Combined local anesthesia and monitored anesthesia care for cochlear implantation

IntroductionCochlear implantation has become a routine procedure for patients with hearing loss. In some patients, general anesthesia might be contraindicated due to multiple co-morbidities. We describe a successful protocol for cochlear implantation under local anesthesia with light sedation.Case reportAn 81-year-old patient presented with profound sensorineural hearing loss. Her past medical history revealed ischemic coronaropathy, managed by stenting. After multidisciplinary evaluation and clear adapted information to the patient, surgery was performed under local anesthesia with light sedation and monitored anesthesia care. The procedure lasted 70 min, and was without incident and under good conditions for the surgeon. During the intervention, the patient was comfortable. No nausea or vomiting was noted. The postoperative period was smooth and uneventful.ConclusionWe find local anesthesia with light sedation a good alternative to general anesthesia for patients where general anesthesia is contraindicated. An experienced surgical and anesthesiology team is essential to shorten the duration of the procedure.     

婴幼儿人工耳蜗植入手术的配合与护理

目的总结人工耳蜗手术中婴幼儿的护理配合要点和经验,以提高手术的安全性和术后效果。方法118例小于5岁的婴幼儿接受了人工耳蜗植入手术。均在全麻插管下经面神经隐窝入路手术。选择足内踝上方大隐静脉末端做静脉穿刺。使用可调试微量输液器控制滴速。加强对患儿身体、输液装置及气管插管的固定。做好负极板粘贴、眼部护理及保暖工作。结果118例婴幼儿人工耳蜗植入手术的成功率为100％,术后全部患儿重新获得听觉。结论巡回护士精心调控仪器和对患儿采取的安全防护措施、器械护士对手术器械特性及手术程序的充分了解和密切配合是手术成功的关键。     

Bilateral cochlear implantation under local anaesthesia in a young adult – A case report

Objective: Cochlear implantation is routinely performed under general anaesthesia in most centres in the world. There have been reports of this surgery being performed under local anaesthesia and sedation for unilateral cochlear implantation. Our case study reports the first bilateral cochlear implantation carried out under local anaesthesia with sedation. This paper outlines the protocol used and discusses the challenges and advantages of the procedure being performed under local anaesthesia.

Case study: A 28-year-old female with a history of multidrug-resistant tuberculosis presented with bilateral severe to profound sensorineural hearing loss. On evaluation, she was found to be a suitable candidate for cochlear implantation. However, she was clinically unfit to undergo the surgery under general anaesthesia. After counselling the patient, the decision to undertake the procedure under local anaesthesia was made. The procedure took 105 min and was uneventful. The patient was discharged the next day

Conclusion: In the hands of an experienced surgeon and anaesthesiology team, bilateral cochlear implantation is possible under local anaesthesia. Patient motivation and cooperation are extremely important for the procedure to be done under local anaesthesia. This is an option for patients needing cochlear implantation who are medically unfit for general anaesthesia.     

Local anesthesia for cochlear implant surgery: a possible alternative

The aim of this paper is to illustrate the possibility of performing a cochlear implant surgery with local anesthesia and sedation, the anesthetic technique and the advantages of that in comparison to a general anesthesia.Aimsprospective study demonstrating the possibility of doing cochlear implant surgery under local anesthesia and sedation.Materials and methodswe describe three successful cases operated under local anesthesia, including neural telemetry and the conditions the patient presented after the surgery, with a very good recovery and no complications during and after the procedure.Resultsthese three surgeries show the possibility of doing the cochlear implant surgery with this kind of anesthesia, with a fast recovery, no symptoms of dizziness and vomiting after the surgery, and very few complaints from the patient.Conclusionlocal anesthesia with sedation for cochlear implant surgery in adults is a very good alternative for lowering the morbidity for the patient. It bears fewer risks, low costs for the hospital, with a very good procedure control, being very useful for older patients or the ones that have contraindications for general anesthesia. Clinical trial register - IC - 026 (clinicaltrials.gov)     

Cochlear implantation in atelectasis and chronic otitis media: long-term follow-up.

