RU2707835C1 - METHOD FOR CONDUCTING AN ELECTRODE ARRAY OF A COCHLEAR IMPLANT INTO A SCALA TYMPANI WITH OSSIFICATION OF THE MAIN COCHLEA OF MORE THAN 5 mm - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to otorhinolaryngology, and can be used in surgical management of patients with IV sensorineural hearing loss and deafness, in which labyrinth ossification is detected. Posterior tympanostoma is formed, through which access to the drum cavity structures is performed. Metaplastic new bone is removed before turning on the second curl. Cochleostoma is then formed in the medial wall of the barrel in the promontory to the second curl of the cochlea. Under the control of the surgical microscope, the electrode array of the cochlear implant is introduced through the cochleostoma into the lumen of the second cochlear curl with the direction of the electrode towards the apical curl. Microbore is reamed by a bone partition between a basal and a second coil of the cochlea in the form of a groove, and the remaining segment of the proximal portion of the electrode array is laid through the formed groove into a basal spiral.

EFFECT: method makes it possible to locate the electrode array of the cochlear implant completely in the cochlear passage, which enables performing the audio-verbal rehabilitation in the given category of patients.

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Description

Technical field

The invention relates to medicine, in particular to otorhinolaryngology and may find application in the surgical treatment of patients with a high degree of sensory-hearing loss with ossification of the cochlear canal after suffering meningitis.

State of the art

The treatment of sensorineural hearing loss (SNT) is one of the most pressing problems of otorhinolaryngology and is constantly in the center of attention of leading domestic and foreign researchers. The difficulty in providing effective assistance to people with pathology of the sound-sensing apparatus is due to the fact that the disease is caused by various etiological factors, it is difficult to treat, often progressing, leading to irreversible hearing changes.

Over the past two decades, there has been a significant increase in the overall prevalence of hearing loss due to an increase in patients of young and working age. According to statistical studies, the total number of deaf and hard of hearing people remains stably high. [Gappoeva E.T., 2004]

Sensoneural hearing loss is a polyetiological disease, the main subjective and objective manifestation of which is a violation of speech intelligibility and increased tonal thresholds for bone sound conduction at sound frequencies, mainly above 1-2 kHz during audiological examination. [Shidlovskaya T.V., 2007].

A significant role in the pathogenesis of sensorineural hearing loss is played by changes in hemodynamics and microhemocirculation of the inner ear [Romanov VA, 1981], biochemical disturbances, including lipid metabolism, and the activity of the antioxidant system [Palchun VT, Kunelskaya NL, 1987 ]. It is based on the individual predisposition of the organic and functional structures of the auditory receptor and analyzer to the damaging effects of endogenous and exogenous factors.

The auditory analyzer is more complex in its organization and is phylogenetically younger in comparison with other analyzers, and, therefore, has less stability and resistance. Cardiovascular diseases, congenital pathology, immunological dysfunction, hormonal and metabolic disorders, infections, environmental factors, ototoxic drugs, industrial emissions can be predisposing factors in the occurrence of this pathology [B. Sagalovich, 1968; 1978; 1988; Soldatov I.B., 1978; Tokarev O.P., 1992; 1998; Hrappo N.S., 1999; Starokha A.V., 2004;].

Numerous modern treatment options for SNT are intravenous administration of drugs: perfluoran, tompaslin, ginkgo biloba, probucol, bemethyl, phenibut, taufon, glycine, etc .; insertion into the inner ear by stem cell implantation; the introduction of glial cell mass neutrophilic factor (GDNF)), in addition to conventional vasotropic, hormonal therapy, as well as physiotherapeutic methods of treatment, do not give the desired positive effect. Drug therapy of sensorineural hearing loss is ineffective because of the difficulty of penetration of drugs through the blood-labyrinth barrier and the inability to affect all etiological factors and pathogenetic links of this disease. Clinical observations have shown that to achieve positive results is possible only with treatment in the acute period. In all other cases, the task of ENT specialists is to prevent further hearing loss, to reduce the intensity of tinnitus, and to stabilize auditory function.

