Otolaryngology clinical notes

COCHLEAR IMPLANTATION
“Right Patient. Right Time. Best Outcome.”
> “The goal is not just to hear, but to understand, learn and live without limits.”

KEY PRINCIPLE
Bypass damaged hair cells and directly stimulate spiral ganglion cells.

1. AUDIOLOGICAL CRITERIA
Adults
-Bilateral severe-to-profound SNHL (sensorineural hearing loss)
-PTA > 70–80 dB HL
-Poor aided sentence recognition ≤ 50–60% in best-aided condition
-Minimal functional benefit from hearing aids

Children
-Bilateral severe-to-profound SNHL
-Limited auditory & speech-language development despite amplification
-Delayed speech / language milestones
-Hearing aid trial: 3–6 months (unless meningitis / cochlear ossification)

ACI Alliance 60/60 Referral Guideline
Refer for CI evaluation if:
-PTA ≥ 60 dB HL
-Word recognition ≤ 60%

2. AGE
Children
-FDA approved: > 9–12 months*
(*depends on device)
-Earlier is better!
-Best outcomes with implantation early -ideally before 12–18 months of age

Adults
-No upper age limit
-Consider medical fitness, motivation & realistic expectations

3. HEARING AID BENEFIT
-Properly fitted digital hearing aids with adequate trial
-Assess functional benefit through:
-Speech perception in quiet & noise
-Aided audiogram
-Real life performance

Children: Use
MAIS / IT-MAIS
CAP score
SIR score
Poor benefit = key criterion for CI

4. MEDICAL & RADIOLOGICAL CRITERIA
-Intact cochlear nerve
-Patent cochlea suitable for electrode insertion
-No active middle ear infection
-Fitness for surgery & general anesthesia

Imaging Workup
HRCT Temporal Bone
MRI IAC / Brain
To Assess:
Cochlear patency
Cochlear malformations
Cochlear nerve deficiency
Ossification
Mastoid anatomy
Retrocochlear pathology

5. PSYCHOLOGICAL / SOCIAL CRITERIA
Realistic expectations
Strong family / caregiver support
Motivation for rehabilitation
Commitment to long-term AVT
Ability for regular follow-up & mapping
Multidisciplinary team assessment
-ENT
-Audiology
-Speech Therapy
-Psychology

> “Good outcomes are a team effort, not just a surgical one!”

6. CONTRAINDICATIONS
Absolute
Absent cochlear nerve
Complete cochlear aplasia
Medically unfit for surgery / anesthesia
Relative
Severe cochlear ossification
Active CSOM / cholesteatoma
Severe developmental delay
Poor rehabilitation compliance
Unrealistic expectations

7. SPECIAL SITUATIONS
-Single-Sided Deafness (SSD)
-Profound unilateral SNHL with severe tinnitus or poor sound localization
-CI improves quality of life significantly
-Asymmetric Hearing Loss
-CI in poorer ear + HA in better ear (bimodal hearing)
-Better speech in noise & localization
-Auditory Neuropathy Spectrum Disorder (ANSD)
-Selected patients benefit significantly if cochlear nerve is present
-Residual Hearing / Hybrid Implants
-EAS / Hybrid implants preserve low-frequency hearing + electrical stimulation for high frequencies

8. PEDIATRIC RED FLAGS — REFER EARLY!
No startle response by 3–4 months
No babbling by 9 months
No meaningful words by 18 months
Failed newborn hearing screening
Post-meningitic deafness
Progressive / fluctuating hearing loss
> “Early referral. Early implant. Better future.”

9. ASSESSMENT TOOLS
Audiological
BERA / ABR
ASSR
OAE
PTA
Speech audiometry
Aided audiogram

Pediatric Functional Scores
MAIS / IT-MAIS
CAP Score
SIR Score
Meaningful Auditory Integration Scale
Categories of Auditory Performance

10. Recently practice
Earlier implantation in infants
Expansion to SSD, asymmetric loss & ANSD
Hearing preservation & hybrid devices
Bilateral simultaneous implantation in children
Outcome based on auditory deprivation duration
> “Early duration of auditory deprivation inversely affects CI outcomes.”

