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121]
The cochlear implantation surgery: A review of
anesthetic considerations and implications
Sukhminder Jit Singh Bajwa, Ashish Kulshrestha1
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, 1Government
Medical College and Hospital, Sector-32, Chandigarh
ABSTRACT
The advancement in the technology of the cochlear
implants has resulted in increasing trend of cochlear
implantation in both the children and elderly population.
The anesthesiologist is faced with the task of smoothly
conducting the surgery without any interference in
the stimulation techniques used. The preoperative
evaluation is mainly focused on the presence of any
congenital anomalies in these patients which may affect
anesthetic technique. The reduction of anxiety of the
patient as well as the parents of small children is an
important aspect of the preoperative visit. Intraoperatively
the anesthetic technique chosen should not interfere
with the stimulation of the cochlear implant electrode
assembly. The postoperative management is mainly
focused at prevention of agitation and good analgesia.
A close cooperation between the surgeon and the
anesthesiologist is essential for a positive outcome in
this surgery. The current review focuses on the important
anesthesia aspects related to cochlear implant surgery.
Key words: Anesthesia, cochlear implant,
sensorineural deafness
INTRODUCTION
A cochlear implant is an electronic device which is used to
restore hearing in patients with bilateral severe sensorineural
deafness in order to provide improved communication
abilities. These electronic devices have an ability to transform
speech and other sounds into electrical signals used to
stimulate the existing fibers of auditory nerve in the inner
ear. These are different from usual hearing aids in that these
devices do not just amplify the sounds, but actually stimulate
the auditory nerve. Cochlear implants are considered to be
Address for correspondence: Dr. Sukhminder Jit Singh Bajwa,
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical
College and Hospital, Ram Nagar, Banur, Punjab, India.
E‑mail: sukhminder_bajwa2001@yahoo.com
International Journal of Health & Allied Sciences • Vol. 2 • Issue 4 • Oct-Dec 2013
Review Article
an important landmark development in otology.[1] Cochlear
implants are very expensive electronic devices which need a
careful surgical technique to place the internal compressor
assembly within the mastoid antrum and connect the
electrodes to the cochlear neurons. The surgical technique
requires a team approach which includes use of such
anesthetic technique so as to maintain a bloodless surgical
field with stable intraoperative hemodynamics. As such
role of the anesthesiologist is crucial during such expensive
surgical procedures for a better outcome. Total intravenous
anesthesia, locoregional anesthesia, newer induced
hypotension techniques, and advent of newer drugs in
anesthesia practice including newer sedative agents and many
other techniques and drugs have allowed even complicated
surgical procedures to be performed with a great ease.[2‑4]
The most common candidates for cochlear implant surgery
are children but adults and sometimes elderly people, with
failure of hearing aids may be considered for this surgery.
PREOPERATIVE EVALUATION
Selection of patient
Early detection of hearing impairment in childhood is
essential for proper development of learning and listening
skills and early implantation of cochlea leads to acquisition
of these skills and thus also helps in mental and intellectual
development of the child. It has been found that proper
development of both the speech as well as vocabulary occurs
if the child receives the cochlear implant before 2.5 years
of age.[5] Surgical procedure itself needs the facial nerve to
be identified and for which proper development of facial
ridges is important which usually develops by 2 years of age.
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Bajwa and Kulshrestha: Anesthesia for cochlear implantation surgery
After selecting the patients, further investigations required
for surgery include objective assessment of hearing by steady
state evoked potential, auditory brainstem evoked potential,
and electrocochleography. Radiographs of skull and high
resolution computed tomographic scan of the temporal
bone are needed to visualize the basal turn of cochlea, its
patency, and any abnormal ossification within it. It can also
give useful information about degree of pneumatization
of mastoid, any congenital abnormality in inner ear, and
any fluid accumulation in middle ear. Magnetic resonance
imaging (MRI) may be useful in identification of sequelae
of labrynthitis with fibrous tissue filled cochlea where the
placement of electrodes may be difficult.[6] The presence of
acute or chronic suppurative otitis media with or without
cholesteatoma was considered contraindication for cochlear
implant surgery previously, but now with adequate control
of the infection preoperatively and with the measures to
prevent recurrence of the disease, it is no longer considered
a contraindication.
