JOINT MEETING - IV CONSENSUS IN AUDITORY IMPLANTS &
V EAONO INSTRUCTIONAL WORKSHOP - Parma June 16-19, 2010

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Free paper session: 9.30-10.30

Room 1 - Chairmen: D. Cuda (Italy), G. Jablonski (Norway)

Comparison of round window and cochleostomy approaches for hearing preservation:
An analysis using computational structures technology
Kozo Kumakawa 1, Hidemi Miyazaki 2, Chiaki Sakamoto 3, Takuji Koike 3
1. Department of Otolaryngology and Hearing center, Toranomon Hospital, Tokyo, Japan  2. Department of Otolaryngology, Tokyo Kyosai Hospital, 3. Department of Mechanical Engineering and Intelligent Systems，The University of Electro-Communications,

Objective: Preservation of residual hearing in cochlear implant recipients is assumed to be influenced by two factors: the first is intracochlear trauma during the insertion procedure; the second factor involves the mechanical dynamics of the basilar membrane (BM) according to the position, length and thickness of the electrode and stiffness of the round window membrane (RWM). Histological examination has demonstrated that a hearing preservation electrode may be inserted by either a RWM or a scala tympani cochleostomy without evidence of significant intracochlear trauma (Briggs et al; 2006). So, we analyzed the remaining factors using a model of the human cochlea with computational structures technology.   
Method: In this study, a three-dimensional finite-element model of the human cochlea was created. Dynamic behavior of the BM, which is closely related to auditory activity, was analyzed.  In order to investigate the effect of the insertion method, the position, length, stiffness of the electrode and also the stiffness of the RWM were varied. The thickness of the electrode was defined as 0.5mm in the tip to 1.3mm in the root.
Results: If the stiffness of the RWM abnormally increases, as in the ossified condition, the amplitude of the BM movement was suppressed by 20dB relative to the cochleostomy approach.  However, if the RWM is kept mobile, this suppression was much smaller even in RW approach. The BM movement with the full-length electrode was 10dB less than with the short (1/2) electrode.   
Conclusion: Our computer model analysis suggests that the cochleostomy approach has a greater advantage for hearing preservation, if the RWM becomes very stiff with electrode insertion in RW approach. However, softening the electrode material can cover this suppression of the BM movement due to the stiff RWM.

New trends with cochlear implants and implication for the electrode design
C. Jolly, J. Mueller, W-D Baumgartner, S. Helbig, S. Usami (Innsbruck, Austria)

Originally, cochlear implant electrodes were designed for the profoundly deaf patient assuming that a largely depleted neural population survived in the form of spiral ganglion cells and associated axons.   No measurable residual hearing was present in the targeted patient group.  It was often assumed that the dendrites form of neural survival was absent due to the length of deafness and the slow retrograde degeneration of unstimulated neurites.
In recent years however 2 new significant trends in cochlear implantation have emerged:    
1.  Indications have evolved from profoundly deaf to severely deaf, and now to patients with considerable low frequency residual hearing up to 1 kHz or more.  
2.  Age of implantation has rapidly decreased from elderly and middle aged patients to include a majority of young and very young children.  
Today the neural substrate of the predominant beneficiary of CI technology can be assumed to have a substantial dendrite population.  A majority of sensory neural hearing loss includes gene mutation (specially the connexin’s), auditory neuropathy, ototoxic injury such as amino glycoside and cisplatin induced deafness, along with viral and bacterial infection induced deafness.   Duration of deafness for the young and very young candidates for CI is short by definition and little neural degeneration would have taken place.
The evolution of the CI population and indications calls for a reassessment of the neural substrate targeted though electrical stimulation and a reconsideration of requirements for the neural interface.  The high probability of neurites in all turns of the cochlear is both an opportunity and a challenge for electrical stimulation.   The opportunity dwells in the density of electrically excitable neural tissue in the inner ear from base to apex. The challenge resides in focusing the electrical stimulation to the dendrite portion of the neural fibers to achieve better selectivity, and perhaps lower thresholds.

Significance of hearing preservation with deep electrode insertion
Claude Jolly1
1. MED EL, Innsbruck, Austria

As CI candidacy criteria have broadened, there are more patients now with residual hearing in the low frequencies than there were 10-15 years ago. Using specific surgical techniques and a Hearing preservation in Partial Deafnes Treatment by using a new electrode SRA.
Skarżyński H.,  Matusiak M., Lorens A.
Oto-ryno-laryngosurgery Clinic International Center of Hearing and Speech, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland.  
Introduction:
Treatment of partial deafness with normal hearing level within low frequencies by cochlear implantation is a last achievement and also a challenge for treatment of this kind of hearing impairment.
Aim of the study:
The aim of the study was to analyze hearing preservation in low frequencies in a group of patients treated in International Center of Hearing and Speech in Warsaw with partial deafness by using a cochlear implantation with a newest SRA-Cochlear electrode.
Material and Methods:
Analyzed group consisted of 22 patients suffering from different types of partial deafness treated with cochlear implantation by using SRA-Cochlear electrode. All patients enrolled underwent a similar diagnostic procedure: a clinical history collection, ENT examination as well as audiological testing, like pure tone audiometry, speech audiomtery in quiet and noise (10S/NR). All patients were implanted with SRA – Cochlear electrode. Post-operatively a pure tone audiometry was performed to evaluate the level of preserved hearing after cochlear implantation.
Results:
In 21 out of 22 patients post-op assessment showed  full hearing preservation comparing to pre-op measurements. In one case we reported a hearing loss of unknown etiology.    
Conclusions:
Partial deafness treatment by means of cochlear implantation with SRA-Cochlear electrode corroborate our previous results obtained with different types of Med-El electrodes. This also proves that applied surgical procedure, as well as soft 20 mm electrodes provide best outcome in treatment of partial deafness. traumatic electrodes designed to preserve hearing, some or all hearing may be retained postoperatively. Even if there is not enough residual hearing for patients to use a combined electric-acoustic hearing implant, hearing preservation is becoming a benchmark for electrode quality and excellence in surgical expertise and approaches. In addition, a surprising number of patients with deeply inserted electrodes, known as complete cochlear coverage electrodes, have preserved hearing especially when a round window insertion technique is used.   
Hearing preservation is often measured postoperatively by air conduction thresholds. However, bone conduction thresholds may be a more effective measure of intrascalar electrode position. Measurable conduction thresholds imply that the endocochlear potential has been preserved and that the scala media has not been perforated or damaged. Decreased bone conduction thresholds suggest that the organ of Corti was damaged but not that the electrode perforated into scala media. Possible causes of damage include the manner of electrode insertion and post-insertion electrode position.  When there are no measurable air conduction thresholds but some measurable bone conduction thresholds, it might be that the presence of the electrode interferes with the travelling wave at the round window or in scala tympani.
When air conduction but not bone conduction thresholds are measurable postoperatively, the implication is that the electrode has not moved from one scala to the other and that endolymph and perilymph have not mixed together. Complete loss of bone and air conduction thresholds could mean that the endocochlear potential is disrupted, and that the scala media has been perforated with possible electrode deviation from scala tympani to scala vestibuli. Consistent and complete loss of residual hearing might reflect a traumatic electrode insertion with spiral ligament tear or an inflammatory response if no electrode deviation is seen on postoperative imaging.  

The Round Window Revisited: the Natural Way for Cochlear Implants
R. Angeli, E. Piccirillo, G. Di Trapani, M. Sanna, E. Molina (Piacenza and Rome, Italy)

CASE REPORT: HEARING PRESERVATION WITH A COCHLEAR IMPLANT IN A PATIENT AFFECTED BY PARTIAL DEAFNESS
Cuda Domenico*, Murri Alessandra*, Briccola Elisa*, Gurzoni Letizia*
* Hospital Guglielmo da Saliceto, Italy

Background: The EAS system is a semi-implantable hearing device to treat patients affected with partial deafness, defined as a mild to moderate hearing loss in the low frequencies, sloping to a profound hearing loss in the higher frequencies. The system provides both acoustic and electric stimulation of patients’ cochleae: the electric stimulation is achieved through a cochlear implant (CI) provided with a very flexible and atraumatic electrode (FLEXEAS) while the acoustic stimulation is given through a traditional hearing aid (HA). Both, the CI and the HA use the  same processor. The HA stimulates the lower frequencies, where the patient has good residual hearing, and the CI stimulates the middle and high frequencies.
Electric Acoustic Stimulation (EAS) has been shown to provide patients with most natural and richer hearing sensations than CIs alone.
To preserve the patient’s residual hearing, the surgical procedure used is of particular importance.
Objectives: Presentation of the most-recent atraumatic surgical technique for CIs in patients affected by partial deafness.  
Methods: Our exemplary patient is a 60-year-old woman with progressive asymmetrical hearing loss that started at age 40. Her left ear is anacusic, while the right one has good residual hearing: 35 dB threshold up to 500 Hz, then sloping into profound deafness. She has been using hearing aids for five years prior to implantation with minimal benefits (speech understanding with lists of bi-syllabic words always lower than 50% at 65 dB SPL).
Considering the long hearing impairment on the left ear, the worse one, her right ear has been implanted. Sub-optimal results could have been achieved with a traditional CI on said side. It is one advantage of the long FLEXEAS electrode (24 mm) that the implant could also have been activated as a traditional CI in case residual hearing would have been lost in the low frequencies after implantation.
The surgical steps taken are presented in detail.
Results: The patient’s residual hearing could be preserved during surgery and has remained stable over time. Results are shown in terms of pure tone audiometry and speech understanding, highlighting the contributions of the CI and the HA to the patient’s satisfactory performance.
Conclusions: The technical properties of the MED-EL FLEXEAS electrode allow for the preservation of residual hearing. In the case presented, the better ear has been selected for cochlear implantation to maximize benefits for the patient.  

Investigation of Cochlear Implant Electrode Positioning using Flat Detector Computer Tomography (FD-TC)
Greg Eigner Jablonsky, Ralph Greisiger, Marie Bunne, Claude Laurent, Gerhard Bosse, Hilde Korslund, Per Kristian Hof (Oslo, Norway)

Room 2 - Chairmen: W. Livi (Italy), P. Merkus (The Netherlands)

Decision making in advanced otosclerosis: cochIear implantation when and how?
A.F.C. de Cock, C.F. Smit, E.F. Hensen and P. Merkus
Cochlear Implant Center Amsterdam VUmc, Department of Otorhinolaryngology & Head-Neck surgery, VU University Medical Center Amsterdam, the Netherlands
AFC.deCock@vumc.nl, CI@vumc.nl

Background: Stapedotomy or hearing aid rehabilitation is the primary treatment for otosclerosis with disabling mixed hearing loss. In case of severe bilateral hearing loss these options may not result in optimal hearing rehabilitation and cochlear implantation (CI) can be considered. However, there are specific pre- and per-operative surgical dilemmas concerning CI in otosclerosis patients: hearing loss can be partially conductive, there may be significant obstruction of the cochlea and significant spongiosis of the otic capsule.
Objectives: Here, we discuss the role of CI in the management of otosclerosis patients with severe to profound hearing loss and provide a CI selection algorithm for this patient group.
Materials and methods: Recommendations are based on literature survey and own experience and take into account the type and level of hearing loss and radiological findings.
Results: An algorithm based on speech performance guides the surgeon to either advise stapedotomy, hearing aids or CI. Compared to regular CI selection criteria there are two main differences: the possibility of hearing rehabilitation by stapedotomy combined with hearing aids before considering CI and early CI in cases with severe otosclerotic lesions of the otic capsule.
Conclusion:
In the management of patients with otosclerosis an algorithm can be of great help in selecting patients with severe to profound hearing loss for either cochlear implantation or other rehabilitation options in order to achieve optimal hearing with minimal disadvantages.

Dutch Cochlear Implant Group (CI-ON) consensus protocol on postmeningitis hearing evaluation and treatment.
Merkus P, Free R, Mylanus EAM, Stokroos R, Metselaar M, Spronsen, van E, Grolman W, Frijns JHM.
Cochlear Implant team VUMC Amsterdam, VU University Medical Center, Amsterdam, the Netherlands - on behalf of the Dutch Cochlear Implant Group

Objective:
One of the most devastating sequelae of bacterial meningitis is profound hearing loss or even deafness. Although cochlear implantation is able to restore (some) hearing abilities, obliteration due to fibrosis and especially calcification of the cochlea in the post meningitis period is limiting the success rate of an implantation. A national consensus assembled in a post meningitis follow up protocol has to increase awareness and thus the chances of an early detection and possible intervention when profound hearing loss occurs.
Setting:
All cochlear implant centers of the Netherlands located in the 8 academic otorhinolaryngology and audiology departments of the Netherlands, gathered in the Dutch Cochlear Implant Group (CI-ON, Cochlear Implant Overleg Nederland).
Intervention:
A protocol proposed by three centers was send to all other cochlear implant centers in the Netherlands to review and agree on.
Main Outcome Measures:
The Cochlear Implant Centers agreed on the need for, and use of the proposed protocol. Keystones of the protocol are treatment with dexamethasone before start of antibiotics, early MRI and repeated audiological follow up and urgent referral to a CI center in all cases with >30dB SNHL.
Conclusion:
The Cochlear Implant Centers in the Netherlands (CI-ON) have agreed upon a protocolized follow up after bacterial meningitis in order to increase the chances of an early detection and possible intervention when profound hearing loss should occur.
Key Words:
Cochlear implant, bacterial meningitis, hearing loss, diagnostic protocol, Netherlands, audiology, MRI.

Cochlear Implantation in Children with Cerebral Palsy
A. Bacciu, M.T. Bergenti (Parma, Italy)

Cochlear implantation in patients affected by superficial hemosiderosis of CNS: a three-case series
A de Vito, F Forli, S Berrettini
Otology and Cochlear Implant Centre, University of Pisa, Italy

Superficial hemosiderosis of the central nervous system (SH-CNS) is a rare progressive pathology characterized by intracellular and extracellular deposition of hemosiderin in the leptomeninges, cranial nerves, spinal cord and subpial tissue. It is caused by recurrent or chronic bleeding occurring into the subarachnoid space which causes the deposition of hemosiderin which is citotoxic for underlying tissues. Main symptoms of SH-CNS are sensorineural deafness, cerebellar ataxia, pyramidal signs and dementia, less frequently it is also associated with anosmia, anisocoria, and extraocular palsies.
Diagnosis of SH-CNS is often difficult, actually the gold standard is Magnetic Resonance Imaging, particularly T2-weighted sequences are extremely sensitive for the deposition of hemosiderin. This is shown as a marginal hypointense signal which can be present around brainstem, cerebellum, cranial nerves, spinal cord periphery and also brain surface.
Hearing loss in SH-CNS is of neural origin, however the possibility of cochlear damage is debated. Cochlear implant (CI) may be an option for hearing rehabilitation in patients that receive no benefit from hearing aids.  
Actually only 14 cases are reported in scientific paper with very variable outcomes.
We report a retrospective three-case series of patients affected by SH-CNS who underwent to CI procedure in our department.

Cochlear Implantation For Usher Syndrome type III: Finnish Experience
J Jero1,5 MD PhD, AM Abdel-Rahman1 PhD, H Västinsalo2 MSc, J Isosomppi2 PhD, H Löppönen3,4 MD PhD, E Kentala1 MD PhD, R Johansson5 MD PhD, H Valtonen1,3  MD PhD, JP Vasama6 MD PhD, L Pietola1 MSc, EM Sankila2,7 MD PhD and AA Aarnisalo1 MD PhD  
1 Dept. of Otorhinolaryngology, Univ. of Helsinki, Helsinki, Finland
2 Folkhälsan, Biomedicum, Laboratory for molecular biology, Helsinki, Finland
3 Dept. of Otorhinolaryngology, Univ. of Kuopio, Kuopio, Finland
4 Dept. of Otorhinolaryngology, Univ. of Oulu, Oulu, Finland
5 Dept. of Otorhinolaryngology, Univ. of Turku, Turku, Finland
6 Dept. of Otorhinolaryngology, Univ. of  Tampere, Tampere, Finland
7 Dept. of Ophthalmology, Univ. of Helsinki, Helsinki, Finland  

Background: Usher syndrome type III is an autosomal recessive disorder characterized by variable type and degree of progressive SNHL and retinitis pigmentosa. Cochlear implants are widely used among these patients.  
Purpose: To evaluate in a nationwide multicenter retrospective review the results and benefits of cochlear implantation in patients with Usher syndrome type III.   
Material and Methods: During the years 1995-2005 in five different finnish university hospitals 19 Usher syndrome type III patients received a cochlear implant. All these patients participated in this study. Saliva samples were collected to verify the genotype of these patients. Patients answered to three questionnaires (Glascow Benefit Inventory (GBI), Glascow Health Benefit Inventory (GHBI) and a self made questionnaire). Audiological data was collected from patient records.  
Results: All the Usher syndrome type III patients participating the study had the Finmajor mutation. The preoperative hearing was 108 ± 8 dB and the preoperative aided hearing was 57 ± 17 dB. The postoperative hearing was 32 ± 9 dB. The speech discrimination scores preoperatively (5-10 years) showed a mean of 17 ± 25% and prior the surgery 4 ± 9%. Postoperative discrimination was significantly better compared to the preoperative value (52 ± 33%, p<0.001).The GBI total score was 33 ± 19. Total score of GHSI data related to hearing was 59 ± 9 and vision related GHSI was 56 ± 14.    
Conclusions: Cochlear implantation is beneficial to patients with Usher syndrome type III and patients do learn to use the implant independently. GBI results show that cochlear implantation is as successful with Usher syndrome type III patients as with other postlingually deafened

Cochlear Implant in a Common Cavity Case
Walter Livi, Antonio Romano
ENT Department, University of Siena, Italy

Objective: report a clinical experience on a patient suffering from a Common Cavity malformation, undergone a cochlear implantation.
Study design: Case report
Setting: University hospital
Patient: 13-years-old boy, Vietnamese, suffering from congenital bilateral profound deafness caused by a bilateral Common Cavity.
Material: authors use Nucleus Freedom Implant with straight electrode, CI24RE (ST) model, of Cochlear Corporation. The electrode array has 22 intra-cochlear electrodes and the implant has two extra-cochlear electrodes, one on the receiver/stimulator and the other on a lead. The 22 electrodes, platinum made, have a spherical form and are spaced over a 17 mm active array. Diameter of electrodes is 0.6 mm at the basal end, tapering to 0.4 mm at the apical end of the array.
Intervention: using the normal approach through facial recess, with diamond micro-milling skeeter with a diameter of 0.8 mm a 60° angle hole is made in the promontory at 1mm off the back branch of the stapes. After about 2mm of milling we enter into the cavity. All the electrodes are inserted inside the cavity.  The receiver/stimulator is fixed with silk threads. The extra-cochlear electrode is positioned below the temporal muscle.
Results: intra-surgery and post-surgery electrophysiological tests point out a correct positioning and functioning of electrodes. Three months after surgical operation,  audiometric tests shows excellent results.
Conclusions: authors sustain that Nucleus Freedom with straight electrode is the ideal model to implant in case of Common Cavity malformation with normal course of facial nerve. They also conclude that normal approach through facial recess is the less invasive surgery technique.
Key words: Common Cavity, cochlear implant.
Correspondig author: Tel.+39 0577 803349. E-mail address: livi@unisi.it,
romano-antonio@hotmail.it

Room 3 - Chairmen: E. Pasanisi (Italy), J. Mulder (The Netherlands)

Cchlear Implantation programme in the Kingdom of Bahrain Review of 70 cases
H. Jamal (manama, Kingsdome of Barhain)

Objective: This study is designed to observe the results of hearing and speech development of deaf children and adults after Cochlear Implantation surgeries performed in Salmanyia Medical Complex (SMC)
Method: All cases that had Cochlear Implantation surgeries in the periods of May 2001 to October 2002 and April 2005 to June 2008 in Salmanyia Medical Complex – Kingdom of Bahrain, are included in this study.
Results: A total of 70 cases had Cochlear Implantation; the overall age range was from 11 months to 39years. More than half of them (36 cases - 51.4%) are in age group 11months to 5 years.  All of the 70 cases had hearing & speech rehabilitation of 6 months to 2 years after surgeries. All were profoundly deaf preoperatively of 90dB to over 100dB or no responses. Hearing level gain was at level of 15-30dB in 55 cases (78.6%) and to level of 31dB to 40dB in 14 cases (20%) and in remaining 1 case (1.4%) at 50dB. That is 69 cases (98.6%) had serviceable hearing of 40dB or less. Speech development from no speech or poor speech levels in all cases to moderate and near normal levels of speech in 54 cases (77.1%) for overall cases, while in the 36 children aged 5 years or less, 33 of them (91.6%) reached moderate to normal levels of speech,  matched to age.   This speech gain in words and sentences, is less in older age groups, in that the gain of moderate to near normal speech was in 10 out of 13 cases (76.9%) in the 6 to 10 years old group, and in 8 of 16 cases (50%) in the 11 to 20 years old group, and in 3 of 5 cases (60%) in over 20 years age group.
Etiological factors, type of implant and other parameters will be presented.
Conclusion: Cochlear Implantation has made a difference in the life of these patients, in which the majority is children. Hearing restoration achieved in all cases. The speech gain achieved up to moderate to near normal speech levels in overall cases in (77.1%), while it reached 91.6% in children aged 5 years or less. Therefore implantation in younger children gives higher success rates.

Authors: Dr. Ahmed J. Jamal (CI Surgeon), Mr. Omar Al-Sharif (Speech Pathologist) and, Dr. Jamal Al-Sayyad (Epidemiologist). (Speaker underlined)
Presentation including Video clips of patients 20minutes
Address for correspondence:
Dr. Ahmed J. Jamal FRCSI, FRCS Ed.
Consultant ENT Surgeon & Cochlear Implant Surgeon
Chairman, MOH-Centre for Hearing Impairment and Cochlear Implantation
ENT Department – Salmanyia Medical Complex
P.O. Box: 12 Manama, Kingdom of Bahrain
Tel.: mobile: + 973 39660036, off: + 973 17279768
Fax: +973 17279767 or +973 17277707
E-mail: ajamal@health.gov.bh  And      ahmedjjamal@yahoo.com

Universal newborn hearing screening in Clinical Center Nis and cochlear implantation (CI)
Mila Bojanovic, Emilija Zivkovic-Marinkov
ORL Clinic University of Nis, Nis, Serbia

Estimates of the prevalence of moderate, severe and profound congenital hearing loss among newborns range from 1 in 900 to 1 in 2500. Advocates of universal newborn hearing screening (UNHS) believe that earlier detection followed by early intervention could reduce or eliminate the gap in language skills between deaf and hearing children. Early screened children differ significantly from late screened with respect to age of hearing loss and age of hearing intervention.
Objectives: The aim of this study was to present the results of UNHS and to contribute to the implementation of a UNHS in Serbia and earlier cochlear implantation.
Methods: We started performing UNHS at the Gynaecology and Obstetrics Clinic in Nis in July, 2007. In first 8 months we screened 1,733 newborns and in first year 2421 newborns after the first day of life, using two-stage Transient Evoked Otoacoustic Emission (TEOAE) screening test. The automated device we used for the screening was MAICO EROSCAN. The newborns who failed the first screening unilaterally or bilaterally were rescreened 30 days later. The newborns with risk factors for hearing loss as well as those who failed  screening twice were rescreened using an Auditory Brainstem Response (ABR) test.   
Results:From the total number of 2421 newborns (50.3%male and 49.7 female) examined in this study, 90.8% passed the first screening, while 96.6% passed the second screening, performed a month after. 0.75% newborns were refered to additional audiological testing. Hearing loss was confirmed in 3 cases. Hearing screening significantly reduced the age of the time of diagnosis(7,9m vs 18m);age of the first fitting(9,6m vs 18m);age at the time of cochlear implantation.
Conclusions: The use of TEOAE in UNHS is non-invasive, painless, reliable and inexpensive. We hope that this study will contribute to the development of a national newborn hearing screening program, wich will obtain more precise data on the incidence and prevalence of hearing loss and impairment in Serbia  and lead to earlier age of cochlear implantation.
of cochlear implantation.

Evaluation of Med-El CI implanted children in East Algeria
S. Labassi1, N. Djerad2, S. Touati3, B. Boutaceta3, A. Saidia2
1 Vibrant Med-El, France
2 ENT Dept, University Hospital, Annaba, Algeria
3 ENT Dept, Clinique des Allées, Batna, Algeria

Background: This study was aimed, through the administration of several questionnaires, to evaluate the progress in speech perception, comprehension and production in 60 CI children coming from two East Algerian implantation centers.
Method: Several questionnaires, aiming to different speech aspects, were administered. They were filled out by the children’s parents and speech language pathologists in both centers. LittlEars questionnaire, a validated tool, is an investigation of the child’s hearing behavior. The CAP (Categories of Auditory Performance) and the SIR (Speech Intelligibility Rating scale) both rate speech perception and production, respectively. The MAIS questionnaire (Meaningful Auditory Integration Scale) is aimed to rate implant use by the child. Finally, the APCEI profile is a tool giving a visual synthesis of the speech and hearing abilities of the implanted child. These questionnaires were administered to 60 CI implanted children, coming from 2 implantation centers of East Algeria, Annaba (n=48) and Batna (n=12).
Results :We found that the majority of children had a good evolution with performances equal or superior to what is reported in the literature. Conclusion The results obtained support previous findings on speech and hearing development in CI children. Learning outcomes Participants will be able to examine speech and hearing development in CI children through the administration of several validated questionnaires.

Results of cochlear Implantation in pre-lingually deaf adults
Jeff Mulder (Nijmegen, The Netherlands)

Cochlear Implant Outcome in Postlingually DeafenedAdults. Comparison of ThreeDevices
E. Pasanisi, A. Bacciu, P. Fois, M.T. Breghenti, G. Di trapani (Parma and Piacenza, Italy)

Room 4 - Chairmen - G. Bianchin (Italy), D. Adams (Germany)

Benefits of cochlear implants in children with multi-handicaps
F Forli, Palmieri, S Berrettini
Otology and Cochlear Implant Centre, University of Pisa, Italy

The issue of cochlear implantation in deaf children with associated disabilities is an emerging one. Currently there is no consensus on whether to implant children with multiple impairments and on prognostic factors; moreover in these special cases it is generally difficult to evaluate the post-implant results. In fact these children may be difficult to evaluate with standard tests and sometimes they achieve poor speech perception and language skills; despite this they often obtain important benefits in daily life, with a global improvement of quality of life.
We present the post-implant outcomes of 50 profoundly deaf children with additional neuropsychiatric disorders, by using objective measures of speech perception and language development and a questionnaire administered to the parents, specifically developed and aimed at evaluating the benefits in daily life and in terms of quality of life.

