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The Laryngoscope
© 2022 The American Laryngological,
Rhinological and Otological Society, Inc.

Monopolar Electrosurgery With Cochlear Implants

Nathan D. Cass, MD ; Nathan R. Lindquist, MD; Marc L. Bennett, MD; David S. Haynes, MD

Objective: To evaluate safety of monopolar electrosurgery (MES) in patients with cochlear implants (CIs) by reporting
outcomes of a series of patients who underwent MES after CI.
Study Design: Retrospective case series.
Setting: Tertiary referral center.
Patients: Patients with indwelling CI subsequently undergoing surgery with operative note specifically detailing MES use.
Main Outcome Measures: Adverse outcomes in post-operative audiology/otolaryngology documentation; speech recog-
nition scores.
Results: Thirty-five patients (10 with bilateral CI) experienced 63 unique MES exposure events, 85.7% below and 14.3%
above the clavicle. No adverse events or decreased performance due to MES use were reported for any patient. Pre- and imme-
diate postoperative speech recognition scores were not significantly different for patients using either consonant-nucleus-
consonant (CNC; n = 23, 68%–66%, p = 0.80) or AzBio (n = 15, 82%–88%, p = 0.60). For individual CNC performance,
21 (91%) patients demonstrated stability, 1 improved >15%, and 1 declined >15%, although this patient had become a non-
user due to magnet issues and, after resolution of these issues, exceeded baseline pre-operative score. For individual AzBio
performance, 12 (80%) patients demonstrated stability, 3 improved >15%, and none declined >15%.
Conclusions: No adverse events resulted from MES use in CI patients. Given the increased prevalence and expansion of
indications for CIs, and widespread utility of MES, we suggest clarification and improved guidance from device manufacturers
regarding safety and use of MES for patients with these devices. We hope that data regarding electrosurgery exposure events
will better inform clinician decision-making with regards to relative benefits and risks for MES use for CI patients.
Key Words: bovie, cochlear implants, electrocautery, monopolar electrosurgery, safety.
Level of Evidence: 4
Laryngoscope, 133:933–937, 2023

INTRODUCTION opposite ear,” though it is unclear whether this statement

Monopolar electrosurgery (MES) is the delivery of
alternating current electricity through biologic tissue
from an active electrode tool to a return electrode pad, to
accomplish a surgical task such as incision, dissection, or
hemostasis.1 This versatile tool is used worldwide for a
multitude of surgical procedures. However, as the electro-
surgical current traverses the patient’s body, there exists
a theoretical risk of diversion to implanted devices capa-
ble of electrical transmission. Cochlear implants (CIs) are
believed to be at risk for conducting such current diver-
sion. Of the three FDA-approved devices, the labels of
two prohibit MES use in the head and neck after device
placement, while remaining silent on its use in other body
regions. The remaining manufacturer label discourages
MES use “when the patient has a cochlear implant in the
From the The Otology Group of Vanderbilt, Department of
Otolaryngology (N.D.C., N.R.L., M.L.B., D.S.H.), Vanderbilt University Medical
Center, Nashville, Tennessee, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on July
13, 2022.
N.D.C. and N.R.L. contributed equally to this work.
D.S.H. is a consultant for Advanced Bionics Corp., Cochlear Corp.,
MED-EL GmbH, Stryker, Synthes, Grace Medical, and Oticon.
The authors have no other funding, financial relationships, or con-
flicts of interest to disclose.
Send correspondence to Nathan D. Cass, MD, The Otology Group of
Vanderbilt, Department of Otolaryngology, Vanderbilt University Medical
Center, Medical Center East, South Tower, 1215 21st Ave South, Nash-
ville, TN 37232. E-mail: nathan.cass@vumc.org
DOI: 10.1002/lary.30323
refers to all surgical procedures or only to contralateral
CI surgery. Many CI patients who would otherwise bene-
fit from a surgical procedure for which MES avoidance
would be unsafe or impractical are forced to decide
between refusing a useful surgery and placing their
implant and inner ear at risk.
To our knowledge, only a single report substantiates
the possibility of CI device damage via MES.2 After
cadaveric cochlear implantation, five dental tools were
applied to the intraoral cavity while monitoring; an oscil-
loscope monitored current produced in the CI during each
test, and the implant’s electronic integrity was interro-
gated after each. Although 60 MES exposures at various
levels produced no current nor damage to the CI, applica-
tion of the maximum level current in a partially rectified
mode produced “irrevocable damage” to the CI. Partial
rectification is a specific type of blended mode in which a
portion of the sine wave is blocked with a negative polar-
ity, converting the alternating current into a unidirec-
tional current; it is uncommonly used except in dentistry
and dermatology.3
Subsequent animal4 and human5,6 cadaveric studies
applying very high energies of 50–100 W via “cut” and
“coagulation” modes to regions near the CI (including
nasopharynx, tongue, and ipsilateral temporalis muscle)
have failed to replicate the damage seen in the dental
study. Two retrospective reports of three patients under-
going surgery after implantation (one open heart surgery,

