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.     

Patient experiences of sialendoscopy with monitored anesthesia care versus general anesthesia

ObjectiveTo compare the experiences of patients who received sialendoscopy under general anesthesia (GA) with those who received monitored anesthesia care (MAC).MethodsPatients who underwent sialendoscopy for sialadenitis or sialolithiasis from July 1, 2020, to July 31, 2021, were offered inclusion to this prospective observational study. A survey was sent to consenting patients on post-operative day 1 to record aspects of their pre-, intra-, and post-operative experience. The primary outcome was overall satisfaction. Secondary outcomes included pain tolerability and preference for similar anesthetic modality in the future.ResultsSeventy-five patients completed the post-operative survey (86% response rate), of which 39 patients received GA and 36 received MAC. Patient overall satisfaction was similar between groups (GA: “Poor/Average/Good” = 23%, “Excellent” = 77%; MAC: “Poor/Average/Good” = 25%, “Excellent” = 75%, p = 1.00). Tolerability of immediate post-operative pain was likewise similar between the GA (82%) and MAC (97%) groups (p = 0.058). Patients who received MAC reported intra-operative pain as “none/tolerable” 72% of the time and “uncomfortable” 28% of the time. Patients who received GA would prefer the same anesthetic in the future more often than in the MAC group (85% versus 61%, respectively, OR 3.50, 95% CI 1.17–10.50, p = 0.035).ConclusionIn regard to patient satisfaction, both MAC and GA are acceptable anesthetic choices in sialendoscopy for appropriate cases. Patients report similar overall satisfaction and post-operative pain tolerance under either anesthetic modality. Patients who undergo GA report higher rates of preference for similar anesthetic modality in the future. Further study is needed to determine the most appropriate criteria for anesthesia modality selection.     

Multichannel cochlear implantation in children with cochlear ossification.

OBJECTIVE: To compare results of post-meningitic children who had cochlear implantation with partial or complete drill-out to those who had no drill-out. STUDY DESIGN: This study is a retrospective case review. SETTING: The Atlanta Cochlear Implant Group is a private, tertiary, outpatient clinic. PATIENTS: Eligibility included all our post-meningitic patients, 2-17 years, having a cochlear implant between June 1990 and July 1997. INTERVENTIONS: All subjects had a Nucleus 22 cochlear implant surgically implanted, speech processor programming and follow-up testing in our center, and aural rehabilitation in a variety of therapy settings. MAIN OUTCOME MEASURE: Open and closed set speech discrimination tests. RESULTS: Test performance for speech understanding was highest in the non-ossified group and lowest, but above chance, in the ossified group with complete drill-out. CONCLUSIONS: While children with non-ossified cochleas performed best, even children with extensive ossification requiring complete drill-out benefited from cochlear implantation.     

Positional vertigo and cochlear implantation.

OBJECTIVE: To identify patients developing positional vertigo after cochlear implantation. STUDY DESIGN: Prospective study on a cohort of patients undergoing cochlear implantation. SETTING: Academic tertiary referral center. PATIENTS: The study included 70 consecutive patients who underwent vestibular evaluation before and after cochlear implantation. INTERVENTION: Medical record review. MAIN OUTCOME MEASURE: Recorded vestibular symptoms after cochlear implantation. Patients with positional vertigo were considered case subjects, whereas those without vestibular symptoms were considered case controls. RESULTS: Benign paroxysmal positional vertigo (BPPV) occurred in 8 patients (on the cochlear implant [CI] side in 7 patients, and in the other ear in 1). One patient had BPPV of the lateral semicircular canal on the implanted side, and 7 patients had BPPV of the posterior semicircular canal (on the same CI side in 6 patients, and on the opposite side in 1), which were detected and presented during the last examination. In 5 patients, the onset of symptoms varied from 7 to 130 days after implant activation; in 2 patients, the onset occurred before activation. CONCLUSION: Three different mechanisms are proposed for the occurrence of BPPV in patients with CI. The first focuses on the fall of bone dust particles into the cochlea during cochleostomy. In the second, the vibration caused by drilling the cochlea would be sufficient to dislodge otoconia into the labyrinth. The third hypothesis suggests dislodging of an otolith because of the electric stimulation. In our patients, conservative approaches have been used with a minimal invasive cochleostomy and without perilymph suction. Thus, the vibratory trauma affecting the cochlea during cochleostomy seems to play a fundamental role in the development of paroxysmal vertigo in patients with implant.     

Intracranial complications of cochlear implantation.

