Preoperative cranial computed tomography in pediatric cochlear implantation: clinical necessity or optional step?

Due to growing evidence regarding the risks of ionizing radiation, especially in children, some centers now perform cochlear implantation (CI) without a preoperative computed tomography (CT) scan, relying solely on magnetic resonance imaging (MRI). This study evaluates the necessity and safety of omitting CT scans before bilateral CI in children.

A retrospective analysis of 164 children, implanted bilaterally between 2018 and 2024 and aged under 10 years at the time of either simultaneous or second CI, were included. The impact of preoperative imaging on duration of surgery and perioperative complications was analyzed. The surgical procedure was compared between cases with and without a preoperative CT scan and analyzed for surgeons in training and experienced surgeons.

105 children were implanted with a preoperative CT scan and 59 without a CT scan. The duration of bilateral CI surgery was 122.5 (±41.4) min for procedures [CI without CT: 122.5 (±41.4) min; CI with CT: 116.1 (±33.84) min; (p = 0.4861)] and anesthesia [CI without CT: 237.2 (±47.38) min; CI with CT: 226.3 (±41.50) min; (p = 0.1352)] did not differ significantly between the groups, irrespective of the experience of the surgeons. Seven cases showed relevant malformations visible on MRI, such as large vestibular aqueduct syndrome, which were relevant during the surgery. Minor and major complications occurred rarely in both cohorts but more frequently in patients without CT scan (without CT: 10.2% (6/59); with CT: 4.8% (5/105); p = 0.2052; risk difference [RD], 5.4%; 95% CI, -6.3 to 14.3%). Intraoperative X-ray imaging revealed no cases of electrode tip fold-over, and no patients developed postoperative complete or incomplete facial nerve palsy.

In summary, an MRI-based imaging strategy without routine preoperative CT may be safe and sufficient in appropriately selected pediatric CI candidates, with additional CT reserved for patients in whom clinical or MRI findings suggest relevant bony abnormalities, complex inner ear malformations, or syndromic conditions. This approach reduces unnecessary radiation exposure and the use of healthcare resources, while avoiding redundant diagnostic information from both imaging modalities, without compromising surgical safety or outcomes.