Cochlear Implant Surgery: Bangladesh Perspective

Purpose To describe the impact of Judicialization on the performance of Cochlear Implant (CI) surgery in the Brazilian Unified Health System (SUS), including the public service and supplementary health. Methods A documentary survey of judgments of all National Courts and the Dominant Jurisprudence focused on CI surgery in the SUS from 2007 to 2019 was carried out through the Jusbrasil Platform using the term “cochlear implant” to carry out the search. A survey was also carried out on the DATASUS platform on how many uni and bilateral CI procedures were performed in the same period. Results According to DATASUS, from 2008 to 2019, 8,857 CI surgery procedures were performed by Public Entities or Health Plan Operators in the country. With regard to Judicialization, for requesting unilateral or bilateral CI surgery, a total of 216 processes were found, representing a total of 2.43% of Judicialization of Cochlear Implant (CI) surgery. Conclusion In view of the data, it is possible to perceive that the Judicialization of Health when we consider the CI surgery has represented a small portion of the cases, which does not demonstrate a large impact on the public budget and does not have an impact on the organization of the SUS.

A cochlear implant (CI) is a hearing device introduced in the 1980s for profoundly deaf subjects who gained little or no benefit from powerful hearing aids. This device comprises an electrode array inserted in the cochlea, connected to an internal receiver, and an externally worn speech processor. The CI transforms acoustic signals into electrical currents which directly stimulate the auditory nerve. Since the early 1990s, cochlear implantation in children has been developing rapidly. Although it is still difficult to predict how a child will perform with a cochlear implant, the success of cochlear implantation can no longer be denied. In this paper, some recent papers and reports, and the results of the various Nijmegen cochlear implant studies, are reviewed. Issues about selection, examinations, surgery and the outcome are discussed. Overall, our results were comparable with those of other authors. It can be concluded that cochlear implantation is an effective treatment for postlingually deaf as well as prelingually (congenital or acquired) deaf children with profound bilateral sensorineural deafness.

Conclusion: The approach to the cochlea did not influence postural control after cochlear implantation (CI) surgery. Most patients already have impaired vestibular function before surgery. These balance deficits did not change after CI surgery in the majority of patients but static balance might be improved by CI surgery. Objectives: To determine whether the technique used to insert the CI electrode has an influence on vestibular function. Methods: Static and dynamic postural control and caloric vestibular function were measured prospectively before and after CI surgery in 36 CI patients with standard cochleostomy (SC) insertion and 16 patients with insertion across the round window (RW). The test battery consisted of the modified clinical test of sensory interaction on balance (mCTSIB), the Rhythmic Weight Shift (RWS), the Walk Across (WA), and the Tandem Walk (TW) test. Results: Caloric testing was normal in the majority of CI candidates and remained normal after surgery. mCTSIB results were not significantly different before and after CI surgery between the SC and RW groups. Within both subgroups, the mCTSIB composite value improved within 6 weeks after surgery compared with the values obtained before surgery. Dynamic standing balance showed no postoperative change in RWS.

Introduction: Cochlear implantation (CI) surgery is a choice treatment of bilateral profound hearing loss. The most common infectious complications are meningitis, otitis media, surgical site infection and mastoiditis. The aim of current study is to show the prevalence of infectious complications after CI surgery. Methods: In this cross-sectional study, all of the profoundly deaf patients who underwent CI surgery during two years from March 2015 to July 2017 entered to the study and were followed up for 6 months after surgery. All of the complications and documents were recorded in a pre-designed checklist. Results: Finally, 364 Patients were enrolled to the study. The mean(± SD) duration of surgery was 2.3±1.5 hours. The complications after surgery occurred in 30 (8.2%) cases. The most common complication after CI surgery was otitis media followed by surgical site infection, meningitis, and mastoiditis. Conclusion: We found that otitis media is the most prevalent infectious complication after CI surgery. This study showed a significant increase in incidence of otitis media in 4 to 5 year-old children in comparison with other age groups.

