Cochlear implantation in children with otitis media

Subtotal Petrosectomy and Cochlear Implantation in Children With Chronic Suppurative Otitis Media: A Single Institutional Experience

BACKGROUND AND OBJECTIVES

Chronic suppurative otitis media (CSOM) with or without cholesteatoma is a frequent chronic inflammatory condition in children, which may lead to severe hearing loss that affects speech development. Treatment of recurrent CSOM associated with unserviceable hearing requires a specialized approach with regard to disease eradication and hearing rehabilitation. In this study, we investigated the advantages of subtotal petrosectomy (SP) combined with cochlear implantation (CI) in children with CSOM associated with unserviceable hearing and describe our experience with regard to the efficacy of this method, together with a literature review.

SUBJECTS AND METHODS

SP with sequential or simultaneous CI was performed in three children (four ears), and postoperative audiometric data were recorded.

RESULTS

The study included two male and one female patient. Mean age at the time of SP was 10.75 years (7-13 years). Sequential implantation was performed in three ears. Facial nerve palsy occurred after SP in one patient. The latest word recognition scores of Cases 1, 2, and 3 were 80% (at 60 dB), 75% (at 60 dB), and 70% (at 50 dB) and 90% (at 50 dB), respectively.

CONCLUSIONS

SP with CI may be safe and reliable in children with CSOM associated with unserviceable hearing.

Role of Immediate Pre-Operative Tympanometry in Cochlear Implantation: MERF Protocol and Experience

(1) To study the association between an immediate pre-operative tympanometric profile in patients undergoing cochlear implantation with their intraoperative findings. (2) To analyse the intraoperative middle ear findings that require a staged cochlear implantation in patients presenting with a B-type tympanogram. (3) To study the complications in this group of patients during the 1-year follow-up. This retrospective non-interventional cohort study is done over a period of 6 years. Bilaterally profound deaf children, less than 6 years of age, and no history of otitis media with effusion were included in the study. Children who met the inclusion criteria were divided into 4 groups based on their tympanometric profiles that are A, As, B, and C type tympanogram and, their intraoperative findings were categorized as normal, mild oedema, minimal granulation with mild oedema, moderate to extensive granulation with or without oedematous mucosa and glue. Then finally, depending on the intraoperative middle ear and mastoid finding, a single-stage surgery or a two stage surgery was decided upon. A total of 1025 patients were implanted during the study period, 975 patients met our inclusion criteria. In our series, we found a statistically significant difference (p < 0.0001) between the tympanograms and their respective intra-operative middle ear findings. A statistically significant difference was seen (p < 0.0001) between patients who underwent a single-stage cochlear implant and those who underwent a two-staged surgery, regarding their intraoperative middle ear findings. No statistical significance was seen in the occurrence of complications between the groups undergoing a single stage and a two-staged surgery (p > 0.5). This study showcases the importance of immediate pre-operative tympanometry in cochlear implant surgeries. Two-stage surgery is a decision taken on the operating table, depending on the extent of pathology and visibility of the round window niche.

Delayed postoperative complications in 624 consecutive cochlear implantation cases

Background: Sensorineural hearing loss can be cured by cochlear implantation (CI), but complications can occur. Based on when the complications develop, they are categorized as intraoperative complications, early postoperative complications, or delayed postoperative complications (>3 months after the surgery).Aims/objectives: We aimed to investigate the occurrence of delayed complications after CI surgery, and identify appropriate management methods.Material and methods: We analyzed 624 sensorineural hearing loss patients who had been consecutively treated with CI using the conventional surgical technique in our institution and had been followed-up until September 2017.Results: A total of 43 (6.86%) patients out of the 624 CIs (627 ears) reported complications, and 9 (1.44%) were major complications and 34 (5.42%) were minor complications. Wound infection and device failure were the most common major complications, and hematoma was the most common minor complication.Conclusions and significance: CI surgery is a relatively mature technology; the incidence of complications is low, and with early diagnosis and treatment most complications have a good prognosis. Head trauma was the main reason for children's complications, and patients and guardians should be given good education preoperatively about how to manage the CI postoperatively.