From the beginning of the 50s of the twentieth century, hearing-improving operations began to develop actively, which mainly concerned only the pathology of the middle ear. The development of new medical technologies, equipment, and the improvement of surgical micro-instruments, as well as the accumulation of new knowledge about the normal and pathological physiology of the inner ear, finally allowed us to start surgery on the structures of the maze. A real breakthrough was the introduction of cochlear implantation for electroacoustic correction of high-grade sensorineural hearing loss (grade IV and deafness), in which, after performing a typical anthromastoidotomy with posterior tympanotomy, through the membrane of the cochlea (or through the cochleostomy of the main cochlear curl), the cochlear ladder is inserted implant. Over the past decade, this type of surgical treatment has become widespread throughout the world. This type of surgical treatment due to the introduction of the electrode array into the tympanic ladder leads to a complete loss of “residual” hearing, that is, deafness, and therefore can be used in patients only with deafness or sensorineural hearing loss of the fourth degree.

Based on the foregoing, it should be noted that the issue of rehabilitation of patients with sensorineural hearing loss IV and deafness is generally resolved, the nuances remain controversial and not resolved, one of which is the problem of rehabilitation of patients with hearing loss, for example, after suffering meningitis due to ossification of the main cochlear curl , in various pathological conditions, new unorganized bone tissue replaces healthy or obliterates the space inside the bone labyrinth.

Ossifying labyrinthitis (OL) is the process of the formation of new bone tissue in the lumen of the bone labyrinth, leading to impaired auditory and vestibular function, which causes known difficulties in introducing the electrode array of the cochlear implant.

Significant studies on this topic are practically absent in the domestic literature, and in foreign sources there are mainly descriptive works or attempts to systematize ossification by individual features.

Studies of the pathophysiological mechanisms of hearing loss after meningitis suggest the spread of infection into the inner ear through the cochlear water pipe or the internal auditory canal. Such a path was suggested in 1991 by S. Bhatt et al., Conducting animal studies. The connection of the cochlear's aqueduct with the tympanic staircase near the cochlear window and the initial maximum concentration of inflammatory mediators in this area may explain the greater degree of damage to the basal curl. Another predisposing factor for the disproportionate ossification of the tympanic ladder in the main curl, regardless of the etiology, may be the relatively “poor” blood supply to this area. At the same time, there is isolated ossification of the middle and apical scrolls of the cochlea, as well as total ossification of the latter. The process of ossification can begin in a horizontal semicircular canal, subsequently extending to all departments of the inner ear. The infection spreads to the labyrinth in 3 ways: hematogenous, tympanogenic (through the membrane of the cochlea window) and meningogenic (through the subarachnoid space with meningitis). J. D. Scwartz et al. (1985) additionally isolate the metabolic (otosclerosis, Paget's disease) and traumatic mechanisms of the occurrence of ossifying labyrinthitis (OL), and also consider the internal auditory canal and the additional water supply of the cochlea during meningogenic spread of the infection. M.M. Based on studies conducted on humans and laboratory animals, Paparella and S. Sugiura divided the development of OL due to purulent labyrinthitis into three stages: acute, fibrous, and ossification. The acute stage is characterized by purulent inflammation and the formation of serous-fibrinous exudate mainly in the perilymphatic space, without affecting the cavity filled with endolymph. The second stage, fibrous, involves the proliferation of fibroblasts in the perilymphatic spaces and begins about 2 weeks after the onset of the infection process. At the same time, angiogenesis is observed. The ossification stage is characterized by the formation of bone tissue, which is primarily found in the basal curl, starting, according to the authors, from the second month after the development of labyrinthitis. The formation of bone tissue with subsequent calcification and remodeling obliterates both the peri and endolymphatic spaces. It is believed that ossification of the labyrinth in humans can occur during the first year after suffering meningitis or a fracture of the temporal bone pyramid with a fracture line through the cochlear curls, although hearing loss can occur within 48 hours from the onset of the disease.

Bilateral ossification is more often unilateral, pathological changes in the initial (descending) section of the basal curl prevail. There is ossification, for example, of the initial section of the basal curl in combination with the apical, or basal curl in combination with semicircular canals.

The works related to the surgical technique of cochlear implantation (CI) during ossification of the cochlea are mainly devoted to individual cases of surgical interventions after meningitis, without signs of systematization. According to medical literature from countries involved in cochlear implantation, most patients with ossification of the basal curl of the cochlea are denied surgery, citing the inability to install the electrode array in the tympanic ladder. Only in the last decade, there have been some studies demonstrating the possibility of installing an electrode array through the basal curl, while a channel was drilled in it, provided that the ossification site was less than 5 mm (V. Kuzovkov et al., Surgical tactics during cochlear implantation at patients with ossification of the cochlea, Russian Otorhinolaryngology No. 1 (86) 2017, pp. 53-59).