To report the outcomes on a large series of elderly patients who underwent cochlear implantation (CI) surgery under local anesthesia with conscious sedation (LA-CS). Retrospective chart review on 100 consecutive elderly patients (> 65 years) who underwent CI with LA-CS at a tertiary care center between August 2013 and January 2020. An age-matched control group of 50 patients who underwent CI with general anesthesia (GA) are used for comparison. Outcomes measured included time in the operating room, time in the postanesthesia care unit (PACU), and rate of adverse events. Cochlear implant surgery under LA-CS was successfully performed in 99 (99%) patients. One patient requiring conversion to GA intraoperatively. No patients in the LA-CS group experienced cardiopulmonary adverse events; however, three patients (6%) in the GA group experienced minor events including atrial fibrillation and/or demand ischemia. Overnight observation in the hospital due to postoperative medical concerns or prolonged wake-up from anesthesia was required in one patient (1%) from the LA-CS cohort and 12 patients (24%) from the GA cohort. Perioperative adverse events exclusive to the LA-CS group included severe intraoperative vertigo (8%), temporary facial nerve paresis (3%), and wound infection (1%). The average amount of time spent in the operating room was 37 minutes less for procedures performed under LA-CS compared to GA (P < .05). The average amount of time in recovery was similar for both groups (P > .05). Cochlear implant surgery under LA-CS offers many benefits and is a safe, feasible, and cost-effective alternative to GA when performed by experienced CI surgeons. 3 Laryngoscope, 131:E946-E951, 2021.

