Complication profile in a cochlear implantation- surgical audit in a large study population of low socio-economic status in a developing country.

OBJECTIVES: To audit surgical complications and their management in cochlear implant (CI) recipients in a tertiary care referral otorhinolaryngology center in South India. MATERIALS AND METHODS: Hospital data on 1,250 CI surgeries performed from June 2013 to December 2020 was reviewed. This is an analytical study with data collected from medical records. The demographic details, complications, management protocols and relevant literature were reviewed. Patients were divided into the following five age groups: 0-3 years, 3-6 years, 6-13 years, 13-18 years and above 18 years. Complications were divided into major and minor and complication occurrence was divided into peri-operative, early post-operative, and late post-operative, and the results were analyzed. RESULTS: The overall major complication rate was 9.04% (including 6.0% due to device failure). If the device failure rate was excluded, the major complication rate was 3.04%. The minor complication rate was 6%. DISCUSSION: CI is the gold standard in the management of patients with severe to profound hearing loss with minimal benefit from conventional hearing aids. Experienced tertiary care CI referral and teaching centers manage complicated implantation cases. Such centers typically audit their surgical complications, providing important reference data for young implant surgeons and newer centers. CONCLUSION: Although not bereft of complications, the list of complications and its prevalence is sufficiently low to warrant the advocacy of CI worldwide, including developing countries with low socio-economic status.

Satellite habilitation centres following cochlear implantation - Are they the way ahead in improving outcomes in developing countries?

INTRODUCTION: Cochlear implantation is a safe surgery for restoration of hearing in profoundly deaf children. Following cochlear implantation, children undergo rehabilitation (or 'habilitation' for those without previous hearing). The device is programmed after the surgery, so that the user can hear sounds through it and through rehabilitation training, the heard sounds are made to understand. OBJECTIVE: Our study was aimed at analysing the role of satellite habilitation centres following cochlear implantation by analysing the outcomes following habilitation and comparing it with the outcomes of the main centre and correlating it with the percentage of attendance of classes. Our study also aims to compare the attendance of implant patients from outside the geographical area of the main centre before and after starting the satellite centre. MATERIALS AND METHODS: 1004 profoundly deaf children (6 years and below) who had undergone cochlear implantation and completed 12months of habilitation in our institution from July 2013 to December 2019 were retrospectively analysed. The outcomes of all the centres were assessed by comparing the baseline CAP with CAP scores at 12 months and baseline SIR with SIR scores at 12 months. The outcomes of the main centre and satellite centres were also compared. The outcomes were correlated with percentage of attendance of classes. OBSERVATION: The overall attendance in all the centres was between 75 and 80%. Both main and satellite centres showed statistically significant good outcomes and this correlates with percentage of attendance. CONCLUSION: Satellite centres for habilitation across the state has greatly helped to improve the attendance of these patients and outcomes. Reduced drop-out rates and improved speech language outcomes can be achieved by starting satellite centres for habilitation post cochlear implantation in developing countries like India.

Quality of life assessment in paediatric cochlear implant recipients in South India: Parental assessment and correlation with rehabilitation scores using a bilingual quality of life assessment questionnaire.

Objectives: To assess the quality of life (QoL) of prelingually deaf paediatric population after Cochlear implantation (CI), using a bilingual questionnaire and to correlate with rehabilitation scores; to validate the questionnaire and recommend its use in future studies.Methods: This was a questionnaire based cross-sectional study. Parents of 151 paediatric prelingual CI recipients filled the questionnaire using a 5-point rating scale, with a score of 1-5. These scores were correlated with the CAP and SIR scores.Results and discussion: There was a positive correlation of QoL score with rehabilitation outcomes (r = 0.4638 and P ≤ 0.00001 for CAP; r = 0.3563 and P ≤ 0.00001 for SIR scores). The maximum scores (≥4.0) were given by parents for integration into educational system (4.86), response to environmental sounds (4.12) and overall parental satisfaction about child's performance (4.09). Minimum scores were given for ability to speak in sentences (2.9) and response to verbal sounds at a distance (3.23).Conclusion: The QoL of these children as assessed by the institutional questionnaire have correlated with the rehabilitation outcomes. These QoL results have a positive impact in counselling for early CI as well as for rehabilitation.

A Study of Outcome of Pediatric Cochlear Implantation in Patients with Cochleovestibular Nerve Deficiency.