OBJECTIVE: To describe intracranial complications after cochlear implantation in the pediatric and adult populations. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: A chart review of the intracranial complications and their management in 345 patients undergoing cochlear implantation was undertaken. INTERVENTIONS: Variables, including age, sex, implant manufacturer, cause of deafness, intraoperative findings, and postoperative complications, were collected and analyzed. MAIN OUTCOME MEASURE: Presence of intracranial complication of cochlear implantation. RESULTS: There were 134 Nucleus-22 (Cochlear, Englewood, CO) devices, 50 Nucleus-24 devices, 118 Med-El (Durham, NC) devices, and 43 Advanced Bionics Corporation (Sylmar, CA) devices in 151 adults and 194 children. There was a 9.3% overall complication rate, with most (59%) being related to device failure. There were three intracranial complications (<1%), two in elderly individuals and one in a child. Two minor dural defects with cerebrospinal fluid leak at the site of the receiver/stimulator recess in Med-El devices were repaired intraoperatively with temporalis fascia. One elderly patient experienced an acute extensive subdural hematoma after Nucleus-24 implantation, which was treated successfully with immediate evacuation. CONCLUSION: Intracranial complication rates associated with cochlear implantation are low, although potentially very serious. Surgeons should be aware of intracranial complications, especially in older individuals, and take immediate appropriate action.     

人工耳蜗精准微创植入术

正从第一例多通道人工耳蜗在维也纳成功开展到今天,人工耳蜗植入手术用于极重度耳聋患者的听力重建已有40年的历史,而这一技术在全球普遍应用于临床也已有超过20年的历史。以往的人工耳蜗植入手术最主要的任务是把电极成功植入耳蜗,经术中测试,植入设备在植入后性能依然完好即可。经过数十年的发展,现在的人工耳蜗植入手术基本     

Electrode migration after cochlear implantation.

OBJECTIVE: To review the occurrence of electrode migration after cochlear implantation. STUDY DESIGN: Review of public database and retrospective case series. SETTING: Tertiary academic referral center, ambulatory. PATIENTS: Retrospective review of electrode migration reported in association with the US Food and Drug Administration Manufacturer and User Facility Device Experience database and a single-institution case series between 1996 and 2006. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURE: Occurrence of electrode migration. RESULTS: During the period 1996 to 2006, 151 reports of electrode migration were filed in the Manufacturer and User Facility Device Experience database. The most common association with migration was cochlear ossification, although 127 of 151 cases had no known association. During an equivalent period, 637 cochlear implant (CI) procedures were performed at the University of Miami. Of 580 primary CI operations, 2 cases of electrode migration were identified, both associated with reossification of a cochlea that was fully ossified at the first procedure. CONCLUSION: Electrode migration is an underrecognized complication of CI surgery and may be associated with cochlear ossification. Electrode stabilization techniques may reduce the incidence of CI electrode migration in nonossified or incompletely ossified cases.     

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.     

人工耳蜗植入术后改良耳蜗位平片的探讨

目的 探讨改良后耳蜗位平片摄影位的临床应用价值。方法 21例人工耳蜗植入术后患儿(年龄30d～4岁)分别摄许氏提倡的耳蜗位平片摄影位和我们改良后的许氏耳蜗位平片摄影位,用Cohen(c)方法测出蜗管内电极数,将术中得数与2种片所得共3组数据行统计处理t检验。结果 2种平片均能清晰地显示蜗管内电极的位置和形态,2组X片结果与手术结果基本吻合,3组数据比较差异无统计学意义。结论 改良后耳蜗位平片摄影位方法简便,易使4岁以下患儿接受,且能满足了解人工耳蜗植入术后精确状态的需要。     

Bilateral cochlear implantation

Cochlear implantation (CI) is the standard of care for the treatment of children and adults with bilateral severe-to-profound sensorineural hearing loss. Because the ultimate and continuous goal of CI teams is to improve patient performance, a potential method is bilateral CI. The potential benefits of bilateral CI include binaural summation, squelch, equivalent head shadow for each ear, improved hearing in noise, sound localization ability, and spatial release from masking. The potential disadvantages include additional or prolonged surgical procedure, unproven cost/benefit profile, and the elimination of the ability to use future technologies and/or medical therapies in the implanted ear.     

Revision cochlear implantation

Reoperation on a patient with an indwelling cochlear implant is uncommon. When necessary, surgery is performed for explantation of an existing device with immediate or delayed reimplantation, or for scalp flap revision and receiver-stimulator repositioning in the case of infection or device migration. Rarely, revision surgery is performed to reintroduce intracochlear electrodes that may have partly or entirely extruded from the cochlea or were placed inappropriately. Successful revision cochlear implant surgery requires attention to certain surgical principles. Good outcomes, asa measured by speech perception tests, are common, but are not guaranteed. This article outlines the indications for revision cochlear implant surgery, the recommended surgical principles, and published outcomes from reimplantation.