DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Total hearing loss.
POSTOPERATIVE DIAGNOSIS: Total hearing loss.
OPERATION PERFORMED:
1. Left cochlear implant.
2. Intraoperative facial nerve monitoring x2 hours.
3. Microsurgery.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS FOR OPERATION: This is a (XX)-year-old male with a previous history of right sudden sensorineural hearing loss. The patient has been doing well for several years now with hearing in his left ear. Recently, he had a sudden left sensorineural hearing loss. The patient had bilateral profound hearing loss. He was treated with steroids with no improvement. The patient elected for a cochlear implant.
OPERATIVE FINDINGS: Left MED-EL cochlear implant was performed. There was a full insertion of the electrode. The electrode was inserted easily. The facial nerve was covered in bone. The implant was secured with a KLS resorbable mesh.
DESCRIPTION OF OPERATION: After proper consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. General endotracheal anesthesia was administered. With the patient asleep, the bed was turned to 180 degrees. The patient’s eyes were taped, and his head was turned to the right, exposing the left ear. The left ear was then prepped in the usual manner. It was injected with 1% lidocaine with epinephrine. Intraoperative facial nerve monitoring electrodes were personally placed by the operating surgeon. These were placed at the orbicularis oris and orbicularis oculi. They were connected to the nerve integrity monitor. The monitor’s proper functioning was confirmed by performing a tap test and by checking electrode impedances. The left ear was then cleansed with Betadine paint and covered with sterile drapes.
The operating microscope was brought in. Throughout the case, the operating microscope and microsurgical technique was used to improve illumination and magnification. A postauricular incision was made 1 cm back from the postauricular sulcus. This was brought superior, just above the root of the helix. The incision was carried down to the level of the temporalis fascia and mastoid periosteum. The periosteum was then incised well posterior to the skin incision, thereby offsetting the two incisions. Dissection was then carried beneath the mastoid periosteum, elevating it up well posterior to create a pocket for the implant.
Next, mastoidectomy was performed. Mastoidectomy was carried down to the level of the horizontal canal. The incus was identified. Using high-speed otologic drill and continuous suction irrigation, the facial recess was opened. Progressively smaller diamond cutting burs were used. The stapedius tendon, stapes, and oval window niche were identified.
Next, a well was created for the cochlear implant. Using the speech processor and implant templates, the implant was placed well posterior to the edge of the speech processor. The well was drilled using a 5 cutter and 4 diamond. A channel was created from the well site to the mastoidectomy site for the electrode. With the implant template in place, the KLS resorbable mesh to hold the implant was brought in. Using the supplied drill, five holes were created around the implant. The template and the resorbable mesh were set aside.
Next, the cochleostomy was performed. The oval window and stapes were well seen. Inferior to this, the oval window was thought to be seen. Using a 1 diamond bur, the oval window niche was opened and the position was confirmed. Palpation of the ossicular chain revealed positive round window reflex. Working anterior, inferior to the round window, the cochleostomy was drilled using a 1 diamond. Once the cochleostomy was opened, the implant was brought onto the field. It was placed within the well. The electrode was inserted into the cochleostomy. It advanced to the depth marker without difficulty. The cochleostomy was sealed using previously harvested temporalis muscle pieces.
With the cochlear implant in the well, the KLS Martin resorbable mesh was placed on top of it. Using the ultrasound probe with Sonic pins, it was secured in place with five pins. The temporalis fascia was then closed in layers using 3-0 interrupted Vicryl. The postauricular wound was closed in layers using 3-0 interrupted Vicryl and 5-0 fast absorbing gut. With the implant in place, it was connected to the computer. The implant was checked and found to be functioning normally with normal electrode impedances within all electrodes.
Throughout the case, intraoperative facial nerve monitoring was performed. The monitor was personally observed and controlled by the operating surgeon. The monitor was used to ensure that while drilling the facial recess and cochleostomy, that the facial nerve was not irritated or damaged. There was no spontaneous activity from the monitor to indicate such damage.
The patient was awakened and extubated. The patient’s ear was dressed with a Glasscock ear dressing and bacitracin ointment. He was transferred to the recovery room in stable condition. Estimated blood loss was 15 mL. Sponge and needle counts were correct.
