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Pediatric Cochlear Implant Risks, Complications & Counseling
Wasiq Nadeem • Sep 3, 2021 • 40 hits
Implantation of pediatric cochlear implants is a procedure that is not without risk. Cochlear implant risks include infections of the middle ear, injury to the dura causing CSF leaks, and facial nerve injury. Certain cochlear implant precautions can be taken to ensure that these risks and complications are minimized. Pediatric cochlear implant complications also include postoperative infections either of the middle ear or of the meninges. Appropriate counseling is vital not only to highlight these risks, but to also set realistic expectations of what is to come for both patients and families. This is best done with a multi-disciplinary approach to ensure long term success in children with cochlear implants.
Dr. Prashant Malhotra shares his experiences on the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Pediatric cochlear implant risks include pain, poor wound healing, CSF leaks, and facial nerve injury. Dr. Malhotra mentions the importance of counseling on improper wound healing as one of the more common cochlear implant complications, along with vertigo being more prevalent in patients with anatomic abnormalities.
• Appropriate anatomical considerations should be taken during surgery, including identification of the facial nerve and proper technique. Topical and/or oral antibiotic therapy can be used for cochlear implant complications such as ear infections, with up-to-date vaccinations being key in preventing meningitis.
• Counseling for pediatric cochlear implant recipients and their families remains a vital aspect of the process and should be practiced by each member of the team involved in the care of these patients.
Table of Contents
(1) Pediatric Cochlear Implant Risks
(2) Managing Cochlear Implant Complications
(3) Counseling Families of Children with Cochlear Implants
Pediatric Cochlear Implant Risks
Cochlear implant risks include injury to the facial nerve, CSF leaks, ear infections, vertigo, and meningitis. Dr. Malhotra states injury to the facial nerve can be avoided by identifying the nerve, as he does in every case, and then working around it. Being prepared for anatomical anomalies can help prevent CSF leaks as well. For children with cochlear implants, Dr. Malhotra mentions counseling families about wound changes and skin-related complications, which are addressed in his cases with two layer closures along with a mastoid Palva flap.
[Dr. Prashant Malhotra]
Generally speaking, issues around the facial nerve are very minimal. I'm fortunate to have not had any sort of those kinds of complications. So I think that if you do a lot of CI surgery, then you're used to finding the nerve, which I do in every case, and then I work around that. Again, the CHARGE syndrome kids are the ones I worry about most. They have a nerve that's very abnormal. It could potentially prevent you from doing an implant. I always bring this up with families ahead of time. I will typically do a case like that with one of my partners, so there are two of us doing it. We do everything we can in case there's a major complication.
Other big issues are CSF leaks or dural injury or something along those lines. However, I don't really worry about those too much. Getting the antrum is relatively straightforward. But if you have a very anterior sigmoid sinus or a low hanging tag, then you have to be prepared for that. I think facial nerve, CSF, those are very low incidence complications.
The complications that I do talk to families about are wound and skin things. In early implantation, the one that I worry about most is actually skin-related complications with young kids. It's not a high number, and it's still not statistically significantly different between children under one year and greater than one year of age. However, it is something that I kind of am very careful about. The modern implants that we put in tend to be lower profile, so they're not as bulky as maybe the ones that were used 5-10 years ago. The modern implants are slimmer, which is nicer because it puts less tension there. I try to do two layer closure and offset incisions with my mastoid Palva flap versus the skin one.
I do antibiotics for a week afterwards because these young kids are still in the ear infection range. So I think that due to the thinness of skin, skin-related and soft tissue complications like infections are things that I really tell families to watch for in the perioperative period.
...I always tell them that if the pain is a mild to moderate level, Tylenol or Motrin are usually all they should use. In all my implant patients, whether young or older, I've gotten away without using any opioids or prescribing anything. It tends to be only one or two days of pain.
...the other thing I counsel on is usually vertigo. Kids who have more abnormal ears, with pendrence syndrome or more dramatic EVAs, are more likely to have vertigo complications afterwards. I want to make sure they're aware of this. However, younger kids with normal anatomy don't typically experience vertigo too much afterwards. In those kids who were starting to walk, I let the family know that they might see nystagmus or something like that.
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Managing Cochlear Implant Complications
Dr. Malhotra speaks on managing cochlear implant complications such as otitis media. Oral and topical antibiotics are used in addition to the 1-week post-operative course of antibiotics, with ear tubes as a therapeutic option as well either at the time of implantation or in a staged fashion. Lastly, vaccinations remain of utmost importance to prevent meningitis in pediatric cochlear implant candidates.