Bimodal stimulation can drastically improve speech intelligibility thresholds even after implantation of the worse ear with long lasting sensorineural deprivation.
Mom T1,2, Akkari M1, Bascoul A1,2, Gilain L1,2, Le Calvez V1, Ménétrier D1, Avan P1,2
1Department of Otolaryngology Head and Neck Surgery
2Laboratory of sensory Biophysics (EA2667)
Centre Hospitalier Universitaire de Clermont- Ferrand
FRANCE

Objective: To reveal the benefit of a contralateral hearing aid in cochlear implant recipients using bimodal stimulation after implantation of their worse ear.
Materials and Methods: Analysis of the auditory performances of 18 cochlear implant patients using a contralateral hearing aid. All patients were implanted with a Neurelec device. Their preoperative speech intelligibility with hearing aids never scored better than 50% with open-set dissyllabic-word testing. They all were tested by an open-field tonal audiogram and speech intelligibility assessment using open-set dissyllabic-word lists after cochlear implantation, in electrical vs. bimodal stimulation.
Results: There were 6 males and 12 females (mean age 37 y-o; 18 months-86 y-o). Mean follow-up was 31+/-18 months. Tonal audiograms were significantly better on 0.5 kHz only (p=0.002). The maximal score was higher in bimodal conditions at 80+/-15% (p=0.0002). Eleven patients performed better than others with a 50% intelligibility threshold (50%IT) <60dB in bimodal condition. These patients had a better 50%IT at 43+/-10 dB with a bimodal stimulation than with their sole cochlear implant at 73+/-38 dB. Four of them (36%) were remarkable in that they had poor performances when using exclusively their cochlear implant, never reaching a 50%IT whatever the intensity of stimulation. Sensorineural deprivation of the implanted ear in these cases was 19, 25, 8 and 2 years.
Conclusion: Bimodal stimulation did improve the intelligibility in patients implanted with a Neurelec device, even when the implanted ear had a sensorineural deprivation for more than 15 years and gave poor results with electrical stimulation alone.

Automatic and outcome-driven expert fitting: a new approach to program cochlear implants
Paul J Govaerts, Bart Vaerenberg, Geert De Ceulaer, Kristin Daemers
The Eargroup, Antwerp, Belgium

Introduction: Cochlear implant (CI) fitting is a tedious job requiring specific skills and competences.  Expert audiologists need to be familiar with the different implants, their fitting software and their electrical specifications.  It is difficult to establish the validity and reliability of all the fitting procedures encountered.  Routine fitting procedures may sometimes be so laborious that no time is left for in depth assessment of performance, let alone for feedback of such an assessment to modify the fitting.  To overcome this issue, it is essential to automate the entire procedure and to turn it into a simple and quick expert driven and outcome based procedure.

Material & Methods: A software program, FOX®, has been developed to assist the audiologist in programming CIs.  FOX is outcome driven and expert based.  The core is a feed-back engine to which both audiological results and existing CI program-parameters are fed and which delivers modifications to the implant program.  The engine contains a set of mathematical algorithms called an “advice” and programmed by an expert.  Multiple advices are possible.  Data can be entered manually or automatically.

Results: FOX has been operational in the Eargroup for almost two years.  All CI users receive fully automatic switch-on fitting.  All follow-up fittings are done with FOX based on audiological test results and the execution of the FOX advice.   Immediate positive effects are seen on the audiogram, the speech audiogram, the A§E discrimination task and the A§E loudness increase test.  

Conclusion: The introduction of fully automatic and outcome driven expert software substantially reduces the fitting time and improves the fitting quality.  It will standardize and systematize the fitting procedure, allowing highly improved process control and the systematic exploration of new fitting strategies.  It will allow audiologists to allocate their time to the exploration of new fitting strategies and developing in-depth expertise. FOX has already been used outside the Eargroup by pilot centres, and a multicentre study is currently ongoing across several European clinics, using FOX in combination with the Advanced Bionics device

Music Perception in Everyday Life - Subjective Rating of Users of different Cochlear Implant Generations
Doris Adams1, M. Brendel1,2, Stephanie Ruehl1, A. Buechner1, Th. Lenarz1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany
E-Mail: adams@hoerzentrum-hannover.de

Studies showed that current Cochlear Implant (CI) systems can reproduce certain characteristics of music much better than previous systems. Therefore a questionnaire survey was initiated to assess the music appreciation of CI users with various speech coding strategies.
51 adult subjects implanted with any implant generation of Advanced Bionics participated in this survey. They used all available speech processors and speech coding strategies and were split into three groups: user of conventional strategies (CIS, SAS, PPS), users of HiRes and users of HiRes 120. They had a mean age of 51.4 years, a mean age at implantation of 44.7 years and a mean duration of deafness of 5.6 years. Ratings of the CI users were compared to those of normal hearing adults (N = 35).
The ability to understand the lyrics of a song, recognize the style of music or the gender of singers seemed to have an influence on the enjoyment of hearing music.
Users of conventional speech coding strategies showed the largest number of significant differences to the normal hearing control group while HiRes 120 users rated most questions similar to the control group.
Preliminary results indicate that the improvements in both, the temporal and spectral domain, led to advantages for music appreciation.

Estudio Comparativo: Conductal, Hitoa en el Desarrollo y Resultados Educativos en un Grupo de Ninos Sordos Espanoles que Utilizan el IC desde Edades Tempranas, Respecto a Otro de Pares Oyentes
Jiménez MS, Pino MJ, Herruzo J. (Cordoba, Spain)

Speech Perception Benefits of Sequential Bilateral Cochlear Implantation in Adults: Reggio Emilia experience.
G. Bianchin, P. Formigoni, V. Polizzi, G. Portioli
Azienda Ospedaliera S.Maria Nuova di Reggio Emilia

Introduction:
Recent data have shown that 2 cochlear implants provide better sound localization and speech recognition than  2  hearing aids or a hearing aid and an implant .
So bilateral cochlear implantation seeks to restore the advantages of listening with two ears.
We report our experience about a better speech recognition in patients with two implant than one even in noise.
Objective: To support the vantage of bilateral implantation and assess  the summation effect in quiet and in noise
Study design: retrospective review
Seeting: S.Mary N. Hospital
Patients:   6  bilaterally implanted adult patients with progressive post-verbal hearing loss who had used the second implant for more than 6 months were selected for the study: 3 patients became deaf in childhood  and 3 in adult age.
Main outcome Measure: Speech perception measures were performed using appropriate test in quiet and in noise with unilateral and bilateral implant use. Summation effect in quiet and noise were
calculated.  To evaluate this effect, the speech and the noise come from directly in front of the patient (0-degree azimuth). The test is performed 3 times. First, the right CI is activated, then the left, and finally both. The test was measured for a stable noise level of 65 dB and  with different level S/N (+10,+5,0,-5,-10)
Advantage for binaural stimulation with respect to the unilateral condition was assessed for each individual.
Results:
After bilateral cochlear implantation, there is a better and a poorer side as shown in the results of the  test in quiet and noise.
The first implant is the better in all valuation respect the second.
For the perception test used, speech understanding ability was better in the bilateral condition if compared with results from the poorer ear.
For the summation effects, results for the bilateral condition were slightly better in comparison to the better ear alone, results were statistically significant even in noise (SNR=0,SNR=-5).
In particular the results of the second implant  were better in patient group became  deaf in adult age.
Conclusion: Speech understanding is improved with bilateral cochlear implantation even in noise. Although there was improvement with a second Cochlear implant despite length of deafness, age of first-side implantation was a contributing factor to second ear outcome , patients with shorter duration of deafness perform better in the summation test.
These are our considerations about a limited number of bilateral implanted patients.  Further studies are necessary to confirm and to determine the long-term outcomes.

Room 5 - Chairmen: E. Truy (France), M. Dagmar (Czech Republic)

DUET 2: the Second Generation of EAS Processors – Results from a DUET to DUET 2 Upgrade Study
Artur Lorens1, Martin Eisendle2, Malgorzata Zgoda1, Ilona Anderson2, Henrik Skarzynski2
1 Institute of Physiology and Pathology of Hearing, Nadarzyn, Poland
2 Clinical Research Department, MED-EL, Innsbruck, Austria

Objectives
EAS is a promising treatment for individuals with a ski-slope type hearing loss who gain minimal benefit from hearing aid amplification, yet still struggle within their everyday environment. Hearing preservation and sufficient use of still existing low frequency hearing have been professional challenges over the past 10 years. Previously, EAS users had to wear a BTE speech processor plus an ITE hearing aid. This was problematic due to two reasons: i) insufficient gain and ii) reduced compliance to wear both devices in one ear. The introduction of the DUET, the first integrated electric and acoustic EAS processor, led to better acceptance and more frequent use of EAS. In 2009 the DUET 2 was launched, matching the design of the Opus 2, featuring a remote control and allowing for more gain in the low frequencies.  This study aims at comparing the second generation of EAS processors, the DUET 2 with the DUET.
Materials and Methods
Ten experienced DUET users were recruited for this study. All were tested with a battery of speech perception tests, questionnaires and visual analogue scales. Tests were performed with both the DUET and the DUET 2 at the upgrade interval. Post upgrade, participants wore the DUET 2 and were acutely tested with the DUET. All participants were followed-up up to six months.
Results
Results from speech perception tests in quiet and noise revealed that participants performed equally well with the DUET 2. Visual analogue scales indicated subjective preference for the DUET 2. Participants appreciated the new features of the DUET 2 audio processor, especially the FineTuner. They also reported to perceive a better sound quality in general and especially when listening to music.
Conclusion
Earlier studies demonstrated the benefit of integrated processors for EAS users. Although no significant improvements regarding speech perception were shown, the DUET 2 can provide additional advantages over the DUET. Participants reported a better satisfaction and improved sound quality with the DUET 2 as compared with the DUET.

Towards better noise robustness in Cochlear Implants
J.H.M. Frijns, P.P.B.M. Boermans, J.J. Briaire
Leiden University Medical Center, ENT Department – e-mail: J.H.M.Frijns@LUMC.nl

Objective: Cochlear implant (CI) users can achieve remarkable speech understanding scores when the sound environment is clear. Multiple factors have contributed to this success such as improvements in processor design and sound coding and improvements in candidate selection and rehabilitation. Realistic sound environments remain however challenging. In daily life the target speech is often presented in ambient noise, and the signal-to-noise ratio may not exceed 5 dB.  Hearing performance breaks down much quicker for CI users than for normal hearing individuals. In the field of hearing aids, speech enhancement algorithms are already a commonly adopted solution to extend the range of sound conditions over which the auditory prosthesis functions well. In cochlear implants, they are still relatively new. Advanced Bionics recently introduced the ClearVoice™ feature as an option for the HiResolution120™ sound strategy on the Harmony™ processor. In this study we investigate its capability to improve hearing in background noise.
Method: A group of 39 long-term users was upgraded from the Auria™ processor to the Harmony™ processor. Three strategies were evaluated in a blinded, randomized cross-over study with a latin-square design: HiRes-S, Hiresolution120 and ClearVoice. After one month, speech testing in quiet and stationary noise (+10, +5, 0 dB) was conducted and sound quality was evaluated (SSQ questionnaire). Test material consisted of standard CVC word lists (NVA) and sentences (LIST).
Results: To date only preliminary study results are available. So far switching between programs was uneventful. Users reported noticeable sound quality differences between the three algorithms. Formal speech testing did not reveal significant performance difference on the word material. On sentence material a benefit for the ClearVoice algorithm was observed.
Discussion & Conclusion: Cochlear implant users need further sound processing enhancements in order to improve speech understanding in background noise. The ClearVoice approach seems a promising approach. Our initial experience is that the test methodology is important. To evaluate speech enhancement algorithms, long sentence materials reflect better real life use, and seem better suited than isolated word material. The present study indicates that the time has come to update the clinical standard in the Dutch speaking area, and add sentence material to the standard test batteries (monosyllabic words in quiet and noise).

Speech intelligibility in quiet and in noise for patients using a Digisonic® SP Binaural cochlear implant system
Eric TRUY1, Genviève LINA- GRANADE1, Nicolas VERHAERT1,2, Philippe ROMANET3, Bernard MEYER4, Jean-Pierre BEBEAR5
1.Department of Otorhinolaryngology, Edouard Herriot Hospital, Lyon, France
2. Department of Otorhinolaryngology, University of Leuwen, Belgium
3. Department of Otorhinolaryngology, CHU Dijon, France
4 AP-HP, Paris, France
5. Department of Otorhinolaryngology, CHU Bordeaux, France.

Background: A critical aspect of cochlear implantation in the future will be the extent to binaural hearing, in order to improve spatial hearing abilities like localization and ‘cocktail-party’ listening. However, although potential benefits of binaural hearing have been recognized for implanted listeners, current proposals remain “bilateral” (two implants), rather than “binaural” (two ears) in concept. In fact, bilateral implantation is an expensive practice that is not systematically funded in several countries. The only truly binaural device available today, and evaluated in the present study, is the Digisonic® SP Binaural developed by Neurelec. As this implant provides electrical stimulation in both ears through only one implanted receiver/stimulator, it is an alternative to bilateral implantation at a lower cost. Indeed two microphones are adapted to the patient to ensure stereophonic perception.
Methods: A multicenter prospective study has been designed and conducted at different University hospitals in France. Speech intelligibility in quiet and in noise, and sound localization abilities have been assessed for a group of 15 binaurally-implanted patients. Speech intelligibility was assessed using dissyllabic words, presented in free field at a 70dB SPL level in quiet, or merge into a 65dB SPL steady noise, through a loudspeaker facing the patient. For the localization task, white noise was presented through one loudspeaker randomly chosen out of five (five loudspeakers uniformly set around the patients), and the patients had to identify the loudspeaker. All these audiometric tasks were performed with left ear activated only, right ear activated only, and with both ears activated.
Results: Speech intelligibility in quiet and in noise is significantly better with both ears activated than with one ear only; results are equal than those described in literature using bilateral cochlear implantation. Sound localization abilities appear good with both ears and similar than described in literature with bilateral CIs, whereas it is very poor with only one ear activated.
Conclusion: These results collected with the binaural implant are quite consistent with previous data collected on bilateral implants, suggesting that the binaural implant seems to offer a benefit similar to that offered by the bilateral implantation.
Learning outcome: Speech performance in binaurally-implanted adult patients.

Binaural Digisonic SP cochlear implant : clinical results.
Eric Truy 1, Nicolas Verhaert 1,2, Jean-Pierre Bebear 3, Bernard Meyer 4, Philippe Romanet 5, Geneviève Lina-Granade 1.
Hopital Edouard Herriot,  Lyon, France
Leuwen University Hospital, Leuwen , Belgium
Hopital Pellegrin, Bordeaux, France
AP-HP, Paris, France
CHU, Dijon, France

Introduction: Binaural audition with cochlear implants is not hearing with bilateral uncontrolled inputs. We designed a binaural cochlear implant with two microphones, only one implanted stimulator driving electrical stimulation to both ears. This implant has been developed over past years and achieved maturation and obtained CE mark.
Aims of the study: 1. to briefly present the technology. 2. to report clinical results in 15 patients implanted at different University hospitals.
Material and methods: All patients underwent surgery using a routine surgical procedure and were implanted with the 12+12 channel Binaural Digisonic SP CI (Neurelec, Antibes, France). A prospective longitudinal follow-up was performed over a minimal period of 6 months. Audiological data included pre and post assessments with pure tone aided audiometry, speech audiometry in quiet and with various signal/noise ratios, and sound localization testings.
Results: Patients displayed improvement of speech perception after fitting over time. Speech intelligibility in binaural condition was better that the one with only the best side activated, in quit and in noise. Sound localization testings were excellent when patients were activated in both ears. These results are similar than those reported in literature with bilateral cochlear implants.
Conclusion: Binaural Digisonic SP CI offers similar performance to patients for speech intelligibility in noise and in quiet and for sound localization, than bilateral cochlear implants with two separated devices. A lower cost offers possibilities to conduct cost-utility studies.

Champions profile for evaluation of paediatric cochlear implant users with complex needs – European retrospective study
D. Herrmannova1 , Th. Lenarz2, R. Phillips3, G. O’Donoghue4, T. Twomey4,R. Ramsden5, L. Henderson5, B. Bertram6
1 Advanced Bionics Europe, Prague, Czech Republic,
2Medical University of Hannover, Germany
3 Royal School for the Deaf and Communication Disorders, Manchester,UK
4 Nottingham Cochlear Implant Programme, Nottingham, UK
5 Manchester Cochlear Implant Programme, Manchester, UK
6 Cochlear Implant Centrum “Wilhelm Hirte”, Hannover, Germany
Dagmar Herrmannova MA
Tel: +420 604 748 637
Email: dagmarh@abionics.fr

Introduction
In the last years the inclusion criteria for cochlear implantation have been widened.  The consensus is growing that additional disabilities are not a contraindication.  Therefore more deaf children with complex needs receive cochlear implants.  Following implantation, their unique combination of disabilities makes the potential of these children difficult to evaluate and progress difficult to monitor.  Not all of the traditional outcomes, typically measuring speech perception or production, will be predictable, or indeed applicable, but the experience of having a cochlear implant (CI) may bring exciting and significant life rewards.  
Objectives
This survey introduced the “Champions” profile to assess the influence of cochlear implantation on medical and audiological aspects, communication strategies, social and psychological aspects as well as quality of life. The objectives were to verify the profile and to determine the usefulness of data gathered for the potential management of complex needs children.  
Materials and methods
Children with complex needs from four European centres were evaluated using the ‘Champions’ scales.  The data were analyzed to illustrate and compare the important outcomes for these children in terms of everyday life. Data collection is underway with a target of 52 data sets to be completed for analysis.  Initial results point to the different development and benefits from CI for children with complex needs as well as quality of life.  
Results
The graphic presentation of the scales makes it easy to see the areas in which progress has been good and those areas in which the child will benefit from more intensive support.  The Champions evaluation is unique in providing a unified system for recording the progress of paediatric CI users through a system that makes monitoring the child’s progress highly accessible.  
Conclusion
The outcomes present a meaningful measure, which relates to real world benefits with this complex group of children.  Further details on the usefulness of the Champions profile will be presented and discussed.

”Champions” Evaluation Scales for Paediatric CI Users with Additional Disabilities
Dagmar Herrmannova, Rob Phillips, Gerard O’Donoghue, Richard Ramsden
Mgr.Dagmar Herrmannova MA
Speech and Language Therapist and Special Pedagogue
Czech Republic

Many studies confirm that during the last two decades the population of children with complex needs has grown. In particular, a greatly increased number of very premature babies are now surviving through advanced medical care where this is available. However, up to 40% of very early born babies have significant and permanent disabilities. These frequently include difficulties in the areas of hearing, vision, kidney function and respiration. Society can now offer much to premature babies. Significant changes have taken place, and continue to take place, in the tools and technology to support them.
One example is the Cochlear Implant (CI): this can benefit children who are profoundly deaf, including those with complex additional needs. Cochlear implants can bring benefits across a range of areas, including listening, the development of communication, psychosocial skills, and pre-academic and academic function. However, there are differences in the type of benefits cochlear implantation will bring to children who are deaf with complex additional needs and to those whose primary need is caused by deafness alone.
Champions Evaluation Scales for Paediatric CI Users with Additional Disabilities was designed for multidisciplinary use. The scales track the progress of the child in different areas over time and can be used within CI programmes and in establishments working with CI users.
The graphic presentation of the scales makes it easy to see the areas in which progress has been good and those areas in which the child will benefit from more intensive support.  A major goal of Champions, therefore, is to help professionals in devising programmes for the child. Champions is unique in providing a unified system for recording the progress of CI users through a system that makes monitoring the child’s progress highly accessible.
The authors wish to thank the many colleagues who offered their invaluable advice and support.
Special thanks belong to Advanced Bionics Europe, the Ear Foundation (Nottingham, UK), and to the Royal School for the Deaf and Communication Disorders (Manchester, UK). These establishments made the publication of Champions possible.

 

Room 6 - Chairmen: B. Gunduz (Turkey), G. Sprinzl (Austria)

Vibrant Soundbridge. Classical and New Indications
Pedro Claros (Barcelona, Spain)

Round window implantation of the FMT of the VIBRANT SOUNDBRIDGE in problematic ears
J. Maurer, E. Savvas
ENT-Department, Katholisches Klinikum Koblenz, Germany

The implantation of the Vibrant Soundbridge has proven to be useful in sensorineural hearing loss in the last decade. During the last several years the indication of this device spread out to mixed hearing loss conditions like after unsuccesful stapes surgery, middle ear malformation, chronic inflammatory processes and others by different methods of coupling the FMT-transducer directly or inderectly to the cochlea. One way of direct coupling is to place the FMT in the round window on the round window membrane. In our hands this method proved to be especially succesful in ears with combined hearing loss after multiple previous surgeries with audiologically unseccusful reconstruction of the ossicular chain. In 12 patients we implanted the FMT in the round window niche. None of the operated ears had less than 5 previous surgeries and except one alle middle ears were atelectatic or fibrotic. 7 patients had radical cavities. All surgieries had no complications. After the fitting procedure all patients were very satisfied with the results. Methods and exact auiological results will be shown during this presentation.

VIBRANT SOUND BRIDGE MED-EL: INDICATIONS AND RESULTS.
Francesco ACHENA*, Giuseppe LAI *, Enzo D’AURIA**-  ENT Institute Iglesias*; Cattedra di Audiologia- Cagliari University ** Italy

Vibrant sound bridge ( VSB ) MED-EL became, in the last years, one of the most utilized middle ear implant to rehabilitate patients with sensorineural hearing loss( SNHL ) who were unable to use an acoustic hearing aid. Patients suffering by otitis externa, with troublesome occlusion effect or needing better gains in the higher frequencies or better cosmesis effect constitute the most important indications to VSB implant. Although SNHL continue to be the major indication to VSB implant, recently even the patients presenting a conductive or mixed hearing loss has become candidate to VSB implant.
The objective of this study is to present the series of VSB implanted patients operated at the ENT Institute of Iglesias.
Methods
16 patients were included;  10 patients with SNHL in wich the FMT was inserted onto the incus, 5 patients with absence of ossicular chain for middle ear pathology required round window implantation and finally 1 patient with necrosis of incus lenticular process required stapes( between the crus and the capitulum )  implantation.
Results
All the patients were operated by  Achena’s surgical procedure the “bony bridge down-up approach” and discharged the day after the operation. They all had a significant gain on air conduction thresholds and on speech audiometry.
Conclusion
The VSB its an efficient alternative, in patients with SNHL who are unable to use an acoustic hearing aid. On the other hand patients with conductive or mixed hearing loss with external or middle ear pathology may receive a significant benefit from the VSB utilize.

Intraoperative Measurements - are necessary for VSB surgery ?
G. Sprinzl (Innsbruck, Austria)

PRELIMINARY RESULTS OF PLACING FLOATING MASS TRANSDUCER  ON THE MIDDLE EAR WINDOWS
Gunduz B(1), Bayazit Y(1), Goksu N(1), Ataş A(2)
(1) ENT Department, University of Gazi ,Ankara, Turkey
(2) ENT Department, University of Hacettepe ,Ankara, Turkey

OBJECTIVE:
A middle ear implant (MEI) is defined as a device that uses vibrational energy to directly drive a vibratory component of the human ear or the cochlea and that does not occlude or impede incoming sound traveling to the tympanic membrane or auditory canal. It improves output and gain, especially in the high frequencies, eliminates acoustic feedback and  improves hearing in background noise for many patients.  To assess the functional results of placing floating mass transducer (FMT) on the middle ear windows
MATERIALS and METOD
Eleven patients with hearing loss whose ages ranged from 22 to 68 years participated in the study. In 8 patients with mild or severe mixed hearing loss, the FMT transducer was placed onto the round window membrane. In 2 patients with mixed hearing loss, FMT was on the oval window. In one patient, the FMT was placed between the stapes superstructure and tympanic membrane like a partial ossiculoplasty prosthesis. All of the patients had a clinical history of previous otosurgery due to middle ear disesase and in this study candidates for the application of the FMT on the middle ear windows membrane are subjects with mixed hearing loss for whom the coupling of a tradional hearing aid would be problematic and insufficient.
Each subject served as their own control in a repeated measures design consisting  of pre and post operative assessment of the audiological findings. The assesment protocol consisted of hearing evaluation and speech tests. In the hearing evaluatin, air condaction and bone conduction thresholds were measured monoaurally.  Preoperative unaided free-feld thresholds and free-field speech tests, and post-operative aided free-feld thresholds and free-feld speech tests were applied monoaurally to the implant ear as the contralateral ear was masked. Speech testing was performed in the free-field conditions using calibrated bisyylabic words, and the word lists were selected randomly to avoid learning effects.  
RESULTS
For both air and bone conduction, the pre and postoperative unaided threshold assessment did not reveal a statistically significant alteration in the theresholds across all frequencies ( p>0.01).
After activation of the FMT processor, a statistically significant improvement was encountered in BC theresholds in the frequencies, 1000,2000, 4000 and 6000 Hz) (p<0.01). Despite the improvement in the BC thresholds of thelower frequencies, this increase was no t statistically significant in the frequencies, 250 and 500 Hz (p>0.05).
A statistically significant imporvement was encountered in aided the speech reception test in quiet and noise compared to unaided tests (p>0.01)

CONCLUSION
A middle ear implant of direct driving the cochlear fluids seems to be promising alternative for individuals with a moderate and severe mixed hearing loss. The post-operative results for middle ear windows implantation with the FMT suggest a treatment option for patients with a moderate and severe mixed hearing loss.  But further study is needed to consequences for hearing  

Round window, oval window or „third window“ coupling of the Vibrant Soundbridge
Hans Wilhelm Pau, Tino Just (Rostock, Germany)

Originally designed for a coupling to the long process of the incus in more or less anatomically normal ears with sensorineural hearing loss, the vibrant soundbridge has also proven excellent effectiveness in many cases of conductive hearing loss. Particularly in “old” open mastoid cavities or ears in which previous attemps of hearing improvement were unsuccessful, the device may offer new possibilities.
Many surgeons perform a coupling to the round window if the ossicular chain is missing or the stapes footplate is fixed.
If however the stapes footplate is mobile but the stapes is missing, the authors prefer a “oval window coupling”. If both, the round and the oval window are blocked for any reason (e.g. tympanosclerosis), an application via a new “third” (promontorial) window may be considered.
Thus, the vibrant soundbridge system offers the possibility for an individual approach in each patient regarding the special anatomical or functional situation.
In the presentation our methods of coupling the device to the round, oval or “third” window will be demonstrated, with special focus on the feasibility of the last-mentioned technique.