EDITORS' INTRODUCTION In the early years of its publication, the American Journal of Otology published articles featuring some of the most notable otology and neurotology programs in the country and the world. Over the years that journal has grown, changed names, and developed a second (fully open access) journal. At the same time, the subspecialties of Otology and Neurotology have changed and grown. With the advent of more formal certification and the need for an increasing number of specialty trained surgeons as well as other hearing, balance, and skull base professionals, the number of notable programs has dramatically increased both inside and outside the United States. Each of these programs is dedicated to providing quality patient care, performing cutting edge research, and training the next generation of both surgeons and scientists that will help lead our specialty in the future. As we launch the newest addition to the family of journals that started with the American Journal of Otology, we wanted to revive the tradition that started with the American Journal of Otology. The Journal's editorial board has formed a special group of individuals to consider which programs to highlight with each issue of the journal. Programs can be featured for a variety of achievements in the past or in the present and can be self-nominated or nominated by the committee. As we launch this series, the obvious first choice was to start where this all started, and it is our pleasure to begin this series with a look at the birthplace of the American Journal of Otology. We hope our readers find these historical looks insightful but also utilize these historical profiles as a method to help our current and future programs to evolve into even better institutions for future generations. HISTORY The Otology Group was founded in a small building in Nashville, TN, on State Street (Fig. 1), as a private practice by Michael E. Glasscock III, M.D. (1933–2018) in 1970. Nearly 51 years later, The Otology Group at Vanderbilt celebrates its anniversary as one of the largest, most innovative centers for skull base surgery, speech and hearing sciences, and neurotologic education. The historic reputation of The Otology Group of Vanderbilt transcends generations of fellows and faculty members and the group remains deeply rooted in the same fundamentals and principles from which it was founded.FIG. 1.: The small building of which The Otology Group was founded on State Street, Nashville, TN, by Dr Michael E. Glasscock III, M.D., in 1970.Michael E. Glasscock III, M.D. (Fig. 2) was a world-renowned clinician dedicated to patient and physician education (1). In 1980, He founded the American Journal of Otology, now known as Otology and Neurotology. He also founded the nonprofit organization, the EAR Foundation, dedicated to educating patients and physicians on ear and hearing disorders. In his career, he published nearly 250 peer-reviewed articles and was the editor of Surgery of the Ear. In conjunction with his partner, C. Gary Jackson, M.D., they possessed a passion for educating fellows and this passion continues to resonate within the fellowship and will do so for years to come. Dr Glasscock had sincere respect for his patients and strived to provide them with unrivaled state-of-the-art care. He was known for "doing things my way," and such mentality (and bravado) paved the way for center that exists today.FIG. 2.: Michael E. Glasscock III, M.D. (1933–2018).The Vanderbilt Bill Wilkerson Center (Fig. 3) was founded in 1951 by Dr Wesley Wilkerson, and named in honor of his son, Bill Wilkerson who was killed in Germany in 1945 during WWII. Wesley Wilkerson was an otolaryngologist in Nashville with a passion for pediatric hearing loss and chartered the Tennessee Hearing and Speech Foundation. In 1997, the Bill Wilkerson Center merged with Vanderbilt University Medical Center (VUMC). The Center was under the leadership for many years by Freeman O'Connell, Ph.D., then Fred Bess, Ph.D. (1978–2009) and is now under the leadership of Anne Marie Tharpe, Ph.D. (2009–current). Partnered with the Vanderbilt Department of Otolaryngology, the combined departments are now known as the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences. The Department of Otolaryngology, Head and Neck Surgery was reorganized in1985 and was led by Robert H. Ossoff, M.D. (1985–2009), Roland Eavey, M.D. (2000–2021) and is now under the leadership of Eben Rosenthal, M.D. (2021–present). The Department is ranked highly by external rankings nationwide and holds a strong reputation in both clinical care, research, and resident/fellow training (2). In 2004, the private practice which Mike Glasscock founded, The Otology Group, merged with the Vanderbilt Department of Otolaryngology, forming what is now known as The Otology Group of Vanderbilt. Within the Center is housed, in addition to The Otology Group of Vanderbilt, the Departments of Otolaryngology and Hearing and Speech Sciences, The Mama Lere Hearing School, The Pi Beta Phi Rehabilitative Institute, The Temporal Bone Lab, The Cochlear Implant Research Lab, The Balance Disorders Clinic, and The National Center for Childhood Deafness and Family Communication.FIG. 3.: The Vanderbilt Bill Wilkerson Center as it exists today and the home of The Otology Group at Vanderbilt, The Departments of Otolaryngology and Hearing and Speech Sciences, The Mama Lere Hearing School, The Pi Beta Phi Rehabilitation Institute, Cochlear Implant Research Laboratory, The Temporal Bone Lab, The Balance Disorders Lab, and National Center for Childhood Deafness and Family Communications.CLINICAL ENTERPRISE Under Dr Glasscock III, M.D.'s guidance, The Otology Group evolved into one of the world's most preeminent centers for skull base, cochlear implants, and ear disorders. The group is now led by David S. Haynes, M.D., M.M.H.C., a direct trainee of Glasscock III, M.D. The group is composed of 5 additional faculty and 2 nurse practitioners, including Robert Labadie, M.D., Ph.D., Marc Bennett, M.D., M.M.H.C., Matthew O'Malley, M.D., Kareem Tawfik, M.D., Elizabeth Perkins, M.D., Ken Watford, D.N.P., A.P.R.N., and Emily Brignola, D.N.P., A.P.R.N., F.N.P.-C. As one of the oldest and largest neurotology practices in the country, the clinicians strive to provide innovate, evidence-based, and honorable patient care. The Otology Group at Vanderbilt clinical practice involves a wide range of surgical approaches and techniques aimed at providing care for the most complex tumors and ear-related disorders. This includes advanced approaches to the skull base, cochlear implantation, otologic surgery, repair of cerebrospinal fluid leaks, and surgical treatment of balance disorders including superior canal dehiscence and Meniere disease. VUMC was one of the first centers to adopt endoscopic ear surgery (led by Alejandro Rivas, M.D., now at Case Western Reserve University) and to begin an annual endoscopic ear course, educating our residents, fellows, and other otolaryngologists on the new techniques of endoscopic ear surgery. The Otology Group at Vanderbilt encompasses the renowned Skull Base Center and Hearing Implant Program, a premiere destination for patients from all over the world. The Skull Base Center upholds a strong and collaborative relationship with The Department of Neurological Surgery including neurosurgeons, Reid C. Thompson, M.D. (Chair), Lola B. Chambless, M.D., and Peter J. Morone, M.D., M.S.C.I. The Skull Base Center and Hearing Implant Programs provide multidisciplinary, coordinated care, allowing for a large number of patient visits and surgical procedures, while providing the highest quality patient care. We also have a monthly multidisciplinary aural atresia clinic attended by audiology, neurotology, facial plastics, and other specialists. In addition, we have multidisciplinary teams that care for Neurofibromatosis Type II, and pediatric hearing loss, led by Kareem Tawfik, M.D. and Elizabeth L. Perkins, M.D., respectively. In 2020, The Otology Group of Vanderbilt performed over 400 skull base consultations and 140 skull base procedures despite the challenges brought by a global pandemic. Nearly 1500 patients were evaluated in the Balance Disorders Lab in 2020. In addition, 300 patients underwent cochlear implantation both in 2019 and in 2020, making VUMC the largest cochlear implant center in the United States and one of the largest in the world. RESEARCH The Cochlear Implant Research Laboratory includes principal investigators René Gifford, Ph.D. and Robert Labadie, M.D., Ph.D., and other investigators who continue to lead in international cochlear implant research. Research at VUMC ranges from reports on clinical and surgical effectiveness and quality outcomes reviews, to randomized controlled trials, such as the impact of image-guided cochlear implant programming on pediatric speech development. Research is supported from departmental resources, industry sponsored trials, and extramural funding (3–6). Our departments are ranked no. 2 in the nation in National Institute of Health (NIH) research and recent recipients of a $3.1 million NIH grant. Our recent NIH funding includes analysis of pre- and postinsertion computed tomography scanning to accurately estimate the electrode position which is used in preoperative planning and postoperative cochlear implant mapping (Fig. 4A, B) (7,8).FIG. 4.: Computed tomography (CT) scan analysis of electrode array placement following cochlear implantation. A, CT scan analysis with a perimodiolar electrode array including the cochlear, vestibule, and semicircular canals. B, Closer visualization of the electrode array and cochlea allows for assessment of the electrode array position with the modiolus (yellow) and scala tympani (blue) and scala vestibuli (green).A highly integrated, multidisciplinary team consisting of audiologists, speech language pathologists, hearing scientists, computer science engineers, and surgeons has been facilitated by institutional resources. VUMC sits on the same campus as Vanderbilt University, allowing close collaboration with other departments primarily Department of Speech and Hearing Sciences, Electrical Engineering and Computer Sciences. Vanderbilt Institute for Surgery and Engineering arose from these collaborations and continues to develop innovative solutions for surgical procedures including skull base and cochlear implant procedures. Our colocation of services has also allowed for extensive optimization of clinical delivery that includes same-day work up and surgery for cochlear implants and bundled pricing for cochlear implant services, the first in the world (9). This collaborative environment motivates basic discoveries which can then be clinically translated to improve individual outcomes. Efforts to use our electronic medical record and artificial intelligence to better coordinate clinical care and discovery is being explored by Matthew O'Malley, M.D., and will help to define our future. EDUCATION The Vanderbilt Bill Wilkerson Center is not only home to the Otology Group of Vanderbilt clinical practice but also houses our Temporal Bone lab (Fig. 5) and our research facilities. The Otology Group of Vanderbilt accepts 1 fellow per year into the neurotology program for a complement of 2 who join the neurotology service with 3 otolaryngology residents. Through the generous support of Michael E. Glasscock III, M.D. and Mr Herbert O. Christopher, the fellowship is enabled to pursue educational, academic, and research endeavors that will improve patient outcomes. Keeping with the theme of physician education, the first temporal bone lab was built in 1970 by Michael E. Glasscock III, M.D., with Jack Urban. The Otology Group of Vanderbilt continues to host multiple workshops and continuing medical education (CME) courses. This includes the annual temporal bone course, with the 85th version being held in the Fall of 2021 and the 7th annual Endoscopic Ear Course held next spring. In addition, an annual CME Otolaryngology course is held in Vail, CO, providing neurotologic education to neurotologists, otolaryngologists, and resident trainees. We also host an in-house resident/fellow temporal bone and endoscopic courses spanning 6 weeks led by Marc Bennett, M.D.FIG. 5.: The VUMC temporal bone lab resides in the Bill Wilkerson Center. The group hosts an annual temporal bone course, with nearly 300 participants in the virtual course in Fall 2020. VUMC indicates Vanderbilt University Medical Center.Fellow and resident education is ubiquitous, with weekly grand rounds on Friday mornings and weekly dedicated neurotology lectures on Thursday mornings led by prominent speakers within the field. Stepping beyond medical education, a leadership course is instituted throughout the year covering topics such as operations, cost accounting, organizational structure, strategy, and leadership (10). Multidisciplinary care is executed through many conferences for both skull base and cochlear implant recipients. The cochlear implant conference is held monthly and attended by audiologists, speech language pathologists, surgeons, social workers, administrative team members, implant research team members, and the cochlear implant coordinator. The monthly skull base conference is attended by neurotology faculty and fellows, neurosurgeons, radiologists, radiation oncologists, skull base coordinators, and research team members. Keeping with the Glasscock scholarly mission, The Otology Group at Vanderbilt takes considerable pride in the education of fellows and residents. This education begins with otologic surgery but transcends into every aspect of being a clinician and a leader. Fellows are "raised" to emulate the Glasscock mentality of prioritizing patient care and practicing with honor and integrity. Previous graduates and current fellows are customarily found at the podium at national and international conferences (Fig. 6) with nearly 30 to 34 peer-reviewed publications per year and over 90 scientific presentations at meetings, courses, and workshops annually. Prior fellows have held leadership positions in multiple international organizations including the American Neurotologic Society, the American Otologic Society, Triological Society, The Collegium Oto-Rhino-Laryngologicum Amicitiae Sacrum, the American Cochlear Implant Alliance, and many others. The fellows graduate with extensive operative and clinical experience, moving on to flourish within the field as division directors and chairpersons, academic deans, successful private practitioners, and academic leaders. This year, the Otology Group at Vanderbilt will proudly graduate its 73rd fellow in neurotology. Built on the legacy of Michael E. Glasscock III, M.D., the Otology Group at Vanderbilt will continue to strive for excellence in research, education, leadership training, and constantly seek innovation and improvement in patient care.FIG. 6.: The Otology Group will graduate its 73rd fellow in the upcoming year, as shown in this group composite. In the center of the composite proudly pictures the faculty mentors and Michael E. Glasscock III, M.D.As a rapidly growing department, The Otology Group at Vanderbilt is committed to providing care for all populations and modeling diversity. Such vision is facilitated through expanding care to remote populations involving telehealth, expedited and personalized care, and physician outreach. The group fosters diversity and equality through onboarding international faculty and fellows who reflect the increasingly diverse society we serve. CONCLUSION The Otology Group at Vanderbilt has strived from its inception to provide the highest quality patient care and to train the best neurotologic surgeons to become leaders in our field. We aspire to discover and provide novel and innovative treatments that will improve the lives of our patients. Education of patients, practicing physicians, and physicians in training remains an essential component of our group. As we celebrate our 51st year, our values remain stronger than ever.

