Complications of pediatric cochlear implantation

Comparison of Adult and Pediatric Cochlear Implant Wound Complications: A Meta-Analysis

OBJECTIVE

To compare age-related differences in wound complications following cochlear implantation (CI).

METHODS

We performed a systematic review of PubMed, Cochrane Database, and Web of Science databases to identify original research evaluating the patient-level factors (demographics and medical history) associated with wound complications following CI. Outcomes were expressed as relative risk (RR) with 95% confidence intervals using the inverse variance method. Studies without comparison groups were described qualitatively.

RESULTS

Thirty-eight studies representing 21,838 cochlear implantations were included. The rate of wound complications ranges from 0% to 22%. Patient age (adult versus pediatric) was the only factor with comparison groups appropriate for meta-analysis. The 10 studies (n = 9547 CI's) included in the meta-analysis demonstrated that adults had a higher incidence of overall wound complications (2.94%) than in children (2.44%) (RR 1.31, 95% CI 1.01-1.69). Adults had a higher incidence of general/unclassified wound complications (2.07%) than in children (1.34%) (RR 1.68, 95% CI 1.12-2.52). There was no difference between adults and children for specific complications such as hematoma, infection, or seroma. Elderly patients (over age 75) have wound complication rates that range from 1% to 4%. No studies contained comparison groups regarding other patient-level factors and CI wound complications.

CONCLUSION

CI wound complication rates reported in the literature are low; however, adults have a higher risk of these complications than pediatric patients. The reported complication rate in elderly adults is low. There is a gap in CI research in consistently reporting wound complications and rigorous research investigating the impact of patient-level factors and wound complications.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:218-226, 2023.

Effects of Age on Delayed Facial Palsy After Otologic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To report 4 cases of delayed facial palsy (DFP) after pediatric middle ear (ME) surgery and systematically review and analyze the associated literature to evaluate the effects of age on DFP etiology, management, and prognosis.

METHODS

Systematic review of PubMed, Cochrane Library, and Embase for articles related to DFP after cochlear implantation (CI) was performed. These articles were assessed for level of evidence, methodological limitations, and number of cases. Meta-analysis was performed to assess the effects of age on DFP incidence. Furthermore, a comprehensive list of all pediatric DFP cases after otologic surgery was assembled through a multi-institutional retrospective review and systematic review of the literature.

RESULTS

Twenty-nine articles fit the criteria for inclusion in the meta-analysis. The incidence of DFP after CI was 0.23% and 1.01% for pediatric and adult cases, respectively. This difference was statistically significant (P < .001, odds ratio 4.36). Twenty-three cases, adding to the 4 presented herein, were suitable for a comprehensive list. The mean age was 6.9 years. Average postoperative day of paresis onset was 5.4, with an average maximum House-Brackmann grade of 3.5. All patients obtained full facial recovery after an average of 23.5 days.

CONCLUSIONS

The systematic review demonstrates that DFP after pediatric CI is rare and occurs at a significantly lower rate than in adults, further supporting the viral reactivation hypothesis of DFP. The prognosis for pediatric DFP after otologic surgery is excellent, with a high rate of full recovery in a short time frame. However, steroid administration can be considered.

LEVEL OF EVIDENCE

IIa.

Cochlear implant - state of the art

Cochlear implants are the treatment of choice for auditory rehabilitation of patients with sensory deafness. They restore the missing function of inner hair cells by transforming the acoustic signal into electrical stimuli for activation of auditory nerve fibers. Due to the very fast technology development, cochlear implants provide open-set speech understanding in the majority of patients including the use of the telephone. Children can achieve a near to normal speech and language development provided their deafness is detected early after onset and implantation is performed quickly thereafter. The diagnostic procedure as well as the surgical technique have been standardized and can be adapted to the individual anatomical and physiological needs both in children and adults. Special cases such as cochlear obliteration might require special measures and re-implantation, which can be done in most cases in a straight forward way. Technology upgrades count for better performance. Future developments will focus on better electrode-nerve interfaces by improving electrode technology. An increased number of electrical contacts as well as the biological treatment with regeneration of the dendrites growing onto the electrode will increase the number of electrical channels. This will give room for improved speech coding strategies in order to create the bionic ear, i.e. to restore the process of natural hearing by means of technology. The robot-assisted surgery will allow for high precision surgery and reliable hearing preservation. Biological therapies will support the bionic ear. Methods are bio-hybrid electrodes, which are coded by stem cells transplanted into the inner ear to enhance auto-production of neurotrophins. Local drug delivery will focus on suppression of trauma reaction and local regeneration. Gene therapy by nanoparticles will hopefully lead to the preservation of residual hearing in patients being affected by genetic hearing loss. Overall the cochlear implant is a very powerful tool to rehabilitate patients with sensory deafness. More than 1 million of candidates in Germany today could benefit from this high technology auditory implant. Only 50,000 are implanted so far. In the future, the procedure can be done under local anesthesia, will be minimally invasive and straight forward. Hearing preservation will be routine.