Room 7 - Chairmen: N. Frau (Italy), O. Deguine (France)

The BAHA Devices Indications and Techniques
M. Amadori (padova, Italy)

BAHA Indications and Results
Antonio Caruso (Piacenza and Rome, Italy), Maurizio Negri (Carpi, Italy), Claudio Cola (Rimini, Italy)

BAHA or MedEl Vibrant Soundbridge : results and criteria of decision
O. Deguine (1, 2), M. Marx (1,2), M. Côté (1,3), T. Sorrentino (1), MN Calmels (1), G. Iversenc (1), B. Fraysse (1)
1. Service ORL, Hôpital Purpan, CHU Toulouse, 1 place du Docteur Baylac, 31059 Toulouse, France
2. Centre de Recherche Cerveau et Cognition, UMR CNRS 5549, Faculté de Médecine de Rangueil, 31062 Toulouse Cedex 9, France
3. ENT departement, Quebec University Hospital (CHUQ) Hôtel-Dieu de Québec, Québec, Canada

Background
Extension of indications of Middle Ear Implants (MEI) open new possibilities in the choice between BAHA and MEI in mixed hearing loss (MHL). This choice depends on audiological and anatomical data, and on patient’s expectations.
Methods
14 patients with MHL were implanted with a MedEl Vibrant Soundbridge (VSB). Audiological data were compared for each patient with VSB and headband BAHA. 2 patients were previously implanted with BAHA. 2 patients had normal bone conduction. Main outcome measures : Pure tone thresholds in quiet , speech audiometry in noise, Glasgow Benefit Inventory scale.
To validate the method, pure tone audiometry was measured in 15 experimented patients with BAHA. Thresholds were compared with headband and transcutaneous abutment in the same patient.
Results
The mean gain with the MEI in quiet was 31 dB (± 11). The calculated gain on the speech reception threshold with VSB was 27 dB (±16). The mean gain in speech intelligibility in noise with the VSB compared to BAHA was 24% at 0 dB S/N ratio (p<0,02 Wilcoxon signed rank). The general health score or total benefit was +33 on the GBI scale.
Comparison of headband and abutment thresholds shew an mean attenuation of 4,7 (+1,4) dB due to skin attenuation.
Conclusion
Whereas BAHA remains the only usable implant in some types of MHL, MEI may have some common indications with BAHA. Normal bone conduction is not a contraindication to VSB. Testimony of patients implanted with BAHA then with VSB is irreplaceable for evaluation of the differences between the two devices. Thresholds should not be the single criteria of choice, neither of comparison between the two devices. Patient’s audiological and anatomical characteristics and expectations are mandatory to do the good choice.

Saloon Doors: A new technique for BAHA surgery
Daniel aWengen (Binningen, Switzerland)

Upgrade from BAHA to vibrant sound bridge
Tommaso Sorrentino (Toulouse, France)

Middle Ear Implants in Otosclerosis
Nicolò Frau (Rovereto, Italy)

Room 8 - Chairmen: T. Kobayashi (Japan), B. Mostafa (Egypt)

Cancer of temporal bone: reported on 30 patients
Shujiro Minami, Sho Kanzaki, Yasuhiro Inoue, Hideyuki Saito, Toshiki Tomita, Takahisa Watabe, Masato Fujioka, Reiko Watanabe, Kaoru Ogawa
Keio University, School of Medicine, Department of Otolaryngology-Head and Neck surgery,

OBJECTIVE: Although radical surgery has been considered the best treatment for temporal bone cancers, often causes disturbances in function such as facial nerve. We have treated theses tumors with the multidisciplinary approach; surgery, radiation, and chemotherapy to optimize the chance of achieving locoregional control and preserve the functions. This study discusses various treatment strategies that employ these modalities in combination, in an attempt to improve survival rates and the outcome of complications for patients who have temporal bone malignancies.
METHODS: The patients with histologically confirmed malignant of the temporal bone received treatment at the Keio University between 1980 and 2008. Of the total 30 patients, 16 were males and 14 females with age varying from 21 to 75 years, median 53.9 years. Tumors were staged retrospectively using the modified Pittsburgh classification based on clinical and radiographic information.
RESULTS: Histology was squamous cell carcinoma (SCC) in 24 patients, adenoid cystic carcinoma 3 patients, adenocarcinoma 2 patients, and chondrosarcoma in 1 patient. There were 11 early stage (T1/T2) and 19 advanced-stage (T3/T4) tumors. Neck node metastasis was present in 2 cases, and no distant metastases were reported at the time of diagnosis. Combined modality treatment was used in 24 cases as a primary curative treatment, 21 in patients with SCC. Eighteen of 19 advanced-stage cancers received combined treatment compared with 6 of 11 early stage cancers. Of the total 30 patients, 13 were treated with induction chemotherapy, most of whom (9 patients) were administered the combination chemotherapy with docetaxel, cisplatin, and 5-FU. Surgery was chosen for 27 patients, of whom only 4 were sacrificed with their facial nerves. Nineteen patients received postoperative radiation therapy. The 5-year estimated survival rates for early stage (T1/T2) and advanced-stage (T3/T4) were 100% and 57% respectively. The full multidisciplinary treatment (induction chemotherapy + surgery + postoperative radiotherapy) improved the estimated survival ratio to 67% as opposed to 50% without the full multidisciplinary treatment in advanced-stage (T3/T4) patients, and we didn’t sacrifice the facial nerves of the patients with the full multidisciplinary treatment. There were 7 local recurrences of the total, which were not successfully salvaged at all.
CONCLUSION: Patients with early stage disease achieved better cause-specific survival than those with advanced tumors. The full multidisciplinary treatment (induction chemotherapy + surgery + postoperative radiotherapy) may be effective for improving the estimated survival of patients with an advanced stage of temporal bone cancer with preserving the facial nerve functions.

SDHAF2 (PGL2) and hereditary head and neck paraganglioma
Kunst H, Rutten M, Bayley JP, Cremers C  (Nijmegen, The Netherlands)

Hereditary head and neck paraganglioma syndromes (HNPGL) are associated with mutations in PGL1, PGL3, PGL4 (SDHD, SDHC, and SDHB) genes encoding succinate dehydrogenase subunits. We recently described mutations in a previously uncharacterized human gene, now called SDHAF2, and showed that this was the long-sought ‘imprinted’ PGL2 gene, in which mutations show a parent-of-origin expression pattern. Here we present a new branch of the Dutch SDHAF2 (PLG2-SDH5) family.   The SDHAF2 family has been collected over a 30-year period, primarily at the Radboud University Nijmegen Medical Centre. The families described here were identified by linkage analysis, and at-risk family members were invited to participate in this study. Patients were investigated, and treated dependant on tumor size and localization. All family members have now been analyzed for SDHAF2 mutation status.    Of the 57 family members, 23 were linkage-positive, including 7 risk-free carriers showing inheritance via the maternal line. Of the 16 at-risk individuals, 11 patients had a total of 24 tumors, with primarily carotid (71%) and vagal locations (17%). Multifocality of tumors was prominent (91%), but no tumors at other less common sites in the head and neck region, nor malignancy were detected. The average age at onset was 33 years, and many affected patients (42%) were asymptomatic prior to screening. SDHAF2 mutation analysis confirmed the findings of the previously performed linkage analysis. No discrepancies were detected. We established the SDHAF2 mutation status of PGL2 family members. Phenotypic characterization of this family confirms the currently exclusive association of SDHAF2 mutations with HNPGL. This family shows a strikingly young age of onset and very high levels of multifocality compared with previous reports of SDHAF2 families and other PGL-syndromes. A high percentage of patients were asymptomatic at time of detection.

The Keyhole Retrosigmoid approach to the CPA : indications and technical modifications
Professor Badr Eldin Mostafa
Ain-Shams University
Cairo-Egypt

Objectives: Establish the versatility and usefulness of the keyhole retrosigmoid approach to the cerebello-pontine angle (CPA) in various pathologies. Design: Prospective clinical study. Setting: Tertiary referral university hospital. Methods: One hundred twenty-one patients with various pathologies of the CPA underwent the relevant investigations and were operated upon by the retrosigmoid microendoscopic approach. The technical modifications and progression of our technique are described. Results: This group consisted of 121 patients (103 men and 28 women). The pathologies included were 60 acoustic neuromas, 28 vestibular neurectomies, nine meningiomas, and four arachnoid cysts. For nonmass lesions, no additional facial nerve injury or deterioration of hearing occurred. Total excision of mass lesions was achieved in 94.5% of cases. Facial nerve integrity was preserved in 92.3% of cases with mass lesions and permanent facial paralysis occurred in 8.3%. There were no mortalities, and the most frequent complication was a delayed cerebrospinal fluid leak from the site of the wound (15%), which was managed conservatively in all cases. Conclusions: The keyhole retrosigmoid approach is a versatile one. It can be used to deal with different pathologies through a unified access, and with the increasing exclusive use of endoscopes, a truly minimally invasive surgery can be achieved.

Bioactive Glass in Skull Bone Trauma with CSF-leaks
Aitasalo K1, Peltola M1, Vuorinen V2
1Department of Otorhinolaryngology- Head and Neck Surgery, 2Department of Neurosurgery, Turku University Hospital, Turku, Finland
kalle.aitasalo@tyks.fi

Intruduction: Synthetic, osteoconductive and antimicrobial bioactive glass (BAG) has used in various craniofacial applications. BAG is available in granules and plates. Long-term clinical follow up of BAG in frontal sinus and mastoid cavity obliteration have shown good clinical outcomes. On the basis of  above mentioned good results  BAG was also used in cerebro spinal fluid leaks (CSF) occlusions after skull base fractures.
Material and Methods: Retrospective series of 19 patients operated during 2000- 2009 in the Turku University Hospital Department of Otorhinolaryngology- Head and Neck Surgery is presented. BAG, S53P4 (Composition, SiO2, 53.0; CaO, 20.0; Na20, 23.0; P205, 4.0 wt%) has been used in the clinical CSF- leak cases. Twelve of the patients underwent fronto basal fracture reconstruction, 4 of them skull base fracture and 3 temporal bone fracture reconstructions. Preoperative evaluation with computer tomography with contrast medium and, beta 2 transferrin analyse were done from to ensure the CSF leaks. In 15 cases BAG granules and in 4 cases BAG plates were used. Postoperative follow ups included clinical, hematologic and X-ray studies at 1 week, 3, 6, 12 months and thereafter annually up to 8 years.
Results: Both fracture reconstructions and CSF-leaks in all 19 cases healed well with good functional and aesthetic outcomes without postoperative infections. There was no need for reoperations. The BAG granules and plates exhibited no signs of resorption in computer tomographies and a beginning   new bone formation was seen at 3 years postoperatively. The granules or implants did not cause any foreign body reaction. Also the infection parameters were normal in laboratory controls.
Conclusions: BAG granules and plates are promising materials in the  treatment of complicated frontobasal and skull bone fractures with CSF-leaks. The benefits of synthetic and antimicrobial BAG in bone defect reconstructions are avoidance of graft operation, donor site morbidity and biohazard infection, shorter operation time compared to autograft utilizing operations and exact knowledge of the BAG composition. However more patients and comparative knowledge between BAG and conventional methods in CSF-leak treatment is needed to draw final conclusions.

Different cases of postoperative facial palsy
Kensaku Hasegawa MD, Yasuomi Kunimoto MD, Hiroaki Yazama MD, Hiroya Kitano MD, PhD
Division of Otolaryngology, Head and Neck surgery, Department of Medicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine

Postoperative facial palsy was drastic episode for the patient and also surgical team. Last year, regrettably, we experienced different types of post operative facial palsy, classified into delayed facial palsy and postoperative facial damage.
Case 1 was 72-years old male who complained right side hearing loss and ottorhea caused by middle ear cholesteatoma. The lesion was expanded epitympanic sinus and mastoid so we treated him with canal wall down approach. The fallopian canal was eroded from geniculate ganglion to 2nd genu. On his 4 POD, he suddenly suffered right side facial palsy and we carried out further surgery to confirm the wound free from contamination. This patient was diagnosed delayed facial palsy and the facial score recovered H-B 5 to 2 after 6 months from surgery with conservative therapy.
Case 2 was 63-yaers old male who was occasionally detected petrous bone cholesteatoma. The lesion was involved epitympanic sinus, internal auditory canal, upper-side of cochlear and facial nerve, then progressed toward posterior and middle fossa dura (classified supralabyrinthine cholesteatoma by Mario Sanna, supralabyrinthine apical cholesteatoma by David Moffat). We performed middle fossa approach combined with trans-mastoid approach. Intraoperativelly, hematoma formation was observed at the geniculate ganglion which might be occurred from the damage of superficial petrosal artery. Facial paresis was gradually developed after 4 months of his operation and completed within one month. On his 2nd operation, tight connective tissue surrounded the geniculate ganglion and we repaired facial nerve with great auricular nerve cable graft.
The objects of this report are to compare clinical course, 3T MRI images of the pathology and therapeutic process in these cases.

EROSIVE LESIONS OF THE TEMPORAL PRESIGMOID RETROMEATAL POSTERIOR FOSSA PLATE: CASE REPORTS AND DIFFERENTIAL DIAGNOSIS.

Casqueiro JC1, Aristegui M2, Lopez-Moya JJ1, Martin C2, Lowy A2, Scola B2.
1Servicio ORL, Hospital Universitario Severo Ochoa, Leganes, Madrid, Spain.2Servicio ORL , Hospital General Universitario Gregorio Marañon, Madrid, Spain.

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The posterior surface of the temporal bone is thick when compared to the thin wall of the tegmen timpani. It is not affected by gravity and unlike that, rarely shows bone defects. Several uncommon lesions can erode this plate and invade the temporal bone, and they are misdiagnosed very often.  We have excluded of this report those lesions involving the posterior foramen lacerum (paragangliomas, lower cranial nerve neuromas and meningiomas) and those involving the petrous apex (premeatal posterior fossa dura). Our report illustrates some cases, their differential diagnosis and management.
We report a series of cases that include endolymphatic sac tumors (Von Hippel-Lindau), posterior fossa meningoencephalic herniation, arachnoid granulations (Pacchionian bodies), cholesterol granuloma, and petrous bone cholesteatoma, all of them involving the presigmoid retromeatal posterior fossa dura.
MRI is mandatory for differential diagnosis and helps distinguishing each disease. Bone window CT scan defines bone erosion and aids in surgical planning.  
These are all very rare lesions. We will show intraoperative pictures of those cases operated on, and a rationale for an adequate decision-making on such uncommon cases.

Room 9 - Chairmen: G. Magliulo (Italy) E. Saleh (Egypt)

Frequency of otosurgical procedures and its 1-year  results related to middle ear pressure dysregulation
Jannik Bertelsen, Michael Gaihede, Louis S Rasmussen,  Kjell Tveterås
Department of Otolaryngology,  Head and Neck Surgery,  Aalborg Hospital, Aarhus University Hospital,  Denmark

Hypothesis: Impaired regulation of middle ear pressure (MEP) is a  major pathogenetic factor in middle ear disorders, which form indications for  otosurgery.
Background:  Secretory otitis media is a very frequent childhood disorder resulting in  decreased hearing and various sequelae. These conditions are basically  explained by negative MEP, which is commonly treated by insertions of  ventilation tubes into the tympanic membrane. However, the majority of patient  referred for otosurgical procedures can also be related to negative MEP, as  well as the post-operative course of many patients is complicated by negative  MEP. While quantitative data are documenting the high frequency of both  secretory otitis media and ventilation tube insertions, there are no data  describing the high occurrences of problems in otosurgery related to negative  MEP.
Materials & methods: Retrospective study from  otosurgical data base and patients records from 1st Jan to 31st Dec 2002,  which included 299 surgical procedures. Cases with congenital, traumatic,  degenerative disorders were excluded, while cases with perforation after  ventilation tubes, atrophy, retractions and atelectasis including  cholesteatoma were included.
Results: The frequency of patients  referred for hospital based otosurgical procedures, which could be related to  previous impaired MEP regulation amounted to 79 %. At 1-year follow-up 41 % of  these patients still displayed post-operative conditions, which could be  related to the occurrence of negative MEP.
Conclusions: These  data document a very high proportion of patients in otosurgical units, where  dysregulation and negative MEP is the main pathogenetic factor. These problems  also prevail in a significant part of the patients at 1-year  follow-up.

Keywords: Secretory otitis media, middle ear  pressure, sequelae, otosurgery
Venlig hilsen Michael Gaihede
Forskningsansvarlig overlæge,  lektor
Øre-Næse-Halskirurgisk Afdeling
Aalborg Sygehus, Århus  Universitetshospital
Hobrovej 18-22, DK-9000 Aalborg
Phone +45 9932  2933;  +45 9932 2911 (secretary); Fax 9932 2938; mail mlg@rn.dk

“Incidence of middle ear cholesteatoma, locations, extensions, and complications during 1993 to 2009”.
Peter F Nieland, Michael Gaihede, Morten Søvsø, Jørn Rosborg  (Aalborg, Denmark)

Hypothesis: The incidence of cholesteatomas have been decreasing during recent years including their  complications.   Background:  A cholesteatoma originates from a defect in the eardrum through which squamous epithelium grows into the middle ear or mastoid. The accumulation of epithelial debris causes in a series complications with bony destruction, hearing loss, facial paresis, destruction of the vestibular organ and cochlea, dizziness, and intracranial infections. It has been the impression by some otosurgeons that larger cholesteatomas and their resulting complications have been decreasing over time. Any direct and specific explanation is not known, yet it has been speculated weather the increasing incidence of ventilation tube insertions could be a factor.   
Materials:  Retrospective study based on a otosurgical database and patients records were reviewed from 1st January 1993 to 31st December 2009, which included 682 patients (patients with bilateral cholesteatomas where included twice).   
Results: The average rate of incidence of cholesteatoma surgeries was 9.2 per 100,000 inhabitants per year in the period 1993-2007, and change in incidence was found over time. Among ossicular defects crus longum was defect in 50 % of the cases, stapes supra structure in another 21 % of these, and additional defects was found in yet another 47 %. Different complications (facial palsy, vestibular and cochlear fistula, neuro-infections) were found in  10 to 15 % of the cases, and their occurences also did not vary during the study period.   
Conclusions: No significant changes was demonstrated in the incidence of cholesteatoma surgeries over the last 17years. Moreover, we found no significant changes in frequency of various complications from cholesteatomas.   Keywords: cholesteatoma incidence, location, extension, and complications.

Experience of Intraoperative Use of  Topical Mitomycin C for Prevention of Recurrent External Ear Canal Stenosis.
Lev Shlizerman MD, Yoseph Rakover MD, Salim Mazzawi MD.
Department of ENT, Haemek Medical Center, Afula, Israel.
E-mail: lev_sh@clalit.org.il (Lev Shlizerman).

Background: The ability of mitomycin C to inhibit fibroblast proliferation has prompted its use as an adjunction to surgical procedures in order to decrease scarring and fibrosis.   Chronic otitis media and cholesteatoma usually are treated by surgery. Despite appropriate surgical technique and postoperative care, some patients develop excessive scar and granulation tissue in external ear canal, middle ear or mastoid cavity. Use of topical mitomycin C in the ear appears to be safe in previous animal and human studies. Since mitomycin C has been used successfully in ophthalmologic and laryngeal surgery to prevent restenosis after surgery, the topical application of mitomycin C has increased use in ear surgery to prolong patency of myringotomies and to reduce scarring and granulation tissue growth in external ear canal, tympanic and mastoid cavity.
Our goal was to evaluate the use of topical mitomycin C in the prevention of stenosis in the external auditory canal after surgical treatment of chronic otitis media and cholesteatoma.
Patients and methods: A retrospective analysis was performed on 6 adult patients with recurrent external ear canal stenosis or intractable granulations in middle ear and mastoid cavity (one patient). All patients had history of mastoidectomy and canaloplasty due to chronic otitis media and cholesteatoma . During the standard surgical revision of canaloplasty(resection of scar and granulation tissue) we applied 1 ml of mitomycin C (0.2mg/ml) for 4 minutes to the external ear canal. The follow up between 8 and 30 months included otoscopic and audiometric examinations.
Results:  Open external ear canal was achieved in 4 of 6 ears (66%). Failure was found in 2 cases. Only partial improvement was seen in case of granulations in the mastoid. Bone-conduction thresholds did not change in any of the 6 patients.
Conclusion: Intraoperative topical application of Mitomycin C can be effective and safe treatment of recurrent external auditory canal stenosis. Due to limited clinical experience there is no sufficient data about efficient and safe method of application (dose, ototoxicity, form of application).

The Effects of Parental Attitudes on Rehabilitation of hearing-Impaired Children with and without Cochlear Implant
S. Ristic, B. Kocic, M. Raykov, M. Bojanovic, E.Z. Marinkov, S. Carapic, P. Pavlovic

INTRODUCTION
The rehabilitation of children with hearing impairments is a long-term and complex process. Apart from the individual characteristics of each child, the environment he/she lives in, the attitudes of parents confronted with their child’s defect, and the consequences the defect implies are all of vital importance.
AIM
The aim of our study was to determine to what extent parents’ attitudes towards their children affect the rehabilitation process. An additional objective was to determine differences in parents’ role in the rehabilitation of children with and without cochlear implants.
MATERIALS AND METHODS
Methods used in the study include a semi-structured interview and a parental attitudes scale (PAD). The participants were parents with children aged 4 to 15 years. The children who participated in this study were included in the rehabilitation process for a minimum of three months. For better analysis, this study applied descriptive and inferential statistical techniques.
CONCLUSIONS
The research indicates that parental attitudes significantly affect the rehabilitation process of children with hearing and speech impairments. There are indications that parents’ attitudes are especially important for children with major hearing loss. The results demonstrate that fostering close cooperation and qualitative interactive relationships with the parents of these children is a precondition for successful treatment.

Prevention and Management of Facial Palsy
G. Magliulo (Rome, Italy)

The Retrolabyrinthine Approach in the Management of CPA Tumors and Meniere’s Disease
Vincent Darrouzet (Bordeaux, France)

Free Paper Session: 11.00 - 12.00

Room 1- Chairmen: F. Achena (Italy), D. Kaplan (Israel)

THE BONY BRIDGE DOWN-UP APPROACH: A NEW SURGICAL PROCEDURE TO SECURE COCHLEAR AND MIDDLE EAR IMPLANTS.
Francesco ACHENA*, Giuseppe LAI *, Enzo D’AURIA**-  ENT Institute Iglesias*; Cattedra di Audiologia- Cagliari University ** Italy

Objectives: the authors describe a new method, the bony bridge down-up approach, to secure the cochlear and middle ear implants without a tie-down ligature. The surgical procedure’s name  “the bony bridge  down\up  approach” is a consequence of  the necessity to create between the mastoid cavity and the bony well for the implant insertion, a bony bridge. This is initially break-down superiorly ( bony bridge down)  and then rebuilt with bone pate ( bony bridge up ) .
Materials and Methods: the principles and technical description with cases reports and surgical outcomes of 37 patients submitted at the surgical approach for cochlear and middle ear implantation, by the first  author, at the ENT Department of Iglesias are presented.  
Results: all patients were successfully implanted by the bony bridge down\up  approach, wound healing was uneventful in all cases. At follow-up( mean 1.6 years, range 6 months – 3 years ) no migration of the receiver-stimulator  were observed. At the moment all recipients are full-time users of the device.  
Conclusion: with the bony bridge down\up approach it’s possible to achieve reduced surgical morbidity ( the majority of the patients are discharged the day after surgery ) and moreover it shows to be a safe and easily reproducible surgical procedure.

Advanced Bionics’ minimally traumatic electrode array: temporal bone experiments with a 3-D force measurement system
Thomas Lenarz1, Timothy Beerling.2, Filiep Vanpoucke3
1Medical University of Hannover, Hannover, Germany
2Advanced Bionics LLC, Valencia, California
3Advanced Bionics European Research Center, Niel, Belgium

The forces leading to cochlear trauma during electrode insertion are still quite poorly understood. This work used a state-of-the-art 3-D force measurement system (FMS) to correlate human temporal bone insertion measurements performed on the FMS with histology. In addition, a fluoroscopy video feed was synchronized such that movement of the electrode array could be reviewed with the corresponding FMS values.
Approximately 125 fixed human temporal bones have been implanted using full-turn candidate electrode array designs. Variables studied included: stiffness, lateral wall and mid-scala locations, electrode cross-sectional area and length. Insertions were made via a cochleostomy or via the round window; both free hand and using prototype insertion tools.
Lateral wall electrode arrays generally show an exponential increase in force with distance, in agreement with other studies. Lateral forces on the cochlea, not reported in other studies, are generally not negligible. The precurved electrode arrays generally felt smooth during the full insertion, with normal and lateral wall forces in the low 10’s of millinewtons. The curvature of the arrays was modified on the basis of the histology and force measurement data. Only one inadvertent tip-fold over was observed from 75 temporal bones implanted with precurved designs. One tip-fold over was deliberately instigated by early deployment from the stylet to confirm insertion instructions.
In this work the FMS has shown itself to be an invaluable tool for understanding the complex forces associated with cochlear implantation. Design changes made during the course of these experiments have led to improvements which have been confirmed through histological analysis. Further experiments are planned using the final lateral and precurved electrode array candidates with fresh temporal bones.

Hearing preservation in Partial Deafnes Treatment by using a new electrode SRA.
Skarżyński H.,  Matusiak M., Lorens A.
Oto-ryno-laryngosurgery Clinic International Center of Hearing and Speech, Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland.  

Introduction:
Treatment of partial deafness with normal hearing level within low frequencies by cochlear implantation is a last achievement and also a challenge for treatment of this kind of hearing impairment.
Aim of the study:
The aim of the study was to analyze hearing preservation in low frequencies in a group of patients treated in International Center of Hearing and Speech in Warsaw with partial deafness by using a cochlear implantation with a newest SRA-Cochlear electrode.
Material and Methods:
Analyzed group consisted of 22 patients suffering from different types of partial deafness treated with cochlear implantation by using SRA-Cochlear electrode. All patients enrolled underwent a similar diagnostic procedure: a clinical history collection, ENT examination as well as audiological testing, like pure tone audiometry, speech audiomtery in quiet and noise (10S/NR). All patients were implanted with SRA – Cochlear electrode. Post-operatively a pure tone audiometry was performed to evaluate the level of preserved hearing after cochlear implantation.
Results:
In 21 out of 22 patients post-op assessment showed  full hearing preservation comparing to pre-op measurements. In one case we reported a hearing loss of unknown etiology.    
Conclusions:
Partial deafness treatment by means of cochlear implantation with SRA-Cochlear electrode corroborate our previous results obtained with different types of Med-El electrodes. This also proves that applied surgical procedure, as well as soft 20 mm electrodes provide best outcome in treatment of partial deafness.

Surgical Experience with the Neurelec cochlear Implants
Mom T1,2, Akkari M1, Bascoul A1,2, Gilain L1,2, Avan P1,2
1Department of Otolaryngology Head and Neck Surgery
2Laboratory of Sensory Biophysics (EA2667)
Centre Hospitalier Universitaire de Clermont- Ferrand
FRANCE

Objective : To assess the surgical issues with the Neurelec cochlear implants.
Materials and Methods : Retrospective analysis of a series of 96 consecutive patients implanted through a posterior tympanotomy with a Neurelec cochlear implant, focused on surgical issues.
Results: Mean age of the population of implanted patients was 41+/-27 y-o (26 children; extremes were 13 months and 86 y-o). The mean follow-up was 45+/-28 months (7- 105 months). The insertion of the electrode array was achieved either through the round window or through a transpromontorial route. Full insertion was obtained in 67 cases (70%). In the remaining cases, on average, 0.7+/-0.5 electrode was left out of the cochlea. The transpromontorial route allowed for a better insertion than the round window insertion although the difference was not significant (83% vs 71%). No displacement of the implant or the electrode array was observed as checked by X-ray or CT-scan, in case of alteration of the fitting, whatever the technique of fixation of the implant. The use of one or two monocortical screws for fixation of the recent devices shortened drastically the duration of the surgical procedure (by 30 min on average). Improvement of the tip of the electrode array (soft tip) significantly allowed for an easier insertion through the round window (22 full insertions over 25 (88%) with the soft tip array vs. 45 over 71 (63%), CHI square= 5,32, DF=1, p<0.025). No severe complications occurred after implantation, in particular, no infection, no permanent facial paralysis. Three device failures were responsible for replacement of the implant (~3%), one of them under local anesthesia. All 3 devices were from the oldest generation.
Conclusions: Cochlear implantation with a Neurelec device can lead to a full cochlear insertion in more than 70% of cases whatever the approach, with an 88% rate through the round window with the soft tip array. The fixation by one or two monocortical screws allows for a very short surgical procedure.

