The management of acute mastoiditis in children with cochlear implants: saving the device

An overview of risk factors, management and prevention of cochlear implant infections

PURPOSE OF REVIEW

With cochlear implantation becoming increasingly performed worldwide, an understanding of the risk factors, preventive measures, and management of cochlear implant (CI) infection remains important given the significant morbidity and cost it conveys.

RECENT FINDINGS

At the turn of the 21st century there was a decrease in rates of CI infection, particularly meningitis, following the discontinuation of positioner use for CI. However, in more recent years rates of CI infection have remained largely static. Recently, studies evaluating preventive measures such as pneumococcal vaccination, S. aureus decolonization and surgical antibiotic prophylaxis have emerged in the literature.

SUMMARY

Prompt recognition of CI infection and appropriate investigation and management are key, however at present treatment is largely informed by cohort and case-control studies and expert opinion. Preventive measures including pneumococcal vaccination, S. aureus decolonization and preoperative antibiotic prophylaxis play a role in reducing rates of CI infection. However, there remains a need for well designed clinical trials to provide higher level evidence to better guide preventive measures for, and management decisions of, CI infections in the future.

The effect of ventilation tube insertion in pediatric cochlear implantation candidates with otitis media with effusion on postoperative complications

OBJECTIVE

Otitis media with effusion (OME) is a common finding in pediatric cochlear implant(CI) candidates and may be managed by inserting ventilation tubes. This study aimed to compare postoperative complication rates in children who underwent CI without and with OME, including patients who were treated without and with ventilation tube insertion.

METHODS

A population-based retrospective cohort study was conducted, including all CI patients, under ten years of age, at our institution, between 2007 and 2020. The study's population was divided into three groups based on their middle ear status at CI: 1) OME previously treated with VT, 2) untreated OME, and 3) normal-aerated ears. Postoperative complications of the groups were reviewed and served as our primary outcome measure.

RESULTS

Of the 257 implanted ears included, 53, 42, and 162 ears belonged to the VT-treated OME, untreated OME, and aerated groups, respectively. Acute mastoiditis (AM) rate was significantly higher in the OME group compared to the aerated groups (9.5 % vs. 2.5 %, p = 0.0134) and in the VT-treated compared to the untreated OME groups (15.1 % vs. 2.3 %, p = 0.0356). Similarly, the rate of developing chronic suppurative otitis media without cholesteatoma (CSOMWC) was significantly higher in the OME compared to the aerated groups (12.6 % vs. 2.5 %, p = 0.0011) and in the VT-treated compared to the untreated OME groups (18.8 % vs. 4.7 %, p = 0.0366). Other complications rated were very low and similar between the groups. No other statistical difference was found between the groups.

CONCLUSION

VT insertion in pediatric CI candidates with OME increased postoperative AM and CSOMWC. We believe that, at least in our population, VT introduction prior to CI, for OME, surgery should be avoided.

Acute mastoiditis in cochlear implanted children: A single-centre experience

BACKGROUND

Acute mastoiditis (AM) is the most common complication of acute otitis media and primarily affects children under the age of two; current data on its prevalence in paediatric patients with cochlear implant (CI) are still scant. Proper management of AM in CI children is crucial in order to avoid the implications (financial and emotional) of an explant. Aim of this paper is to describe the cases of AM occurred among young patients with CI in follow up at our department, also in order to evaluate its prevalence, potential predisposing factors, clinical course and therapeutic strategies.

PATIENTS AND METHODS

Retrospective study. Medical records of all paediatric patients with CI, who had at least one year of follow-up, were searched aiming to identify those who developed AM, from January 1st 2002 to January 31st 2022. The following data were collected and analysed: demographic features, implant type and side, interval between CI surgery and AM, treatment, laboratory tests, clinical course, vaccination history, associated diseases.

RESULTS

AM was developed by six (1.3%) of the 439 children with CI (541 implanted ears). In total, 9 episodes (2.05 %) were recorded, as three patients reported two consecutive infections. Average time interval between CI surgery, to the first or only AM diagnosis, was 13.8 months (range 3-30 months). Furthermore, 3/6 of patients had a history of recurrent acute otitis media; 2/6 an autism spectrum disorder, associated to a combined immune deficiency in one case. All patients were hospitalized and promptly treated by intravenous antibiotic therapy; 4/6 also underwent a mastoidectomy. CI was not explanted in any cases of this series.