Ossification of the basal cochlea of the cochlea during the transition of the lesion site from the descending to the ascending segment fundamentally changes the tactics of intervention during CI. The distance to the “turn” - the place of transition of the descending segment of the main curl to the ascending one, which is practically inaccessible for drilling during the operation in the presence of obliteration, is 8 ± 0.6 mm. If, according to CT data, the temporal bones of the ossification of the cochlear ossification of the cochlea are found to be up to 5 mm, the normal course of surgery is assumed. The large length of the obliteration site, more than 5 mm, suggests a different operation volume, which will allow introducing and laying the electrode grating of the cochlear implant in such a way that the latter has contact for as long as possible with cochlear neurons, while trying to preserve the helical plate as much as possible. So, we know the method we took for the prototype, the installation of cochlear implants with two electrode arrays, one of which should be installed in the drilled basal curl, the other through an additional cochleostomy - in the second (Clinical recommendations: “Preoperative examination and surgical treatment of patients with sensorineural hearing loss IV degrees and deafness ”, compiled by MD, Prof. NA Daihes et al., Moscow 2015). The disadvantages of this system are its significantly higher cost in comparison with standard CI systems, the impossibility of its rapid use during operations (such systems should usually be ordered in advance), if the otosurgeon understands during the operation that a standard electrode cannot be drawn through the ossified basal curl .

Based on the foregoing, a promising direction is the development of optimal surgical access to the cochlear curls, which allows them to control the location of the inserted electrode array of the cochlear implant.

The purpose of the present invention is as follows: based on the accumulated knowledge of normal and pathological microanatomy and physiology of the inner ear, to develop a method for introducing the cochlear implant electrode array into the cochlear curls during ossification of the cochlear cochlear curl length of more than 5 mm in surgical treatment of patients with grade IV sensorineural hearing loss with ossification snail basal curl with the least trauma to the structures of the inner ear.

To achieve this goal, we propose a method for introducing an electrode lattice of a cochlear implant into the tympanic ladder during ossification of the main cochlear curl of more than 5 mm, which consists in the following: under general anesthesia behind the ear, an anthromastoidotomy is performed with thinning of the posterior wall of the external auditory meatus, with visualization of the main anatomical landmarks: anthrum , a short appendix of the anvil, a horizontal semicircular canal, then retreating posteriorly from the short appendix of the anvil by 2 mm in the projection of the facial pockets in the direction of the tympanic cavity, drill the posterior tympanostomy through which access to the structures of the tympanic cavity is carried out, remove the bone canopy above the cochlea window with a diamond bur, dissect the secondary membrane with a microneedle, and then visualize the channel of the main cochlear curl, from which the metaplastic sections are removed the newly formed bone before turning on the second curl, then the tympanostomy is expanded upward, without injuring the tympanic string and facial nerve, the bones of the distal part of the external auditory meatus, in the medial wall of the tympanic cavity, in the promontrium, caudally from the vestibule and 2 mm anteriorly from the vestibule, drill a cochleostomy to the second curl of the cochlea and insert a cochleostomy electrode grid through the cochleostomy implant into the lumen of the second cochlear curl with the electrode directed to the apical curlicue, drill a bony septum between the basal and second cochlear curls in the form of BSA, the size of the groove should correspond to the size of the electrode array, and the remaining segment of the proximal part of the electrode array is placed over the groove formed in the basal curl, whereupon sealing snail fragments connective autotkani patient postoperative wound sutured by layers.

The technical result of the claimed invention is to reduce the trauma of the structures of the inner ear and the ability to achieve the location of the electrode lattice of the cochlear implant completely in the cochlear channel by creating additional access to the cochlear channel through the second curl by applying a cochleostomy in the medial wall of the tympanic cavity so that the electrode grating is inserted into it the second and apical curl, and the remaining proximal portion of the electrode array is laid through the groove into the bone to the septum between the basal and second cochlear scrolls into the drilled basal curl (thus bypassing the section of ossification of the cochlear basal curl "inaccessible" for drilling), thereby the electrode is located completely in the inner ear, which helps to stimulate the maximum number of cells of the spiral ganglion, which gives the ability to conduct auditory rehabilitation in this category of patients.

