95. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie

Prof. Dr. med.

Chairs

NUR Wissenschaftliches Programm/ ONLY Scientific Program

Innovation in Endoscopic Ear Surgery

Invited lecture

5 Years of Robot-Based Otologic Surgery

MD, PhD

Dipl.-Inform.

Prof. Dr.

Crossing borders in Cochlear Implantation – from research to clinical application of minimally invasive drilling

Crossing Borders in Cochlear Implantation – von der Forschung bis zur klinischen Anwendung minimalinvasiver Bohrungen

Introduction: The surgical procedure of cochlear implantation remained mainly unchanged for decades. Today, robotics in otologic surgery aim for two main goals as we have summarized in [1]:1) Access to a target structure in a minimally invasive manner with high accuracy2) Assisting the insertion of electrodes. Methods: We addressed (1) in an ongoing study (MHH IRB 9030_BO_S_2020) with 11 adult patients undergoing cochlear implantation. The first six patients involved sham drill bits, as reported in [2]. In this work, we present the results (usability, accuracy and surgical workflow analysis) of the remaining five patients, involving actual drilling the access tunnel with the help of a mini-stereotactic frame and patient specific positioning jigs. Results: The facial nerve and other risk structures were preserved as planned and the trajectory was deemed suitable for electrode insertion. No post-operative study-related adverse events were reported. In two cases the surgery was reverted to the conventional approach due to technical issues with the steam sterilizer.DiscussionJig-guided access to the middle is both, feasible and safe. It is possible to integrate in the operating workflow requiring neither setting up a robotic arm, nor a navigation system. This benefit, combined with a single bone-screw fixation concept contributed to the success, showing that the required accuracy was reached in challenging clinical conditions and showcase a successful transfer of basic research into a product realization. References [1]: Lenarz et al. (2023). Robotics in Neurotology. In Robotics in Skull-Base Surgery (pp. 73-92). Springer Nature.[2]: Salcher et al. (2022). Minimally invasive cochlear implantation: first-in-man of patient-specific positioning jigs. Frontiers in NeurologyConflict-of-Interest: The authors SJ, MK and TL declare being limited partners of HörSys IP GmbH &amp; Co. KG, which holds a financial stake in OtoJig GmbH, a German company that owns and further develops the described technology. SJ, FR, MK, and JS are employed by OtoJig GmbH. MF is employed by MED-EL Deutschland GmbH.

Crossing borders in Cochlear Implantation – from research to clinical application of minimally invasive drilling

Chirurgische Assistenzverfahren / Robotik / Navigation

Sonstiges

Free lecture

The Dresden in vivo OCT data set for automatic middle ear segmentation

Dresdner in-vivo-OCT-Datensatz für die automatisierte Mittelohrsegmentierung

Introduction Endoscopic optical coherence tomography (OCT) enables a non-invasive high-resolution morphological and functional assessment of the middle ear in vivo. Yet, he interpretation of these OCT images remains challenging and time-consuming due to artifacts and shadowing effects of bony structures. Deep neural networks offer the ability to enhance this process in multiple aspects, including segmentation, classification, and registration. Nevertheless, the scarcity of annotated datasets of OCT middle ear images poses a significant hurdle to the performance of neural networks. Materials and methods We utilized a custom endoscopic OCT system with a swept source laser in the range of 1300 nm. The endoscope has a diameter of 3.5 mm. 43 OCT volume scans from both healthy and pathological middle ears of 29 subjects were included in the data set. For each sample, five anatomic structures, including tympanic membrane, malleus, incus, stapes suprastructure, and promontory, were segmented by three different segmentators. Training of the neural network (nnUnet) was done in three iterations, including pathologic samples in the second and third iteration. Technical validation was done by calculation oft he F1 scores and the Hausdorff distance. Results The data set is stored at OpARA. The F1 scores were highest fort he Tympanic membrane and lowest for the stapes suprastructure and promontory. The Hausdorff scores were highest for the Malleus. Conclusion The Dresden in vivo data set offers a data set of both healthy and pathological OCT volumes oft he middle ear. Thus, it facilitates the training and evaluation of algorithms regarding various analysis tasks with middle ear OCT images, e.g. diagnostics.Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

The Dresden in vivo OCT data set for automatic middle ear segmentation

Digitalisierung / Künstliche Intelligenz / eHealth / Telemedizin / Applikationen

PD Dr. med.

