X-linked Malformation and Cochlear Implantation

Transcription

1 X-linked Malformation and Cochlear Implantation Henrik Smeds, Jeremy Wales, Ulrika Löfkvist, Lena Anmyr, Babak Falahat, Britt-Marie Anderlid, Eva Karltorp Karolinska University Hospital Stockholm, Sweden 7/13/16 CI2016 Toronto 1

2 Disclosures Two authors (H.S. and E.K.) are on the Surgical Advisory Board of MED-EL 7/13/16 CI2016 Toronto 2

3 X-linked deafness Locus (OMIM) Loca-on Gene (OMIM) Important reference 1-5% of all hereditary hearing loss is x-linked POU3F4 DFNX1 (DFN2) Xq22 PRPS1 Liu et al., 2010 Transcription factor DFNX2 (DFN3) Xq21.1 POU3F4 De Kok et al., 1995 Mapped to locations DFNX 1-6 Development of cochlea DFNX3 (DFN4) Xp21.2 unknown Lalwani et al., 1994 DFNX2 (POU3F4) is most commonly affected DFNX4 (DFN6) Xp22 SMPX del CasIllo et al., 1996 DFNX5 (AUNX) Xq23-q27.3 DFNX6 Xp22.3 Expressed in developing brain unknown Wang et al., 2006 COL4A6 Rost et al., /13/16 CI2016 Toronto 3

4 Radiology of X-linked Malformation (Incomplete partition III) Aplasia of the cochlear modiolus Lack of cribiform plate between IAC and basal turn of the cochlea Enlarged internal auditory canal 7/13/16 CI2016 Toronto 4

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6 Demographics 10 children Early identification Early fitting with HA Progression of HL Severe-profound mixed HL Case Sex Age at identification of hearing loss Age amplification of sound Age when seen in CIC Progression of HL 1 M 0,2 0,4 1,1 No 2 M 1,8 1,9 2 Progressive 3 M 0,2 0,3 0,7 No 4 M 0,2 0,3 0,7 Progressive 5 M 0,2 0,3 0,7 Progressive 6 M 0,3 0,4 0,6 Progressive 7 F 0,2 0,5 and 1,3* 1,8 Unknown 8 M 0,3 0,6 2,6 Progressive 9 M 0,2 0,7 n=10 1,1 Progressive 10 M 0,2 0,5 2,6 Progressive 7/13/16 CI2016 Toronto 6

7 Genetics Case Sex Genetics Cognitive and developmental issues Additional diagnonsis in family 1 M Hemizygotic deletion in POU3F4, c.1?_1086+? None No Verified deletions in POU3F4 in 7 cases 3 cases whole gene sequenzing pending 2 M No mutation identified in POU3F4 with MLPA, sequenzing pending None No 3 M Hemizygotic deletion, 2 probes in exon1 POU3F4, c.[1-?_1086+?del] None No 4 M Hemizygotic deletion, 4 probes upstream POU3F4, c.[1-?_1-?del] and heterozygotic deletion, probe GJB2(172nt) ex 2, c.[35delg] None Mother mild HL One female Inactivation study pending 5 M 6 M 7 F Deletion in the POU3F4 gene, mother positive for deletion upstreams POU3F4 Hemizygotic deletion, 4 probes upstream POU3F4, c.[1-?_1-?del] and heterozygotic deletion, probe GJB2(172nt) ex 2, c.[35delg] Heterozygotic deletion, 2 probes in exon1 POU3F4, c.[1-?_1086+?del] and heterozygotic deletion, 6 probes upstream POU3F4, c.[1-?_1-?del] Inactivation study pending 8 M No mutation identified in POU3F4 with MLPA, sequenzing pending None None Delayed motor development Unclear cognition "Difficult to assess and evaluate his cognitive level." 9 M No mutation identified in POU3F4 with MLPA, sequenzing pending "Poor eye contact" No Mother mild HL No No Half sister with Downs syndrome 10 M Hemizygotic deletion, 6 probes upstream POU3F4, c.[1-?_1-?del] "Poor concentration" Both parents dyslexic 7/13/16 CI2016 Toronto 7