Iatrogenic facial nerve injury is one of the most severe complications of cochlear implantation (CI) surgery. Intraoperative facial nerve monitoring (IFNM) is used as an adjunctive modality in a variety of neurotologic surgeries. The purpose of this retrospective study was to assess whether the use of IFNM is associated with postoperative facial nerve injury during CI surgery. The medical charts of 645 patients who underwent CI from 1999 to 2014 were reviewed to identify postoperative facial nerve palsy between those who did and did not receive IFNM. Four patients (3 children and 1 adult) were found to have delayed onset facial nerve weakness. IFNM was used in 273 patients, of whom 2 had postoperative facial nerve weakness (incidence of 0.73%). The incidence of facial nerve weakness was 0.54% (2/372) in the patients who did not receive IFNM. IFNM had no significant effect on postoperative delayed facial palsy (P = 1.000). All patients completely recovered within 3 months after surgery. Interestingly, all 4 cases of facial palsy received right CI, which may be because all of the surgeons in this study used their right hand to hold the drill. When right CI surgery is performed by a right-handed surgeon, the shaft of the drill is closer to the inferior angle of the facial recess, and it is easier to place the drilling shaft against the medial boundary (facial nerve) when the facial recess is small. The facial nerve sheaths of another 3 patients were unexpectedly dissected by a diamond burr during the surgery, and the monitor sounded an alarm. None of these 3 patients developed facial palsy postoperatively. This suggests that IFNM could be used as an alarm system for mechanical compression even without current stimulation. Although there appeared to be no relationship between the use of monitoring and delayed facial nerve palsy, IFNM is of great value in the early identification of a dehiscent facial nerve and assisting in the maintenance of its integrity. IFNM can still be used as an additional technique to optimize surgical success.

