BackTable / ENT / Podcast / Transcript #22

Podcast Transcript: Pediatric Cochlear Implants

with Dr. Prashant Malhotra

We talk with Dr. Prashant Malhotra from Nationwide Children’s Hospital about Pediatric Cochlear Implants, including workup and patient selection. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Referral Pattern for Pediatric Cochlear Implants

(2) Diagnostic Workup for Cochlear Implant Candidates

(3) Multidisciplinary Hearing Care

(4) Timelines for Pediatric Cochlear Implantation

(5) Counselling Families About Hearing Loss

(6) Surgical Considerations for Inner Ear Malformations

(7) Cognitive Outcomes After Pediatric Cochlear Implantation

(8) Post-Implantation Complications

(9) Long-Term Mapping for Pediatric Cochlear Implants

(10) Guidelines for MRI Compatibility

Stay Up To Date

Follow:

Subscribe:

[Dr. Ashley Agan]
Hey, everybody. Welcome to the BackTable ENT podcast. I'm Ashley Agan, and I'm a general otolaryngologist practicing in an academic setting at UT Southwestern in Dallas, Texas.

[Dr. Gopi Shah]
And I'm Gopi Shah. I'm a pediatric otolaryngologist practicing at Children's Health at UT Southwestern. We're your hosts, and we're so glad you stopped by today. I'm excited because I have an old friend who's our guest today. [Dr. Prashant Malhotra] is a pediatric otolaryngologist at The Ohio State University. Dr. Malhotra was my chief resident when I was a PGY-2 at Thomas Jefferson University Hospital in Philadelphia. He went on to Palo Alto to complete a pediatric otolaryngology fellowship at Stanford. He's here today to talk about pediatric cochlear implantation. Welcome to the show, Prashant.

[Dr. Prashant Malhotra]
Gopi, it's great to be here. It's so nice to see you.

[Dr. Gopi Shah]
So tell us a little bit about yourself and your practice, and then we'll get into the topic of pediatric cochlear implants.

[Dr. Prashant Malhotra]
I grew up in Ohio and then I wanted to leave Ohio as soon as I was able to. So I went to the Chicago area for undergrad, went back to Case Western for med school, then went on to do ENT residency at Jefferson. After fellowship at Stanford, I actually was at the Cleveland Clinic for a few years in practice before ending up here in Columbus. Being at the Clinic was a great experience, and I fondly remember the group there. However, I was recruited to come down to Columbus to work on the hearing and pediatric cochlear implant program side of things. I've been here for about eight years. So my practice is about 75% pediatric otology at this point, but I do all the tertiary care stuff. I'm at an academic tertiary pediatric center, so Nationwide Children is a pretty huge hospital. I enjoy an academic tertiary care practice. That's what I'm doing right now.

[Dr. Gopi Shah]
So you're still doing the airway foreign bodies when they come in.

[Dr. Prashant Malhotra]
Yeah. It's nice. We have a big group. There's about 13 of us pediatric people here. It allows me to be able to specialize. There's two of us, Oliver Adunka and I at Ohio State. He and I are the two main people who do pediatric otology. The whole group kind of funnels the ear stuff to us, for the most part. It allows us to sort of develop in those sub-specialties in peds, which is really nice for us.

(1) Referral Pattern for Pediatric Cochlear Implants

[Dr. Ashley Agan]
Today we're really going to focus on pediatric cochlear implantation. We've had some podcasts on congenital hearing loss. In Episode 16, we had Rachel St. John and Walter Kutz. We also had Jake Hunter talking to us about adult cochlear implantation in Episode 15. For any of our listeners who haven't caught those, we highly recommend you check those out. So we won't rehash anything we talked about back then, but today our focus is pediatric cochlear implantation. Maybe you can kind of set the stage for us and talk about how these patients present to you for evaluation.

[Dr. Prashant Malhotra]
Sure. It comes in a wide variety of ways, so the program has really changed a lot over the years. When I first came, there wasn't a lot of dedication to developing the peds cochlear implantation side of things. They were doing about 10 to 12 implants a year. And over a couple of years, one thing that I was proud of is that we sort of were able to coordinate the group to develop the practice so that we can now do about 80 peds implants a year.