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two adenotonsillectomies) demonstrated no adverse TABLE I.
effects on the implant or patient.7,8 The literature on the Monopolar Electrosurgery Exposure Event Characteristics and
most common similar implantable electrical devices— Demographics.
pacemakers and cardioverter defibrillators—discusses Monopolar Electrosurgery Exposure Events n = 63
electromagnetic interference from MES in a desire to
reduce unintended discharges, yet we find no reports of Gender

irrevocable destruction of a device in the setting of MES. Female 36 (57%)

Given an increasing CI patient base and expanding Male 27 (43%)

indications for CI, as well as the widespread usage and Laterality
utility of MES, we sought to evaluate whether evidence Left 25 (40%)
exists for MES adversely affecting CI devices, as has been Right 38 (60%)
widely believed, by utilizing CI patients at our institution Manufacturer
who have undergone such MES exposures. Advanced bionics 9 (14%)
Cochlear 33 (53%)
MED-EL 21 (33%)
MATERIALS AND METHODS Body region of monopolar electrosurgery exposure event
After approval from our institutional review board (Vander-
Abdominal/Gastrointestinal 17 (27%)
bilt IRB #220255), we performed a query of our institution’s
Research Derivative database of clinical and related data for Head and neck 8 (13%)
patients with CPT codes for both CI surgery and major cardio- Lower extremity 8 (13%)
vascular, neurosurgical, orthopedic, gynecologic, urologic, gen- Spine 11 (17%)
eral, and otolaryngologic surgeries between January 2009 and
Thoracic/breast 11 (17%)
December 2021.9 The operative notes for 318 patients were
Upper extremity 2 (3%)
reviewed to assess for specific mention of MES use for patients
with an existing CI in place. Data collection included demo- Urologic/gynecologic 6 (10%)
graphics, surgery dates, type of surgery performed with CI in Relation to clavicle for monopolar electrosurgery
place, revision CI surgery, adverse events, or change in perfor- Above clavicle 9 (14%)
mance, as well as immediate pre-operative, soonest post-operative,
Below clavicle 54 (86%)
and most recent CI-only assessments (i.e., consonant-nucleus-
consonant [CNC] word recognition and AzBio sentence recognition
in quiet). Based on prior studies for revision CI surgery outcomes,
an increase of speech recognition scores ≥15% is considered
5 were midline (C1-C2 spinal fusion, cleft rhinoplasty,
improved, a decrease of ≥15% is considered worsened, and changes
of <15% are considered unchanged.10–14
2 adenotonsillectomies, and 1 adenotonsillectomy com-
Adult patients underwent audiologic evaluation according bined with a septoplasty), 3 contralateral to the CI (1 ven-
to the Minimum Speech Test Battery.15 Speech recognition test- triculoperitoneal shunt and 2 vagal nerve stimulators),
ing was completed in a sound booth with speech presentation and 1 ipsilateral to the CI (vagal nerve stimulator). The
level of 60 dBA in quiet conditions. Stimuli were presented from most common types of surgery included abdominal, tho-
a single loudspeaker at 0 azimuth (1 m). Patients completed racic/breast, spine, lower extremity orthopedic or vascular
CNC and AzBio testing in quiet.16,17 All patients were tested in surgeries, and head and neck surgeries. Audiology and
the unilateral CI-only condition. otolaryngology follow-up notes after MES exposure did
Demographics were characterized with standard descrip- not report any adverse events for any patient related to
tive statistics. Normal distribution was assessed using the
such use. A total of 4 (6.3%) CI devices ultimately under-
Shapiro–Wilk test and presented with means and standard devi-
ations, whereas non-parametric data were described utilizing
went revision surgery after the electrosurgery exposure
median values with interquartile range (IQR) or total range event occurred, although no revision surgery was attrib-
when appropriate. Nominal data were analyzed using Fisher’s uted to the use of MES. Of these revisions, one patient
exact test. p-values <0.05 were considered statistically signifi- had a known soft failure of the CI prior to electrosurgery,
cant. Analyses were performed using GraphPad Prism 9.2.0 two implants in one patient demonstrated unexplained
(GraphPad Software, La Jolla, California, U.S.A.). decreased CI performance after magnet removal for mag-
netic resonance imaging (MRI), and one revision occurred
due to persistent facial nerve stimulation and concern for
RESULTS infection.
Demographics and Clinical Characteristics
A total of 35 patients, 10 of which had bilateral CIs,
experienced 63 unique MES exposure events as noted in Speech Recognition Outcomes
the surgeons’ operative report, with CI in vivo (Table I). Immediate preoperative and postoperative CNC CI-
Demographic data included a median age at electrosur- only speech recognition scores were available for
gery exposure of 51.6 years (range 5.4–78.7 years), 23 patients, at a median of 4.9 months (range 0.2–
36 (57%) women, 25 (40%) left ears, and 3 FDA-approved 57 months) before and 4.6 months (range 0.9–52 months)
manufacturers. A total of 9 (14.3%) exposure events after MES exposure, respectively (Fig. 1). The pre-
involved surgeries above the clavicle, with 54 (85.7%) operative (median 68%, IQR 40%–72%) and postoperative
below the clavicle; of the above-the-clavicle procedures, (median 66%, IQR 34%–82%) CNC scores were not

