Percutaneous Cochlear Access Using Bone-Mounted, Customized Drill Guides

Abstract

Percutaneous cochlear access can be performed using bone-mounted drill guides that are custom made on the basis of preintervention computed tomographic scans. We have previously demonstrated the ability to use image guidance based on fiducial markers to obtain percutaneous cochlear access in vitro. A simpler approach that has far less room for application error is to constrict the path of the drill to pass in a predetermined trajectory using a drill guide. Cadaveric temporal bone specimens (n = 8) were affixed with three bone-implanted fiducial markers. The temporal bone computed tomographic scans were obtained and used in planning a straight trajectory from the mastoid surface to the cochlea without violating the boundaries of the facial recess, namely, the chorda tympani, the incus buttress, and the facial nerve. These surgical plans were used to manufacture a customized drill guide by means of rapid prototyping (MicroTargeting Platform; FHC Inc.; Bowdoinham, ME, U.S.A.) that mounts onto anchor pins previously used to mount fiducial markers. The specimens then underwent traditional mastoidectomy with facial recess. The drill guide was mounted, and a 1-mm drill bit was passed through the guide across the mastoid and the facial recess. The course of the drill bit and its relationship to the boundaries of the facial recess were photographed and measured. Eight cadaveric specimens were subjected to the study protocol. In seven of eight specimens, the drill bit trajectory was accurate; it passed from the lateral cortex to the lateral wall of the cochlea without compromise of any critical structures. In one specimen, the access to the middle ear was achieved, but the incus was hit by the drill. The average shortest distance +/- standard deviation from the edge of the drill bit to the boundaries of the facial recess was 0.78 +/- 0.56 mm (chorda tympani), 2.00 +/- 1.06 mm (incus buttress), and 1.27 +/- 0.54 mm (facial nerve). Our study demonstrates the ability to obtain percutaneous cochlear access in vitro using customized drill guides manufactured on the basis of preintervention radiographic studies.