What are the considerations for single-stage cochlear implantation (CI) in a patient with significant hearing loss and a dry tympanic perforation?

Single-Stage Cochlear Implantation with Dry Tympanic Perforation

Single-stage cochlear implantation can be safely performed in patients with a dry (inactive) tympanic membrane perforation, provided there is adequate soft tissue coverage to protect the electrode array. 1

Surgical Approach for Dry Perforation

Proceed with single-stage cochlear implantation when the perforation is dry and there is sufficient soft tissue in the surgical field to cover the electrode. 1 The key distinction is between active versus inactive disease:

• Dry perforation without active inflammation: Single-stage procedure is appropriate, as the absence of active infection eliminates the primary risk factor for postoperative complications 1
• Active inflammation or inadequate soft tissue: Two-stage procedure is mandatory to first eradicate infection and establish protective tissue coverage 1, 2

Critical Preoperative Assessment

Evaluate these specific factors before proceeding:

• Confirm absence of active otorrhea or mucosal inflammation on otoscopic examination 1
• Assess adequacy of soft tissue layer in the mastoid and middle ear to protect the electrode array from exposure 1
• Document intact cochlear nerve via MRI or CT imaging, as required for all cochlear implant candidates 3
• Verify audiometric criteria: severe to profound sensorineural hearing loss with aided word recognition ≤60% at 60 dB presentation 3

Management of the Perforation During Surgery

The perforation itself does not require repair prior to implantation:

• The perforation can be managed concurrently during the cochlear implant surgery without delaying the procedure 3
• Myringoplasty can be performed simultaneously if desired, though this is not mandatory for successful implantation 2
• The primary surgical goal is ensuring adequate soft tissue coverage over the electrode, not perforation closure 1

When Two-Stage Surgery Is Required

Reserve staged procedures for these specific scenarios:

• Active suppurative otitis media at presentation requires complete eradication of infection before implantation 1, 2
• Inadequate soft tissue in the mastoid bowl necessitates first-stage obliteration with temporalis muscle flap, followed by implantation after 6 months 2
• Cholesteatoma presence mandates staged approach with disease eradication, obliteration, and delayed implantation 2

Expected Outcomes and Complications

Single-stage implantation in dry perforations has favorable outcomes:

• No increased risk of local or intracranial infection when inflammation is absent 1
• Tympanic membrane perforation occurs as a complication in only 1.5% of cases overall 4, 5
• Electrode exposure risk is minimal with adequate soft tissue coverage 1
• 96% of patients achieve tinnitus improvement following successful cochlear implantation 3

Critical Pitfalls to Avoid

• Do not delay cochlear implantation to repair a dry perforation first, as the perforation can be addressed during the same surgery and does not contraindicate implantation 3, 1
• Do not proceed with single-stage surgery if any active inflammation is present, even if the ear appears "mostly dry"—complete eradication is mandatory 1, 2
• Do not underestimate the importance of soft tissue coverage assessment, as inadequate protection of the electrode array leads to exposure and requires revision surgery 1
• Do not use ototoxic preparations in the perioperative period when the tympanic membrane is not intact 6