Surgical Atlas of pediatric otolaryngology - part 4 doc

246 Surgical Atlas of Pediatric Otolaryngology • An intraoperative portable X-ray is strongly advised to verify elec- trode placement while the patient is still asleep. The patient’s head is straightened on the table, preferably prior to application of the dress- ing. A single anteroposterior transorbital view (slightly over-penetrat- ed) is taken (Figure 9–20). An incorrectly placed or compressed elec- trode should be discovered in the operating room rather than weeks later when the child is found to be nonstimulable. • A gentle mastoid dressing is applied. Figure 9–20 An intraoperative transorbital X-ray is taken to verify electrode position. A, Straight electrode. B, Peri- modiolar electrode. B A Cochlear Implants 247 Postoperative Care • The dressing is removed the morning following surgery. Staples are gen- erally removed in 10 days; no specific aftercare is necessary. • Ventilation tubes should not be placed in an ear that has received a cochlear implant. • Certain sports and activities are best avoided after cochlear implant surgery, including wrestling, rugby, and heading the ball in soccer. Chil- dren engaging in contact sports, cycling, horseback riding, etc, should always wear protective headgear. • MRI must be avoided unless the magnet can be removed (as with the Nucleus CI 24 series); there is no contraindication to CT scanning. • Monopolar cautery should never be used in the vicinity of the cochlear implant or in cases where the implant lies between the active and the ground electrodes. Other forms of radiant energy (eg, diathermy) should also be avoided, as well as plastic playground slides while the external hard- ware is being worn. Complications • No deaths or life-threatening surgical complications have been reported after cochlear implantation, and the complication rate has decreased over the years (Table 9–1). Complications for children are less than for adults (Table 9–2). Table 9–1 Cochlear implant complications over time (for both adults and children) Type of 1991 1993 1995 1998 2000 complication (N=459) (N=2,751) (N=4,969) (N=9,221) (N=12,300) (%) (%) (%) (%) (%) Flap 5.4 3.0 2.7 2.1 0.9 Electrode 1.7 1.5 1.2 1.0 0.9 Facial nerve 1.7 0.7 0.6 0.4 0.1 Table 9–2 Cochlear implant complications in adults vs. children Type of complication Adults (%) Children (%) Flap 2.70 1.40 Electrode 1.20 0.76 Facial nerve 0.43 0.39 Extrusion, receiver-stimulator 1.47 0.37 Extrusion, electrode 0.17 0.22 Data for tables collected by authors from Cochlear Corporations. Compilations, summaries and charts adapted from Cohen NL, Hoffman RA. Complications of cochlear implant surgery. In Eise- le DW, editor. Complications in Head and Neck Surgery. St. Louis: Mosby-Year; 1993. p. 722–9 and Hoffman RA, Cohen NL. Complications of cochlear implant surgery. Ann Otol Rhinol Laryn- gol 1995;166 Suppl 420–2. 248 Surgical Atlas of Pediatric Otolaryngology • Major complications include facial palsy and others requiring re-hospi- talization for surgery or intravenous antibiotics. ♦ The most common major complications include flap necrosis or infection, migration of the device and/or electrode, and electrode misplacement or damage, many of which might have been avoided by more appropriate planning and surgical technique. ♦ A displaced cochlear implant electrode detected by an intraoperative X-ray would be replaced without delay or a second operation. ♦ Most cases of facial palsy occur shortly after surgery, but others may be delayed until well after discharge. Most are probably caused by thermal injury from the bur-shaft when drilling the facial recess or cochleostomy, rather than direct trauma to the nerve. Most resolve completely. • Minor complications are those handled in an outpatient setting; no sig- nificant increase in morbidity occurs. • Finally, there has not been an increased incidence of otitis media in chil- dren who have received cochlear implants, complications caused by the presence of the implant, or the loss of an