Surgical considerations and safety of cochlear implantation in otitis media with effusion

Surgical

considerations

and

safety

of

cochlear

implantation

in

otitis

media

with

effusion

Rasit

Cevizci

,

Alper

Dilci

*,

Fatih

Celenk

,

Recep

Karamert

,

Yildirim

Bayazit

a

DepartmentofOtolaryngologyandHead&NeckSurgery,IstanbulMedipolUniversity,Istanbul,Turkey

b

DepartmentofOtolaryngologyandHead&NeckSurgery,YunusEmreStateHospital,Eskisehir,Turkey

c

DepartmentofOtolaryngologyandHead&NeckSurgery,GaziantepUniversity,Gaziantep,Turkey

d

DepartmentofOtolaryngologyandHead&NeckSurgery,GaziUniversity,Ankara,Turkey

1. Introduction

Cochlear implant is the best option for patients with profoundsensorineuralhearingloss whodo notbenefit from

hearingaids.Widespreadimplementationofnewbornhearing screeningandemergingevidenceonbenefitsofimplantationat earlyagescausedasignificantdecreaseinageatimplantation

[1,2].Otitismediawitheffusion(OME)isacommonchildhood disease, and can be seen before age of one year as well

[3].Sincetheageatwhichachildwillreceivecochlearimplant has decreased, some cochlear implant candidates may have OME at the time of surgery, whichmay impacton auditory assessmentsandcreatesurgicaldifficulties.Theincidenceand AurisNasusLarynx45(2018)417–420

ARTICLE INFO

Articlehistory: Received14March2017 Accepted11July2017 Availableonline26July2017 Keywords: Cochlearimplant Otitismedia Effusion Surgicalconsideration Safety ABSTRACT

Objective: Toevaluatethe effectsofotitismediawitheffusion onsurgicalparameters,patient safety,perioperativeandpostoperativecomplications.

Methods: Total890childrenwhounderwentcochlearimplantationbetween2006and2015were included.Theagesrangedfrom12 monthsto63months(mean:32months). Thepatientswere dividedintotwogroupsaccordingtothepresenceorabsenceofotitismediawitheffusion;otitis mediawitheffusiongroupandnon-otitismediagroup.

Results: Of890children,105hadotitismediawitheffusionpriortosurgery.Innon-otitismedia withgroup,therewere785children.Theaveragedurationofsurgerywas60min(rangedfrom28to 75min)innon-otitismediagroup,and90min(rangedfrom50to135min)inotitismediawith effusiongroup(p<0.05).Granulationtissueandedematousmiddleearandmastoidmucosawere observedin allcasesofotitismediawitheffusionduringthesurgery.Therewasnosignificant difference between the complications of groups with or without otitis media with effusion (p>0.05).In5of105patients,therewasaventilationtubeinsertedbeforecochlearimplantation, whichdidnotchangetheoutcomeofimplantation.

Conclusion: There is no need for surgical treatment for otitis media with effusion before implantationsinceotitismediawitheffusiondoesnotincreasetherisksassociatedwithcochlear implantation.Operationdurationislongerinthepresenceofotitismediawitheffusion.However, otitis media with effusion leads to intraoperative difficulties like longer operation duration, bleeding,visualizationoftheroundwindowmembrane,cleansingthemiddleeargranulationsas wellasmastoidandpetrousaircells.

©2017ElsevierB.V.Allrightsreserved.

*Correspondingauthorat:DepartmentofOtolaryngology,YunusEmreState Hospital,26190Eskisehir,Turkey.

E-mailaddress:alperdilci@yahoo.com(A.Dilci).

ContentslistsavailableatScienceDirect

Auris

Nasus

Larynx

j our na l ho me p a ge : w ww . e l se v i e r . com / l oc a te / a n l

http://dx.doi.org/10.1016/j.anl.2017.07.012

severityof theotitismediadonotincreaseafter implantation

[4],whichmaybeattributedtodecreasedoverallotitismedia prevalence by age, and mastoidectomy performed during cochlear implantation. In addition, inner ear malformations, cerebrospinalfluidleak,otitismediamayalsoincreasetherisk ofinfectiouscomplications,mainlymeningitis[4].