Bilateral Cochlear Implants
Emmanuel Mylanus (Nijmegen, The Netherlands)

Results of the new Behind-the-ear Processor Harmony with the First Generation of Advanced Bionics Cochlear Implant Systems
M. Brendel1,2, T. Rottmann1, C. Frohne-Buechner1,2, Th. Lenarz1, A. Buechner1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany
E-Mail: martinab@abionics.fr

At the Medical University of Hannover, there are 450 users of a Cochlear Implant (CI) system of the first generation of Advanced Bionics implants, the “C1 implant” (Clarion 1.0 and 1.2). In the past they could use any of the four processors: Clarion 1.2, Clarion S-Series, PSP (Platinum Sound Processor) and Platinum behind-the-ear processor. The new Harmony behind-the-ear processor could only be used with the recent implant generations CII and HiRes90K. With the development of a new Digital Signal Processing code the combination of the Harmony with C1 implants became possible. This study collected experience with the new system and collected speech perception data as well as subjective feedback.
During the baseline appointment subjects performed speech perception tests (Freiburger monosyllables, HSM sentence tests in quiet and noise) with their current clinical processor and the Harmony was fitted. After one month take home period the test battery was repeated with the Harmony. Additionally subjects were asked to fill in questionnaires concerning sound quality and comfort of the processor and to administer a battery log.
In total 29 adult C1 implant users participated in this study. They were all postlingually deafned, had a mean test age of 56.5 years (24.4 to 81.1 years), a mean duration of implant use of 12.2 years (9.1 to 15.5 years) and a mean duration of deafness of 4.9 years (0 to 21.3 years).
Speech performance with the C1 Harmony improved significantly compared to the clinical processors. Subjectively understanding in adverse listening situations was rated significantly better with the C1 Harmony. For certain subjects the sound quality and the comfort had improved substantially. In total 75% of the CIS users and 62% of the SAS users preferred the C1 Harmony after the 1-month test phase.
Speech understanding with the Harmony was comparable to the understanding with clinical processors. The majority of subjects preferred the Harmony.

Room 2 - N. Quaranta (Italy), L. Sennaroglu (Turkey)

Auditory Brainstem Implantation in Children with Severe Inner Ear Malformations and Cochlear Nerve Aplasia
Levent Sennaroglu (Ankara, Turkey)

Retrolabyrinthinne approach for surgical placement of auditory brainstem implants in children
Ricardo Ferreira Bento, Robinson Kogi Tsuji, Marcos de Queiroz Gomez, Mariana Hausen Pinna, Valeria Goffi-Gomez, Rubens de Brito

Objective: To describe our experience with a extended retrolabyrinthine approach (RLA) for the placement of auditory brainstem implants in children, describing the anatomical landmarks that allow appropriate exposure of the foramen of Luschka.
Study Design: prospective serie of cases
Setting: Otolaryngology department of a tertiary referral hospital.
Patients: Three children undergoing surgery for auditory brainstem implant placement between January of 2009 and May of 2009.
Intervention: An extended RLA was used in all cases and was modified to allow the exposition of the anatomical landmarks for auditory brainstem implant placement, mainly the IX cranial nerve and the cerebelar floculus.
Main Outcome Measures: The safety and efficiency of the RLA for ABI placement in children.
Results: The RLA used for auditory brainstem implant placement in children was similar than that used for the removal of vestibular schwannomas except for the need of  the posterior semicircular canal removal. The lateral and superior semicircular canals, as well as the vestibule, remained intact, and there was no need to expose the dura of the internal auditory meatus. The jugular bulb was fully exposed in order to allow adequate visualization of the ninth cranial nerve and cerebellar flocculus. A postoperative complication, namely multidirectional nystagmus, occurred in one child.
Conclusion: The RLA adequately exposes the surgical landmarks for auditory brainstem implant placement and can be safely used in children.

Surgical Challenges in Cochlear Implantation
Sakeel Saeed (London, United Kingdom)

Cochlear Implants in Challenging Cases
Nicola Quaranta (Rome, Italy)

Cochlear Implantation as treatment for single-sided deafness
Andrea Kleine Punte1, Katrien Vermeire2, Anouk Hofkens1, Paul Van de Heyning1
1Univ. Dept. Otorhinolaryngology and Head and Neck Surgery, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
2Christian Doppler Laboratorium for Active Implantable Systems, Institute of Ion physics and applied physics, University of Innsbruck, Innsbruck, Austria

Background: People with unilateral deafness have a reduced speech understanding in noisy environments, especially when the signal is from the direction of their deaf ear. Also their ability to adequately locate sound is reduced. This loss of binaural hearing can reduce patient’s quality of life and can affect their social activities and reduce participation.
Methods: 23 subjects participated in this study. Cochlear Implantation was performed in order to restore binaural hearing and reduce tinnitus. Patients were implanted with a COMBI 40+ M implant or a PULSAR CI100 FLEXsoft implant, with the electrode fully inserted into the scala tympani. Twelve of these subjects had contralateral normal hearing, eleven subjects used a hearing aid contralaterally. Spatial Speech in noise tests were performed at regular intervals up to 36 months after implantation. Test conditions were: i) acoustic hearing only and ii) CI and acoustic hearing (bimodal condition).  Subjective improvement of hearing in daily situations was evaluated using the Speech, Spatial and Qualities of Hearing Scale (SSQ).  
Results: Speech recognition in noise improved significantly after cochlear implantation. After 12 months of CI experience a significant combined headshadoweffect and binuaural squelch effect was found, but no significant summation effect. Speech recognition with CI continued to improve over time and 36 months after first fitting, a significant binaural summation effect, binaural squelch effect and combined headshadow- and squelch effect could be detected. Scores on the SSQ significantly improved after cochlear implantation. Tinnitus also significantly reduced after cochlear implantation.
Conclusions: Cochlear implantation in unilateral deafness provides significantly improved speech recognition in noise compared to monaural listening conditions. These results suggest that cochlear implantation is an adequate treatment for single-sided deafness and is able to at least partially restore spatial hearing. Performance in speech recognition with CI increases in time.

References:
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. Epub 2008 Nov 13.
Authors contact details:
Andrea Kleine Punte, MSc
University Hospital Antwerp
Dept of Otorhinolaryngology
Wilrijkstraat 10
2650 Edegem
Belgium
Andrea.kleine.punte@uza.be

Cochlear Implantation and Contralateral Auditory Brainstem Implantation
Mr AR Sinnathuray 1 , Dr R Meller 1 , Marie Cosso 1, Professor M Sanna 2, Professor J Magnan 1
1. SERVICE d’OTO-RHINO-LARYNGOLOGIE ET CHIRURGIE CERVICO-FACIALE, Hôpital Nord – Chemin des Bourrelly - 13915 Marseille Cedex 20, France
2. Gruppo Otologico, 29100 Piacenza, Italy
Email :  rajsinn@aol.com (1st choice)
Arasa@sinnathuray.wanadoo.co.uk

Objective: Report outcomes of two first known cases utilising a cochlear implant (CI) with a contralateral auditory brainstem implant (ABI).
Patients: Two adult patients with post-lingual sensorineural deafness.
Intervention: Both patients had initial CI, and were unsuitable for contralateral CI insertion due to a non-functioning VIII, undergoing contralateral ABI.  In one case there was a large vestibular schwannoma necessitating translabyrinthine excision in the left only hearing ear.  Thus in the right dead ear, ‘prophylactic’ CI was first performed, but with an unpredictable outcome due to longterm ipsilateral deafness.  At the time of left translabyrinthine surgery shortly after, a left ABI was therefore also inserted.  The other patient had bilateral Meniere’s disease, with a right dead ear following an ‘old’ translabyrinthine vestibular neurectomy.  She then underwent left retrosigmoid vestibular neurectomy with auditory nerve preservation, allowing subsequent left CI.  She wanted further improvement, and after an unsatisfactory trial of a CI-CROS system requested a right ABI.
Main Outcome Measures: Pure tone audiometry, speech discrimination in quiet, speech discrimination in noise, and sound localisation.  Testing was performed with (1) CI activated alone, (2) CI-CROS system, and (3) CI and ABI activation (CI-ABI).  Quality of life assessments were made using validated questionnaires.
Results: Pure tone audiometry was similar comparing CI alone and CI-ABI.  The CI- CROS system produced slightly worse thresholds in one patient.  Speech discrimination in quiet with the CI alone was poor in both patients (20% and 30%).  The CI-CROS system delivered better speech discrimination in quiet than the CI-ABI.  The CI-CROS system also delivered better speech discrimination in noise (with noise from in front, or from the CI / better hearing side), although a CI-ABI combination worked better with noise from the ABI / worse hearing side in one patient.  No method produced useful sound localisation.  Quality of life was better with bilateral sound input, and favoured the CI-CROS system.
Conclusion: Bilateral sound input appears better than unilateral.  In this patient scenario, a CI-CROS combination appears to produce equal or better gains than a CI-ABI combination.

Room 3 - Chairmen: A. Tani (Italy),G. Wenzel (Germany)

Evaluation of Pre-processing Algorithms of Hearing Aids in the Advanced Bionics Cochlear Implant System
T. Rottmann1, C. Frohne-Buechner1,2, H. Saalfeld1, T. Lenarz1, A. Buechner1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany
E-Mail: rottmann@hoerzentrum-hannover.de

Even though multi channel pre-processing algorithms are common practice in hearing aids, there is only minor attention on such algorithms in cochlear implant systems. Cochlear implant users have less independent auditory channels (estimation: 6 to 8) and often struggle when listening in noise. While good hearing aid users are typically able to understand speech at a negative signal to noise ratio most cochlear implant users need a signal need a signal which is louder than noise.
Three study conditions were evaluated in a cross-over study: the signal enhancement algorithm ClearVoice, as well as a multi-channel automatic gain control (AGC) with two or four channels, respectively. 10 cochlear implant users were already recruited and finished the study; in total 15 subjects shall participate. Subjects received each condition for one month. Speech performance tests in quiet as well as in various types of noise were performed during each study visit. Additionally the subjects rated the sound quality in a questionnaire.
In stationary noise the ClearVoice algorithm improved speech performance (by 10% in CCITT noise, by 15% in plane noise in average), while in simulated multi-talker babble only four of the ten subjects showed a benefit. For half of the study participants the multichannel AGC led to an improved speech understanding, for others the speech performance decreased. The subjective rating showed mixed results.
These results show the potential of pre-processing algorithms in cochlear implant systems, but also indicate that further research is needed. The current status of the signal enhancement algorithm ClearVoice is already leading to a significant benefit, even though parameters were not individually adjusted.

Measure of loudness growth in cochlear implants recipients
R. Malesci¹, P. Riccardi¹, G. Lilli¹, G. Auletta¹, F. Cutugno², E. Marciano¹
Audiology Unit¹, Computer Science Dept. ² - University of Naples “Federico II”  

Aim of this work is to assess the loudness growth in cochlear implants recipients. For this study 21 cochlear implated patients were enrolled. The acoustic loudness was evaluated and compared to electric stimulations levels. In order to collect the data the “electric loudness was established as a new value of measurement of the subjective sensibility to the electric stimulation of the auditory nerve. The subjects engaged in the experiment presented a hearing dynamic range between 6-40 dB unlike normal hearing subjects basically reporting a value of 100 dB. Thus, evaluating the loudness growth may result remarkable in order to redefine the parameters influencing the outcomes of a cochlear implant mapping session.

SPEECH DISCRIMINATION IN IMPLANTED PATIENTS UNDER DIFFERENT COMPETITION MODALITIES
Tani A., Patelli I., Danesi G.
Ospedali Riuniti di Bergamo

Evaluate the effectiveness of the auditory aids (hearing aids – cochlear implants) in terms of recovery of a suitable speech discrimination ability is often very difficult, in particular if we look for terms of comparison with normal-hearing people in daily real-life situations.
Many of the common discrimination tests used in conventional audiometry show a scarce adherence with real-life performances and, after all, don’t give realistic appraisement about the communicative performance in aided condition.
In this research were evaluated alternative methods and strategies aiming to evaluate the rehabilitation results in implanted subjects submitted to discriminative treatment and training under different competing conditions.
The utility of a personalized rehabilitation program is strengthened out.

Long term results of cohlear implantation during the first year of life
Domenico Cuda (Piacenza, Italy)

Clinical Outcomes of Cochlear Reimplantation
Masaaki Ishikawa (Fukui City, Japan)

We reviewed cochlear reimplantation surgery in cochlear implant  recipients. Cochlear implant surgery was performed in 252 patients, and 10  patients ( 6 children, 4 adults ) underwent cochlear reimplantation. The  most common reason of reimplantation was, infection/device extrusion (50%)  in children, and hard failures (50%) in adults, respectively. A full  reinsertion was performed in 9 patients (90%).  In most cases, auditory  performances equaled or surpassed the best preoperative performances.  Cochlear reimplantation appears to be a safe and effective procedure.

Benefits of Cochlear Implantation for Unilateral Deaf Patients with Ipsilateral Tinnitus
G. Wenzel1, C. Frohne-Buechner1,2, M. Brendel1,2, A. Lesinski-Schiedat1, B. Jaeger3, A. Buechner1, T. Lenarz1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany
3 Medical University of Hannover, Department of Psychosomatic and Psychotherapy, Hannover

Introduction
Tinnitus suppression in bilaterally deaf patients, utilizing electrical stimulation of the hearing nerve, has been reported to be successful by various research groups. Acoustic stimulation for the purpose of tinnitus-suppression in hearing tinnitus patients is as well an established therapeutic tool. However, for patients experiencing tinnitus in their unilateral deaf ear, a combined treatment method would be desirable. This study was therefore initiated to assess the benefits of cochlear implantation in this specific group.
Method
Five patients with unilateral deafness and ipsilateral tinnitus were implanted with a HiRes90K Cochlear Implant (CI) device on the affected ear. In monthly visits, the speech processor program was optimized and their hearing performance monitored, as well as their tinnitus. Additionally, the potential for the CI to improve hearing in adverse listening situations has been analyzed.
Results
Three patients experienced a significant tinnitus-suppression while wearing the device. The other two patients reported a reduction of their tinnitus just in certain situations. In three patients, speech perception tests revealed a significant hearing benefit when using the CI in combination with the normal hearing side. All participants accepted the device in a clinical setting, adaptation of the frequency allocation was not required.
Summary
Improvements of the hearing status as well as the tinnitus due to the CI could be observed. Not all participants benefit from the CI to the same degree and in the same situations. The results indicate that cochlear implantation in patients with unilateral deafness and ipsilateral tinnitus may be beneficial. Further studies with increased number of patients as well as different stimulation strategies are on the way.

Room 4 - E. Cassandro (Italy), D. Gazibegovic (Germany)

Music evaluation in adult users of HiRes® 120 and previous generations of Advanced Bionics® sound coding strategies
MHH – Hannover, Adelante – Venlo, CIC – Friedberg, CMAP – Liege, Fundación Jiménez Díaz – Madrid,
H. Central de Asturias – Oviedo, H. de la Ribera – Alzira, H. de Móstotes – Móstoles, H. Sant Pau i Santa Creu – Barcelona, H. Son Dureta – Palma de Mallorca, H. Universitario Dr. Peset – Valencia, KKR – Chennai, St. Augustinus – Antwerp, University clinic – Dijon, University Hospital – Ghent, 1Advanced Bionics Europe
Dzemal Gazibegovic1, Laure Arnold1

Objectives
In 2007 Advanced Bionics has launched the novel sound coding strategy HiRes 120.The strategy incorporates the concept of current steering and offers up to 120 stimulation sites using only 16 electrodes.
Early clinical results showed improved speech understanding in noisy environments. Also the naturalness of speech and music and the sound quality overall were improved.
Objective of the evaluation is to observe if there is a difference in music perception, listening frequency, enjoyment and ability to differentiate special musical features, between the three main group of subjects using different generations of strategies:
CIS/MPS/SAS
HiRes
HiRes 120
Methods
The evaluation is based on a questionnaire. Forty three questions are divided into several sections:
Individual sections will help collecting information on etiology, equipment used for listening to music, sound coding strategy, frequency of listening to music, musical activity, and enjoyment of music before becoming deaf and with the cochlear implant. Last section is assessing subject’s ability to recognize special musical features.
Results
In the pilot phase of the evaluation a group of twenty five normal hearing subjects were tested as control group. Present multicentric results show that the normal hearing subjects are out performing the cochlear implant group in all musical performance related questions as expected. Nevertheless, there are in some instances also significant differences among the cochlear implantees using different sound coding strategies.
Discussion
Based on the data obtained from normal hearing subjects, the evaluation seems to be appropriate to collect a large number of data within a short time period. The present results do indicate that users of latest sound processing technology of Advanced Bionics tend to have improved musical performance

Fitting to Outcomes eXpert (FOX®): Preliminary results of the multicentric study in adults
Dzemal Gazibegovic, Laure Arnold (Advanced Bionics Europe, Germany)

Objectives: Cochlear implant programming requires specific skills and competences.  Expert audiologists need to be familiar with the implant technology and its fitting software. It is difficult to establish the validity and reliability of all the fitting procedures encountered.  Routine fitting procedures may sometimes be so laborious that no time is left for in depth assessment of the performance, let alone for feedback on such an assessment to modify the fitting.  To overcome this issue, a software program FOX® was developed at the Ear Group to assist the audiologist in programming Advanced Bionics® cochlear implants.  FOX is outcome driven and expert based.  The core is a feed-back engine to which both audiological results and existing program parameters are fed and which delivers modifications to the program.  The engine contains a set of mathematical algorithms called an “advice” and programmed by an expert fitter.  
A European multicentric study is ongoing to evaluate the efficacy of FOX.
Methods: Two subject groups, the control and the FOX group are being investigated from the initial switch on over a period of six months. Fitting time requirements, learning trajectory and overall performance based on speech assessment in noise at the end of the study will be compared between the two study groups.
Results: FOX is operational in the Eargroup since June 2008.  All implant users receive fully automatic switch-on fitting.  All follow-up fittings are done with FOX based on audiological test results and the execution of the FOX advice.   Immediate positive effects are seen on the audiogram, the speech audiogram, the Auditory Speech Sound Evaluation (A§E) discrimination task and the A§E loudness increase test. The preliminary results of the multicentric study will be presented.
Conclusion/Discussion: The introduction of fully automatic and outcome driven expert software has the potential to substantially reduce the fitting time and to provide good fitting quality.  It may further standardize and systematize the fitting procedure, allowing audiologists to allocate their time to the exploration of new fitting strategies and developing in-depth expertise.

Self-assessment and Habits of Cochlear Implant Users at School and Education
D. Adams1, C. Frohne-Buechner1,2, A. Lesinski-Schiedat1, S. Ruehl1, A. Buechner1, Th. Lenarz1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany
E-Mail: adams@hoerzentrum-hannover.de

A questionnaire based survey was initiated to collect data regarding the application of assistive listening devices by young Cochlear Implant (CI) users. The results shall help to improve counselling. The survey addressed hearing in everyday life situations and use of accessories to improve speech understanding.
30 children and teenagers were included so far; all of them used an Advanced Bionics implant system with any processor and any speech coding strategy. The participants had a mean age of 13.6 years, a mean age at implantation of 6.7 years and a mean duration of deafness of 4.3 years. Following an appointment of the clinical routing subjects were interviewed via 61questions regarding their hearing habits, use of assistive listening devices, a self assessment of hearing performance at school or education. The evaluation also involved the clinical speech perception data.
When breaking down the results by school visited neither the subjective rating of speech understanding at school nor results of speech perception tests did show significant differences between the groups. When looking at the speech coding strategy no significant difference could be found in the subjective rating. To improve speech perception in everyday life the pupils mainly used the T-Mic or a wireless system. The majority of the users of FM systems were pupils of standard schools; they were younger when they were interviewed and their age of implantation was lower than the subjects who didn’t use FM systems.
The reason why older pupils were not using an FM system could not be found yet. An explanation could be a subjective low advantage of FM technique, the potentially high stigmatism or the demonstration of independence regarding advices of adults.

The effect of pre-operative developmental delay on speech intelligibility of children with cochlear implant
Harukazu Hiraumi, Norio Yamamoto, Tatsunori Sakamoto, Juichi Ito (Kyoto, Japan)
Department of Otolaryngology-Head and Neck Surgery
Kyoto University, Graduate School of Medicine
54, Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
Phone +81-75-751-3346
FAX +81-75-751-7225
E-mail hhiraumi@ent.kuhp.kyoto-u.ac.jp

The effectiveness of cochlear implantation in hearing loss children with additional disability is still controversial. Previous reports suggested that children with cognitive delay showed limited hearing outcomes. In this study, we report the effect of pre-operative developmental delay on the post-operative speech performance. Between July 1991 and August 2008, 83 congenital deaf children with normal cochlea underwent cochlear implantation at Kyoto University Kyoto University Hospital Department of Otolaryngology-Head and Neck Surgery. Among those, 44 patients were followed up at Kyoto University Kyoto University Hospital, and were included in the analysis. The pre-operative cognitive–adaptive developmental quotient was evaluated by the Kyoto Scale for Psychological Development. The post-operative speech performance was evaluated with speech intelligibility test. Vowels, consonant-vowel (CV) syllables, and short sentences were phonated by a male professional announcer and digitized at the sampling rate of 44100 Hz. These speeches were presented through speakers at 70 dB SPL using computer in random order, and the percentage of correct answers was obtained. The pre-operative developmental quotient and speech intelligibility were analyzed by calculating Spearman’s correlation coefficient. The correlation coefficient between cognitive–adaptive developmental quotient and vowel intelligibility was not significant. The correlation coefficient between cognitive–adaptive developmental quotient and the intelligibility of consonant-vowel syllables and phrase was 0.34 and 0.44, respectively. These results indicated that pre-operative developmental delay in cognition adversely affected the post-operative speech intelligibility but the impact was small.

Evaluation of the Fitting Assistant FOX® -  “Fitting to Outcomes eXpert”
M. Brendel1,2, Paul J Govaerts3, C. Frohne-Buechner1,2, Geert De Ceulaer3, Th. Lenarz1, A. Buechner1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany
3Eargroup Antwerpen, Belgien
E-Mail: martinab@abionics.fr

To achieve a standardized and time efficient Cochlear Implant (CI) fitting the Eargroup of Antwerp developed the software FOX® (Fitting to Outcomes eXpert). Based on existing program parameters and acutely collected psychophysical and speech perception data the patient’s program was modified by FOX. Following a pilot phase, where the software was tested outside the Eargroup for the first time, a chronic study with experienced users will be started, as well as one with newly implanted cochlear implant users.
During the pilot phase, four patients of the Medical University of Hannover were fitted with the automated fitting system. They all used a HiRes90K implant system, had a mean age of 63.4 years, a mean duration of deafness of 6.5 years and a mean duration of implant use of 5.1 years.
At first the HSM sentence test in noise was performed with the clinically fitted program to obtain baseline data. FOX modified the program parameters on the basis of measures like loudness scaling, audiogram and Freiburger monosyllables test at four different presentation levels. After fitting, the HSM sentence test in noise was repeated with the programs generated by FOX. Subjects were asked to fill in the APHAB questionnaire after at least two weeks of take home experience.
While the speech perception test results did not show a significant difference between the clinical program and the FOX program in the acute setting, subjects preferred the FOX program.
The fittings generated by the assisted fitting software FOX yielded equal hearing performance compared to conventionally programmed maps in our pilot study group. As FOX needs much less experienced personnel during the fitting procedure, it has the potential to improve the fitting in the clinical routine especially in centers with limited fitting expertise.

Assessment of the relationship between performance and predictive variables in a cohort of children wearing an Advanced Bionics cochlear implant
J. Bestel, N Noel Petroff, T. Van den Abeele (Advanced Bionics, France)

Objective: to propose a mathematical model of the relationship between an indicator of performance with a cochlear implant and variables such as demographics, device features and usage duration.
Methods: we applied a multinomial logistic regression model on an indicator of performance with a cochlear implant. The latter is an ordinal scale named K, ranging from 1 to 5, which reflects complementary aspects of performance: acceptance, perception, understanding, expression and intelligibility.
Patients: we looked retrospectively at a cohort of 101 children implanted with an Advanced Bionics cochlear implant, followed up during 4 years after activation. For each subject, the database contains the following information: age at implantation, malformation, etiology, level of hearing before implantation, familial background, type of processor, type of implant, coding strategy, and assessment (K). We applied multinomial logistic regression to model the relationship between K and all explanatory variables.
Results: Among the best models trading off quality of fit against number of variables, the simplest one contains three variables: usage duration, level of hearing before implantation and coding strategy. Analysis of this model shows the positive impact of time, the negative one of no auditory experience before implantation and the positive impact of the most recent coding strategy (HiRes120). The formalization aspect allows quantifying the statistical significance of those effects. In addition, the multinomial logistic regression does not assume that the probability law for K is normal, but that K simply follows a multinomial law for each population.
Conclusion: In term of prediction, the proposed model was considered satisfactory. Even if it has to be refined on an extended cohort, it can now be used to predict performance of newly implanted children, and to assess more deeply the impact of predictive variables on

Room 5 - H.M. Frijns (The Netherlands), N. Yehudai (Israel)

Performance with the OPUS 2 processor remains uncompromised in roving-level speech
Nopp P, Schleich P, Meister D, Möltner A, Zierhofer C, Brill S, Müller J

Introduction and objectives: As performance with cochlear implants improves, and as the expectations of cochlear implant users increase, it becomes increasingly important to assess performance under more realistic and challenging conditions than in state-of-the-art speech tests. Based on the results of a study [Haumann et al., 2008) by the Medical University of Hannover, we performed speech tests aiming at testing speech at variable presentation levels.
Materials and methods: Seven subjects were tested using a modified version of the Oldenburg sentence test where speech was presented at three levels (50 dB, 65 dB, 80 dB) and the noise level was adaptively varied to obtain speech reception threshold. In one test, the three levels were interleaved so that level varied from sentence to sentence, and in additional tests, each level was tested individually.
Results: Results do not show a significant effect of the roving level method on test outcomes.
Conclusion: Results show that performance with the OPUS 2 processor remains uncompromised at fixed levels ranging from soft to loud, and even in speech fluctuating between soft and loud, without the need of processor adjustments.