Considerations for and initial clinical results of a totally implantable Cochlear Implant. First results of a feasibility study &amp; 3 year follow up

Überlegungen für und erste klinische Ergebnisse eines vollständig implantierbaren Cochlea-Implantats. Erste Ergebnisse einer Machbarkeitsstudie mit 3 Jahren Follow Up

Cochlear implants (CI) are neuroprosthetic devices which restore hearing in severe-to-profound deafness through direct electrical stimulation of the auditory nerve. Current CIs use an external audio processor that is worn behind the ear, which houses the microphone, power source, and signal processing hardware. For users, this external device can be a source of both inconvenience and cosmetic limitations. A long-term goal in the field has been to develop a new generation of implants in which all components are contained within a single subdermal implant. We present clinical results from the one year follow up feasibility study with the totally implantable cochlear implant (TICI). The first six implantations started from September 2020 onwards in two centers. Data collected over the subsequent 52 weeks are presented. In addition own data for 3 years follow up until November 2023 from the Munich Center are shown. Implantation was carried out via the standard surgical approach, and post-surgical recovery was uncomplicated. Clinical testing showed that the TICI provides high levels of hearing performance early after first fitting, equivalent to that of a conventional CI. At the one year interval we found no difference between invisible mode and the classical CI mode. The development of the TICI advances the field of audiology and hearing implants.kein Interessenskonflikt. Die Studie wurde von MED-EL unterstützt

Considerations for and initial clinical results of a totally implantable Cochlear Implant. First results of a feasibility study &amp; 3 year follow up

Cochleaimplantat

Otologie / Neurootologie / Audiologie

Prof.

Partial ossicular reconstruction with a novel ball joint prosthesis – the mCLIP ARC partial prosthesis

Der partielle Ossikelersatz mit einer neuen Kugelgelenksprothese – die mCLIP ARC Prothese

Introduction: Middle ear surgery involves reconstruction of the ossicular chain, predominately using rigid implants. New middle ear prostheses strive to mimic the physiologic micromovements of the ossicular chain and prevent protrusion. Material and Methods: 35 patients were included in a monocentric, prospective observational study. Patients received tympanoplasty with ossicular reconstruction using the mCLIP ARC partial prosthesis. This titanium prosthesis is equipped with a clip mechanism for coupling at the stapes and a ball joint connecting headplate and shaft. At short-term (ST) and mid-term (MT) follow-up, pure-tone audiometry was performed and the pure tone average of 0.5, 1, 2, and 3 kHz (PTA4) was calculated. Results: The new prosthesis shows favorable clinical results. Pure-tone audiometry showed satisfactory results in ST and MT follow-up, with the PTA4 air-bone gap (ABG) decreasing from 24.5 (±11) dB to 17.4 (±7.9) dB at the ST follow-up at 27 days to 15.6 (±10.3) dB at MT follow-up at 196 days (n=32). A PTA4-ABG value of less than 20 dB was achieved by 63 % of patients at ST follow-up and by 77 % at MT follow-up. Conclusion: The mCLIP ARC partial prosthesis, a new middle ear prosthesis with a balanced ball joint, shows promising audiological results and is a safe and effective choice for patients with chronic ear disease.Der partielle Ossikelersatz mit einer neuen Kugelgelenksprothese - die mCLIP ARC Prothese Einleitung: Die Rekontruktion der Gehörknöchelchenkette erfolgt überwiegend durch starre Implantate. Neue Mittelohrprothesen versuchen die physiologischen Mikrobewegungen der Gehörknöchelchenkette zu imitieren und Protrusionen zu vermeiden Material und Methoden: 35 Patienten wurden in einer monozentrischen, prospektiven Studie eingeschlossen. Die Patienten erhielten eine Tympanoplastik mit Rekontruktion der Ossikelkette unter Verwendung der mCLIP ARC Prothese. Diese Titanprothese ist mit einem Clip-Mechanismus zur Kopplung am Steigbügel und einem zentrierten Kugelgelenk zur Verbindung von Kopfplatte und Schaft ausgestattet. Bei der kurzfristigen (ST) und mittelfristigen (MT) Nachuntersuchung wurde die Hörschwelle mittels Reintonaudiometrie erfasst und der pure tone average der Frequenzen 0,5, 1, 2 und 3 kHz (PTA4) berechnet. Ergebnisse: Die Reintonaudiometrie zeigte zufriedenstellende Ergebnisse bei der ST- und MT-Nachuntersuchung, wobei der PTA4-Air Bone Gap (ABG) von 24,5 (±11) dB auf 17,4 (±7,9) dB bei der ST-Nachuntersuchung nach 27 Tagen und auf 15,6 (±10,3) dB bei der MT-Nachuntersuchung nach 196 Tagen (n=32) sank. Ein PTA4-ABG von weniger als 20 dB wurde von 63 % der Patienten bei der ST-Nachuntersuchung und von 77 % bei der MT-Nachuntersuchung erreicht. Schlussfolgerung: Die mCLIP ARC Teilprothese, eine neue Mittelohrprothese mit einem ausbalancierten Kugelgelenk, zeigt vielversprechende audiologische Ergebnisse und ist eine sichere und effektive Wahl für Patienten mit chronischen Ohrerkrankungen.Es besteht kein Interessenkonflikt