OBJECTIVE: To report the long-term results of cochlear implantation in cases with chronic otitis media or atelectasis using a single surgical technique performed in a single cochlear implant center. PATIENTS: Nine patients who were implanted using the blind-pit closure of the external ear canal technique (4 patients with adhesive otitis media and 5 with radical mastoid cavities). Follow-up ranged from 18 months to 12 years (mean, 7.05 yr). INTERVENTION: The surgical procedure was performed in 2 stages. The first stage included canal wall down or lowering any high facial ridge in previous mastoidectomies, removal of all skin, and blind-pit closure of the external ear canal without mastoid cavity obliteration or eustachian tube obliteration. Cochlear implantation was performed 6 months after the first surgical procedure. RESULTS: All operations were uneventful, and during cochlear implantation, as a second stage, no epithelia or other problems were encountered. No serious complications were encountered during the follow-up period. One case had a minor disruption of the external canal closure that was reclosed successfully under local anesthesia. All patients were using the device at the last follow-up interval with no device problems. CONCLUSION: Blind-sac closure of the external ear canal without obliteration is a rather safe surgical procedure in cases with chronic otitis media or atelectasis. Meticulous surgical technique and proper patient selection are of paramount importance. However, a 2-stage procedure may not always be necessary and might best be confined to those patients who have active inflammatory disease at the primary procedure.     

Cochlear implantation under conscious sedation with local anesthesia; Safety,Efficacy, Costs,and Satisfaction

Objective: To evaluate the safety, efficiency, cost effectiveness, and satisfaction of patients undergoing cochlear implantation under conscious sedation versus general anesthesia.

Study design: Retrospective case review of 20 patients who underwent cochlear implantation under conscious sedation which was compared to 20 age-matched patients where surgery was performed under general anesthesia.

Methods: Perioperative times, length of stay, anesthesia drug costs, postoperative complications, and patient satisfaction were compared between the two groups.

Results: Conscious sedation was associated with decreased drug costs, surgery time, and anesthesia time. Length of stay was significantly longer for patients undergoing general anesthesia. Patient satisfaction was superior with conscious sedation. Perioperative morbidity was not significantly different between the two groups.

Conclusion: Conscious sedation for cochlear implantation is a safe, efficient, and cost-effective alternative to general anesthesia. The efficacy of conscious sedation for cochlear implant surgery may expand the treatment of profound hearing loss to the elderly who are deemed too sick for general anesthesia or are fearful of the cognitive or medical consequences of general anesthesia.     

术中圆窗耳蜗电图对人工耳蜗植入电极安全性评估

目的：分析人工耳蜗电极植入前后圆窗耳蜗电图（R W EcochG）中耳蜗微音电位（CM）阈值的变化，以客观评估人工耳蜗植入手术是否对耳蜗基底膜造成损伤。方法：对40例拟行人工耳蜗植入术的患者在全身麻醉下行R W EcochG测试，分析植入电极前后CM阈值的变化。结果：40例人工耳蜗植入患者中，39例电极植入前后CM阈值相近，且在个别频率植入电极后CM阈值减小5dB；仅有1例患者电极植入后CM阈值比植入前明显增加，术中植入电极时有阻力感。结论：术中RWEcochG测试可以客观评估人工耳蜗植入手术本身是否对耳蜗基底膜造成损伤。     

Retrograde parotidectomy under local anesthesia for benign,malignant, and inflammatory lesions

Objective

To report the patient selection, surgical technique, and outcomes of parotidectomy using local anesthesia under monitored anesthesia care (MAC).

Hearing loss after cardiopulmonary bypass surgery

Hearing loss (HL) is a rare complication following cardiac surgery with extracorporal circulation (CSWEC) or other non-otologic surgery under general anesthesia, as is HL caused by loss of cerebrospinal fluid during neurosurgery or spinal anesthesia. The incidence of HL after CSWEC is not known since preoperative hearing testing is not commonly done and a perioperative HL may occur unnoticed. We present four cases of profound sensorineural hearing loss following CSWEC for coronary artery bypass or cardiac valve surgery. The hearing loss was noticed immediately on waking from anesthesia in three of the patients, whereas the fourth patient noticed decreased hearing during the first postoperative week. In all patients audiological investigation suggested a cochlear etiology of the HL. The possible mechanisms for HL are discussed. HL after CSWEC is most likely caused by a microembolism generated by atheromatous material. Received: 25 January 1999 / Accepted: 12 April 1999     