There may be high incidence of bleeding and inflamed mucosainthemiddleearandmastoidboneincasesofOME, which may impede proper visualization of the anatomic structuresandcarryhigherriskofintraoperativecomplications

[5].Inaddition,middleeareffusionmayalsoincreasetherisk of infectious complications,mainly meningitis [4]. Although ventilationtube(VT)insertionmayhelpimprovetheinflamed mucosaand decrease the incidence of complications, it may possessseveraldisadvantageslike disruptionof the tympanic membrane which makes children susceptible to infectious complications.In addition, VT insertion may delay cochlear implantationandinturnthe durationofauditorydeprivation. On the otherhand,cochlear implantationsurgery consists of mastoidectomy with posterior tympanotomy. Therefore, healthy and aerated middle ear can be provided following cochlear implantations, which help eliminate the need of a previousVTinsertion.

TheaimofthisstudywastoevaluatetheeffectsofOMEon surgicalparameters,patientsafety,perioperativeand postoper-ativecomplicationsincochlearimplantation.

2. Materials andmethods

This retrospective study included 890 children who underwent cochlearimplantationbetween 2006 and2015 by thesamesurgicalteamatdifferentcenters.Therewere523boys (59%)and367girls(41%)withagesrangingfrom12monthsto 63months(mean 32months).

The patientselectionwasmade accordingtothefollowing criteria;absenceofinnerearmalformationorossification,signs andsymptoms of acuteor chronic otitis mediaor cholestea-toma, systemic or neurological disease, and absence of cerebrospinalfluidleakandpartialimplantelectrodeinsertion. Therewerenootitispronechildrenas evidencedbyhistory.

Datawerecollectedfrommedicalandsurgicalrecordsofthe patientsandincludedtheageandgenderofthepatient,presence of OME, peri and postoperative complications, duration of surgeryandfollow-upperiod.Adetailedmedical historywas obtained and a thorough otologic and audiologic assessment wasperformedonallpatients.Allpatientsunderwentmagnetic

resonanceimaging(MRI)fortheevaluationofcochlearnerve and/or high resolution computed tomography (CT) of the temporalbone.

Thepatientsweredividedintotwogroupsaccordingtothe presenceorabsenceofOME;OMEgroupandnon-OMEgroup. Diagnosisof OME was basedonhistory, otoscopic findings, audiologicwork-upandpreoperativeCTscans,andabacterial cultivation was not performed [6]. One stage cochlear implantation with full electrode insertion was performed in allcasesindependentofOME.ApreoperativeVTplacementor medicaltreatmentwasnotmadeinthepresenceofOMEunless a VT placement was performed in another center before cochlearimplantation.

All operations were performed under general anesthesia using double flaptransmastoid technique.A mastoidectomy was performed in all cases. After identification of mastoid antrumandshortprocessofincus,posteriortympanotomywas performed.Cochlearimplantwas insertedthrough theround window orcochleostomy which was anterior inferior to the round membrane. All patients were followed up at least 12monthspostoperatively.Atympanicmembraneatelectasis was not encountered in the follow up period. Chi square or independent samples-t test was used in the statistical analyses.

3. Results

Of890children,105hadOMEpriortosurgery.Therewere 63boysand42girlswithameanageof34months.Innon-OME group, there were 785 children. Non-OME group included 460boysand325girlswithameanageof47months(Table1). Theaveragedurationofsurgerywas60min,rangingfrom 28to75mininnon-OMEgroupand90min,rangingfrom50to 135min in OME group. There was a significant difference between two groups regarding the mean duration of surgery (p<0.05) (Table1).

Granulation tissue andedematousmiddleear andmastoid mucosawereobservedinallcasesofOMEduringthesurgery. Inflamedmucosaandpathologicalgranulationsobscuringthe round window were removed for identification of the round window membrane. In someof the casesglue was aspirated fromatticor throughposteriortympanotomy.In 14casesthe incuswas removed to cleanthe granulationsin the atticand middle ear. In 6 cases further drilling is performed in the attackedpetrous aircells around thesemicircular canals,and mastoidandgeniculatesegmentsofthefacialnerve(Table1).

Table1

Comparationofmainparameters(meanofpatientsage,durationofsurgery,operativedifficultiesandcomplications)betweenOME andnonOMEgroup.

Parameter OMEgroup N=105

NonOMEgroup N=785 Meanpatientage(months) 34 47 Durationofsurgery(min) 90(50–135) 60(28–75) Operativedifficulties Incusremovaln=14

Extradrillingofpetrousaircellsn=6

Narrowfacialrecessn=3 Complication None Temporaryfacialparesisn=1

Explantationduetobiofilmformation R.Cevizcietal./AurisNasusLarynx45(2018)417–420

NocomplicationwasencounteredinOMEgroupinperior postoperativeperiod.Innon-OMEgroup,complicationswere encounteredin2patients;onetemporaryfacialparesisdueto thermalinjuryinthe mastoid segmentof the fallopiancanal, whichresolved spontaneously within a few months; and the otherpatienthadaninfectionofthereceiver-stimulaterofthe cochlearimplantduetobiofilmformation,andneededrevision surgery. There was no significant difference between the complications of groups with or without OME (p>0.05) (Table1).

