该协议由当地伦理委员会根据赫尔辛基宣言（波鸿鲁尔大学：注册号：21-7373;因斯布鲁克医科大学注册号：1060/2021）。已获得所有参与者的知情同意。
1. 手术前的准备
<ol><li>确保获得听力学测试报告，包括纯音测听、客观测试（例如，脑干诱发反应测听、言语测试）和前庭诊断（例如，视频头冲动测试或热量测试）。获取放射影像学报告，包括颅底的高分辨率计算机断层扫描 （HRCT） 和磁共振成像 （MRI），作为手术的准备和指征。 注意：需要进行 MRI 以确保前庭蜗神经的存在和耳蜗的通畅。在 HRCT 中，可以识别解剖学变异（例如面神经）或畸形。</li>
	<li>检查阻抗测量所需的硬件和软件（即 IM 软件、视频录制软件、MAESTRO）。</li>
	<li>获得患者的书面知情同意书。</li>
	<li>根据麻醉师的决定，考虑患者的临床病史和危险因素进行全身麻醉。</li>
	<li>将患者的头部定位，使面神经的乳突部分大致水平运行。通过倾斜头部并将其稍微定位到另一侧来实现这一点。</li>
	<li>剃掉耳后区域（约 3 厘米）的头发，以避免头发渗透到坐位。</li>
	<li>安装面神经监测。将监测针插入口眼肌和眼轮匝肌。将参比电极放在胸部或肩部。确保固定电缆，以免在手术过程中意外拔出它们。</li>
	<li>对手术部位进行消毒。根据诊所的标准使用消毒剂（例如 Octenisept）。</li>
	<li>使用无菌铝箔覆盖覆盖显微镜和患者。确保在计划的接收器线圈位置区域中，盖子尽可能薄，以避免发射线圈和接收线圈之间的连接问题。不要使用许多手术室中使用的布制发膜。使用自粘铝箔悬垂，并确保避免多层。</li>
</ol>2. 手术
<ol><li>种植牙的准备工作<ol><li>标记处理器的位置和大约 8 厘米的皮肤切口。确保耳廓和种植体外壳之间有足够的空间。</li>
		<li>在皮肤切口前，在耳廓后面的 S 形区域注射局部麻醉剂（例如，Ultracain 1% -Suprarenin，Sanofi，Paris，France）。</li>
		<li>用手术刀切开皮肤直至颞筋膜。解剖骨膜，展示外耳道和 Henle 的脊柱。 注意：手术器械是可变的，对于所提出的方法不是决定性的。可以使用适当的手术器械来执行手术步骤。</li>
		<li>将伤口牵开器设置在与计划的植入物侧相反的位置，以避免以后与遥测线圈的相互作用（磁吸引/电干扰）。</li>
		<li>对于人工耳蜗植入，进行胃窦切开术、乳突切除术和后鼓室切开术8。</li>
		<li>使用大切割毛刺将硬脑膜暴露于颅中窝作为第一个标志。 注意：毛刺的大小可能因手术部位而异。</li>
		<li>用相同的毛刺减薄外耳道的后耳道壁。</li>
		<li>暴露胃窦中的短砧突，并识别外侧半规管。 注意：在钻孔过程中，胃窦和半规管都可以目视识别。</li>
		<li>作为下一个手术步骤，暴露鼓索离开面神经的脊索面部角度。在此步骤中，使用大的金刚石毛刺并平行于预期的面神经钻取骨头。 注意：金刚石毛刺的大小可能因手术部位而异。</li>
		<li>用小菱形毛刺打开面部凹陷。让面神经覆盖一层薄薄的骨质覆盖物。</li>
		<li>通过后鼓室切开术进入中耳。</li>
		<li>将后鼓室切开术向尾部扩大，直到看到圆窗壁龛。</li>
		<li>最大化后鼓室切开术，使中耳暴露在外，优化插入过程的可视化。使用小金刚石毛刺去除圆形窗龛的骨质悬垂部分，直到圆形窗膜可以完全可见。 注意： 当移动听骨链时，可以看到圆形窗膜的运动，以清楚地识别圆形窗膜。确保不要用毛刺接触膜或意外打开它。</li>