Laryngoscope 133: April 2023 Cass et al.: Monopolar Electrosurgery With Cochlear Implants
934

Fig. 1. Consonant-nucleus-consonant (CNC) pre- and post-
operative results. Comparison of cochlear implant-only CNC scores
(%) at audiologic testing before and after monopolar electrosurgery
exposure event. (A) utilizes a spaghetti plot for individual patient
performance, while (B) plots median values with boxplot illustrating
interquartile range and whiskers signifying overall range.
significantly different (p = 0.8002). For individual perfor-
mance, 21 (91%) patients demonstrated stable perfor-
mance, 1 patient demonstrated improvement >15%, and
1 patient demonstrated decline >15%, although this
patient had become a non-user due to magnet issues and,
after resolution of these issues, has thus exceeded base-
line preoperative score on most recent testing.
Immediate pre-operative and postoperative AzBio
CI-only speech recognition scores were available for
15 patients, at a median of 10 months (range 0.9–
57 months) before and 6.7 months (range 1.3–52 months)
Fig. 2. AzBio pre- and post-operative results. Comparison of
cochlear implant-only AzBio in quiet scores (%) at audiologic test-
ing before and after monopolar electrosurgery exposure event.
(A) utilizes a spaghetti plot for individual patient performance, while
(B) plots median values with boxplot illustrating interquartile range
and whiskers signifying overall range.
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after MES exposure, respectively (Fig. 2). The preopera-
tive (median 82%, IQR 23%–90%) and post-operative
(median 88%, IQR 36%–92%) AzBio scores were not sig-
nificantly different (p = 0.5988). For individual perfor-
mance, 12 (80%) patients demonstrated stable
performance, three patients demonstrated improvement
>15%, and no patients demonstrated decline >15%.
DISCUSSION
The use of MES has been widely regarded as con-
traindicated in the setting of CI due to presumed risk to
the device, although limited data exists to support this
notion. Only one report exists suggesting electrical
changes or damage to CIs during MES. Manufacturer
labeling is vague, recommending avoidance of MES in the
head and neck or while performing contralateral CI sur-
gery, but silent on the subject of MES use in other body
regions for patients with CI in place. Given the increasing
incidence of CI and other surgical procedures performed,
improved understanding and clarification of the role of
MES is imperative for patients with CIs in place. Until
now, large patient series examining adverse events and
speech recognition scores for patients undergoing electro-
surgery exposure events have been non-existent.
One finding of this study is that patients with CI are
known to undergo surgery with MES, even in the head
and neck. This prevalence suggests a lack of knowledge
on contraindications to MES use in CI recipients among
patients and surgeons, even otolaryngologists,18 as well
as the need for improved pre-operative implant screening
prior to subsequent surgical procedures—of note, only
two operative notes discussed surgeon awareness of the
CI and that the possibility of MES-induced damage was
discussed with the patient. Routine preoperative counsel-
ing of patients regarding this potential risk, though ideal,
is hindered by lack of awareness or understanding of such
risks by most surgical, anesthesiology, and nursing
teams. Patients themselves must be counseled at the time
of implantation regarding the risks of future surgery with
MES (in similar fashion to restrictions regarding MRI), so
that they can be their own best advocate for future con-
sultations with surgeons who may not be aware of addi-
tional risks with CI.
Though regrettable, the frequency of such events
provides serendipitous insight into the function of CIs
after MES exposure events. We identified a total of
63 MES exposure events for 35 individual patients as
documented in operative notes. However, many more
perioperative nursing notes identified a return electrode
pad or site, implying that either MES was readied for use
and not utilized, or else utilized without specific docu-
mentation in the surgeons’ operative notes. In addition,
many surgeries that routinely utilize or would be imprac-
tical or unsafe without MES were not included unless
explicitly documented. Surgeries occurring at outside
facilities were not routinely included as operative notes
were often unavailable. As a result of these factors, we
hypothesize that the occurrence of MES exposure events
is likely higher than noted herein.
Cass et al.: Monopolar Electrosurgery With Cochlear Implants
935