Objective Mastering Cochlear Implant (CI) surgery requires repeated practice, preferably initiated in a safe – i.e. simulated – environment. Mastoidectomy Virtual Reality (VR) simulation-based training (SBT) is effective, but SBT of CI surgery largely uninvestigated. The learning curve is imperative for understanding surgical skills acquisition and developing competency-based training. Here, we explore learning curves in VR SBT of CI surgery and transfer of skills to a 3D-printed model. Methods Prospective, single-arm trial. Twenty-four novice medical students completed a pre-training CI inserting test on a commercially available pre-drilled 3D-printed temporal bone. A training program of 18 VR simulation CI procedures was completed in the Visual Ear Simulator over four sessions. Finally, a post-training test similar to the pre-training test was completed. Two blinded experts rated performances using the validated Cochlear Implant Surgery Assessment Tool (CISAT). Performance scores were analyzed using linear mixed models. Results Learning curves were highly individual with primary performance improvement initially, and small but steady improvements throughout the 18 procedures. CI VR simulation performance improved 33% (p < 0.001). Insertion performance on a 3D-printed temporal bone improved 21% (p < 0.001), demonstrating skills transfer. Discussion VR SBT of CI surgery improves novices’ performance. It is useful for introducing the procedure and acquiring basic skills. CI surgery training should pivot on objective performance assessment for reaching pre-defined competency before cadaver – or real-life surgery. Simulation-based training provides a structured and safe learning environment for initial training. Conclusion CI surgery skills improve from VR SBT, which can be used to learn the fundamentals of CI surgery.