		<li>在打开膜之前，将一些肾上腺素 （1 mg/mL） 放入中耳，并用可吸收海绵（例如 Spongostan）保护其免受骨尘侵害。</li>
	</ol></li>
	<li>定位植入物<ol><li>通过在接收线圈的未来位置将床钻入骨骼来准备种植体外壳。使用制造商提供的种植体外壳假人标记种植体床的边界。通过使用罗森毛刺创建边缘来避免植入物滑落。使用金刚石毛刺使表面光滑。 注意：种植体外壳的边缘可防止种植体向乳突切除术缺损移动。</li>
		<li>将线圈装入无菌套管中，因为线圈在插入过程开始时就已经放置好了。</li>
		<li>将植入物放置在钻孔的植入物床中，用缝合线固定，并用肌肉瓣覆盖它。</li>
		<li>更换牵开器以避免与刺激线圈发生任何磁相互作用。</li>
	</ol></li>
	<li>植入和阻抗测量<ol><li>使用两台计算机 - 一台用于 Maestro，一台用于 IM 录音。</li>
		<li>启动IM软件。</li>
		<li>将遥测线圈放在接收线圈的磁铁上方。用夹子固定它，以避免移动和断开连接。</li>
		<li>等待临床医生、工程师或听力学家启动软件并提供有关耦合的反馈。更改接收器线圈的位置，直到实现安全连接。</li>
		<li>确保没有出血阻碍插入过程的可视化或进入外淋巴。</li>
		<li>在屏幕上传达手术区域的可见性。对显微镜的光学焦距进行调整，以便临床医生、工程师或听力学家可以跟踪插入过程。</li>
		<li>确保面部凹陷尽可能干燥，以避免早期假阳性措施。</li>
		<li>用针打开圆窗膜。</li>
		<li>避免在圆窗附近有任何吸力。</li>
		<li>请勿触摸电极阵列。</li>
		<li>将插入的开始时间传达给临床医生、工程师或听力学家，以便他/她可以调整状态按钮。指示工程师在插入电极时一个接一个地标记状态按钮。</li>
		<li>将第一个电极触点插入耳蜗。等待临床医生、工程师或听力学家的反馈和音频信号继续。每 10 秒应用一次音频信号，以实现恒定且缓慢的插入速度，总插入时间约为 2 分钟。<ol><li>对于听觉信号，播放 500 Hz 恒定脉冲开和关的正弦波信号，并使用软件 Audacity 每 10 秒重复一次。不要根据插入过程调整信号和暂停的时间，而是保持恒定。</li>
		</ol></li>
		<li>缓慢插入电极阵列以避免耳蜗损坏。每 10 秒推进一个电极触点（在声音信号的引导下）。</li>
		<li>通过清楚地传达插入的触点数量，将进度通知临床医生、工程师或听力学家，以便临床医生、工程师或听力学家可以通过按下 IM 工具的状态按钮在软件中尽可能精确地标记进度。</li>
		<li>指导临床医生、工程师或听力学家根据外科医生的反馈标记插入电极触点的数量（图 2）。</li>
		<li>继续测量直到完全插入，以观察阻抗下降。</li>
		<li>传达手术步骤。</li>
		<li>将电极导线存放在乳突腔中。确保通过找到一个无张力的位置来避免挤压力。</li>
	</ol></li>
	<li>手术结束<ol><li>用楣板密封圆窗壁龛。</li>
		<li>检查植入物的完整性（阻抗遥测、电诱发镫骨肌反射阈值（如果适用）和电诱发复合动作电位）。</li>
		<li>分层闭合伤口。</li>
		<li>继续进行重复的遥测测量，直到伤口完全闭合。避免刺激线圈错位。</li>
		<li>在结束手术之前，检查鼓膜和外耳道的皮肤是否有任何手术损伤。</li>
	</ol></li>
</ol>

