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The patient was referred from the regional hospital due to a sudden worsening of hearing in the LE, accompanied by ipsilateral tinnitus of one month's onset. Otological examination was normal. Tonal audiometry, profound SNHL in the LE and severe-profound in the RE (vocal audiometry: maximum syllable discrimination 50% at 95<span class="elsevierStyleHsp" style=""></span>dB). The patient had stopped using his hearing aid 2 months previously because it was not performing well. Tinnitus Handicap Inventory (THI): 54 points (severe). CT and conventional MRI scans were normal.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was included in the cochlear implant (CI) study protocol. High definition MRI with contrast showed a loss of fluid signal intensity at the turn of the basal cochlea, with homogeneous and intense enhancement after contrast administration compatible with a developing labyrinthitis. An intracochlear schwannoma (ICS) could not be ruled out (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no pathological findings in the right ear.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">It was decided that a CI was indicated for the LE due to the long history of right-sided total hearing loss.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the operation a classical approach was taken for the cochlear implantation. After opening the round window, bluish tissue of fibrous appearance was observed. This was removed until cochlear permeability was achieved at the first turn. The pathology department reported an intracochlear schwannoma. A perimodiolar electrode was then fitted (Nucleus Freedom Contour Advance).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The hearing outcomes at 2 years post implantation showed tonal thresholds of 25<span class="elsevierStyleHsp" style=""></span>dB SPL (Pure-Tone-Average 250–4000<span class="elsevierStyleHsp" style=""></span>Hz) and 90% discrimination of syllables in open lists in silence (65<span class="elsevierStyleHsp" style=""></span>dB SPL) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) on free-field tonal audiometry with the implant. An improvement in the tinnitus was observed, both subjectively and objectively (THI: 12; mild). High definition CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) after the cochlear implantation, and 2 years post-implant, revealed no relapse.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Vestibular schwannoma is a slow-growing benign tumour, which originates in the eighth cranial nerve. It is the most common tumour of the cerebellopontine angle and the inner ear canal. It rarely originates in the inner ear, where it is termed intralabyrinthine schwannoma (ILS).<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> ICS make up a small percentage of ILS and are mainly diagnosed by MRI. ILS are classified into 7 groups according to the inner ear structures affected: intravestibular, intracochlear, intravestibulocochlear, transmodiolar, transmacular, transotic and tympanolabyrinthine.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> A hundred cases have been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The most common are intravestibular, and intravestibulocochlear and transotic are the rarest.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> They present clinically as unilateral SNHL (93%–100%), vertigo (30%–51%) and tinnitus (50%).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Recent advances in MRI enable small ICS (<2<span class="elsevierStyleHsp" style=""></span>mm) and their precise location to be detected. They are typically lesions with sharply delineated edges that present an intermediate signal on T1 with effacement of the normal fluid on T2, and intense and homogeneous uptake on T1, after intravenous injection of gadolinium. This uptake of contrast on T1 enables intralabyrinthine schwannomas to be differentiated from other diseases that cause effacement of the normal fluid signal on T2, such as intralabyrinthine haemorrhage, infectious labyrinthitis and ossification of the labyrinth (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Labyrinthitis will be the most important differential diagnosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment will depend on the size of the tumour, its growth, the extent of hearing loss, and the vestibular symptoms. It is not possible to preserve hearing in the majority of cases, although it should be borne in mind that almost 90% will have no useful hearing at the time of diagnosis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Nowadays it is known from long-term follow-up studies<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a> that the majority of ICS will not grow after diagnosis. We decided to remove the ICS and during the same operation place a cochlear implant. Other authors<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> prefer to leave the ICS in situ, in order to preserve the internal cochlear architecture to the greatest extent possible. Like Carlson et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> we believe that the use of a styleted electrode is the best option in these types of cases, since it can help to achieve a complete insertion. We used a Contour Advance Electrode (Cochlear<span class="elsevierStyleSup">®</span>) for this case.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Although we monitored our case by high definition CT (post-implantation and at 2 years), most of the recent literature<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> recommends post-implantation follow-up at one year with MRI (1.5<span class="elsevierStyleHsp" style=""></span>T). If no growth is seen, an MRI scan every 2 years is mandatory. It is important to place the implant stimulating receiver in an exaggeratedly posterosuperior position to avoid the device in MRI follow-up checks.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">MRI is essential in the study of patients who are candidates for CI, since it is the only procedure that enables cochlear permeability to be observed and the detection of intralabyrinthine disease.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Cochlear implantation in patients with ICS is possible when the cochlear nerve is present and functioning. Because these are very slow-growing tumours, in our opinion the tumour should be removed as far as is possible, without making it impossible to place the electrodes correctly in the cochlea and thus optimise the outcome of the cochlear implant.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of Interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical Case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of Interests" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-27" "fechaAceptado" => "2016-08-10" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Paula Vernetta C, Atrache Al Attrache N, Cavallé Garrido L, Mas Estellés F, Morera Pérez C. Implante coclear en paciente con schwannoma intracoclear. Acta Otorrinolaringol Esp. 2017;68:297–299.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2120 "Ancho" => 2512 "Tamanyo" => 425779 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">1.1: axial T1 MRI without contrast; 1.2: axial T1 MRI with contrast; 1.3: axial T2 MRI showing the filling defect in the tympanic duct of the basal turn of the cochlea; and 1.4: axial CT post cochlear implantation.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2156 "Ancho" => 2879 "Tamanyo" => 471011 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">2.1: tonal audiometry pre-implant; 2.2: vocal audiometry pre-implant; 2.3: free field tonal audiometry post-implant; and 2.4: open list syllables in silence post-implant.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transcanal surgical excision of an intracochlear schwannoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.F. 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Journal Information
Vol. 68. Issue 5.
Pages 297-299 (September - October 2017)
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Vol. 68. Issue 5.
Pages 297-299 (September - October 2017)
Case study
Cochlear Implant in Patient With Intracochlear Schwannoma
Implante coclear en paciente con schwannoma intracoclear
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