The overall aim of this study was to evaluate personal protective equipment (PPE) that may facilitate the safe recommencement of cochlear implantation in the COVID-19 era, with the broader goal of minimizing the period of auditory deprivation in prelingually deaf children and reducing the risk of cochlear ossification in individuals following meningitis. The study design comprised 1) an objective assessment of mastoid drilling-induced droplet spread conducted during simulated cochlear implant (CI) surgery and its mitigation via the use of a protective drape tent and 2) an evaluation of three PPE configurations by otologists while performing mastoid drilling on ex vivo temporal bones. The various PPE solutions were assessed in terms of their impact on communication, vital physiological parameters, visual acuity and fields, and acceptability to surgeons using a systematic risk-based approach. Droplet spread during simulated CI surgery extended over 2 m, a distance greater than previously reported. A drape tent significantly reduced droplet spread. The ensemble of a half-face mask and safety spoggles (foam lined safety goggles) had consistently superior performance across all aspects of clinical usability. All other PPE options were found to substantially restrict the visual field, making them unsafe for microsurgery. The results of this preclinical study indicate that the most viable solution to enable the safe conduct of CI and other mastoid surgery is a combination of a filtering facepiece (FFP3) mask or half-face respirator with safety spoggles as PPE. Prescription spoggles are an option for surgeons who need to wear corrective glasses to operate. A drape tent reduces droplet spread. A multicenter clinical trial to evaluate the effectiveness of PPE should be the next step toward safely performing CI surgery during the COVID-19 era. 4 Laryngoscope, 130:2693-2699, 2020.

