Pediatric Cochlear Implant Risks, Complications & Counseling

[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]
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.