We're pretty busy now. During our evolution, we've definitely had a change in how kids came to us. Early on, when you're establishing yourself, you're really laying the groundwork for people to know about the program. There wasn't a lot of standardization to it. Part of our standardization was to really make sure that newborn hearing screening and early capture of patients became more standardized in our own birthing hospitals and in the surrounding hospitals.

We really try to have a big influence in the surrounding community and throughout the state. We have done a lot of outreach there. Now, we are able to really see the newborn babies right after identification, which is so key. In the end, our success with pediatric cochlear implantation starts from the very beginning. We want to follow up the newborn hearing screening, get the early ABR testing done, and see the babies very early if there's a concern.

Our goal is to see them right upon identification of hearing loss. We're not just a pediatric implant center. We actually manage kids with hearing losses of all types. We have Ohio School for the Deaf here in Columbus, so there's a strong deaf community here. We take care of these kids as well, who still require their needs to be met.

[Dr. Gopi Shah]
For the pediatric cochlear implant population, what percentage is your failed newborn hearing screen? And then what percentage is your delayed onset kids who are over the age of two? I guess your two categories would be prelingual and postlingual?

[Dr. Prashant Malhotra]
I think that earlier on, about eight years ago, we were capturing a lot of the older kids because there was a backlog of their cases. It was probably 80% postlingual, late ID patients. Now, I would say that we are seeing more young babies and kids, so the split is about 50%.

We still see with etiologies like congenital CMV and other progressive losses as we've implemented targeted and then universal screening for CMV in our NICUs and trying to extend them to the surrounding areas. We're capturing those kids and monitoring them very carefully, and then following them when they become implantable later on. But I would still say, we're probably 50% of the babies at this point.

[Dr. Ashley Agan]
What does the appointment look like? First, we can talk about the patients who were diagnosed at birth. So they've failed their newborn hearing screen and they're referred to you to have additional testing. What can parents expect as they go through that process, up to the point when they're actually being recommended for a cochlear implant?

[Dr. Prashant Malhotra]
After diagnosis, which may be done at an outside facility, they'll come to us. Actually, we have a pretty wide catchment area, so we might capture them at first. A very consistent message from the very beginning is incredibly valuable. We've got good relationships with audiologists, and they are pretty well aware of when patients are coming to cochlear implant category level. After that first diagnostic ABR is complete, audiologists may say, "Hey, look, we need to set up an ENT appointment and a follow-up audiology appointment." They'll kind of lay that groundwork.

At that first ENT appointment with me, I view these counseling appointments as super essential. I take the appropriate amount of time to do it, and I tell this to the residents and the fellows as well. I honestly believe that if we don't take the time to do it, nobody else does. I don't think that a lot of general ENTs feel very comfortable with the pediatric cochlear implant counseling pathway. They might not want to put words in the mouth of the program that they refer to.

The general pediatricians don't typically feel very comfortable counseling on permanent hearing losses. So I take strong ownership of saying: Okay, I'll start with going over the hearing testing, looking over the ABR results, explaining sensorineural hearing loss, explaining that it’s permanent, and walk them through all that stuff.

I don’t do this with the intent of overwhelming them with information, but I want to at least make sure they understand so that they make it to the next appointment. I really want to make sure that at the first appointment, they understand the gravity of it. Then, they are motivated to make the next appointment with audiology and the next appointment with me. I'm going to treat every family differently, based on where they're at. In peds, we're all accustomed to reading the family a bit. Some families come in the door and they're like, "I know my kid needs implants. When can they get their implants?" And then there are some families that are so overwhelmed by the concept of the kid might actually have a hearing loss, or not believe it, so I gauge how I counsel that first appointment based on where they're at.

I don't necessarily bring up cochlear implantation as a strategy in that first appointment, but I may bring it up as a possibility if they're already in that bilateral severe to profound range.

[Dr. Gopi Shah]
I totally hear you. And even as a pediatric ENT who does not do pediatric cochlear implants, I think that the counseling session, before I refer them to our implant program, is hard. I don't always know if I've covered all of the concerns. Like you said, every family is different. There could be an otherwise healthy baby, versus a baby where hearing loss is one thing out of a constellation of symptoms. There can be heart, lungs, and a lot of other things going on. And for both types of cases, it's very difficult to gauge, read, and know how to counsel.

