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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 1  |  Page : 29-34

Delayed Complications of Cochlear Implant Surgical Site, Al Nahdha Hospital 17 Year's Experience


1 Oman Medical Specialty Board (OMSB), Oman
2 ENT Department, Al Nahdha Hospital, Oman

Date of Web Publication23-Dec-2019

Correspondence Address:
Ammar Al Lawati
Al Nahdha Hospital
Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.273916

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  Abstract 


Background: Since the era of Cochlear Implant (CI) has started varies complications were reported in the literature. These complications range from simple wound infection to much more severe and complicated complications such as meningitis and facial nerve paralysis. In Oman we started our CI program in 2000 and we came across several complications over the last decade. Objective: To report our hospital experience in post CI complications at the wound site in the last 17 years.
Methods: Retrospective analysis of 350 cases operated at our tertiary hospital in the period of 2000 until March 2017.
Results: 11 cases developed wound site complications in which 6 of them needed to be taken to the operating theatre while 5 cases were managed as outpatients. The types of complications were seroma, hematoma, wound infection, Abscess and we had one patient with device extrusion.
Conclusion: Post CI wound site complications are uncommon but when present, they might lead to major morbidities.
Early detection and management is highly advised.

Keywords: cochlear implant complications, wound infection post CI


How to cite this article:
Al Zaabi K, Al Lawati A. Delayed Complications of Cochlear Implant Surgical Site, Al Nahdha Hospital 17 Year's Experience. Saudi J Otorhinolaryngol Head Neck Surg 2018;20:29-34

How to cite this URL:
Al Zaabi K, Al Lawati A. Delayed Complications of Cochlear Implant Surgical Site, Al Nahdha Hospital 17 Year's Experience. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2018 [cited 2021 Apr 21];20:29-34. Available from: https://www.sjohns.org/text.asp?2018/20/1/29/273916




  Introduction Top


Historically, the first cochlear implant that was performed on a human being had taken place in 1984[1]. The evolution of cochlear implant has grown dramatically over the following years. A lot of otology centres started to practice cochlear implant all over the world. In our department, we started the cochlear implant program in the year of 2000. Our National neonatal screening program was introduced to the health care system at the same time. Any child who fails oto-ocoustic emission twice was referred to our centre from all over Oman. If the patient found to have profound hearing loss after evaluation, then he /she will be enrolled in the program. There was some attempts of classifying the complications of the procedure for example, Cohen et al. proposed a classification system of cochlear implant complications in 1988 that divided the complications into intraoperative and post-operative [2]. The type of devices we used in our cases were Med el and cochlear.


  Materials and methods: Top


A series of 350 patients who underwent cochlear implants in our centre in the period between 2000 and March 2017 were reviewed. All the operations were performed by the same team. The data included 321 from paediatric age group and 29 from adult age group. All patients follow up with our clinic for 3 years then they continue their follow up with our speech therapist and audiologist until the school entry age. After discharge, they can report to our clinic if they have any complain in regard to the device or the surgical site. With the advance in social media technology our patient had an easier contact with the operating team and with each other. We created a CI group also for psychological support which had a great influence on post-operative patient’s psychology. From 350 patients, only 11 patients reported a complication at the surgical site ranging from simple skin irritation up to abscess, skin necrosis and device extrusion at the surgical site.


  Results Top


Of 350 patients, we had 11 (3.1%) patients reported a delayed wound site complications. Five of them were managed as out patients and 6 were admitted to the hospital either for intravenous antibiotics or surgical intervention.
Table 1

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Case 1:

2 years old hyperactive boy presented with a swelling after one week of the surgery. There was no history of fall or trauma. Examination revealed large fluctuating swelling at the internal device site. [Figure 1]. CT scan was done [Figure 2]. He was admitted and started on IV antibiotics. Intraoperative findings were consistent with hematoma. [Figure 3]
Figure 1

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Figure 2

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Figure 3

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Case 2:

4 years old boy presented 2 months after the surgery with erythema and discharge at the surgical site. He was managed conservatively and improved. One month later he presented with skin loss and partial exposure of the device [Figure 4]. He required a skin excision and local flap [Figure 5], [Figure 6],[Figure 7]
Figure 4

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Figure 5

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Figure 6

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Figure 7

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Case 3:

3 years old boy presented 4 months after the CI post auricular seroma. Conservative management failed and the seroma ruptured and was managed surgically [Figure 8],[Figure 9].
Figure 8

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Figure 9

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Case 4:

4.5 years old boy presented after 3 months with a picture of post aural infection [Figure 10]. He was admitted and managed conservatively over 2 weeks with which he had dramatic improvement [Figure 11]. After infection subsided, he was taken to operating theatre and the wound closed primarily. Unfortunately, he presented two months later with skin necrosis and exposure of the device [Figure 12]. Admission and surgical management was the treatment of choice in his case [Figure 13].
Figure 10

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Figure 11

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Figure 12

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Figure 13

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Case 5:

6 years old girl with background of multiple medical and neurological problems, skull deformity and small cochlea. She was implanted with a short electrode. She presented with post auricular swelling six weeks after the surgery. Conservative management failed and she presented 3 months later with the same infection at the surgical site and managed surgically. Unfortunately, her device was extruded and we lost the function of the device. Finally, we had to remove the device. [Figure 14],[Figure 15]
Figure 14

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Figure 15

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Case 6:

2 years old boy presented 8 months post CI with post auricular redness and swelling. He was managed with IV antibiotics in the private sector for 12 days and he improved and was discharged home on oral antibiotics. Two weeks later he was brought to our clinic with the same complain. Examination illustrated fluctuated swelling representing abscess collection. Incision and drainage was done. Recovery was full after the surgery [Figure 16],[Figure 17].
Figure 16

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Figure 17

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  Discussion Top


Cochlear implant is a procedure that introduced a huge advancement in the management of profound hearing loss leading to a great help to those who were born deaf or those who lost their hearing due to other factors later in their life. It was reported that postoperative complication rate is low, therefore it was considered one of the safest surgeries performed in this field [3],[4],[5]. Bradford Terry et al has a systematic review of delayed complications of cochlear implant. They analysed 88 articles in English literature including total of 22842 patients with 1302 (5.7%) delayed complications. The top three common complications in their review were vestibular complications, device failure and taste problems respectively. In their review skin infection rate was 1.3 % in general with no specifications regarding the surgical site [6]. The 11 cases we reported in our series constituted 3.1 % of our total patients.

Hematoma: we had one patient present with hematoma and two patients showed up with seroma at the surgical site. There was no clear history whether these complications were related to trauma or to other factors. The three of our patients were from paediatric age group.

In his study, Loundon and colleagues reported a number of 18 patients all from paediatric age group with some kind of skin problems related to seroma or hematoma [7]. on the other hand, the incidence of delayed seroma and hematoma in adult age group reported to be very low [8]. they were managed with observation, local cream and pressure dressing, however hematoma patient needed to be taken to the operating theatre and in was aspirated under GA [Figure 3]. One of the patients with seroma improved with conservative management but the other one came with ruptured seroma and was managed surgically. Aspiration should be avoided if there is a chance of hitting the electrode or it was not infected.

