Release: September 9, 2001
Contact: Kenneth Satterfield(703) 519-1563[email protected]303-228-8460 (9/7-9/12)
COCHLEAR IMPLANTATION WILL BENEFIT THE HIV-POSITIVE CHILD
The first of a kind case study finds that a positive HIV status will not result in an adverse reaction following surgical implantation of this device
Denver, CO -- Cochlear implantation surgery has been proven to be cost-effective in the general pediatric population, which has a life expectancy of over 50 years. This statistic cannot be applied to HIV-positive children, where life expectancy is generally between ten and 20 years from diagnosis. In addition, there is the confounding factor that patients with moderate and severe HIV disease (CDC categories B and C) may have impaired wound healing with potentially increased rejection of an implanted device. Because of the incidence of central nervous system disease in HIV, it is possible that these patients may have additional central sensory stimuli processing disorders compounding their cochlear hearing loss.
However, many physicians believe that what was once a rapidly fatal disease has evolved, and AIDS or HIV is now considered a chronic illness. The use of protease inhibitors, as well as maternal treatments to minimize vertical transmission and treatment of secondary medical problems, are allowing a greater percentage of these patients to live longer. Now, pediatricians caring for these children can anticipate watching them graduate from high school and beyond. As a consequence, possibilities for performing elective surgery are expanding. By the same token, questions as to the appropriateness of certain levels of surgical intervention are raised, especially with the cochlear implant where (1) chronic ear infections confound the CI effectiveness; and (2) meningitis/encephalitis can reduce the brain's ability to respond to CI generated sounds.
A team of hearing experts has examined the case of a nine year old, HIV-infected child undergoing cochlear implantation. Their findings represent the first case of cochlear implantation in an HIV infected individual presented in the literature. The authors of the study, "Cochlear Implantation in the HIV-Infected Individual: A New Challenge," are Sujana S. Chandrasekhar, MD, Associate Professor & Director of Otology/Neurotology, Mount Sinai School of Medicine, New York, NY; Patricia E. Connelly, PhD, Assistant Professor of Otolaryngology--Head and Neck Surgery, and Lisa Bell, CCC-A, from the Audiology Service, both with the University of Medicine and Dentistry (UMDNJ) of New Jersey University Hospital, Newark, NJ; and Tahl Y. Colen, a UMDNJ medical student. Their findings were presented at the American Academy of Otolaryngology--Head and Neck Surgery Foundation Annual Meeting/OTO EXPO, being held September 9-12, 2001, at the Colorado Convention Center, Denver, CO.
Case Study: The patient, "FL" was a nine year old boy with vertically acquired HIV disease (CDC Class B3). He is one of six special-needs children adopted by an inner-city family. His past medical history is significant and included multiple opportunistic infections such as lymphointerstitial pneumonitis and pneumococcal sepsis. In early infancy he had chronic otitis media complicated by bilateral effusion and tympanic membrane perforations. Audiometric evaluation at age 6 years revealed mild hearing loss in the right ear and profound mixed hearing loss in the left. FL was hospitalized with probable CMV encephalitis at age seven. Four months later he returned for care with complaints of right hearing loss and academic difficulties. At this time, audiologic evaluation revealed profound sensorineural hearing loss bilaterally. He was fitted with binaural behind-the-ear hearing aids.
Follow-up testing indicated that hearing-aids were not sufficient to bring conversational level speech into his range of audibility. He underwent audiologic, radiologic, and psychological evaluation and it was determined that this patient would benefit from cochlear implantation. Consultation was made with the Pediatric AIDS service that felt that there were no contraindications to proceeding with surgery. The decision was made to implant the left ear, despite its longer history of unaided sensorineural hearing loss, because of the long history of chronic otitis media in the right ear.
FL underwent left cochlear implantation at age nine with a Nucleus CI24RCS ContourTM implant. Precautions were used in the operating room to reduce risk of transmission of HIV disease to the surgical team. The surgical procedure was uneventful, as was his postoperative course. He was discharged from the hospital the following day.
Initial stimulation was carried out over a two-day period four weeks postoperatively, as the operative site had healed well. Soundfield testing performed in the auditory-only condition (without visual cues) two months later demonstrated excellent cochlear implant benefit. Soundfield thresholds were obtained at 25dBHL at 250 Hz and 35dBHL at 500 to 6000 Hz. He scored 88% on the Word Identification Picture Index (WIPI) at 55dBHL.
FL healed so quickly that his cochlear implant was turned on at four weeks following surgery instead of the normal six weeks. He is very happy with his device and has been mainstreamed into a regular classroom this school year.
Discussion and Conclusions: During the early years of the HIV epidemic, the guiding criteria for surgery were necessarily stringent for an HIV-positive patient due to concerns regarding life expectancy, effective wound healing and surgical team risks. The consensus now is that standard criteria should be followed especially when the patient is healthy and CD4 lymphocyte count is greater than 200 cells/mL. Risk to the surgeon and surgical staff is considered to be minimal when following standard universal precautions.
Most pediatric HIV-positive patients will manifest head and neck diseases during the course of their illness requiring the intervention of an otolaryngologist. Both conductive and sensorineural hearing loss have been associated with HIV. Sensorineural hearing loss is most commonly ascribed to destruction caused by opportunistic infections, ototoxic medications and the direct effect of the HIV virus. When the degree of such hearing loss is bilaterally severe to profound, interventions must be initiated to ameliorate the effects of the hearing impairment. Children with HIV and hearing loss, and their families, are often contending with a myriad of health care issues. The benefits of mainstreaming these children back into the regular classroom may be even greater than in the otherwise healthy child.
Based on the available literature and the current case, HIV infection alone should not be viewed as an impediment to cochlear implant surgery.
- end -