Cochlear Implantation in Children with Otitis Media

One of the concerns during the cochlear implant candidacy process is the presence of chronic otitis media which could delay the implantation process. The aim of this study was to evaluate the surgical difficulties and the long-term complications in children with otitis media and to examine whether it is necessary to delay the implantation until the infection is resolved. The study used a comparative retrospective design based on chart review of all patients who received their implant(s) from January to December of 2012. A total of 200 patients were identified and were followed for 4 years post surgery. Patients were divided into three groups based on their history of otitis media (non-otitis media, chronic otitis media with effusion, and acute otitis media). Data included long-term complications, operative time and duration from first clinical visit to the time until implantation was received. None of study participants had long-term complications during the study period. The operative time was longer in the acute otitis media group with a difference of 45 min. The average delay in cochlear implantation due to the presence of otitis media in chronic group was more than 5 months. Pediatric patients with otitis media could be implanted in one stage safely and effectively.

Infectious complications of pediatric cochlear implants are highly influenced by otitis media

OBJECTIVE

Determine the incidence of ear infections in cochlear implant patients, evaluate the contribution of otitis media to complications, describe the bacteriology of otitis media in the cochlear implant population, the treatment provided at our center, and the long term outcome.

METHODS

Data collected included age at implantation, history of otitis media or ear tubes, etiology of hearing loss, inner ear anatomy, postoperative infections, time to infection, route of antibiotic administration, and interventions for infections. Categories of infection were acute otitis media, otitis media with effusion, tube otorrhea, meningitis, scalp cellulitis, and infection at the implant site.

RESULTS

Middle ear infections were diagnosed in 37% of implanted ears. Extension of middle ear infections into the implant site occurred in 2.8% of all implants (n = 16). Of the 16 infected devices, 10 were successfully treated with antibiotic therapy and did not require explantation. The retained implant group and explanted group both included some middle ear microbes such as Haemophilus influenzae and Streptococcus pneumoniae, as well as skin flora such as Staphylococcus aureus.

CONCLUSION

Otitis media in pediatric cochlear implant patients is a common event and usually does not lead to complications of the cochlear implant. However, when the ear infection spreads to the scalp and the implant site, it is still possible to eliminate the infection using antibiotic therapy, particularly when treatment is directed to the specific organism that is recovered from the infected space and the duration and route of antibiotic treatment is carefully considered.

Acute mastoiditis in children with a cochlear implant

OBJECTIVES

Cochlear implantation is performed at a young age, when children are prone to acute otitis media. Acute mastoiditis is the most common complication of otitis media, but data on its management in the presence of a cochlear implant are sparse. The objective of this study was to assess the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant.

METHODS

The medical files of all children who underwent cochlear implantation at a pediatric tertiary medical center in 2000-2014 were retrospectively reviewed. Those diagnosed with acute mastoiditis after implantation were identified, and data were collected on demographics, history, presentation, method of treatment, complications, association with untreated otitis media with effusion, and long-term middle-ear sequelae.

RESULTS

Of the 370 children (490 ears) who underwent cochlear implantation, 13 (3.5%) were treated for acute mastoiditis (median age at acute mastoiditis, 32 months). Nine had a pre-implantation history of chronic secretory or acute recurrent otitis media, and 5 had been previously treated with ventilation tubes. In all 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. The time from implantation to mastoiditis was 5-61 months. The same treatment protocol as for normal-hearing children was followed, with special attention to the risk of central nervous system complications. Primary treatment consisted of myringotomy with intravenous administration of wide-spectrum antibiotics. Surgical drainage was performed in 8 out of 13 patients, with (n=7) or without (n=1) ventilation-tube insertion, to treat subperiosteal abscess or because of lack of symptomatic improvement. There were no cases of intracranial complications or implant involvement or need for a wider surgical approach. No middle-ear pathology was documented during the average 3.8-year follow-up.

CONCLUSIONS

The relatively high rate of acute mastoiditis and subperiosteal abscess in children with a cochlear implant, predominantly involving the implanted ear, supports the suggestion that recent mastoidectomy may be a risk factor for these complications. Despite the frequent need for drainage, more extensive surgery is usually unnecessary, and recovery is complete and rapid. As infections can occur even years after cochlear implantation, children with otitis media should be closely followed, with possible re-introduction of ventilation tubes.

