Nancy M. Young

Postoperative Pain Relief in Children Undergoing Tympanomastoid Surgery: Is a Regional Block Better than Opioids?

Peripheral nerve blocks of the surgical site can reduce the need for perioperative opioids thereby decreasing their unwanted adverse effects, such as postoperative nausea and vomiting. In this prospective, randomized, double-blinded study, we examined the efficacy of a great auricular nerve (GAN) block compared with IV morphine sulfate in children undergoing tympanomastoid surgery. After the induction of general anesthesia, children were randomized to receive either a GAN block with 2 mL of 0.25% bupivacaine with epinephrine (1:200,000) and a sham IV injection of 2 mL of saline solution or a sham GAN block with 2 mL of saline solution with an IV injection of 0.1 mg/kg morphine sulfate diluted to 2 mL. Patients’ objective pain scores were assessed by a blinded observer and the incidence of vomiting was recorded. The GAN-Block patients as a group required more pain rescue in the postanesthesia care unit; this difference was not statistically different from the IV-morphine group (P = 0.084). Nine GAN-Block patients never received opioid or other analgesics at any time in the first 24 h after surgery. The group that received the GAN block also had a less frequent incidence of vomiting requiring intervention (7 versus 19) during their entire hospitalization or at home (P = 0.027). The GAN-Block group also had more patients who never experienced vomiting (13 of 20 versus 5 of 20, P = 0.026). In this cohort, a peripheral nerve block decreased the overall incidence of postoperative vomiting thereby reducing associated costs.

Pediatric cochlear implantation of children with eighth nerve deficiency

OBJECTIVE To evaluate the auditory outcomes of children implanted in an ear with eighth nerve hypoplasia or aplasia and to determine whether preoperative characteristics are predictive of auditory performance achieved. METHODS STUDY DESIGN retrospective case review. SETTING tertiary care medical center. PATIENTS ten children implanted in an ear with eighth nerve hypoplasia or aplasia, as determined by high resolution magnetic resonance imaging. MAIN OUTCOME MEASURES Neural response test measurements, detection and speech awareness thresholds, Meaningful Auditory Integration Scale scores, as well as speech perception level achieved. RESULTS Post-implantation, three children demonstrated little to no detection of sound, three had improved detection and awareness of environmental sounds, one developed closed-set speech perception and spoken language, and three developed open-set speech perception and spoken language. No imaging findings appeared related to outcomes. Significantly better implant detection thresholds and Meaningful Auditory Integration Scale scores were found in children who had preoperative aided auditory detection (ps ≤ 0.02-0.05). CONCLUSION Some children with eighth nerve hypoplasia or aplasia may derive significant benefit from a cochlear implant. In our study high resolution magnetic resonance imaging was more sensitive than high resolution computer tomography in detecting neural deficiency. However, no imaging findings were predictive of auditory performance level achieved post-implantation.

Postmeningitic ossification in pediatric cochlear implantation

OBJECTIVE The goals of this study were to retrospectively review high-resolution CTs (HRCTs) of pediatric postmeningitic cochlear implant recipients and to correlate results with surgical findings. METHODS HRCTs of 20 children (11 months to 12 years old) who underwent implantation with multichannel devices were reviewed. Results were correlated with the degree of ossification observed at surgery. RESULTS Ninety percent of subjects required drilling of ossified bone within the basal turn at surgery. HRCT of the cochleas suggested ossification within the basal turn in 45% (50% sensitivity). Ossification of the lateral semicircular canal on HRCT was present in 72% (77% sensitivity). Five of 6 cases without radiographic evidence of ossification had positive findings at surgery. CONCLUSION Ossification is a common occurrence in postmeningitic deaf children. Ossification of the lateral semicircular canal on HRCT is a more sensitive measure for predicting ossification than evidence of cochlear involvement. Absence of ossification on HRCT is no guarantee of cochlear patency at the time of implantation.

