Pneumococcal otogenic meningitis is a rare postsurgical complication that can develop following stapedectomy or after cochlear implantation. The bacterial infection can be fatal in some instances. A recent increase in the incidence of otogenic meningitis among cochlear implant wearers is of concern. The majority of meningitis cases are associated with a 2-component electrode manufactured by one cochlear implant company. The device with the added ‘positioner’ component has been withdrawn from the market (FDA Public Health Web Notification: Cochlear Implant Recipients may be at Greater Risk for Meningitis, Updated: August 29, 2002, www.fda.gov/cdrh/safety/cochlear.html). Not all cases have been subsequent to otitis media and symptoms have developed from less than 24 h up to a few years after implantation. The purpose of this paper is to review and discuss the pathogenesis, pathology/bacteriology and to elaborate on some clinical features of otogenic meningitis in implanted children and adults. Essential aspects of surgery, electrode design, and cochleostomy seal are discussed. Conclusions are drawn from the available data and recommendations are made for good practice in cochlear implantation and follow-up.

Surgery for cochlear implants has undergone several modifications since the beginning of cochlear implantations [1,2]. Nowadays the most frequently used technique worldwide, the so-called 'classic' technique, uses a mastoidectomy and a posterior tympanotomy approach to the middle ear and the cochlea, with several options, regarding soft tissue handling. Even though this classic technique has been very efficient for the vast majority of the cases, we feel that in certain cases there were two main disadvantages: limited accessibility to the cochlea and related structures and a lot of trauma. In order to overcome these problems, we designed our own surgical technique. This involves using a transcanal approach to the middle ear and the cochlea and a direct tunnel drilled through the posterior bony canal wall to the facial recess. This tunnel is used as the pathway for the active electrode, which is then absolutely protected from being in contact with canal skin. Methods and Patients Operation DesignThe steps of the operation are: (1) endaural approach to the middle ear, (2) inspection of the middle ear and facial nerve anatomy by a small atticotomy if necessary, to rule out any irregularities, (3) drilling a direct tunnel, from behind the suprameatal spine to the facial recess, (4) cochleostomy through the endaural approach, (5) extension of the skin incision superoposteriorly, to expose the temporomastoid region, (6) creation of two flaps: a skin flap inferiorly based and a fascial flap superiorly based, (7) drilling the well for the device,

A high-performance liquid chromatographic (HPLC) method has been developed for the analysis of several benzodiazepines and some of their metabolites in blood, plasma and urine. The method included a liquid-liquid extraction with n-hexane:ethylacetate, a gradient elution on a C8 reversed phase column with a non-electrolyte eluent and a photo diode array detection. This allowed a rapid detection, a purity check, and identification as well as quantitation of the eluting peaks. The detection limit was 10 to 30 ng and the limit of quantitation was 0.05 μg/mL, using 1 mL of blood, plasma or urine. The procedure is applied routinely in forensic toxicological analyses involving blood, stomach content, urine and organ samples. About 30 positive cases are reported. The avoidence of the use of an electrolyte buffer in the eluent resulted in a robust procedure, free of technical problems and of long rinsing periods, suitable for routine use in forensic toxicology analysis involving blood, urine, stomach content and tissue samples.

The Veria operation is a non-mastoidectomy technique for cochlear implantation. It uses the transcanal approach to the middle ear and the cochlea. The steps of the procedure are: (1) endaural approach, that offers a wide accessibility to the middle ear structures; (2) inspection of the middle ear anatomy; (3) straightening of the postero-superior bony canal wall, which is usually concave; (4) performing the cochleostomy through the outer ear canal; (5) drilling of the suprameatal hollow, which is used for the accommodation of the electrode excess; (6) drilling of the trans-wall direct tunnel, which is the pathway for the active electrode; (7) alignment of the direct tunnel to the cochleostomy; (8) extension of the incision and preparing of the flaps; (9) creating of the bed and fixing the device; (10) insertion of the electrodes; (11) manipulating the excess of the active electrode, and (12) closing. For this technique, two special instruments have been developed: a special perforator used for the drilling of the direct tunnel for the active electrode, making it completely safe, and a safety electrode forceps used to manipulate the active electrode during insertion. The direct tunnel can be enlarged superiorly permitting insertion of two electrodes, in cases where a double electrode array implant has to be used. The method is an efficient tool for handling all cochlear implant cases, including difficult ones such as revision cases, malformations, cochlear ossifications and poor mastoid development. It is safe without complications in over a hundred cases and easy to learn.

The ‘Veria operation’ is a new technique for cochlear implantation. It is a non-mastoidectomy technique and uses the endaural approach for the cochleostomy and a direct tunnel drilled through the supero-posterior bony canal wall for the electrode. Two special instruments have been developed for this technique: a special perforator for the drilling of the direct tunnel and a safety electrode forceps for the insertion of the electrode. The method has been used in 101 cases with an age range from 2.5 to 75 years. 78 of them were primary operations and 23 revision cases. From the revisions, 18 were surgical failures and 5 were device failures. There were two complications: in 1 case there was a thick skin flap, which was corrected under local anesthesia, and in 1 malformation case there was a retrograde insertion to the vestibule and the posterior semicircular canal, corrected 6 weeks later. The analysis of the results shows that this method has certain advantages, which are: it is simple and therefore the learning curve is fast; it is safe for the facial nerve, as the drilling is precisely controlled by the special perforator; it produces minimal bone trauma and due to fast healing, it permits early fitting a few days after operation; it is suitable for the difficult and revision cases and it can be used for very small children where the mastoid may have not been yet sufficiently developed.