The method is illustrated by the following figures:

Figure 1, where 1 is a line drawn through the upper edge of the window of the cochlea and processus cochleoriformis; 2 - window of the cochlea after removal of the secondary membrane; 3 - cochleostomy in the projection of the second curl of the cochlea; 4 - processus cochleoriformis; 5 - front pole of the vestibule window.

Figure 2 - removal of the bone canopy over the window of the cochlea.

Figure 3 - partial bone removal of the distal ear canal.

Figure 4 - the electrode lattice of the cochlear implant is inserted through the second cochleostomy into the lumen of the second cochlear curl with the direction of the electrode to the apical curl.

Figure 5 - reaming of the bony septum between the basal and second scrolls of the cochlea in the form of a groove.

Figure 6 - the proximal part of the electrode array is laid through the groove in the basal curl.

Figure 7 - sealing of the cochlea with fragments of the patient’s connective tissue.

Figure 8, 9 - CT control the location of the electrode array.

The method is as follows.

Anthromastoidotomy with thinning of the posterior wall of the external auditory meatus, with visualization of the main anatomical landmarks: anthrum, a short appendix of the anvil, and a horizontal semicircular canal, is performed under general anesthesia behind the ear. Retreating 2 mm posteriorly from the short process of the anvil in the projection of the front pocket towards the tympanum, the posterior tympanostomy is drilled through which access to the structures of the tympanic cavity is made. A bone canopy over the cochlear window is removed with a diamond bur (Figure 2), for a good overview of the secondary membrane. The microneedle dissects the secondary membrane, after which the channel of the main scroll of the cochlea is visualized. When data for ossification are revealed (in the preoperative period, according to CT data, the ossification site is more than 5 mm) of the main scroll of the cochlea, sections of the metaplastic newly formed bone are removed from the lumen of the latter before turning to the second curl within the visual control. Then, the tympanostomy is expanded upward (without going beyond and not injuring the tympanic cord in front, posterior - the facial nerve) with the removal of the anvil and partial removal of the bone of the distal part of the external auditory meatus (for obvious reasons for a good view) (figure 3). In the medial wall of the tympanum, in the promontorium, a second cochleostomy is drilled. The cochleostomy to the second curl is superimposed caudally from the place of attachment of the tendon of the muscle that stretches the eardrum (processus cohlearormis) and 2 mm anterior to the vestibule window (Figure 1). The cochlear implant is typically located subperiosteally under the temporal muscle. Under the control of an operating microscope, the cochlear implant electrode array is inserted through the second cochleostomy into the lumen of the second cochlear curl with the electrode directed toward the apical curl (figure 4). A microbore drills a bone septum between the basal and second scrolls of the cochlea in the form of a groove so as not to damage the modiolus and spiral plate, and the size of the groove should correspond to the size of the electrode grating (figure 5). The remaining segment of the proximal part of the electrode array is laid through the groove in the basal curl in the form of a loop (figure 6), thereby the electrode is located completely in the inner ear, which helps to stimulate the maximum number of spiral ganglion cells.

After the electrode lattice is completely laid in the channels of the cochlea according to the above method, the cochlea is sealed (the cochlea window and the second cochleostomy) with fragments of the patient’s connective tissue (figure 7). Then, standard measures of intraoperative testing of the implant are carried out (determination of electrode resistance, telemetry and registration of an electrically induced stapedial reflex). The postoperative wound is sutured in layers. In the postoperative period, patients undergo standard anti-inflammatory antibiotic therapy, intramuscular administration of analgesics. Be sure to perform CT control of the location of the electrode array (figure 8 and 9).

The implementation of the invention.

Clinical example 1. Patient P., born in 1993, was hospitalized for surgical treatment in the Department of Ear Diseases of the Federal State Budgetary Institution NCCO FMBA of Russia.

Diagnosis at admission: Chronic bilateral sensorineural hearing loss, IV degree. Condition after suffering meningitis 11 years ago. Bilateral ossification of cochlear canals.

Complaints on admission: Lack of hearing in both ears.

Anamnesis morbi: hearing began to decline from 2.5 years after suffering meningitis at the age of one and a half years. It was observed in Nizhny Novgorod by an audiologist, hearing aid. Conservative vascular therapy was performed. Hearing aids have recently begun to help poorly. An extended audiological examination at the FSBI NCCO FMBA of Russia revealed sensorineural deafness. Due to the ineffectiveness of conservative therapy and hearing replacement surgery, he is directed to surgical treatment at the FSBI NCCO FMBA of Russia.

