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Cochlear implantation has become established worldwide as a safe and effective method of auditory rehabilitation of selected severely and profound deaf children and adults.
Cochlear implantation (CI) has become established worldwide as a safe and effective intervention for auditory rehabilitation of selected severely and profound deaf children and adults with sensorineural hearing loss (1, 2). The aim of a cochlear implant is to replace a non-functional inner ear hair cell transducer system by converting mechanical sound energy into electrical signals that can be delivered to the cochlear nerve in profoundly deaf patients (6). Data relating to patients who received cochlear implantation between October 2007 and February 2010 were studied.
From the outset of the programme, the classical surgical technique for cochlear implantation has been used on all patients.
Post-auricular incision performed with a view of the cochlear implant (Courtesy of Dr Anwer Esriti). The study revealed that 21 (56.8%) patients presented with congenital hearing loss as the primary aetiology of their deafness (Table 1). Seventeen patients (45.9%) had a positive history of deafness in the family (a first degree relative suffering from deafness).
Two patients were installed with cochlear implants in spite of their diagnosis of auditory neuropathy.
Until now, there has been no study identifying geography as a cause or an influence on the aetiology of deafness.
Due to financial implications associated with developing a cochlear implant programme in a developing country, post-operative hearing testing was very limited. A number of studies have shown that excellent results are feasible as well as achievable in pre-lingual patients when a cochlear implant is received before the age of three without surgical complications or functional tuning difficulties (3, 6, 8). Initially, early identification of high risk patients is necessary, particularly patients with a positive family history. Firstly, this has led to earlier presentation of patients with a complaint of hearing loss.
As prevention is better than cure, it is a timely opportunity for the obstetrics and neonatal services in Libya to be reviewed. Inherited causes of hearing impairment are an important cause of severe and profound hearing loss (13). Although all patients benefited greatly from their implants, it is difficult to compare these results to other studies, without the use of pure tone audiograms and listening profiles. The LCIP has proved to be a successful rehabilitative intervention for children and adults in the country so far. The authors have not received any funding or benefits from industry or elsewhere to conduct this study.
The Pakistan (Lahore) cochlear implant programme: issues relating to implantation in a developing country. Cochlear implantation in a district general hospital: problems and complications in the first five years.
Cochlear implantation at King Abdulaziz University Hospital, Riyadh, Saudi Arabia: a 12-year experience.
Surgery and functional outcomes in deaf children receiving cochlear implants before age 2 years. Libyan Journal of Medicine eISSN 1819-6357, ISSN 1993-2820This journal is published under the terms of the Creative Commons Attribution-Noncommercial 4.0 Unported License. Over 100,000 patients have received cochlear implants worldwide with the paediatric population proving to be the main beneficiaries.
Cochlear implantation allows the implant beneficiary to reintegrate with the hearing world (3).
Prior to the development of the programme, patients predominantly travelled to Europe as well as neighbouring Arab countries such as Egypt and Jordan for cochlear implantation. However, other ENT departments in Libya have offered this procedure mainly to be carried out by visiting surgeons from across the world. One patient had a cerebrovascular accident that led to deterioration in hearing and as a result was installed with a cochlear implant. While in comparison, patients with a negative family history of deafness, 2 patients (10%) had parents related to the first degree, 1 (5%) with second degree related parents, and 17 patients (85%) with parents not blood related.
However, as with any type of surgery, it possesses the risk of minor and major complications (2). There were minor complications in three patients (8.1%), all of whom had a haematoma surrounding the implant occurring within the first week of surgery.
The remote location of some patients and the distances travelled by these patients to reach Tripoli is remarkable.

Currently, a post-operative x-ray is performed to identify the location of the implant as well. The desired aim of the LCIP, as well as other cochlear programmes, is to implant younger pre-lingual children as soon as possible, eventually even during the first year of life from a neuro-developmental point of view (6). Extensive media coverage of the programme on local television has encouragingly raised awareness and provided great exposure to the public about hearing loss and the cochlear implant programme among the general public. Secondly, this has lowered the thresholds of families in coming forward with their children with delayed hearing development. Perinatal and neonatal causes of hearing loss appear to be prevalent in this study for some reason or another. Previous studies (14, 15) have revealed that 70% of cases of severe hearing loss were the result of consanguineous marriages (1). As a number of patients travel vast distances to present to TMC, outreach programmes could be offered and set up in a number of cities across Libya in order to assess patients locally and intervene sooner. Further government funding is required to continue the progress already made and provide the means to improve the existing programme. Essentially, the aim of a cochlear implant is to provide direct stimulation of the spiral ganglion cells of the cochlear nerve bypassing the damaged hair cells (6). Tripoli Medical Centre (TMC) is a public hospital with about 1,450 beds, 1,000 physicians, and approximately 3,000 employees.
However, due to substantial financial implications of medical care and travelling among many other factors, very few patients could afford the costs of surgery, aftercare, and rehabilitation. Data relating to these procedures and patient profiles of those implanted outside TMC, although very few, are unfortunately unknown and have not been included in this report. Patient records available at the time of the study includes age of patient at implantation, year of implantation, place of birth, diagnosis leading to hearing loss, perinatal, neonatal and medical history, pre-operative investigations (Computed Tomography [CT] and Magnetic Resonance Imaging [MRI]), pre-operative audiometry tests, and any post-operative complications.
Each patient taking part in the LCIP was given a specialist auditory and communication skills training that was incorporated in their rehabilitation programme at TMC. Thirty-five patients (94.6%) presenting to the programme were diagnosed with sensorineural hearing loss (SNHL). This patient unfortunately died a number of months after being implanted, the cause of which was not linked to the surgery. As classified by the WHO, all patients were identified as having profound hearing impairment (81 dB or greater in better ear).
The hypothesis of geographical factors influencing deafness will be reviewed in the discussion section of this paper.
A major complication is defined as one leading to explantation or re-implantation, death of a patient, or stay in hospital in excess of 1 week. In two of these patients, their haematomas resolved spontaneously, while the third patient had his haematoma aspirated and all recovered without incidence.
The matter of installing cochlear implants in patients with auditory neuropathy is still a contentious one and is currently being hotly debated. One of the main criteria in selecting patients for the LCIP was their commitment to rehabilitation post-operatively.
Ideally, the assessment of speech and language development post-implantation include hearing threshold levels, measured by pure tone audiograms as well as listening progress profiles.
In reality this concept, however, is dependent on a number of factors for it to succeed in Libya. This issue has so far been dealt with well in Libya, ever since the introduction of the LCIP. Thirdly, it has given members of the multi-disciplinary team an opportunity to intervene at an earlier stage and offer their services and recommend rehabilitation sooner than what was previously possible. Firstly, government funding and backing is required to set up a successful screening process. Eleven patients (29.7%) had history relating to conditions such as birth asphyxia, meconium aspiration, and febrile convulsions. Future research is required to identify the genetic causes of hearing loss particularly in consanguineous marriages and in those with a positive family history of hearing impairment. Future initiatives such as health education, genetic counselling, adequate perinatal and neonatal care, immunisation programmes, and screening will all go a long way in preventing deafness, identify those at risk, and allow earlier intervention of people affected by a hearing impairment in Libya. Data relating to the patients who received cochlear implantation at Tripoli Medical Centre between October 2007 and February 2010 were analysed.
It is estimated that over 100,000 patients have received cochlear implants worldwide with the paediatric population proving to be the main beneficiaries from this prosthesis (1, 3). The aim of this report is to describe the experiences and progress of the cochlear implant in Libya.