Subtotal Petrosectomy for Cochlear Implantation

Objectives:

The purpose of this study was to review the indications for subtotal petrosectomy for cochlear implantation, report our management of complications, as well as review those technical factors that are critical for successful implantation.

Methods:

Patients (n = 104) that underwent subtotal petrosectomy with closure of the external auditory canal and obliteration of the cavity with abdominal fat in combination with cochlear implantation were analyzed.

Results:

The most frequent indication for subtotal petrosectomy was the existence of a previous canal wall down technique. Postoperative complications occurred in 13 patients (11.83%). Extrusion of the device took place in 5 cases (4.55%).

Conclusions:

Subtotal petrosectomy in cochlear implantation permits obtaining a cavity isolated from the external environment, and when needed, it improves the access and visibility during the surgical procedure. Subtotal petrosectomy is a safe technique, with a low rate of complications.

Retrospective complication rate comparison between surgical techniques in paediatric cochlear implantation

OBJECTIVE

To compare paediatric complication occurrence between the Mastoidectomy with Posterior Tympanotomy and the SupraMeatal Approach for cochlear implantation.

DESIGN

Retrospective cohort study.

SETTING

Children receiving a cochlear implant before 5 years of age between 1996 and 2014 in our tertiary center.

PARTICIPANTS

A total of 144 patients receiving a cochlear implant (121 by Mastoidectomy with Posterior Tympanotomy and 23 by SupraMeatal Approach) operated on 165 ears (129 and 39 respectively).

MAIN OUTCOME MEASURES

The severity (minor or major) using Cohen and Hoffman criteria and time of occurrence of complications (intraoperative, early postoperative or late postoperative) were identified. Intraoperative surgical challenges were correlated to complication occurrence.

RESULTS

The mean age at implantation was 2.13 ± 1.14 years old. Patients operated by the SupraMeatal Approach (1.27 ± 0.69 years old) were significantly (P < .001) younger than those receiving a cochlear implant by Mastoidectomy with Posterior Tympanotomy Approach (2.40 ± 1.12). Most complications were minor (Mastoidectomy with Posterior Tympanotomy Approach: 64.0%; SupraMeatal Approach: 73.1%) and occurred early postoperatively (Mastoidectomy with Posterior Tympanotomy Approach: 61.5%; SupraMeatal Approach: 76.9%). More overall complications occurred in SupraMeatal compared to Mastoidectomy with Posterior Tympanotomy Approach cases (61.5% versus 20.6%; P < .001). Younger SupraMeatal Approach cohort patients (6 - 12 and 18 - 24 months; P < .008 and P = .016) most often developed these complications. When looking at specific complications, more infectious complications occurred in patients receiving a cochlear implant through the SupraMeatal Approach (P < .05). Logistic regression showed that the surgical technique and not the age at implantation was responsible for the documented complications. No relationship between complications and intraoperative difficulties was identified.

CONCLUSION

In our institution, cochlear implantation in young patients through the SupraMeatal Approach resulted in significantly more (infectious) complications than those operated through the Mastoidectomy with Posterior Tympanotomy Approach. Outcomes from our institution recommends using the Mastoidectomy with Posterior Tympanotomy Approach when opting for a cochlear implant surgical technique in young children who are more prone to develop infectious complications.

Infectious complications and ventilation tubes in pediatric cochlear implant recipients

OBJECTIVES/HYPOTHESIS

At many centers, ventilating tubes (VTs) are placed routinely in otitis-prone pediatric cochlear implant recipients. However, this practice is controversial, as many otologists believe VTs represent a possible route for contamination of the device. Toward better understanding of the safety of VTs, we reviewed our center's infectious complications and their relationship to the presence of tubes.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients undergoing cochlear implantation at our institution between 1990 and 2012 were reviewed for complications and their association with the presence of VTs.