8 Case Age first CI Age second CI Bimodal stimulation Implant model Electrode length Cochleostomy/RW Gusher Full insertion R Pulsar Medium L Sonata Medium R 24 mm L 24 mm 1 1,6 2,3 Yes Average age first CI: 1 year 2 and 10 2,2months Yes, HA R ear L Sonata Medium L 24 mm Yes, 2 L Sonata Medium R Sonata Medium L 24 mm R 24 mm Half have received Yes 4 0,9 bilateral implants Yes, HA L ear R Sonata Medium R 24 mm R Cochleostomy Yes R Yes 5 1,6 2, ,5 R Sonata Standard L Concerto Medium 24 mm electrode in 13 of 15 surgeries R Sonata Medium L Concerto Flex 24 R 31 mm L 24 mm R 24 mm L 24 mm R RW R RW R Cochleostomy R RW Yes Yes R Yes L Yes L Yes, 3, 3 L Yes 7 2,3 Yes, HA L ear R Concerto Medium R 24 RW mminsertion in R RW Yes, 2 12 of 15 surgeries L FORM 24 L 24 mm L Cochleostomy L Yes 8 2,8 3,8 Yes R Flex 28 R 28 mm R RW R Yes Full insertion in 9 1,7 Yes, HA R ear L Synchrony Flex 24 L 24 mm Yes L Yes 11 of 15 surgeries 10 2,7 Yes, HA L ear R Concerto Medium 24 mm R RW Yes R Yes R Yes L Yes 7/13/16 8 CI2016 Toronto

9 Recommended Surgical Procedure Standard transmastoid approach Always a gusher, ml CSF Insertion when gusher has ceased Test electrode optional 24 mm straight electrode Intraoperative x-ray / CT mandatory Firm packing around the electrode 7/13/16 CI2016 Toronto 9

10 Complications Case 1 Cochleostomy/RW R RW Electrode position on intraoperative x-ray R Test electrode in IAC L Good position Postop CSF leak R Yes- 6 day conservative treatment Revision surgery Three cases of electrode in IAC on introperative x- ray One case of postoperative rhinorrhea No cases of revision surgery 2 L Good postion 3 R RW L Good postion R Elecrtode in IAC, repositioned 4 R Cochleostomy R Good position 5 6 R Cochleostomy R RW R Electrode in IAC, repositioned L Good psition R Good position L Good position 7 R RW R Good position 8 L Cochleostomy R RW L Good position R Electrode in IAC, repositioned R 2 mo post-op a short period of rhinnorea, never cofirmed to be CSF 9 L Good postion 10 R RW R Good position 7/13/16 CI2016 Toronto 10

11 Hearing outcome Speech audiometry N=6, remaining too young MWS in quiet (%): mean (SD) = 48 (19) MWS in noise (%): mean (SD) = 24 (10) Significantly worse than Karolinska mean Quiet: mean (SD) = 87 (16) Noise: mean (SD) = 61 (20) Sound localisation (EI): mean (SD) = 0.36 (0.14) High stimulation levels 7/13/16 CI2016 Toronto 11

12 Language Follow-up time: 0,1-8,1 years All are full time users Oral communication Mainstream school Case Age last follow-up Follow-up time Daily use of CI Communication mode School setting 1 9,7 8,1 Full time Oral Mainstreem school 2 9,8 7,6 Full time Oral Mainstream school 3 7,3 6,3 Full time Oral Mainstreem school 4 7,1 6,2 Full time Oral and Sign* Special unit 5 7,1 5,5 Full time Oral Special unit 6 5,6 4,6 Full time Oral and Sign* Deaf Pre School 7 4,2 1,4 Full time Sign, only word "mamma" Mainstream preschool, personal assient 8 4 1,2 Full time Oral Mainstream preschool 9 2 0,3 Full time Pre-communication Mainstream preschool, personal assistant 10 2,8 0,1 Full time Some words, some signs Mainstream preschool 7/13/16 CI2016 Toronto 12

13 Correlation to behavioural development? Preliminary findings indicate: Normal IQ Good speech Poor communication, especially in interactions with others Executive function difficulties, especially in the domain of impulse control, working memory and attention Most patients exhibit hyperativity and conduct problems that is indicative of ADHD 7/13/16 CI2016 Toronto 13

14 Summary Cochlear implantation is possible in x-linked deafness through a standard transmastoid approach with a 24 mm straight electrode. Good hearing outcomes can be achieved. X-linked POU3F4 deafness is today described as non-syndromal, however we believe that DFNX2 is instead a syndrome with HL and hyperactive disability. 7/13/16 CI2016 Toronto 14

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