Soft tissue complications after pediatric cochlear implantation in children younger than 12 months

Cochlear Implantation in Children Under 9 Months of Age: Safety and Efficacy

OBJECTIVE

To assess the safety of cochlear implants (CIs) in children under 9 months of age to better understand expected postoperative complication rates, and to provide a preliminary look at efficacy.

STUDY DESIGN

Single-center retrospective review.

SETTING

Tertiary referral center.

PATIENTS

Children 5 to 8 months of age who received a CI between 2011 and 2021.

INTERVENTIONS

Therapeutic-CI.

MAIN OUTCOME MEASURES

The primary outcome was 6-month postoperative complication rate. Secondary outcomes included length of stay, device explantation/reimplantation, rehabilitation supports, and hearing and language outcomes. Complications of children implanted under than 9 months of age was compared with a cohort of children implanted 9 to 18 months of age between the years 2011 and 2016 using a chi-squared test ( p < 0.05).

RESULTS

One hundred six children under 9 months of age were implanted (204 CIs) at a mean age of 6.6 months (range: 5-8). Postoperative complications occurred in 28 patients (26%) and were often minor. There were no mortalities. There was no statistically significant difference in complications, including reimplantation rates, between patients implanted under 9 months of age and those implanted 9 to 18 months of age. Speech discrimination outcomes were excellent, and mean spoken language outcomes were near normative for typically developing children.

CONCLUSIONS

Cochlear implantation can be a safe and effective treatment option for children 5 to 8 months of age. Early hearing screening and referral for infants to receive appropriate intervention will continue to play a critical role in optimizing speech and language outcomes.

Safety and Early Outcomes of Cochlear Implantation of Nucleus Devices in Infants: A Multi-Centre Study

This multi-center study examined the safety and effectiveness of cochlear implantation of children between 9 and 11 months of age. The intended impact was to support practice regarding candidacy assessment and prognostic counseling of pediatric cochlear implant candidates. Data in the clinical chart of children implanted at 9-11 months of age with Cochlear Ltd devices at five cochlear implant centers in the United States and Canada were included in analyses. The study included data from two cohorts implanted with one or two Nucleus devices during the periods of January 1, 2012-December 31, 2017 (Cohort 1, n = 83) or between January 1, 2018 and May 15, 2020 (Cohort 2, n = 50). Major adverse events (requiring another procedure/hospitalization) and minor adverse events (managed with medication alone or underwent an expected course of treatment that did not require surgery or hospitalization) out to 2 years post-implant were monitored and outcomes measured by audiometric thresholds and parent-reports on the IT-MAIS and LittlEARS questionnaires were collected. Results revealed 60 adverse events in 41 children and 227 ears implanted (26%) of which 14 major events occurred in 11 children; all were transitory and resolved. Improved hearing with cochlear implant use was shown in all outcome measures. Findings reveal that the procedure is safe for infants and that they show clear benefits of cochlear implantation including increased audibility and hearing development.

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

JT, Waltzman SB. Cochlear Implantation in Infants: Evidence of Safety

The aim of this study was to investigate surgical, anesthetic, and device-related complications associated with cochlear implantation (CI) in children younger than 1 year of age. This was a multicenter, retrospective chart review of all children with severe-to-profound sensorineural hearing loss who underwent cochlear implantation with a Cochlear Nucleus Implant System before 1 year of age. Endpoints included perioperative course, major and minor surgical, anesthetic and device-related complications, and 30-day readmission rates. One hundred thirty-six infants (242 ears) met criteria. The mean age at implantation was 9.4 months (standard deviation 1.8). Six-month follow-up was reported in all patients. There were no major anesthetic or device-related complications. Adverse events were reported in 34 of implanted ears (14%; 7 major, 27 minor). Sixteen adverse events occurred ≤30 days of surgery, and 18 occurred >30 days of surgery. The 30-day readmission rate was 1.5%. The rate of adverse events did not correlate with preexisting medical comorbidities or duration under anesthesia. There was no significant difference detected in complication rate for patients younger than 9 months of age versus those 9 to 11 months of age. This study demonstrates the safety of CI surgery in infants and supports reducing the indication for cochlear implantation to younger than 1 year of age for children with bilateral, profound sensorineural hearing loss obtaining a Cochlear Nucleus Implant System.

Pressure ulcers and skin infections after cochlear implantation: A delayed yet serious issue

OBJECTIVES

Skin flap infection is one of the most common complications of cochlear implantation (CI). We identified the causes of skin flap pressure ulcer over the antenna site and proposed wound management strategies.

METHODS

A total of 250 consecutive pediatric patients who underwent CI to treat profound hearing loss were retrospectively assessed. Data on demographic characteristics, the cause of skin infection, and the time of onset were obtained.