[Dr. Prashant Malhotra]
Yeah. For some families I'm going to do a quicker play. But sometimes, I’ll do a slow play and say, "Hey, look, you know what? Let's just make sure we go to the hearing aid evaluation, or we'll get our second ABR, and then we'll meet again to take the next steps." Typically at that first appointment, we'll try to do two things: Set up the diagnostic pathway, and then set up the treatment pathway.
My first appointment (and actually all every follow-up appointment) is: Where are we at on those pathways? My diagnostic part, do we know the reason why? And then, what are we doing about it? And are we where we need to be on our timeline for that?

(2) Diagnostic Workup for Cochlear Implant Candidates

[Dr. Gopi Shah]
I know we've talked about workup and congenital hearing loss, but I would love to hear your personal algorithm or diagnostic part. Do you have a checklist in your head?

[Dr. Prashant Malhotra]
I have a pretty thorough questionnaire. It asks for a lot of historical context like perinatal stuff, such as the prematurity, hyperbilirubinemia, and ECMO exposure. There's also a family history part of it, which delves into genetic patterns of hearing loss. Then, I do a thorough physical exam, which is fairly limited in infants. I look at the eyes and the palate. I look for branchial anomalies and obvious facial dysmorphisms or asymmetry. Now, if something comes up pretty clearly, like they're premature with all this exposure, or they come to me already knowing that it is CMV, then it's a readily apparent diagnosis.

If it's an unknown diagnosis, and I can see them early, then I'll do a CMV IDG. Oftentimes, I'm not going to see them within three weeks. But I want to at least know as early as I can, if they've been exposed to CMV. I'll do that and the Connexin test with one blood draw. Connexin is done at our institution, so we get it back within a few weeks.

At the first visit, I start with those targeted tests if it's a bilateral loss. By the next visit, I'll know the Connexin status and whether they have CMV exposure or not. After that, I will usually get imaging, especially if we're talking about implantation. I'm going to want an MRI, unless I know the Connexin, in which case I’d be comfortable with a CT. But I want to know the nerve status and the MRI will let me look at that much better. If they're syndromic, I want an MRI and a CT, typically if they have a CHARGE syndrome or something along those lines.

After imaging and initial testing, I'll typically do the next generation genetic sequencing. I encourage families to do it. It’s not a must, but it's typically well-covered, soI'll do a genetics referral. Our genetics people will pre-authorize it, write a letter to get it covered, and we have good experience and good success with getting the next generation sequence genetic panel of the 170 different genes. It depends on whether it's unilateral or bilateral hearing loss, but I will usually make sure I know my CMV status, my Connexin status, my imaging, and the overall genetic status.

(3) Multidisciplinary Hearing Care

[Dr. Gopi Shah]
When patients come in, do they see an entire pediatric cochlear implantation team?

[Dr. Prashant Malhotra]
This is one of those things that definitely evolved as time went on. We used to have a multidisciplinary hearing clinic where we had audiology, speech, ENT, and social work involved. We have sort of changed that because as our volume got high enough, it became inefficient for us. When you're doing 10 implants a year, you can do that. When you have 80 implants a year, we need our CI audiologists to not be wrapped up in an inefficient multidisciplinary clinic.

We've transitioned to keeping our appointments independent, which has worked wonderfully for us. If they're going to see speech, they're going to be seeing speech for evaluation or therapy. They're going to see audiology for diagnostic testing, hearing aid fitting, or pre-implantation evaluation. All of that is done separately from the ENT appointment with me.

We have a weekly Thursday morning meeting with our audiologists, speech therapists, and surgeons. The meeting is one hour long, and we discuss every patient. We cover new IDs, cochlear implant patients, radar patients, candidate patients, those who are having surgery, and anyone with a problem. We keep a list, which anybody can add to, and we talk about those patients as we need to. It becomes a virtual multidisciplinary concept. We have a discussion, and then we set our plan. From a billing standpoint and from a schedule standpoint, it's all done in a way that is most efficient and least redundant for the family.