MUSICAL INTERVALS DISCRIMINATION WITH HIGH RESOLUTION COCHLEAR IMPLANTS
Tani A., Patelli I., Danesi G.
Ospedali Riuniti di Bergamo

Listening to the music is a particular task involving several structures, both in peripherial and central auditory system.
Hearing impaired patients affected by acquired loss and “acoustically experienced” bear evidence of difficulties when asked to recognize musical sequencies like simple melodies; in addition, listening to complex musical sequencies can give rise to annoyance, maily due to the acoustic muddle perceived through hearing instruments (aids and implants).
In these last years some manufacturers have shown a growing interest in music discrimination, and some modern hearing aids – evaluated in a collateral investigation – exibit extraordinary acoustical features.
The present study aims to evaluate the ability of implanted patients in a particular task: discriminate between some of the simplest units of melody, the musical intervals.
The patients, treated with a complex rehabilitative strategy, are wearers of an Advanced Bionics AURIA device, and the test consists in discriminating different intervals (0.5 – 1.0 – 1.5 – 2.0 tones) respect to the “unisono” (0 tones) in 3 frequency bands (low-mid-high).
Results, matched with those obtained in the same patients fitted with the new Advanced Bionics HARMONY device (sporting 120 virtual channels) show that, increasing the channels, well-fitted cochlear implant patients can easily discriminate small musical intervals and brief melodies when the training  is not limited to a simple speech therapy.

Demographic Factors Influencing Educational Placement of Hearing-Impaired Children with a Cochlear Implant
*Noam Yehudai, M.D., *Naama Tzach, M.Sc., *Talma Shpak, M.Sc., †Tova Most, Ph.D., and *Michal Luntz, M.D.
*Department of Otolaryngology - Head & Neck Surgery, Bnai-Zion Medical Center, Technion - Israel Institute of Technology, Haifa, Israel; and † School of Education and Department of Communication Disorders, Tel-Aviv University, Israel
Abstract
Introduction: Severe or profound hearing impairment impedes children’s development of spoken language and communication skills, in turn affecting their academic and social achievements and frequently mandating placement in special education programs. Integration of these children into mainstream schools forms the foundation for their future successful participation in the general society. Post-implantation rehabilitation and age at implantation are considered to be the most important factors influencing success of pediatric implantation. The twofold aim of this study was to analyze the educational placement settings of children with cochlear implants (CIs) and to evaluate the effects of certain demographic variables that may predict success of integration into the mainstream educational system.
Methods: The study population comprised 245 Israeli children (49% Jewish, 51% Arab) with severe to profound hearing impairment, who had undergone unilateral cochlear implantation and had used their CIs for at least 1 year. Demographic variables (ethnicity, age at implantation, and parental education level) were recorded and their effects on educational placement assessed. Mean age at implantation was 4.5 ± 3.9 years and mean duration of experience with the CI was 5.4 ± 2.8 years; these parameters did not differ between the two ethnic groups.
Results: Mainstream schools were attended by 47.5% of the Jewish children and only 25.6% of the Arab children (P = 0.0001). University degrees were held by 65.4% of the Jewish parents and by 18.3% of Arab parents (P = 0.0001). Multivariate analysis of the data obtained for the Jewish children using a logistic regression model revealed that both age at implantation and parental education level were positively related to integration rates in mainstream schools.

Consensus on a Cochlear Coordinate System Applicable in Histological, Physiological and Radiological Studies of the Human Cochlea
JHM Frijns1a, BM Verbist1b, MW Skinner (ϯ)2, LT Cohen3, PA Leake4, C James5, C Boёx6, TA Holden2, CC Finley7, PS Roland8, JT Roland9, M Haller10, JF Patrick11, CN Jolly12, MA Faltys10, JJ Briaire1a
e-Mail: J.H.M.Frijns@LUMC.nl
1Leiden University Medical Center, aENT Department and bDepartment of Neuroradiology, Leiden, The Netherlands
2Department of Otolaryngology-HNS, Washington University School of Medicine, St. Louis, Missouri, U.S.A.
3Department of Otolaryngology, The University of Melbourne, East Melbourne, Vic. 3002, Australia
4Department of Otolaryngology, University of California, San Francisco, California, USA
5Service ORL, Hôpital Purpan, Toulouse, France
6Service de Neurologie, Département des Neurosciences Cliniques, Hôpitaux Univ.  de Genève, Genève, Switzerland
7Department of Otolaryngology-HNS, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
8Department of Otolaryngology, UT Southwestern Medical Center, Dallas, Texas, USA
9New York University School of Medicine, New York, New York, USA
10Advanced Bionics, Sylmar, Ca, USA
11Cochlear Limited, Lane Cove NSW 2066, Australia
12Med-El, Innsbruck, Austria

Hypothesis: An objective cochlear framework, for evaluation of the cochlear anatomy and description of the position of an implanted cochlear implant electrode, would allow the direct comparison of measures performed within the various sub-disciplines involved in cochlear implant research.
Background: Research on the human cochlear anatomy in relation to tonotopy and cochlear implantation is conducted by specialists from numerous disciplines such as histologists, surgeons, physicists, engineers, audiologists and radiologists. To allow accurate comparisons between and combinations of previous and forthcoming scientific and clinical studies, cochlear structures and electrode positions must be specified in a consistent manner.
Methods: Researchers with backgrounds in the various fields of inner ear research as well as representatives of the different manufacturers of cochlear implants (Advanced Bionics Corp, Med-El, Cochlear Corp) were involved in consensus meetings held in Dallas, March 2005 and Asilomar, August 2005. Existing coordinate systems were evaluated and requisites for an objective cochlear framework were discussed.
Results: The consensus panel agreed upon a 3-dimensional, cylindrical coordinate system of the cochlea using the “Cochlear View” as a basis and choosing a z-axis through the modiolus. The zero reference angle was chosen at the centre of the round window, which has a close relationship to the basal end of the Organ of Corti.
Conclusions: Consensus was reached on an objective cochlear framework, allowing the outcomes of studies from different fields of research to be compared directly.

New data collection for C. I. fitting improvement
L. Todini*, S. Cavicchiolo*, C. Amadeo*, E. Fagnani*, A. Zaghis*
*Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policinico, U.O.C. Audiologia

Activation and re-activation of auditory feedback at an early age, within the critical period of plasticity of CNS improve the perceptive-auditory capabilities so much to foster the development of those processes decoding  verbal messages. These processes, basic  for linguistic acquisitions, are developed through : clinical aspect, hearing device use, and rehabilitative factors that we have to compare and integrate during the child’s learning period.
Clinical aspect: early and more  detailed diagnosis
Hearing device use: carrying out fitting of cochlear implants in order to provide the young patients with a more and more defined and complete hearing.
Rehabilitative factor: development of  the auditory processing capabilities of verbal messages, constant monitoring of impairment correction effectiveness, and support to the linguistic development according to developmental patterns.
In daily practice many young patients implanted in our department come from centers located far from our hospital or in other regions, therefore we carry out only clinical and speech tests and mainly fittings.
The poor auditory, linguistic, and relational information mentioned by parents and by the speech therapists  working with these children, led us to develop a global  information model that can be useful for the specialists carrying out the fitting  and fundamental for C.I. optimization.
The proposed form wants to highlight, apart from the child’s clinical data , other connected elements as perceptive and linguistic assessments, observations,  auditory and linguistic difficulties, rehabilitation kind, use of the hearing device (time and condition), and reasons for new fitting request.
Therefore it is very useful to share the same information, use the same language and define precisely the abilities and the level of the child’s skills in order to allow to have the right fitting.
The constant use of this monitoring let us point out children’s real difficulties and to perform more and more precise and adequate fitting and assessment.

Performance of young children first fitted with HiRes 120®
1Niemczyk S, 2Akhmetshin, 3Attias J, 4Kameswaran M, 5Vaid N, 6Neumann K, 7Cervera J,  8Sainz M,  9Arweiler-Harbeck D, 10Ernst A, 11Jones J, 12Mathias N
1University Clinic, Warsaw, Poland
2 Children University Hospital, Ufa, Republic Bashkortostan, Russia
3Schneider Children’s Medical Center, Tel-Aviv, Israel 4Madras ENT Research Foundation, Chennai, India
5KEM Hospital and Research Center, Pune, India
6Klinikum der J.W. Goethe Universität, Frankfurt, Germany
7Hospital del Nino Jesus, Madrid, Spain
8Hospital Clinico San Cecilio, Granada, Spain
9Universitäts-Hals-Nasen-Ohren-Klinik Essen, Essen, Germany
10Unfallkrankenhaus Berlin, Berlin, Germany
11Oxford Cochlear Implant Program, Oxford, UK
12Advanced Bionics, Rixheim, France

Background: After the HiResolution® strategy which doubled the number of spectral bands and increased temporal rates compared to conventional strategies, Advanced Bionics® launched HiRes 120®, a sound coding strategy that implements virtual channels by steering current between two adjacent electrodes. The electrical fields produced are deliberately combined to steer stimulation to sites between the physical electrode contacts. In this way the number of stimulation sites is no longer limited to 16, the same as the number of electrode contacts but may be extended to 120 locations which correspond to 120 spectral bands. This should produce an improvement in spectral representation and bring benefits when listening to music or in background noise. Theory would predict that the HiRes 120 strategy would improve hearing performance in both adults and children.
Objective: The aim of the project is to verify this theory in children according to the following objectives: 1) Verify the ability to fit HiRes 120 easily at first fitting; 2) Define the benefit of HiRes 120 for speech production, perception and music development; 3) Monitor the outcome over a 24 month period; 4) Document psycho-physical fitting parameters.
Method: Children between twelve months and four years of age are included in the evaluation. All subjects are first fitted with HiRes 120 using either their Harmony® or Platinum SoundTM processors. Pre-implantation, baseline is evaluated using the Children’s Implant Profile (Nottingham Version) and a free field audiogram if available. The children are evaluated with a series of questionnaires: MUSS, (IT) MAIS, SIR, CAP, PRISE and a Musical Stage Profile at approximately the 3, 6, 9, 12, 18 and 24 month visits. Performance data using the clinic’s routine tests are collected.
Results: 43 subjects from 11 centres in Europe, Russia, India and Israel are taking part in the survey. The first data obtained so far for 3, 6, 9 and 12 months show a clear improvement from session to session for all the above quoted questionnaires. The evaluation design will be presented as well as the preliminary data obtained so far.
Conclusion: The first outcomes are very promising in terms of acceptance and performance with HiRes 120. More results and long term data are now needed to formally conclude on the benefits of HiRes 120 in children.

Room 6 - C. Streitberger (Italy), A. Deveze (France)

ELECTRO-MECHANICAL STIMULATION THROUGH THE COCHLEAR WINDOWS WITH THE VIBRANT SOUNDBRIDGE
C. Streitberger and N. Giarbini
ENT and Head-Neck Surgery Department, Hospital of Meran - Italy

Introduction
The idea of placing an active middle-ear implantable devices at the round window in order to direct drive the inner ear, has offered a new surgical option in the treatment of conductive and mixed hearing loss. As one of the most challenging issues in middle-ear reconstructive surgery is to gain satisfactory long term functional results, this new treatment option has been appreciated by many middle-ear surgeons. Different devices and sites of application have been tried out in different middle-ear conditions, but an agreement on positioning-choice is still missing.
Aim
The application of an active middle-ear implant needs to guarantee satisfactory functional results on a long term. The aim of this presentation is to describe the audiological results obtained for round and oval window positioning of the Vibrant Soundbridge’s (VSB) Floating Mass Transducer (FMT) and to discuss the device’s effectiveness on the bases of results obtained.
Subjects and Methods
Of the 50 cases treated with Vibrant Soundbridge (VSB) during the last 4 years, the results obtained in 50 cases suffering from mixed hearing loss of different etiologies who received a VSB either on the round window (15 patients) or on the oval one (15 patients) will be described. The surgical approach was adapted case by case for all subjects and was alternatively: revision of radical cavities (CWU and CWD), transmastoid with posterior tympanotomy, transmeatal, or combined transmeatal-transmastoid.
For the round window placement, the niche was adapted for the FMT and positioning was in contact to the round window membrane, with or without interposition of autologues fascia.
For the oval window placement, the FMT was positioned in direct contact with the stapes footplate in 8 cases, on stapes supra-structure in 6 cases, and directly on oval window after stapedectomy in 1 case.
Results
One major surgical complications with total loss of inner ear function did occur in a case of Franceschetti Syndrome, but in all other subjects no significant worsening of bone conduction was observed post-operatively. All patients have improved speech understanding at VSB activation when comparing aided with unaided condition.
The results obtained after a minimum of six months post-surgery were evaluated in terms of aided threshold improvement and functional gain.
For round window placement, data from 12 cases showed unaided mean pure tone average PTA4 at 75,83 dB HL (s.d.= 16,77) with mean speech recognition threshold (SRT) of 85,2 dB HL. At 6 months from VSB activation mean PTA4 was 40,45 dB HL (s.d.=11.26) with mean SRT of 58,4 dB.
For oval window placement, data from 13 cases showed unaided mean pure tone average PTA4 at 74.71 dB HL (s.d.=19.95) with mean SRT of 86.3 dB HL. At 6 months from VSB activation mean PTA4 was 35.73 dB HL (s.d.=9.04) with mean SRT of 54,5 dB.
Results were maintained with a slight improvement over time in subjects with a longer period of observation.
Indications, surgical technique in different anatomical conditions and results will be discussed for the two different placements.
Conclusions
In our opinion, the cochlear windows’ placement of the VSB has shown satisfactory functional results and the choice to direct drive the inner ear through the oval or the round window should be done on the base of imaging and intra-operative findings, aiming the best possible transfer of vibratory energy to the inner ear. Nevertheless the risk of damaging the inner ear should be kept in mind, especially in severe malformations of the middle ear.

VSB Surgery and Aural Atresia
G. Sprinzl (Innsbruck, Austria)

Bilateral Vibrant Soundbridge Implantation: Audiologic and Subjective Benefits in Quiet and Noisy Environments
Garin, P. (1,2) ; Schmerber, S. (3,4) ; Magnan, J. (11,12) ; Truy, E. (5,6); Uziel, A. (7); Triglia, J.M. (8) ; Bebear, J.P. (9) ; Labassi, S. (10); Lavieille, J.P. (11,12).

Objective: To evaluate the benefit of bilateral Vibrant Soundbridge middle ear implantation as compared with unilateral implantation in quiet and noisy environments.
Method : Multicentric and retrospective study of 15 patients with symmetrical sensorineural hearing loss who were implanted sequentially on both ears. The performance of each subject was compared under three conditions : with the right implant activated, with the left implant activated, and with both implants activated. Audiometric tests were compared with self assessment subjective evaluation by questionnaire.
Results: Both qualitative and quantitative assessments demonstrated improvement in speech intelligibility, especially in background noise, but also for low voice intensity in quiet.
Conclusions: These results support bilateral sequential implantation for patients who feel not completely satisfied after implantation of one side

Results of the Vibrant Soundbridge (VSB) Fixed to the Stapes or Round Window Niche
Jeff Mulder (Nijmegen, The Netherlands)

MRI safety of the floating mass transducer
Ingo Todt*, Grit Rademacher+, Friederike Wagner*, Eva Schedlbauer *, Jan Wagner*, Dietmar Basta*, Arne Ernst*
*Dept. Otolaryngology, Head and Neck Surgery; +Department of Radiology, Unfallkrankenhaus Berlin,Germany.

The electromagnetic actuator function of the Vibrant Soundbridge FMT in the middle ear and its coupling abilities are very different compared with other implantable hearing devices. The MRI safety of the system has central importance in case of a regular observation as well as for a accidental and/or urgent MRI scanning required for medical reasons.
Aim of the study was to observe 1) 1.5 T MRI-related changes to the Vibrant Soundbridge floating mass transducer (FMT) magnetization, function, and position in different coupling modes within the middle ear, 2) changes to middles ear structures and 3) possible effects on the transfer function to the inner ear.
9 FMTs were repeatedly investigated before and after MRI scanning. Changes in the position of the FMT (RW, classic, stapes) and the ossicular chain in human cadaver temporal bones (TB) were estimated by microscopy, micro endoscopy, and flat panel angiography. Functional investigations of the FMT’s mode-of-action in different coupling modes were done by laser doppler vibrometry (LDV).
A qualitative demagnetization after MRI scanning with 1.5 T could be ruled out in all specimens even after up to 11 scans. In 3 TBs, FMT coupling to the long process of the incus (n = 18) showed a change in the FMT position, and in 2 cases a 90o rotation along the axis of the incus process. A dis- or ex- articulation of the ossicles or a displacement of the FMT from the long process of the incus was not observed. Mean LDV measurements showed MRI related changes in the stapes velocity. When the FMT was coupled to the round window (RW), we observed a fixation-dependent influence of MRI scanning on the FMT position and mean transfer function.
The functional integrity of the FMT was not significantly influenced even after multiple MRI scans at 1.5 T. Positional changes of the FMT within the middle ear are possible, but we observed no structural damage to the middle ear structures. Although effects on the transfer function can be possible a outpatient intervention should restore it.

How to Improve the Efficiency of the MET: Influence of the Coupling to the Ossicular Chain
Arnaud Devèze, MD
Department of Otolaryngology, University La Méditerranée, Assistance Publique Hôpitaux de Marseille, Marseille, France.
Stéphane Tringali, MD
University Claude Bernard Lyon 1, CNRS, UMR5020 Neurosciences sensorielles, Comportement, Cognition, F-69366, Lyon, France.
Herman A. Jenkins, MD
Department of Otolaryngology, University of Colorado Denver, School of Medicine, Aurora, CO, USA.

Conventional hearing aids have advanced tremendously throughout the last decade with miniaturization and improvements in digital signal processing. However, conventional hearing aid technology suffers from drawbacks, such as unsatisfactory sound quality (limited frequency range, undesired distortion), occlusion of the external ear canal, acoustic feedback with high amplification, and social stigma. Recently, active middle ear implants have been developed to overcome these issues. The Middle Ear TransducerTM (MET, Otologics, Boulder, CO, USA) is available in both a semi-and fully implantable active middle ear implant commercially available for treatment of moderate to severe sensorineural and mixed hearing loss in adults (available in Europe since 2000, undergoing clinical trials in United States). The semi-implantable is composed of an external part containing the microphone, the battery and the sound processor, and of an internal part implanted in the middle ear in which the transducer is connected to the body of the incus. The fully implantable system (Carina) has all components implanted under the skin as a unit.
In this instructional course, the surgical techniques, problems and results with these active middle ear implants in sensorineural and mixed hearing losses will be presented. These include: 1) Authors’ experiences in conductive and mixed hearing losses, using semi- and fully implantable devices, and 2) update of US clinical trials of the fully implantable Carina system.
Numerous results have been reported so far in the literature. Although this appears to be a reliable solution, achieving success requires significant attention to details.  Discussions of candidate selection, specifics on placement and coupling of the transducer to the ossicular chain or round window, and limitations of the device will provide information to be used as a guide for surgeons in implantation.

Room 7 - Chairmen: S. Tringali (France), V. Koci (Austria)

Active Middle Ear Implants: a simplified surgical approach with the Semi-implantable Middle Ear Transducer from Otologics.
Stéphane Tringali, Annie Moulin, Paul Berger, Christian Dubreuil, Eric Truy.
Hospices Civils de Lyon, Department of Otology, Lyon, France.
Université Claude Bernard Lyon 1, CNRS, UMR5020, Lyon France.

Objectives: To report the audiometric and the clinical outcomes of patients implanted with a semi-implantable active middle ear implant (MET, Middle Ear Transducer, Otologics, Boulder, CO, USA) for sensorineural hearing loss using two surgical approaches.
Patients: Forty patients (ages, 35-77 years) with moderate to severe sensorineural hearing loss were implanted between July 2004 and December 2008. Since January 2007, the surgical approach was simplified and the tip of the transducer was performed without using laser hole approach.  
Method: Audiometric testing was performed the day of activation (two months post-operative) and after one, three, and six months for both groups (with and without laser approach). We assessed speech intelligibility in silence and in noise using the Speech Recognition Threshold (SRT), the maximum discrimination score (Dmax, %) (maximum speech intelligibility score), and the speech intelligibility obtained using a stimulus intensity of 65 dB HL.
For each follow-up, the MET was optimized according to the patient’s hearing loss. Subjective benefit analyses were determined through the APHAB questionnaire. Results were compared between both surgical approaches (with or without laser hole surgery).
Results: 25 patients were implanted with laser-hole surgery and 15 without. No significant differences were observed between pre- and postoperative air conduction and bone conduction pure tone averages in the both groups. The average free field functional gain obtained with the implant ranged from 22 to 39 dB at each individual frequency and no significant difference was demonstrated between the both groups. Word recognition scores demonstrated significant differences between unaided and implant-aided conditions. No significant difference was observed between the two surgical approaches in terms of complications.
Discussion: The performance of the MET and the absence of occlusion of the external auditory canal could explain the improved benefit. For maximum gain, the MET requires a regular follow-up during the first six month to obtain the best result. The technique could be simplified without using a laser. Results were explained by the stability of the device due to the solid fixation of the transducer in the mounting bracket.
Conclusion: MET appears to be a suitable and successful treatment option resulting in significant improvement in speech comprehension, especially after six months, in patient with moderate to severe sensorineural hearing loss. Initial’s results with the simplified technique seem to be safe and give equivalents results in term of gains and complication rate.

Surgical Topics for Middle Ear Implants
Fitzgerald O’Connor (London, United Kingdom)

Window Stimulation Directly to the Cochlea: Output Determination of the Direct Acoustical Cochlea Stimulator Partial Implant (DACS PI).
Hannes Maier, Gérard Loquet, Georg FeiglIzabel Kós
1Phonak Acoustic Implants SA, 2SciCoMeD GmbH, 3University of Graz, Dept. of Anatomy, Austria, 4Hôpital Cantonal, Universitaire de Genève, Switzerland

Introduction The Direct Acoustic Cochlea Stimulator Partial Implant (DACS PI, Phonak Acoustic Implants) is intended to provide direct stimulation to the cochlea by circumventing the middle ear. Although the approach to stimulate cochlear fluids with an actuator is well fitted for the treatment of middle ear transmission diseases the determination of the actual actuator output remains challenging. Here the actuator output of the DACS PI to an artificial
window is compared experimentally in human temporal bones to the natural sound input to the middle ear using the stapes footplate vibration as reference. Methods To determine the stimulation efficiency of the DACS PI the ASTM standard (F2504.24930-1) for output determination of implantable middle ear hearing devices (IMEHDs) in human cadaver temporal bones (TBs) was adapted. Fresh human temporal bones were opened surgically by a posterior approach and stapes footplate displacement response to sound at the tympanic membrane was determined with a LASER Doppler velocimeter (LDV). Only TBs fulfilling the ASTM acceptance criteria were implanted with DACS PI actuators and contributed data to further analysis. Cochleae were opened next to the stapes footplate drilling a circular hole to the scala vestibuli, leaving the oval window unchanged and a piston connected to the actuator was inserted. After implantation actuator driven footplate displacement was determined. Using the sound evoked footplate displacement at the same frequencies the equivalent sound pressure level (eq dB SPL) was calculated for a realistic output voltage of 1Vrms. Results Only 15 fresh temporal bones out of 37 were found within the acceptance criteria of the ASTM standard and used for further analysis. Comparison of sound evoked stapes footplate vibration to actuator driven lead to a gross average MPO at 2 kHz and nominally 1Vrms input of 115 ± 12 eq. dB SPL (MV ± SD, N=15). A subgroup analysis of Ø 0.6mm pistons (N=8) and Ø 0.8mm (N=7) pistons demonstrated a significant higher efficiency for bigger piston diameters. Results of the DACS PI in combination with the larger piston size showed a flat response of 106 – 117 eq. dB SPL in the range 125Hz to 8kHz (∅ 0.8mm, N=7). Discussion The here found maximum output and frequency response of the DACS PI (Phonak Acoustic Implants) is sufficient to substitute pronounced sensorineural hearing loses even at low frequencies. This gives rise to the expectation that an implant using this actuator may substitute combined hearing losses above the limitations of current devices. Having in mind that the applicability of this approach is given by the sensorineural hearing loss component alone, its indication for combined hearing losses where the total hearing loss may exceed the sensorineural component by approx. 50 dB has major advantages. The treatment of combined hearing losses that are currently difficult or impossible to treat with conventional devices becomes a realistic option by bypassing and substituting the middle ear with the DACS PI.

Linguistic issues in candidacy criteria of electric acoustic stimulation method
Kozo KUMAKAWA 1, Hidehiko Takeda 1, Megumi Iba 1, Fumiai Kumagai 1, Hidemi Miyazaki  2, Masataka Ohta 3, Makoto Tateno 3
1: Department of Otolaryngology and Hearing Center, Toranomon Hospital, 2: Department of Otolaryngology, Tokyo Kyosai Hospital, 3: Rion corporation

Objective: Electric acoustic stimulation (EAS) system combines stimulation through a hearing aid and a cochlear implant in the same ear for patients with residual hearing in the low frequencies. The audiometric criteria for EAS is now universally defined as a mild to moderate low frequency sensorineural hearing loss (within 60～65dB in 125, 250, and 500Hz) sloping to a profound hearing loss in the higher frequencies in USA and European countries.  However, Japanese language contains more vowels in sentences and is thought to have more importance in the lower frequency range compared to English. So, we investigated whether the audiometric threshold criteria should be changed or not according to language specifications.
Methods: We designed a comprehension test of Japanese and English using the experimentally designed deaf filters with residual hearing in the low frequencies. The test sentences were given from CD to the subjects in 60dB SPL in the free field via four designed deaf filters in the lower frequencies (Fig 1). The scores of CID sentence scores (English) and CI- 2004 (Japanese). Subjects: Eight bilingual subjects for Japanese and American English who have normal hearing.. Both test sentences were given to the same subjects respectively.
Results: The speech comprehension scores were much better in Japanese CI-2004 rather than in English CID. The data in two groups were statistically analyzed using the paired t-test and the result showed that the mean scores were significantly different (p<0.001 or 0.005) (Fig 2).
Conclusion: The audiometric threshold criteria should be changed and the proper guidelines including mono-syllable test and sentence comprehension tests should be added according to language specifications for EAS cochlear implantation.

Audiological results in patients using the Vibrant Soundbridge (VSB)
KOCI, V., ZOROWKA, P., SPRINZL, G
Innsbruck Medical University, Austria

BACKGROUND:
The middle ear implant system Vibrant Soundbridge is an established method for the treatment of sensorineural, mixed and conductive hearing losses.
SUBJECTS AND METHODS:
Since February 2008, 39 VSB surgeries have been performed at the Innsbruck Medical University. A total of 29 patients received a unilateral VSB and 10 patients were implanted bilaterally. Two of the bilateral patients had already received their first implant before the start of the Innsbruck VSB programme. The average age of those implanted was 60.8 years (youngest: 9 years old; eldest: 84 years old). All patients had previously had several years of experience with hearing aids, however, they had provided insufficient functional gain or the patients could not be fitted with a conventional hearing aid for medical reasons. All patients fulfilled the audiological selection criteria and were fitted with the Audio Processor eight weeks after the implantation. Bone and air conduction thresholds were assessed before and after surgery. Functional gain was calculated comparing aided and unaided air conduction thresholds. Sentence recognition in noise was tested using the Oldenburg sentence test (OLSA). Speech shaped noise at a fixed level of 65dB was used. The speech level was varied accordingly and the speech reception threshold (SRT) was assessed at the 50% intelligibility point. Speech and noise were both presented from the front (S0N0).
RESULTS:
Postoperatively, the bone conduction threshold did not change significantly in the implanted ear. The mean functional gain was 30dB in the range of 0.5 to 4kHz, where 1 to 4kHz showed more gain than 0.5kHz. The average speech reception thresholds were found to be at a signal to noise ratio of -1dB for unilateral VSB use and -1.75dB for bilateral VSB use.
CONCLUSIONS:
The Vibrant Soundbridge is a safe and effective treatment for patients suffering from sensorineural, mixed and conductive hearing losses, which cannot be compensated effectively by conventional hearing aids. Further improvement can be reached by bilateral implantation.

