Cochlear implantation in obstructed cochleas: the effect of the degree of obstruction on the number of activated electrodes and the amount of postoperative speech perception.

OBJECTIVE: With cochlear implantation, insertion of the electrodes can be hampered by cochlear obstructions. The aim of this study was to investigate the effects of these obstructions on the number of activated electrodes and postoperative speech perception. STUDY DESIGN AND SETTING: Retrospective analysis of the operation reports and CT-scans of patients who underwent cochlear implantation, at the Department of Otorhinolaryngology of the University Medical Center of Utrecht (n = 295). PATIENTS AND INTERVENTIONS: Fifty patients with a certain degree of cochlear obstruction were included. Based on the surgical intervention to overcome these obstructions they were subdivided into first-, second- and third degree obstructions. The number of implanted and activated electrodes was determined. MAIN OUTCOME MEASURES: Three different speech perception tests after 12 months of cochlear implant use. RESULTS: The number of activated electrodes significantly diminished with increasing obstruction degree (P < 0.01). This was caused by a lower amount of implanted electrodes combined with a higher amount of switched off electrodes. With a higher degree of obstruction the amount of postoperative speech perception decreased significantly (P < 0.01). This is partly explained by the lower number of activated electrodes and partly explained by the fact that a higher obstructions degree correlates with a higher degree of (retro-) cochlear pathology. Significantly more electrodes can be inserted into the severely obstructed cochlea using a Double Array Cochlear Implant. CONCLUSION: Cochlear obstructions pose a surgical threat and negatively influence the postoperative speech perception results. Fortunately, due to surgical techniques, first and second degree obstructed cochleas can often be bypassed. Implanting of a Double Array implant brightens the prospects of patients with third (severe) degree obstructed cochleas.

Sensory cell damage in two-phase endolymphatic hydrops: a morphologic evaluation of a new experimental model by low-voltage scanning techniques.

HYPOTHESIS: The aim of this study was to create a more dynamic animal model of Ménière's disease combining multiple causes, such as the role of endocrine factors and endolymphatic sac dysfunction, that may mimic the fluctuant characteristics of Ménière's disease. BACKGROUND: Endolymphatic hydrops remains to be considered a pathologic substrate in the etiology of Ménière's disease. The classic guinea pig model of inducing hydrops by total destruction of the endolymphatic sac is a nonphysiologic rigid model of Ménière's disease. METHODS: The authors developed the two-phase endolymphatic hydrops model by inducing hydrops by mild chronic endolymphatic sac dysfunction, in combination with increased endolymph production by aldosterone. Sensory cell damage was evaluated by low-voltage field emission scanning microscopy. RESULTS: This study describes a wide spectrum of morphologic effects of the outer hair cells in radial gradients, in which most effects were observed in the third to second row of outer hair cells, and longitudinal gradients in which the most severe effects were observed in the apical turns. Most affected were the ears that underwent distal endolymphatic sac dissection followed by the administration of aldosterone. Damaging effects proceeded from degeneration and absence of short stereocilia of outer hair cells and even some inner hair cells in the apical turns, to stereociliary disarrangement and atrophy, followed by degeneration and absence of outer hair cells, which were replaced by supporting cells. CONCLUSION: The two-phase endolymphatic hydrops model seems to represent a functional model that may mimic the fluctuant characteristics of Ménière's disease and emphasizes the influence of multiple and coexisting hydrops-inducing influences.

Ultrastructure of the endolymphatic sac in two-phase endolymphatic hydrops in the guinea pig.

Two-phase endolymphatic hydrops is a subtle experimental model for Meniere's disease. Chronic dysfunction of the endolymphatic sac, induced by dissection of the most distal part without causing damage to the intermediate part, is combined with increased endolymph production induced by administration of aldosterone which stimulates the N/K-ATPase in the stria vascularis. A transmission electron microscopic study was performed on the endolymphatic sacs of four groups of guinea pig cochleas: controls: non-operated aldosterone-treated cochleas; operated (dissection of the endolymphatic sac) cochleas; operated and aldosterone-treated cochleas. Light and electron microscopy showed a normal morphology in the controls. Aldosterone treatment had no visible effect. Dissected ears revealed severe deviations. The epithelium of the intermediate sac was low, showed dilated lateral intercellular spaces indicating elevated fluid transport and displayed serious degenerative processes. Distally, the endolymphatic sac was completely blocked by newly formed bone. Additional aldosterone treatment had no cumulative effect on the dissected ears.

Two-phase endolymphatic hydrops: a new dynamic guinea pig model.

The classical guinea pig model for Meniere's disease, in which endolymphatic hydrops was achieved by destruction of the endolymphatic sac and obliteration of the endolymphatic duct, is a non-physiological profound model with shortcomings in relation to Meniere's disease as seen in patients. We developed a more subtle animal model; the two-phase endolymphatic hydrops. This model is based on a combination of chronic endolymphatic sac dysfunction, induced by slight destruction of the most distal part of the endolymphatic sac, and acute stress-induced endolymph production by stimulation of the Na/K-ATPase in the stria vascularis with aldosterone. Light microscopy of the fluid compartments of four groups of cochleas was used to examine them for the presence of endolymphatic hydrops: i) Normal (control) cochleas showed no hydrops; ii) some of the non-operated (no destruction) aldosterone-treated cochleas showed small degrees of hydrops mainly present in the basal turns; iii) mild dissection of the endolymphatic sac without administration of aldosterone produced a hydrops which was mainly present in the cochlear apex; iv) combination of chronic endolymphatic sac dysfunction and acute attacks of endolymph production by aldosterone administration revealed the most severe degrees of hydrops in all cochlear windings, damage to cochlear structures, and cellular disturbances of the epithelial lining of the endolymphatic sac. This new model may represent a more physiologic and dynamic approach to Meniere's disease and may explain the etiology of many symptoms in patients such as the fluctuant nature and the types of sensoneuronal hearing losses.