OBJECTIVES: A cochleovestibular nerve deficiency (CVND) could compromise stimulation of nerve by electrical pulses delivered from a cochlear implant, thereby hindering activity along auditory pathway. The evaluation of children with congenital hearing loss with a high-resolution magnetic resonance imaging is presently the investigative modality of choice to diagnose CVND. The aim of this study was to determine the outcomes in pediatric cochlear implant recipients with a diagnosis of CVND. The objectives included (1) to study the prevalence of CVND among children with prelingual congenital severe to profound hearing loss; (2) to assess post cochlear implantation (CI) outcomes in children with CVND using categories of auditory performance (CAP), speech intelligibility rating (SIR), and cortical auditory evoked potentials (CAEPs); and (3) to propose a management protocol for these children. MATERIALS AND METHODS: All CI procedures performed during the study period in children 5 years or younger were included in study. All patients who were older than 5 years or had syndromic associations, multiple disabilities, second side or revision CI were excluded from the study. Children with unilateral cochleovestibular nerve aplasia and all other cases of CVND (type IIa and IIb) were advised to undergo CI on side with more radiologically robust nerve and/or cochlea anatomy. Children with bilateral CVND were included in group A, and age-matched cochlear implant candidates with normal cochleovestibular nerve anatomy were included in group B for statistical comparison of outcomes. RESULTS: In group A, post CI CAP and SIR, CAEP amplitude and latency at 12 months showed statistically significant difference (p<0.05) compared with preoperative values. However, mean score of CAEP latency and amplitude and SIR score was worse for group A compared with group B at 12 months, which was statistically significant (p<0.05). CONCLUSION: This study supports the fact that CI is a viable option to be offered in children with CVND (type IIa and IIb) for the development of auditory perception and speech.

Anatomic and Pathophysiologic Considerations in Surgical Treatment of Obstructive Sleep Apnea.

Evaluation of the upper airway is key for a successful surgical management. Proper evaluation can be done only with a good understanding of the anatomy and pathophysiology of the upper airway. The authors discuss surgical anatomy from a soft tissue and bony perspective in detail along with its clinical implications. The complex interaction among pharyngeal dilator tone, arousal threshold, respiratory control instability, and changes in lung volume during sleep play an important role in obstructive sleep apnea. Because all the anatomic and physiologic characteristics discussed have genetic predisposition, gene therapy may play a pivotal role in the future.

Syndromic deafness-prevalence, distribution and hearing management protocol in Indian scenario.

BACKGROUND: The estimated prevalence of Sensory Neural Hearing Loss (SNHL) in patients less than 18 years of age is 6 per 1000. Roughly 50% of cases of congenital SNHL can be linked to a genetic cause, with approximately 30% being syndromic and the remaining 70% being non-syndromic. The term "syndromic" implies the presence of other distinctive clinical features in addition to hearing loss. The aim of our study was to find the distribution of various Syndromic associations in patients with profound deafness, presented at Madras ENT Research foundation, Chennai and to formulate a management protocol for these patients and to discuss in detail about the clinical features of commonly encountered syndromic deafness. MATERIALS AND METHODS: Our retrospective study was aimed at describing the various Syndromic associations seen in patients with congenital profound deafness. Information was collected from the medical records. At our centre all patients undergo a comprehensive evaluation. The distribution, etiological factors and management protocol for various syndromes are here presented. RESULTS: Out of 700 patients with congenital profound deafness all patients with Syndromic associations (n = 35) were studied. 5% of profoundly deaf candidates were found to be syndromic. Most common syndrome in our series was found to be congenital rubella syndrome followed by Jervell and Lange-Nielsen syndrome. CONCLUSION: Congenital deafness is an associated feature of many syndromes. Detailed history taking with comprehensive evaluation is mandatory to rule out the associated syndromes. Diagnosis must be confirm by a genetic study. Multidisciplinary approach is essential for appropriate diagnosis and management.

Comparison of treatment modalities in syndromic children with obstructive sleep apnea--a randomized cohort study.