Despite a high number of MES exposure events,
audiologic and otolaryngologic documentation reported no
CI-related adverse events, device malfunctions, or perfor-
mance changes directly attributed to use of MES. Fur-
thermore, audiologic and speech recognition testing for
patients before and after surgical procedures involving
MES did not demonstrate significant changes in speech
recognition scores either at group or individual level.
MES mode and energy output may play a significant
role in the potential for CI damage. MES applied to the
adenoid of implanted cadaveric pigs at a setting of
50 (double the normal intensity) for 15 min failed to pro-
duce any damages upon manufacturer testing of the CI.4
Similarly, no adverse effects were noted in CI devices on
manufacturer testing after MES was applied at up to
50 W for up to 30 min to the abdomen and tongue of two
fresh human cadavers.6 Even with application of MES at
up to 100 W for 1 min to a location as close as the ipsilat-
eral temporalis muscle immediately overlying a CI in a
fresh human cadaver, manufacturer testing noted no
damage to the implant.5 However, in the dental study
noted previously, the combination of maximum electro-
surgical unit device energy output and the use of a mode
applying unidirectional electrical current resulted in
“irrevocable damage” to the CI.2 Direct current may be
more likely than alternating current to be diverted to
the CI in its course toward the return pad. As this mode
is uncommon in most surgical fields, its role in produc-
ing the only known damaging exposure event should be
noted, but perhaps not used as evidence to support com-
plete prohibition of MES in all modes, at all energy
levels, in all body regions for patients with currently
indwelling CIs.
Data from analogous electrical implanted devices are
sparse. Research on the perioperative management of
pacemakers and implantable cardioverter-defibrillators
revolves around reducing unwanted responses of the
devices to extra-cardiac electric current19–23; no damage
to the device itself is discussed or implied. Conversely,
labeling for the hypoglossal nerve stimulator notes that
aberrant stimulation and nerve, tissue, or generator dam-
age can occur if MES is used near or in contact with the
stimulator or leads, yet mentions that “if electrocautery
must be used in the vicinity of the generator, therapy
should be turned off.”24 Vagal nerve stimulator labeling
likewise notes that MES may turn off therapy, damage
the implant, or injure the patient, “particularly if used in
close proximity to the device.”25 In similar fashion to CI
literature, one event of dubious relevance changed the
use of MES in the field of deep brain stimulation: a
patient with a deep brain stimulator died in 2001 after
medical diathermy treatment (therapeutic heating of tis-
sue via electromagnetic waves), which is distinct from
electrosurgery. A recent animal cadaver study showed
that with MES usage at a power of 50 for 1 min at dis-
tances of 15, 30, and 50 cm away from the device, no rise
in temperature occurred at the site of the implanted deep
brain leads outside of normal physiological variation
(2.6 C), with no histologic evidence of thermal injury to
the brain.26 The authors postulate greater safety of MES
in the setting of neuromodulating devices than previously
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believed. Indeed, battery changes and revisions of
neuromodulation devices including deep brain stimula-
tors, vagal nerve stimulators, and intrathecal spinal cord
stimulators are routinely performed with use of a MES
system which produces lower energy output (Peak
PlasmaBlade, Medtronic; Minneapolis, Minnesota,
U.S.A.).27 This same system is also used in the presence
of implantable cardiac devices to reduce ventricular
oversensing.28
Limitations of this study include its retrospective
nature and that clinical documentation was not designed
to report adverse events or other issues related to MES.
As mentioned above, we hypothesize that the actual num-
ber of CI electrosurgery exposure events are grossly
underestimated due to documentation issues. Of the
63 electrosurgery exposure events identified herein, a
much smaller proportion had pre-exposure and post-
exposure audiologic testing. Unfortunately, no patient
with an electrosurgery exposure event above the clavicle
also had pre-exposure and post-exposure speech recogni-
tion testing. However, scrutiny of the medical records for
these subjects did not elucidate any adverse events or
subjective reports of decline in CI performance. Further
data for patients with MES exposure events above the
clavicle will be needed to better inform recommendations
for this cohort of patients.
CONCLUSION
Herein, we present the largest cohort of patients
undergoing MES exposure events with CI in place, to
date. There were no adverse events related to the events,
with pre-exposure and post-exposure speech recognition
testing supporting continued function of and benefit from
the CI devices. Given the increased prevalence and
expansion of indications for CIs, and widespread utility of
MES, we suggest clarification and improved guidance
from device manufacturers regarding the safety and use
of MES for patients with these devices. Extensive testing
by manufacturers will likely be necessary to confirm
safety of MES in patients with CIs. We hope that data
regarding electrosurgery exposure events will better
inform clinician decision-making with regards to the rela-
tive benefits and risks for the use of MES for patients
with CI(s) in place.
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