Epicutaneous patch test--a new diagnostic option to prevent the rejection of silicone-covered cochlear implants in children

OBJECTIVES

Cochlear implantation (CI) is a revolutionary method for hearing rehabilitation in patients with severe or profound sensorineural hearing loss. One of the surgical complications may be the necrosis of the skin flap above the receiver-stimulator coil, resulting in device extrusion. Our aim was to find the plausible causes of the silicone covered implant rejection.

PATIENTS AND METHODS

Authors present four cases of cochlear implant rejection, briefly describe their dermato-surgical solutions and analyse their innovative method - the epicutanoeus patch testing with silicone samples.

RESULTS

They observed positive skin reaction in three of the four cases.

CONCLUSION

Authors analyse the applicability and results of their surgical solutions and the epicutaneous testing in connection with the prevention of skin flap necrosis and rejection of silicone-covered cochlear implants.

A Study of Complications and Morbidity Profile in Cochlear Implantation: The MERF Experience

Cochlear implantation (CI) has been established worldwide as the surgical treatment for individuals with bilateral severe to profound hearing loss. This is a safe and standard procedure in the hands of experienced implant surgeons. Complications due to surgery are minimal and are often encountered in cases with congenital anomalies of the temporal bone and inner ear. Complications in CI are related to malfunctioning of the device or the process of wound healing. In most cochlear implant centers, as the surgeon's skill and clinical expertise in managing various cochlear implant cases improves with years of experience, the complication rates in his series ideally come down over time. Over the years, these well experienced clinics become tertiary referral centers for CI, receiving many difficult cases for implantation and hence such centers report data on complications, which become an important reference for many aspiring implant surgeons. Our study, performed in a premier CI centre in Chennai, looks at the various complications which were encountered in a case series of 300 implantees. Retrospective descriptive study with data collected from operative notes, patient questionnaires, auditory habilitation registers and medical records of cochlear implantees operated between, November 2006 to November 2010. A spectrum of major and minor complications, were categorized. Their incidence rates in relation to the demography of the patient profile and various events during surgical procedure were documented and analyzed. Appropriate management protocols were defined. Our management protocols have been highlighted and the relevant literature reviewed. This report of our experience with 300 cochlear implantees, reveals that complication rates at our center are in comparison with reputed centers worldwide. CI is very safe in the long term and provides optimal auditory awareness with speech perception and intelligibility for profoundly deaf individuals giving them an avid opportunity to integrate within the normal society.

Cochlear Implantation in Children with Anomalous Cochleovestibular Anatomy

Objective. To determine the influence of inner ear dysplasia on both surgical and audiologic outcomes following pediatric cochlear implant (CI) surgery.

Data Sources. MEDLINE (1982-2009) and data from Massachusetts Eye and Ear Infirmary.

Review Methods. A systematic review of the literature was performed. Variables assessed included age at implantation, duration of CI use, radiologic and operative findings, and speech perception outcome data.

Results. The initial search yielded 1326 articles. Including data from our own study, twenty-two fulfilled criteria for inclusion, representing 311 patients. Data for bilateral implants were recorded only for the first implant. Data on simultaneous bilateral implants were not recorded. The most common anomaly seen was large vestibular aqueduct (89/311 or 29%). When comparing patients with mild-moderate or severe dysplasia, rates of cerebrospinal fluid gusher were 31% versus 35% (odds ratio [OR] = 0.50), anomalous facial nerve anatomy was seen in 11% versus 51% (OR = 0.15), and postoperative speech perception abilities were found in 84% versus 54% (OR = 1.93), respectively. A large heterogeneity was found among studies regarding all outcome measures.

Conclusion. Although we found that severe inner ear dysplasia was associated with increased surgical difficulty and lower speech perception, the lack of uniformity in published clinical data limited the strength of these results. Standardization of surgical and radiologic reporting as well as more consistent speech perception testing is needed to better determine the association between anomalous cochleovestibular anatomy and clinical outcomes.

Management of otitis media-related diseases in children with a cochlear implant

CONCLUSION

In all, 4 of 19 children with a cochlear implant (CI) with otitis media developed cholesteatoma. The insertion of a CI may interfere with normal mastoid pneumatization, stimulate mucosa as foreign body, or act as a nidus of infection. Regular follow-up is necessary for children with a CI at the prevalent ages of otitis media. Antibiotic treatment is suggested whenever acute otitis media is suspected, to prevent chronic progress of infection, cholesteatoma, or even meningitis.

OBJECTIVE

To evaluate treatment modality and outcomes of otitis media-related diseases in children with a CI.

PATIENTS AND METHODS

This was a retrospective case review in a tertiary referral center of Taipei Medical University, Chi Mei Medical Center. All patients had a history of otitis media or related disease in the implanted ear. Treatments included antibiotics, tympanotomy, and tympanomastoidectomy.