INTRODUCTION: Obstructive Sleep Apnea (OSA) is a common medical problem in adults that is becoming increasingly recognized in children. It occurs in the pediatric age group, from newborns to teens. More recently, many specialists have estimated OSA prevalence to be between 5 and 6%. However, in syndromic children, the prevalence of OSA can be from 50 to 100%, having a significant effect on their Quality-of-Life. As they are a challenging population for management, it is essential to evaluate them thoroughly before planning appropriate intervention. OBJECTIVE: To compare the efficacy of Adenotonsillectomy (T&A) and Continuous Positive Airway Pressure (CPAP) in syndromic children [Down syndrome (DS) and Mucopolysaccharidoses (MPS)] with Obstructive Sleep Apnea (OSA). MATERIALS AND METHODS: In a prospective, randomized, cohort comparative study, 124 syndromic children (DS and MPS) aged between 6 and 12 years were recruited from a private MPS support group and the Down Syndrome Society, Chennai. A standard assessment was performed on all children who entered the study including a full overnight Polysomnogram (PSG), Epworth Sleepiness Scale-Children (ESS-C) and Quality-of-Life (QOL) tool OSA-18. The children with positive PSG who consented for the study (n = 80) were randomly distributed to two groups, T&A group & CPAP group. The children were followed up with repeat PSG, clinical evaluation, ESS-C and Quality-of-Life (QOL) tool OSA-18 for a period of 1 year. OBSERVATION AND RESULTS: Follow-up was available for 73 syndromic children. Both the groups, T&A group and CPAP group, showed statistically significant (p < 0.05) improvement in Apnea-Hypoapnea Index (AHI), ESS-C, QOL from the intervention. In our study, T&A showed equal outcome compared to CPAP. The contrasting feature between the two groups was that CPAP use gave immediate sustained improvement while T&A gave gradual progressive improvement of symptoms over a period of 1 year. CONCLUSION: On average, T&A gives equal outcomes as CPAP and it can be suggested as a first-line treatment in this group of syndromic children.

Cochlear implantation and cardiac associations.

INTRODUCTION: Cochlear implantation is a safe surgery for restoration of hearing in profoundly deaf candidates. Profound deafness may at times, manifest as a part of a syndrome associated with cardiac anomalies. Cardiac co-morbidities may influence cochlear implantation in a spectrum of ways from minor intra operative issues to major life threatening complications. Issues related to pre operative, intra operative and post operative care needs to be addressed by an efficient in house cardiologist. OBJECTIVES: Our retrospective study was aimed at analyzing the various cardiac co-morbidities encountered in 30 out of 500 cochlear implantees over a period of 14 years (July 1999-June 2012). This study was focused on developing a profile of cardiac complications influencing cochlear implantation and suggests a protocol for management of various cardiac issues related to cochlear implantation. Our article also reflects the cardiologist's perspective of peri-operative care to be given during cochlear implantation. Relevant literature has been reviewed. METHODS: Case series of 30 profoundly deaf children (below 12 years) who had associated cardiac problems and underwent cochlear implantation in our institution were included in our study. Overall cardiac disease was identified in 30 out of 500 implantees (16.6%) in our experience. The cardiac disease can be categorized into 3 groups: candidates with isolated Patent Ductus Arteriosus (PDA) as Group A (8/30), candidates with syndrome and other anomalies with PDA association as Group B (18/30), and candidates with syndromes without PDA association as Group C (4/30). RESULTS: The overall incidence of cardiac problems in profoundly deaf candidates is identified. Descriptive profile of the same has been created and appropriate management for the same described. CONCLUSIONS: A protocol for management of cardiac co-morbidities influencing cochlear implantation has been designed and detailed insight for the optimal management of these issues has been discussed with cardiologist's perspective.

Randomised comparative study of adenotonsillectomy by conventional and coblation method for children with obstructive sleep apnoea.

INTRODUCTION: Adenotonsillectomy is one of the most common surgical procedures throughout the world for children in otolaryngology. One of the current indications for adenotonsillectomy is adenotonsillar hypertrophy causing Obstructive Sleep Apnoea (OSA). The choice of surgical tools and technique affects the outcome and morbidity due to adenotonsillectomy. AIM OF THE STUDY: To assess the efficacy and safety of coblation adenotonsillectomy as compared to dissection method. To evaluate the morbidity and to study complications associated with each procedure. MATERIALS AND METHODS: This prospective and comparative study of dissection and coblation method of adenotonsillectomy was conducted in our institute, Madras ENT Research Foundation, Chennai over a period of 6 months. 50 cases of children with OSA age group between 5 and 12 years were randomly selected for each group and studied. Duration of surgical procedure, blood loss, post operative pain, post operative reactionary and secondary bleeding was noted and compared. OBSERVATION AND RESULTS: Operative time was more in dissection method compared to coblation technique. Blunt dissection tonsillectomy was associated with greater blood loss than coblation tonsillectomy. Post operative pain was more in dissection method and it was less in coblation technique. Post operative bleeding in both the techniques were found to be minimal. CONCLUSION: We conclude that the use of coblation for adenotonsillectomy may have several advantages over standard methods for the treatment of children with Obstructive Sleep Apnoea. It is highly efficacious, practical and safe with less morbidity and less complications.