RESULTS

A total of 478 patients (557 ears) were reviewed, representing over 2,978 patient-years of follow-up. In 135 ears (24.2%), a VT was present at time of, or placed at some point after, implantation. The remainder either never had a VT or it had extruded prior to implantation. Overall, 63 complications occurred, of which 17 were infectious. The most common were cellulitis (four), device infection (five), and meningitis (four). Only one occurred while a tube was present, and was a device infection in an ear having a retained VT in place for almost 4 years. No difference was observed in overall rates of infectious complications between the group with VTs and those who never had VTs.

CONCLUSIONS

This series, the largest to date, indicates that infectious complications after cochlear implantation are rarely associated with the presence of VTs, supporting the concept that, overall, VTs are safe in cochlear implant recipients. Close monitoring is essential, including prompt removal of tubes when they are no longer needed.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1671-1676, 2016.

Effect of otitis media with effusion on cochlear implant surgery: technical difficulties, post-operative complications and outcome

Objective:

This study evaluated the complications and outcomes of cochlear implantation in patients who had otitis media with effusion at the time of surgery.

Methods:

A retrospective chart review study was performed of 87 consecutive paediatric patients (age range 22 months to 10 years, mean 4.8 years) who underwent successful cochlear implantation, with follow-up periods of 5–6 years. All patients had unilateral implants, with eight on the left side. All devices were activated two weeks after implantation. The effect of the middle-ear condition on the procedure, post-operative complications and outcome were evaluated.

Results:

Unilateral ears of 17 otitis media with effusion patients were implanted with some surgical difficulties but no long-term post-operative complications.

Conclusion:

For children admitted for cochlear implantation who are subsequently found to have otitis media with effusion, surgeons should be aware of possible surgical difficulties. Greater intra-operative risks should be anticipated and more surgical time allowed for cochlear implantation in these patients.

Cochlear implantation with round window insertion in children with otitis media with effusion

AIMS

To discuss indications and surgical techniques for cochlear implantation (CI) in children with profound sensorineural hearing loss and otitis media with effusion (OME).

METHODS

Between January 2003 and May 2013, a total of 550 patients received cochlear implants at the Anhui Provincial Hospital, Hefei, China. Of these, 30 children with OME underwent CI with round window insertion in one stage.

RESULTS

One-stage operations of CI with round window insertion were carried out in 30 children with OME. All electrodes were implanted successfully. CI was performed without complications and the electrode arrays were protected well. All implant devices worked normally and all patients performed well during an average follow-up period of 12 months. None of the patients experienced any immediate or delayed postoperative infection-related complications.

CONCLUSIONS

CI with round window insertion could be safely and effectively performed in one stage in children with profound sensorineural hearing loss and OME. It is unnecessary to delay implantation to control OME, but it remains a challenging problem in operation.

Bacterial infection complications in children with cochlear implants in the Czech Republic

OBJECTIVE

Studies describing wound infections after cochlear implantation are rare. Meticulous operative techniques and sufficient surgical skill can help to avoid severe postoperative complications. Minor complications such as seromas, superficial wound infections, skin emphysema, and swelling can all be successfully treated using conservative methods. Serious problems, however, could be caused by Pseudomonas aeruginosa and Staphylococcus aureus infections.

STUDY DESIGN

Retrospective case series.

SETTING

Pediatric cochlear implant center in the Czech Republic.

RESULTS

In our cohort of 360 children operated on between 1994 and 2009, there were no major surgical complications. However, there were four serious wound infections, two of which resulted in explantation of the device. Two patients with a well-bordered abscess formation were successfully treated with antibiotics and drainage. Explantation was required in another two children with refractory P. aeruginosa infection. Despite favorable sensitivity to a number of antibiotics, intravenous and intensive local treatment failed. After explantation, the operative sites healed immediately. Both children were successfully implanted contralaterally 6 months later. Detailed bacteriological tests from different parts of the device were performed.

CONCLUSION

The consequences of explantation were discussed in our cochlear implant center. Confirmed by the microbiological results and reports in the scientific literature, it seems preferable to cut the electrode near the cochlear array and leave it inside the cochlea in order to use the same ear for reimplantation at a later date.