To identify demographic predictors of patients undergoing cochlear implantation evaluation and surgery. Consecutive adult patients between 2009 and 2018 who underwent cochlear implantation evaluation at a university cochlear implantation program were retrospectively identified to determine (1) cochlear implantation qualification rate and (2) pursuit of surgery rate with respect to age, gender, race, primary spoken language, marital status, insurance type, and distance to the cochlear implantation center. A total of 823 cochlear implantation evaluations were analyzed. Overall, 76.3% of patients qualified for cochlear implantation and 61.5% of these patients pursued surgery. Age was the only independent predictor for cochlear implantation qualification, such that, for each year younger, the odds of qualifying for cochlear implantation increased by 2.5% (OR 0.98; 95% CI: 0.96-0.99). Age, race, marital status, and insurance type were each independent predictors of the decision to pursue surgery. The odds of pursuing surgery increased by 2.8% for each year younger (OR 1.03; 95% CI: 1.01-1.05). Compared to White patients, non-Whites were half as likely to pursue surgery (OR 0.47; 95% CI: 0.25-0.88). Single (OR 0.49; 95% CI: 0.26-0.94) and widowed patients (OR 0.46; 95% CI: 0.23-0.95) were about half as likely to pursue surgery as compared to married patients. Patients with military insurance were 13 times more likely to pursue surgery as compared to patients with Medicare (OR 13.0; 95% CI: 1.67-101.4). Younger age is an independent predictor for a higher cochlear implantation qualification rate, suggesting the possibility for delayed candidacy referral. Rate of surgical pursuit in qualified cochlear implantation candidates is lower for racial minorities, single and widowed patients, and older patients.

The outcome of the cochlear implant is dependent highly on the knowledge, belief and practice of cochlear implant in otolaryngologists who are among the important team members. The study explored the knowledge, beliefs, and practices towards cochlear implantations among otorhinolaryngologists in India. An online cross-sectional survey study was carried out using convenient sampling among otorhinolaryngologists in India. Phase-I involved developing and validating of a questionnaire to study the knowledge, beliefs, and practices towards cochlear implants among otorhinolaryngologists in India while phase II involved administration of the questionnaire and analysis. Data collection was conducted using Google Forms. A total of 106 otorhinolaryngologists participated across 24–65 years of age and with experience ranging from 1 to 42 years. The participating otorhinolaryngologists reported having good knowledge about the candidacy for a cochlear implant but having limited knowledge of the recent developments and governmental schemes. The otorhinolaryngologists displayed positive beliefs regarding cochlear implantation. Most recommended a battery of tests to determine the candidacy and gave a lot of importance to rehabilitation (96.2%) and surgery for implantation (83%). The respondents also practiced giving importance to a team approach involving multiple team members. High costs and financial burden emerged to be the major challenges for cochlear implantation in India. The findings of the survey indicate an overall positive belief and practices towards cochlear implantation by otorhinolaryngologists in India. However, there is a need to spread more awareness among them about the recent advances and schemes that would further improve their service delivery.

To identify vestibular dysfunction in children after cochlear implant surgery and to study the utility of static posturography in evaluating vestibular function in children. A prospective study was carried out on 25 children between 2 and 7years of age with sensorineural hearing loss with no overt vestibular dysfunction. All children underwent static posturography using Synapsis Posturographic System (SPS) software (Version 3.0, REV C) using a static platform with foam. The centre of pressure (COP) shift was recorded as statokinesiogram on the software and the mean vestibular, visual and somesthetic scores were obtained. Cochlear implantation (CI) surgery was done with insertion of Med-El Pulsar standard cochlear implant with 12 twin electrodes. Children were evaluated again after 4weeks of CI surgery (2weeks after switch on) with static posturography on the same SPS software. The scores obtained were compared with pre op value and data analyzed statistically by paired t tests on SPSS 18 software. The mean age was 4.6years with range 2-7years. All the children in the study were able to complete the test with no difficulty and the mean time required for each child was 10.2min. The mean pre op somesthetic score was 95.16 (SD 1.52) and post op score was 94.06 (SD 1.79). The mean pre op visual score was 86.64 (SD 2.24) and post op score was 82.55 (2.89). The mean pre op vestibular score was 84.11 (SD 2.20) and post op score was 73.66 (SD 4.25). Correlation and statistical analysis of the pre and post values of each score revealed statistically significant reduction in vestibular scores post CI. The vestibular system is at high risk of injury leading to vestibular dysfunction in children during CI. Our study found the static posturography as a simple, fast and efficient tool to screen children for vestibular dysfunction post CI. Identifying the dysfunction early can help in initiating early rehabilitation measures.