We also have a common philosophy amongst ourselves with ENT, speech, and audiology. At each one of our appointments, we check to make sure they have the other appointments scheduled. So any time they see me, I make sure they have their audiology and speech appointments arranged. When they see speech, they make sure they have ENT and audiology appointments arranged. We're all making sure that the patient is seeing all three services as they need to.

Social work is embedded in our ENT clinic. We can always call the social worker to assist with any needs. We have nurses who actively do a lot of organization and coordination stuff. So that's how we have it set up for a high volume practice, and we're able to make it work. We're fortunate to have resources to do it that way.

[Dr. Ashley Agan]
Do you only see your ear patients in your otology clinic, or do some of these patients come into your general clinic?

[Dr. Prashant Malhotra]
It used to be a little bit more carved out. I had more of a general clinic, which would be for all things: tonsils, airway, and neck masses. I had a separate otology clinic for hearing loss cases. As we move away from that prior hearing clinic model, I'll see new ID kids, implant kids and everything at any clinic. From an access standpoint, my practice is now mostly otology, and there's no difference in clinics from me anymore.

(4) Timelines for Pediatric Cochlear Implantation

[Dr. Gopi Shah]
We usually say: screen by one month, ID by three months, aids by six months. How do we know when the aids aren't benefiting those babies?

[Dr. Prashant Malhotra]
You’re actually referring to the one, three, six model from the EHDI (Early Hearing Detection and Intervention standards). We've actually kind of gone to more of a one, two, three model. We try to keep our scheduling and other things on that timeline as compressed as possible. Now when it comes to the hearing aid, are you asking about a hearing aid trial?

[Dr. Gopi Shah]
Yeah. You have to try the hearing aids and show that there's not a maximal benefit from them before you can jump to the CI, right?

[Dr. Prashant Malhotra]
We get them on hearing aids right away, around three to four months of age. However, we don't make the formal hearing aid trial a strict thing. The reality of it is, if you have a 80 decibel loss, it is about 80% likely that a cochlear implant is going to be preferential over a hearing aid. If you have a greater than 95 decibel loss, you're at a greater than 95% chance that a cochlear implant is going to be more beneficial to you. Early ABRs do predict who's going to benefit more from cochlear implants versus hearing aids. In the cases of bilateral loss and no response ABR, we make sure that those kids get the cochlear implantation as early as possible. We try to do it at nine months of age, and nothing really delays that timeline.

There's very little data to support that a hearing aid trial in infants of that age has significance. We need to prove a lack of aided benefit. And that's very important for us to do. We do that in an aided setting at a separate appointment where we do speech audiometry, questions, and testing. We're using the data logging and compliance for the hearing aid and doing it for a set period of time.

If they come to me a little bit late and I see them at seven months of age, I'm not going to make them wear hearing aids with a bilateral profound loss for a certain period of time before I implant them. One of the most fundamentally critical things I can do is to get the implant in early, and that has clear data to support its benefit. Once we've proven lack of benefit, the duration of time to wear the hearing aids is not very meaningful to us.

Insurance companies are starting to get away from requiring that as well. That used to be one of the kinds of things we had to fight, but it's less of an issue now.

[Dr. Ashley Agan]
Before we move on to talking about the surgery, can you talk a little bit about kids who come to you who are postlingually deaf? What are the differences? Is there anything that stands out, or is it the same?

[Dr. Prashant Malhotra]
If they're postlingually deaf, then our focus is less on the communication modality and asking if we will be able to get them to speak. Those first three years of life are so critical from a developmental standpoint. If they're going to cross that boundary of having a foundation of spoken language, it means a huge deal for them if they lose hearing afterwards due to sudden loss, progressive loss, or the enlarged vestibular aqueduct (EVA).

Generally speaking, the success of the implant is that they can plug back into hearing what they used to, and they tend to perform very well, as long as the etiology of the hearing loss supports good nerve anatomy and cochlear anatomy. If they're in the postlingual age range, we can get more dedicated speech perception testing, literacy testing, and word-recognition testing. We have a lot more tangible data from looking at their abilities. For the infants, it's really challenging to get this data. The success rate for older children tends to be very good when we're talking about bilateral hearing loss, but we are still learning from the emerging cases of single-sided deafness (SSD) CI.