人工耳蜗植入期间的实时遥测阻抗测量

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提交人无需声明任何利益冲突。

重复阻抗测量是一种很有前途的方法，可以在插入过程中从耳蜗获得实时反馈。它们指示哪些电极触点位于外淋巴内部或未位于外淋巴内部。通过本文介绍的柔性侧壁电极新方法（MED-EL，因斯布鲁克，奥地利）7，可以在人工耳蜗植入过程中使用插入电极阵列实时测量阻抗。然而，为了获得可靠的测量结果，标准化程序至关重要。
该协议描述了对现有阻抗测?...

在人工耳蜗植入 （CI） 手术中，保留残余听力是一个越来越受关注的话题，并且适应症已转向具有功能性残余听力的候选人。因此，可能客观化电极阵列位置以及手术过程中由此产生的潜在耳蜗内损伤的测量变得越来越重要。成功保留听力的 CI 使用者已被证明在手术后使用植入物时具有卓越的听力性能，即使在仅电刺激的情况下也是如此1.他们中的一些人可能还受益于声刺激（电声刺激;EAS）。围手术期听力损失被认为是由创伤性插入引起的。为了提高对这些术中变化的洞察力并建立监测算法，需要客观的测量方法和生物标志物。在这种情况下，阻抗遥测可能是感兴趣的2,3。阻抗增加已被证明与听力损失或眩晕有关 4,5。进一步的证据显示，在插入电极阵列6 期间会出现血液包涵体。然而，有必要进行进一步的研究，以探索阻抗在多大程度上可能与手术创伤和术后表现有关。为此，重复的术中阻抗测量是一种很有前途的方法。另一方面，阻抗提供有关电极位置的附加信息。高阻抗表示导电性差，因此表明接触位置在耳蜗外，而低阻抗（阻抗下降）可能表明已经插入触点。因此，阻抗可以用作电极阵列插入状态的客观反馈机制。在这段视频中，我们介绍了使用人工耳蜗制造商 MED-EL（奥地利因斯布鲁克）7 的柔性侧壁电极进行重复阻抗测量的新方法的设置和首次体验。
为研究目的而设计的研究软件用于执行重复阻抗测量。在这项研究中，该软件根据 MED-EL 内部程序进行了验证，适用于仅供研究使用的设备。在手术过程中，仅显示最新的阻抗遥测数据。 图 1 显示了电子测量设置。插入监控 （IM） 软件具有用于标记当前插入的电极触点数量的按钮（红色/绿色突出显示）。启动后，软件会周期性地重复测量阻抗。IM 软件在 12 个图中显示了测量的阻抗结果和随时间变化的阻抗。此外，如果出现连接问题，它会显示警告。视频录制软件（Open Broadcaster Software [OBS]）用于录制 （i） 电极插入视频（连接显微镜，例如通过 HDMI），（ii） IM 软件用户界面的视频，包括所有用户交互和 （iii） 声音。音频编辑软件（Audacity）用于在电极阵列插入过程中定期播放声音，以促进缓慢插入。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Audacity</td>
			<td>Open source</td>
			<td>https://www.audacityteam.org/</td>
			<td>Audio editor software</td>
		</tr>
		<tr>
			<td>Coil cable</td>
			<td>Any appropriate brand</td>
			<td></td>
			<td>Implant interface</td>
		</tr>
		<tr>
			<td>Computer</td>
			<td>Any appropriate brand</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Electrode array</td>
			<td>MED-EL</td>
			<td>https://s3.medel.com/pdf/21617.pdf</td>
			<td>Standard, FlexSoft, Flex28</td>
		</tr>
		<tr>
			<td>IM Software</td>
			<td>MED-EL</td>
			<td>https://www.medel.com/</td>
			<td></td>
		</tr>
		<tr>
			<td>Maestro</td>
			<td>MED-EL</td>
			<td>https://www.medel.com/</td>
			<td></td>
		</tr>
		<tr>
			<td>MAX Interface USB</td>
			<td>Any appropriate brand</td>
			<td></td>
			<td>Interface connection</td>
		</tr>
		<tr>
			<td>Octenisept</td>
			<td>SCH&#220;LKE &#38; MAYR GmbH</td>
			<td>N/A</td>
			<td></td>
		</tr>
		<tr>
			<td>Open Broadcaster Software</td>
			<td>Open source</td>
			<td>https://obsproject.com/</td>
			<td>Video recording software</td>
		</tr>
		<tr>
			<td>Spongostan</td>
			<td>&#160;Ethicon</td>
			<td>N/A</td>
			<td>Resorbable sponge</td>
		</tr>
		<tr>
			<td>Ultracain 1%</td>
			<td>&#160;Suprarenin, Sanofi</td>
			<td>N/A</td>
			<td>Local anesthesia</td>
		</tr>
	</tbody>
</table>

