Difference between revisions of "Cochlear implant surgery"

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{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV
| monitors = Standard; facial nerve monitoring
| considerations_preoperative = Patients' hearing is limited
| considerations_intraoperative = Facial nerve monitoring (avoid paralytics)
| considerations_postoperative =
}}'''Cochlear implant surgery''' is a novel surgical approach to address deafness and sensorineural hearing loss. The surgery consists of implanting a cochlear implant device that resides externally and receives and processes sound, and an internal component that transmits the received sound and stimulates the cochlear nerve<ref>{{Cite journal|last=Naples|first=James G.|last2=Ruckenstein|first2=Michael J.|date=2020|title=Cochlear Implant|url=https://pubmed.ncbi.nlm.nih.gov/31677740|journal=Otolaryngologic Clinics of North America|volume=53|issue=1|pages=87–102|doi=10.1016/j.otc.2019.09.004|issn=1557-8259|pmid=31677740|via=}}</ref><ref>{{Cite journal|last=Mowry|first=Sarah E.|last2=Woodson|first2=Erika|date=2020-01-01|title=Cochlear Implant Surgery|url=https://pubmed.ncbi.nlm.nih.gov/31556929|journal=JAMA otolaryngology-- head & neck surgery|volume=146|issue=1|pages=92|doi=10.1001/jamaoto.2019.2274|issn=2168-619X|pmid=31556929}}</ref>. This surgery has been applied to post-lingual adults and prelingual children with hearing loss. Typically, during surgery, a 2-channel electrode is used to monitor the upper and lower divisions of the facial nerve. The classical approach is a posterior tympanotomy - used both for adults and children. Surgical incision is postauricular and that the cochlear implant device sits internally under the skin behind the incision usually. There is no external mechanical component of the device on the surface of the skin that can be seen immediately post-op. A suprameatal approach is reserved for patients with anatomical variations (16%). 
 
==Preoperative management==
 
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->===
*Patients' limited hearing may impair preoperative consultation
*Investigate genetic/syndromic sources of hearing loss such as neurofibromatosis it's multi-organ pathology
 
===Operating room setup===
*Standard GA setup
*Consider straight connector with accordion to ETT
*Circuit extensions for 180-degree supine position
 
 
==Intraoperative management==
 
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===
*Facial nerve monitoring
*PIV (consider 2nd IV in lower extremity with 180-degree positioning)
 
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===
*GETA
 
===Positioning===
*180-degree turn (head is away from anesthesia team)
*Head positioned away from operating site.
*Surgeons may conduct frequent head position changes intraoperatively
*Surgeons frequently tilt table for adequate visualization under the microscope. Patients must be carefully strapped to table during these extreme table-tilt angles. Consider 3-4 safety straps during initial positioning
 
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===
* Avoid paralytics to maintain facial nerve monitoring. Consider high-depth of anesthesia or remifentanil infusion
*During microscopy, minimize patient movement
**Consider remifentanil infusion
*Consider TIVA with propofol infusion to aid in preventing PONV
*Volatile anesthetics are appropriate despite facial nerve monitoring
 
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
 
==Postoperative management==
 
===Disposition===
*PACU
*Home discharge
 
=== Post-op considerations ===
 
* Patient hearing is still impaired post-op. Patients must wait weeks before external sound sensor is activated and the patient can hear
* Glasscock pressure dressing<ref>{{Cite journal|last=Levy|first=Joshua M.|last2=Johnson|first2=Bradley T.|last3=Molony|first3=Timothy B.|date=2011|title=Effectiveness of the Glasscock dressing compared to the mastoid pressure dressing in cochlear implantation|url=https://onlinelibrary.wiley.com/doi/10.1002/lary.22279|journal=The Laryngoscope|language=en|volume=121|issue=S5|pages=S323–S323|doi=10.1002/lary.22279}}</ref> remains on the patient for 2 days post-op
* Eye and lip sites from facial nerve monitor needles may cause oozing of blood or bruising
 
===Pain management===
*Oral narcotics
*Multi-modal, non-narcotic medications
 
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
*PONV
 
==Procedure variants<ref name=":0">{{Cite journal|last=Xu|first=Bai-Cheng|last2=Wang|first2=Su-Yang|last3=Liu|first3=Xiao-Wen|last4=Yang|first4=Ke-Hu|last5=Zhu|first5=Yi-Ming|last6=Chen|first6=Xing-Jian|last7=Du|first7=Wan|last8=Li|first8=Yong|last9=Chen|first9=Chi|last10=Guo|first10=Yu-Fen|date=2014|title=Comparison of Complications of the Suprameatal Approach and Mastoidectomy with Posterior Tympanotomy Approach in Cochlear Implantation: A Meta-Analysis|url=https://www.karger.com/Article/FullText/358922|journal=ORL|language=en|volume=76|issue=1|pages=25–35|doi=10.1159/000358922|issn=0301-1569}}</ref>==
 