Older kids don't do as well with single-sided deafness CI. I don't want to get too off topic, but when you have a normal hearing ear and an implant ear, someone may really rely on the lesser quality sound that comes from an implant. Older kids don't really necessarily adopt it right away when it's for single-sided deafness. Generally, I'm going to expect most postlingual kids to do well if they're implanted pretty soon after their drop, but with the single-sided deafness patients, I would call them out a little bit and say, "We really have to carefully counsel those guys."

[Dr. Gopi Shah]
Just to go on the tangent for a second, the single sided deafness: I have two questions. One, how often are you doing implantation in those kids? And two, do you find that an alternative like a bone-anchored hearing aid (BAHA) or a contra-lateral routing of signals system (CROS) is ever better? How do you know when to implant for a single sided deafness?

[Dr. Prashant Malhotra]
The two indicators for how well they're going to do with single-sided deafness are age and motivation. As far as the alternatives, which include the CROS, BAHA, FM system, observation, and CI, the CI is the only option that can truly bring sound to that ear. The other ones are not going to help sound localization. They can help with some of the complex listening environments, head-turning, and some subtle aspects that a child is not really able to tell you about until they're older. Younger kids aren't going to be very successful with those alternative options. Honestly, it's just too hard to understand the benefits in a two year old, so why bother with something like a bone anchored hearing aid.

By the time they are able to understand those benefits from alternative options, they're so much older and then they're out of the cochlear implantation window. It's a fundamental dilemma that we encounter. We're presenting a study at the American Cochlear Implant Alliance, where we have a large selection of SSD kids, 338 children that we've implanted in the last several years. Our experience is, the younger the better. Past the age of four, it can take up to a year to attain quality speech perception.

The habilitation afterwards is more challenging. There's a lot more non-compliance or not wanting to use the CI long-term in those kids, and that cutoff seems to us to be around four years of age. The habilitation really has to focus on covering their good ear and doing habilitation on that bad ear. But, it's tough to convince an older kid to do this, because they’re wondering: why do that when I can hear well out of my other ear? It poses a problem that's pretty unique. And I think that we are seeing benefits to doing it, but we're realizing it has to be a bit more appropriately selected.

(5) Counselling Families About Hearing Loss

[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.

(6) Surgical Considerations for Inner Ear Malformations

[Dr. Ashley Agan]
When you think about surgery, do you think about it differently based on age? Is there a difference in implanting a nine month old, versus a five year old, versus a ten year old with single-sided deafness?

[Dr. Prashant Malhotra]
I'll answer it two ways. In some ways, they are not that different to me, and I don't think about it very much. The cases that I really think about ahead of time are the ones that have different anatomy. Those are the ones with complex medical concerns or complex anatomy, like a CHARGE kid.

First of all, the safety profile has been demonstrated to be there in looking at patients under 12 months of age versus over patients 12 months of age. It's pretty well-established in both intraoperative and postoperative complications. If you're accustomed to doing the CI surgery, there are some modifications to be made, but generally speaking, the surgeries are not that different. The main thing that I do differently in a young child who's nine months old is, I'm careful with injections on the external part. I always palpate the mastoid tip to make sure I know how developed it is. I don't let my infiltration of lidocaine go down below the EAC just in case there is a superficial component of the nerve there. I go to a diamond drill early because that lateral third of the mastoid is not pneumatized and has a lot of marrow. Once I get to the cortex, I pretty much go to a diamond drill pretty quickly because it helps me really get that soft marrow bone and get oozing under control quickly. The mastoids are small and make sure I really drill out the mastoid tip all the way to the mastoid tip.

When I'm working with the residents and fellows, I always say, "Look, you may not think you need this, but you need it all the way down to the mastoid tip, because otherwise, when you're drilling at the facial recess and facial nerve, you’re coned in on a very small space. You want broad strokes to help keep you safe. Your technique keeps you safe. The more you have this exposure out maximally and laterally, then the better it is that you're getting in the recess. Otherwise, they tend to be very healthy mastoids. The young kids tend to go very easily and smoothly. I'm not worried about the blood loss level that's there. It's typically not very substantial. The goal is to kind of do it very quickly so you get the young child out of anesthesia very fast.

[Dr. Ashley Agan]
You mentioned special considerations for kids who have inner ear malformations. Can you unpack that a little bit more and talk about special considerations?