The sex hormone levels in the patients with vestibular disorders
Pawlak-Osinska Katarzyna, Kazmierczak Henryk, Burduk Pawel
ENT Clinic of Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Poland   

The aim of the study was to analyze the eventual sex hormonal effect on vestibular system in the patients suffering from vertigo. Material and methods: 104 persons were tested otoneurologically to put the proper diagnosis of peripheral or central vestibular lesions. Every woman (56 cases) underwent the laboratory testing of estradiol and testosterone levels. In each man (48 cases) the level of testosterone was checked. Then the group of women was devied according to the phase of the menstrual cycle. Results: Among 56 female, the abnormal estradiol level was observed in 17 cases.The most frequently, the estradiol disorders were noted in menopausal women (11 normal levels and 11 pathological): in this group 3 of the patients used hormonal therapy ordered by the ginecologists. In the other pre-menopausal female: 6 underwent the hormonal contraception and in 2 cases estradiol level was disturbed. In male, the level of testosterone was generally normal with the average value of 5,58; only a few cases demonstrated the changes of testosterone level. Conclusions: Generally, the disturbances of estradiol and testosterone levels is not frequent in the patients with vestibular disorders. But they may be expected in menopausal women and in these cases the estradiol level is suggested to be routinally tested.

Room 8 - Chairmen: S. Kanzaki (Japan), H. Sunose (Japan)

Sporadic unilateral vestibular schwannoma in pediatric patients
Yasuhiro Inoue, Jin Kanzaki, Hideyuki Saito, Sho Kanzaki, Kaoru Ogawa
Department of Otolaryngology, School of Medicine, Keio University

The incidence of the sporadic unilateral vestibular schwannoma is very rare in children. We report the two cases of 8 year-old girls, with confirmed histological diagnosis of the vestibular schwannoma.
(Case 1) An 8-year-old girl noticed her left hearing loss 1 year ago, and her hearing was gradually worsened. She visited the nearby hospital, and MRI revealed the 3 cm tumor on her left CP angle. There were no findings, which suggested the neurofibromatosis type 2 (NF2). Then she consulted to our hospital for the treatment of the tumor. The PTA of her left ear was 30dB, however, the speech discrimination score was only 15%. Thus, we underwent the tumor removal via the modified trans-labyrinthine approach. The tumor was completely removed and the facial nerve function was preserved intact after the surgery. The recurrence of the vestibular schwannoma and the new tumor lesion in the other nerves has not been detected in the MRI until now, 15 years after the surgery.
(Case 2) An 8-year-old girl noticed the deterioration of her right hearing for a several months. She visited the children’s hospital in her neighborhood. The MRI revealed the intra-canalicular tumor with the marked enlargement of the internal auditory canal (IAC) in her right ear. The PTA was 65dB at that time. After 1year follow up, MRI revealed the growth of the tumor (protruding 3mm to the CP angle) and her hearing became deaf. Then, she consulted to our hospital. We underwent the tumor removal via the modified trans-labyrinthine approach because her hearing was deaf. The tumor was fulfilled to the fundus of the IAC, and made severe adhesion to the dura mater. The tumor was completely removed and the facial nerve function was preserved intact after the surgery. There is no recurrence of the vestibular schwannoma and the new tumor lesion in the other nerves has not been found in the MRI until now, 2 years after the surgery.
Most of the vestibular schwannoma in the pediatric patients are related to the NF2. Thus, we have to evaluate the patients precisely with the MRI before surgery of the “unilateral vestibular schwannoma”. And watchful follow up will be needed for more than 10 years after surgery. Whether the “unilateral vestibular schwannoma” would develop the NF2 in the future or not, the hearing preservation surgery is preferable in the pediatric patients. However, the tumors in the pediatric patients are usually detected after they grew too large to undergo the hearing preservation surgery successfully. And their hearing level has already been deteriorated too much.

Acoustic neuroma and controlateral sudden hearing loss
Alexandre Karkas, Raëd Rtail, Sébastien Schmerber
Otology/neurotology unit, University Hospital of Grenoble, Grenoble, France

Objectives: Describe the possibility of occurrence of sudden hearing loss (SHL) contralateral to an acoustic neuroma (AN).
Patients and methods: We report on 3 patients who had AN and controlateral SHL from 2008 to 2010. Diagnosis of AN was based on MRI findings.
Results: Two men and 1 woman (mean age 66 years old) have been studied. The 1st patient had sensorineural hearing loss (SNHL) of -50 dB pure-tone average (PTA) on the AN side and anacusis on the SHL side; speech discrimination test (SDT) showed 18% distorsions at 90 dB on the AN side. The 2nd patient had an old anacusis on the AN side and SNHL of -100 dB PTA on the SHL side; SDTs were not measurable. The 3rd patient had bilateral and symmetrical high-frequency SNHL with a mean of -40 dB PTA; SDTs at 80 dB showed 12% distorsions on the AN side and 4% on the SHL side. MRI was ordered for SHL in the 1st and 3rd cases and for the old anacusis in the 2nd case. In all 3 cases, the AN was intracanalicular (stage 1). None of the patients had his tumor removed, because of tumor size, patient age, and especially contralateral hearing loss. Hearing was restored by the Bicros wifi system for the 1st patient, a cochlear implant on the side contralateral to the AN for the 2nd patient, and bilateral conventional hearing aids for the 3rd patient. Hearing results were satisfying for the 3 patients.
Discussion and conclusion: The association between AN and contralateral SHL is to be kept in mind, although very rare. One single article dealing with this subject has been found in the literature. The occurrence of a SHL on the opposite side of an AN would be explained by secretion of toxic proteins by the tumor into the cerebrospinal fluid, eventually resulting in worsening of hearing in the contralateral ear. The risk of this occurrence is increased in case of prolonged watchful waiting of an AN, as is the case of the advent of a SHL ipsilateral to the AN.

Spontaneous Tegmen Defects associated with Superior Semicircular Canal Dehiscence
T. Elhadi, T. Sorrentino, MN. Calmels, B. Fraysse, O. Deguine
Department of Otology/Neurotology, CHU Purpan, Toulouse, France

Background
Superior semicircular canal dehiscence (SSCD) has been a topic of discussion and research since the discovery of the syndrome by Minor in 1995. However many aspects related to its etiopathogeny remain mysterious. In our experience, association of SSCD to spontaneous tegmen defects (STD) was encountered. This may suggest new hypothesis concerning the etiopathogeny of both conditions.
Methods
We did a retrospective study of 17 patients operated for STD between 2000 and 2009. Patients presenting history of head trauma and chronic otitis were excluded. Demographic data and clinical symptoms were gathered. CT scans and MRIs were analyzed looking for common features of the mastoids where such a combination is present. We looked for potential common factors.
Results
Seventeen patients were included. Five of them had STD combined to SSCD. Mean age was 55 years old. 65% were male and 35% female. 15 patients presented conductive hearing loss or cerebrospinal fluid leak due to STD. The STD was incidentally discovered on CT scan performed to evaluate vestibular symptoms in the remaining two patients.
The Analyzed CT scans showed very pneumatized mastoids and very thin tegmen roof in all cases. Three patients presented MRI evidence of hydrocephalus.
Middle cranial fossa (MCF) repair using the Sandwich technique was used in 12 cases. 5 patients underwent transmastoid with one recurrence. Totally the middle fossa approach was performed in 13 patients with no recurrence. The cases of association of CSSD and tegmen defects were all perfomed via MCF approach.  
Conclusion
Special CT scan reconstructions should always be performed to assess the superior semicircular canals in case of tegmen defects.
In our study, association of tegmen defects to SSCD was encountered in 29% of cases. This finding supports the hypothesis of excessive bone resorption during development all parts of the roof of petrous bone. Intracranial pressure, which is rarely measured, could play an important role in the etiopathogeny of both conditions. Further advanced research pathways should be conducted in this direction.

Stapedectomy in Sheep: An animal model for surgical training
CORDERO A1, MEDINA M2, ALONSO A3, LABATUT T4.
1,2,3,4 Otolaryngology Department, Ramón y Cajal University Hospital, Madrid, Spain.
cordev71@gmail.com

INTRODUCTION: Stapedectomy is a surgical technique that requires progressive training. The external and middle ear of sheep have a close resemblance to the human and have been previously used as surgical training models. In our project we describe the anatomy of the middle and external ear in sheep focusing on surgical landmarks and technique in order to determine whether the sheep´s ear is an adequate model for stapedectomy training.
MATERIAL AND METHODS: We reviewed the literature on sheep anatomy and use of sheep as an otologic surgical model. Stapedectomy was performed on 40 sheep using a 4mm platinium piston prosthesis by first year residents. Macroscopic sections as well as temporal bone computed tomography were obtained.
RESULTS: Most of the structures in the sheep´s middle ear are similar to those in human although the size is about two thirds smaller. An exception is the anteroposterior diameter of the tympanic membrane, which is significantly smaller. Incus short process is shorter and thicker, and closer to the malleus body, dificulting piston insertion and adjustment.   Surgical time of stapedectomy  was reduced from 120 to 45 minutes after completing training. There was also a reduction in rate of complication (flap disruption, incus luxation, and mobilization of the footplate).
CONCLUSIONS: Sheep´s ears constitute a cheap, easy to obtain and anatomically adequate model for stapedectomy training.  
KEY WORDS: Stapedectomy, Residency, Training, Animal Model, Sheep ear.

Significant correlation between audiogram and perioperative testing ossicular mobility in otosclerosis patients
Sho Kanzaki1), Takuji Koike2), Takashi Suzuki1), Kunio Mizutari1), Yasuhide Okamoto1), Naoki Oishi1), Shujiro Minami1), Takahisa Watabe1), Hideyuki Saito1), Yasuhiro Inoue1), Yu Yuasa3), Ryo Yuasa3), Hiroshi Wada4), Toshimitsu Kobayashi5), Kaoru Ogawa1)
1) Department of Otorhinolaryngology, Head and Neck Surgery, Keio University Medical School, Tokyo Japan
2)  Department of Mechanical Engineering and Intelligent Systems, TheUniversity of Electro- Communications, Tokyo, Japan
3) Sendai Ear Surgicenter, Sendai, Japan
4) Department of Bioengineering and Robotics, Tohoku University, Sendai,
Japan
5) Department of Otorhinolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan

Background; Confirmation of the conditions of the ossicles is essential for stapedectomy or stapedetomy. However, at present, ossicular mobility is experimentally estimated with palpation by a surgeon, and the results depend on the surgeon’s skill.
Objectives; In this study, a new apparatus for quantitatively measuring ossicular mobility we developed tested in patients with otosclerosis to be compared with preoperative audiogram.
Subjects and Methods; With this apparatus, the ossicles were displaced and the reaction force from the ossicles, was simultaneously detected as previously reported (Koike et al International Journal of Audiology 2006).
Ossicular mobility including incus long process, stapedial head and footplate of nine patients with otosclerosis was tested in 9 patients with otosclerosis.
Results; We observed significant correlation between mobility and preoperative audiogram. Our data showed the significant correlation between mobility of stapedial head and air bone gap ranged from 250 to 4000 Hz or air conductive threshold at 2000Hz of preoperative audiogram, between mobility of stapedial footplate and air conductive threshold at 250 Hz. However, there is not significant correlation between mobility and tympanogram.
There is no complications in those patients have not seen after testing. All the patients have better hearing after surgery and testing.
Conclusions; We concluded that preoperative air bone gap is the most reliable predictive factor of stapedial head mobility and will further investigate more cases.

Corresponding author:
Sho Kanzaki  MD PhD
Department of Otorhinolaryngology, Head and Neck Surgery
Keio University Medical School
35 Shinanomachi ShInjuku
Tokyo Japan, 160-8582
FAX: +81-3-3353-1261
Email : skan@sc.itc.keio.ac.jp

Results of inverse stapedotomy using manual perforator
N.Arsović, B. Mikić, B. Babić, B.Panovic
Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia

After four decades of classic stapedotomy, reversal of the steps has been proposed  by Fisch.
The authors have analyzed a group of 111patients (126 operations) that have underwent stapes surgery over three years period. First group of 50 patients(55 operations)  have been operated on by a classic stapedotomy from 2006 to 2007 and the second group of 61 patients(71 operations)  by inverse stapedotomy in 2007 and 2008. Manual perforator has been used in all of the patients.
In a group of patients operated by inverse technique not a single case of floating basal plate has occurred during surgery. Rate of postoperative complaints regarding nausea and balance disorders  was considerably  lower when reversal of the steps has been used. Closure of air bone gap better than 20dB  in about 80% patients in both series, with slight advantage of the inverse technique, but no statistically significant difference was proven.
Inverse stapedotomy is efficient procedure as compared to classic stapedotomy with less intraoperative complications and postoperative complaints. Postoperative audiograms have shown similar improvement of hearing thresholds in both groups. Inverse technique in stapes surgery is strongly advocated especially when manual perforator is used.

Free Paper Session: 12.00-13.00

Room 1 - Chairmen: T. Sorrentino (Italy), P. Romanet (France)

Cochlear implantation in very young children
E.F. Hensen, C.F. Smit, P. Merkus
Cochlear Implant Center Amsterdam VUMC,
VU University Medical Centre, Amsterdam, the Netherlands
e.hensen@vumc.nl

Objective
In congenitally deaf children, the ideal age for cochlear implantation is usually approximately 12 months. This timeframe is determined by the increased risk of anesthesia and possible incomplete neuronal development in younger patients on one hand, and a delayed language and speech development in older patients on the other. In case of severe sensorineural hearing loss and imminent cochlear fibrosis after meningitis, earlier intervention is necessary. Here, we discuss the surgical aspects of cochlear implantation in children younger than 12 months.
Material and Methods
The literature on surgical aspects of cochlear implantation in very young children was reviewed. In addition, the surgical experience from the VU University Medical Center with children younger than 12 months was evaluated, including a patient that was implanted at 4 months of age, to our knowledge the youngest implanted patient to date.
Results
In all our patients younger than 12 months, the indication for early implantation was meningitis and imminent cochlear fibrosis. Full insertions with normal implants were possible in all cases. The surgical key points include the undeveloped mastoid tip, the superficial trajectory of the facial nerve, the thin cortex of the skull, extensive bone marrow within the mastoid bone, the small distance between cortex and antrum, and the more horizontal position of the round window. Furthermore, the altering dimensions of the developing skull have to be considered.
Conclusion
Cochlear implantation is feasible in children younger than 12 months, when taking specific surgical aspects into account. Up till now, implantation in this age group is mainly performed after meningitis, when postponing surgery would decrease the chances of successful implantation and rehabilitation.

The Binaural Cochlear Implant: Preliminary Results
Philippe Romanet (Dijon, France)

Functional evaluation of atraumatic electrode insertion in cochlear implantation
T. Sorrentino, A. Elmaghrabi, M. Guibert, M. Marx, ML. Laborde, O. Deguine, B. Fraysse
Department of Otology and Neuro-otology, CHU Purpan Toulouse, France
Aim of the study: To evaluate vestibular and cochlear function after cochlear implantation (CI) and to compare results among different sites of cochleostomy.
Material and methods: we present a study of 40 patients who underwent CI in the last two years. For each patient we determine: cause of deafness and its duration before CI, site of the cochleostomy (through round window (RW), anteroinferiorly (AI) or scala vestibuli), pure tone audiogram pre and postoperative, VEMPs, VNG and speech performance of CI with disyllabic words and sentences in noise (SNR 10 dB) done at least 2 months after the implant activation. Among this group 13 patients answered the DHI questionnaire pre and postoperative and a postoperative CT scan was performed to ensure a good insertion of the electrode.
Results: In regard to the direct surgical trauma, we compared the incidence of residual hearing conservation and the vestibular function in 3 types of cochleostomy: 11 anteroinferiorly (27.5%), 4 scala vestibuli (10%), round window 25 (62.5%). In all cases of AI insertion VEMPs were preserved after surgery; whereas the electrode was inserted through the RW VEMPs were preserved in 71% of patients. All but one of patients implanted through the scala vestibuli lost saccular function. Preservation of residual hearing was significantly associated with preservation of VEMPs on the implanted side (p = 0.0018). Patients with preserved saccular function showed better discrimination of sentences in noise.
Conclusion: Balance disorders and loss of residual hearing are possible events following CI. We believe they are associated with traumatic insertion of the electrode destroying the basilar membrane or the sacula. Electrode insertion through AI cochleostomy seems to be the most atraumatic method. We stress on the importance of balance tests, including vestibular evoked potentials, and the necessity of an atraumatic insertion in cochlear implant surgery.

Cochlear implantation at Casa di Cura “S. Camillo”, Forte dei Marmi: a 10-year experience
E. Dinelli, F. Iovane, M. Guida, T. Berghenti, M. Magnani.
U.F. Otorinolaringoiatria, Casa di Cura “S. Camillo”, Forte dei Marmi

OBJECTIVE: to report our experience with two different multichannel cochlear implant devices, and to examine the results as well as any complication occurred.
SETTING: cochlear implantation was undertaken in 57 patients (28 males and 29 females) with severe and profound hearing loss over a 10-year period. The average age was 42 years (ranging from 3 to 80 years). Our series included 39 postlingual and 18 prelingual patients. The average pure tone audiometry with the hearing aid in free field showed a threshold between 0,5-1-2 KHz of 85-80-90 dB. The cause of hearing loss in our series was unknown in approximately 40 per cent of cases. Standard selection criteria and operative techniques have been applied for all cases. Two cochlear implant systems were used: Nucleus (24M, and 24 R Contour, Cochlear) in 31 patients, and  Digisonic SP (MxM-Neurelec) in 26 cases.
RESULTS: implantation was successful in all patients except in 1 case. No major postoperative complications were observed. All patients receiving a successful procedure showed significant post-implantation improvement in perception and discrimination of sound and speech. Better results were noted in pre-lingual patients under the age of six, as well as in post-lingual adults with a recent history of hearing loss.
CONCLUSION: the outcomes of our patients series are comparable to literature results. No real difference between the two implantable devices have been noted during rehabilitation and follow-up. According to literature evidence we suggest an accurate selection of patients and a proper preoperative assessment performed by multidisciplinary and experienced cochlear implant team to avoid any delay to implantation.

Surgical Complications in 455 Cochlear Implantation
Rubens V. de Brito Neto, Aquiles F. Leal, Robinson K. Tsuji, Mariana P. Hausen and Ricardo F. Bento
Departament of Otorhinolaryngology, Clinics Hospital of Sao Paulo University, Brasil

Objective: To report the surgical complications found in patients undergoing implantation in a single center.  
Study Design: Prospective study assessing the complications of adults and children undergoing cochlear implantation.
Setting: Brazilian tertiary referral center for cochlear implantation.
Patients: The study includes the first 455 adult and pediatric patients undergoing cochlear implant operations carried out at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during a ten-year period (1999 to 2009). The mean duration of follow up was 3 years.
Results: The mastoidectomy/posterior timpanotomy approach was chosen in all patients but two, which underwent middle fossa approaches. The only significant change in relation to surgical technique occurred in the flap design. The overall complication rate related to the operative procedure was 18.2%. Major surgical complications accounted for 3.9% of the complications including 10 flap related complications (infection, dehiscence) with five of them requiring explantation. Two cholesteatomas, 2 CSF leaks, 2 meningitis and 1 severe facial nerve damage match the rest. The minor surgical complication (e.g., temporary facial weakness, hematoma and posterior canal wall/eardrum lesions without late repercussion) corresponded to 14.3% of the complications and in all cases they were solved with conservative measures or minimal intervention, without impairs the implantation and the use of the device. The long term follow up was of extremely importance by the fact that some severe complications occurred many years after the implantation.
Conclusion: This study confirms that cochlear implant is a relatively safe surgery in experienced centers and most surgical complications can be managed with conservative measures or minimal intervention. Expertise in this specific type of surgery, attention to surgical planning and technique and skills for the management of major complications are essentials requirements for the surgical team.  The long term follow up is of paramount importance in this type of surgery.

COMPLICATIONS FOLLOWING  COCHLEAR IMPLANTATION IN ADULTS
Georgios Stamatiou,  Efthimios Kirodimos,  Aristides Sismanis   
Cochlear Implant Center, Department of Otolaryngology – Head and Neck Surgery, Hippocration General Hospital, University of Athens, Athens, Greece

Objectives: To describe our experience on intraoperative complications following cochlear implantation in an adult population.
Setting: Cochlear implantation performed in two tertiary referral centers.
Materials and methods: Retrospective chart review of 202 implanted adults out of 435 cochlear implantations performed by the same surgeon (the senior author) in two different institutions from April 1986 to April 2009. The operative technique was similar in all studied cases and complications were managed by the same team each time.  
Results: Devices implanted in adults were 93 Cochlear-Nucleus, 81 Med-El and 28 Advanced Bionics. Out of 202 implanted subjects, complications were observed in 14 cases. The total rate of complications in our adult series was 6.93%. Device failure was the prominent complication in 7 cases (3.47%). In 4 subjects (1.98%) a wound infection was noted right after implantation and treated successfully in the office. In two elderly patients (0.99%), a minor dural injury with cerebrospinal fluid leak was controlled with temporalis fascia grafting intraoperatively. In 1 patient (0.5%) a subdural haematoma was observed after cauterization of a prominent dural vein.   
Conclusion: Cochlear implantation is generally a safe procedure. Although  complications in adult population were rather uncommon, some of them were severe and an immediate intervention was necessary for a successful outcome.

Room 2 - Chairmen: A. Taibah (Italy), R. Brito (Brazil)

Cochlear Implant in the Management of Vestibular Schwannoma in the Only Hearing Ear
Abdelkader Taibah, Michela Spigaroli (Piacenza and Rome, Italy)

Auditory Brainstem Implants
Sakeel Saeed (London, United Kingdom)

Indications and Contraindications in ABI
Mario Sanna, Maurizio Guida (Piacenza and Rome, Parma, Italy)

Simultaneous Fast-ABR and CNAP in decision making in cochlear implantation vs. ABI
Enrico Piccirillo MD, Maurizio Guida PhD, Enzo Molina Phd, Giuliano Sequino MD, Mario Sanna MD
GRUPPO OTOLOGICO (Piacenza – Roma) , Italy

Decision making in Cochlear Implantation versus Auditory Brainstem Implant (ABI) is a difficult topic. It is related to cases of surgical treatment of Vestibular Schwannoma (VS) in the only hearing ear or Neurofibromatoisis Type-2 (NF-2) patients.
In some cases VS surgical removal becomes necessary also in the only hearing ear in which preservation of any auditory function is mandatory. Intraoperative Cochlear Nerve Monitoring (ICNM) has been developed in the recent years to check the auditory function during the operation. Fast-ABR and Cochlear Nerve Action Potentials (CNAP) are routinely used in functional VS surgery. Strategy in preserving any auditory function in VS surgery in the only hearing ear and NF-2 patients is described.
In cases which hearing preservation or rehabilitation are necessary, tumor removal is perfomed through a combined Retrosigmoid-Retrolabyrinthine approach. In cases which cochlear nerve integrity is maintained, but hearing is lost, the option of Cochlear Implantion  is prevalent. If cochlear nerve integrity is lost,  placement of  ABI is made at the time of tumor removal. Intraoperative Cochlear Nerve Monitoring (Fast ABR and CNAP) is performed in all cases and Electrical Auditory Brainstem Responses following the ABI insertion is recorded.
Nowadays it is difficult to achieve the activation of all the ABI electrodes; in our experience eight functioning electrodes can be enough to obtain adequate hearing/eyesighting performances.   

RESULTS OF AUDITORY BRAINSTEM IMPLANTS ON 3 CASES OF COCHLEAR NERVE APLASIA
J. Magnan*, J. Economides**, Maria Economides**, Maria Zarifi**. (Marseille, France)

Objective:
Auditory Brainstem Implants (ABI) in children for cochlear nerve aplasia is still challenging both in the assessment and in surgical procedure. We present the results of three children who underwent auditory brainstem implants in such application.
Materials:
Three children respectively aged 6, 5 and 4,5 years old were selected as cochlear nerve aplasia after complete imaging assessment. The first and oldest case was a Charge syndrome boy aged 5,5 years old, with bilateral dysplasia of the petrous bone and bony atresia on the right side. Upon radiologic examination absence of both internal auditory canals is found. The second case was a boy aged 5 years old with cleft lip and absence of the cochleae and the vestibules bilaterally. There was doubt concerning the presence of auditory pathways. The third case was a girl aged 4,5 years old, born with esophageal and anal atresia, tetralogy of Fallot, absence of radius and absence of the two left hand fingers. Imaging revealed absence of the auditory pathways bilaterally.
Method:
Surgery was performed in one case via the translabyrinthine approach, in the two other cases the retrosigmoid approach was used. The auditory brainstem implant Neurelec was used with 15 electrodes.
Results:
For the first case:
Perception & Discrimination of environmental sounds: Perceives and discriminates bell, drum, and rattle. Perceives almost always quality of voice (i.e. who is speaking to him, his father/mother/sister).
Perception & Discrimination of oral sounds: Perceives and discriminates all consonants except the velar fricative [γ] and the alveolar liquid sound [l]. Perceives and discriminates all vowels but sometimes confuses the vowel [I]. ]. Can discriminate two words that differ in both consonants and in length but cannot discriminate similar words that differ by one only consonant.
Language Development: Orally produces 2-word sentences (usually verb-noun) (up to 4 syllables) with the help of MAKATON pictures.
Intelligibility of Speech: You can clearly understand what he has said on a one-word level and usually on the noun. Still lacks in producing a lot of consonants and thus intelligibility falls.
For the second case:
Perception and Discrimination of environmental sounds: Perceives drum, bell rattle and also perceives his father’s voice.
Perception & Discrimination of oral sounds: Perceives and discriminates vowels [a,e,o,I,u]. Cannot perceive or discriminate any consonants. No word discrimination as yet.
Language Development: Orally produces few words (only nouns) (up to two syllables) with the help of simple color cards.
Low Intelligibility of speech, as most of the consonants are still not produced.
For the third case:
Only Perception of environmental sounds is her present progress. She seems to only perceive drum, bell.
Results show that in 2 years follow up, two cases are classed as successful and very beneficial for both the social behavior and basic sound recognition. One case, interestingly the child with the less associated problem, get any benefit although the ABI was responding.