儿童人工耳蜗植入年龄下限降至9月龄的启示与应对

食品与药品管理局(FDA)批准将儿童人工耳蜗植入年龄下限降至9月龄表明：有必要更早地植入人工耳蜗，以收获聋儿植入后更佳的听力、言语和语言康复成效。在低龄婴幼儿中进行人工耳蜗植入，离不开一批训练有素的医护及麻醉团队提供围手术期支持，对诊断、麻醉风险、外科技术、术中测试和术后编程、长期安全等方面提出了更高要求。同时也对婴幼儿听力学诊断、干预和评估带来了挑战。9~24月龄儿童植入人工耳蜗的指征仍为双侧极重度感音神经性听力损失，围绕“先天聋儿植入人工耳蜗的指征和时机”“植入前是否试配助听器”等话题，耳外科专家与听力学专家应携起手来，审慎、稳妥、积极地开展低龄儿童人工耳蜗植入的循证医学研究。     

小儿专科医院开展人工耳蜗植人手术的优势

目的通过本组6家小儿专科医院开展人工耳蜗植入手术的临床工作,讨论小儿专科医院开展人工耳蜗植入手术的优势。方法从1998年5月-2009年3月11年间,本组6家小儿专科医院耳鼻咽喉科共开展了103例人工耳蜗植入手术。术前信息：全部为双耳重度和极重度感音神经性聋,年龄8．5个月-10．2岁,平均年龄为3．8岁,全部为语前聋患儿。术前进行听力学评估、发育和智力评估、影像学评估、人工耳蜗植入适应证的评估。术前进行全麻风险的评估。进行与综合性医院开展人工耳蜗植入手术的优势比较,包括：①术前评估水平,②术中麻醉风险,③人工耳蜗植入手术结果,④围手术期护理和并发症处理水平。结果①术前评估：术前视觉强化行为测听检查：103例查出有残留听力49例,平均听力98dB,余54例无残留听力。畸变产物耳声发射检查：103例均未引出耳声发射。听觉脑干诱发电位、40Hz、多频稳态诱发电位检查：引出波形41例,未引出波形62例。术前影像学检查：颞骨CT检查103例中正常颞骨形态84例,内耳畸形19例,其中双耳大前庭导水管畸形ll例、Mondini畸形7例、前庭与外半规管共同腔畸形1例。脑常规MRI检查,正常98例、脑白质轻度异常5例。行为和智力测试：格雷费斯智力测试〉86分99例、〈86分4例。术前检查结果与综合性医院检查结果比较,无显著差异。②术中麻醉风险：全麻插管、拔管中出现心电、氧、二氧化碳监测问题、气管支气管痉挛并发症0例,综合性医院发生率为0．37％,有明显的安全优势。③人工耳蜗植入手术结果：103例手术均成功,与综合性医院比较,无明显差异。④围手术期护理与并发症的处理：103例术前常规静脉采血、术中,术后常规建立静脉通道未出现失败,综合性医院出现静脉采血、建立静脉通道失败率约5%右,?     

人工耳蜗植入术中圆窗耳蜗电图评价耳蜗残余听功能

目的应用术中圆窗耳蜗电图评估极重度感音神经性聋患者耳蜗残余听功能。方法20例患者全麻下人工耳蜗植入手术过程中,行术中圆窗耳蜗电图测试,测出的复合动作电位（CAP）阈值与术前纯音测听或其他听力测试之阈值进行比较。结果20例患者术中圆窗耳蜗电图测试测出的复合动作电位（CAP）阈值与术前1、2、4kHz听力测试阈值分别有较好的相关系数（0．20429,0．04076,0．38163）。结论术中圆窗耳蜗电图可以较准确客观地评估极重度感音神经性聋患者耳蜗残余听功能,且是人工耳蜗植入术前听力学评估方法的有意义的补充。     

Cochlear implantation in children with Jervell and Lange-Nielsen syndrome - a cautionary tale

OBJECTIVE AND IMPORTANCE: Jervell and Lange-Nielsen (JLN) syndrome is a rare cause of congenital profound hearing loss associated with a prolonged QT interval on the electrocardiogram. Children presenting for cochlear implantation with this condition may be asymptomatic but are at risk of sudden death. SCREENING AND SUBSEQUENT: careful management is therefore required to ensure a successful outcome. We present our experience of cochlear implantation in children with JLN syndrome, including two who died unexpectedly, and suggest a protocol for management of such cases. Clinical presentation Four cases of cochlear implantation in JLN syndrome are described. None had any previous cardiological family history. Two were diagnosed pre-operatively but, despite appropriate management under a cardiologist, died from cardiac arrest; the first in the perioperative period following reimplantation for infection, and the second unrelated to his cochlear implant surgery. The other two patients were diagnosed only subsequent to their implantation and continue to use their implants successfully. CONCLUSION: These cases highlight the variation in presentation of JLN syndrome, and the spectrum of disease severity that exists. Our protocol stresses the importance of careful assessment and counselling of parents by an experienced implant team.     