[Dr. Prashant Malhotra]
I'm not too concerned when it comes to things like EVA or incomplete partition type 2 (IP2) because they tend to have good success with the CI. About the gusher that many people are concerned about with an EVA, I find that it's not very clinically significant in most EVAs. Now the more abnormal the cochlea, the more deficient the modiolus, like an IP1 deformity or IP3. The more deficient the modiolus, the higher pressure CSF flow, and then you're going to actually get more of a real gusher.

Gusher is one of the things I'm always thinking about. I ask: What's the likelihood that there's going to be a gusher in these kids? Generally, they're managed pretty conservatively. You kind of let the egress come out. Most of the time you can just let that happen and give it a little time for it to equilibrate, and you could implant pretty comfortably. There are very few times that I think I've encountered where you're getting very high pressure flow. In this case, I do a round window insertion virtually every time. I make my incision in the round window, so I have everything ready to go and I’m prepared to stop the gusher. If it's a high pressure gusher, I just insert the implant and that tends to stop the flow.
That's a common question that residents ask: Is the gusher going to cause us major issues? And I find that it does not tend to be a big player.

If we're talking about other malformations, then the more severe the malformation, the more it affects my selection of the electrode array. I want to be prepared to potentially have multiple arrays available.
If I have a hypoplastic cochlea, I'm going to want a compressed or shorter array if I know I'm not going to get a full insertion with a full length array. If I have a common cavity or another malformation like that, I'm going to want a lateral wall array. I’m trying to avoid injuring the central neural elements and predicting: Where do I think the electrodes can sit in a way that helps?

The lateral wall array is nice. It's a straight array, it's reloadable, you can put it in, and you can take it out if you don't feel like it's going in. If you're meeting resistance, you can re-alter it. The perimodiolar array is pre-curled, and it’s going to sit a certain way. I typically will go with a lateral wall array if I'm going to have a more malformed cochlea. The major things I usually think about are the specific array that I will need and being prepared for a gusher.

(7) Cognitive Outcomes After Pediatric Cochlear Implantation

[Dr. Gopi Shah]
How are your cochlear implant outcomes (in terms of hearing, speech, usability) different, based on the amount of inner ear malformation? How do you counsel expectations for yourself and the family?

[Dr. Prashant Malhotra]
That's a great question and an important one too. I think that we're often guilty of overselling what the benefit is going to be. I think Connexin kids usually do outstanding. I would say that the EVA kids, and kids with minor malformations along those lines, I still expect speech perception in the 70% to 90% range. I think that spoken language is anticipated if all the other factors are okay.

The kids with CHARGE syndrome, like I said, tend to have the most numerous malformations. As you get the more malformed cochleas, I may prepare the families for the possibility that we may only be able to get sound awareness. In this particular scenario, we should make sure that we have a low threshold for expecting that sign language may still be needed. If the patient has a common cavity or a hypoplastic nerve, then I'm also going to counsel the family ahead of time about it. I try to direct my counseling based on age, cochlear anatomy, nerve anatomy, and any other factors I think that are in the way.

[Dr. Gopi Shah]
I think sometimes it's easy to undervalue sound awareness, because we're so hyper-focused on speech, but interaction with your surroundings, even just hearing Mom's voice, can probably bring a lot more value than maybe we give it credit for.

[Dr. Prashant Malhotra]
Completely. I think it's actually a very crucial idea, especially when you and I are accustomed to working with very complicated kids. In some of these kids, it's not the hearing that's preventing them from really getting their language development. Many of those kids will need manual communication devices regardless.

When we have families who are trying to make that decision about whether to implant, I'm thinking, "Okay, well, what is this kid like without an implant versus with an implant?" I’m not comparing these kids to outstanding star performers who speak three languages. I'm thinking, “Can an implant change this kid's life?”

The outcomes are not just language. Some families say, "Look, I just want them to hear my voice." There are definitely demonstrated benefits of being able to participate in other therapies, like being able to do their physical therapy or other therapies at a higher level. Also, the kid will have more autonomy as they grow older. I may not do a bilateral implant under some circumstances, but going from zero sound to one-sided sound awareness allows a child to interact with their environment more, especially if they have visual losses and other compounding issues.

