Complication profile in a cochlear implantation- surgical audit in a large study population of low socio-economic status in a developing country

OBJECTIVES

To audit surgical complications and their management in cochlear implant (CI) recipients in a tertiary care referral otorhinolaryngology center in South India.

MATERIALS AND METHODS

Hospital data on 1,250 CI surgeries performed from June 2013 to December 2020 was reviewed. This is an analytical study with data collected from medical records. The demographic details, complications, management protocols and relevant literature were reviewed. Patients were divided into the following five age groups: 0-3 years, 3-6 years, 6-13 years, 13-18 years and above 18 years. Complications were divided into major and minor and complication occurrence was divided into peri-operative, early post-operative, and late post-operative, and the results were analyzed.

RESULTS

The overall major complication rate was 9.04% (including 6.0% due to device failure). If the device failure rate was excluded, the major complication rate was 3.04%. The minor complication rate was 6%.

DISCUSSION

CI is the gold standard in the management of patients with severe to profound hearing loss with minimal benefit from conventional hearing aids. Experienced tertiary care CI referral and teaching centers manage complicated implantation cases. Such centers typically audit their surgical complications, providing important reference data for young implant surgeons and newer centers.

CONCLUSION

Although not bereft of complications, the list of complications and its prevalence is sufficiently low to warrant the advocacy of CI worldwide, including developing countries with low socio-economic status.

Management of post-COVID mucormycosis at a tertiary care center in Northern India

Purpose

Our study aims to compile data on the clinical presentation, pathological and radiological findings in cases of post-COVID mucormycosis, and present the management strategy used in our center.

Methods

This is a retrospective cohort observational study based at a tertiary healthcare institution in Northern India. All COVID-positive patients presenting with clinical features of mucormycosis were included in the study. They underwent complete otorhinolaryngeal, medical, and ophthalmological examination after thorough history taking. Biochemical tests, biopsy and imaging studies were done for all the patients. The treatment strategy included a multidisciplinary team approach, that is, intravenous antifungals as well as surgical debridement of necrotic tissue via Modified Denker’s approach or open maxillectomy, and orbital exenteration, if required. Patients were followed up for six months to look for recurrence.

Results

Twenty-three patients were studied, out of which 14 were males and 9 were females. Pathological findings of 13 out of 15 patients, who underwent surgical debridement revealed mucormycosis as a causative agent, received Amphotericin. Aspergillus was found in two cases which received Voriconazole. Eleven out of 20 patients who were treated in our hospital survived. Three patients were lost to follow up. The average hospital stay of discharged patients was 14 days.

Conclusion

Post-COVID mucormycosis was reported at an alarming rate after the second COVID wave in India especially after steroid therapies in diabetic patients. Thus a timely, aggressive, team approach using Modified Denkers or open maxillectomy along with proper intravenous antifungals is the key to survival in such patients.

Socio-demographic profile and its influences on rehabilitation in children undergoing revision cochlear implantation - MERF experience

INTRODUCTION

Revision cochlear implant surgery (RIS) is an unusual and unfortunate event, but not an uncommon occurrence in today's time, with more and more children being implanted. It is accepted that a pediatric cochlear implant recipient may require one or two revision procedures during their lifetime. The indication of RIS can be due to a multitude of causes like trauma, device failure (hard failure or soft failure), infection at the implant site, electrode extrusion, device migration, magnet migration, and upgradation in the technology. Scenarios, where the child is deprived of hearing once again is worrisome for the family. And, they need financial and psychological assistance as well.

AIMS AND OBJECTIVES

(1) To scrutinize the socio-demographic profile of children who underwent RIS. (2)To profile the social, intellectual, and economic backgrounds of these families.

MATERIAL AND METHODS

A retrospective, observational, non-interventional, cohort study conducted at the Implantation otology department of Madras ENT Research Foundation (MERF), Chennai, Tamil Nadu, India.

DATA COLLECTION

(1) Detailed medical records of all the children who satisfied the inclusion criteria were reviewed.(2)This was followed up by a telephonic interview with the guardian of the consenting patients, to obtain further data based on a customized questionnaire.

SAMPLE SIZE

Of the 99 children who underwent RIS, 80 families consented to be part of the study.

STATISTICAL ANALYSIS

(1) Cause of revision implant surgery and Family system Risk estimate.(2) Correlation of sex, family system, patient non-compliance to habilitation, and residential area with RIS.(3) Correlation of the residential area of the patient with completion of 1-year habilitation.

RESULTS

A significant association observed between RIS and Sex (P = 0.03). A significant co-relation between patient non-compliance to habilitation and cause of revision implant surgery observed (P = 0.02). A significant co-relation was seen between residential area (Rural/Urban) and cause of RIS (P = 0.02). A statistically significant correlation seen with the residential area (Rural/Urban) of the child and completion of 1-year habilitation (P = 0.01). Uni-variant association was found between patients that have completed one year of habilitation, patient compliance, and modified Kuppuswamy Socio-Economic status.