Infant cochlear implantation and anesthetic risk

In light of the strong trends toward performing cochlear implantation in infants, it is necessary to consider anesthetic issues. Just as anesthetic risk may play an important role in surgical candidacy in the elderly population, anesthesia is also of special consideration in infants. Even healthy infants are known to be at increased risk for anesthetic complications; for this reason, most elective surgical procedures are not routinely done within the first year of life. Therefore, it is necessary to consider anesthetic issues when contemplating the use of cochlear implants in infants less than 12 months of age.

Superselective embolization of glomus jugulare tumors.

The purpose of this report is to introduce the technique of superselective embolization (SSE) and to review our experience in surgically treating glomus jugulare tumors with and without preoperative SSE. Retrospective chart review was performed to determine estimated blood loss and operative time, and illustrative case reports are presented. The technique of preoperative SSE represents an important advance in the surgical management of glomus jugulare tumors. In our experience, surgical ligation of tumor-feeding vessels or nonselective embolization of the external carotid system is unsatisfactory. Inadequate devascularization and excessive risk of complications have caused us and others to abandon these procedures. However, SSE performed by an experienced neuroradiologist can produce effective and safer tumor devascularization. Preoperative SSE results in shrinkage of tumor size and significantly decreases blood loss. The advantages to the surgeon include improved visualization and ease of dissection as well as increased confidence that complete tumor excision has been achieved.

Limitations of Universal Newborn Hearing Screening in Early Identification of Pediatric Cochlear Implant Candidates

OBJECTIVES To determine whether implementation of universal newborn hearing screening (UNHS) in the state of Illinois has affected the ages at diagnosis of hearing loss and implantation in children receiving cochlear implants and to determine how often children undergoing implantation had UNHS results with no indication of hearing loss (pass). DESIGN Retrospective case review of 417 randomly selected pediatric implant recipients born before and after UNHS was mandated by law in Illinois. Data analyzed included hearing screening status, ages at initial diagnosis of sensorineural hearing loss (SNHL) and severe to profound SNHL, and age at implantation. SETTING Tertiary care medical center. PATIENTS Children receiving implants from 1991 through 2008. MAIN OUTCOME MEASURES Ages at diagnosis of SNHL and implantation. RESULTS Children born after legally mandated UNHS had significantly younger ages at diagnosis and implantation. However, a younger age at diagnosis of SNHL was not achieved in children who had passed UNHS or who were not screened. Approximately 30% of pediatric implant recipients passed UNHS, regardless of the cause of hearing loss or the presence or absence of known risk factors. CONCLUSIONS Almost one-third of our pediatric implant recipients pass UNHS and are older at the time of initial diagnosis and implantation than their peers who fail UNHS. Delayed onset of SNHL limits our ability to achieve early diagnosis and implantation of a significant number of deaf children. This problem will not be solved by the current design of universal hearing screening programs.

Comparison of pediatric Clarion recipients with and without the electrode positioner

Objective To compare surgical experience and measures of electrode and patient performance of children who were implanted with the Clarion (Advanced Bionics, Sylmar, CA, U.S.A.) device with and without the new electrode positioner (EP). Study Design Prospectively and retrospectively collected data were compared between two independent groups. Setting Tertiary care childrens hospital. Patients Twenty-four children (mean age, 3.0 years) implanted during the original Food and Drug Administration (FDA) clinical trial required for commercial approval of the Clarion and 15 children (mean age, 3.4 years) implanted with the EP as part of an ongoing FDA trial. Intervention Cochlear implant with and without EP. Main Outcome Measures Electrical psychophysical threshold, most comfortable loudness level (MCL), electrode impedance, and speech perception measures were compared at 3 and 6 months after initial stimulation. Results and Conclusion All children had complete insertion of electrodes. No difficulty inserting the EP occurred nor did subsequent related complications. Subjects with the EP had significantly lower threshold and MCL levels. Electrode impedance declined on stimulated electrodes in both groups. Meaningful Auditory Integration Scale scores significantly improved in both groups; the EP group appeared to receive as much benefit as the non-EP group.