performing repeated intraoperative impedance telemetry measurements during cochlear implantation

阻抗测量是在人工耳蜗植入 （CI） 期间常规进行的，在最终电极插入后。它们可以对电极和植入物的功能得出结论。在术后环境中，通过分析阻抗变化可以识别电极周围的疤痕或炎症过程。最近的研究报告了阻抗遥测与刺激部位之间的关联。因此，在人工耳蜗电极插入过程中重复测量阻抗可以客观地反馈电极是位于外淋巴内还是内耳外。利用所提出的新方法，可以在人工耳蜗植入过程中实时测量阻抗。该协议系统地解释了如何在 CI 手术期间执行重复的阻抗记录。这些重复测量具有挑战性，因为它们取决于多种术中方法学因素，从患者的悬垂开始。因此，为了成功录音，标准化程序是强制性的。在本文中，我们全面说明了 CI 手术期间进行术中测量的系统设置和程序。

Preserving residual hearing is an increasing topic of interest in cochlear implantation (CI) surgery, and the indication has changed towards candidates with functional residual hearing. Thus, measurements that may objectify the position of the electrode array and the resulting potential intracochlear damage during surgery are becoming increasingly important. CI-users with successfully preserved hearing have been shown to have superior hearing performance with the implant after surgery, even when stimulated electrically-only1. Some of them may additionally benefit from acoustic stimulation (electro-acoustic stimulation; EAS). Perioperative hearing loss is assumed to result from traumatic insertion. To improve insights into these intraoperative changes and to establish monitoring algorithms, objective measures, and biomarkers are needed. In this context, impedance telemetry may be of interest2,3. Increased impedances have been shown to be associated with hearing loss or vertigo4,5. Further evidence associates blood inclusions during the insertion of the electrode array6. Nevertheless, further investigation is necessary to explore to what extent impedances may be associated with surgical trauma and postoperative performance. For this purpose, repeated intraoperative impedance measurements are a promising approach. On the other hand, impedances deliver additional information about the electrode&#39;s position. High impedances indicate poor conductivity and thus indicate a contact position outside the cochlea, whereas low impedances (impedance drops) may indicate already inserted contacts. Thus, impedances may be used as an objective feedback mechanism for the status of the electrode array insertion. In this video, we present our setup and first experiences with this novel approach of repeated impedance measurements using flexible lateral wall electrodes from the cochlear implant manufacturer MED-EL (Innsbruck, Austria)7.
A study software designed for research purposes is used to perform repeated impedance measurements. In this study, the software is verified according to the MED-EL internal procedures for research-use-only devices. During surgery, only the most recent impedance telemetry data is shown. Figure 1 shows the electronic measurement setup. The Insertion Monitoring (IM) software has buttons to mark the number of electrode contacts currently inserted (red/green highlighting). After starting, the software measures impedances repeatedly in cycles. The IM software shows a table of the measured impedance results and impedances across time in 12 plots. Furthermore, it shows warnings in case of connection problems. A video recording Software (Open Broadcaster Software [OBS]) is used to record (i) the video of electrode insertion (microscope attached, e.g., via HDMI), (ii) a video of the IM software user interface, including all user interactions and (iii) sound. An audio editor software (Audacity) is used to regularly play a sound during the insertion of the electrode array to facilitate a slow insertion.