Anamnesis vitae: normal growth and development. Satisfactory nutrition. Normostenic physique. Living conditions are satisfactory.

From chronic diseases: Chronic urethritis. Nephrolithiasis

Of the diseases: SARS, colds, meningitis 11 years ago.

Taking medications: not taking.

Injuries and operations: was not

Botkin's disease (viral hepatitis A); viral hepatitis B and C; HIV infection, sexually transmitted diseases, tuberculosis - denies. Bad habits: denies

Condition at admission: satisfactory. The skin of normal color, clean. In the lungs, harsh breathing, no wheezing. Heart sounds are sonorous, the rhythm is correct, systolic murmur is heard. HELL 110/70 mm. Hg, heart rate = Ps = 76 per min. The stomach is soft. Local pain on palpation was not detected. The chair is normal, regular. From the genitourinary system, pathology was not detected. There are no dysuric disorders. The symptom of striking is negative. Urination is free, painless. From the side of the nervous system, pathology was not detected. Consciousness is clear. There are no meningeal symptoms. FMN: without pathology. From the musculoskeletal system, pathology was not detected. Movement in all joints without restrictions. Vestibular function: gait in a straight line is normal, in the Rumberg position is stable. Finger-nasal and finger-pointing test performs without overshooting. The test for adiadhokinesis is negative. Spontaneous nystagmus is absent. The fistula test is negative. LOR-status:

Nose: the shape of the external nose is not changed, there is no infiltration of the soft tissues of the nose, its palpation is painless. With rhinoscopy: the nasal mucosa is pale pink. The nasal passages are wide, free. There is no pathological discharge in the nasal passages. The lower and middle nasal concha are not changed. Their mucous membrane is pale pink. The nasal septum is slightly curved without impaired nasal breathing. The area of the sinuses is not changed, percussion and palpation of the projection of the SNP is painless. Nasal breathing is not impaired. Oropharynx: the mucous membrane of the oral cavity is not changed. Dental maxillary system without features. The teeth are sanitized. The language is clean. Palatine-lingual and palatine-pharyngeal arches are not changed, normal color, without infiltration. The pharynx is symmetrical. Tonsils protrude slightly beyond the edges of the arches, their mucosa is not changed. There is no pathological discharge in the gaps. No raids. The back wall of the pharynx is pink, moist, single lymphoid follicles are determined. Swallowing is painless.

Larynxopharynx: free breathing. With laryngoscopy, the entrance to the larynx is free. Epiglottis in the form of a petal, not changed, mobile. The mucous membrane of the visible lingual surface is not changed. The scoop-epiglottis, vestibular vestibular folds, as well as the area of the arytenoid cartilage and intercarpal notch are not changed. The vocal folds are gray, shiny. When phonation is symmetrically moving. The lumen of the larynx is wide. The voice during phonation is sonorous. The pear-shaped sinus region is not changed. The area of entry into the esophagus is not changed, without raids. The ligament of the larynx is not changed, the visible mucosa of the upper trachea is not changed.

Ears: AD - the auricle is not changed. The area of the mastoid process is not changed. Percussion and palpation are painless. The auditory meatus for otoscopy is wide. There is no pathological discharge in the lumen of the auditory meatus. With otomicroscopy: The eardrum is gray, shiny. Light reflex is positive. Identification marks are clearly expressed. The stretched part is not changed. The relaxed part is not changed. The mobility of the membrane during the Toynbee and Valsalva test is not disturbed. AS - the auricle is not changed. The area of the mastoid process is not changed. Percussion and palpation are painless. The auditory meatus for otoscopy is wide. There is no pathological discharge in the lumen of the auditory meatus. With otomicroscopy: The eardrum is gray, shiny. Light reflex is positive. Identification marks are clearly expressed. The stretched part is not changed. The relaxed part is not changed. The mobility of the membrane during the Toynbee and Valsalva test is not disturbed.

Conducted preoperative examination:

SKT of the temporal bones - no bone-destructive changes in the temporal bones were detected. Ossification of snail curls, more pronounced on the right.

MRI of the temporal bones - MP signs of ossification of the cochlea.

Audiometry is a bilateral sensorineural hearing loss of the fourth degree.