implant secondary to otitis media. CONCLUSIONS Cochlear implant surgery in children can be accomplished satisfactorily and safely in the overwhelming majority of properly selected candidates. The surgery requires some modifications from the adult technique, especially in the child under age 2 years, but the complication rate is not greater. After more than a decade of experience, there does not appear to be a deleterious effect on the middle or inner ear from implanting a multichannel cochlear implant in children. The benefit of these devices, on the other hand, has been even greater than anticipated, even in the very young congenitally deaf child. Unexpectedly, many older congenitally deaf children have also received significant demonstrable benefit from cochlear implantation. BIBLIOGRAPHY Balkany T, Gantz BJ, Stevenson RL, et al. A sysematic approach to electrode insertion in the ossi- fied cochlea. Otolaryngol Head Neck Surg. 1996 Jan;114(1):4–11. Bielamowicz SA, Coker MJ, Jenkins HA, Igarashi M. Surgical dimensions of the facial recess in adults and children. Arch Otolaryngol Head Neck Surg 1988;114:534–7. Cochlear Corporation. Surgical procedure manual. Englewood (CO): Cochlear Corporation; 1987. Cochlear Limited. Surgeon’s guide for the CI24R (CS) cochlear implant. Sydney, Australia: Cochlear Limited; 2000. Clark GM, Cohen NL, Shepherd RK. Surgical and safety considerations of multichannel cochlear implants in children. Ear Hear 1991:12 Suppl 4:15S–24S. Cohen NL, Hoffman RA. Complications of cochlear implant surgery. In: Eisele DW, editor. Com- plications in head and neck surgery. St Louis: Mosby-Year Book; 1993. p. 722–9. Cohen NL. Surgical techniques to avoid complications of cochlear implants in children. Adv Oto- Rhino-Laryngol 1997;52:161–3. Cochlear Implants 249 Cohen NL. Surgical techniques for cochlear implants. In: Waltzman SB, Cohen NL, editors. Cochlear implants. New York: Thieme; 2000. p. 151–6. Fishman AJ, Holliday RA. Principles of cochlear implant imaging. In: Waltzman SB, Cohen NL, editors. Cochlear implants. New York: Thieme; 2000. p. 79–107. Hoffman RA, Downey LL, Waltzman SB, Cohen NL. Cochlear implantation in children with cochlear malformations. Am J Otol 1997;18:184–7. Hoffman RA, Cohen NL. Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol 1995;166 Suppl:420–2. Kveton J, Balkany TJ. Status of cochlear implantation in children. American Academy of Otolaryn- gology – Head and Neck Surgery Subcommittee on Cochlear Implants. J Pediatr 1991;118:1–7. Lenarz T, Battmer RD, Bertram B. Cochlear implantation in children under 2 years of age. In: Waltzman SB, Cohen NL, editors. Cochlear Implants. New York: Thieme; 2000. p. 163–5. Roland JT Jr, Fishman AJ, Alexiades G, Cohen NL. Electrode to modiolus proximity: a fluoroscop- ic and histologic analysis. Am J Otol 2000;21:218–25. Roland JT Jr, Fishman AJ, Waltzman SB, et al. Stability of the cochlear implant in children, Laryn- goscope 1998;108:1119–23. Shpizner BA, Holliday RA, Cohen NL, et al. Postoperative imaging of the multichannel cochlear implant. Am J Neuroradiol 1995;16:1517–24. Waltzman SB, Cohen NL. Cochlear implantation in children younger than 2 years old. Am J Otol- ogy 1998;19:158–62. Webb RL, Lehnhardt E, Clark GM, et al. Surgical complications with the cochlear multiple-chan- nel intracochlear implant: experience at Hannover and Melbourne. Ann Otol Rhinol Laryn- gol 1991;100:131–6. [...]... calipers is transferred to the paper template 278 Surgical Atlas of Pediatric Otolaryngology • The free graft is placed between the mucous membrane flaps with the notch under the nasal bones Two interrupted sutures of the 4- 0 Mersilene are placed through the ULCs and the edge of the free graft 1 and 3 mm from the nasal bones (Figure 11– 24) The first knot of each suture is a double throw, as this will... 2 minutes (Figure 11 40 ) Figure 11–38 Correct position of dorsal onlay graft 292 Surgical Atlas of Pediatric Otolaryngology • Marginal incisions are made at the caudal margin of the lower lateral