cochlear implants international, Vol. 11 Suppl.

2, September, 2010, 5763

Cochlear Rotation and its Relevance to

Cochlear Implantation
Simon KW Lloyd
Department of Otolaryngology, Manchester Royal Infirmary, UK

Anand V Kasbekar and Bruno Kenway

Department of Otolaryngology, Cambridge University Hospitals, UK

Toby Prevost
Department of Applied Medical Statistics, Cambridge University, UK

Maurice Hockman
Johannesburg Cochlear Implant Group, South Africa

Timothy Beale
Department of Radiology, Royal National Throat Nose and Ear Hospital,
UK

John Graham
Department of Otolaryngology, Royal National Throat Nose and Ear
Hospital, UK

Objectives: To investigate changes in cochlear orientation with age and discuss the implications of any change with respect to cochlear implantation.
Study Design: Cross-sectional study of computerized tomography scans of
the temporal bones in patients with no congenital abnormalities.
Patients: 159 patients were included in the study making a total of 318 ears.
The age range was nine months to eighty five years.
Intervention: Axial compututed tomography scans showing the basal turn of
the cochlea were identified. The angle of the basal turn of the cochlea was
measured by drawing a line through the long axis of the basal turn and
measuring its angle with a line drawn through the midsagittal plane. The
patients were grouped according to age and a one way analysis of variance
was used to identify any statistically significant change in basal turn
angulation. Inter- and intra-observer errors were calculated and presented as
2010 W. S. Maney & Son, Ltd

DOI 10.1179/146701010X12726366067815

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SIMON KW LLOYD et al.

repeatability co-efficients. The basal turn angles of 3 difficult cases of

cochlear implantation were related to the findings.
Results: The mean basal turn angle was 54.6 (range 46.863.8; SD 3.5).
There was a statistically significant reduction in the angulation of the basal
turn with increasing age (F=10.1; p=0.002). The majority of the change
occurs between the ages of eleven and fifteen. The inter-observer reliability
co-efficient was 4.8. The intra-observer reliability co-efficient was 2.0. The 3
difficult cases all had basal turn angles that were at the upper limit of the
normal range.
Conclusions: There is a statistically significant reduction in basal turn angulation relative to the midsagittal plane with increasing age. However, care
should be taken in interpreting these results in light of the inherent error in
the measuring technique although the intra-observer repeatability coefficient
was only 2.0. The more obtuse angulation of the basal turn in children may
have implications for cochlear implantation.
keywords anatomy, cochlea, cochlear implant, temporal bone

Introduction
It has become doctrine in Otolaryngology that the labyrinth reaches adult size and
morphology by 16 to 20 weeks gestation(1). However, there is some evidence that
subtle changes may occur to the labyrinth into adulthood(2).
Following review of the computed tomography (CT) images of three paediatric
patients in whom cochlear implant was difficult, it appeared that the orientation
of the basal turn of the cochlear was more obtuse relative to the midline than in
other patients. The authors therefore decided to analyse a series of patients undergoing computed tomography imaging in order to investigate changes in cochlear orientation with age and discuss the implications of any change with respect to cochlear
implantation.

Methods
This study was a cross-sectional study of CT scans of the temporal bones in patients
with no congenital abnormalities. The most representative axial slice through the
basal turn of the cochlea was identified. A line was drawn through the midline and
through the long axis of the basal turn. The midline was defined by a line drawn
through the junction of the face of the sphenoid bone and the nasal septum anteriorly and through the internal occipital protruberanceposteriorly. The angle between
these bisecting lines was then measured using radiological software (Figure 1).
One hundred and fifty nine patients were included in the study making a total of
318 ears. The mean age was 33.7 years (range 9 months to 85 years). There were 73
females and 86 males.
The patients were grouped according to age (as shown in Table 1).The age categories were narrower for the younger groups as it was assumed that any observed
change in cochlear orientation was more likely to occur in the early years. All angles

COCHLEAR ROTATION AND ITS RELEVANCE TO COCHLEAR IMPLANTATION

59

figure 1 Axial high resolution CT scan of the temporal bones showing the basal turn of
the cochlea in a six year old and the technique used to measure the angle of the basal turn
relative to the midsagittal plane. In this case the basal turn is obtusely angled with an angle
of 63.21 degrees to the midline. Length refers to the length of the line representing the
midline is not relevant to the measurement of basal turn angle.

