Sub-Galeal Pneumocele 20 Years after Cochlear Implantation

Arun Gadre

Sub-Galeal Pneumocele 20 Years after Cochlear Implantation

Abstract

This case report documents a rare case of a subgaleal pneumocele occurring more than 20 years after cochlear implantation. On presentation, the presence of air under the scalp followed vigorous nose blowing was observed. The patient was treated conservatively with a pressure dressing, which resulted in complete resolution of the surgical emphysema. Only a handful of such cases have been reported in the literature. Most of these cases occur early after cochlear implantation. Our case is even more unique as it occurred 24 years following implantation and presented with a painless swelling associated with deterioration in cochlear implant performance. A review of the current literature is included in the discussion. KEYWORDS: Cochlear implantation, postoperative complications, subcutaneous emphysema

Figures (2)

Figure 1. Axial computed tomography scan reveals a pneumocele is visual-
ized around the receiver-stimulator package.
All patients with cochlear implants should be counseled on avoiding
the performance of forceful or excessive nose blowing particularly
in the early postoperative period. However, as is evidenced in our
patient, this complication can occur decades after implantation as
well. Although rare, it is important to try and prevent this complica-
tion. Hagr and Bance ®! reported a rare case of an intraparenchymal
pneumocephalus in addition to a subcutaneous pneumocele. This
was thought to be the result of habitual nose blowing due to an un-
treated sinus disease. Their patient was treated with antibiotics and
ventilation tube placement. They recommended that nasal disease
such as nasal polyposis be treated prior to cochlear implantation. An-
other case of pneumocephalus, evidently as a result of performing
Valsalva maneuver up to 30 times a day, was reported by Gillett et
al." Their patient was treated conservatively with resultant sponta-
neous resolution, followed by insertion of a Shah mini grommet for
the prevention of repeat occurrences. — Figure 1. Axial computed tomography scan reveals a pneumocele is visual- ized around the receiver-stimulator package. All patients with cochlear implants should be counseled on avoiding the performance of forceful or excessive nose blowing particularly in the early postoperative period. However, as is evidenced in our patient, this complication can occur decades after implantation as well. Although rare, it is important to try and prevent this complica- tion. Hagr and Bance ®! reported a rare case of an intraparenchymal pneumocephalus in addition to a subcutaneous pneumocele. This was thought to be the result of habitual nose blowing due to an un- treated sinus disease. Their patient was treated with antibiotics and ventilation tube placement. They recommended that nasal disease such as nasal polyposis be treated prior to cochlear implantation. An- other case of pneumocephalus, evidently as a result of performing Valsalva maneuver up to 30 times a day, was reported by Gillett et al." Their patient was treated conservatively with resultant sponta- neous resolution, followed by insertion of a Shah mini grommet for the prevention of repeat occurrences.

Figure 2. Coronal computed tomography scan demonstrates air tracking
along the electrode from the mastoid to the pneumocele. — Figure 2. Coronal computed tomography scan demonstrates air tracking along the electrode from the mastoid to the pneumocele.

Objectives: Cochlear implantation is a relatively safe procedure with a low complication rate. The overall rate of complications among cochlear implant patients ranges from 6% to 20%. Major complications are those that are life-threatening or require surgery, whereas minor complications are those that can be medically treated. Nonetheless, certain complications, even if highly rare, may require specific investigations and treatments. Among these rare complications are those with endocochlear involvement, such as cochleitis or labyrinthitis, with fibrosis or ossification that could lead to explantation. The aims of the present study were to report a particular case of post-operative cochleitis and to review the rate of complications after cochlear implantation, emphasising those conditions with proven endocochlear involvement. Methods: We refer to the case of an eight-year-old Italian boy affected by the sudden onset of headache, ipsilateral otalgia and facial paresis, who presented to our clinic for inexplicable worsening of the performance of his implant and his residual hearing, six years after surgery. A complete investigation including (clinical history, routine, autoimmune and serological blood tests, electrophysiological measurements from the cochlear implant and neuroimaging) was performed and is herein described. Additionally, a comprehensive review of the literature was conducted using internet search engines; 274 papers were selected, 88 of which were best suited to our purposes. Results: In our case, the progression of the symptoms and the performance decrement required explantation, followed by a complete recovery. Reviewing the literature revealed only three reports concerning cases of proven endocochlear phlogosis that required revision surgery. Wound swelling/ infection and vertigo remain the two most common complications of cochlear implantation. Failure of the device is the third most frequent complication (10.06% of all complications and 1.53% of cochlear implantations). Other rare conditions (such as granulating labyrinthitis with cochlear fibrosis, ossification and erosion, silicone allergy and the formation of a biofilm around the internal device) are possible and unpredictable. Although rare (approximately 1%), such cases may require explantation. Conclusions: Despite efforts by both surgeons and manufacturers, device-related and surgical complications still occur. These and other rare conditions demand specific management, and their frequency may be underestimated. Further studies are needed to assess more realistic rates of complications and devise more efficient strategies for early diagnosis and treatment.

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