CONCLUSIONS

Over a 20-year period, AM rate in CI children was 1.3%, which is consistent with the current literature rates of 1-4.7%. All cases were successfully treated, preserving the integrity of the device. In our experience, the early parenteral antibiotic therapy and, when necessary, surgical treatment were adequate to eradicate the infection.

Infectious complications and optimising infection prevention for children with cochlear implants

AIM

To describe the clinical epidemiology of children receiving cochlear implants, as well as the management and outcomes of cochlear implant infections and adherence to infection prevention measures.

METHODS

A retrospective observational study was conducted in children ≤18 years who received cochlear implants in Western Australia's tertiary paediatric hospital. Information was obtained from medical and laboratory records regarding demographics, indication for implant, implant infection and preoperative Staphylococcus aureus screening/decolonisation. Immunisation history was examined using the Australian Immunisation Register.

RESULTS

Overall, 118 children received cochlear implants, with 158 devices inserted (599 cochlear implant insertion-years). An implant infection rate of 3.8% (6/158) was identified during the study period (four pneumococcal and two community-acquired methicillin resistant S. aureus infections). All required surgical management, with an overall median duration of antibiotic therapy of 37 days (interquartile range (IQR) 29-48) and median length of stay of 8 days (IQR 8-9.5). All devices were retained and there were no relapses or deaths. Half of the children who developed cochlear implant infections (50%, 3/6) were up-to-date with additional pneumococcal vaccinations and no children (0%, 0/118) received S. aureus screening/decolonisation before implant insertion.

CONCLUSIONS

Favourable outcomes were achieved with cochlear implant retention; however, the treatment was burdensome for families. We demonstrate significant scope to improve adherence to existing infection prevention strategies and provide direction for optimising preventative measures in the future. These include ensuring parental education, additional pneumococcal vaccinations and S. aureus decolonisation which are delivered as an infection prevention bundle to the growing population of infants receiving cochlear implants.

Characteristics of CI children with complicated middle ear infections

OBJECTIVE

To describe cases of complicated middle ear infections in children with cochlear implants (CI), i.e., episodes of acute otitis media (AOM) and acute mastoiditis (AM), resulting in hospitalization.

METHODS

A total of 206 children under 16 years (300 implantations) were implanted between 1 January 2008 and 31 December 2014 at the West Danish CI Center, Department of Otorhinolaryngology Head and Neck Surgery, Aarhus, Denmark. By means of two prospective local databases, episodes of AOM or AM and demographics were retrieved including biochemistry, microbiology, length of follow- up, and variable treatment modalities (intravenous (IV) antibiotics, revision mastoidectomy, and insertion of ventilation tubes).

RESULTS

Overall rate of AOM and/or AM was 9.2% (AOM: 9%, AM: 1.9%). Mean age at CI was 46 months. Mean follow-up was 45 months. Mean time from CI operation to AOM or AM was 3 and 4 months, respectively. Children younger than 2 years were at highest risk of AOM and/or AM. All had antibiotics prescribed before admittance, and two- thirds of infected ears had already ventilation tubes inserted. Bacteria could not be detected in more than half of cases. The most frequently isolated strains were pneumococci and nontypable Haemophilus influenzae. The majority of patients were successfully treated with IV cefuroxime (64% of cases) and insertion of ventilation tubes. None of the children developed facial nerve paralysis, intracranial infections, or septicemia.

DISCUSSION

Almost 10% of CI children required at least one hospitalization due to AOM and/or AM compared with 0.1 per thousand of non-CI children. This discrepancy can be explained by a low threshold for active treatment of otitis media in CI children and hence referral to a CI center. The results suggest that benzylpenicillin might be an appropriate initial treatment of AOM and AM. However, cephalosporin was the most preferred antibiotic. Most CI children were already treated with ventilation tubes at admission and almost all children without ventilation tubes, had a tube inserted during admission. Insertion of ventilation tubes is still much debated and more research in this field is needed.

CONCLUSION

AOM and/or AM were seen in Danish children with CI as often as in other western countries. Treatment of complicated middle ear infections was sufficient with IV cephalosporin and ventilation tube insertion. Special attention should be paid to children younger than 4 years and the associated microbiology including serotyping should be monitored.

Acute mastoiditis in children with a cochlear implant

OBJECTIVES

Cochlear implantation is performed at a young age, when children are prone to acute otitis media. Acute mastoiditis is the most common complication of otitis media, but data on its management in the presence of a cochlear implant are sparse. The objective of this study was to assess the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant.