Secondary tracheoesophageal puncture with local anesthesia

OBJECTIVES: To present a new technique for secondary tracheoesophageal puncture (TEP) in laryngectomized patients. The technique is performed on an outpatient basis under local anesthesia. STUDY DESIGN: Laryngectomized patients waiting for secondary TEP procedures were given the choice between the new technique under local anesthesia on an outpatient basis and the traditional technique under general anesthesia requiring hospitalization. METHODS: Using basic implements available in an outpatient clinic, the traditional TEP technique was modified with the oral introduction of an intubation tube with an illuminated, inflatable cuff at the puncture site. The illuminated, inflated cuff serves as a beacon during the procedure and the tube protects the posterior tracheal wall. RESULTS: Nine patients underwent the procedure under local anesthesia. In 8 of them the procedure went smoothly, but in 1 of them the inflatable cuff could not be satisfactorily placed as a result of the local anatomy and the procedure was canceled. All patients were pleased with the technique and said the procedure was painless. CONCLUSIONS: With some modifications, the traditional TEP technique has been rendered suitable for selected outpatient use under local anesthesia, and the necessary hospitalization for secondary TEP can thus be avoided.     

Minimal access surgery for the Symphonix/Med-El Vibrant Soundbridge middle ear hearing implant.

OBJECTIVE: To develop a minimal access approach for implantation of the Vibrant Soundbridge middle ear hearing implant. This approach ideally uses the smallest skin incision possible, minimal or no hair shave, and the least possible amount of tissue and bone manipulation. This will facilitate the acceptability of the procedure to the general community and reduce the flap-related complication rate. The procedure is similar to the minimal access approach described for cochlear implantation. STUDY DESIGN: Eight patients with various degrees of sensorineural hearing loss and one with a mixed hearing loss who met implant criteria for the Vibrant Soundbridge middle ear hearing implant received the device over a 42-month period. The first two patients underwent the traditional implant procedure with postauricular hair shave, postauricular S-shaped incision, and implant receiver suture fixation to the temporal bone. The following seven consecutive patients received a progressively smaller C-shaped postauricular skin incision, no hair shave, retrograde skull drilling for the implant seat, and no implant suture fixation until the technique closely approximated the minimal access cochlear implant procedure. Postoperative performance of the Soundbridge/Vibrant Med-El was evaluated through audiology testing and subjective patient reports. SETTING: Private neurotology clinic and tertiary care teaching hospital. RESULTS: The technique was feasible in all patients. Follow-up for the minimal access group ranged from 3 years to 5 months. There were no complications related to the approach, and all patients were satisfied users of the implant. The lack of hair shave and small incision size was greatly appreciated and warmly endorsed by the patients. CONCLUSION: The Vibrant Soundbridge/Vibrant Med-El can be safely implanted using the minimal access method that has been popularized for cochlear implant surgery. A large incision, extensive hair shave, risk of flap necrosis, and possibility of unsightly scar may deter patients from pursuing the potential benefits of implanted hearing technology. The technique may make the device more accessible to individuals who have concerns regarding cosmetics and potential flap complications.     

Cochlear implantation and meningitis

OBJECTIVE: Study clinical presentation, diagnosis and treatment of cochlear implant patients diagnosed with bacterial meningitis. BACKGROUND: Cochlear implantation in children is necessary for the optimal development of speech in the developing child diagnosed with profound sensorineural hearing loss. Approximately 60,000 devices have been inserted in adults and children worldwide to date. SETTING: The Department of Pediatric Otolaryngology of a tertiary care children's hospital. METHODS: All patients undergoing cochlear implantation from April 1997 were identified. Patients diagnosed with bacterial meningitis after implantation were selected for study. RESULTS: Of 30 children, two developed bacterial meningitis after cochlear implantation. One patient developed Streptococcus pneumoniae meningitis. One patient developed nontypable Haemophilus influenzae bacterial meningitis. Both patients made a complete recovery. CONCLUSIONS: Prompt diagnosis and treatment of meningitis is essential to optimize outcome.     