[Dr. Prashant Malhotra]
For kids who have early recurrent OM or effusions, I'll plan on putting tubes in at the time of the procedure. A lot of times, if I see nonpurulent effusions, I'll let the families know that if I will put the tubes in during the surgery. If they have purulent effusions, we may have to put tubes in and reschedule the surgery.
I have a low threshold for putting tubes in and having kids have tubes with CI. I’m not concerned about that. This allows you to manage the prevention part, with topical drops. Those kids that have tubes, if they are in the younger age group and they're having infections, I will not only do drops, but actually the oral antibiotic as well, just to be aggressive. In those first two months afterwards, the risk of a soft tissue infection related to implantation tends to be the highest. If they're coming in with tube otorrhea a month after surgery, I don't want them to just be on drops. We're always telling pediatricians, "Don't do the oral antibiotics, just do drops." But in the CI kids, I say, "Please give the drops and the oral antibiotics."
[Dr. Ashley Agan]
A patient who has acute otitis media and also an implant is at risk of meningitis, is that right?
[Dr. Prashant Malhotra]
...even if it's a very low incidence, it is important that we do everything we can to protect against it. We do have a strict vaccination protocol. At our practice, we actually administer the vaccines on site for anything that is not done at the pediatrician's office. All the routine childhood vaccinations will need to be done.
[Dr. Gopi Shah]
And then just to clarify, you'll do tubes at the time of implant? You don’t put a tube in six weeks ahead of time and then put an implant, because you can do it all at the same time?
[Dr. Prashant Malhotra]
If I have it my way and I can anticipate it, I'd prefer to do it staged. If they're getting a second ABR and MRI, I’m typically thinking then, do they need tubes? I'd rather do it ahead of time if I have it my way, but at the time of implantation, if you haven't really seen them for a few months, you may look at their ears and find that there's something going on there.
Counseling Families of Children with Cochlear Implants
Counseling remains a cornerstone in the journey of pediatric cochlear implant recipients and their families. Dr. Malhotra counsels families on how cochlear implants work while setting realistic expectations for what to expect based on the diagnosis the child may have. He describes the importance of identifying different levels of knowledge that families of children with pediatric cochlear implants may have, and to address them appropriately. Separation of appointments with different teams also helps to not overwhelm families, while also answering their questions and ensuring needs are met from ENT, audiology, and speech therapy aspects for pediatric cochlear implant candidates.
[Dr. Ashley Agan]
Going back to families who are consulting with you, how do you explain to families how a cochlear implant works? I think some people imagine it being magically fully implanted, with no external processor and perfect hearing.
[Dr. Prashant Malhotra]
I fundamentally believe that this is sort of a phenomenal device. It’s one of the most successful neural prostheses. The tonotopic nature of the cochlea can allow a linear electrode ray to really work in an effective way. The central organization all the way to the brain is pretty amazing. I still do find it almost magical. Now, this is not what I tell families.
I counsel each family appropriately based on etiology and age to try to give a realistic expectation of what they're going to get with an implant. With the Connexin baby and the CHARGE kid, I'm not going to say the same things. But as far as how it works, I always point out that there's an external part and an internal part. I say that I'm going to be putting the internal part in, and they will get the external part two weeks later when we do the first activation with the audiologist. The external part has a microphone which picks up sound coming from the environment. The sound goes through a digital processor, and then it is broken up into different signals across all the different frequencies. It goes across the coil and magnet attached to the internal part with radiofrequency. This delivers the information to the internal parts, which stimulates and powers the electrode array that stimulates the nerve endings in the cochlea.
If they have more questions, then I can delve into it and talk about it more. Honestly, some families will go out and do a lot of research on their own, talk to families, look at the websites, and oftentimes get pretty good information. If they’ve done a lot of detailed digging, then I can just polish off some of the questions that they've got.
After my spiel, the audiologists also have a separate pre-device selection where they go over all three manufacturers. It's done independently from the surgeon. They talk over the equipment, they go over all the accessories and whistles and bells, and they do a whole informative slideshow. This is done at a separate appointment, where that's the only focus of the appointment, so it is not overwhelming for the family.
Dr. Prashant Malhotra
Dr. Prashant Malhotra is a member of the Department of Otolaryngology and the Hearing Program at Nationwide Children's Hospital and an Assistant Professor in the Department of Otolaryngology Head and Neck Surgery at The Ohio State University College of Medicine.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, May 11). Ep. 22 – Pediatric Cochlear Implants [Audio podcast]. Retrieved from https://www.backtable.com
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