AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 5 (2 0 1 4) 7 03–7 0 7

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Management options for cochlear implantation in patients with chronic otitis media☆,☆☆ Myung Hoon Yoo, MD, Hong Ju Park, MD, Tae Hyun Yoon, MD⁎ Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

ARTI CLE I NFO

A BS TRACT

Article history:

Objective: Patients with chronic otitis media with/without cholesteatoma present a

Received 23 April 2014

significant challenge to safe cochlear implantation (CI). The aim of our study is to describe our experience and propose management options for CI in patients with chronic otitis media. Study design: Retrospective case study. Setting: Tertiary academic center. Subject and methods: We enrolled the 9 ears of 8 subjects who received CI in the ear with chronic otitis media from 2006 to 2013 by a single surgeon. CI was performed as a singlestage or staged operation with mastoid surgery according to the activity of ear infection. Results: Six patients had bilateral chronic otitis media and 2 patients had long history of sensorineural hearing loss at contralateral ear. CI was performed with simultaneous radical mastoidectomy with closure of the EAC as a single-stage in 3 ears with a history of previous open cavity mastoidectomy and no active discharge. Staged CI was performed in 6 ears, after radical mastoidectomy with closure of the EAC in 3 ears and after intact canal wall mastoidectomy in 3 ears, due to active inflammation or complications related to otitis media. In one patient, wound infection had occurred, and implant was removed along with implantation at contralateral ear. Other subjects showed no evidence of recurrence. Conclusion: Decision whether implantation as a single-stage or staged operation depends on the presence of active inflammation. Single-stage CI with proper mastoid surgery can be performed in patients without active inflammation. Staged procedure need to be done in ears with active inflammation. Proper application of mastoid surgery leads to safe CI for patients with chronic otitis media. © 2014 Elsevier Inc. All rights reserved.

1.

Introduction

Cochlear implantation (CI) has become a safe and effective method for rehabilitation of profound sensorineural hearing loss. Nevertheless, CI in patients with chronic middle ear problem presents a significant challenge to the otologic ☆

surgeon. Profound hearing loss can be accompanied by or be the result of chronic otitis media (COM). It was suggested in the past that COM is a contraindication to CI because of the possible problems associated with inserting a foreign body through an infected mastoid or middle ear into a space with possible intracranial communication [1].

Conflict of interest: None. Financial disclosure: None. ⁎ Corresponding author at: Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, 88 Olympicro-43-gil, Songpa-gu, Seoul 138-736, Republic of Korea. E-mail address: [email protected] (T.H. Yoon). ☆☆

http://dx.doi.org/10.1016/j.amjoto.2014.08.001 0196-0709/© 2014 Elsevier Inc. All rights reserved.

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AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 5 (2 0 1 4) 7 03 –7 0 7

However, well established benefits of CI and improved surgical and radiological techniques in early reports have made CI feasible in the presence of COM, and CI in COM has been performed in many centers [2–4], but controversy still exists in the literature regarding the choice of staged operation or single stage operation [5,6], and there are also controversies about indications for radical mastoidectomy with closure of the EAC (RMCE), and appropriate approach for CI in COM [7–12]. This article describes our experience of CI in patients with chronic middle ear problems, and proposes management principles according to the presenting status of the ear.

2.

Methods

Subjects who received CI in the ear with COM with/without cholesteatoma from January 2006 to February 2013 by a single surgeon (senior author) were enrolled in the study. COM was defined as chronic inflammation of the middle ear and mastoid mucosa in which the tympanic membrane is not intact (perforation, adhesion, granulation and/or cholesteatoma). Nine ears (in 8 patients) with history of COM who received CI were identified. Medical and surgical records, including radiologic findings were reviewed retrospectively. History, etiology of hearing loss, and management of the implanted ear were evaluated. There was an overlap of the patients which was discussed in our former paper about CI in ears with cochlear fistula [13]. Preoperative audiological assessment included pure-tone audiometry and speech discrimination tests. Pure tone audiometry average (PTA) was calculated as the average of the thresholds at 0.5, 1, 2 and 3 kHz. CI was performed as a single-stage or staged operation with mastoid surgery according to the activity of ear infection. Electrodes were inserted via cochleostomy approach in all ears. All patients received Nucleus Freedom (Cochlear Inc, Australia) device. Postoperative speech performance was evaluated by using the Korean version of the Central Institute for the Deaf sentence test during follow-up period.

The study protocol was approved by the institutional review board of the Asan Medical Center, a 2800-bed University associated teaching hospital in Seoul, Republic of Korea.

3.

