Revision Surgery CI512 to CI24RECA.pdf - For professionals

CAM-MKTP-290
Nucleus® CI24RE Cochlear
Implant Surgery Tips
Revision surgery
from Nucleus® CI512 Contour Advance
to Nucleus® CI24RE Contour Advance

Nucleus® CI512 to Nucleus CI24RE revision
This presentation reviews key surgical steps
This document is supplemental information – refer to
Nucleus ® CI24RE Contour Advance Surgeons Guide for
complete information regarding implantation of the CI24RE
Cochlear Implant
Note: Every implant includes a copy of the Surgeons Guide
as part of the document pack
Ensure the following is available in OR prior to starting:
• Primary and backup CI24RE device
• Explant kit

Purpose of this supplemental information
Primary goal of procedure is to describe surgical steps to
replace a Nucleus 5 Cochlear Implant (CI512) to a Nucleus
CI24RE Cochlear Implant
Note: If there are any questions regarding the steps provided
in this document contact Steve Hazard – Surgical Support
Manager to discuss further
Mobile # 1-661-803-4745

Caution
Monopolar Electrocautery cannot be used when a patient has
a cochlear implant or any portion of an electrode lead/ground
lead present – whether the implant is functioning or not
Bipolar Electrocautery is acceptable as long as it remains a
minimum of 1 cm away from any electrode lead or ground
lead and does not touch the receiver package

Primary physical differences: CI24RE and CI512
3.3mm
3.6mm
Nucleus CI24RE
16 mm x 2.3 mm
Nucleus CI512
3.9 mm
4.6 mm
1. CI24RE has a vertical lead and
ground electrode exiting the
receiver stimulator package.
• Recess this in electrode
channel
2. CI24RE has a pedestal
• Recess the pedestal in bone
2.3mm
Note: With these differences the
CI24RE should be placed slightly
further away from the pinna to
avoid pressure between the
electrode lead exit and the external
sound processor.

Important point – No overlap
As with all CI surgery
It is important to mark
out device location and
ensure there is no
overlap between the
BTE processor and the
internal device

Exposing receiver package
Widen fibrous tissue pocket adjacent to coil to assist in
“releasing” receiver package
Exiting Lead

Removing receiver package
Cut the electrode lead at a distal location leaving
approximately 1 cm outside the facial recess – then remove
the receiver package, most of the electrode lead and also
remove the ground lead/pin

Clear fibrous tissue & line up recess instrument
1. Clear fibrous tissue from the recessed seat and electrode
channel. Note: The channel may require widening due to bone
growth
2. Use Bone Recess Template (Z60479) or Recess Check Gauge
(Z60480) and place circular portion approximately 5mm behind
the lead exit location
5mm
Figure 1. Bone Recess Template
Caution: Always consider the
possibility of exposed dura in
the recessed seat or electrode
lead/ground lead channel –
proceed with care.

Mark location of recess for pedestal
3. Mark location then drill recess including the electrode
lead/ground lead exit into the channel flush with the recess
(Figure 3). Note: The electrode lead/ground lead channel
may require widening due to bone growth
Figure 2. Site for recess drawn Figure 3. Site for recess drilled including
lowering of the electrode lead/ground
lead exit to be flush with the recess

Create tie-down holes
5. Drill (or reuse) tie-down holes adjacent to the new recess seat
per Nucleus CI24RE Surgeons Guide. Use a non-absorbable
synthetic suture to secure the receiver package to bone

Verify final recess dimensions
4. Use the Recess Check Gauge (Z60480) to verify final
dimensions including the electrode lead/ground lead exit
being flush with the bottom of the new recess seat for the
CI24RE receiver package
Figure 4. Verify dimensions using
Recess Check Gauge
NOTE: Failure to have the lead
exit flush with the bottom of
the recess will force the exiting
electrode lead/ground lead to
be deflected upward toward
the soft tissue.