RESULTS

Seventeen patients (17/250, 6.8%) had a total of 23 skin pressure injuries in the area covering the antenna. We used the National Pressure Ulcer Advisory Panel pressure injury staging system to grade injury severity. Twelve patients had 16 (16/23, 69.6.%) stage 1 pressure injuries; the skin reaction resolved after the patients stopped wearing the device for a brief period, loosened the magnet to relieve pressure on the coil, and received topical antibiotics. Five patients with six (6/23, 26.1%) stage 2 pressure injuries and one (1/23, 4.3%) stage 3 injury, were treated with oral antibiotics. The patient with the stage 3 injury was instructed not to wear the external device for 10-14 days. The incidence of skin reactions associated with the ESPrit speech processor (0/17, 0%) was significantly lower than that associated with the Freedom (2/17, 11.8%), N5 (8/17, 47.1%), and N6 (7/17, 41.1%; p < 0.05) processors. Pressure injuries were more common in younger children (≤7 years, 100%) than in older children (>7 years, 0%; p < 0.05) most likely due to their thinner scalps.

CONCLUSIONS

Early detection and treatment can prevent implant-threatening infections, particularly in younger children. We believe that better antenna designs will reduce this complication.

Safety and Effectiveness of Cochlear Implantation of Young Children, Including Those With Complicating Conditions

OBJECTIVE

Determine safety and effectiveness of cochlear implantation of children under age 37 months, including below age 12 months.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care children's medical center.

PATIENTS

219 children implanted before age 37 mos; 39 implanted below age 12 mos and 180 ages 12-36 mos. Mean age CI = 20.9 mos overall; 9.4 mos (5.9-11.8) and 23.4 mos (12.1-36.8) for the two age groups, respectively. All but two ≤12 mos (94.9%) received bilateral implants as did 70.5% of older group. Mean follow-up = 5.8 yrs; age last follow-up = 7.5 yrs, with no difference between groups.

INTERVENTIONS

Cochlear implantation.

MAIN OUTCOME MEASURES

Surgical and anesthesia complications, measurable open-set speech discrimination, primary communication mode(s).

RESULTS

Few surgical complications occurred, with no difference by age group. No major anesthetic morbidity occurred, with no critical events requiring intervention in the younger group while 4 older children experienced desaturations or bradycardia/hypotension. Children implanted under 12 mos developed open-set earlier (3.3 yrs vs 4.3 yrs, p ≤ 0.001) and were more likely to develop oral-only communication (88.2% vs 48.8%, p ≤ 0.001). A significant decline in rate of oral-only communication was present if implanted over 24 months, especially when comparing children with and without additional conditions associated with language delay (8.3% and 35%, respectively).

CONCLUSIONS

Implantation of children under 37 months of age can be done safely, including those below age 12 mos. Implantation below 12 mos is positively associated with earlier open-set ability and oral-only communication. Children implanted after age 24 months were much less likely to use oral communication exclusively, especially those with complex medical history or additional conditions associated with language delay.

Limiting asymmetric hearing improves benefits of bilateral hearing in children using cochlear implants

Neurodevelopmental changes occur with asymmetric hearing loss, limiting binaural/spatial hearing and putting children at risk for social and educational challenges. These deficits may be mitigated by providing bilateral hearing in children through auditory prostheses. Effects on speech perception and spatial hearing were measured in a large cohort of >450 children who were deaf and used bilateral cochlear implants or bimodal devices (one cochlear implant and a contralateral hearing aid). Results revealed an advantage of bilateral over unilateral device use but this advantage decreased as hearing in the two ears became increasingly asymmetric. Delayed implantation of an ear with severe to profound deafness allowed asymmetric hearing, creating aural preference for the better hearing ear. These findings indicate that bilateral input with the most appropriate device for each ear should be provided early and without delay during development.

Low surgical complication rates in cochlear implantation for young children less than 1 year of age

OBJECTIVE

To identify risk factors for perioperative morbidity among a large national cohort of pediatric patients undergoing cochlear implantation.

STUDY DESIGN

Retrospective study utilizing the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (2012-2013).

METHODS

Pediatric cochlear implantation cases were identified using current procedural terminology 69930. Patients were categorized by age, and operative characteristics along with 30-day perioperative outcomes were analyzed.