The presence of mental retardation and any central nervous
disease affecting the auditory pathway should be assessed
preoperatively[7] and so is the presence of any congenital
cataract which should be corrected preoperatively in order
to achieve maximum help from the improved vision for
postoperative hearing rehabilitation.
Anesthetic aspects
Majority of the patients coming for cochlear implant
surgery are children with hearing impairment and hence
communication with these children is very important to
establish a good rapport preoperatively. The children and
the parents should be counseled after detailed description
of the surgical and anesthetic procedure. This also helps
in allaying anxiety of both the child as well as the parents.
Preoperatively, it is essential to screen for the presence of
various congenital syndromes leading to deaf‑mutism as
the systemic involvement in these syndromes may affect the
anesthetic management. Also, the various types of dysplasia
of temporal bone and cochlea associated with these syndromes
may render the surgeons to change the surgical technique of
cochlear implantation. The various congenital syndromes and
their anesthetic implications are shown in Table 1.[8‑13]
A thorough preoperative examination is required to assess
the presence of any congenital abnormalities, developmental
milestones, cerebral palsy, any neuromotor deficits, and
presence of any active upper respiratory infections.
Premedication with oral midazolam 0.5 mg/kg given about
20-30 min prior to anesthesia induction remains the preferred
226 International Journal of Health & Allied Sciences • Vol.2 • Issue 4 • Oct-Dec 2013
Table 1: Various congenital syndromes associated with
deaf‑mutism and anesthetic implications
Congenital syndromes Anesthetic implications
Treacher Collins Facial dysplasia associated
syndrome can lead to difficulty in airway
management
Klippel‑Fiel anomaly Fusion of cervical vertebrae leads
to restricted neck movements and
difficult intubation
Pendred syndrome Metabolic derrangements
involving goiter and
hypothyroidism
Alport syndrome Renal and endocrine abnormalities
Jervell and Prolonged QT interval, risk of
Lange‑Neilsen syndrome ventricular arrhythmia, and history
of syncopal attacks
drug owing to its reasonable and reliable effect with no serious
side‑effects. It helps in reduction in separation and induction
anxiety in children with a favorable pharmacokinetic profile
and minimal effects on recovery profiles.[14]
Anesthesia induction
Induction of anesthesia can occur in the standard
manner in adults using thiopentone 3-5 mg/kg or
propofol 2-3 mg/kg intravenously with the analgesia
given by fentanyl 2 mg/kg intravenously. The induction
in children without intravenous access can be achieved by
inhalational induction by oxygen and sevoflurane. Tracheal
intubation is achieved after neuromuscular blockade with
vecuronium 0.1 mg/kg intravenously with appropriate sized
endotracheal tube which is then firmly secured in place
after confirming bilateral equal air entry. Attenuation of
pressor response with preoperative dexmedetomidine in a
dose of 1 mg/kg not only provides stable hemodynamics
during induction and intraop period enabling a smoother
control to provide a bloodless field during surgery, but also
decreases the requirement of anesthetic drugs during periop
period.[15] Anesthesia is usually maintained with oxygen,
air, and isoflurane with intermittent doses of vecuronium.
Alternatively, a total intravenous technique involving
infusion of propofol can be used to maintain anesthesia.
However, the choice of anesthetic technique and drugs is
solely the priority of the attending anesthesiologist whether
to use experience‑based or evidence‑based anesthesia
based on scientific logical empiricism.[16] The standard
monitoring should include five lead electrocardiogram,
noninvasive blood pressure, pulse oximetry, capnography,
and neuromuscular monitoring.
