a retroauricular tympanotomy approach
to the middle ear in which the facial nerve is protected by the body of the incus. Draw-
backs to the suprameatal approach include the following31:

 The electrode is stretched during insertion into the cochleostomy.

 Low-lying dura is a relative contraindication.
 A round window insertion and inferior cochleostomy is difficult.
 Additionally, the revision surgery rate is much higher with this technique
(J. Thomas Roland Jr, MD, personal communication, 2011).
Endaural Approach
Another nonmastoidectomy technique uses an endaural approach for access to the
cochleostomy and a superoposterior transcanal wall approach for the electrode.
This endaural approach, also known as the Veria operation, requires a special perfo-
rator for drilling a direct tunnel and a safety electrode forceps for inserting the
electrode.32,33
Minimal Access Incision Techniques
Minimal access incision techniques14,34,35 have also been described. A percutaneous
cochlear implant technique that involves a single, image-guided drill passed from the
mastoid cortex through the facial recess to access the cochlea has been developed.
The percutaneous cochlear implant technique uses an intraoperative CT scan and
three fiducial markers in the bone surrounding the mastoid to plan a safe trajectory
for the drill and has been validated in vitro36–38 and in vivo.39,40 Access to correct
cochleostomy or round window insertion may also be limited and the 3-D approach
to scala tympani insertion is limited.

COCHLEOSTOMY VERSUS ROUND WINDOW INSERTION

Because the human brain has the capability to integrate both acoustic and high-
frequency electrically processed information,41 much attention has been paid to the
possibility and benefit of electroacoustic stimulation (EAS). The goal of EAS is to
use the cochlear implant for high-frequency loss and use a hearing aid to improve
the residual low-frequency hearing. Benefits of EAS when compared with electrical
stimulation only or acoustic stimulation only include improved listening to speech in
74 Mangus et al

quiet, in noise, or in competition with another speaker.2,41–53 Other benefits of EAS

include improvement in identification of melodies and reception of musical
sounds47,49,54 With the benefits of EAS in mind, many investigators have sought the
least traumatic way to insert the electrode array in hopes of preserving residual low-
frequency hearing.

Traditional Cochleostomy Technique

 The traditional way to drill the cochleostomy is through the promontory anterior
and inferior to the round window membrane using a 1-mm to 1.5-mm diamond
burr (Fig. 5).
 The round window membrane is usually 1-mm to 1.5-mm inferior to the stapes
tendon.6
 If necessary, the round window niche is removed to identify the round window.
 Meticulous drilling with a 1-mm diamond burr is then used and continued until the
“blue” lining of the endosteum is visible, taking care to avoid inadvertent penetra-
tion of the endosteum because this may expose the inner ear to significant
acoustic trauma, up to 130 dB.55 The endosteum is at the same level and is
continuous with the round window membrane.
 The size of the cochleostomy is determined by the size of the electrode array,
which ranges from 1.0 mm to 1.4 mm.
 Once the endosteum is exposed, great care is taken to prevent bone dust or
blood from entering into the cochleostomy. Some centers encourage the use
of hyaluronic acid or dilute surgical-grade glycerin at this point to prevent
entrance of blood and bone dust.56 These substances have a buoyant density
greater than bone dust and blood, thus preventing ingress to the scala tympani.
 At this point, a straight pick is used to open the endosteum and the electrode is
inserted (Fig. 6).
 Suction is prohibited at this stage to avoid loss of perilymphatic fluid. Systemic
and/or topical intratympanic steroids may be used in hearing preservation cases.

The use of the traditional cochleostomy approach in combination with a short/hybrid

electrode in patients with residual low-frequency hearing has resulted in improved
hearing in noise and music perception.48,54 Although temporal bone studies have
shown that the basal turn structures can be damaged with the traditional

Fig. 5. Opened facial recess. (B, incus buttress; C, cochleostomy; E, stapes; *, facial nerve).
Left ear.
 Surgical Techniques in Cochlear 75

Fig. 6. Cochleostomy with electrode (arrow) in place (C, cochleostomy). Left ear.

cochleostomy approach,57,58 this approach is preferred by many surgeons to avoid

the complicated negotiation of the hook region of the cochlea and initiate insertion
at an appropriate angle up the scala tympani in the proximal basal turn of the cochlea
(pars inferior).