Cochlear implantation in patients with acute or chronic middle ear infectious disease: a review of the literature

Although in the past cochlear implantation was considered contraindicated in patients with acute (AOM) or chronic suppurative otitis media (CSOM) with or without middle ear cholesteatoma, recent developments now make it possible to perform cochlear implantation in these patients. Various procedures are available to make the ears of patients with either acute or CSOM suitable for cochlear implantation and to minimize the risk of recurrence of the disease, device extrusion, or intracranial complications. This review discusses these different approaches for optimizing implant survival and preventing complications related to otitis media. We performed a comprehensive literature search of the MEDLINE database. Cochlear implantation can be safely performed in patients with otitis media. However, the infection should be adequately controlled well before implantation, and all measures should be taken to prevent recurrent disease. Therefore, the procedure used should be tailored to individual clinical findings. This article provides a guideline to optimize the course of action in patients suffering from AOM, CSOM or their sequelae in preparation for cochlear implantation.

Infectious complications in pediatric cochlear implants

OBJECTIVES

Infectious complications may cause significant delay in cochlear implant device initiation and programming and be a source of additional morbidity. We reviewed our experience with infectious complications in the pediatric age group to determine specific sources that may not be seen in adults.

STUDY DESIGN

A retrospective analysis from a single implant center.

METHODS

Cases of pediatric cochlear implants were reviewed for data on infectious complications. Complications were identified as "major" or "minor," "early" or "delayed." Information was gathered regarding any comorbid, chronic health condition. Data related to the causative organism(s) were collected.

RESULTS

Two hundred sixty-eight cases of pediatric implants were reviewed. Twenty-two cases were identified (an infection rate of 8.2%), all classified as "major." The majority, 12, were classified as "delayed" complications. Twenty-one cases required explantation with 14 successfully reimplanted. Five cases (in 4 patients) or 23% were associated with a specific chronic pediatric condition including two children with tracheostomies. Among implanted children who had chronic health conditions, 42% developed implant-related infections. Among otherwise healthy implanted children, only 6.6% developed implant-related infections. Resistant bacterial infections were not identified.

CONCLUSIONS

Health conditions in the pediatric age group were associated with 23% of our complications, a risk factor not previously identified in the literature. These children, demonstrating seven times the infection rate of healthy children, should be carefully observed postoperatively. Overall, cochlear implantation in children continues to be associated with a low risk of infectious complications.

Cochlear implantation in children: implications for the primary care provider

PURPOSE

To define hearing loss (HL), discuss the impact of HL on child development, and review the literature on cochlear implantation in children. The criteria for and the benefits and limitations of cochlear implantation in children, as well as the implications for the primary care provider with regard to children who have cochlear implants, are presented.

DATA SOURCES

Review of published literature on the topic.

CONCLUSIONS

A child's future development depends greatly on speech and language skills. Any type of HL can impact and may even hinder speech and language acquisition. It is therefore crucial to enforce early identification of HL. For severe to profoundly hearing-impaired children, cochlear implantation serves as an avenue for hearing and language development.

IMPLICATIONS FOR PRACTICE

Nurse practitioners ought to be up to date with criteria for and the benefits and risks of cochlear implantation. Health-related issues, such as vaccination, otitis media, and meningitis, must be assessed for and managed promptly.

Surgical and Medical Complications following Cochlear Implantation: Comparison of Two Surgical Approaches

Our study was designed to evaluate the complication rate of cochlear implantation (CI) and to compare two different surgical approaches that are currently being used for implantations in our department. This retrospective study was conducted on the patients who underwent CI in our center between 1989 and 2003 and who were followed-up for at least 18 months. The patients were divided into two groups according to the surgical technique that had been used for the implantation: the mastoidectomy with posterior tympanotomy approach and the suprameatal approach (without mastoidectomy). The incidence of complications following CI was compared between the two groups and between children and adults. Facial nerve paralysis, electrode misplacement, injury to the chorda tympani nerve and mastoiditis occurred only in the mastoidectomy with posterior tympanotomy approach group. Acute middle ear infection with or without mastoiditis emerged as the most common complication in both groups, followed by vestibular and wound problems. Disequilibrium was significantly more common among the adults than among the children (p < 0.0001). The suprameatal approach was demonstrated as being a good alternative technique to the classical surgery for CI.