The conclusion of the audiologist is bilateral sensorineural hearing loss of the fourth degree. Consultation of a sound educator is recommended, cochlear implantation on the left in the absence of contraindications.

Tympanometry - Type A on both sides

Reflexometry - reflexes are not recorded

Conclusion of an audio teacher - the prospects for using a cochlear implant system are low.

The conclusion of the neurologist - at the time of examination of neurological symptoms there.

Dentist's opinion - the oral cavity is sanitized

Ultrasound of the kidneys - multiple echo inclusions in the projection of hls (sand). Echoes are signs of diffuse changes in the renal parenchyma.

The conclusion of the urologist is urethritis, unstable remission. There are no contraindications for surgical treatment.

Therapist's conclusion - Diagnosis: nephrolithiasis on both sides. There are no absolute contraindications for surgical treatment.

Laboratory research data:

HCV, HBs, HIV, RW (01/25/16) - negative.

General analysis of blood and urine (01/25/16) - within normal limits.

Coagulogram (01/25/16) - within normal limits.

A biochemical blood test (01/25/16) is within normal limits.

ECG (01/25/16) - without features.

Rg organs of the chest (01/25/16) - no pathology from the chest

The treatment carried out in accordance with the standards of inpatient care:

(Code of the standard 068.060. Code according to MKD-10 N90.3)

Surgical treatment: cochlear implantation on the left ear in accordance with the claimed method.

After treating the surgical field with an alcoholic skin antiseptic under ETN, behind the left ear, 0.5 cm from the behind the ear fold with a scalpel, an arcuate incision of the skin and subcutaneous tissue was made. Along with the first incision, an incision was made in the soft tissues and periosteum. Soft tissue with periosteum laid aside with a raspator. The site of the mastoid process within the Shipo triangle is exposed. The periosteum with soft tissues is separated from the bones of the skull behind the ear region with the formation of a bed for the implant. A mastectomy was performed with a large cutting boron within the anterior border of the sigmoid sinus and sino-dural angle; tegmen mastoidei, tegmen antri were visualized within the linea temporalis, smoothed with a diamond boron; visualized horizontal semicircular canal; visualized short process of the anvil. With a diamond bur in the projection of the front pocket, the posterior tympanostomy is made, the bone edges of the tympanostomy are smoothed. The window of the cochlea, the anvil-stirrup joint, the pyramidal process with the tendon of the stirrup muscle, and the promontorium were visualized. The mucous membrane of the tympanum without inflammation. Diamond canopy 1.0 and 1.4 removed the canopy above the cochlea window, the secondary membrane of the cochlea window is ossified. After opening the window of the cochlea, a complete ossification of the main cochlear curl was found. The distal calving of the posterior wall of the external auditory meatus has been partially removed, the anvil has been removed, and the suprastructure of the stapes has been removed. Drilled cochleostomy in the projection of the second curl of the cochlea caudally from the place of attachment of the tendon of the muscle, stretching the eardrum (processus cohleaformis) and 2 mm anterior to the vestibule window. The cochlear implant is typically located subperiosteally under the temporal muscle. Under the control of an operating microscope, the cochlear implant electrode array is inserted through the second cochleostomy into the lumen of the second cochlear curl with the electrode directed toward the apical curl. A bony septum between the basal and second scrolls of the cochlea in the form of a groove is drilled with a microboron, preserving the modiolus and spiral plate. The remaining segment of the proximal part of the electrode array is laid through the groove in the basal curl in the form of a loop, thereby the electrode is located completely in the inner ear. The cochlea was sealed with autotissues (autosensor). An intraoperative audiological testing of the implant was carried out: telemetry within normal limits. Produced layer-by-layer suturing of the postoperative wound. Stitches are applied to the skin.

The postoperative period without features. Received anti-inflammatory therapy, analgesics: Ceftriaxone 1000 mg once a day IM; Ketonal 2.0 ml IM for pain. Daily dressings were performed: treatment of the postoperative wound with alcohol antiseptics and a solution of Diamond greens, aseptic dressings. Postoperative sutures were removed on the 7th day.

