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Otology & Neurotology
26:202–204 Ó 2005, Otology & Neurotology, Inc.

Epidural Hematoma After Cochlear Implantation
In A 2.5-Year-Old Boy
Jan Gosepath, Jan Maurer, and Wolf J. Mann
Department of Otolaryngology—Head and Neck Surgery, University of Mainz,
School of Medicine, Mainz, Germany.

Objective: Report a case of an epidural hematoma after
cochlear implantation in a 2.5-year-old boy, the diagnostic and
therapeutical emergency management, as well as the postinterventional course and rehabilitation of the child.
Study Design: Retrospective case review.
Patient: Two and a half-year-old boy, suffering from early
onset, profound sensorineural hearing loss had been diagnosed
at an age of 1.5 years, which had been more severe on the right
side initially, but had progressed to bilateral deafness.
Intervention and Complication: Cochlear implantation on
the left side, followed up by an extensive epidural hematoma,
causing intracranial compression with a midline shift of 15 mm
to the right side. This initial complication was followed up by

arterial infarction not only of the middle but also the posterior
as well as the anterior cerebral artery, most likely caused by
incarceration through the tentorium.
Results: After immediate neurosurgical intervention and
intensive care treatment including low-dose anticoagulation
and high doses of corticosteroids, the child recuperated
completely within 3 weeks without any remaining neurologic
deficits.
Conclusion: In cochlear implantation, especially if placement
of the implant housing is associated with considerable bone
work, epidural hematoma has to be considered as an extremely
rare, but life-threatening, complication.
Otol Neurotol 26:202–204, 2005.

Cochlear implantations have become a routinely
performed and very successful surgical intervention in
both children and adults, performed so far in more than
10,000 patients worldwide. Generally, this procedure is
associated with rather low complication rates, regardless
of the individually chosen cochlear implant device.
Different reports have detailed possible medical, surgical or audiologic complications (1–6).
We are reporting to our knowledge the first case of an
epidural hematoma after cochlear implantation in a 2.5year-old boy, resulting in a critical and life threatening
situation. The diagnostic and therapeutical emergency
management as well as the postinterventional course and
rehabilitation of the child are discussed.

initially but had progressed to bilateral deafness. An
initial brainstem evoked response audiometry had shown
responses at 100 dB on the right and between 100 dB
and 120 dB on the left side. However, repeated evaluation, including brainstem evoked response audiometry
as well as otoacoustic emissions throughout the 12 preoperative months displayed better results on the left side.
Cardiologic workup had revealed a ventricular right-toleft shunt. The boy appeared healthy otherwise without
any evidence of autoimmune or syndromal disease. Preoperative imaging showed normal cochlear and tympanic
structures bilaterally and symmetrical pneumatization of
both mastoids. The operation was planned, and informed
consent was achieved from both parents for a cochlear
implant on the left side.
The cochlear implantation was performed using the
Med EL Combi 40+ device (Innsbruck, Austria). This
implant requires rather extensive bone work to create an
implant bed posterior to the mastoid cavity for firm and
proper placement of the implant body. Dummies of the
device are routinely used to exactly adapt the size of the
bony cavity to the actual size of the implant. Using this
type of implant, we routinely drill the bone down to
a thin layer covering the dura at the edges of the implant
bed and leave a thin shell of bone in the center. In the

CASE REPORT
A cochlear implantation was performed in a 2.5-yearold boy suffering from early onset profound sensorineural hearing loss had been diagnosed at an age of 1.5
years, which had been more severe on the right side
Address correspondence and reprint requests to Jan Gosepath, M.D.,
Ph.D., Universitaets-HNO-Klinik, Langenbeckstrasse 1, 55101 Mainz,
Germany; Email:gosepath@hno.klinik.uni-mainz.de

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EPIDURAL HEMATOMA AFTER COCHLEAR IMPLANTATION
presented case, the surgical procedure was uneventful,
and the electrode array was completely inserted into the
cochlea through the cochleostomy by way of the facial
recess. Intraoperative blood loss was within normal range,
and minor bleeding was observed from stitches during
wound closure; however, there was no evidence of arterial bleeding at any time, and the wound was dry and
normal upon termination of the procedure. Recurrent
adenoids after a previous operation elsewhere had been
removed at the beginning of the operation.
General anesthesia was well tolerated and uneventful. No adverse events or remarkable observations were
reported during the immediate postoperative period,
and the child was transferred back to the pediatric unit
of our department. The child was awake with a regular
and stable cardiovascular as well as neurologic status and nurses as well as the parents did not observe
any abnormalities during the immediate postoperative
period.
Four hours postoperatively, the child developed progressive somnolence and appeared to have intermittent
minor bleedings from his nose. The immediate laboratory workup revealed a blood sugar of 380 mg/100 ml,
combined with a metabolic acidosis. Because of the observed bleeding from the nose, the nasopharynx as well
as the retroauricular incision were reinspected in the
operating room. No significant bleeding was detected in
the nasopharynx, and the retroauricular wound appeared
normal without evidence of a subcutaneous hematoma,
so the wound was not opened at this time. A repeated
blood analysis displayed a hemoglobin level of 8.1 mg/dl,
indicating a significant decrease from the preoperative
value 12.5 mg/dl, which could not be explained. Except
for the reduced vigilance, the child was still free of severe neurologic symptoms with bilateral adequate pupillary
reflexes to light.
The child was now transferred to the pediatric intensive care unit (ICU) and a cranial computed tomography
(CT) scan was performed. This CT scan revealed an extensive epidural hematoma compressing the left hemisphere with a midline shift of 15 mm to the right side
(Fig. 1). Neurosurgical revision and draining of the epidural hematoma was performed immediately. The arterial bleeding, originating from a dural branch of the
middle meningeal artery, was located centrally underneath
the implanted processor, right at the edge of the bony
cover, and was stopped by bipolar coagulation. Most
likely, this vessel had been eroded by pressure caused by
the processor in the absence of a complete bony shell on
top of the dura. Questionable unrecognized intraoperative trauma caused by the performed drilling is a factor
that might have led to some initial weakening of vascular structures of the dura.
After this revision, the child was transferred back to
the pediatric ICU for further close monitoring. The
repeated hemoglobin analysis now revealed a value of
6.1 mg%. Packed blood cells were given during the after
hours, followed up by an increase of the hemoglobin
back to 11.5 mg%. The boy was extubated in the early

