The usual age of cochlear implantation in children corresponds to the peak age for the development of AOM [1, 2] . Teele et al. [18] reported that by 1 year of age, 62 % of the children had one or more episodes of AOM, and 17 % had three or more episodes of AOM. By 3 years of age, 83 % had one or more episodes of AOM, and 46 % had three or more episodes of AOM. This can be explained by the anatomy and physiology of the Eustachian tube of a young child and the surrounding lymphoepithelial ring that can prevent adequate drainage of the middle ear in childhood [18]. Of concern is the belief that children with CIs may be more susceptible to the complications of otitis media (OM) due to the surgical violation of the cochlea, the presence of a foreign body in the inner ear, and the potential for spread from a purulent middle ear through the cochleostomy to the CSF via the inner ear.

In a retrospective review of 234 patients who underwent cochlear implantation, it was found that children with a preimplantation history of AOM had a higher risk of postimplantation AOM than healthy children with CIs [19]; but this risk does seem to decrease after cochlear implantation [19, 20, 21]. More than half of the children who suffered from AOM after cochlear implantation had no history of AOM prior to implantation [19].

There is debate as to how aggressive the treatment of AOM should be in CI patients. Four retrospective studies [19, 22–24] of AOM in children with implants have been conducted. In three studies, the treatment of the AOM was found to be satisfactory when using standard treatments of systemic antimicrobial therapy with initial empiric treatment with an oral antimicrobial agent (e.g., amoxicillin at a dose of 80–90 mg/kg per day). In contrast, the fourth study [24] revealed that patients with implants were more likely to require intravenous antimicrobial therapy and a myringotomy. Of the 11 episodes of AOM reported in this fourth study, 7 patients underwent surgical treatment for mastoiditis. No child in any of the four series was reported to have developed bacterial meningitis. The immediate postoperative period appears to be a sensitive time for the potential development of meningitis. For this reason, AOM in the immediate postoperative period demands aggressive treatment. Rubin and Papsin [16] recommend that AOM diagnosed during the first 2 months after implantation be initially treated with parenteral antibiotics (e.g., ceftriaxone or cefotaxime).

Watchful waiting is inappropriate for CI patients as the presence of such a large foreign body, with the increased risk of meningitis even without a prior history of AOM, makes the prompt use of antibiotics mandatory [25]. There are certain circumstances in which a CI patient would be at higher risk for developing meningitis. Those risk factors include: (1) The CI has a space/positioner (Advanced Bionics model AB-5100H or AB-5100H-11); (2) the episode occurs within the first 2 months of implantation; (3) the patient has a known inner malformation or CSF/middle ear fistula; (4) the patient appears severely ill with evidence of mastoiditis or inner ear infection [16]. In such circumstances, a middle ear aspirate should be sought immediately for culture and sensitivity to antibiotics. Based on clinical judgment and culture results, the physician can decide on the mode of antibiotic treatment (oral vs. intravenous), which antibiotics to use, and whether or not to hospitalize the patient [26]. Implant patients with a middle ear effusion or an AOM along with suspected meningitis should have both CSF and a middle ear aspirate sent for culture and sensitivity. If presenting in the first 2 months after implantation, antimicrobials should include coverage against gram-negative bacilli (e.g., meropenum) plus vancomycin [16].

Traditionally it was thought that disruption of the tympanic membrane with a foreign body in the middle ear could pose a potential risk for dangerous seeding of the CI. This theory likely arises from stapedectomy surgery where, like cochlear implantation, the inner ear is opened, and it is felt ideal to perform such surgery in a “sterile” middle ear with an intact tympanic membrane. However, children frequently arrive for their initial CI assessment with myringotomy tubes (MTs) in place. The MTs may have been placed for a middle ear effusion to ensure an adequate hearing aid trial, or they may have been placed for recurrent OM [27].

In a survey of CI surgeons [28], 56 % of respondents stated that they would proceed with cochlear implantation with MTs in place if the ears were clean and dry. The majority of the remaining respondents stated that they would remove the tube and wait for the tympanic membrane perforation to heal. However, as Kennedy and Shelton noted in their study [28], this choice of action may be fraught with difficulty—the tympanic membrane may fail to heal spontaneously, or fluid or infection may return behind the tympanic membrane. Such situations would undoubtedly cause anxiety, frustration, and delay for the patient and caregivers. Also, early implantation is vital to take advantage of the plasticity of hearing development in young children , and unnecessary delay should be avoided [29].

The American Academy of Pediatrics approved the judicious use of MTs in CI candidates. A policy statement was issued [16] on the management of OM in CI patients which states that surgeons should manage OM with MT placement either before or at the time of cochlear implantation to prevent further OM episodes.

In the event that a child with a CI develops OM while an MT is in place, a sample culture can be taken, and the patient should be started on systemic and topical antibiotics as well as local otorrhea care [26].

For those patients who develop recurrent bouts of AOM with a CI in place, it has been argued that the indications for MTs and their management in the CI recipients should be the same as those in the patients without a CI. MTs should be placed in any CI patient having recurrent bouts of AOM. There does not appear to be an issue having a CI and MTs in place if warranted [27].