cartilages as in the endonasal delivery technique 1 A fine-tipped delicate scissors is inserted in front of the medial crura, from one marginal incision site to the other (Figure 11 41 ) 2 The scissors is... sutures Medial and lateral osteotomies have been completed in 20% of 169 patients (mean age 12 years, youngest age 6 years) that have had the free graft procedure during the past 14 years Figure 11– 24 The free graft being sewn to the upper end of the upper lateral cartilages 280 Surgical Atlas of Pediatric Otolaryngology • Other rhinoplasty-type maneuvers (see below) tip grafts, dorsal grafts, ULC augmentation,... made from anterior to posterior to avoid damaging the alar rim (Figure 11–5) Figure 11–5 Completing the right hemi-transfixion incision 266 Surgical Atlas of Pediatric Otolaryngology • On the concave side of the nasal septum, the mucoperichondrium is dissected back 4- 5 mm from the edge of the QC using Converse scissors (Figure 11–6) A Beaver blade is used to gently incise the perichondrium layer; the... (Figure 11 46 ) is used if the supratip area is still too full following conservative cephalic trim This suture of 5-0 Prolene is placed in a mattress fashion behind the domes, but should not be overly tightened to prevent postoperative airway obstruction caused by internal nasal valve compromise Figure 11 44 A cartilaginous strut is sutured between the medial crura 296 Surgical Atlas of Pediatric Otolaryngology. .. right dome area 4 Lastly, through the right rim incision, the skin is undermined inferiorly beyond the transcolumellar incision Figure 11–11 The location and form of the transcolumellar incision 272 Surgical Atlas of Pediatric Otolaryngology • The transcolumellar incision is completed using a No 11 blade held at right angles to the skin (Figure 11– 14) using a sawing motion Only 2 mm of the blade tip... the incision is “rubbed” with an applicator stick so the proper plane is entered with the Freer elevator Figure 11– 14 The No 11 blade is utilized to complete the transcolumellar incision 2 74 Surgical Atlas of Pediatric Otolaryngology • Dissection will be limited because of the attachment of the ULCs to the QC This attachment is divided under direct vision in a progressive fashion with a Beaver blade... until remodeling • Bone off the midline is now removed from the vomer and the nasal crest of the maxilla, while maintaining the perpendicular plate of the ethmoid intact The upper surface of the anterior spine is trimmed to take off any irregular spicules of bone, but caution is exercised to not remove any significant amount of bone in this area • The inferior fixation suture ( 4- 0 Mersilene) to be used... are placed in both sides of the nasal cavity Procedure • The membranous septum and the submucoperichondrial layer of the anterior aspect of the quadrilateral cartilage (QC) are infiltrated with 5-1 0 mL of 1% lidocaine with 1:200,000 epinephrine solution using a 25-gauge needle • Using a No 15 scalpel blade, a right hemi-transfixion incision is used to expose the caudal end of the QC The incision is... after 2 weeks, running and jumping at 4 weeks, and has no restrictions after 6 weeks 2 64 Surgical Atlas of Pediatric Otolaryngology SEPTOPLASTY Septoplasty eliminates nasal septal pathology interfering with normal nasal function Most children with nasal septal pathology have nasal obstruction, which is a nonspecific and common complaint The differential diagnosis of pediatric nasal obstruction also includes . the right hemi-transfixion incision. 266 Surgical Atlas of Pediatric Otolaryngology • On the concave side of the nasal septum, the mucoperichondrium is dis- sected back 4- 5 mm from the edge of the QC. Ann Otol Rhinol Laryn- gol 1995;166 Suppl 42 0–2. 248 Surgical Atlas of Pediatric Otolaryngology • Major complications include facial palsy and others requiring re-hospi- talization for surgery. 246 Surgical Atlas of Pediatric Otolaryngology • An intraoperative portable X-ray is strongly advised to verify elec- trode placement while the patient is