CT data of the temporal bones after surgery - Condition after cochlear implantation on the left ear. Bilateral ossification of the maze. Description: Condition after cochlear implant surgery on the left ear with implant placement. Intracochlear implant placement was achieved through the cochleostomy of the main scroll of the cochlea. The implant differentiates without significant artifacts at the level of the basal and second scroll of the cochlea, occupies a lateral position, located on the lower-lateral wall. The integrity of the cortical plate of the mastoid process for 30.7 mm is broken, a mastoid cavity with a total size of 22 × 21 × 19 mm is formed, the lumen of which is filled with a visually soft tissue density substrate. Pneumatization of the cells of the mastoid process is reduced due to the partial filling of their lumen with a pathological component.

A partial mechanical block is noted in the area of the bony part of the auditory tube. The pneumatization of the tympanic cavity is violated due to the total filling of its lumen with an inhomogeneous component with the presence of air bubbles, against which the elements of the malleus are differentiated.

Condition at discharge: Satisfactory. Consciousness is clear. Neurological symptoms are absent. T - 36.7. From the internal organs without negative dynamics. All physiological settings are normal.

Nasal breathing is free. The nasal mucosa is pale pink, moist. Nasal septum in the midline. There are no pathological discharge in the nasal passages. The nasal passages are wide enough for free breathing. Mouth: pharynx symmetrical. The back of the pharynx is pink. Tonsils are clean. Swallowing is painless. Ears: AD - The external auditory meatus is not changed. B / p - gray, identification marks are clearly expressed. AS - postoperative wound in the behind the ear area with no signs of inflammation, epithelialized, the skin over the implant is not changed. On palpation, there is no subperiostal hematoma. The implant is in place. The skin of the external auditory meatus is not changed. The eardrum is gray, the contours are clear, with the Toynbee and Valsalva samples moving.

Clinical diagnosis at discharge: Chronic bilateral sensorineural hearing loss, grade IV. Condition after suffering meningitis. Bilateral ossification of cochlear canals. Condition after cochlear implantation on the left ear.

Discharged in a satisfactory for further outpatient observation by an otorhinolaryngologist, audiologist and audiologist at the place of residence.

This method of surgical treatment of sensorineural hearing loss of the fourth degree with ossification of the cochlea is used in clinical practice in the scientific and clinical department of ear diseases of the FSBI NCCO FMBA of Russia. From April 2015 to September 2017, using this technique, 17 patients with confirmed chronic sensorineural hearing loss of the fourth degree with ossification of the cochlea after suffering meningitis were operated on. At the preoperative stage, all patients underwent an extended audiological examination, CT and MRI diagnostics of the temporal bones. After confirming the diagnosis, surgical treatment was performed - cochlear implantation. In the postoperative period, standard anti-inflammatory antibiotic therapy was performed. CT data of the temporal bones after surgery showed the location of the implanted electrode array completely in the inner ear. 1 month after the surgical treatment, the patients were referred for the subsequent auditory-speech rehabilitation to the scientific and clinical department of audiology and hearing replacement. In the near and distant postoperative period, complications were not observed.

Claims (1)

The method of introducing the electrode grating of the cochlear implant into the tympanic ladder during the ossification of the main cochlear curl of more than 5 mm, which consists in the following: anthromastoidotomy is performed under the anesthesia with the posterior approach with thinning of the posterior wall of the external auditory meatus, with visualization of the main anatomical landmarks: the anthrum, the short process of the anvil a semicircular canal, then retreating posteriorly from the short process of the anvil by 2 mm in the projection of the front pocket towards the tympanum, A posterior tympanostomy is drilled through which access to the structures of the tympanic cavity is carried out, a bone canopy over the cochlea window is removed with a diamond bur, a secondary membrane is cut with a microneedle, and then the channel of the main cochlear curl is visualized, from which the sections of the metaplastic neoplastic bone are removed before turning to the second curl then expand the tympanostomy up, without injuring the drum string and facial nerve, remove the anvil and partially the bones of the distal section and the external auditory meatus, in the medial wall of the tympanum, in the promontorium, caudally from the place of attachment of the tendon of the muscle stretching the eardrum, and 2 mm anteriorly from the vestibule window drills the cochleostoma to the second curl of the cochlea, the cochlear implant electrode grating is inserted into the lumen through the cochleostoma cochlea with the direction of the electrode to the apical curl, drill a bony septum between the basal and second cochlea of the cochlea in the form of a groove, while the size of the groove should correspond Vova size of the electrode array, and the remaining segment of the proximal part of the electrode array is placed over the groove formed in the basal curl, whereupon sealing snail fragments connective autotkani patient postoperative wound sutured by layers.

Images