PREOPERATIVE DIAGNOSIS: Bilateral sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Bilateral sensorineural hearing loss.
PROCEDURES PERFORMED:
1. Nucleus Freedom cochlear implantation, left.
2. Steroid perfusion.
3. Operating microscope with facial nerve monitoring.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal, local 1% lidocaine with 1:100,000 epinephrine.
DRAINS: None.
SPECIMENS: None.
IV FLUIDS: One liter of crystalloids.
URINE OUTPUT: Not recorded.
ESTIMATED BLOOD LOSS: Less than 75 mL.
ANTIBIOTICS: One gram of IV cefazolin, topical Avelox irrigation.
STEROIDS: Decadron 8 mg IV.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable. The patient will be admitted to the PACU and then admitted for overnight observation.
INDICATIONS FOR OPERATION: This patient was referred to me for bilateral sensorineural hearing loss. The patient had little benefit with her hearing aids due to the level of hearing loss. Options of continued hearing aid use versus surgery were discussed with the patient. The patient wanted to proceed with surgery. We discussed left versus right cochlear implantation.
We discussed sequential implantation. Since the patient uses the hearing aid on the right and considers that to be her hearing ear, she wanted to have the left side implanted; although, the patient was told it is possible that she would actually benefit more from the right side. The patient has a questionable history of prior stroke. She was told that this may reduce her chance of good success with the cochlear implant. Despite this, both she and her husband wanted to proceed with the surgery.
All the potential risks and complications were discussed including no guarantee of success, need for revision surgery, need for cochlear implant removal if there is infection, risk of meningitis, brain abscess, facial nerve paralysis, continued deafness, dizziness, tinnitus, taste changes, wound healing problems, cosmetic concerns, auricular numbness, as well as other significant problems or complications. Despite the potential risks and complications, the patient and her husband desired to proceed with the surgery.
INTRAOPERATIVE FINDINGS:
1. Well-aerated mastoid.
2. Slight difficulty inserting the active electrode of the cochlear implant due to the preexisting curvature of the active electrode noted upon removal from the implant package.
3. See procedure in detail section below for more details.
DESCRIPTION OF OPERATION: The patient was taken from the preoperative holding area to the operating room where she was placed supine on the operating room table. The patient was intubated. Once the endotracheal tube was secured, the table was rotated 180 degrees. SCDs were placed on the patient’s legs. She was adequately padded, belted, and test rolled to make sure she was in a good position on the table. Hair was shaved posterior and superior to the left auricle. The proposed incision site was marked with a marking pen and infiltrated with local. Facial nerve monitoring needle electrodes were assessed for proper placement and functioning.
After she was prepped and draped in standard surgical fashion, a 15 blade scalpel was used to make a hockey stick incision. It was carried from the postauricular sulcus region up into the scalp. Temporalis fascia was harvested. Weitlaner was used to retract the soft tissue. Microscope was brought into view in the surgical field. Palva flap was created with Bovie electrocautery. The Bovie was used until cochlear implant packages opened up, at which point the Bovie tip was removed and only bipolar cautery was used. Antibiotic irrigation was used throughout the procedure.
Complete mastoidectomy was performed with cutting, coarse and fine diamond burs. Tegmen was identified. Sigmoid was identified. Lateral semicircular canal was identified. The incus was identified. Facial nerve was identified in the mastoid and tympanic segments and extended facial recess procedure was performed. This was done because of the narrow facial recess and inability to get to the round window without sacrificing the chorda tympani nerve.
After identifying the incudostapedial joint on the round window, the cochlear implant well was drilled over two fingerbreadths behind the EAC. This well was drilled larger than the size of the implant to help it be on a flatter surface of the bone. Suture holes were created and nylon suture was placed. The implant was placed and tied down to the stitch. The ground electrode was placed. There was difficulty in advancing the electrode due to preexisting curvature noted on the active electrode. However, the cochleostomy was large enough to finally advance the active electrode. There was full insertion. Stylet was then removed. Once stylet was kept in place and advanced, off-stylet technique was not used due to the preexisting curvature over the electrode. Solu-Medrol 100 mg/mL was then placed into the cochleostomy. Temporalis fascia was then used to close the cochleostomy site. Intraoperative photos were taken.
The wounds were irrigated with antibiotic irrigation. Interrupted Vicryl sutures that were antibacterial-coated were placed in subcutaneous tissue and the skin flaps and Prolene sutures were used to close the skin. All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated, and transferred to the recovery room in stable condition. The patient will be admitted for overnight observation.
