13The Only-Hearing Ear and the Medically Complex Patient

TImplanting the only-hearing or better-hearing ear

Historically surgeons refused to implant a patient's only or better-hearing ear, fearing that the residual acoustic hearing would be destroyed and the person left worse off; this reluctance is now recognised as often unjustified. Modern soft-surgery technique, slim and flexible arrays, and round-window or extended-round-window insertion let many such ears retain useful low-frequency acoustic hearing, supporting electric-acoustic stimulation in the same ear. When residual hearing in the better ear has deteriorated to the point that amplification no longer delivers intelligible speech, implanting that ear can give a substantially better outcome than persevering with a failing hearing aid. The classic dilemma is the vestibular schwannoma in the only hearing ear, where the choice lies between a cochlear implant (if the cochlear nerve can be preserved) and an auditory brainstem implant (if it cannot). Etiologies that threaten the contralateral ear over time, such as Meniere disease, autoimmune inner-ear disease, congenital CMV, enlarged vestibular aqueduct, and neurofibromatosis type 2, raise the value of securing hearing on the better side proactively. Counselling must frame the realistic worst case honestly: total loss of any residual acoustic hearing in that ear, with electric hearing as the fallback, versus the expected gain.[2020][2009]

CAnticoagulation and bleeding risk

Many older candidates take antiplatelet or anticoagulant drugs for cardiac and vascular disease, and the instinct to stop them before surgery must be weighed against the thrombotic risk of interruption. A series of 46 adults implanted without interrupting therapy recorded only a small number with postoperative bruising and no hematoma, supporting the safety of continuation in selected patients. Cochlear implantation is a soft-tissue and well-vascularised-bone procedure with no entry into a closed cavity under tension, so the consequences of minor bleeding are usually limited and controllable. For patients at high thrombotic risk, continuing antiplatelet or anticoagulant therapy through the perioperative period is a reasonable and increasingly accepted strategy. Decisions about bridging, dose-holding, or continuation should be made jointly with cardiology or haematology and individualised to the specific agent and indication.[2016][2020]

CSystemic comorbidity, the heart, and the long-QT ear

Diabetes, cardiac disease, and immunocompromise affect wound healing, infection risk, and anaesthetic safety rather than the prospect of hearing benefit, and are managed by optimisation rather than exclusion. Jervell and Lange-Nielsen syndrome couples congenital profound deafness with a markedly prolonged QT interval and a risk of torsades de pointes, syncope, and sudden death. Because surgical stress and general anaesthesia can themselves trigger fatal arrhythmia, a preoperative ECG is justified in congenitally deaf children to detect this otherwise silent risk before anaesthesia. Around 90 percent of Jervell and Lange-Nielsen cases arise from KCNQ1 mutations, and a substantial proportion of affected patients suffer sudden cardiac death, with anaesthesia among recognised triggers. When identified, the arrhythmic risk is mitigated with beta-blockade, careful avoidance of QT-prolonging agents, and cardiology co-management, after which cochlear implantation proceeds safely and is the treatment of choice for the deafness. MRI-dependence is its own comorbidity: patients needing repeated brain imaging, as in NF2 tumour surveillance or oncology, must be planned around magnet artefact, magnet removal, or removable-magnet and MRI-conditional device choices.[2020][2009]

TShared decision-making when the stakes are high

When the downside is loss of a person's last functional hearing or an elevated surgical risk, the team's role shifts from gatekeeping to structured, transparent shared decision-making. The patient must understand both the realistic best outcome and the worst plausible outcome, expressed in terms of everyday function rather than audiometric numbers alone. Multidisciplinary input, from cardiology, haematology, oncology, and the candidate's family, broadens the safety net and clarifies which risks are modifiable. Documenting the reasoning, the alternatives considered, and the patient's informed preference protects both the patient and the team and reflects the genuinely individualised nature of these cases. The default should be inclusion with mitigation rather than exclusion, since blanket refusal denies benefit to patients who often have the most to gain.[2020][2009]