were measured by a single observer (BK). However, in order to check intra-observer

error, the measurements of thirty three randomly selected patients were repeated by
the same observer more than 1 week after the original measurements were taken.
Similarly, inter-observer error was checked by comparing angles measured by the first
observer in fifty nine randomly selected patients with those of a second observer. For
the purposes of analysis, the right and left ear angles were averaged to produce a
single angle for each individual patient. A one way analysis of variance was used to
identify any statistically significant change in basal turn angulation. Inter- and intraobserver errors were calculated and presented as repeatability co-efficients according
to the Bland Altmann technique. The basal turn angles of the three difficult cases of
cochlear implantation were related to the findings.

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SIMON KW LLOYD et al.

TABLE 1
TABLE SHOWING THE MEAN BASAL TURN ANGULATION RELATIVE TO THE MIDSAGITTAL PLANE
GROUPED INTO AGE CATEGORIES.
Age Category (years)

Mean (degrees)

SD

01

55.5

4.0

25

14

57.0

3.9

610

10

55.3

5.0

1115

13

56.2

3.0

1620

15

54.8

3.8

2130

18

53.9

2.9

3140

24

54.5

2.7

4150

20

53.4

3.5

5160

16

53.2

3.6

6170

11

54.5

3.7

7185

12

53.6

2.5

Total

159

54.6

3.5

Results
All data were normally distributed. The mean basal turn angles for right and left
ears respectively were 54.9 (Range 46.464.0; SD 3.7) and 54.2 (Range 45.564.3;
SD 3.8). These were strongly correlated (Pearson correlation co-efficient=0.768).
Following averaging of the right and left basal turn angles for each patient, the mean
basal turn angle was 54.6 (Range 46.863.8; SD 3.5). This data is summarised in
Figure 2. Table 1 summarises the basal turn angles according to age stratification.
This data is shown in the form of a box-whisker chart in figure 3. There was a statistically significant reduction in the angulation of the basal turn with increasing age
(F=10.1; p=0.002). The majority of the change occured between the ages of 11 and
15. The inter-observer reliability co-efficient was 4.8. The intra-observer reliability
co-efficient was 2.0. The 3 difficult cases all had basal turn angles that were at the
upper limit of the normal range (66, 63, 71).

Discussion
Current opinion in the literature investigating post-partum developmental changes in
the labyrinth is still divided. However, it would seem that some significant although
subtle changes in labyrinthine morphology may be possible even after complete
ossification of the otic capsule. Data regarding cochlear orientation in particular is
sparse but the results of Jeffery and Spoor suggest that there is a significant agerelated reduction in the angle of the cochlea relative to the sagittal plane during
foetal life although they found that postnatal changes in this angle were not statistically significant(2). The findings of this study suggest that there may be subtle changes
in cochlear orientation post-partum. However, it is important to bear in mind that

COCHLEAR ROTATION AND ITS RELEVANCE TO COCHLEAR IMPLANTATION

figure 2
plane.

61

Histogram illustrating the distribution of cochlear angles relative to the sagittal

the measurement error inherent in the technique used in this study, although small,
means that the results should be interpreted carefully.
It is possible that the observed changes in orientation of the basal turn of the
cochlea do not reflect remodeling of the otic capsule itself but instead result from
changes in the morphology of the cranium during post-partum development. It is
widely accepted that remodeling of the otic capsule is inhibited once the labyrinth is
fully developed and that this inhibition is required for maintenance of normal hearing. In contrast, the cranial vault and skull base undergo considerable change during
post-partum development.
The growth of the cranium is not linear and differs between the sexes. There is a
period of rapid growth between the ages of 1 and 4 years and another around the
ages of 11 and 12 years following which the spheno-occipital synchondrosis fuses(3).
These periods of rapid growth occur earlier in females. The temporal changes documented in this paper appear to mirror those of the cranium as a whole. However,
it should be noted that the basicraniummay have a more linear growth pattern
compared with the rest of the cranium.
It is clear from the results of this study, that there is considerable variation in the
normal range of cochlea orientation. This is consistent with the findings of other
authors(4). It should also be noted that although congenitally abnormal cochleas were

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SIMON KW LLOYD et al.