(8) Post-Implantation Complications

[Dr. Ashley Agan]
Absolutely. I think that's a really beautiful point. Can you talk to us a little bit about complications that patients can have, post-op?

[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.

[Dr. Ashley Agan]
But I assume that's temporary.

[Dr. Prashant Malhotra]
Yes, and young kids don't see it that much. I caution them about it just in case they see the nystagmus because I don't want them to think they're having a seizure or something. Older kids and adults tend to experience that, especially in the more aged adults. But in younger kids, honestly, the vertigo seems to be fairly negligible unless they have those anatomic issues.

[Dr. Gopi Shah]
What about the long-term? The patient that you did a CI on at nine months, now they're 18 months and they have acute otitis media (OM). The pediatrician calls you because they have a CI and there's puss behind the ear drum. Is there a different way to manage that acute OM episode? Are you jumping to tubes sooner, because this is their first ear infection, and you don’t want them to get a further complication?

[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."

And the kid who's older who doesn't have tubes and has acute OM then definitely there's no role for watchful waiting. They need an antibiotic. They need to be monitored to make sure that it improves. Maybe they see their pediatrician and see me a couple of days or several days later or a week later, and just make sure that that's resolving and responding. If they're having more than one episode in a few months, then I would have a low threshold for putting tubes in.

[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]
Yep. It's interesting. I recently had to kind of review some of this stuff because I had a family who was refusing vaccinations, and then it was like, ethically, what do we do here in this scenario? We had to talk to the ethics committee and the legal department.

The topic comes up regularly because of the concerns of increased risk of meningitis to occur, especially earlier on, in the early 2000s, between 2002- 2009. Some of that was related to specific devices that were recalled because they were clearly traumatic and caused increased risk of meningitis, so they were taken off the market.

So then what is the risk of meningitis that occurs in kids who get implants solely because of the implants? Now we do know that the risk of meningitis is higher in kids who have inner ear anomalies, so that raises the background from the baseline. What is the risk of that versus those that have just a cochlear implantation? There is an elevation that's probably about two to three times the baseline by having an implant alone in relatively normal anatomy. But, the data is not so clear about what it is. Initially, there was a concern that it was about 30 times or even 100 times higher. That seems to be not true. A kid, who has relatively normal anatomy and just has a CI, does not have a much greater risk than the baseline, but the risk is elevated. And the effect of meningitis from strep pneumonia is a devastating consequence.

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.

The pneumococcal vaccines should be age-appropriate, including Prevnar 13 one for babies. At two years of age, they should get the Pneumovax. That's not always given to otherwise healthy kids. And that's the one that we have to make sure is really on everyone's radar. We still make sure they're appropriately vaccinated for Hib or Haemophilus influenza, as well as do the annual influenza vaccines. Now, if they haven't had their vaccines, there's a lot of tiny issues about the order you do vaccines and when you can give them.

The reason we do onsite vaccinations is because we did find that at times, we sent them out to get a vaccine for meningitis. They sometimes came back with a meningococcal vaccine, which is not what we were trying to get vaccinated for. We wanted to make sure there's no confusion. A lot of pediatrician offices don't actually have Pneumovax on-site. To prevent delays, our nurses provide it on site.

[Dr. Ashley Agan]
For those patients who have a CI and acute otitis media, we could treat with Augmentin and follow them closely?

[Dr. Prashant Malhotra]
Yes. And if there's a concern that is not resolving, then the question is: Do you go quickly to tubes? I'm not a big fan of IV antibiotics for something along those lines.

[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.

(9) Long-Term Mapping for Pediatric Cochlear Implants

[Dr. Ashley Agan]
I think we've covered everything that we wanted to ask you about. Is there anything that you feel like we missed or anything you just would like to leave our listeners with, final pearls or other considerations?

[Dr. Prashant Malhotra]
I really appreciate you guys having me on. I guess a couple of other things that I was thinking about is, any child with an implant who's not doing well. If you see them, capture them in your office and send them out to the CI center to evaluate what's going on. They should make sure their mapping is up to date. If need be, get a CT scan to make sure there are no issues with the implants.

If I haven't seen them in a couple of years, because now they're in school, my goal is to make sure they're making the progress we anticipated them to make. It always pains me when I see somebody comes back and they haven't seen anybody in like six years, and their speech is not very well managed and they're struggling in school. I just wish that they had seen somebody.