Skin loss and device exposure: we had 3 patients presented with infection at the surgical site followed by skin necrosis/loss and device exposure. It was related by Telian SA et al to several factors including wound dehiscence, Hematoma formation or infection [9]. Yeon Hoo Kim and Sung IL Cho reported a case of 55 year old female who developed a skin necrosis due to usage of bone marking with methylene blue [10]. In our three patients, the skin necrosis and device exposure were due to surgical site infection which support what Telian proposed in his paper, but the other patient who had hematoma did not had skin necrosis. We believed that because the hematoma was slightly caudal to the surgical wound and the flap that’s why he did not develop this kind of complication. One patient among these three had device extrusion, hence damage and failure. In one study, Cullen et al reported device failure in a group of 65 patients from total study group of 952 paediatric patients [11]. In his study, 20 of their patients came after head trauma. In our patient, the end result was device explanation. Later on, we implanted the other side and the patient did great in terms of postoperative hearing development. The last patient in our series presented with delayed wound site abscess due to neglect from the family. He presented to our outpatient department with redness over the surgical site and was advised to be admitted for IV antibiotics. Despite all our efforts to admit the patient, family refused due to social reasons. He came later with fluctuated abscess which was drained successfully. This complication could be prevented if the management started earlier.


  Conclusion: Top


Post cochlear implant surgical site infections are relatively rare complications. It really important to maintain meticulous aseptic technique and the surgical incision should be made as long as required only. Covering the implanted device with periosteum without tension is a key step to prevent flap necrosis and therefore device extrusion. All patients should be counselled thoroughly regarding the possible intra-op or post op complications in order to limit the morbidity early.

Authors Contribution:

Dr Khalid Al Zaabi contributed in the designs of the study, in the analysis of the data and in the write up of this manuscript. Dr Ammar Al Lawati supervised the whole work process and contributed in analysis and in final reviewing of the manuscript.

Declaration:

All Authors declare that there is no conflict of interest and no fund was received from any authority to complete this work.



 
  References Top

1.
A.Ramos, R. Charlone, I. de Miguel, A.Valdivielso, J.M.Cuyas, D. Perez, J.R.Vasallo. Complications of Cochlear Implantation. Acta Otorrinolaringol Esp. 2006; 57: 122-125.  Back to cited text no. 1
    
2.
Cohen NL, Hoffman RA. Medical or Surgical Complications related to the Nucleus multichannel Cochlear Implant. Ann Oto Rhino Laryngol. 1988;97:8-13.  Back to cited text no. 2
    
3.
Fayad JN, Baino T, Parisier SC. Revision cochlear implant surgery: causes and outcome. Otolaryngol Head Neck Surg. 2004;131(4):429-432.  Back to cited text no. 3
    
4.
CôtéM, Ferron P, Bergeron F, Bussières R.Cochlear reimplantation: causes of failure,outcomes, and audiologic performance. Laryngoscope. 2007;117(7):1225-1235.  Back to cited text no. 4
    
5.
Lassig AA, Zwolan TA, Telian SA. Cochlear implant failures and revision. Otol Neurotol. 2005;26(4):624-634.  Back to cited text no. 5
    
6.
Bradford Terry, Rachel E. Kelt, Anita Jeyakumar. Delayed Complications After Cochlear Implantation. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2015.2154  Back to cited text no. 6
    
7.
Loundon N, BlanchardM, Roger G, Denoyelle F,Garabedian EN. Medical and surgical complications in pediatric cochlear implantation. Arch Otolaryngol Head Neck Surg. 2010;136(1):12-15  Back to cited text no. 7
    
8.
Ovesen T, Johansen LV. Post-operative problems and complications in 313 consecutive cochlear implantations. J Laryngol Otol. 2009;123(5):492-496  Back to cited text no. 8
    
9.
Telian SA, El-Kashlan HK, Arts HA. Minimizing wound complications in cochlear implant surgery. Am J Otol. 1999;20:331–334.  Back to cited text no. 9
    
10.
Yeon Hoo Kim and Sung IL Cho. Skin Flap Necrosis by Bone Marking with Methylene Blue in Cochlear Implantation, J Audiol Otol. 2015 Sep; 19(2): 108–110.  Back to cited text no. 10
    
11.
Cullen RD, Fayad JN, Luxford WM, Buchman CA. Revision cochlear implant surgery in children. Otol Neurotol. 2008;29(2):214-220.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
 
 
    Tables

  [Table 1]



 

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