RESULTS

In all, 19 of 186 children with a CI were identified as having otitis media, and 4 of them as having cholesteatoma. Among the others, 10 were identified as having acute otitis media, 4 as having middle ear effusion, and 1 as having mastoiditis in the implanted ear. Surgery was performed in children with cholesteatoma and mastoiditis. The CIs of three children were eventually explanted to eradicate cholesteatoma.

An Evaluation of the Risk of Cerebrospinal Fluid Leakage as a Function of the Surgical Approach to the Cochlear Nerve

OBJECTIVE

Direct implantation into the cochlear nerve can bypass the potential limitations of conventional cochlear implants. Implantable electrical arrays increase the number of stimulation sites, broaden frequency selectivity, require less activating current, and are not dependent on cochlear anatomy. Cochlear nerve implantation demands a unique surgical exposure to the modiolus. This study comprises an assessment of the risk of generating an intraoperative cerebrospinal fluid (CSF) leak using this approach.

METHODS

Five fresh cadavers were obtained for dissection. Using dyed normal saline as an indicator, the central nervous system was pressurized to physiological parameters. Surgical approaches to the cochlear nerve were initiated. Leakage of indicator fluid for each approach was quantitatively and qualitatively assessed. Indicator dye in the surgical field was considered a CSF breech. Indicator fluid was collected and quantified.

RESULTS

Eighty percent of the surgical approaches caused quantifiable leaks with rates ranging from 0.1 mL/minute to 6 mL/minute. For directly implanted microarrays, the utilization of a modified facial recess approach with cochleostomy and modiolar drillout carries significant risk for generating a CSF leak during the procedure.

Complications in Children with Long-Term Cochlear Implants

OBJECTIVES

To evaluate the complications in children who underwent cochlear implantation between 1991 and 2002 at Chi Mei Medical Center, Taipei Medical University.

METHOD

The medical records of 169 cases of pediatric cochlear implants from 1991 to 2002 with a follow-up period of 3-11 years were reviewed for demographics and complications. A follow-up phone call and clinical visits were performed to determine the long-term results.

RESULTS

The medical-surgical complications were facial nerve stimulation, transient dizziness, flap breakdown, minor change of taste, cholesteatoma, otitis media with effusion and mastoiditis. The device-related complications included 4 device failures and 1 device breakage in a traffic accident.

CONCLUSION

Chronic otitis media and cholesteatoma developed in children as long-term complications and surgical challenges. Nevertheless, cochlear implantation surgery in children is a reliable and safe procedure with a low percentage of severe complications. To prevent cholesteatoma formation, parents are advised to schedule a regular ENT consultation at least yearly for early identification and treatment in the stages of acute otitis media or drum retraction.

[Complications of cochlear implant surgery]

During the last several decades, cochlear implant has been fully recognized in treatment of severe hearing loss. Development of modern technology enabled inconceivable possibilities of technical qualities of the device as well as development of usable coding strategies, which led to extraordinary results in patient rehabilitation. Although cochlear implantation has become one of the routine operative procedures throughout the world nowadays, it gives rise to certain complications. These complications, though rare, can sometimes be very serious, even with fatal outcome. If cochlear implantation is performed by experienced and well-educated team of experts, the possibility of complications is minimal and is certainly not the argument against cochlear implantation as a method of treatment of severe hearing impairments.

Pediatric cochlear implants

Cochlear implants are a safe and effective treatment for children with severe to profound sensorineural hearing loss. As implant technology continues to improve and outcomes are analyzed, younger and younger children are being deemed candidates for implantation. The decision to operate is made after a thorough evaluation by a multidisciplinary team. This review will highlight the preoperative and postoperative issues related to pediatric cochlear implantation.

Cochlear implants in children

Cochlear implants are electronic prostheses that provide a high quality sense of hearing to severely and profoundly deaf children and adults. As improvements in surgical technique and device performance have occurred, indications for implantation have expanded.

Mastoiditis and acute otitis media in children with cochlear implants: recommendations for medical management

Acute otitis media (OM) or mastoiditis is a very dangerous condition for the ear after cochlear implantation. However, acute OM is very common in childhood and can occasionally occur in an implanted ear. Most cases of acute OM can be successfully treated with intravenous high-dosage antibiotics. In cases of mastoiditis and clinical signs of mastoid abscess, retroauricular drainage is necessary to prevent infection of the implant bed. In a series of 366 children given implants (1 to 14 years), acute OM occurred in 5.6% during a follow-up period of 1 to 8 years. Seven ears had to be opened by means of myringotomy. Five ears were opened by retroauricular incision with mastoid revision on the implanted side. Adenoidectomy and use of ventilation tubes before cochlear implantation, as well as careful subtotal mastoidectomy during the implantation, can reduce the incidence of acute OM in children after implantation. Early and subsequent treatment with operative mastoid drainage can prevent implant loss and should be performed at the implantation center.