Acute otitis media and mastoiditis following cochlear implantation

OBJECTIVE

To examine the incidence of acute otitis media (AOM) and mastoiditis in children after cochlear implantation (CI) and to evaluate the role of mastoidectomy in decreasing the rate of AOM in implanted children by comparing two surgical techniques: the Posterior tympanotomy approach (MPTA, with mastoidectomy) and the Suprameatal approach (SMA, without mastoidectomy).

METHODS

A retrospective study was conducted on 234 children up to 16 years of age who underwent CI between 1993 and 2003 in our department. The children were divided into two groups according to the surgical technique that had been used for the implantation: the MPTA group and the SMA group.

RESULTS

Part of the children with a history of pre-implantation AOM (22 of 29 in MPTA group and 26 of 38 in SMA group) did not suffer from AOM post-CI (p=0.59), and an incidence of AOM after CI in children who did not have history of AOM prior to implantation (13 patients of MPTA group and 15 patients of SMA group) was unrelated to surgical approach (p=0.65). The incidence of pre-implantation AOM was similar for the two groups and declined after CI unrelated to performing of mastoidectomy in surgical technique. Overall, 47 children (20.1%) had post-CI AOM compared to 67 children (28.6%) who had pre-CI AOM. Mastoiditis developed in 11 children (4.7%), all 11 in the MPTA group. A subperiosteal abscess was incised and drained with the retroauricular approach in three of these children and the others were managed with intravenously administered ceftriaxone 50mg/kg/day for 3-5 consecutive days, followed by a course of oral cephalexin until there is complete clinical resolution of the effusion in the middle ear. The implants were preserved in all cases. Seven out of 11 children with mastoiditis had no history of AOM prior to implantation.

CONCLUSIONS

AOM and mastoiditis represent common complications of CI that can be successfully treated with the prompt use of antibiotics. However, the subperiosteal abscess could require surgical drainage. In our opinion, the decrease of incidence of AOM in implanted children is the result of natural history of otitis media and is unrelated to the surgical approach.

The Influence of Mastoidectomy on Natural History of Secretory Otitis Media in Cochlear Implant Children

Secretory otitis media (SOM) is a common childhood disease. The goal of the present study was to determine the influence of mastoidectomy on the incidence of postimplantation SOM in cochlear implant children. We conducted a retrospective study of all the children up to the age of 8 years, who underwent cochlear implantation from 1993 to 2001 in our department. The children were divided into two groups according to the surgical technique used for the implantation: 94 children underwent implantation with the posterior tympanotomy approach (including mastoidectomy) and 48 children were implanted with a suprameatal approach (without mastoidectomy). The incidence of SOM before and after the implantation was compared between the two groups. There were no significant differences between the two study groups in terms of age and the pre- and postimplantation incidence of SOM. Mastoidectomy failed to demonstrate any influence on the natural history of SOM.

Cochlear implantation in a patient with eosinophilic otitis media

Eosinophilic otitis media is an intractable middle ear disease with gelatinous mucoid fluid containing eosinophils associated with bronchial asthma and nasal allergy that sometimes induces deterioration of sensorineural hearing loss. Here, we report a case of eosinophilic otitis media in a 50-year-old woman who received a Nucleus 22 multi-channel cochlear implant in the right ear at the age of 42 years. She had received treatment for bronchial asthma, chronic sinusitis with nasal allergy and otitis media with effusion since the age of 30 years and had noted bilateral sudden deafness and vertigo at the age of 35 years. Preoperative CT and MRI showed cochlear ossification in the left ear, in which mastoidectomy was performed as treatment of eosinophilic otitis media. Long-term follow-up revealed that cochlear implant is indicated for deafness induced by eosinophilic otitis media, and an early decision for cochlear implant surgery is necessary. Steroid administration was remarkably useful in controlling eosinophilic otitis media in patients with bronchial asthma and chronic sinusitis with nasal allergy.

Magnet Displacement Following Cochlear Implantation

OBJECTIVE

To describe a rare complication of cochlear implantation, such as magnet displacement.