RESULTS

We identified 1,351 cases of pediatric cochlear implantation. The median age was 3.6 years, and 73 patients were less than 1 year of age. Of 21 complication occurrences (1.55%), superficial incisional surgical site infection (SSI) was the most common (n = 13, 61.9%). Thirty-nine patients (2.9%) required readmission. The median operative time was 142 minutes, and the mean postoperative length of stay was 0.58 days. When comparing patients younger than 1 year old to those 1 year or older, no significant differences were noted in complication rate, postoperative length of stay, or reoperation rate. Patients less than 1 year of age were more likely to be readmitted (6.9% vs. 2.7%, P = 0.04) and had longer mean operative times (191 minutes vs. 160 minutes, P = 0.0015). Steroid use was a risk factor for unplanned reoperation, SSI, and readmission.

CONCLUSION

Despite a slight increase in readmission rates and operative times among patients less than 1 year of age, cochlear implantation appears to be safe in this population, with complication rates, reoperation rates, and postoperative lengths of stay similar to children undergoing the procedure at the current U.S. Food and Drug Administration-approved age of 1 year and older.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:720-724, 2017.

Skin Flap Necrosis by Bone Marking with Methylene Blue in Cochlear Implantation

One of surgical complications in cochlear implantation is the necrosis of the skin flap above the receiver-stimulator coil. We present a case of 55-year-old woman who underwent cochlear implantation and developed a bluish skin necrosis due to bone marking. The planned position for the receiver-stimulator was marked using methylene blue through skin to bone. She did not undergo skin flap thinning and underwent successful implantation with complete electrode insertion. Few weeks postoperatively, the patient developed bluish discoloration with progressive thick, blue eschar formation and skin flap necrosis. She subsequently underwent wound debridement and skin flap closure. Cochlear explantation was not necessary. Timely diagnosis and management about this complication is necessary to prevent further skin breakdown and subsequent device extrusion. This report identifies the marking using methylene blue as another possible source of skin flap necrosis in cochlear implantation, and surgeons should be aware of this potential complication.

Safety of cochlear implantation before 12 months of age: Medical University of South Carolina and Pediatric American College of Surgeons-National Surgical Quality improvement program outcomes

OBJECTIVES/HYPOTHESIS

The primary objective of this study was to determine the safety profile of cochlear implantation (CI) in infants <12 months old.

STUDY DESIGN

Retrospective review of institutional (Medical University of South Carolina [MUSC]) and national data (Pediatric American College of Surgeons-National Surgical Quality Improvement Program [ACS-NSQIP]).

METHODS

Cases were subdivided into two groups according to age at CI: <12 months and 12 to 18 months. The primary outcome measure of interest was occurrence of a postoperative medical or surgical complication. Operative time, anesthesia time, time in the postoperative anesthesia care unit, and length of stay were also assessed.

RESULTS

In infants <12 months of age, the incidence of a 30-day postoperative surgical complication using the ACS-NSQIP database was 3.6%; this did not differ from the rate observed in the 12- to 18-month-old group (3.2%, P = 1.0). In the MUSC series, the occurrence of a 30-day postoperative complication in children <12 months old was comparable (2.7%). At longer-term follow-up (mean = 3.7 years), the incidence of a postoperative surgical complication in infants <12 months old using MUSC data was 13.5%. When compared to older children at longer-term follow-up, no difference was noted (12.7%, P = 1.0). The incidence of a postoperative medical or anesthetic complication in children <12 months of age was extremely rare in both MUSC and ACS-NSQIP series (0% and 1.3%, respectively).

CONCLUSIONS

Institutional and national data demonstrate that CI in children <12 months of age is a safe procedure. Although infants <12 months old are at risk for postoperative complications, the rates of surgical and medical complications were no different compared to children 12 to 18 months of age.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:707-712, 2016.

Safety and postoperative adverse events in pediatric otologic surgery: analysis of American College of Surgeons NSQIP-P 30-Day outcomes

OBJECTIVES

Describe safety and postoperative sequelae of pediatric otologic surgery and identify predictive factors for postoperative events.

STUDY DESIGN

Retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database.

SETTING

Data pooled from the 2012 NSQIP-P public use file (50 institutions).

SUBJECTS AND METHODS

Current procedural terminology codes were used to identify children who underwent otologic surgery. Variables of interest included demographics and 30-day postoperative events grouped as reoperation, readmission, and complication. Event rates were determined and prevalence of events compared by procedure type and within patient subgroups according to chi-square analysis. Multivariate logistic regression evaluated predictive factors for postoperative events.

RESULTS

Of 37,319 pediatric operations, 2556 (6.8%) were otologic procedures. The most common procedure was tympanoplasty (n = 893, 34.9%), followed by myringoplasty (n = 741, 30.0%), cochlear implantation (n = 464, 18.2%), and tympanomastoidectomy (n = 458, 17.9%). There were 9 reoperations (0.4%), 32 readmissions (1.3%), and 18 complications (0.7%). Children undergoing tympanomastoidectomy or cochlear implantation were more likely to be readmitted irrespective of other factors (odds ratio = 5.5, P = .010; odds ratio = 3.5, P = .083). Children <3 years old were 4 times more likely to be readmitted than older children (odds ratio = 4.4, P < .001).