The families don't always know that long-term mapping and programming needs to be done. I think that you come across someone and they're not really performing very well, send them back to the CI center. If they haven't had a mapping in a year, they need to be seeing somebody.

We do try to help families with those transitions on educational milestones. In kindergarten, as they go to middle school and high school, there is still a ceiling on some of the things that an implant can provide kids. They still have issues with reading, spelling, and literacy kinds of things.

If I think about all the things a family will ask me when they find out their kid is deaf. They always think about things like sports and academics and all these things, and the kids can usually do these very well. But, they still need to be ushered even after that critical period of when they started to get into school. And I think it's not in our realm to typically think about this as otolaryngologists. We’re not teachers, but I've definitely seen that as time has gone on, I've really taken on just making sure that we really plugged them in with the resources appropriately so they can succeed. It does take work even after they've left our halls. When I see the older kids, I'm really worried about the long-term outcomes a lot.

If you send them back to the CI center, then they should at least be visiting a speech therapist when they're older, doing literacy evaluations, and making sure their IPEs are written. All of these things can still help them from an educational standpoint, even if they don't specifically need speech therapy.

[Dr. Gopi Shah]
What's the followup? Should they be coming every year? Do they see you during that one month when you put the processor on? What does the post-op short-term and long-term look like?

[Dr. Prashant Malhotra]
After surgery, I'll see them at a post-op visit, which typically is a telemedicine visit, just for an incision check. Then, they will be seeing the audiologist in-person, who will be able to monitor. If anybody has any concerns, they'll notify me and I can always get them in for an in-person appointment.

I'll usually see them at six months afterwards, to make sure that they've been plugged in and making their appointments. I'd rather find out in several months, as opposed to like a year later, that they'd never made their activation appointment, or they're not seeing speech therapy. So I'll see them at the post-op, at six months, and every six months for the first year or so. For the younger kids, I'll see them every six months until they get into kindergarten. For the older kids, I'll see them every six months for at least a year and then annually. I do want to see them every year. There is a Medicaid expansion, in our state, in which hearing loss is an eligible qualifying diagnosis. In order to continue with these services, they have to see me once a year. So that's a nice thing to help some people keep coming back. The older kids don't often see me every year. That's just not going to necessarily happen, especially if they're doing really well. But, they should still be seeing audiology at least yearly from their mapping.

(10) Guidelines for MRI Compatibility

[Dr. Gopi Shah]
Are there any other resources that you think are important for our listeners who want to look deeper into pediatric cochlear implants?

[Dr. Prashant Malhotra]
Before I answer that, one last thing I wanted to mention was MRI compatibility. It's a common topic and I'll just point out that all three manufacturers now have MRI-compatible devices. So anybody implanted after 2019 has an MRI-compatible device. The manufacturers have updated information about MRI compatibility, and most do not need to have a magnet removed at this point. This information is readily available on the manufacturers’ websites.

[Dr. Ashley Agan]
So, meaning that you don't have to wrap the head anymore.

[Dr. Prashant Malhotra]
Right. The current ones that are being put in don't require a head wrap or magnet removal. They're not even recommending it anymore. Most MRI places will say, "Look, the manufacturer says, we can't do it." Even if you say, "Look, we want a wrap," they'd be like, "Well, the manufacturer says you can't." So that was a little bit of a snoozer thing that just happened this past year that caught me off guard recently. But generally speaking, anytime you're confronted with it, just make sure you look at device-specific MRI requirements, but the modern ones are at least going to hopefully take that out of the picture.

I'm a big supporter of the American Cochlear Implant Alliance, ACIA, and the resources they have on that website. AG Bell, Alexander Graham Bell, has a lot of information on the speech and auditory verbal therapy (AVT) side of things.

[Dr. Gopi Shah]
Thank you so much, Prashaz. It was awesome to catch up. I'm so proud of you. Anyways, thank you for coming on the show and hopefully I'll see you in person sometime soon.

[Dr. Prashant Malhotra]
Yeah. I would love to.

Podcast Contributors

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 pediatric otolaryngologist and the co-host of BackTable ENT.

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist 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

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.