The LCIP currently accepts the minimum age for implantation of 2 years for anatomical reasons. The pericranium is raised with the skin flap in order to maintain good vascular supply, as mentioned in previous studies (4). Two patients (5.4%) that were diagnosed with auditory neuropathy were referred for cochlear implantation and will be discussed further on in this study.
A minor complication is defined as self-limiting or improves with conservative management (2, 3).
Two patients (5.4%) included in the study were re-implanted due to damaged implants that were performed in 2004.
However, there are promising signs as demonstrated by a previous study (12), which suggests that the outcome of implanting patients with auditory neuropathy does not differ drastically from their paediatric counterparts with sensorineural hearing loss. However, due to a lack of funds, politics and the LCIP being a relatively new cochlear programme, these forms of monitoring after implantation were neither available nor correctly recorded to be added to this study.
Secondly, a more intensive and interactive campaigning with the general population about hearing loss are needed for quicker presentation. Future research and review of these services in Libya may help tackle what may possibly be avoidable causes of hearing loss. Additionally, an appraisal of the perinatal and neonatal services in Libya is needed to review the high numbers of perinatal and neonatal conditions leading to impaired hearing. Studies have revealed that the majority of CI users, affected by pre- or post-lingual deafness, acquire considerable benefit from this intervention (4).
In addition to the inhabitants of Tripoli, patients from across Libya present to TMC due to its level of expertise, facilities, and provision of care.
Afterwards, a cortical mastoidectomy is performed and a bed (bony well) is drilled for the receiver-stimulator unit (8). Both remaining adult patients underwent intensive auditory post-implantation and have since integrated well into society and are content with the results of the implant.
During the programme, only one patient (2.7%) developed CSF gusher, which is considered a major complication (Table 3).
Previous studies hypothesise that the cochlear implant is able to overcome the theory of principal desynchronisation as thought with auditory neuropathy (12). There were 56.8% patients that presented with congenital hearing loss, which is comparable to other reports (3).
Hopefully, this will eventually take in the form of genetic counselling of blood-related parents and families with positive histories of hearing impairment.
Cochlear implantation is currently the only means of restoring a sufficient level of hearing in patients with severe to profound hearing impairment that are not remedied by conventional methods such as hearing aids (5). Posterior tympanotomy is then carried out, followed by cochleostomy, which has been enthusiastically adopted by cochlear implant surgeons as it provides good access to the round window and promontory (9). This complication was managed by operating on the patient again and occluding the Eustachian tube and the cochleostomy site. The incidence of sensorineural hearing loss among children in Libya until today is still unknown and requires further research.
Although, perhaps not common in the West, the practice of consanguineous marriages is prevalent and frequent practice in many countries across the world, especially in the Middle East and parts of Asia for a number of social and cultural circumstances (1, 3, 14, 15).
All these factors make cochlear implantation arguably the most successful neural prosthesis in the history of medicine. Care and precision is taken not to mistake hypotympanic cells for the round window niche in order to correctly insert the electrode array in the scala tympani, in order to prevent what is considered an unacceptable complication (4).
Two patient's otoacoustic emissions were identified, in addition to their abnormal ABR and hence were given a diagnosis of auditory neuropathy.
In spite of this, certain steps could be taken in view of preventing hearing loss as much as possible. All paediatric patients were given intra- and post-operative prophylactic antibiotics (ceftriaxone) against meningitis. Schemes such as health education, genetic counselling, adequate perinatal and neonatal care, immunisation programmes and screening will all synergistically benefit the citizens of Libya and its health service in treating those with a hearing impairment.
The overall rate of minor and major complications was 16.2%, which is comparable to previous studies.

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