Results

Eight patients ranged in age between 37 and 69 years, with a mean of 55.5 years. There were 5 females and 3 males. The characteristics of the 8 patients (9 ears) are presented in Table 1. Six patients had bilateral COM (with or without cholesteatoma) and 2 patients had unilateral COM in the ear deemed most appropriate for implantation. These 2 patients had long history (more than 30 years) of profound sensorineural hearing loss at the contralateral ear. In four ears, there were histories of previous open-cavity mastoidectomy (OCM). Three of them (case No 1, 3 and 4 in Table 1) showed no active inflammation at presentation and CI was performed with RMCE as a single-stage procedure. Among patients with history of previous OCM, one ear (case no. 5) showed chronic discharge at presentation, and received RMCE initially and then CI was performed 3 months later as a staged procedure. One patient (case no. 7) showed cochlear fistula as a complication of cholesteatoma in preoperative temporal bone CT scan (TBCT). The patient received CI in a staged manner 5 months after RMCE and fistula repair. Another patient with COM (without cholesteatoma) (case no. 6) also had cochlear fistula in TBCT, which was repaired along with intact canal-wall mastoidectomy (ICWM) and tympanoplasty. Second stage operation, CI with RMCE was done 6 months after initial mastoidectomy. In three ears (case no. 2, 8 and 9), which showed active discharge with tympanic membrane perforation at initial visit to our hospital, CI was performed as a two stage procedure, 3– 4 months after ICWM. In one of these ears (case no. 2), wound infection had occurred after CI, and will be discussed in detail in the following section. The mean follow-up duration was 38 months (ranged 6–85). Excluding the ear which underwent implant removal, other ears showed no evidence of recurrent infection or other complication. Preoperative audiological results and postoperative speech test

Table 1 – Demographic characteristics of the patients and management procedures. Case no. Sex Age Ear Status at presentation

First-stage procedure

1 2⁎ 3⁎ 4 5 6 7 8 9

RMCE + CI ICWM RMCE + CI RMCE + CI RMCE ICWM, fistula repair RMCE, fistula repair ICWM ICWM

F F F F M F M M F

64 57 57 52 37 50 59 69 56

R R L L R R R L R

OCM state, dry COM, wet OCM state, dry OCM state, dry OCM state, wet COM with cochlear fistula Cholesteatoma with cochlear fistula COM, wet COM, wet

Second-stage procedure

CI ( Ywound infection occurred)

CI RMCE + CI CI CI CI

Contralateral ear status OCM state OCM state COM SNHL OCM state OCM state OCM state COM SNHL

OCM, open-cavity mastoidectomy; RMCE, radical mastoidectomy with closure of the EAC; CI, cochlear implantation; SNHL, sensorineural hearing loss; COM, chronic otitis media; ICWM, intact canal wall mastoidectomy. ⁎ Implantation in same patient.

AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 5 (2 0 1 4) 7 03–7 0 7

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Table 2 – Audiological assessments and speech reception test results. Case Preoperative no. PTA operated PTA Monosyllable ear (dB) contralateral ear word (%) (dB) 1 2⁎ 3⁎ 4 5 6 7 8 9

99 90 108 120 113 NR NR 113 98

108 109 NR 115 95 NR NR 110 99

0 0 0 0 0 0 0 0 0

Open-set sentence (%)

FollowPostoperative up Monosyllable duration CAP (months) score word (%)

Open-set sentence (%)

0 0 0 0 0 0 0 0 0

38 62 35 85 31 46 46 18 6

24 98 ⁎⁎ 100 100 100 98 90 94 100 ⁎⁎

5–6 7 ⁎⁎ 7 7 7 7 7 7 7 ⁎⁎

30 60 ⁎⁎ 90 70 80 60 50 80 50 ⁎⁎

Speech reception test results of one year postoperative. PTA, pure tone audiometry average; CAP, Categories of auditory performance. ⁎ Implantation in same patient. ⁎⁎ Six months postoperative results.

results are summarized in Table 2. Mean open-set sentence score at follow-up was 86.8% (ranged 26–100).

3.1.

Major complication

A 57-year-old female (case no. 2 in Table 1) had suffered from discharging both ears since childhood. Two years before initial visit to our hospital, her left ear was deafened after left ear ICWM at other hospital, and there was no active inflammation in left ear at presentation, and right ear showed active discharge with large tympanic membrane perforation initially, and methicillin-sensitive Staphylococcus aureus (MSSA) was cultured. She had used hearing aid in her right ear due to severe mixed hearing loss. She received ICWM with tympanoplasty at right ear, and hearing was aggravated after operation. Consequently, 2 years after primary operation, there was no evidence of inflammation at her right ear clinically and radiologically, and CI was performed as a second stage operation at right ear. During CI operation, granulation tissues were found at mastoid cavity and middle ear, so granulation tissues were all removed before implantation, but 6 months after implantation, wound infection had occurred at postauricular device area, and methicillin-resistant S. aureus (MRSA) was isolated. Despite antibiotics treatment (including vancomycin) and operation (incision and drainage; wound repair using local flap), wound infection was uncontrollable. Therefore, CI device removal in right ear and CI with RMCE in left ear was done simultaneously, 1 year after first CI. Wound infection was well controlled after device removal, and 3 months later the patient's open set sentence score had reached 100%.

4.