Round Window Approach

The round window approach to electrode insertion has gained much attention due to
the potential for reduced damage to intracochlear structures, as demonstrated in by
several temporal bone studies.59–61

 To avoid insertion into the wall of the scala tympani, the electrode is inserted into
the round window at an oblique/anterior angle to the surface. The electrode itself
seals the insertion incision, and further sealing is accomplished with muscle and/
or periosteum.
 Good visualization of the round window may be achieved in most cases by
removing the bony round window niche with a 1-mm diamond as well as per-
forming an adequate facial recess with drilling away of the bone anterior to the
descending facial nerve over the stapedius muscle (Figs. 7 and 8).
Use of the round window approach with a standard electrode has resulted in pres-
ervation in residual low-frequency hearing and the benefit of EAS in children.62 In addi-
tion to avoiding the potential trauma that the inner ear experiences from the 130 dB
produced from drilling the traditional cochleostomy,55 the round window approach
may reduce postoperative vertigo.62,63
Concerning the cochleostomy versus round window debate, James and
colleagues50 concluded, “it appears that the correct approach to opening the cochlea,
whether via the round window or. via an anterior-inferior cochleostomy, is vital to
avoid basal trauma, whether a long or short electrode is used.” Even if hearing is
not preserved, it is expected that minimally invasive techniques and preservation of
fine structures will optimize postoperative performance.

POSTOPERATIVE RADIOGRAPH/TELEMETRY.NEED OR NO NEED

Previously, intraoperative radiographs of the skull have been routinely used to confirm
electrode placement into the cochlea and detect possible electrode kinking. The initial
76 Mangus et al

Fig. 7. Round window niche lip removed exposing the round window membrane. Left ear.

MED-EL surgical manual stated, “A postoperative x-ray is not required, but is recom-
mended for verification of electrode insertion and as a baseline reference for electrode
placement.”64 Intraoperative plain radiographs were also purported to play a role in
the initial programming of patients.65 Intraoperative plain radiographs, however,
have not been found useful for uncomplicated cochlear implantations because their
usefulness in patient management is negligible66 and subsequent versions of MED-
EL’s surgical manual have not mentioned plain radiographs.67 The authors’ technique
is to only obtain intraoperative plain radiographs in unique or suspect cases. Many
centers, including the NYU group, routinely perform intraoperative radiographs to
verify the absence of tip rollover, verify intracochlear insertion, and act as a baseline
for postoperative analysis should electrode extrusion be suspected. Intraoperative
CT scanning has recently been available at the authors’ center. The authors have
found the scanner useful for complex cases of severe malformations or in cases of
significant osteoneogenesis. Scanning in the operating room allows making intraoper-
ative decisions regarding electrode placement in difficult cases, eliminates the need
for postoperative scanning, and potentially reduces revision surgical cases. Intraoper-
ative fluoroscopy is commonly used by the NYU team in cases of cochlear anomalies
and obstructed cochleas. This technique has been shown to prevent intrameatal

Fig. 8. Round window membrane where electrode will be placed. Left ear.
 Surgical Techniques in Cochlear 77

internal auditory canal (IAC) electrode insertions and verify an insertional stop point in
common cavities and hypoplastic cochlea cases.68,69
Neural-response telemetry and impedence testing obtained intraoperatively can
also help confirm proper functioning of the device and correct placement. Spread of
excitation testing can also detect electrode tip rollover. Intraoperative measurements,
fluoroscopy, and intraoperative radiographs may alert surgeons to a malfunctioning or
misplaced device allowing a surgeon to replace the implant at that time, saving
a patient from a future operation.

SUMMARY

Advanced technology, new surgical techniques, and refining established techniques

are hallmarks of cochlear implant surgery. Minimally invasive techniques, shorter
operative times, and near-zero complication rates are the current benchmarks.
Further advancements, including image-guided surgery, hearing preservation even
with full insertion, and telemetry-based advanced programming, are expected to be
standard in the future.

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