Endolymphatic hydrops after total dissection or cauterization of the distal portion of the endolymphatic sac.

In this study, a more subtle animal model of Menière's disease is investigated by damaging the distal portion of the endolymphatic sac by dissection or cauterization to produce mild dysfunction of endolymphatic outflow. Cauterization resulted in low degrees of hydrops without any correlation with the inflicted damage. Total dissection of the distal portion of the sac adjacent to the sigmoid sinus produced moderate to severe endolymphatic hydrops with interanimal variation. The consequences of these relatively severe effects, in relation to the mild damage of the endolymphatic sac, and the influence on damaged and undamaged parts of the endolymphatic sac will be discussed.

Demonstration of the fine structure of stereocilia in the organ of Corti of the guinea pig by field emission scanning electron microscopy.

A combined perfusion- and immersion prefixation with glutaraldehyde followed by a tannic acid/arginine/osmium tetroxide (TAO) treatment of the guinea pig cochlea is described for field-emission gun scanning electron microscopy (FEG-SEM) observation of the fine structure of the stereocilia of the organ of Corti. Conventional osmium tetroxide postfixation methods in combination with a thin conductive coating failed to show the fine structure of the glycocalyx of the epithelial lining in the endolymphatic compartment of the cochlea, in particular, on the stereocilia surface. The antennulae-like glycocalyx covering of the stereocilia surface of the more pronounced rows of outer hair cells has been demonstrated only in ultrathin sections by means of cationic markers. The side- and tip-links connecting the stereocilia have been demonstrated both in scanning and transmission electron microscopy, although at that time these structures often were considered as artificial. However, they can be visualized with FEG-SEM at low accelerating voltage (2-3 kV), and at appropriate working distance and probe current, in combination with a glutaraldehyde perfusion/immersion prefixation and TAO postfixation. Stereo images enhance considerably the three-dimensional appreciation of the stereocilia with glycocalyx lining and side- and tip-links, proving that these connections are a structural part of the hair cell.

Low-voltage field-emission scanning electron microscopy of non-coated guinea-pig hair cell stereocilia.

The stereociliar structures of the guinea-pig cochlear organ of Corti were studied at low-voltage (1-5 kV) with field-emission scanning electron microscope (SEM) using various pre- and post-fixation methods, such as OTOTO (OsO4/thiocrbohydrazide/OsO4/thiocarbohydrazide/OsO4) and TAO (tannic acid/arginine/OsO4), and different dissection procedures of the cochlea. A perfusion and immersion pre-fixation with glutaraldehyde, in combination with removal of the bony wall and stria vascularis from the cochlea, followed by the TAO non-coating treatment gave the best result at 2 kV acceleration voltage. Due to these new technique, several interesting delicate structures of the stereocilia, in particular fine surface structures, were detected for the first time using SEM. These findings include the different types of cross-links and tip links, i.e., the fine surface morphology of the stereocilia and their attachments and imprints in the tectorial membrane (TM). One of the most interesting findings in this study is a network of long filamentous structures, which has been identified mainly at the top of the longest stereocilia and the undersurface of the TM and which may represent the glycocalyx. These findings and their possible implications in the process of mechanoelectrical transduction will be discussed.

Scleral flap sutures and the development of shallow or flat anterior chamber after trabeculectomy.

To determine whether closing the scleral flap with extra sutures can reduce the risk of overfiltration after trabeculectomy, we divided 339 trabeculectomies into three groups based on the number of scleral flap sutures used in the procedure, and studied the postoperative complications and results. The incidence of shallow or flat anterior chamber was significantly less in eyes that had received seven to nine sutures than in those that had received from two to six. Also, the incidence of cornea-lens touch was significantly less in the eyes with seven to nine sutures (P = .02, Fisher Exact Test). This study suggests that extra scleral flap sutures (in combination with laser suture lysis) is a safe and effective method of significantly reducing the risk of overfiltration after trabeculectomy.

Treatment of an alkali burn-induced symblepharon with a Megasoft Bandage Lens.

Chemical burning of the external eye by a strong acid or alkali often results in symblepharon formation despite conventional therapy. We report a case with application of a Megasoft Bandage Lens to prevent symblepharon reformation after surgical correction. Complete epithelial healing was established after 3 months, when the lens could be removed. No complications were found with this lens. No symblepharon reformation occurred < or = 6 months after the surgical reconstruction.

Physiological effects of kangaroo care in very small preterm infants.

Kangaroo care for preterm infants has great benefits for the parents and for the parent-infant bonding process. A clinical observational study was conducted in which several physiological variables were collected, including among others transcutaneous oxygen pressure, heart rate, respiratory rate, occurrence of apneic attacks, breathing pattern (studied with power spectrum analysis), behavioral states and rectal temperature, during kangaroo care in small preterm infants. Kangaroo-care did not significantly affect any of these physiological variables comparing the period of 1 h before, 1 h during and 1 h after kangaroo care. We conclude that kangaroo care is a safe method, even for very small nonstabilized preterm infants.