Discussion

Cochlear implantation in patients with COM with/without cholesteatoma is a challenge to an otologist. The incidence of COM in patients receiving CI is relatively rare, and is variable between reports (range 2.2–10.9%) [14–16]. Therefore, the risk of complications in these patients is not exactly known. Although a few cases were reported, there are potential risks

of recurrence of cholesteatoma, wound infection, device extrusion, meningitis and other intracranial complications [15–18]. Thus, it is essential to completely eradicate the middle ear disease before implantation to prevent postimplantation complications. Most otologists prefer a staged procedure for implantation in patients with active COM or cholesteatoma [3,6,16,18,19]. Staged operation has several advantages compared to single stage operation. First, during second stage operation, whether residual inflammation or cholesteatoma is persistent can be checked as a second look, and if residual disease was encountered at second stage operation, CI can be delayed for third stage procedure after revision mastoidectomy for disease eradication. Second, direct wound infection or device infection can be prevented theoretically with several months interval between two stages. On the contrary, staged procedure also has some disadvantages. First, implantation has to be delayed in staged procedure, and patient has to suffer inconvenient times during the interval, and second stage can slow down the speech development especially in pediatric patients [20]. Second, almost twice duration of hospitalization and general anesthesia are needed in staged procedure compared to single stage procedure. In our study, in active COM patients with no history of ear surgery, we performed ICWM with tympanoplasty as a first stage procedure prior to CI. In sequence, CI can be placed after a delay of 3–6 months if the disease is eradicated. In patients with chronic discharge after OCM, RMCE was performed as a first stage operation prior to CI. In our study, one of six implantations, which were done as a staged operation, developed major complication (device extrusion due to wound infection). This underwent CI 2 years after ICWM, although granulation tissues were found during surgery. Six months after CI, wound infection has occurred, and MRSA was cultured. Implant device had to be removed despite antibiotics therapy and surgery (incision and drainage, wound repair via local flap). This suggests that there is still a possibility of serious complications even after staged operations when there is active granulation tissue remnant,

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AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 5 (2 0 1 4) 7 03 –7 0 7

Fig. 1 – Management algorithm of cochlear implantation in patients with chronic otitis media. COM, chronic otitis media; CI, cochlear implantation; RMCE, radical mastoidectomy with closure of the EAC; ICWM, intact canal wall mastoidectomy.

and if any residual inflammation is suspected after first stage mastoidectomy, CI can be delayed for the third stage procedure after eradication of granulation tissue. Our management algorithm is shown in Fig. 1. In patients with inactive COM, single stage procedure can be done, and severe complications after CI are rare, although some cases are reported previously [17]. In this study, no complication has occurred after implantation in 3 patients with inactive state. All 3 patients had previous history of OCM, and received CI with RMCE in a single-stage procedure. This result is in keeping with the low complication rates reported in literature [5,16,19]. There was no patient who presented as an inactive COM with no previous history of ear surgery in our study. In patient with only dry small perforation without evidence of active inflammation, single-stage surgery (CI with IWCM or RMCE) can be simply done (Fig. 1). An RMCE is comprised of complete exenteration of all accessible air-cell of the temporal bone, sealing the Eustachian tube orifice and closure of the external auditory canal [21]. This may be accompanied by obliteration of the tympanomastoid cleft with a pedicled temporalis flap or with abdominal fat. In our study, RMCE was done in 6 among 9 implantations. The tympanomastoid cleft of all patients that underwent RMCE was obliterated by pedicled temporalis flap and abdominal fat. Lack of complications using RMCE with CI in our study, is in agreement with other published data [3,14,22]. Although number of patients in literature is too small to have strong evidence on the role of a RMCE in patients with COM undergoing CI, the overall results in literature are supportive [3,6,11,14,21–23]. In case of radical cavity or minimal chance of disease recurrence, RMCE should be considered as a primary technique simultaneously with or before CI.

There is another surgical technique to insert CI in patients with chronic middle ear problems. Middle fossa approach can bypass the middle ear, which is a possible infected route for CI [10,24–26]. The electrode is inserted thorough a basal turn cochleostomy at the floor of the middle cranial fossa. In this approach the cochleostomy can be created further along the basal turn, and the electrode may be inserted deeper in the cochlea. Whether this has a negative effect on functional result remains to be demonstrated. Possible problems of this approach are inherent risks of a craniotomy and compression of the temporal lobe [18,26].

5.

Conclusion

Decision whether implantation as a single-stage or staged operation depends on the condition of each cases. In patients without active inflammation, CI with RMCE or ICWM can be performed as a single stage procedure. In COM patients with active inflammation or complication, CI should be done as a staged operation. Proper application of mastoid surgery leads to safe cochlear implantation for patients with COM with/ without cholesteatoma. REFERENCES

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Management options for cochlear implantation in patients with chronic otitis media.

Patients with chronic otitis media with/without cholesteatoma present a significant challenge to safe cochlear implantation (CI). The aim of our study...
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