QUICK DECISION FLOW
Severe-Profound SNHL
↓
Trial with Hearing Aids
↓
Poor aided benefit
↓
Audiological + Radiological evaluation
↓
Cochlear nerve present & cochlea patent
↓
Motivated patient/family
→ CI

Gist idea
Best predictor of good pediatric CI outcome is early implantation
Presence of cochlear nerve on MRI is mandatory
CI bypasses damaged hair cells and directly stimulates spiral ganglion cells
Post-lingual adults generally perform better than pre-lingual adults

BASED ON GUIDELINES FROM
AAO-HNS Clinical Practice Guidelines
American Cochlear Implant Alliance (ACI)
FDA Device Indications
NICE (UK) Guidelines
Manufacturer Guidelines (Cochlear, MED-EL, AB)
Contemporary CI Literature & Consensus

FINAL MESSAGE
“RIGHT CANDIDATE + RIGHT TIME + RIGHT REHABILITATION = LIFE-CHANGING OUTCOMES”

Post-operative Follow-up after Thyroidectomy

Time What to Check Important Action

0–6 hours Airway, neck swelling, bleeding, stridor, voice Watch for neck hematoma → emergency
Day 1 Pulse, BP, drain, wound, voice, swallowing- Check serum calcium ± PTH, look for hypocalcemia
Day 2 Drain output, wound, Chvostek/Trousseau sign Remove drain if low output; continue calcium if needed
Day 3–5 Pain, fever, wound redness, voice change Discharge if stable; give wound + calcium advice
Day 7 Wound review, suture/clip removal, serum calcium Check calcium especially after total thyroidectomy
2 weeks Histopathology report, voice, scar, swallowing Plan further treatment if malignancy
4–6 weeks TSH, FT4, calcium, voice Adjust levothyroxine dose
3 months Voice, calcium, scar, thyroid hormone control Persistent hoarseness → laryngoscopy
6 months–1 year Long-term hypothyroidism, hypocalcemia, recurrence Cancer cases need thyroglobulin/US follow-up

Post-thyroidectomy follow-up commonly includes wound/drain review, voice assessment, and calcium monitoring; calcium is often rechecked about 1 week after discharge, especially after total thyroidectomy.

Daily Checklist: “A-B-C-D-V-W”
A – Airway
Breathing difficulty, stridor, neck swelling.
B – Bleeding
Expanding neck hematoma is most dangerous in first 24 hours.
C – Calcium
Perioral tingling, finger tingling, cramps, tetany.
D – Drain
Amount, color, sudden increase.
V – Voice
Hoarseness, weak voice, aspiration.
W – Wound
Redness, discharge, fever, seroma.

Red Flags after Thyroidectomy
Sudden neck swelling
Respiratory distress / stridor
Severe hypocalcemia symptoms
Progressive hoarseness
Fever with wound discharge
These need urgent surgical review.

Mechanical Ventilator basics

Intrinsic Muscles of Larynx

Thyroarytenoid (TA)
Forms main body of vocal cord
Relaxes & shortens vocal cord
Produces deep/heavy voice

Lateral Cricoarytenoid (LCA)
Adducts vocal cords
Important for phonation
Main muscle for cord closure
🔹 Paralysis → breathy voice

Transverse Arytenoid
Closes posterior glottic gap
Prevents air leakage during speech
🔹 Paralysis → posterior gap + breathy voice

All intrinsic laryngeal muscles
→ supplied by Recurrent Laryngeal Nerve (RLN)
Exception:
Cricothyroid muscle
→ supplied by External branch of Superior Laryngeal Nerve (EBSLN)

Cord Closers
LCA
Transverse arytenoid

Cord Relaxer
Thyroarytenoid