Inadvertent hyperthermia during anaesthesia is a rare but life-threatening complication. We have encountered several cases of severe hyperthermia in paediatric patients undergoing anaesthesia for cochlear implantation. This study aimed to describe the clinical characteristics of children who developed hyperthermia while undergoing cochlear implantation, and to explore possible mechanisms and predisposing factors. The anaesthetic charts of all patients aged under 18 years who underwent cochlear implantation, or mastoid or ophthalmic surgery, between 1 January 2006 and 31 December 2009, at Soroka Medical Center in Beer Sheva, Israel, were reviewed. Patients undergoing mastoid and ophthalmic surgical procedures were used as controls. A larger percentage of patients who underwent cochlear implant surgery (10 per cent) developed hyperthermia compared to controls (0.7 per cent, p < 0.05). In five of the seven cases, hyperthermia appeared in combination with tachycardia and hypercapnia, adhering to the clinical triad of malignant hyperthermia. Patients undergoing cochlear implantation are susceptible to developing intra-operative hyperthermia. This article describes the hyperthermic events that occur during paediatric cochlear implantation, and attempts to identify potential triggers of hyperthermia.

Clear identification of the round window (RW) through the facial recess is a key surgical step for successful cochlear implantation (CI) surgery, which may be very challenging in some cases. Objective is to predict round window (RW) accessibility during CI surgery using high-resolution computed tomography (HRCT). We retrospectively reviewed preoperative HRCT scans of 142 patients who underwent CI surgery via the standard posterior tympanotomy approach at our ENT Head and Neck Surgery department. Surgical accessibility of the RW was assessed according to 2 methods, similar to the ones introduced by Mandour et al and Elzayat et al. Pre-operative imaging findings were then compared to the actual surgical accessibility of the RW by reviewing surgical notes and video recordings. Difficult surgical access to the RW was correctly predicted in our series by Mandour's method in 81.8% of the cases, with a sensitivity and specificity of 56.3% and 96.4%, respectively, and by Elzayat's method in 72.2% of the cases, with a sensitivity and specificity of 50% and 94.5%, respectively. Combining both methods showed an increase in sensitivity levels (Se=71.9%). When the 2 methods both predicted difficult RW access, there was a strong probability that drilling a cochleostomy would be necessary for safe electrode insertion along the scala tympani of the basal turn of the cochlea (P < .001). These 2 methods are both simple and reliable tools that can help the surgeon anticipate difficult surgical access and prepare for the potential use of alternative techniques.

Objectives To evaluate the impact of the Video Head Impulse Test (vHIT) on side determination in cochlear implantation (CI) surgery. Methods Retrospective analysis of vHIT results from 75 adult sequential CI recipients at a regional auditory implant centre between January 2023 and April 2024. Patients were grouped by side of implantation (right, n = 40; left, n = 35). vHIT results were assessed through clinical assessment and normative comparison. For categorical analysis, patients were classified as having their ‘better’ or ‘worse’ balance ear implanted, or normal or equally abnormal function bilaterally. Clinical assessment was based on clinician interpretation of vHIT graphs, while normative comparison applied established gain thresholds and corrective saccades to define abnormality. Results Neither clinical nor normative analysis demonstrated a significant association between vHIT findings and the side implanted. This is supported by continuous gain value analysis showing no statistical differences between cohorts. Discussion Although implanting the ear with poorer vestibular function may minimise postoperative disequilibrium, vestibular testing is not universally performed nor advocated for. Other factors, including patient preference and anatomical constraints, may have considerable influence on side selection. Conclusion Concerns about implanting the ‘better’ balance ear are valid, however, vHIT does not outweigh other factors when determining CI sidedness.