Partial ossicular reconstruction with a novel ball joint prosthesis – the mCLIP ARC partial prosthesis

Mittelohr

Dr. med.

PD Dr.-Ing. Dr. habil. med.

Prof. Dr. Dr. h. c.

Evaluation of a 3D-printed coupler for round window stimulation of the Cochlea with the Vibrant Soundbridge

Evaluation eines 3D-gedruckten Couplers für die Rundfensteranregung der Cochlea mit der Vibrant Soundbridge

Introduction The effectiveness of round window stimulation using the Floating Mass Transducer (FMT) of the Vibrant Soundbridge is dependent on conditions like coupler design, contact pretension and anatomical factors. This study evaluates the effectiveness of a novel, in-house created coupler against established coupling methods. Material/Methods We developed a 3D-printed coupler (3D-C) made of elastic polymer, which has the form of a slanted cylinder adapted to the round window membrane. The 3D-C was compared to the MED-EL RW-Soft Coupler (RWSC) and cartilage through insertion in 5 human temporal bones in natural (nRFN) and exposed Round Window Niches (eRWN) under a contact force of 5 mN. The volume velocity of the footplate was measured with a vibrometer during excitation by the FMT with an exponential sweep (100 Hz - 10kHz). Results In the nRFN, the 3D-C (0.364 ± 0.787 mm³/s/V) resulted in a significantly improved transfer function compared to the RWSC (0.161 ± 0.193 mm³/s/V; p = 0.030) and cartilage (0.216 ± 0.394 mm³/s/V; p = 0.030) over all third-octave center frequencies in the range 400 – 8000 Hz. In the eRFN, all couplers performed equally efficiently (p &gt; 0.999). Compared to the RWSC, the 3D-C performed worse (p = 0.317) in the low frequency range (400 – 1600 Hz) by -0.371 ± 0.900 mm³/s/V, while showing an improvement (p = 0.074) in higher frequencies (2000 – 8000 Hz) of +0.168 ± 0.207 mm³/s/V. Discussion In comparison to the RWSC, the newly designed 3D-C allows more efficient cochlear stimulation in natural RWN and comparable stimulation in exposed RWN. Thus, the 3D-C represents an alternative for effective and standardised stimulation of the inner ear, without the need to expose the RWN.Einleitung Die Effektivität der Rundfensteranregung mit dem Floating Mass Transducer (FMT) der Vibrant Soundbridge wird u.a. vom Design des Couplers, dem Anpressdruck sowie den anatomischen Gegebenheiten beeinflusst. Diese Studie evaluiert die Effektivität eines neuen, in-house kreierten Couplers gegenüber bewährten Ankopplungsmethoden. Material/Methode Wir entwickelten einen 3D-gedruckten Coupler (3D-C) aus elastischem Polymer in Form eines abgeschrägten, an die Rundfenstermembran angepassten Zylinders. Dieser wurde in fünf humanen Felsenbeinen an der natürlichen (nRFN) und exponierten Rundfensternische (eRFN) mit einer Anpresskraft von 5 mN verglichen mit dem MED-EL RW-Soft Coupler (RWSC) und Knorpel. Die Messgröße war die per Vibrometer gemessene Volumengeschwindigkeit der Fußplatte nach Anregung des FMT mit einem exponentiellen Sweep (100 Hz-10 kHz). Ergebnisse An der nRFN führte der 3D-C (0,364 ± 0,787 mm³/s/V) zu einer signifikant besseren Übertragung als der RWSC (0,161 ± 0,193 mm³/s/V; p = 0,030) und Knorpel (0,216 ± 0,394 mm³/s/V; p = 0,030) über alle Terzmittenfrequenzen im Bereich 400 – 8000 Hz. An der eRFN waren alle Ankopplungsmethoden gleich effektiv (p &gt; 0,999). Verglichen mit dem RWSC führt der 3D-C im tieffrequenten Bereich (400 – 1600 Hz) zu einer um -0,371 ± 0,900 mm³/s/V verminderten Übertragung (p = 0,317), während er bei 2000 – 8000 Hz um +0,168 ± 0,207 mm³/s/V effektiver ist (p = 0,074). Diskussion Der neu designte 3D-C erlaubt verglichen mit dem RWSC und Knorpel an der natürlichen RFN eine effektivere und an der exponierten RFN eine vergleichbare Innenohranregung. Somit stellt der 3D-C eine Alternative für eine effektive und standardisierte Anregung der Cochlea dar, ohne die Rundfensternische exponieren zu müssen.Kooperation mit MED-EL