Surgical complications in ABI placement in children and adults.
Ricardo Bento, Robinson Kogi Tsuji, Marcos de Queiroz Gomez, Mariana Hausen Pinna, Graziela Queiroz, Rubens de Brito

Objective: Our aim was to describe surgical complications occurring after auditory brainstem implant (ABI) surgery  in children and adults.
Study Design: Prospective study of 10 consecutive ABI surgeries.
Setting: This study was conducted at the department of Otolaryngology at University of São Paulo, Brazil.
Patients: Ten patients, from 2006 to 2009, received ABI for different tumor and non-tumor diseases.  There were 6 adults and 4 children. Five NF2 adults patients had their acoustic tumors removed during the ABI surgery and one adult was deaf due to meningitis. Three children had inner ear malformation and one had  total cochlear obliteration due to meningitis.
Intervention: The translabirynthinne approach was performed for all the adults patients. A enlarged retrolabirynthinne approach was used in three children and a retrosigmoid approach was performed in one case.
Main Outcome Measures: Presence of immediate postoperative complications in patients undergoing surgery for surgical placement of auditory brainstem implants and surgical difficulties, as the impossibility of electrode anatomical landmarks exposition were described.
Results: The surgeries have been done without any surgical difficulties, including the very young children underwent to a retrolabirynthinne approach. Cerebro-spinal fistula (CSF) occurred in two adult patients with acoustic tumors. One patient was treated only with lumbar puncture, and the other underwent a new surgical procedure for cavity obliteration with abdominal fat. Among children, one had transient facial palsy (retrosigmoid approach), and another had a multidirectional nystagmus, which appeared immediately after recovery from anesthesia and lasted 8 days.
Conclusion: Surgery for placement of auditory brainstem implant is a safe procedure with low complications in both children and adults, however certain complications may require specific attention to correct them

Room 3 - Chairmen: V. Achilli (Italy), I. Todt (Germany)

How to connect a Mobile Phone to a Cochlear Implant?
T. Rottmann1, M. Brendel1,2, A. Buechner1, Th. Lenarz1
1Hearing Center of the ENT clinic of the Medical University of Hannover, Director: Prof. Dr. med. Th. Lenarz, Germany
2Advanced Bionics European Research Center GmbH, Hannover, Germany

E-Mail: rottmann@hoerzentrum-hannover.de

For many years Cochlear Implant (CI) users asked for recommendations regarding mobile phones and accessories to improve sound quality. Therefore an acute trial was initiated to evaluate various connections between the CI speech processor and a mobile phone.  
Twelve adult Cochlear Implant users were recruited so far, further subjects will be enrolled. All of them used the Harmony behind-the-ear processor in combination with a CII or HiRes90K implant system. The subjects had a mean age of 56.0 years, a mean duration of deafness of 9.7 years and a mean age at implant of 52.9 years.
The Freiburger monosyllables speech test was performed via telephone in four conditions: direct connection between CI and telephone via cable, the pinnar microphone TMic, the in-built microphone as well as a bluetooth headset in combination with the TMic. A questionnaire assessed the use of the telephone in everyday life.
Ten of the twelve subjects were using a mobile phone in their everyday life. The Freiburger monosyllables test showed similar results for the in-built microphone (57.3%), the TMic (56.9%) and the bluetooth headset (58.8%), but significantly poorer speech perception for the direct connection via cable (37.1%). Subjectively subjects preferred the T-Mic (mean value of 2.3 on a scale from 1 to 4), while they disliked the cable (mean value of 0.2).
The direct connection between CI and telephone complicated the handling and reduced the sound quality. All three other configurations showed better results and were more comfortable to use. Both, objective and subjective results, led to the recommendation to use the regularly used microphone in combination with a mobile phone. A bluetooth headset is a good solution e.g. in a car when a hands-free set is required.

Cochlear Implant Patients - Vestibular Function Testing in Comparison with Flat Panel CT Imaging
Karl Friedrik Norfalk, Ralf Greisiger, Marie Bunne, Claude Laurent, Gerhard Bosse, Hilde Korslund, Per Kristian Hof, Greg Eigner Jablonski (Oslo, Norway)

Static posturography with interactive balance system analysis in patients with cochlear implants
Barozzi S*, Proto M., Filipponi E., Forti S, Di Berardino F,  Ambrosetti U, Zaghis A, Cesarani A.
* Audiology, Department of Specialistic Surgical Sciences. Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico. University of Milan – Italy

Introduction. The auditory pathways are anatomically and functionally connected to the vestibular ones. Few reports deal with the electrical stimulation delivered by cochlear implants (CI) effect on stance by means of static posturography and controversial results are reported in literature.
Aim of this study was to evaluate the possible interferences between CI stimulation and vestibulospinal system using an interactive balance system analysis.
Methods. 15 adult implanted patients without vestibular symptoms were tested in 6 different conditions on a stabilometric platform (IBS; Tetrax Inc., Ramat Gan, Israel) with CI turned on and off
Results. The index of stability and sensorial analysis by somatosensory, visual and vestibular ratios (obtained applying the formulas used with the SveP system) were not significantly different between CI turned on and off mode.
Conclusions. Interactive balance system analysis confirms that CI did not change significantly any stabilometric parameter and evidenced that CI did not alter the sensory pattern emerging from the sensory analysis.

Influence of cochlear implantation on the vestibular system
Ingo Todt, Anne Kathrin Coordes, Jan Wagner, Dietmar Basta, Arne Ernst
*Dept. Otolaryngology, Head and Neck Surgery, Unfallkrankenhaus Berlin, Germany.

Vertigo after cochlear implantation is with a described variance of 0 % to 75 % one of the most common complications after cochlear implantation.
Related to the complex factors which contribute to postural stability cochlear implantation can affect this balanced system in multiple, different ways. So far a correlation between single factors and the occurrence of postoperative vertigo after cochlear implantation is difficult.
The aim of the present study was, beside focusing on different observations, giving an overview on the different factors which contribute to the possible occurrence of postoperative vertigo.
Surgical factors could be shown to influence the occurrence of postoperative vertigo. Bilateral cochlear implantation is a risk factor for a bilateral loss of vestibular function. Subjective occurrence of vertigo is significant higher after the second implantation.
Vestibular activation by the cochlear implant could be shown and is of clinical and electrophysiological importance.
Cochlear implantation is a  step in the complex balanced labyrinthine system. Working on a cochlear implantation with as less complications as possible, a consideration of the vestibular system is of central importance.

Vestibular function following Cochlear Implantation
E Ionescu1,3, C Ferber-Viart1,3 , E Truy1,3, L Collet1,3
1 - Service d’Explorations Orofaciales et Vestibulaires, Hôpital Edouard Herriot, Lyon, France
2 -  Service d’ORL et Chirurgie cervico-faciales, Hôpital Edouard Herriot, Lyon, France
3 - Equipe Audiologie UMR CNRS 5020

16 to 47% of patients who underwent cochlear implant procedures experience vertigo symptoms after surgery. At the origin of this symptom most authors indicated weakness of the vestibular-ocular response or areflexia on the implanted side. The underlying mechanism of this vestibular impairment is supposed to be either the direct surgical trauma over the inner ear structures induced by the introduction of the port-electrode across the cochleostomy (Basta et al.) or by a secondary endolymphatic hydrops induced by electrochemical phenomena related to the electrical stimulation generated by the implant (Tien et al.,) .
Several studies reported amelioration of vestibular ocular response in the implanted subjects. These ameliorations were encountered not only in unilateral implanted patients but also in some bilateral or binaural implanted ones. Furthermore there was observed some improvements on the contralateral side as were already reported previously (Ribari et al.). Recent studies also reported noticeable amelioration of the postural control after the cochlear implant activation tested with computerized dynamic posturography (Buchman et al.).
The aim of this paper is to present a meta-analyse of the literature on this subject to report our results and discuss the results. Using “soft surgery” technique as described by Thomas Lenarz there was no post implantation vestibular areflexia in all ears with normal function prior surgery. Some weakness of the vestibular ocular response at caloric stimulation was noticed but this result was not necessarily correlated with poor vestibular performance on the Equitest platform. Vestibular performances improved in 15% to 20% of patients after IC procedure. In 5 patients with binaural/bilateral cochlear implantation the vestibular results were even better, with preservation or amelioration of the caloric tests and consistent improvement of vestibular score on Equitest platform.  
While in case of vestibular impairment after IC procedures we dispose of some pertinent hypothesis, in case of unilateral or bilateral amelioration of the vestibular ocular response the underlying mechanism is still speculative. In the future more Longitudinal multicentric randomised studies should be design in order to study this subject which appears at this moment an important scientific and medical challenge for the cochlear implantation teams.    
References
Basta D, Todt I, Goepel F, Ernst A. (2008) Loss of Saccular Function after Cochlear Implantation : The Diagnostic Impact of Intracochlear Electrically Elicited Vestibular Evoked Myogenic Potentials. Audiology & Neuro-otology vol. 13 : 187-192.
Tien HC, Linthicum FH (2002) Histopathologic changes in the vestibule after cochlear implantation. Otolaryngology and Head and Neck Surgery 127:260–264.
Ribari O, Kustel M, Szirma A, Reppasy G (1999) Cochlear implantation influences contralateral hearing and vestibular responsiveness. Acta oto-laryngologica 119 : 225-228  
Buchman CA, Joy J, Hodges A, Telischi FF, Balkany TJ. The Laryngoscope. 114 : 1-22. Vestibular effects of Cochlear implantation

Reconstruction of external auditory canal in patient with lateral temporal bone resection: a case series of four patients
Masato Fujioka, Hideyuki Saito, Yasuhiro Inoue, Sho Kanzaki, Shujiro Minami, Takahisa Watabe, Reiko Watanabe, Yukiko Watada and Kaoru Ogawa  
Department of Otorhinolaryngology, School of Medicine, Keio University, Tokyo Japan   

Objectives: To investigate the results of reconstruction of external auditory canal with free-flapped skin graft over the temporo-parietal facial flap (TPFF) in the patients with temporal bone cancer treated with lateral temporal bone resection (LTBR) in adult Study
Design: Case report Setting: The study was carried out in Keio University Hospital, Tokyo, Japan.
Patient: All four cases suffered malignant tumors localized in the external auditory canal (EAC) with no apparent extension into the middle ear or the mastoid. In one of four cases, the bony erosion of external auditory canal was pathologically pointed out (T2N0M0); the others were T1N0M0 (Pittsburg staging grades). Pathology of all four cases was squamous cell carcinoma. Initial radiotherapy was not performed in any case. Intervention: In all cases the LTBRs were performed followed by the reconstructions of EAC. Reconstruction procedures were generally in accordance with a conventional method for congenital aural atresia by using skin graft, except with TPFF underlaid for the better attachment and survival of the grafts.
Results: Three of four cases have been followed up for longer than a year at this moment: All three patients survived without recurrences. The reconstructed EACs were epithelized within two months and remained with cosmetically successful outlook. The average of five frequency air-bone gaps in each patient was 26 ± 2.9, 45 ± 2.0, 36 ± 3.7 dB, respectably. The remaining case is still under observation and the data will be presented at site.
Conclusion: Malignant tumor in EAC is usually managed with radical surgery and the conductive function is sacrificed even though the otic capsule was preserved by LTBR. By applying the skin graft method for building EAC, which is a common procedure for congenital aural atresia, we successfully reconstructed surgically removed EAC with favorable cosmetic outcome. Recreated canals were well attached in all cases with the underlay of TPFF, which has rich blood perfusion from superficial temporal artery and vein. Hearing outcomes were favorable assessed by air-bone gap although the lateral healing of the tympanic membrane was observed and seems a major prognostic factor of audiological outcomes. We assume further efforts to avoid from lateralization are still indispensable. Discussions, suggestions or comments for further technical achievement will be appreciated at the poster.

Room 4 - Chairmen: C. De Palma (Italy), L. Arnold (France)

NRT over-threshold responses in subjects with cochlear implants Nucleus CI24/RE
C. De Palma, F. Freni, F., Galletti
Università degli studi di Messina
Dipartimento delle specialità chirurgiche
Unità Operativa Complessa di ORL
Direttore Prof. Francesco Galletti

Introduction: L’ N.R.T. ® is a non invasive methodic, using in intraoperative and postoperative time, to appraise the response of the acoustic nerve to the electric stimulation. A speech processor model Freedom connected to a cochlear implant CI24R/RE measures the ampleness of the VIII cranial nerve’s  potential of action.
Objective: Development of a specific protocol for the testing of the cochlear implants in intraoperative and postoperative time and, particularly, for the evaluation of the response of the nerve (ECAP) to threshold levels (T-NRT ®) and over-threshold.
Materials and Methods: In the period January-November 2009 have been valuted six patients (age 16 - 40 months) in intraoperative time, at the first fitting time and follow-up at 1, 3, 6 and 12 months. Using the Cochlear’s software Custom Sound 2.0 EPs with interface POD for the System Nucleus CI24RE.
The protocol correlates the intensity of the tide of stimulation, at over-threshold levels, with the ampleness of the response (N1/P1).
Conclusions: The results have been correlated with the data of the fitting and use for the cochlers implant’s fitting.
Keywords: Neural Response Telemetry – Cochlear Implant – Objective measurement

Speech understanding and subjective assessment after upgrade of the speech processor from Medel Tempo+ to Opus2
Martin Kompis, Pascal Senn, Christoph Schmid, Benjamin von Gunten,
Mattheus Vischer, Marco Caversaccio
Department of ENT, Head and Neck Surgery, Inselspital, University of Bern, Switzerland

Introduction
Currently, the Opus2 behind-the-ear speech processor (Medel Inc., Austria) for cochlear implants is replacing the older Tempo+ device by the same manufacturer. The most apparent differences between the two models are an improved coding strategy called Fine structure processing (FSP), a remote control, an integrated telephone coil and a smaller housing. The aim of this study was to compare speech understanding in quiet and the subjective assessments of users, who have been upgraded from the Tempo+ to the Opus2 speech processor.
Materials and method
21 CI users (11 children, ages 11-17, and 10 adults, ages 18-83) who have been fitted with the new Opus2 speech processor in the last 10 months participated in the study. All participants were implanted with a Medel C40+ cochlear implant and had used a Tempo+ processor for at least 2 years at the beginning of the study. In all participants, the coding strategy was changed from CIS+ to the new FSP strategy. Understanding of German monosyllabic words and 2-digit-numbers from the Freiburger Tests at 60 and 80 dB were compared before the processor upgrade and after 2 months of use of the Opus2. Furthermore, all participants were asked to fill in a questionnaire regarding their subjective assessment and their use of the new speech processor.
Results
On average, speech understanding improved by +0.9 % for numbers and +6.5 % for monosyllabic words with the new speech processor. The difference was statistically significant only for monosyllabic words at 80 dB (p=0.002). Subjectively, size, weight, the cosmetic aspect and speech understanding in different situations were regarded as superior. Overall, 20 of 21 participants preferred the new speech processor. Only 8 participants used their remote control on a regular basis.
Conclusions
Our results show an overall benefit of the new Opus2 speech processor for the user, when compared to the older Tempo+. Besides a better subjective rating by the users, improved speech recognition scores in quiet were found both in children, and in adults.

Music evaluation in adult users of HiRes® 120 and previous generations of Advanced Bionics® sound coding strategies
Laure Arnold, Dzemal Gazibegovic (Advanced Bionics Europe, Germany)
Objectives
In 2007 Advanced Bionics has launched the novel sound coding strategy HiRes 120.The strategy incorporates the concept of current steering and offers up to 120 stimulation sites using only 16 electrodes.
Early clinical results showed improved speech understanding in noisy environments. Also the naturalness of speech and music and the sound quality overall were improved.
Objective of the evaluation is to observe if there is a difference in music perception, listening frequency, enjoyment and ability to differentiate special musical features, between the three main group of subjects using different generations of strategies:
CIS/MPS/SAS
HiRes
HiRes 120
Methods
The evaluation is based on a questionnaire. Forty three questions are divided into several sections:
Individual sections will help collecting information on etiology, equipment used for listening to music, sound coding strategy, frequency of listening to music, musical activity, and enjoyment of music before becoming deaf and with the cochlear implant. Last section is assessing subject’s ability to recognize special musical features.
Results
In the pilot phase of the evaluation a group of twenty five normal hearing subjects were tested as control group. Present multicentric results show that the normal hearing subjects are out performing the cochlear implant group in all musical performance related questions as expected. Nevertheless, there are in some instances also significant differences among the cochlear implantees using different sound coding strategies.
Discussion
Based on the data obtained from normal hearing subjects, the evaluation seems to be appropriate to collect a large number of data within a short time period. The present results do indicate that users of latest sound processing technology of Advanced Bionics tend to have improved musical performance.

Varese Mapping System
L. Dalla Costa, S. Burdo (Varese, Italy)

Rehabilitation of Cochlear Implants in Adults
L. Cucinotta, S. Burdo (Varese)

PHONEME LISTENING AND AUDITORY MEMORY IN COCHLEAR IMPLANTED CHILDREN
Branka Mikic, Nenad Arsovic, Danica MIric, Sanja Ostojic, Mina Mikic
Institute of ENT&HNS, Clinical Centre of Serbia, Belgrade, Serbia Faculty for Special Education and Rehabilitation, Belgrade University  

Introduction: Cochlear implantation improves auditory perception and memory in congenitally deaf children especially if it is performed early, before the age of 3. Both functions are essential for future speech and language development, learning and literacy.
Material and methods:  A group of 40 cochlear implanted children aged 3 to 12 has been enrolled in the study. Phoneme listening was tested by Ling 6 sounds test, Global articulation test and Test of immediate verbal memory (Subtest I-IV). Results were compared between early and later implanted children as well as regarding to hearing age and duration of postoperative rehabilitation.
Results: Children implanted before the age of 3 have done considerably better in all three tests. Phoneme listening and auditory memory has been much better in children with more of 2 years after switch on. After 3 years of rehabilitation children have fully developed phoneme listening and superior auditory memory as compared to those who had shorter speech and hearing rehabilitation.
Conclusion: Early cochlear implantation, before the age of 3, enables better outcome regarding listening skills and auditory verbal memory. Development of those skills, however, takes time so that assessment of the results should be followed over years. Long standing postoperative rehabilitation is essential for optimal achievements

Room 5 - Chairmen: D. Zanetti (Italy), A. Incesulu (Turkey)

The change in hearing level and growth rate of acoustic neuromas in wait and scan policy
Takahisa Watabe, Yasuhiro Inoue, Hideyuki Saito, Sho Kanzaki, Shujiro Minami, Masato Fujioka, Reiko Watanabe, Yukiko Yahata-Watada and Kaoru Ogawa (Tokyo, Japan)

Objective: This study aimed to evaluate a related factor with the changes in hearing level or the growth rate of tumor diameter in wait and scan policy. Subjects: 69 patients with acoustic neuromas (mean age, 55 years; range, 15-82 years) who have allocated to wait-and-scan management with magnetic resonance imagings (MRI) and audiological examination and have been followed over a year were analyzed retrospectively. Two complete pure tone audiograms were available for all patients and two MRI were available for 62patients. Method: A correlation between the change of hearing level or annual growth and the age, sex, tumor location, property and hearing level (which was evaluated according to the guidelines established by American Committee on Hearing and Equilibrium) at the initial diagnosis was analyzed retrospectively. Results: The mean annual growth rate was 0.77 mm/year (range, -5.6－7.5 mm), and the mean change of hearing level was 4.51 dB/year (range, -4.78－29.04 dB), and no correlation was recognized between them. An increase in tumor size (≧2mm/year) was noted in 12 patients and the declination in hearing level (≧10dB/year) was noted in 11 patients. No related factor with the changes in hearing level or the growth rate was recognized. But to make a comparison in the changes of hearing level between class A,B  and D under 50 dB in pure tone audiogram (PTA), a tendency of declination in hearing level was recognized in class D under 50 dB in PTA (P=0.022). Conclusion: When we select the wait and scan policy in acoustic neuromas , we consider hearing level, tumor size, tumor position, tumor property, age and so on at initial diagnosis. But this study dosen’t show that these factor lead to prediction of the changes in hearing level and tumor size. Only under 50dB in PTA at initial diagnosis, a tendency of declination in hearing level was recognized in class D. This result may show that attention must be paid to speech discrimination test in cases under 50dB in PTA. Discussions, suggestions or comments in detail will be appreciated at the poster.

Critical Issues and Outcomes of Cochlear Implantation in Bilingual Deaf Children
Diego Zanetti (Brescia, Italy)

Direct Drive Fitting Study
Millo Achille Beltrame, MD1; Giuseppe Nicolo’.Frau, MD1, Guido Cumer, MD1, Francesca Maronato, MD1, Laura Bellini1, Silvano Prosser, MD2
1 U.O. di Otorinolaringoiatria, Ospedale Santa Maria del Carmine, Rovereto, Italy
2 University of Ferrara; Arcispedale Sant’Anna, Ferrara, Italy

Background:
The Vibrant Soundbridge (VSB) is a semi-implantable middle ear hearing device used in the rehabilitation of patients suffering from sensorineural, mixed and conductive hearing loss. In this study we compared the bone conduction thresholds (THRBC) with the Vibrogram (THRVG), which is obtained by measuring the hearing thresholds by directly stimulating the middle ear with the VSB. The Vibrogram represents the individual transfer function of the active Floating Mass Transducer (FMT) and is determined by THRs and UCLs values. The difference between the bone conduction thresholds (THRBC) and the Vibrogram (THRVG) provides information about the quality of the coupling of the FMT and the inner ear for all types of Vibroplasties.
Objective:
The first objective was to investigate the transfer function of the FMT in dependence of different placements of the FMT. 3 types of Vibroplasty have been analysed: OW, RW and Incus Vibroplasty. The quality of the coupling of the FMT to the Middle Ear was assessed by comparing the bone conduction thresholds (THRBC) and the Vibrogram (THRVG). The second objective was to develop a new fitting method which is based on the Vibrogram.
Subjects:
The Vibrogram has been measured in 40 patients divided in 3 groups: OW, RW and Incus Vibroplasty. All patients fulfilled the candidacy criteria for VSB after surgery and showed good coupling of the FMT to the inner ear.
Methods and procedures:
Free Field testing was performed providing to the patients two different fittings of their Audioprocessor. The first fitting was based on the Audiogram, while the second fitting was based on the Vibrogram. Tone threshold and speech was compared. In addition a subjective evaluation of the two fitting methods has been performed.
Results and conclusions:
The fitting based on Vibrogram is a useful and easy method to provide information about the coupling of the FMT to the IE and to the ME
71% of the patients report more natural sound perception with the fitting based on the Vibrogram. The speech results measured by SRT of the Incus Vibroplasty group improved by 16,5 dB, while the SRT improved by 15 dB for Round Window Vibroplasty group and 8 dB for the Oval Window group.
The fitting based on the Vibrogram is an easy objective programming method to standardize the Vibrant Soundbridge Fitting.
Keywords : Vibrant soundbridge, Vibrogram, SNHL, Mixed HL ,Vibroplasty, bone conduction

ELECTRIC +ACOUSTIC  STIMULATION FOR TREATMENT OF PARTIALLY DEAFENED PATIENTS: OUR RESULTS.
Francesco ACHENA*, Giuseppe LAI *, Enzo D’AURIA**-  ENT Institute Iglesias*; Cattedra di Audiologia- Cagliari University ** Italy

The results of three patients with partial deafness implanted at ENT Department of Iglesias with the EAS Implant( MED-EL ) are presented. In these patients there was essentially normal hearing or moderate hearing-loss( no more than 45 dB ) in the low frequencies and profound high frequency hearing loss at frequencies greater than 1500 Hz. The combination of electric and acoustic stimulation has enabled these group of patients to gain improved word understanding compared to their preoperative hearing with bilateral hearing aids, particularly in noise. Two subjects have preservation of low frequency acoustic hearing within 15 dB of their preoperative pure tone levels. In no patients the low frequency were totally lost.
Conclusion
EAS implant( MED-EL) should be  considered in partially deafened patient rehabilitation. Soft surgical procedures allowing hearing preservation based on round window approach or cochleostomy are demanded.

THE SAFETY OF ELIMINATING THE MIDDLE EAR: A REPORT OF 51 CONSECUTIVE CASES IN 19 MONTHS
C. Martin-Oviedo, MA. Arístegui Ruiz A. X. Araujo, A. Lowy Benoliel, M. Gutierrez, D. Poletti, J. Riestra,  B. Scola Yurrita.
ENT Department, Hospital General Universitario “Gregorio Marañón”, Madrid.
Address for correspondence:
Carlos Martín Oviedo
ENT Department, Hospital Gregorio Marañon
carmoviedo@yahoo.es
H. General Universitario Gregorio Marañón, C/Dr. Esquerdo 46, 28007, Madrid, Spain.
0034915868155/ 0034626911379

Blind sac closure of the external auditory canal (EAC), with occlusion of the Eustachian tube and drilled out of all the middle ear cells, was described as Subtotal Petrosectomy. Such principle has been applied to otologic, neurotologic and skull base procedures. There are many advantages to do so, but the main has been the safety of the procedure to eradicate or prevent infection in selected cases.
We have been using such strategy for decades. We have reviewed the last 51 cases performed between July 2008 and January 2010. Approaches such as subtotal petrosectomy, Modified Translabyrinthine approach, Modified Transcochlear approach, Infratemporal Fossa approaches and temporal bone resection are among those that have been used on a wide range of indications that will be shown.
Only one case of CSF leak with meningitis in a complex case of malignancy that required a large pedicled flap for reconstruction, and a wound infection, both resolved favorably with conservative methods, are the complications found in this series.
We are convinced that this technique offers the best strategy to eradicate or prevent infection in complex otologic, neurotologic and skull base cases, and this series demonstrates its safety in terms of infectious complications.

Vestibular Rehabilitation
Arnagan Incesulu (Ankara, Turkey)

Room 6 - Chairmen: L. Bruschini (Italy), H. Jenkins (USA)

Comparative Study of the Hearing Quality between the Fourth and the Last Generation of Audioprocessors for Vibrant Soundbridge Implant
Dott. L. Bruschini. Dott. S. Prosser, Prof S. Berrettini

Background:  The safety and efficacy of the Vibrant Soundbridge (VSB) for mild to severe sensorineural, conductive or moderate to severe mixed hearing losses have been shown by several publications. The Middle Ear Implant Vibrant Soundbridge has been approved by regulatory authorities for the above indications.
As the sound processing technology is implemented in the external part of the Middle Ear Implant, the system can be upgraded by changing this part. All current Vibrant Soundbridge users may benefit from the upgrade.  
Objectives:  This study is investigating the hearing benefits of the new Audioprocessor called Amadé in comparison with the former model (AP 404 SR) currently in use, in terms of:
a)   Subjective hearing impression
b)   Speech understanding in quite and in noise
c)    Different listening situations
d)   Improvement of quality of life  
Subjects:  10 Vibrant Soundbridge users with more than 2 month experience and a daily usage of the VSB of at least 6 hours have been selected. The coupling of the VSB to the Inner Ear has been evaluated and found to be adequate for all patients.  
Methods:  The Vibrogram has been used in order to verify the coupling of the VSB to the Inner Ear and as programming base for both Audioprocessors to guarantee the same method.
Comparative free field testing including pure tone and speech tests in quite and adaptive speech tests in noise with the former Audioprocessor and the new Amadé have been performed. In addition patients have filled out a subjective questionnaire evaluating the three different listening situations (unaided, aided situation with both Audioprocessors).  
Conclusions:  As the Amadé has doubled the number of frequency bands and compression channels in comparison with the former Audioprocessor it was possible to adjust the functional gain more precisely. The new features introduced with the Amadè processor, like speech and noise management, sound smoothing and wind-noise reduction are found to be useful to guarantee best listening sensation. The Amadé Speech Processor was very well accepted and found to be superior in performance for all listening conditions.  