Regional anesthesia can be used by the block of great
auricular nerve, but studies in tympanomastoid surgeries
have not shown any benefit of such blocks on the reducing
the incidence of postoperative pain.[17] The newer drugs
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Bajwa and Kulshrestha: Anesthesia for cochlear implantation surgery
and techniques have greater potential in providing adequate
sedation during surgical procedure, but need larger studies
so as to establish their overall efficacy and safety.[3,18]
Intraoperative management
The surgical duration is usually 3 h with no significant
blood loss and thus requirement of blood transfusion is
minimal, however sometimes significant blood loss may
occur from large non‑collapsible mastoid emissary veins.
Adequate blood volume is maintained by infusion of
crystalloids compensating for fasting and blood losses and
large amounts of fluids should be avoided as it can lead
to bladder distension leading to postoperative agitation as
catheterization is not done in the surgery.
An important step during the surgery is preservation of
facial nerve which may be identified intraoperatively by
electrical stimulation thus precluding the use of muscle
relaxants. This should be used after the effect of the muscle
relaxant used for intubation has weaned off as evidenced
by the response on the train of four stimulation and during
this process the anesthesia can be maintained by propofol
infusion.
Cochlear implant being an electrical device, can easily be
damaged by static electrical discharges from electrocautery
so the use of electrocautery should be discouraged once
the cochlear implant is inserted in place. However, proper
hemostasis should be done before placement of cochlear
implant. At the conclusion of surgery, the integrity of
the implant is checked by brain stem auditory evoked
responses and by electrically evoked stapedius reflexes.
This is very essential for postoperative fitting of external
speech processor which may be difficult in small children
postoperatively.
The two main aspects of electrical stimulation are usually
used, that is, the electrically elicited stapedius reflex
threshold (ESRT) and electrically elicited compound
action potential (ECAP).[19] ESRT mainly determine the
maximum comfort level which is defined as the loudest
sound tolerated without pain, while ECAP mainly
determines the noise threshold, that is, lowest acoustic
stimulus perceived as sound. Anesthesia can affect the
ESRT leading to wrong estimate of the maximum comfort
level which may produce pain during stimulation. In various
studies it has been found that there is a strong correlation
between the level of hypnosis and the mean stapedius
reflex threshold value and it is thus postulated to reduce the
concentration of inhalational agents with maintenance of
normal carbon dioxide levels during such stimulations.[20]
The use of electroencephalograph has been found to be
International Journal of Health & Allied Sciences • Vol. 2 • Issue 4 • Oct-Dec 2013
useful in maintaining light but sufficient level of hypnosis.
In a prospective study including children, it was found
that the ESRT increased with increasing concentration
of inhalational agent with minimal effect of propofol and
nitrous oxide. The ECAP was not found to be affected by
either the inhalational agents or the propofol. Thus, it can
be concluded that the use of total intravenous anesthesia
using propofol and opioid is beneficial in pediatric cochlear
implant surgery.[21]
Sudden coughing and bucking should be avoided at the end
of surgery to prevent dislodgment of the electrode array
of the implant and the neuromuscular blockade should be
reversed and spontaneous respiratory efforts are allowed.
The child can be extubated in deeper planes and kept in
lateral recovery position to prevent sudden agitation. The
child should be nursed in post‑anesthesia care unit (PACU)
in presence of the parents with proper care of postoperative
analgesia.
Postoperative care
The major postoperative concern in cochlear implant
surgery is the prevention of postoperative nausea and
vomiting (PONV) which is common in ear surgery. The
various measures employed are adequate anxiolysis
preoperatively, use of total intravenous anesthesia with
propofol, avoidance of nitrous oxide, administration of
antiemetics like ondansetron 0.1 mg/kg intravenously
at the end of surgery, and the use of dexamethasone
0.15 mg/kg intravenously at the beginning of surgery.
