Correspondence

Bacterial Meningitis in Children with Cochlear Implants

N Engl J Med 2003; 349:1772-1773October 30, 2003

Article

To the Editor:

Dr. Reefhuis and colleagues (July 31 issue)1 investigated the increased risk of bacterial meningitis in recipients of cochlear implants. To document the number of cases of postimplantation meningitis, the Ottawa Cochlear Implant Team conducted a survey of implantation centers across Canada in September 2002 and again in June 2003.2 During the same period, Health Canada sent a questionnaire to all Canadian cochlear-implant recipients.3 The difference between the two investigations in the number of identified cases of postimplantation meningitis is clinically significant, with neither method identifying all the cases. This discrepancy reflects one of the many challenges in obtaining accurate data with which we might arrive at a true estimate of the risk to patients. All health care professionals need to recognize and report clinically significant findings to help improve the description of the problem as well as to help develop more effective recommendations.

Rénee D. Lefrançois, M.H.Sc.(A.)
Linda M. Moran, M.Sc.
Children's Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada
lefrancois_r@cheo.on.ca

3 References

1. 1

   Reefhuis J, Honein MA, Whitney CG, et al. Risk of bacterial meningitis in children with cochlear implants. N Engl J Med 2003;349:435-445
   Full Text | Web of Science | Medline

2. 2

   Schramm D, Lefrancois R, Rickard L, Moran L, Seguin C. Meningitis and patients with cochlear implants: recent developments. Paediatr Child Health 2003;8:Suppl B:44B-44B abstract.
   

3. 3

   Wilson SD, Squires SG, Deeks SL, King A. Investigating the risk of bacterial meningitis among Canadian children with cochlear implants. Paediatr Child Health 2003;8:Suppl B:16B-16B abstract.
   

To the Editor:

Reefhuis et al. recommend vaccines and treatment of otitis media to prevent meningitis in children who have received a cochlear implant. However, their study also confirms that an inner-ear malformation and previous attacks of otitis media and meningitis are risk factors for meningitis before and after implantation. Many of the children in their study probably had a congenital defect between the middle and inner ears that could have been repaired by middle-ear surgery. Examination of the temporal bones of a child who died of meningitis after implantation revealed that the illness had not originated in the ear with the implant, but rather had resulted from an underlying inner-ear anomaly and otitis media in the contralateral ear.1 My recommendations for recipients of implants and candidates for implantation, as well as others in whom an inner-ear malformation may confer a predisposition to meningitis, have recently been reported in detail.2 Children in whom labyrinthitis or meningitis (especially a recurrence) develops in association with otitis media should undergo temporal-bone imaging. The goal is to prevent deafness before a cochlear implant is needed and to prevent all attacks of meningitis.

Charles D. Bluestone, M.D.
Children's Hospital of Pittsburgh, Pittsburgh, PA 15213
bluecd@chp.edu

2 References

1. 1

   Suzuki C, Sando I, Fagan JJ, Kamerer DB, Knisely AS. Histopathological features of a cochlear implant and otogenic meningitis in Mondini dysplasia. Arch Otolaryngol Head Neck Surg 1998;124:462-466
   Web of Science | Medline

2. 2

   Bluestone CD. Prevention of meningitis: cochlear implants and inner ear abnormalities. Arch Otolaryngol Head Neck Surg 2003;129:279-281
   Web of Science | Medline

Author/Editor Response

Lefrançois and Moran report that, in their experience, complete ascertainment of all cases of meningitis occurring after cochlear implantation is difficult. For our investigation, we used several methods of case finding to maximize ascertainment. Having combined data obtained from manufacturers, the parents of cochlear-implant recipients, audiologists, state health departments, the Food and Drug Administration Adverse Event Reporting System, and the Centers for Disease Control and Prevention surveillance systems, we believe that our reported rates of meningitis are reasonable estimates. Nonetheless, we acknowledge that the rates could have been underestimated because of incomplete case ascertainment.

As noted by Bluestone, many of the patients in our study had inner-ear malformations. Although several of these malformations have been associated with recurrent meningitis,1-5 the relative risk of meningitis among patients with these anomalies, as compared with that in the general population, is currently unknown. In our analysis, children with a cochlear implant and both an inner-ear abnormality and a cerebrospinal fluid leak or gusher had a higher risk of meningitis than other children with implants. The study design and small sample size limited our ability to evaluate further the risk of meningitis associated with inner-ear malformations alone. We agree with Bluestone's recommendation of early identification and institution of preventive measures such as vaccination and surgical repair (when appropriate) for children with cochlear malformations, regardless of their implantation status.

Jennita Reefhuis, Ph.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333

Eric A. Mann, M.D., Ph.D.
Food and Drug Administration, Rockville, MD 20857

Cynthia G. Whitney, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30333

5 References

1. 1

   Hayashi N, Kino M, Nobori U, et al. Recurrent bacterial meningitis: secondary to malformation of the inner ear. Clin Pediatr (Phila) 1989;28:139-141
   CrossRef | Web of Science | Medline

2. 2

   Herther C, Schindler RA. Mondini's dysplasia with recurrent meningitis. Laryngoscope 1985;95:655-658
   CrossRef | Web of Science | Medline

3. 3

   Ohlms LA, Edwards MS, Mason EO, Igarashi M, Alford BR, Smith RJ. Recurrent meningitis and Mondini dysplasia. Arch Otolaryngol Head Neck Surg 1990;116:608-612
   Web of Science | Medline

4. 4

   Phelps PD, King A, Michaels L. Cochlear dysplasia and meningitis. Am J Otol 1994;15:551-557
   Medline

5. 5

   Valmari P, Palva A. Recurrent meningitis due to pneumococci and non-typable Haemophilus influenzae in a child with a Mondini malformation. Infection 1986;14:36-37
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   T Ovesen, L V Johansen. (2009) Post-operative problems and complications in 313 consecutive cochlear implantations. The Journal of Laryngology & Otology 123:05, 492
   CrossRef

2. 2

   B. P. C. Wei, R. M. Robins-Browne, R. K. Shepherd, G. M. Clark, S. J. O'Leary. (2008) Can We Prevent Cochlear Implant Recipients from Developing Pneumococcal Meningitis?. Clinical Infectious Diseases 46:1, e1-e7
   CrossRef

3. 3

   F B. van der Beek, P P. B. M. Boermans, B M. Verbist, J J. Briaire, J H. M. Frijns. (2005) Clinical Evaluation of the Clarion CII HiFocus 1 with and Without Positioner. Ear and Hearing 26:6, 577-592
   CrossRef