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Posterior
Tympanotomy
!Suprameatal
|-
| Unique considerations
|
|Positioning of the device
 
via the external auditory canal
|-
|Position
|
|
|-
|Surgical time
|180min
|43min
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|Facial nerve damage (1%)<ref name=":0" />
|
|}
 
==References==
 
[[Category:Surgical procedures]]
 
<references />

Latest revision as of 12:14, 31 October 2022

Cochlear implant surgery
Anesthesia type

General

Airway

ETT

Lines and access

PIV

Monitors

Standard; facial nerve monitoring

Primary anesthetic considerations
Preoperative

Patients' hearing is limited

Intraoperative

Facial nerve monitoring (avoid paralytics)

Postoperative
Article quality
Editor rating
Unrated
User likes
0

Cochlear implant surgery is a novel surgical approach to address deafness and sensorineural hearing loss. The surgery consists of implanting a cochlear implant device that resides externally and receives and processes sound, and an internal component that transmits the received sound and stimulates the cochlear nerve[1][2]. This surgery has been applied to post-lingual adults and prelingual children with hearing loss. Typically, during surgery, a 2-channel electrode is used to monitor the upper and lower divisions of the facial nerve. The classical approach is a posterior tympanotomy - used both for adults and children. Surgical incision is postauricular and that the cochlear implant device sits internally under the skin behind the incision usually. There is no external mechanical component of the device on the surface of the skin that can be seen immediately post-op. A suprameatal approach is reserved for patients with anatomical variations (16%).

Preoperative management

Patient evaluation

  • Patients' limited hearing may impair preoperative consultation
  • Investigate genetic/syndromic sources of hearing loss such as neurofibromatosis it's multi-organ pathology

Operating room setup

  • Standard GA setup
  • Consider straight connector with accordion to ETT
  • Circuit extensions for 180-degree supine position


Intraoperative management

Monitoring and access

  • Facial nerve monitoring
  • PIV (consider 2nd IV in lower extremity with 180-degree positioning)

Induction and airway management

  • GETA

Positioning

  • 180-degree turn (head is away from anesthesia team)
  • Head positioned away from operating site.
  • Surgeons may conduct frequent head position changes intraoperatively
  • Surgeons frequently tilt table for adequate visualization under the microscope. Patients must be carefully strapped to table during these extreme table-tilt angles. Consider 3-4 safety straps during initial positioning

Maintenance and surgical considerations

  • Avoid paralytics to maintain facial nerve monitoring. Consider high-depth of anesthesia or remifentanil infusion
  • During microscopy, minimize patient movement
    • Consider remifentanil infusion
  • Consider TIVA with propofol infusion to aid in preventing PONV
  • Volatile anesthetics are appropriate despite facial nerve monitoring

Emergence

Postoperative management

Disposition

  • PACU
  • Home discharge

Post-op considerations

  • Patient hearing is still impaired post-op. Patients must wait weeks before external sound sensor is activated and the patient can hear
  • Glasscock pressure dressing[3] remains on the patient for 2 days post-op
  • Eye and lip sites from facial nerve monitor needles may cause oozing of blood or bruising

Pain management

  • Oral narcotics
  • Multi-modal, non-narcotic medications

Potential complications

  • PONV

Procedure variants[4]

Posterior

Tympanotomy

Suprameatal
Unique considerations Positioning of the device

via the external auditory canal

Position
Surgical time 180min 43min
EBL
Postoperative disposition
Pain management
Potential complications Facial nerve damage (1%)[4]

References

  1. ↑ Naples, James G.; Ruckenstein, Michael J. (2020). "Cochlear Implant". Otolaryngologic Clinics of North America. 53 (1): 87–102. doi:10.1016/j.otc.2019.09.004. ISSN 1557-8259. PMID 31677740.
  2. ↑ Mowry, Sarah E.; Woodson, Erika (2020-01-01). "Cochlear Implant Surgery". JAMA otolaryngology-- head & neck surgery. 146 (1): 92. doi:10.1001/jamaoto.2019.2274. ISSN 2168-619X. PMID 31556929.
  3. ↑ Levy, Joshua M.; Johnson, Bradley T.; Molony, Timothy B. (2011). "Effectiveness of the Glasscock dressing compared to the mastoid pressure dressing in cochlear implantation". The Laryngoscope. 121 (S5): S323–S323. doi:10.1002/lary.22279.
  4. ↑ 4.0 4.1 Xu, Bai-Cheng; Wang, Su-Yang; Liu, Xiao-Wen; Yang, Ke-Hu; Zhu, Yi-Ming; Chen, Xing-Jian; Du, Wan; Li, Yong; Chen, Chi; Guo, Yu-Fen (2014). "Comparison of Complications of the Suprameatal Approach and Mastoidectomy with Posterior Tympanotomy Approach in Cochlear Implantation: A Meta-Analysis". ORL. 76 (1): 25–35. doi:10.1159/000358922. ISSN 0301-1569.

Top contributors: Nirav Kamdar, Jashvin Patel, Chris Rishel and Tony Wang

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