Difference between revisions of "Cochlear implant surgery"
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}}'''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 | }}'''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== | ==Preoperative management== | ||
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | ===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=== | ===Operating room setup=== | ||
| Line 40: | Line 34: | ||
*Head positioned away from operating site. | *Head positioned away from operating site. | ||
*Surgeons may conduct frequent head position changes intraoperatively | *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. -->=== | ===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 | * Avoid paralytics to maintain facial nerve monitoring. Consider high-depth of anesthesia or remifentanil infusion | ||
*During microscopy, minimize patient movement | *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 | *Volatile anesthetics are appropriate despite facial nerve monitoring | ||
| Line 53: | Line 50: | ||
*PACU | *PACU | ||
*Home discharge | *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=== | ===Pain management=== | ||
| Line 61: | Line 64: | ||
*PONV | *PONV | ||
==Procedure variants< | ==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" | {| class="wikitable wikitable-horizontal-scroll" | ||
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| Unique considerations | | Unique considerations | ||
| | | | ||
| | |Positioning of the device | ||
via the external auditory canal | |||
|- | |- | ||
|Position | |Position | ||
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|- | |- | ||
|Surgical time | |Surgical time | ||
| | |180min | ||
| | |43min | ||
|- | |- | ||
|EBL | |EBL | ||
| Line 95: | Line 100: | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
| | |Facial nerve damage (1%)<ref name=":0" /> | ||
| | | | ||
|} | |} | ||
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 | |
| 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 4.0 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.
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