Evaluation of a 3D-printed coupler for round window stimulation of the Cochlea with the Vibrant Soundbridge

Aktive Mittelohrimplantate / Knochenleitungshörsysteme

Surgical landmarks for accessing the Cochlear Apex

Chirurgische Landmarken für den Zugang zum Apex cochleae

Access to the cochlear apex has so far been of minor importance in otosurgery. However, new concepts of cochlear implantation and tinnitus suppression using extracochlear electrical stimulation require electrode placement at or in the apex via a direct apical approach. The present study examines the relation between the cochleariform process, tensor tympani muscle and apex cochleae in 34 temporal bone specimens. For this purpose, experimental CTs with a resolution of 99 µm were prepared and the relevant structures of the middle and inner ear were segmented in the 3D data set. A coordinate system based on the A and B vectors was then drawn. The distances between proc. cochleariformis and apex as well as between apex and canalis m. tensor tympani were recorded. In addition, it was recorded whether the projection of the modiolus intersected the m. tensor tympani. A very stable positional relationship was found between the apex and proc. cochleariformis with a median distance of 4.3 mm (SD 0.72 mm) and between the apex and canalis m. tensor tympani of 1.5 mm (SD 0.49 mm). The apex was within the projection of the modiolus onto the tensor canal in 33 of 34 temporal bones, i.e., surgically below the easily recognizable canal. Processus cochleariformis and tensor canal are therefore well suited for direct access to the apex cochleae. For this purpose, it is recommended to dissect from the cochleariform process along and below the tensor canal medially until the apex appears through the thinned bone. The incus usually has to be removed for this procedure.Der Zugang zum Apex der Cochlea war bislang von untergeordneter Bedeutung für die Otochirurgie. Neue Konzepte der Cochleaimplantatversorgung und der Tinnitussuppression mithilfe von extracochleärer elektrischer Stimulation erfordern jedoch eine Elektrodenplatzierung am oder im Apex in einem direkten apikalen Zugang. Die vorliegende Arbeit untersucht an 34 Felsenbeinpräparaten die Lagebeziehung zwischen Proc. cochleariformis, M. tensor tympani und Apex cochleae. Hierzu wurden experimentelle CTs mit einer Auflösung von 99 µm angefertigt und die relevanten Strukturen des Mittel- und Innenohres im 3D-Datensatz segmentiert. Anschließend wurde ein Koordinatensystem auf Basis der A- und B-Vektoren eingezogen. Die Abstände zwischen Proc. cochleariformis und Apex sowie zwischen Apex und Canalis m. tensor tympani wurden erfasst. Zudem wurde erfasst, ob die Projektion des Modiolus den M. tensor tympani schnitt. Es zeigte sich eine sehr stabile Lagebeziehung zwischen Apex und Proc. cochleariformis mit einem medianen Abstand von 4,3 mm (SD 0,72 mm) sowie zwischen Apex und Canalis m. tensor tympani von 1,5 mm (SD 0,49 mm). Der Apex lag in 33 von 34 Felsenbeinen innerhalb der Projektion vom Modiolus auf den Tensorkanal, chirurgisch gesehen also unterhalb des gut erkennbaren Kanals. Processus cochleariformis und Tensorkanal eignen sich damit gut für einen direkten Zugang zum oder an den Apex cochleae. Hierzu ist eine Präparation vom Processus cochleariformis entlang und unterhalb des Tensorkanals nach medial empfohlen bis der Apex durch den ausgedünnten Knochen durchscheint. Der Incus muss hierzu in der Regel entfernt werden.Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

International Session 10
Innovations in Ear Surgery

Appointment

Chairs

Topic

Language

Programme

International Session 10Innovations in Ear Surgery

Appointment

Chairs

Topic

Language

Programme

International Session 10
Innovations in Ear Surgery