Dental implants in irradiated areas: a series of 33 patients

INTRODUCTION: Prosthetic rehabilitation, particularly in radiated areas, can be particularly difficult in patients with partial or total edentation following treatment for orofacial cancer. We report a series of patients who underwent a protocol of implantation in radiated bone with evaluation of the prosthetic rehabilitation. MATERIAL AND METHOD: Thirty-three patients given radiotherapy for an orofacial cancer were implanted, followed by a dental prosthesis. The three phases of the protocol were a preoperative clinical and radiological analysis, a surgical phase under general anaesthesia and a postoperative clinical and radiological follow-up.RESULTS: Fifteen patients were treated for an oral cavity tumor, ten for a pharyngeal lesion, six for a laryngeal tumor and two for a maxillary cancer. The average dose of radiotherapy was 60.5 Gy. Sixty-eight implants were positioned, 91.9% in the anterior mandible. The delay between radiotherapy and implantation was 54 months. The delay between implantation and loading was seven months. The average follow-up was 31.9 months. No peri-implantitis was observed. DISCUSSION: Implantation in irradiated bone is possible if a strict protocol is used; a good rate of success and improved quality of life will favour development of this technique. Criteria for dental implant placement include local and general conditions, the psychological situation and technical possibilities. Sufficient delay after radiotherapy is necessary to verify healing and the good prognosis of the cancer. The vascular supply can be preserved by implantation under general anesthesia. All patients were satisfied with the functional and esthetic results.     

老年及老年前期人工耳蜗植入的临床初步研究

目的 探索人工耳蜗在双耳重度或极重度聋和全聋的老年患者中的临床应用安全性和效果.方法 2008年11月至2009年11月解放军总医院先后对8例50岁以上患者行人工耳蜗植入术,其中男5例,女3例;年龄52～76岁,中位数58岁.所有患者术前均为双侧极重度感音神经性听力损失,佩戴助听器无效或效果不佳.观察患者手术耐受及并发症情况.开机后3个月进行助听听阈评估和言语评估.结果 8例患者手术顺利,术中神经反应遥测均引出反应.术后康复顺利,无任何并发症.开机3个月后声场内言语频率平均助听听阈啭音(听力级)为35～50 dB,但言语测听结果个体差异较大.部分患者单音节、双音节、安静及噪声环境下的句子可实现较好识别率.结论 老年前期及老年患者可耐受全身麻醉状态下的人工耳蜗植入,只要术前准备充分则为安全的手术,但部分病例为中耳炎(胆脂瘤)或颞骨外伤等因素导致,需要特别注意中耳情况.老年重度以上听力损失患者人工耳蜗植入可明显改善言语识别能力.     

耳大神经阻滞对人工耳蜗植入术后患儿苏醒期谵妄的影响

目的 评价耳大神经阻滞对七氟烷全麻人工耳蜗植入术患儿苏醒期谵妄(ED)的影响。 方法 择期七氟烷全麻下单侧人工耳蜗植入术患儿80例,0~6岁,ASA分级Ⅰ~Ⅱ级。采用随机数字表法分为耳大神经阻滞组(A组)和对照组(B组)。麻醉诱导后,A组在超声引导下耳大神经周围注入0.2%罗哌卡因1 mL,B组在切口周围注射2%利多卡因2 mL。七氟烷维持麻醉。术后使用儿童麻醉苏醒期谵妄量表(PAED)评估ED发生率,使用面部、腿部、活动、哭泣和安慰程度量表(FLACC)评估术后疼痛。PAED≥13分或FLACC≥4分者,给予芬太尼0.5 μg/kg静脉注射。记录患儿七氟烷平均用药浓度、ED持续时间、拔管时间、麻醉后恢复室(PACU)停留时间、芬太尼总用药量、护士满意度评分和术后24 h内不良反应发生率。 结果 与B组比较,A组ED发生率(P=0.036)和PAED(P=0.024)评分降低,FLACC评分(P=0.008)和FLACC≥4分的比率(P=0.006)降低,芬太尼补救镇痛率(P=0.011)降低,PACU停留时间(P=0.040)缩短,护士满意度(P=0.021)得到改善(P均<0.05),PAED≥13分的比率(P=0.289)、ED持续时间(P=0.962)、拔管时间(P=0.913)和术后不良反应发生率(P呕吐=0.737;P呛咳=0.487;P低氧=1.000)差异无统计学意义(P均>0.05)。 结论 耳大神经阻滞能降低七氟烷全麻人工耳蜗植入术后儿童苏醒期谵妄的发生率、减轻术后疼痛且不增加术后不良反应发生率。