In5of105patients,therewasaVTinsertedinanothercenter beforecochlearimplantation.TheseVTswereremovedatthe timeofimplantationandtympanicmembraneperforationswere repairedusingdumbbellfatgraft.Noneofthepatientswhohad aVTpreoperativelyhadcomplication.Inthepatientwhohada previousVTinsertionduetoOME,granulationsinthemastoid aircellsandmiddleearmucosaledemawerepersistingtosome extent.

4. Discussion

OME is acommon problem inyoung children andmany cochlearimplant candidates may present with OME prior to implantation.TherateofOMEmaybeupto44%atthetimeof implantation [3]. Management of OME in cochlear implant candidatesremainscontroversial.Treatmentofthemiddleear effusionanddelayingtheimplantation,VTinsertionatthetime ofimplantation,andperformingtheimplantationwithoutdelay are the possible options in cochlear implantcandidates with OME [7]. Additionally, short term medical treatment with antihistaminesandsteroidsarealsosuggested[8].

TimingofcochlearimplantationinthepresenceofOMEisa major challenge confronting physicians. Theoretically, an implant placement into the sterile inner ear through an inflammed middle ear bears risk of implant extrusion and spreadofinflammatorymediatorstothe innerearwhichmay result in an intracranial infection [9,10]. In addition, the presence of OME before implantation is associated with the need of removal of obscuring granulation tissues and inflammedmucosa, as wellas bleeding inthe surgical field. Therefore,consequencesofOMEseemtoincreasetheriskof complicationsassociatedwithcochlearimplantsurgery.

Many surgical difficulties canbe seen during CI surgery. These can be in the mastoid like anteriorly located sigmoid sinus, Körner’s septum, narrow facial recess. These can be overcomebytheknownsurgicaltechniquesandadjunctiveuse ofendoscopes.InOME,openingthefacialrecessissomewhat timeconsumingbecausethegranulationsintheperifacialarea may interfere with locating the fallopian canal. Sometimes incusremovalanddrillingtheboneinposteriorbuttressmaybe needed.Inaddition,itisdifficulttovisualizetheroundwindow due to inflamed or hyperplastic middle ear mucosa and granulations.Thesefactorselongatethedurationofoperation. VTinsertionpriortoimplantationandmedicaltreatmentfor OMEmayallowforprovidingasterilemiddleear.VTinsertion reduces granulation tissue and heals inflammed mucosa and consequently may help to reduce intraoperative difficulties associated with obscuring bleeding and diseased mucosa

[11]. By contrast, the placement of VT may lead toseveral potentialcomplicationsincludingrecurrentorchronicotorrhea and persistent tympanic membrane perforation [12–14]. Dis-ruptionofthetympanicmembraneandrecurrentotorrheamay increase the risk of infectious complications following the surgery.However,VTinsertion,waitingforthemiddleearto heal,removingtheVTandwaitingforthetympanicmembrane tohealalsocauseadelayincochlearimplantation[10].Asthe earlyimplantationiscriticaltoyieldbetteroutcome,adelayin cochlear implantation may impact on speech, language and education[15].

Previousreports suggestthatthereisnobenefitoftreating OME before cochlear implantation [10,14,16], and cochlear implantcandidateswithOMEcanbesafelyimplantedwithout preimplantation VT insertion [14]. These contentions are comparablewiththefindingsinourstudy,whichisoneofthe largestseriescomparingchildrenwithandwithoutOMEwho underwentcochlearimplantsurgery.

5. Conclusion

In conclusion, there is no need for surgical treatment for OME before implantation since OME does not increase the risksassociatedwithcochlearimplantation.Operationduration is longer in the presence of OME. However, OME leads to intraoperative difficulties like longer operation duration, bleeding, visualization of the round window membrane, cleansing the middleeargranulations as wellas mastoidand petrousaircells.

Financialdisclosures

Thereisnofinancialsupportandallauthorsdonotreceive anyfundingfor thisstudy.

Ethics

This study was approved by local institutional ethical committee.

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