Does a preemptive block of the great auricular nerve improve postoperative analgesia in children undergoing tympanomastoid surgery

We performed a double-blinded randomized controlled trial to evaluate the efficacy of preemptive analgesia in children undergoing tympanomastoid surgery. Children were divided into two groups: group block-block (BB) received a preemptive great auricular nerve block (GAN-block) with 0.25% bupivacaine with 1:200,000 epinephrine before incision followed by a second GAN-block with 0.25% bupivacaine with 1:200,000 epinephrine 1 h before the end of the procedure. Group sham block-block (SB-B) received a preemptive GAN-block with normal saline before surgical incision followed by a GAN-block with 0.25% bupivacaine with 1:200000 epinephrine 1 h before the completion of the procedure. All patients were evaluated for pain with the objective pain score (OPS) by a blinded observer. There was no difference in pain rescue requirements in the postanesthesia care unit (BB versus SB-B, 1 of 20 versus 3 of 20, P = 0.60) or in the short-stay unit (BB versus SB-B, 5 of 20 versus 11 of 20, P = 0.107) or for the entire hospital stay (P = 0.20). There was no significant difference between groups in the time to first rescue pain medication (BB versus SB-B, 226 ± 71 min versus 201 ± 94 min). There was no significant difference between groups regarding vomiting in the postoperative period (P = 0.52). We conclude that a preoperative GAN-block does not offer significant advantages for postoperative pain relief in children undergoing tympanomastoid surgery.

Speech perception of young children using nucleus 22-channel or CLARION cochlear implants.

This study compares the auditory perceptual skill development of 23 congenitally deaf children who received the Nucleus 22-channel cochlear implant with the SPEAK speech coding strategy, and 20 children who received the CLARION® Multi-Strategy™ Cochlear Implant with the Continuous Interleaved Sampler (CIS) speech coding strategy. All were under 5 years old at implantation. Preimplantation, there were no significant differences between the groups in age, length of hearing aid use, or communication mode. Auditory skills were assessed at 6 months and 12 months after implantation. Postimplantation, the mean scores on all speech perception tests were higher for the Clarion group. These differences were statistically significant for the pattern perception and monosyllable subtests of the Early Speech Perception battery at 6 months, and for the Glendonald Auditory Screening Procedure at 12 months. Multiple regression analysis revealed that device type accounted for the greatest variance in performance after 12 months of implant use. We conclude that children using the CIS strategy implemented in the Clarion implant may develop better auditory perceptual skills during the first year postimplantation than children using the SPEAK strategy with the Nucleus device.

Usher syndrome: characteristics and outcomes of pediatric cochlear implant recipients.

Objective To evaluate the characteristics and outcomes of pediatric cochlear implant recipients diagnosed with Usher syndrome (US). Study Design Retrospective study of consecutive pediatric cochlear implant recipients (1991–2010). Setting Tertiary care children’s hospital. Patients Children who received a cochlear implant who were diagnosed with US either before or after implantation. Main Outcome Measures Electroretinography and ophthalmologic findings, cochlear anatomy based on preoperative imaging, age of independent ambulation, age at implantation, speech perception level, and communication method. Results Approximately 26 (3.7%) of 712 cochlear implant recipients were diagnosed with US based on the results of electroretinography and/or genetic testing. Preoperative imaging revealed no evidence of cochlear malformations. Average age of independent ambulation was 21.9 months (range, 12–30). Average age at implantation was 3.3 years (range, 6 mo to 11.6 yr). Mean follow-up after implantation was 7.8 years (range, 10 mo to 15.6 yr). Open-set speech perception was present in 92% of children, with use of a primarily oral communication mode in 69.2%. Conclusion In this large series of patients with the diagnosis of US who have undergone cochlear implantation, CT and MRI imaging were normal. Significant delay in independent ambulation was present in this population secondary to abnormal vestibular function associated with US Type I. A majority of children developed significant open-set speech perception and oral communication skills. Implantation of US children provides them with the opportunity to develop useful hearing and oral communication.