Bony overhangs
6. Verify there are bony overhangs in the mastoid cavity to retain
excess electrode lead once coiled into position (Figure 5)
Figure 5. Verify bony overhangs are sufficient
in mastoid cavity
Bony Overhangs

Place device
7. Place CI24RE receiver package in position and tie-down
(Figure 6 and 7). Ensure knots are to the side of the receiver
package.
Figure 6. Freedom Receiver Package
sutured in place
Figure 7. Picture demonstrates a tiedown
technique on an initial cochlear
implant procedure, where a tight
pocket could not be maintained

Electrode Array Removal and
Replacement Considerations
Contour Advance Electrode

Array considerations
8. Considerations prior to removal and replacement of CA array:
• Goal is to end up with same depth of insertion
• Be observant of any dura exposure or facial nerve exposure
• Leave old array in position until ready to insert new array
• Allow array to serve as a stent until ready to replace
• Use old cochleostomy site (if previously successful)
• Clear away all fibrous tissue from around array at the
cochleostomy site – including exposing Silastic Ribs
• No delay between removal and replacement of electrode array –
the “no blink” rule applies – primary concern is the potential for
the fibrous tissue/tunnel to collapse once the old array is removed
• Do not perform AOS insertion technique in any revision

Fibrous tissue considerations
Note the fibrous tissue
as electrode array
enters the facial
recess
Caution: If in the
previous surgery any
facial nerve was
exposed then fibrosis
could be attached to it
It is recommended to
assume that facial
nerve is exposed

Silastic “ribs” or rings should be visible
All fibrous tissue is
dissected away at
cochleostomy site
Some surgeons
use a laser
Verify that Silastic
“ribs” or rings are
visible
Silastic “rib”
or ring

Preparation for new array insertion
Prepare to go in
with new array –
loaded on AOS
Insertion Forceps
ready to insert
New Array
Old Array

Important reminder
Do not take eyes off of the cochleostomy site during the
transition from old array to new array. “No Blink” rule
applies
Transition within seconds
If there is to be any delay place the tip of the array into
the cochleostomy site 5 – 6 mm (to retain fibrous tunnel
opening intact)

New array insertion / old array removal sequence 1
View 1 of 7: Old array beginning to come out
Verify that Silastic “ribs” exit cochleostomy site
Silastic “ribs” coming out
1 See the following seven slides (beginning with the current slide)

New array insertion / old array removal sequence
View 2 of 7: Continue removing old array
Silastic “Ribs” continuing
to come out

New array insertion / old array removal sequence
View 3 of 7: Old array out – note cochleostomy site – enter
immediately with new array into lumen
New Array Old Array (out
of cochlea)

New array insertion / old array removal sequence
View 4 of 7: New array entering cochleostomy
Do not perform AOS (Advance Off Stylet)

New array insertion / old array removal sequence
View 5 of 7: Continue insertion – stylet left in place
Do not perform AOS – Advance off-stylet)

New array insertion / old array removal sequence
View 6 of 7: Almost fully inserted

New array insertion / old array removal sequence
View 7 of 7: Fully inserted array – stabilize array and remove
stylet completely

What If Array “Hangs Up”
If insertion is less than 2/3rds complete
• Back array out approximately 2mm
• Rotate 90 degrees toward floor of cochlea
• Attempt to advance (if does not advance, rotate 180 degrees
toward osseous spiral lamina – then attempt to advance)
If insertion is greater than 2/3 complete (3 – 4 electrodes
outside cochleostomy)
• Rotate array into correct orientation then
• Back up array approximately 2 mm – carefully and firmly hold
array and pull stylet 1-2 mm. This allows the distal tip to
angle toward modiolus (attempting to allow array to advance
in new direction – and past any lateral wall fibrosis)
• Advance array further if possible

Closure Preparation
Place ground lead ball under temporalis/periosteum
“Seal” cochleostomy site
Coil excess lead in mastoid cavity and close

Closure

Plain Film Transorbital X-Ray
Not required – at surgeon’s discretion