Objective measurements with Vibrant Soundbridge
Dott.M.Perotti, Department of Otorhinolaryngology, Ospedale Civile Tortona, Italy
Dott.M.A.Beltrame, Department of Otorhinolaryngology, Ospedale Santa Maria del Carmine, Rovereto, Italy
Dott.C.Streitberger, Department Of ENT, Head And Neck Surgery, Hospital of Meran - Italy

Background: The middle ear implant Vibrant Soundbridge VSB (Vibrant Med-El. Innsbruck, Austria) consists of an electro-mechanical floating mass transducer (FMT) which provides direct mechanical stimulation to the Middle Ear. The VSB is an effective way to restore hearing in patients with sensorineural and mixed hearing loss, in patients which cannot benefit from conventional hearing aids.
Objectives: The primary objective is the assessment of the functioning of the Middle Ear implant during the surgical procedure.
The secondary objective is to evaluate the effectiveness of the coupling of the FMT to the Inner Ear during the surgical procedure.  
Methods: 30 patients with sensorineural and mild to severe mixed hearing loss have been investigated using intra-operative cochleography. The neural response was induced by directly stimulating the implant with a defined electrical signal, while the compound action potential (CAP) was measured with a promontory electrode.
Starting from 110 dB, the intensity of the stimulation of the FMT was lowered in steps of 5 dB until the hearing threshold of the patient was reached.
In order to assure good coupling the difference between the bone conduction thresholds and the threshold found with the electrocochleography was evaluated.
This difference should be as small as possible to achieve optimal energy transfer into the Inner Ear.
In case that the difference is higher than 20 dB the placement of the FMT is varied and the measurements are carried out again.
Results: The CAP measurements show nerve response due to mechanical stimulation with the FMT for the whole frequency range demonstrating correct functioning of the implant. All evaluated implants did not suffer from any damage due to surgical manipulation.
In all patients the electrocochleography measurements was shown to correlate to the bone conduction after manipulation of the FMT placement to the optimal position.  
Conclusions: The objective measurements assess the correct functioning of the implant.  
The difference between the bone conduction and the threshold of the CAP is an effective way to verify the coupling of the FMT to the Inner Ear.
Further investigations are necessary to verify the coupling stability after surgery.

The fully implantable Cochlea amplifier CARINA – an experience in 58 patients with combined sensorineural as well as middle ear hearing loss
Authors: M.Pfister, J.Rodriguez and H.P. Zenner
Department of Otolaryngology,
Elfriede Aulhornstr. 5
University of Tuebingen, Germany

Objective:
In 2007 the Carina implant has received the CI-certification in Europe and is since then used in different Departments of Otolaryngology in Europe. Based on its amplification and coupling possibilities it offers a solution to treat patients with moderate to  severe sensorineural hearing loss as well as combined hearing loss. The purpose of this presentation is to report on 58 patients with different Carina coupling  strategies and the current results.
Study design:
Prospective a case series
Setting:
Tertiary academic practice
Patient population:
58 patients with a combination of middle ear  and sensorineural hearing loss as well as pure sensorineural hearing loss were implanted.
Results:
3 different coupling strategies have been used: Coupling to the incus, coupling to the long process of the incus, coupling to the round window. The results show a simular tendency of efficient transmittance and amplification.
Conclusion: CARINA can be efficiently used to receive a functional gain in patients with hearing loss. It is well accepted after a certain training and fitting period in the patients. The different coupling strategies will be shown and discussed in detail, however the tendency is to avoid a round window coupling in preference to long incus coupling and incus body coupling. Details of functional gain will be presented in comparison to the different coupling strategies.

Rehabilitation of the mastoid cavity combining canal wall implant and active middle ear implant. A new option.
Arnaud DEVEZE, MD, Charbel RAMEH, MD, Mélanie SANJUAN, MD, Jacques MAGNAN, MD.
1. Department of Oto-Rhino-Laryngology and Skull Base Surgery. University Hospital Nord – University La Méditerranée and Assistance Publique Hôpitaux de Marseille. Marseille, France.

Objective
Open mastoid cavity rehabilitation should focus on both anatomical and functional aspects. We hereby report the technique and results of a combined strategy to reconstruct the external ear canal using a titanium wall implant and the middle ear using a fully implantable active middle ear device.
Methods
A fully implantable active middle ear implant was used to rehabilitate the mixed hearing loss of a 63-year-old woman, and a titanium posterior canal wall prosthesis was used to reconstruct the external ear canal during the same procedure. The middle ear implant was placed directly on the footplate. The auditory results were compared to the preoperative unaided thresholds and to the amplification of a conventional hearing aid.
Results
Following the procedure, there was an anatomically normal external ear canal with a healed tympanic membrane separating the external from the middle ear spaces. The postoperative auditory gains were on average 31.8 dB on pure-tone audiometry, and 20 dB on speech reception threshold. No complications occurred.
Conclusion
The rehabilitation of the external ear canal in an open mastoid cavity allows for clinical follow-up of the patient, and the implantation of an active middle ear implant provides appropriate auditory gains both in pure tones and in speech reception thresholds. This new treatment option is feasible and reliable considering the long-term results of both canal wall down rehabilitation procedure and middle ear implantation.

US Phase II Clinical Trials of the Otologics Fully Implantable METTM Hearing System
Herman A. Jenkins,  Kristin M. Uhler, Virginia K. Lupo and Barbara Bell-Lehmkuhler
Department of Otolaryngology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA

Objectives: 1) Assess the efficacy of the Otologics Fully Implantable MET TM Hearing Device Phase II clinical trial in patients with bilateral moderate to severe sensorineural hearing loss
Methods:  a repeated measures within subjects design assesses outcomes in aided sound field thresholds, speech performance and subjective benefit scales, comparing the implanted device with the subject’s own appropriately-fitted “walk-in” hearing aid. Patients were surgically implanted with the Otologics device with coupling of the transducer to the incus, using a laser-drilled hole. Patients were managed in a variety of academic and private practice settings.
Results: A cohort of 58 patients have been implanted at 11 centers in the U.S. Individual patient results were compared with their own “walk-in” hearing aid. No significent differences were seen between the pre- and postoperative assessments of air and bone conduction thresholds, p > 0.05. Similarly, there were no significant differences between the patients’ own aid and the implant in their aided thresholds,
CNC word and BKB-SIN scores. Functional gain results were slightly lower than their own aid’s performance. APHAB evaluations showed a distinct preference for the implant in subjective measures of ease of communication, background noise and reverberation, p < 0.05. Aversiveness ratings were similar for both devices. Gradual improvements over time were noted in the implanted patients, attributable to stabilization of the device in the healing operative site. Subjective questionaires completed by the patients showed a distinct preference for the fully implanted device.
Conclusions: Data from implanted subjects demonstrate that the performance of the Otologics METTM Fully Implantable Hearing Device is essentially equivalent to that of the patient’s own appropriately fitted hearing aid.

Vertigo as a presenting symptom for otosclerosis
Topsakal V, Tange R, Grolman W.
Department of Otorhinolaryngology Head and Neck surgery, University Medical Center (UMC) Utrecht, the Netherlands.

Background:
Otosclerosis is most often presented by hearing loss in patients and is exceptionally associated with vestibular symptoms. In a strict definition of this disease otosclerotic foci can occur randomly at any spot on the human otic capsula. Therefore it is commonly accepted that otosclerosis can cause both conductive hearing loss as well as sensorineural hearing loss due to stapedial or cochlear otosclerosis, respectively. Although otosclerotic foci can also occur around the vestibular system, balance disorders are rarely encountered in otosclerosis patients. Here we present an unusual case of a 38 years old male patient that consulted our emergency department because of acute balance disorders.
Case presentation:
Our patient complained of positional and paroxysmal vertigo with nausea and vomiting. He mentioned having progressive hearing impairment over the last 3 years and fullness over both ears with a stable and well compensated tinnitus. Clinical examination showed clearly a Schwarze sign on the right ear. No nystagmus could be substantiated and the Dix-Hallpike test did not show nystagmus indicating for Benign Paroxysmal Positional Vertigo (BPPV). Hallmaygi Head Trust Test (HHTT) was negative for both sides. Audiometric evaluation showed a bilateral conductive hearing loss as indicated in figure 1 with absence of stapedial reflexes on both sides. We performed standard clinical electronystagmography with caloric testing that demonstrated symmetrical caloric responses. In addition ocular Vestibular Evoked Myogenic Potentials (oVEMPs) were examined but could not be substantiated. Masses in the cerebellopontine angle were ruled out with MRI imaging. The high resolution CT Scan demonstrates clearly cochlear otosclerosis that is shown with a 4th ring of Valvassori around the cochlea in figure 2 showing the right ear. Figure 3 show right and left ear with slices demonstrating otospongiosis and foci with otosclerosis around horizontal semicircular canals (SCC). The same radiological findings are shown in figure 4 at Superior SCC on both sides.
Discussion:
Balance disorders are rarely encountered in otosclerosis patients. The causal relation between otosclerosis and balance disorders can be debated. There have been histological studies suggesting the implication of Meniere disease in otosclerosis patient and others have shown copular deposits containing otosclerotic foci. Here, we show abnormal radiological findings at the SCC most probably caused by otosclerosis that could explain the balance disorders in this patient. Probably a 3rd window phenomenon such as in dehiscent SCC could explain a causal relation between otosclerosis and balance disorders.
No support or conflicts of interest to report
Correspondence:
Vedat Topsakal
Department of Otorhinolaryngology Head and Neck surgery,
University Medical Center (UMC) Utrecht, the Netherlands.
Heidelberglaan 100, Room G05.129, P.O. Box 85500
3584 CX Utrecht
The Netherlands
Phone: 00.31.88.75 566 52
Fax: 00.31.30.25 419 22
Email: v.topsakal@umcutrecht.nl

Room 7 - Chairmen: J. Magnan (France), M.Gaihede (Denmark)

Outcomes of the ClearVoiceTM Evaluation in Adults
N. Mathias, L. Arnold
Advanced Bionics Europe, Clinical Research Department

Objective: Cochlear implant (CI) users often achieve high levels of speech understanding when listening to well articulated speech in quiet, for presentation at a comfortable listening level, without substantial reverberation or other distortions, which are commonly encountered in real life listening environments.  In such difficult situations, it is still challenging for CI users to understand speech well. ClearVoiceTM, a new proprietary algorithm from Advanced Bionics® has been designed to improve speech understanding in such difficult listening environments.  The basic principle of the algorithm is to reduce the stationary noise and emphasize the dynamic channels containing more speech.  The aim of this multicentre clinical evaluation is to collect user feedback on benefit of ClearVoice in various types of noisy situations and optimize parameter choice in the use of ClearVoice.
Method: During a routine fitting session, adult subjects with at least six months of HiRes 120® experience with a Harmony® processor receive in addition two ClearVoice programs (one “medium”, one “high”) saved in a random order on their processor.  The subjects are asked to complete a questionnaire at home.  A first part is dedicated to demographics information. Then, following use of the three programs for one week each they are asked to complete the Abbreviated Profile of Hearing Aid Benefit (APHAB) and additional questions.  Finally, a third part of the questionnaire about program preference is completed after use of each of the three programs.  
Results: To date twelve subjects have been included across two centres. Switch-over to ClearVoice was uneventful and preliminary feedback collected just after fitting was promising. Recruitment is still ongoing with the aim to enroll around 100 subjects across 15 centres. The project design will be presented as well as the data obtained so far.
Discussion: Preliminary studies on ClearVoice on small groups of subjects had already been conducted and had shown very promising results in terms of improving hearing performance in noise with ClearVoice.  In addition, most subjects preferred ClearVoice programs compared to their initial clinical programs. The current new project should make it possible to confirm the preliminary findings in a larger group of adults in a short timeframe.

Middle ear implants long term follow up
J Magnan, R Meller, A Deveze, C Rameh
ENT Department, CHU NORD, Marseille

Material and method: 140 patients were implanted between 1998 and 2009 with three different implantable hearing devices, the Vibrant SoundBridge® (VSB) (Vibrant Med-el®, Innsbruck, Austria), the semi-implantable Otologics MET® implant (Otologics®, Boulder, Colorado), and the fully implantable Carina® implant (Otologics®, Boulder, Colorado).
This study reports results of 74 cases of SNHL patients with 19 Semi-implantable Otologics implants, 10 Carina implants, and 45 VSB implants.
Results were collected trough a special questionnaire and pre and post operative audiological data.
Results : Free-field functional gain and SRT improvement were undeniable for all implants. However, this was not always reflected in real life patient satisfaction.
Conclusion :
Implantable hearing devices offer a reasonable and acceptable alternative to hearing-impaired patients with SNHL with stable long-term results. “In-situ”Audiological results are good, but the different implants have to be further improved to offer more patient satisfaction in real life situations.

Electromechanic Active Middle ear implants: the best way to achieve stability of the transducer in oval and round windows.
A. Lowy Benoliel; MA. Arístegui Ruiz; C. Fernánde-Jañez; C. Martin-Oviedo; G. Aránguez Moreno; C. Alonso Martinez, I. Cardoso Lopez; B. Scola Yurrita.
ENT Department, Hospital General Universitario “Gregorio Marañón”, Madrid.

The anatomical variability of both oval and, specially, round window can cause difficulties in stabilizing transducers in cases of active electromechanic middle ear implants (Vibrant-Medel ® and Carina – Otologics ®).
We have performed an anatomical study through temporal bone dissection to find out the anatomical variations of both windows and the best way to stabilize transducers of the above mentioned active middle ear implants.
We will present the results on 25 specimens. Round window niche shows a greater anatomical variability when compared to the oval window. The oval window presents more complex stabilization options in the case of Vibrant implants. In the round window, stability could be achieved in both kind of implants using different techniques; although Carina may present some impediments in cases of atresia auris.  
Address for correspondence:
A. Lowy Benoliel
ENT Department, Hospital Gregorio Marañon
alowy@telefonica.net
H. General Universitario Gregorio Marañón, C/Dr. Esquerdo 46, 28007, Madrid, Spain.
0034915868155

Active Middle Ear Implants. New Indications and Surgical Procedures
Prof. Manuel Manrique, Prof. Angel Ramos, Prof. Carlos Cenjor (Spain)

Vibroplasty in conductive or mixed hearing loss
Daniele Bernardeschi, Diane Lazard, Tarek Benchaa, Samia Labassi, Michel Beliaeff, Bernard Meyer, Olivier Sterkers, Alexis Bozorg Grayeli,
Otolaryngology Dept., APHP, Hôpital Beaujon, and Inserm UMRS 867, Université Paris 7, France
Vibrant Med-El Inc., Sophia Antipolis, France

Objective and Background: The efficiency and safety of the Vibrant Soundbridge middle ear implant (VSB) in the rehabilitation of sensorineural hearing loss with normal middle ear has been demonstrated. The aim of this work was to evaluate the anatomical and functional results of these implants in various conditions with conductive or mixed hearing loss.
Materials and methods: Twenty-seven adult patients (29 ears) with a mixed or conductive hearing loss, impossibility or intolerance of conventional hearing aids and implanted with VSB between 2006 and 2009 were included in this study. Two patients were implanted bilaterally. The mean age was 41 years (range: 23-61). The population comprised 26 mixed hearing losses, and 3 pure conductive hearing losses due to otosclerosis in 6 cases, to chronic otitis media in 19 cases and to external and/or middle ear aplasia in 3 cases and one case of acquired external auditory canal stenosis . The pre operative ipsilateral PTA was 68 ± 3,4 dB for air conduction and 39 ± 3,5 dB for bone conduction (n=17). VSB was placed through a posterior tympanotomy in 15 cases, through the external meatus in 7 cases, and in a radical mastoidectomy cavity in 7 cases. The floating mass was placed on the long apophysis of the incus in 16 cases, in the round window in 10 cases and on the stapes in 3 cases. The mean follow-up period was 7 months (range: 2-19 months, n=17).
Results: No intra operative complications were noted. Postoperative course was uneventful. All patients had a closed tympanic membrane or a dry healed mastoid cavity at the last visit. Three patients required revision: one postoperative residual tympanic perforation, one FMT displacement from the round window and one case of excessive prosthetic piston penetration into the labyrinth. The bone conduction threshold remained unchanged (n=17). The VSB was activated in all cases with a subjective high quality hearing gain. The ipsilateral postoperative PTA without VSB was 53 ± 4.3 dB and with VSB 35 ± 5.3 dB.
Conclusions: VSB is an efficient means of auditory rehabilitation in conductive and mixed hearing losses when a conventional hearing aid cannot be used or tolerated.

Coherence Analysis of Suggestive Brain Areas Involved in Middle Ear Pressure Regulation in Humans
Michael Gaihede (1), Saber Sami (1,2)
1) Department of Otolaryngology, Head and Neck Surgery, Aalborg Hospital, Aarhus University Hospital, Denmark
2) Wellcome Trust Laboratory for MEG Studies, Aston University, Birmingham, England

Hypothesis: Middle ear pressure (MEP) regulation is a part-active process that is likely to involve several components of the nervous system.
Background: Persistent negative MEP is a major pathogenetic factor in a series of ME conditions. Aspects of central components have become increasingly important, because these conditions may be interpreted as an overall dysregulation due to impairment of its sensory-motor functions. Here, we attempted to investigate the possibility of cerebral components that could play a role in middle ear pressure regulation in humans.
Materials and Methods: Eight healthy adult subjects without any history of otological or neurological disorders participated. Multi- channel EEG experiments were conducted by stimulating the ear with a novel reliable computer controlled pressure triggering system for rapid harmonized static pressure loads of +2 kPa. Quasi-static pressures were investigated following the localization of brain components. This was followed by connectivity analysis of multi- channel wavelet transformed of EEG data to yield easy interpretable time-frequency plots to describe the binding properties of the neural connections that may play a role in MEP regulation.
Results: The connectivity analysis of middle ear static pressure stimulation gave evidence to early gamma-activity at cerebellar locations followed by connectivity to the motor cortices in the beta band.
Conclusions: This is suggestive of an early sensory-motor feedback mechanism in middle ear pressure regulation. Future studies in diseased ears may provide important new information about MEP regulation and have clinical implications.
Keywords: Middle ear pressure regulation, source coherence, EEG, cerebellum

Room 8 - Chairmen: G. Bertoli (Italy), M. Tong (Hong Kong)

The preliminary study of thinly sliced cartilage for reconstruction of canal wall and tympanic membrane
Yasuomi Kunimoto, Kensaku Hasegawa, Hiroaki Yazama, Daizo Taguchi, Hiroya Kitano
Division of Otolaryngology, Head and Neck Surgery, Department of Medicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Japan

Objective:
The use of cartilage in middle ear surgery is not a new concept, having been previously utilized in various indications such as retraction pockets, recurrent perforations and atelectatic ears. We theorized that thinly sliced cartilage would be very useful for middle ear surgery, including when inflammatory adhesion is present, as this cartilage has both good conductive efficiency and shape retention.
Material and methods:
We performed a retrospective chart review in order to identify all patients who had undergone tympanoplasty using thinly sliced cartilage at Tottori University from 2005 to 2009. After the pathology removal in these patients, cartilage was harvested and then thinly sliced using a cartilage slicer. This material was then introduced over the adhesive area while simultaneously being used to reconstruct the posterior canal wall. For the procedure to be successful, the graft needed to be placed on the malleus handle. Recently we add the insertion of a ventilation tube into the reconstructed tympanic membrane. Post-procedure hearing results were determined by comparing the pre- and postoperative pure-tone audiometry (PTA)-air bone gap (ABG), with the averaged data obtained over a minimum of six months of follow-up. In addition, we inspected the postoperative retraction of the reconstructed tympanic membrane and the aeration of the tympanic cavity.
Results:
The overall average of the preoperative PTA-ABG was 30.5dB and the postoperative PTA-ABG was 22.8dB. The reconstructed tympanic membrane was not retracted in most cases. The mild recess was seen in some cases, but there were no cases of forming a retraction pocket. A ventilation tube into the reconstructed tympanic membrane led the better aeration of the postoperative tympanic cavity.
Conclusion:
Tympanoplasty with thinly sliced cartilage is one of a reliable technique for hearing improvement and prevention of retraction pocket in selected cases.

Consent for Mastoidectomy:A Patient’s Perspective
D.Marev
Departement of Otorhnolaryngology Universiti Hospital “Sv.Marina”-Varna,Bulgaria

Abstract
Nineteen patients who had undergone mastoid surgery were asked to identify which risks of mastoid surgery they felt were important to be informed of prior to surgery. This was compared to twenty ENT consultants’ answers on which risks they routinely discuss with patients preoperatively.
Our results show the “average” patient would expect to be consented for all of the risks we asked about except for keloid scarring and altered taste, compared with the “average” consultant who would discuss all risks routinely except for bleeding, intracranial complications and keloid scarring. The most obvious difference between doctor patient opinions is the topic of intracranial problems arising from surgery, 84.2% of patients would want to be warned about this but only 20% of surgeons routinely mention it. (P Value <0.001)
The main reasons for consultants omitting discussion of intracranial complications were their rarity and patients potentially finding it distressing
However recent court rulings indicate that these reasons are invalid and not giving comprehensive consent may be indefensible.

Hearing preservation in patients with labyrinthine fistula
Anamaria Gocea 1, Brigida Martinez ¹, Charlotte Panuschka 1, Pilar Epprecht 2, Miguel Caballero 1, Manuel Bernal-Sprekelsen 1
1 Servicio de ORL, Hospital Clinic, Barcelona, Spain
2 Servicio de ORL, Hospital Son Dureta, Palma de Mallorca, Spain

Background: The management of labyrinthine fistula has been controversially debated. In these cases hearing preservation represents a challenge.
Matherial and methods: Retrospective study on 28 patients with intraoperatively confirmed labyrinthine fistula found during cholesteatoma surgery. The Dornhoffer-Milewski classification for fistulas was used. In all cases total matrix removal was performed, the fistula covered with bone dust, periostium and/or cartilage. Twenty-three patients received intraoperatively a high dosage (500 mg) of intravenously applied steroids a minimum of 15 minutes before handling the fistula. Outcome measurements included the comparison of the preoperative and postoperative bone conduction to assess the inner ear function. Type I fistulas were excluded from the audiological evaluation.
Results: The fistula was located on the lateral semicircular canal (LSC) in 22 patients (78.57%) and at the oval window in 5. One patient had a double localization (superior and lateral semicircular canals). Five patients (17.85%) had a fistula type I, 8 had type IIa (28.5%), 4 patients (14.4%) presented a type IIB fistula, and 6 had a type III (21.40%). Preoperatively the bone conduction displayed an average threshold of 34 dB. Patients treated intraoperatively with steroids showed a preserved or improved bone conduction in almost 70%. Patients with fistulas of the oval window and those with a fistula type IIa on the LSC treated by cortisone experienced a good sensorineural hearing outcome (preservation or significant improvement of the inner ear function), whilst the auditory results for groups IIb and III are inconclusive. Five patients (fistulas > type I) did not receive steroids. Three of them developed a partial sensorineural hearing loss, one got deaf and in one the preoperative hearing level remained unchanged.
Conclusions: Matrix removal over the fistula after a high dosage metilprednisolone administration before handling the fistula followed by repair seems to be helpful in preventing permanent inner ear damage. In patients with fistulae on the oval window or type IIa fistulae of the LSC the threshold for bone conduction could be improved.

Hearing prognosis in antineutrophil cytoplasmic antibody associated vasculitis syndrome
<!--StartFragment-->Hiroaki Yazama,M.D., Kensaku Hasegawa,M.D., Yasuomi Kunimoto,M.D., Daizou Taguchi,M.D., Hiroya Kitano,M.D.. <!--EndFragment-->
Division of Otolaryngology, Head and Neck Surgery, Department of Medicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine

We treated about 7,500 patients who had acute otitis media or mastoiditis from April 2000 to January 2010. In those patients, there were 6 cases who had the intractable otitis media caused by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis syndrome. The major symptoms of this syndrome are interstitial pneumonia, subacute glomerulonephritis and upper respiratory symptoms. On the other hand, there were atypical patients who had only otitis media symptoms and progressive hearing loss. Because they had no major symptoms, it was difficult to make a definite diagnosis. The initiation of therapy was often late for those patients. In our cases, they all had no typical symptoms in middle ear. We confirmed it by the kidney or the lung biopsy. We estimated good outcomes of the patients who were treated within 4 months after the onset. To make early detection, we need careful observation about the symptomatic progression and appearance of major symptoms. If we had suspected ANCA-associated vasculitis syndrome, we should measure PR3-ANCA and MPO-ANCA so as not to miss the chance for diagnosis. And we should conduct biopsy from the organ in which we can get enough volume.
Hiroaki Yazama
Department of Otolaryngology:Head and Neck Surgery
Faculty of Medicine Tottori University
36-1,Nishimachi,Yonago 683-8504,Japan
TEL:+81-859-38-6627 TEL:+81-859-38-6629
E-mail : h-yazama@grape.med.tottori-u.ac.jp

Retro-conchal incision: a novel  approach for the treatment of chonic otitis media.
Bertoli GA and Filipo R. (Rome, Italy)

Objective: This study describe an original approach for middle ear surgery  and highlights its advantage for removal of diseases of the attic, antrum and eardrum, expecially in revision surgery, in cases where autologous cartilage is required and when a meatoplasty is needed.
Methods: 50 patients (mean age 39.6, 22 males, 28 females) affected by chronic otitis media (with or without cholesteatoma) which involved eardrum, lateral attic wall and antrum  underwent surgery by this approach.18 were primary cases. Ossicular reconstruction was performed in 25 patients. Follow-up ranged from 1-15 months. An anteriorly-convex skin incision was performed in the posterior aspect of the pinna, over the conchal cartilage. In 38 patients a composite perichondrium-conchal cartilage graft was easily harvested,  the amount depending on reconstructive needs. After removal of the pathology, tissues obtained (temporalis fascia, perichondrium, cartilage or composite graft) were available  for reconstruction of: 1)  eardrum; 2) scutum-attic 3) open cavity.
Results: anatomical results of reconstruction were considered in relation to traditional ear surgery approaches. 5 patients presented minor complication as post-auricolar aedema, pain, immediate pinna asymmetry. No major complications were observed.
Discussion/conclusion: the advantages of this technique consist in a direct approach to conchal cartilage,  giving possibility for an easy, fast and large amount of cartilage tissue to be harvested. Furthermore, the conchal excision permitted to perform an effective meatoplasty.
We consider this approach feasible in alternative to endaural and retro-auricular ones, expecially for the facility of harvesting cartilage when reconstructive  purposes are needed.

Management of Hearing in the Irradiated Ears
Michael Tong (Hong Kong, China)