作者聚焦：人工耳蜗手术阻抗监测的进展

在人工耳蜗植入过程中进行重复的术中阻抗遥测测量

We are working with impedances, since they provide an objective feedback on whether the cochlear implant electrode array is located outside the cochlea or inside the cochlea. High impedances indicate or suggest a poor conductivity, and thus, an electrode contact outside the cochlea. Whereas lower impedances suggest that the conductivity is better, and thus, the electrode contact already inserted.And this information may be used to reduce radiation exposure in the aftercare of cochlear implantation after care. Hearing preservation is an increasing topic of interest in the cochlear implantation field. And with these methods that objectify the position of the electrode array inside the cochlea, and with this, the potentially occurring intracochlear damage are increasingly becoming very important.The current methods for the intraoperative monitoring of the electrode array insertion and the hearing preservation are the electrocochleography and the hear present impedance telemetry. The major tasks to overcome are unexpected high impedances. These high impedances resolve with time and electrical stimulation.Nevertheless, they negatively influence the real-time measurements. We established a method to perform repeated and continuous impedance telemetry measurements, and they open up a whole new perspective on gaining data already during the insertion of a cochlear implant electrode array.

对于人工耳蜗植入过程中的重复阻抗测量，必须采用标准化程序以实现尽可能高的可重复性。被认为起重要作用的主要方面是视频质量以及插入角度。两者都可能妨碍进入圆形窗口的电极触点的可视化，从而妨碍对视频的解释以供将来分析。此外，接收器线圈的放置对于防止插入过程中的中断以及数据丢失至关重要。因此，需要剃光接收线圈的区域，并且窗帘需要尽可能薄。此外，植入体需要被?...

Watch this Scientific Journal Video about Performing Repeated Intraoperative Impedance Telemetry Measurements during Cochlear Implantation at JoVE.com

在这里，我们提出了一种在人工耳蜗植入 （CI） 期间进行重复阻抗遥测测量的协议。它们可以对电极和植入物的功能得出结论。重复的阻抗测量可以客观地反馈电极是位于外淋巴内部还是位于内耳外部。

Impedance measurements are routinely performed during cochlear implantation (CI) after finalized electrode insertion. They may allow conclusions on the ...

我们正在使用阻抗，因为它们提供了关于人工耳蜗电极阵列是位于耳蜗外还是耳蜗内的客观反馈。高阻抗表明或暗示导电性差，因此电极接触耳蜗外。而较低的阻抗表明电导率更好，因此电极触点已经插入。这些信息可用于减少人工耳蜗植入术后护理后的辐射暴露。在人工耳蜗植入领域，听力保护是一个越来越受关注的话题。通过这些方法，电极阵列在耳蜗内的位置客观化，因此，可能发生的耳蜗内损伤变得越来越重要。目前用于电极阵列插入和听力保护的术中监测的方法是耳蜗电图和听力存在阻抗遥测。要克服的主要任务是意想不到的高阻抗。这些高阻抗会随着时间和电刺激而消退。然而，它们会对实时测量产生负面影响。我们建立了一种执行重复和连续阻抗遥测测量的方法，它们为在插入人工耳蜗电极阵列期间已经获取数据开辟了全新的视角。

performing-repeated-intraoperative-impedance-telemetry-measurements

Research

JoVE Journal

Medicine

Performing Repeated Intraoperative Impedance Telemetry Measurements during Cochlear Implantation

808 次观看.  Ruhr-University Bochum, St. Elisabeth-Hospital Bochum. 我们正在使用阻抗，因为它们提供了关于人工耳蜗电极阵列是位于耳蜗外还是耳蜗内的客观反馈。高阻抗表明或暗示导电性差，因此电极接触耳蜗外。而较低的阻抗表明电导率更好，因此电极触点已经插入。这些信息可用于减少人工耳蜗植入术后护理后的辐射暴露。在人工耳蜗植入领域，听力保护是一个越来越受关注的话题。通过这些方法，电极阵列在耳蜗内的位置客?...