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12.10.2020 | Original article | Sonderheft 1/2021 Open Access

HNO 1/2021

Management of transmodiolar and transmacular cochleovestibular schwannomas with and without cochlear implantation

HNO > Sonderheft 1/2021
Prof. Dr. med. S. K. Plontke, P. Caye-Thomasen, C. Strauss, S. Kösling, G. Götze, U. Siebolts, D. Vordermark, L. Wagner, L. Fröhlich, T. Rahne
Wichtige Hinweise

Video online

The online version of this article (https://​doi.​org/​10.​1007/​s00106-020-00919-9) includes a video (2D and 3D versions) of the described surgical technique. Article and supplementary material are available at www.​springermedizin.​de. Please enter the title of the article in the search field, the supplementary material can be found under “Ergänzende Inhalte”.
The German version of this article can be found under https://​doi.​org/​10.​1007/​s00106-020-00918-w.
The manuscript is part of the special issue “Prize winners of the German Society of Otorhinolaryngology, Head and Neck Surgery.” It contains data presented at the 90th Annual Meeting of the German Society of Otorhinolaryngology, Head and Neck Surgery 2019 [34], where it was awarded the “1st poster prize in the category clinical research.”



Hearing rehabilitation with cochlear implants has attracted increasing interest also for patients with cochleovestibular schwannoma. The authors report their experience with the surgical management of tumors with rare transmodiolar or transmacular extension and outcomes after cochlear implantation (CI).


This retrospective case series included nine patients with either primary intralabyrinthine tumors or secondary invasion of the inner ear from the internal auditory canal. The primary endpoint with CI, performed in six patients, was word recognition score at 65 dB SPL (sound pressure level). Secondary endpoints were intra- and postoperative electrophysiological parameters, impedance measures, the presence of a wave V in the electrically evoked (via the CI) auditory brainstem responses, the specifics of postoperative CI programming, and adverse events.


Hearing rehabilitation with CI in cases of transmodiolar tumor growth could be achieved only with incomplete tumor removal, whereas tumors with transmacular growth could be completely removed. All six patients with CI had good word recognition scores for numbers in quiet conditions (80–100% at 65 dB SPL, not later than 6 to 12 months post CI activation). Four of these six patients achieved good to very good results for monosyllabic words within 1–36 months (65–85% at 65 dB SPL). The two other patients, however, had low scores for monosyllables at 6 months (25 and 15% at 65 dB SPL, respectively) with worsening of results thereafter.


Cochleovestibular schwannomas with transmodiolar and transmacular extension represent a rare entity with specific management requirements. Hearing rehabilitation with CI is a principal option in these patients.

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Video 1: the video (2D and 3D versions) demonstrates the surgical technique for removal of the intracochlear tumor parts, cochlear implantation, and cochlear defect reconstruction in a patient with NF2 (patient 5, Fig. 4a,b). After mastoidectomy, posterior tympanotomy, drilling of the implant bed, and canaloplasty for a better approach to the cochlea, the tumor was exposed in the first and second turns of the cochlea by a transmeatal approach. Parts of the tumor were microsurgically removed through the openings of the cochlear capsule. Intrascalar tumor remnants medial to the modiolus were pushed through with a shortened insertion test device (MED-EL, Innsbruck, Austria). Insertion of the implant electrode array was done as in standard implant surgery, i.e., through the posterior tympanotomy and the extended round window. The electrode was additionally approximated towards the modiolus and thus the cochlear spiral ganglion cells in Rosenthal’s canal by means of small cartilage chips. The cochlear defect was closed with a cartilage-perichondrium compound transplant from the cymba conchae, soft tissue, and fibrin glue. A silicon foil was inserted into the middle ear cavity to prevent adhesions between the posterior part of the eardrum (reinforced with temporalis muscle fascia) and the medial wall of the middle ear. Outer ear canal silicon foils and dressing were removed after 4 weeks. (The surgical videos (2D and 3D) were recorded with a fully digital microscope (ARRISCOPE). We thank Dr. Armin Schneider, Munich Surgical Imaging GmbH (formerly ARRI Medical GmbH), Munich, Germany, for support with cutting and postproduction.)
Video 2 (3D version): the same as video 1 but in a 3D version. It can be viewed with a Smartphone 3D Cardboard or a 3D screen.
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