STUDY DESIGN

Retrospective case review.

SETTING

The study was conducted at the Sheba Medical Center, Tel-Aviv, Israel.

PATIENTS

One child presented with an external coil attached to the skin anteriorly to the receiver/stimulator site (20 months after implantation) and another child was seen with a displaced magnet under the skin a few days after a head trauma (28 months after implantation). Both children were implanted with the Nucleus 24 device at the age of 2 years.

INTERVENTION

Plain skull radiographs showed the dislocated magnet in both cases. Surgery for each child was limited to revision of the receiver/stimulator site and reinsertion of the magnet to its pocket.

RESULTS

Intraoperative Neural Response Telemetry well displayed the responses of evoked potentials of the auditory nerve within the cochlea in both children. Postoperative auditory responses were as good as those measured before the complication.

CONCLUSION

The displaced magnet can be successfully managed by a simple revision procedure. The possibility of magnet migration should be considered in cases of device malfunction. Two cases of magnet migration from its pocket after cochlear implantation are presented. The diagnostic and surgical method used for resolving this condition are described.

Ventilation Tubes And Cochlear Implants: What Do We Do?

OBJECTIVE

To determine current practice management with respect to ventilation tubes and cochlear implants.

STUDY DESIGN

Questionnaire.

SETTING

All members of the American Neurotology Society were sent questionnaires.

MAIN OUTCOME MEASURES

Members were asked a series of questions including how they deal with ventilation tubes before cochlear implantation, how they manage serous otitis media in patients undergoing cochlear implantation, and how they manage otitis prone children with cochlear implants.

RESULTS

Two hundred and twenty members returned questionnaires. Surgeons who replied perform an average of 25 implants per year: 15 in adults and 10 in children. Analysis of the data revealed a wide practice variation between surgeons. Fifty-six percent of surgeons will place a cochlear implant in a patient with a clean, dry ventilation tube in place. More than half the surgeons will place a ventilation tube in a child with serous otitis media, let the ear settle down, and perform the cochlear implant at a second operation. Wide variation in the management of otitis prone children with cochlear implants exists with respect to placement of ventilation tubes. Only 5% of surgeons reported any complications with cochlear implants that they attributed to ventilation tubes. There were a number who suggested their practice had changed since the recent identification of issues involving meningitis in implantees.

CONCLUSION

Wide practice variation exists with the management of ventilation tubes in cochlear implant patients. On the basis of the results of this survey, it is acceptable to place cochlear implants in patients with clean, dry ventilation tubes. It also acceptable to place ventilation tubes in otitis prone children with cochlear implants. Despite theoretic concerns, the reported incidence of complications is low.

Chronic Pseudomonas Infections of Cochlear Implants

OBJECTIVE

To discuss chronic, refractory Pseudomonas infections of cochlear implants and their management.

DESIGN

Retrospective case series.

SETTING

Two university-based cochlear implant programs.

PATIENTS

Twenty-eight-year-old (Case 1) and 4-year-old (Case 2), different devices.

INTERVENTIONS

Medical and surgical management.

MAIN OUTCOME MEASURES

Clinical course.

RESULTS

Both patients had delayed presentations, 4 months and 3 years postimplantation, respectively, with fluctuating scalp edema and pain resistant to multiple courses of oral antibiotics. Infections began as localized granulation and progressed to complete encasement of both devices with rubbery, poorly vascularized tissue. In each case, two different strains of multiresistant Pseudomonas aeruginosa were cultured. Infections progressed despite local debridement and targeted antipseudomonal antibiotic coverage, and sensitive organisms continued to appear in cultures of refractory granulation tissue. Both patients underwent partial explantation, with the electrode array left in the cochlea, then received 2 to 3 more months of further medical therapy and observation and then were reimplanted successfully with new devices. Both have shown excellent performance and no sign of recurrent infection.

CONCLUSIONS

Infections of cochlear implants are uncommon, and cases of successful conservative management without device explantation have been reported. However, our experience and the implanted device literature suggest that chronic Pseudomonas infections may represent a distinct clinical entity, likely to fail protracted therapy and ultimately require device removal. Fortunately, successful reimplantation is possible.