Cochlear implant surgery

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. 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

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 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

	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%)