METHODS

The medical files of all children who underwent cochlear implantation at a pediatric tertiary medical center in 2000-2014 were retrospectively reviewed. Those diagnosed with acute mastoiditis after implantation were identified, and data were collected on demographics, history, presentation, method of treatment, complications, association with untreated otitis media with effusion, and long-term middle-ear sequelae.

RESULTS

Of the 370 children (490 ears) who underwent cochlear implantation, 13 (3.5%) were treated for acute mastoiditis (median age at acute mastoiditis, 32 months). Nine had a pre-implantation history of chronic secretory or acute recurrent otitis media, and 5 had been previously treated with ventilation tubes. In all 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. The time from implantation to mastoiditis was 5-61 months. The same treatment protocol as for normal-hearing children was followed, with special attention to the risk of central nervous system complications. Primary treatment consisted of myringotomy with intravenous administration of wide-spectrum antibiotics. Surgical drainage was performed in 8 out of 13 patients, with (n=7) or without (n=1) ventilation-tube insertion, to treat subperiosteal abscess or because of lack of symptomatic improvement. There were no cases of intracranial complications or implant involvement or need for a wider surgical approach. No middle-ear pathology was documented during the average 3.8-year follow-up.

CONCLUSIONS

The relatively high rate of acute mastoiditis and subperiosteal abscess in children with a cochlear implant, predominantly involving the implanted ear, supports the suggestion that recent mastoidectomy may be a risk factor for these complications. Despite the frequent need for drainage, more extensive surgery is usually unnecessary, and recovery is complete and rapid. As infections can occur even years after cochlear implantation, children with otitis media should be closely followed, with possible re-introduction of ventilation tubes.

Using autogenous mastoid cortical bone cap to cover the mastoidectomy defect during cochlear implantation

OBJECTIVES

Assessment of autogenous mastoid cortical bone cap to cover the mastoidectomy defect via transmastoid and posterior tympanotomy approach surgical technique during cochlear implantation.

METHODS

A chart review of the autogenous mastoid cortical bone cap to cover the mastoidectomy defect via transmastoid and posterior tympanotomy approach surgical technique in 540 patients undergoing cochlear implantation was undertaken from January 2010 and December 2013 in Anhui Provincial Hospital.

RESULTS

The mastoidectomy defect was reconstructed using autogenous cortical bone cap in all cochlear implantation patients. No depression was found in the postauricular site. None of the patients had experienced any immediate or delayed postoperative infection complication such as wound infection, post-auricular abscess or intracranial complication.

CONCLUSIONS

The technique of autogenous mastoid cortical bone cap to cover the mastoidectomy defect is a good option during cochlear implantation via transmastoid and posterior tympanotomy approach. It can prevents depression of the postauricular site, and also may be able to prevent infection of the wound and the implanted processor. Autogenous cortical bone cap is easy to handle, ready available, stable, resorption resisting, also cost-saving in cochlear implantation surgery.

Acute Mastoiditis in Children with Cochlear Implants

Objective

Acute mastoiditis is an uncommon but challenging condition when it occurs in children with cochlear implant. The literature is scarce as to the management of this condition with regards to explantation. The objective of the study is to determine the need for explantation in patients with cochlear implants who suffer from acute mastoiditis.

Data Sources

Online medical databases—PubMed, Ovid Medline, Ovid Medline in process, Embase, Cochrane Library, CINAHL, Biosis, Google Scholar, and Scopus.

Review Methods

A systematic review of all publications addressing the treatment of mastoiditis in cochlear implant children prior to November 2013 was conducted. Data were collected from online medical databases—PubMed, Ovid Medline, Ovid Medline in process, Embase, Cochrane Library, CINAHL, Biosis, Google Scholar, and Scopus. The review was performed in 3 phases; an initial screening review of abstracts was performed, followed by a detailed review of full articles based on inclusion and exclusion criteria, and lastly a final review to extract data from selected articles.

Results

Twelve articles were found eligible for this systematic review including a total of 43 patients. Subperiosteal abscess was present in 14.3%. All patients received intravenous antibiotics as an initial treatment, and if needed, surgical intervention was performed. Only 1 patient required explantation (2.3%).

Conclusion

Prompt, aggressive medical and if needed surgical therapy can help in saving the implant and result in a favorable outcome.