figure 3 Box-whisker chart showing mean and quartiles for basal turn angles of each age
category. Circles represent outlying cochlear angles.

excluded from the study, during the screening process it was clear that the majority
of congenitally abnormal cochleas tended to have a greater basal turn angle relative
to the sagittal plane (unpublished data). These findings may have implications for
cochlear implantation, particularly in the paediatric population. In the 3 cases of
difficult cochlear implantation presented, each had a particularly obtuse basal turn
angle that was at the upper extreme of the normal distribution curve. This may have
resulted in the difficulties experienced during implantation.
Kennedy has demonstrated using histological and endoscopic examination of the
cochlea after electrode insertion that there is often significant damage to the spiral
ligament in the basal turn following insertion and that passage of the electrode
beyond the point at which resistance is felt can result in much more significant
cochlear damage including damage to the basilar membrane(5). Although the clinical
significance of such damage remains unclear, it is likely that a smooth linear approach
into the basal turn is preferential to a more oblique approach. In cases with an
obliquely angled basal turn it may be advantageous to consider an approach via the
middle ear rather than through a posterior tympanotomy. Other factors may also
influence the ease of access to the basal turn. These include the size and orientation
of the facial recess, the position of the facial nerve and the chorda tympani together
with the orientation of the posterior canal wall of the external auditory canal.

COCHLEAR ROTATION AND ITS RELEVANCE TO COCHLEAR IMPLANTATION

63

The position of the cochleostomy is critical if damage to the inner ear structures is
to be avoided. This is particularly true now that it has become clear that it is possible
to preserve residual hearing in patients undergoing cochlear implantation. It should
be noted, however, that in the initial cases described here, no specific attempt was
made to preserve hearing as the cases pre-dated the introduction of soft surgical techniques in our department. The ideal position of the cochleostomy in order to prevent
inner ear damage is controversial and recommendations in the literature vary from
different positions in the otic capsule to round window insertion. A recent paper by
Li et al.(6) has suggested that the bone around the round window niche should be
removed and that a cochleostomy immediately anterior and inferior to the round
window membrane should be performed as the critical structures of the inner ear are
at their greatest distance from the cochleostomy site in this position and access to the
scala tympani is optimal. Similarly, in the cochlear implant patients included in the
current study, it was advantageous to remove bone around the round window in
order to identify the scala tympani.

Conclusions
There is considerable variation in the normal range of cochlear orientation between
individuals and there appears to be a significant reduction in the angle of the basal
turn of the cochlea relative to the midsagittal plane with increasing age. This finding
challenges the traditional view that the morphology of the labyrinth does not change
following birth. However, care should be taken in interpreting these results bearing
in mind the measurement error inherent in the study design.
Obtuse angulation of the basal turn relative to the sagittal plane may make
cochlear implantation more difficult. Children are more likely to have an obtusely
angled basal turn that may predispose children to difficult implantation. We recommend measuring the angle of the basal turn of the cochlea relative to the mid-sagittal
plane in all preoperative scans, to identify cases in which the basal turn of the cochlea
may be in an unusual location.

References
Bast, T.H. 1942. Development of the otic capsule. VI. Histological changes and variations in the growing bony
capsule of the vestibule and cochlea. Ann Otol Rhinol Laryngol, 51: 34357.
Jeffery, N. & Spoor, F. 2004 Feb. Prenatal growth and development of the modern human labyrinth. J Anat,
204(2): 7192.
Farkas, L.G., Posnick, J.C. & Hreczko, T.M. 1992 Jul. Anthropometric growth study of the head. Cleft Palate
Craniofac J, 29(4): 3038.
Erixon, E., Hogstorp, H., Wadin, K. & Rask-Andersen, H. 2009 Jan. Variational anatomy of the human cochlea:
implications for cochlear implantation. Otol Neurotol, 30(1): 1422.
Kennedy, D.W. 1987 Jan. Multichannel intracochlear electrodes: mechanism of insertion trauma. Laryngoscope,
97(1): 429.
Li, P.M., Wang, H., Northrop, C., Merchant, S.N. & Nadol, J.B., Jr. 2007 Aug. Anatomy of the round window
and hook region of the cochlea with implications for cochlear implantation and other endocochlear surgical
procedures. Otol Neurotol, 28(5): 6418.

Email: sklloyd@me.com