Vestibular Implantation and the Feasibility of Fluoroscopy-Guided Electrode Insertion Recent research has shown promising results for the development of a clinically feasible vestibular implant in the near future. However, correct electrode placement remains a challenge. It was shown that fluoroscopy was able to visualize the semicircular canal ampullae and electrodes, and guide electrode insertion in real time. Ninety-four percent of the 18 electrodes were implanted correctly (<1.5 mm distance to target). The median distances were 0.60 mm, 0.85 mm, and 0.65 mm for the superior, lateral, and posterior semicircular canal, respectively. These findings suggest that fluoroscopy can significantly improve electrode placement during vestibular implantation.

Cochlear Implant Cochlear implant is the first approved cranial nerve stimulator that works by directly stimulating the cochlear nerve. The medical and societal impact of this revolutionary device cannot be understated. This article reviews the evolving indications for cochlear implant, patient assessment, surgical approach, and outcomes for pediatric and adult cochlear implant that demonstrate its impact. Future concepts in cochlear implant are introduced briefly. This article covers a breadth of information; however, it is not intended be entirely comprehensive. Rather, it should serve as a foundation for understanding cochlear implant.

The Impact and Evolution of Cranial Nerve Stimulators in Otolaryngology As otolaryngologists, we specialize in the management of various individual organs within an anatomical region. This provides our specialty with a unique opportunity to address a breadth of disorders that are largely related to the special senses and often involve specific input from individual cranial nerves. As such, management of these disorders can be challenging because of the sensitive information being relayed and the complexities involved in cranial nerve signaling. When medical options fail to provide benefit, surgical options become available.

Recurrent Laryngeal Nerve Stimulator Electrical stimulation of the recurrent laryngeal nerve is a safe and promising therapeutic approach with the potentiality to overcome the shortcomings of conventional surgical glottal enlargement. Although aberrant or synkinetic reinnervation is commonly considered an unfavorable condition, particularly for recovery of vocal fold movement, its presence is essential to ensure the effective clinical performance of laryngeal pacemakers. Thus, the effective selection of patients who can profit from laryngeal pacemakers implantation demands the implementation of new diagnostic tools based on tests capable of reliably detecting the presence of viable reinnervation on at least one vocal fold.

Auditory Brainstem Implantation Auditory brainstem implants (ABIs) stimulate the auditory system at the cochlear nucleus, bypassing the peripheral auditory system including the auditory nerve. They are used in patients who are not cochlear implant candidates. Current criteria for use in the United States are neurofibromatosis type 2 patients 12 years or older undergoing first- or second-side vestibular schwannoma removal. However, there are other nontumor conditions in which patients may benefit from an ABI, such as bilateral cochlear nerve aplasia and severe cochlear malformation not amendable to cochlear implantation. Recent experience with ABI in the pediatric population demonstrates good safety profile and encouraging results.

Central Effects of Cranial Nerve Stimulation The current literature on peripheral cranial nerve stimulation for the purpose of achieving therapeutic effects via altering brain activity is reviewed. Vagus nerve stimulation, which is approved for use in refractory epilepsy, is the most extensively studied cranial nerve stimulator that has direct impact on the central nervous system. Despite the recognized central effects of peripheral cranial nerve stimulation, the mechanism of action for all indications remains incompletely understood. Further research on both mechanisms and indications of central effects of cranial nerve stimulation has the potential to alleviate burden of disease in a large array of conditions.

The Ethics of Cranial Nerve Implants This overview of ethical and social issues pertaining to cranial nerve implants covers informed consent; risk-benefit assessments; security against unauthorized reprogramming or privacy intrusion; explantation; psychological side effects; equity and social distribution, cultural effects, for instance, on the deaf subculture; enhancement; and research ethics.

The Difficult Airway Airway management is a cornerstone of anesthetic practice, and difficulty with airway management has potentially grave implications—failure to secure a patent airway can result in hypoxic brain injury or death in a matter of minutes. The difficult airway in otolaryngologic surgery requires careful planning and close communication between the anesthesiologist and ENT or head and neck surgeon. Knowledge of predictive factors and a detailed preoperative evaluation can be used to predict which airway strategies are likely to be successful and which are likely to fail.

Anesthesia and Chronic Pain Management The reasons for development of chronic pain are poorly understood. Chronic postoperative pain is linked to severe acute postoperative pain. Head and neck pain is often a complex phenomenon that requires meticulous diagnosis and treatment. Institution of early multimodal analgesic regimens by multidisciplinary teams may attenuate chronic pain formation and propagation in the otolaryngologic patient.

Partnership with Interventional Pulmonologist Via the emergence of new bronchoscopic technologies and techniques, there is enormous growth in the number of procedures being performed in nonoperating room settings. This, coupled with a greater focus from the Centers for Medicare and Medicaid Services for mandated anesthesiology oversight of procedural sedation for bronchoscopy by the pulmonologists has led to a more frequent working partnership between interventional pulmonologists and anesthesiologists. This article offers the interventional pulmonologist insight into how the anesthesiologist thinks and approaches anesthetic care delivery.