Using Combined Approach for Cochlear Implantation in a Deaf Child with Inner Ear Anomaly and Improper Anatomy of Middle Ear: A Case Report

Background: Cochlear implantation (CI) is usually performed through mastoidectomy and posterior
tympanotomy (PT) to access the cochlea. This surgical procedure can expose the surgeon to possible
complications or misplacement of the electrode. Alternative techniques for cochlear implantation with
endomeatal or suprameatal approach without posterior tympanotomy have been described. Here, we report a
4-year-old patient, a candidate for cochlear implantation, for whom due to the difficulty of accessing the round
window, we used the combined approach to reach the cochlea.
Case Report: In this particular patient, there was no restriction on mastoid pneumatization; so, we began
surgery with a posterior tympanotomy approach to access the round window. But after opening the mastoid and
facial recess, because the lateral semicircular canal was not developed well, the oval window and the stapes were
displaced posteriorly. Moreover, because of posterior displacement, the round window was not visible through
the facial recess. Therefore, by adding the trans-canal approach, we could access the round window, and the
prosthesis was successfully inserted. No complication occurred, and six months after surgery, the patient had
acceptable auditory and speech performances.
Conclusion: Familiarity and having experience in different approaches to the cochlea is a prerequisite for a
cochlear implant surgeon to be able to use alternative methods in cases of difficulty in accessing the round
window or finding a proper site for cochleostomy.