203

FIG. 1. Cranial computed tomography scan displaying a large
epidural hematoma on the left side with a 15 mm midline shift.

morning of the next day. Throughout that day, he was
still tired and drowsy with inadequate reactions to
stimuli provided by nursing staff or his parents.
A repeated cranial CT scan was performed after
36 hours, which again unveiled a complication of more
severity than expected. A large area of the left temporal
and temporooccipital lobe displayed radiologic hypodensity, matching a venous cerebral infarction, possibly
with consecutive hemorrhage. After first analysis of
these scans indicated signs of a possible thrombosis of
the superior sagittal sinus, the question of a high-dose
anticoagulation had to be discussed, including the risk of
severe life-threatening massive hemorrhage into the infarcted area. To further clarify the current developments,
the child was now evaluated by sophisticated magnetic
resonance imaging sequences focusing on the venous
and arterial blood flow. These enabled us, without having to take the additional risk of an angiogram, to exclude the differential diagnosis of a sinus thrombosis.
Two important findings lead to the final diagnosis of an
arterial infarction, most likely caused by incarceration
through the tentorium, instead of the suspected venous
thrombosis: the infarction included areas supplied by not
only the middle but also the posterior as well as the anterior cerebral artery. No sinuses, venous, or arterial vessels displayed any abnormalities (Fig. 2). These findings
could only be explained by a transient interruption of the
arterial blood supply during the compression caused by
the epidural hematoma with herniation and subsequent
incarceration through the tentorium.
After this diagnostic procedure, the anticoagulation
was kept at a low dose, and the child was without any
sedating medication. High doses of corticosteroids were
applied intravenously in an effort to minimize and soon
reduce intracranial edema and swelling. During the
proceeding 48 hours, the boy slowly began to recuperate
and regained adequate vigilance. By then we were able
to reestablish a current neurologic status. The expected
right hemiparesis presented as a weakness of the right
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GOSEPATH ET AL.
scheduled 4 weeks postoperatively to evaluate the status
of the cochleostomy and the intracochlear lumen. In case
of a free cochlear lumen, a reimplantation on the identical side was intended; however, in case of obliteration
by scarring, a cochlear implantation on the right side
would be suitable after the audiologic and radiologic
findings.

CONCLUSIONS

FIG. 2. Magnetic resonance imaging 36 hours postoperatively
showing a large cerebral infarction after arterial ischemia caused
by transtentorial herniation caused by the epidural hematoma.

arm and reduced reflexes in the muscles of the left leg.
Furthermore, the child developed a centrally caused
diabetes insipidus, which was controlled medically. A
possible hemianopia was difficult to rule out completely
because of the deafness of the boy and the absence of
speech. However, a pediatric perimetric analysis performed in the department of ophthalmology at our
institution showed no evidence of hemianopia 2 weeks
postoperatively.
Throughout the next 10 days, supported by intensive
physical therapy, the neurologic deficits completely resolved with minor motor weakness and the child being
able to run and play in a normal manner. The diabetes
insipidus also turned out to be of a transient nature, and
medical therapy could be discontinued. Thirteen days
postoperatively, the child was dismissed from the ICU
and transferred to a pediatric ward before being dismissed from our institution at day 16 postoperative.
The cochlear implant, which had to be removed
during the emergency procedure of draining the epidural
hematoma, was checked for technical integrity by the
manufacturer and showed to be intact. A revision was

Otology & Neurotology, Vol. 26, No. 2, 2005

This is to our knowledge the first report of an epidural
hematoma occurring after a cochlear implantation. This
report suggests that this extremely rare, life-threatening
complication needs to be considered as a differential
diagnosis in case of sudden inadequate vigilance in the
postoperative period, possibly accompanied by metabolic dysregulation and unexplained decrease of hemoglobin. Immediate revision of the wound should be
recommended in this situation on the basis of the clinical
findings even without waiting for imaging studies in an
effort to minimize possible cerebral compression and
ischemia.

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