CONCLUSION

The current data has aided in refining our institutional management protocols and predicting high-risk candidates who may need revision surgery in the future. Based on the data, all cochlear implantees and their families especially in the lower socio-economic strata, are now being meticulously educated about device care, the possible reasons for failures, and the importance of timely re-intervention.

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.

A clinical profile of revision cochlear implant surgery: MERF experience

Objective: To study the prevalence of revision cochlear implant study in a tertiary care referral center. To assess the various indications and surgical outcomes of revision cochlear implant surgery. Methods: A retrospective chart review of revision cochlear implant surgery done from June 1997 to December 2019. All the surgeries that were done in children of 12 years and below were included. The revision surgeries were either with or without explantation and reimplantation. The causes included were device failures, electrode extrusion/malposition, magnet migration, persistent foreign body reaction, facial twitching, wound infection, and cholesteatoma. Results: A total of 1636 pediatric cochlear implantation surgery were performed during the study period of 22 years. There were 94 (5.7%) revision surgeries done for various indications during this period. Out of them, 67 patients (71.3%) had device failure thus being the commonest indication for revision surgery, followed by infection in 12.8% of the total patients. Among the total revision, 81 (86.2%) patients had explantation and reimplantation of the new device. Conclusion: Indications of revision cochlear implant surgery are manifold that can be either device-related or patient-related. Revision surgery needs a highly skilled and experienced team of surgeons, audiologists, and habilitationists for achieving optimal results.

Posterior semi-circular canal electrode misplacement in Goldenhar's syndrome

Literature documents the incidence of electrode misplacement within the range of 0.2% to 5.8% with the superior SCC as the most common site, followed by the vestibule. In this report, we present the finding of electrode misplacement in the posterior SCC in a child with Goldenhar syndrome which was subsequently corrected. This child with bilateral congenital profound SNHL presented for unilateral cochlear implant surgery. Intraoperatively, the lateral SCC bulge, stapes, oval window, round window niche and pyramid were noted absent, leading to a surgical decision in favour of a subtotal petrosectomy. Using the aberrant facial nerve and jugular bulb as critical landmarks, a cochleostomy was performed in the posteroinferior aspect of the promontory bulge. Although electrode insertion was smooth and complete, NRT was absent in the presence of normal electrode impedance. A post-operative HRCT scan showed the electrodes in the posterior SCC. Repositioning of the electrodes was carried out by creating a new cochleostomy anteroinferior to the previous one. Complete correct electrode insertion was accomplished via this cochleostomy complimented by robust NRT tracings. Cochlear implant electrode insertion should be supported by correct identification of surgical landmarks. Intraoperative impedance testing and NRT help confirm device integrity and correct placement, the absence of which may raise the suspicion of malposition. In the presence of such a suspicion, the post-operative HRCT scan is a useful retrospective guide to corrective action, in a low-cost setting lacking intra-operative imaging facilities like X-ray, Fluoroscopy, Flat Panel CT & CBCT. Abbreviations, BERA: Brainstem Evoked Response Audiometry; CBCT: Cone Beam Computed Tomography; EAC: External Auditory Canal; ITD: Insertion Test Device; LSCS: Lower Segment Caesarean Section; MDT: Multi-Disciplinary Team; NICU: Neonatal Intensive Care Unit; NRT: Neural Response Telemetry; OAE: Oto-Acoustic Emissions; PIH: Pregnancy Induced Hypertension; SCC: Semi-Circular Canal; SNHL: Sensori-Neural Hearing Loss.

Subtotal Petrosectomy in Cochlear Implant Surgery: Our Experience

Aims

Subtotal petrosectomy (SP) with cochlear implant (CI) is required in certain specific situations in the management of patients who are candidates for cochlear implants. To study and review the indications, surgical issues, and complications of this procedure.

Materials and Methods

Retrospective review of all patients who underwent subtotal petrosectomy with cochlear implant during the period January 2010-December 2016 at a tertiary care and referral centre.

Results

19 patients underwent 20 subtotal petrosectomy with cochlear implant during this period. One patient had simultaneous bilateral implantation. The indications were previous mastoid cavity in 7 patients, 5 patients had chronic otitis media, inner ear malformations in 3,ossified cochlea in 3 and unfavourable anatomy in 2 patients. Fat or musculoperiosteal flaps were used to obliterate the cavity. Ninety percent of patients underwent single stage surgery and ten percent underwent two stage procedure.Complications were seen in three patients (15%).

Conclusion

SP helps in isolating the cavity from external environment after removal of disease, improves the exposure and access, reduces risk of infection and cerebrospinal fluid (CSF) leaks and facilitates CI. Meticulous surgical technique will reduce the complications and long term follow up is needed to detect entrapped cholesteatoma. Subtotal petrosectomy with blind sac closure of external ear canal is required in certain specific situations. It is a safe and effective surgery with acceptable rate of complications.