Brazilian Society of Otology task force - cochlear implant ‒ recommendations based on strength of evidence

OBJECTIVE

To make evidence-based recommendations for the indications and complications of Cochlear Implant (CI) surgery in adults and children.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on cochlear implantation were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) Evaluation of candidate patients and indications for CI surgery; (2) CI surgery - techniques and complications.

CONCLUSIONS

CI is a safe device for auditory rehabilitation of patients with severe-to-profound hearing loss. In recent years, indications for unilateral hearing loss and vestibular schwannoma have been expanded, with encouraging results. However, for a successful surgery, commitment of family members and patients in the hearing rehabilitation process is essential.

Delayed-onset facial paralysis following cochlear implantation: a case study and comprehensive analysis

OBJECTIVES

Cochlear implantation (CI) is a surgical intervention used to rehabilitate hearing in individuals, both pediatric and adult, with severe hearing loss. It is generally a safe procedure with rare postoperative complications. Facial nerve paralysis following cochlear implant surgery poses challenges in diagnosis and treatment.

METHODS

This case report details a 48-year-old male who experienced delayed facial paralysis after cochlear implantation, an uncommon occurrence with limited documentation.

RESULTS

The facial nerve palsy of the patient resolved by the third week with combined therapy.

DISCUSSION

The etiology of this complication is not fully understood, with latent virus reactivation, particularly HSV and VZV, hypothesized as a probable cause.

CONCLUSION

Successful management involves a combination of corticosteroids, antiviral therapy, and antibiotics, leading to a favorable outcome.

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 Complications in Children and Adults: Retrospective Analysis of 148 Cases

Objective

This study aimed to establish and discuss the intraoperative and postoperative complications affecting patients who underwent cochlear implant (CI) surgery from the Cochlear Implant Program of King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.

Methods

A retrospective study was conducted by reviewing the medical records of 148 patients who underwent cochlear implantation at KAUH between 1999 and 2019. Postoperative complications were classified into minor and major complications. Minor complications resolved with minimal or no treatment. Major complications required additional surgery or hospitalization.

Results

Complications occurred in 28 (18.9%) patients. Minor complications occurred in 17 (11.5%) patients, which included otitis media (2%), facial palsy (1.4%), wound infection (1.4%), vertigo (1.4%), intraoperative cerebrospinal fluid (CSF) gusher (1.4%), tinnitus (1.4%), facial stimulation (1.4%), hematoma (0.7%), and chorda tympani nerve injury (0.7%). Major complications occurred in 11 (7.4%) patients. These included flap dehiscence/infection (2%), device failure (1.4%), device migration (1.4%), mastoiditis (1.4%), electrode damage during insertion (0.7%), and misplaced electrodes (0.7%).

Conclusion

This study reported a low rate of surgical complications associated with CI, and most have been managed successfully without further complications. Our results prove that CI is a safe and reliable procedure, with a low complications rate when performed by experienced surgeons.

Herpes simplex 1 stomatitis after cleft palate repair: a case report and guidelines for management

Herpes simplex virus (HSV) primary infection and reactivation has been associated with the inflammation and transient decrease in immunocompetence after surgery and local trauma. In addition, HSV infection is known to impair wound healing, increase risk of scarring, and impede connective tissue graft transplantation. To our knowledge, this is the first case of HSV infection complicating cleft palate repair presented in literature. In this report, we present a case of primary HSV infection occurring in a healthy 26-month-old patient after repair of the secondary cleft palate with mucoperichondrial flaps and V-Y pushback. The patient developed high fever on postoperative day 1, which was followed by perioral vesicular lesions and multiple intraoral ulcerations involving the lips, palate, and posterior pharynx. Unknown to the surgeons, the patient was exposed to HSV before surgery by a sibling with orolabial HSV infection. The infective cause was ascertained via polymerase chain reaction for HSV-1 DNA, and the infection was treated with topical and intravenous acyclovir for 1 week. The patient recovered well with adequate flap healing, good aesthetic outcome, and no complications on 1-month follow-up. This report underscores the importance of prompt recognition of herpetic infections in the patient with craniofacial surgery and reviews the association and complications of HSV infection in surgical healing. Early identification with prompt antiviral therapy and meticulous wound care are essential to ameliorate the scarring and delayed wound healing associated with HSV infection.

Delayed facial nerve weakness after intact canal wall tympanomastoidectomy

OBJECTIVE

To find the etiology, frequency, and prognosis of delayed facial nerve weakness (DFW) in our department after intact canal wall tympanomastoidectomy for a tubotympanic (TT) type of chronic suppurative otitis media (CSOM) without cholesteatoma.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

A total of 315 patients who underwent intact canal wall tympanomastoidectomy for TT type of CSOM without cholesteatoma in our department for the past 3 years were selected. Patients with facial nerve weakness after 72 hours of surgery were noted and assessed for a history of herpes zoster virus infection. There were 6 patients who developed DFW; of these, blood samples of 4 patients for serum antibody titers to varicella zoster virus and herpes simplex type 1 were sent on the 3rd day of developing DFW. Blood samples of each of the remaining 2 patients were sent on the 13th day and 1st day of developing DFW. All 6 patients were treated with prednisolone and acyclovir, and their prognosis was assessed.

MAIN OUTCOME MEASURE

House-Brackmann facial nerve grading system and serum antibody titers for varicella zoster virus and herpes simplex type 1.

RESULTS

Six patients (1.9%) developed DFW in this study. All patients had a history of herpes zoster virus infection. Serology results of 4 patients showed positive immunoglobulins M and G for varicella zoster virus and had significantly elevated titers of serum immunoglobulin G for varicella zoster virus, thus confirming the etiology.

CONCLUSION

The incidence of DFW after tympanomastoidectomy is low and is due to viral reactivation, that is, varicella zoster. The overall prognosis seems impressive because all of the patients' facial nerve function improved by the end of 6 weeks. This study also illustrates the medicolegal importance of informing the patients with a history of herpes zoster virus infection the chance of developing DFW after undergoing tympanomastoidectomy.