Endoscope-Assisted Cochlear Implantation in Atretic Round Window

Different techniques have been proposed for cochlear implant (CI) from its conventional transmastoid posterior tympanotomy approach. Endoscopy role in the otologic field is still relatively new, but it provides a better surgical view with improved image clarity, especially in the challenging anatomical visualization of the critical structures in CI surgery. A 3-year-old girl with bilateral progressive profound hearing loss was scheduled for left cochlear implant surgery. The pre-operative high-resolution computed tomography (HRCT) of the temporal bone and magnetic resonance (MR) of internal acoustic meatus reported no significant abnormality of the middle and inner ears structures bilaterally. The standard left postauricular cortical mastoidectomy and posterior tympanotomy were performed. However, the microscopic view could not visualize the round window (RW) niche despite a widened extended posterior tympanotomy and surgical field manipulation. Transfacial recess endoscopic examination was done and was able to identify the possibly atretic RW. With endoscopic guidance, CI electrodes were inserted via cochleostomy, and intraoperative impedance measurement and neural response telemetry were obtained both during surgery and the postoperative phase. No intra- and postoperative complications were observed in this case. Following activation, the CI was functioning well. In conclusion, atretic RW is a rare anomaly found intraoperatively during CI surgery. Endoscope-assisted electrode insertion offers excellent visualization of targeted middle ear structures, especially in limited or abnormal anatomy of RW, which could minimize the risk of surgical complications.