CONCLUSION

Pediatric otologic procedures are common and have low rates of global 30-day postoperative events. Tympanomastoidectomy and cochlear implantation have the highest risk of 30-day readmission. Young children (<3 years) are more likely to be readmitted following these procedures. Further optimization of the NSQIP-P to include specialty and procedure-specific variables is necessary to assess complete, actionable outcomes of pediatric otologic surgery, however the present study provides a foundation to build upon for safety and quality improvement initiatives in pediatric otology.

Pediatric cochlear implant revision surgery and reimplantation: an analysis of 957 cases

OBJECTIVE

In this study causes, risk factors, prevention strategies, diffuculties encountered during revision cochlear implant surgery, reimplantation in pediatric age group were evaluated.

METHODS

Charts of 957 CI patients younger than 18 years of age implanted at Izmir Bozyaka Teaching and Research Hospital between 1998 and July 2012 and 18 referred CI complications at same age group were retrospectively evaluated. Revision and reimplantation surgeries were systematically reviewed.

RESULTS

We encountered 26 surgical complications in 24 patients and 36 device related problems in 36 patients. Eighteen referred cases including 7 surgical complications and 11 device related problems were also evaluated. A total number of 80 complications were evaluated. In 11 cases conservative management was successful, 19 revision surgery was performed but we failed in 4 cases. We reimplanted 48 cases and 4 additional cases were implanted after failed revision surgery. Implant was extracted in one case. In one case we could implant the other side. Forty-six of reimplantations were done in one stage surgery, 5 cases required second stage surgery.

CONCLUSIONS

Surgical complications and device related problems of cochlear implantation may be different in children and majority of them require revision surgery or reimplantation. Although surgical problems leading to revision surgery and reimplantation are expected to diminish by experience every center has to deal with device failures. Both revision surgery and reimplantation require extra care and it should be better carried out by experienced surgeons. Implant performances are expected to be comparable with primary implantations.

Surgery of the ear and the lateral skull base: pitfalls and complications

Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills. Following a summary about general aspects in pre-, intra-and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation and surgery of vestibular schwannomas and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "dos and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed. An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.

Spoken language benefits of extending cochlear implant candidacy below 12 months of age

OBJECTIVE

To test the hypothesis that cochlear implantation surgery before 12 months of age yields better spoken language results than surgery between 12 and 18 months of age.

STUDY DESIGN

Language testing administered to children at 4.5 years of age (± 2 mo).

SETTING

Schools, speech-language therapy offices, and cochlear implant (CI) centers in the United States and Canada.

PARTICIPANTS

Sixty-nine children who received a cochlear implant between ages 6 and 18 months of age. All children were learning to communicate via listening and spoken language in English-speaking families.

MAIN OUTCOME MEASURE

Standard scores on receptive vocabulary, expressive, and receptive language (includes grammar).

RESULTS

Children with CI surgery at 6 to 11 months (n = 27) achieved higher scores on all measures as compared with those with surgery at 12 to 18 months (n = 42). Regression analysis revealed a linear relationship between age of implantation and language outcomes throughout the 6- to 18-month surgery-age range.

CONCLUSION

For children in intervention programs emphasizing listening and spoken language, cochlear implantation before 12 months of age seems to provide a significant advantage for spoken language achievement observed at 4.5 years of age.

The impact of blood loss during cochlear implantation in very young children

The aim of this study was to investigate if the intraoperative bleeding during cochlear implantation in very young children had any clinical importance and if it should influence the clinical management of such cases. A retrospective chart review of the pre- and postoperative hemoglobin concentration was performed on 14 implantations in children aged 16 months or younger at the time of surgery (11 males and 3 females). A postoperative decrease of the hemoglobin value was noted in 13 cases (93 %), with a mean difference between pre- and postoperative measurement of -1.9 g/dl. The most remarkable case was that of a 2-month-old newborn with a bilateral profound hearing loss caused by bacterial meningitis. In the course of the asynchronous bilateral cochlear implantation and due to a remarkable bleeding, a transfusion of packed red blood cells was performed. The increased loss of blood was reported at the time of detaching and lifting up the muscle-periosteal-flap from the mastoid bone as well as at the time of the mastoidectomy. The special physiological properties of this age can contribute to a rapid cardiovascular decompensation in the case of increased blood loss. The consideration of these aspects is of great importance in the stage of planning the cochlear implantation, which in this group of patients should include the requirement of banked human blood. In addition, the intraoperative bleeding should be taken into account during the decision for a simultaneous bilateral implantation.