Questions Parents Should Ask Their ENT before Giving Their Child an Implant

The issue

Surgery plays a central role in the process of cochlear implantation. Fortunately, it is usually uneventful, and there is little for parents to fear. However, no surgical intervention is without risk and uncertainty. Every patient journey is unique, and it is important that the otolaryngologist (ear-nose-and-throat or ENT doctor) addresses any concerns you might have. Surgeons work under considerable pressure, so you must ensure the short time spent in consultation is as informative as possible—in both directions. Be prepared (and bring a list of concerns, if that helps you). So let’s begin:

What we know

We know that providing and supporting cochlear implantation is an exercise in team work. Therefore, the surgeon should be part of a cohesive, multi-professional team. This is known to support good decision-making, both before implantation as well as in the years to follow. As implantation is for life, and medical attention may be needed even years after implantation, selecting a well-established implant team makes good sense.

We also know that paediatric anaesthesia is a major aspect of patient safety. Thus, ask your surgeon if they practice in an accredited paediatric facility that has all the necessary support services readily available—even if it is highly unlikely your child will need them.

Many studies tracking outcomes over time confirm that cochlear implant surgery is safe even for children in the first year life. While many children have no other health problems beyond their deafness, a significant number do, and this can add to the complexity and risk of the procedure. Thus, discuss any related medical issues with your surgeon in advance.

Advanced imaging, like usually MRI scanning, is crucial to the surgical process. While the anatomy of the inner ear and brain is often perfectly normal, important exceptions exist that can directly affect the surgery. So, ask your surgeon to explain the scan results and how the findings might influence the procedure, the choice of device, and the electrode array.

Complications are rare, but sometimes occur. So, ask the surgeon to explain the likelihood and consequences of uncommon things like infection, hematoma, balance disturbance, facial weakness, meningitis (and the need for vaccination), misplacement of electrodes, device failure, and limitations on future MRI scanning after surgery. Surgeons should provide their own data on complications rather than citing the results of others.

What we don’t know

Variation in outcomes is the hallmark of paediatric cochlear implantation. Some of that variation is understood, but we do not understand all the factors that contribute to individual outcomes. Why some children achieve near age-appropriate spoken language levels. while others fail to make such meteoric progress remains largely unknown. Undoubtedly, biological factors play a part, such as the number and health of surviving connections between the inner ear and the brain’s sensory processing machinery. However, such factors cannot be measured in clinical practice. We also do not know how psychological, social, educational, and communication factors interact to produce an optimal outcome. While there is no shortage of opinion in the field on these matters, there is little supporting evidence. In practical terms, goals should always be set conservatively and assessed continually in order to avoid later disappointment.

What is the best implant for my child? No formal evidence exists comparing the effectiveness or reliability of individual implant systems. Often marketing trumps evidence in the field. Many teams offer choices across available systems, leaving it up to parents to choose, but this requires parents to be technology savvy to make an informed decision.

Will cochlear implantation help or hinder my child benefitting from future breakthroughs like gene therapy, stem cell therapy?  How biological solutions will play out in the years ahead remains unclear but it would be unwise to delay implantation for that reason alone.

Implications

Cochlear implants give deaf children greater opportunities for hearing and speech than ever before. Universal neonatal hearing screening has significantly reduced the age of hearing loss diagnosis. However, definitive testing of hearing in immature infants can be challenging and test results can be ambiguous. We know that early implantation generally is better than later, but implantation early in life may also mean that conditions that can influence outcomes from implantation (e.g., autism) may not have emerged at the time of implantation. The key is to be informed and be prepared. Do not hesitate to ask questions.

Posted on Jan. 12, 2018 by
Gerard O’Donoghue
Nottingham University Hospitals NHS Trust
National Institute for Health Research
Nottingham Biomedical Research Center
Gerard.O’Donoghue {at} nottingham.ac.uk

 

Further reading