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Cochlear Implant Surgery

Background

Cochlear implantation has become a routine procedure in the United States and worldwide for the management of severe-to-profound sensorineural hearing loss. It is a remarkable example of success that was made possible through collaboration between engineers, surgeons, scientists and the medical community. As of 2012, more than 300,000 implants have been performed worldwide. The decision to embark upon cochlear implantation is made either by the patient (if adult) or by the parents or caregivers of a child. This procedure is well tolerated and routinely performed on an outpatient basis in both adults and children.

The team concept in cochlear implant evaluation allows for an exchange of information between the surgeon and other members of the implant and rehabilitation process, including audiologists, speech and language therapists, social workers, and psychologists. Typically, the patient is referred to a cochlear implant center, and initial contact is made. The patient may first be seen and identified as an implant candidate by an audiologist. Hence, a patient can enter the evaluation process in a number of different ways. Nonetheless, various issues are taken into consideration, including medical aspects of the patient’s history, the audiologic evaluation, radiographic studies, and overall expectations of patient and involvement of family (in pediatric patients) in a rigorous rehabilitative process.

An image depicting cochlear implant surgery can be seen below.

Postauricular incision for cochlear implant.

Postauricular incision for cochlear implant.

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Although the team evaluation concept is explained at greater length in the Indications section, it is notable because it allows for proper selection of patients, the continuous flow of pertinent dialogue, and the promotion of realistic expectations on the part of the patient and the patient’s family.

The evaluation process used by the authors at the implant center at the Cleveland Medical Center/University Hospitals of Cleveland and Rainbow Babies and Children’s Hospital is summarized below. At the time of the medical evaluation, the patient’s general medical history and issues regarding hearing loss are reviewed. A complete neuro-otologic and otolaryngologic examination is performed, and obvious conditions (eg, tympanic membrane perforation, chronic otitis media, congenital anomalies) are noted. The patient’s history is reviewed to establish the potential etiology of the hearing loss. Audiologic tests are reviewed and repeated as necessary. Once the patient is deemed to be a potential cochlear implant candidate, the various cochlear implant options are discussed, and audiologic evaluation commences.

Typically, the audiologist measures the patient’s hearing with and without hearing aids. Evaluation with pure-tone audiometry and auditory brainstem response (ABR) testing (in the case of children) is often performed. Otoacoustic emission (OAE) testing complements these studies; OAE results often indicate the need for a trial of newer and sometimes stronger hearing aids.

A CT scan is obtained to evaluate the bony anatomy of the cochlea and to establish the presence of a patent (nonossified) cochlear duct. It is also used to identify various anomalies of cochlea-vestibular anatomy (common cavity, incomplete partition defects, enlarged vestibular aqueduct, and cochlear ossification. In some cases, an MRI is used instead of the CT when questions exist regarding the presence of the eight nerve or severe ossification. In children and young adults, speech and language evaluation and educational placement discussions are performed next. Finally, a psychosocial evaluation is completed. Once a patient has been evaluated, a team meeting commences to recommend cochlear implantation advice. If the patient is cleared for cochlear implantation, the patient proceeds with preoperative medical clearance, chooses a cochlear implant device, and proceeds with surgery.

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