The use of dexamethasone has been found to augment
the other antiemetics used and studies have suggested that
the risk of infection after a single dose of dexamethasone
is unclear.[22‑24] Palonosetron has also proved to be an
efficacious antiemetic drug which has got a long duration
of action.[25]
Postoperative analgesia can be maintained with parent
or nurse controlled boluses of opioids like fentanyl or
morphine. However, intravenous or per rectal paracetamol
has also been found to be effective in reducing doses of
opioids and thus helps in prevention of opioid‑related side
effects.[26,27] The incidence of postoperative shivering can
also be reduced to a large extent by use of perioperative
dexmedetomidine.[28] The patient should be monitored in
PACU till the consciousness is regained fully with minimal
PONV.
Complications
The cochlear implant surgery is considered to be relatively
safe and minimal or no anesthesia‑related complications are
reported. The complications are mainly surgical including
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Bajwa and Kulshrestha: Anesthesia for cochlear implantation surgery
minor complications like mild flap infection, change in taste,
minor balance problems, and transient facial palsy. The
major surgical complications include flap necrosis, device
failure, device migration, cerebrospinal leak, meningitis,
and persistent facial palsy. [29,30] Late postoperative
complications requiring reimplantation can occur late and
are less frequent and thus these patients should be followed
for long‑term.[31] Other less frequent complications include
displaced magnet from the receiver pocket by magnetic toys
and silicone allergy.[32]
Cochlear implantation in special population
Due to advancement in screening and diagnosing hearing
problems, more number of young children often comes for
early surgery for cochlear implantation. There is evidence
suggesting that early bilateral cochlear implant surgery in
children less than 12 months of age results in better auditory
rehabilitation. A multidisciplinary approach involving
pediatric anesthesiologist is essential for a positive outcome
as studies in cochlear implant surgeries in infants have
shown the age of the patient and experience and the skills
of the anesthesiologist to be important risk factors.[33,34]
Due to deterioration in the quality of life brought about
by hearing impairment, many of the older population is
now resorting towards more sophisticated cochlear implant
devices. This is also due to noncompliance with the various
hearing aids available. But the cochlear implant surgery
is less commonly performed in elderly patients due to
presence of coexisting systemic diseases which increase
the anesthetic complications postoperatively. Recent
evidence, however suggest that the incidence of such
complications in elderly patients are minimal and can easily
be managed.[35‑37] Cochlear implantation with pericanal
electrode technique and transcanal cochlear implantation
can be performed under local anesthesia with monitored
anesthesia care in high risk elderly patients.[38] However,
special precautions have to be exercised in few selected
patients who may either be taking alternative medicines
or may have potential contagious diseases like hepatitis or
acquired immunodeficiency syndrome (AIDS).[39,40]
Anesthesia for incidental surgery in patients with
cochlear implant
The major concern in an incidental surgery in patients with
cochlear implant in situ is mainly the electrical interference
caused by electrocautery and monopolar cautery should
be avoided near head and neck areas in these patients.
Even the bipolar cautery should be avoided directly over
the extra cochlear electrodes to avoid damage. The use
of electroconvulsive therapy in these patients should be
228 International Journal of Health & Allied Sciences • Vol.2 • Issue 4 • Oct-Dec 2013
avoided and so is the use of radiotherapy directly over
the implant which can cause serious damage. MRI is also
contraindicated in these patients and can lead to tissue
damage and implant migration. However, if MRI is deemed
to be necessary, the external magnet can be removed by a
minor surgery, and thus MRI can be performed and the
magnet can be replaced post procedure.[41]
CONCLUSION
In conclusion, the cochlear implantation surgery has gained
popularity over the last decade and thus the attending
anesthesiologist is faced with the responsibility of safely
conducting the surgery. The anesthetic technique used
may have implications on the method of stimulation of
the electrodes of the cochlear implant intraoperatively.
Moreover, most of these patients are children and it is the
responsibility of anesthesiologist to prevent any agitation
and smooth induction and emergence from anesthesia.
A close cooperation between the anesthesiologist and
surgeon is essential for a positive outcome.
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How to cite this article: Bajwa SS, Kulshrestha A. The cochlear
implantation surgery: A review of anesthetic considerations and
implications. Int J Health Allied Sci 2013;2:225-9.
Source of Support: Nil, Conflict of Interest: None declared
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