Download Cochlear Implants in adults

Caroline Selvaratnam
Audiologist
NCIP
University of Auckland
Outline
1. Referral criteria.
2. Eligibility for public funding Vs
Suitability for implantation.
3. How do we determine who
receives an implant first?
4. Likely outcomes for different
client groups.
5. More to be aware of
Eligibility for funding
is not the same as
suitability for an
implant.
Who should I Refer?
 For a public referral, clients with 60% or less for
CVC words at Pimax (in the better ear for the
public program. Privately we would look at any
patient who is under performing with well fit aids).
 Clients who have had pre-lingual access to sound.
 Clients who are well enough to have an operation
or deal with the cognitive load that a CI switch on
entails.
 NZ Citizens/ residents.
An example of a
possible CI
candidates
audiogram.
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PTA
What do I need to do to refer?
• Diagnostic hearing test (including bone)
• Check the ear moulds.
• Make sure hearing aids are appropriately
fitted.
• If the client does not tolerate aids any
where near a prescriptive target, please
document the process you have taken to
habitulise the client.
• Do real ear testing.
Regions in NZ
Two CI programs –
Northern (Taupo and above).
Children (under 19 years):
The Hearing House
[email protected]
Adults : The University of
Auckland. [email protected]
Southern –
adults and children
[email protected]
Exceptions to the process?
 Meningitis.
 Immediately notify the team and send
information through as it is collated.
 Scans will be arranged urgently and will not be
dependent on all other information coming in.
 The team may request a hearing aid trial if there
is residual hearing, or they may just ask for ear
moulds or they may not want either.
 Delays can occur if the client is too unwell to
make appointments.
The CI Assessment/ reassessment
 Has four goals.
To determine if a client is likely to do better with
a CI than an aid.
2. To determine if a client is eligible for public
funding.
3. To make sure that the client has the best access
to sound possible while they wait on the funding
list.
4. To make sure that the client understands the
process and their personal likely outcomes.
1.
Contraindications for CI Implantation
 Medical, may not be fit for surgery, anaesthesia.
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Cochlea may be too ossified from meningitis. Other
significant health complications
Auditory nerves not stimulated for a long time, or at
all.
Psychosocial, mental illnesses, poor familial support.
Poor auditory input likely (client doesn’t use sound to
interact with their world)
Very unrealistic expectations
Poor compliance with previous undertakings, e.g.
Hearing aid trial, appointments.
Inability/unwillingness to attend appointments on
a regular basis.
Public vs Private eligibility.
Public
Private
Aided hearing in better ear >
60% for sentence material or
> 30 % for words.
Yes
No, we would look at
each ear individually
and would consider if
there were significant
dead regions within
the cochlear.
NZ citizen or resident
Yes
Doesn’t matter.
Medically suitable for surgery
and cognitively able to cope
with switch on.
Yes must be both
Yes must be both
Appropriate expectations
Yes
Yes
Unlikely to receive benefit
No
No
Why do we care about well fitted
aids?
 Clients may have a long wait for funding.
 Poor communication can impact on
relationships, mental health, work
prospects, safety.
 Auditory stimulation makes the CI
adaptation process easier.
 If there is useable hearing, people perform
better with an aid on the non CI ear.
CIPAC Score
 High scores –Working or looking for work, sudden
HL, dependents, vision acuity problems, hearing
loss has high impact on quality of life, not able to
function with aids etc.
 Lower scores – no urgent needs, still able to function
with aids, poor auditory stimulation.
 Depending on the program clients may be reassesed regularly to determine if their position on
the funding list changes.
 As of this date the longest that some one has been
waiting on the northern funding list is 5 years.
Factors Affecting CI Benefit
Permanent
- Amount of residual hearing pre-implant
- Amount of stimulation of auditory nerves beforehand
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(all frequencies) or duration of deafness.
Age of implantation
Auditory environment
CI use (all day?)
Amount of auditory training/rehabilitation
Motivation
Good/Deep insertion achieved?
Pre-lingual, post-lingual
Word discrimination skills
Poor surgical outcome
Expected outcomes for Post
Lingually Deaf Adults with
normal cognition.
• Sound-field thresholds in the 15-30 dB range
for a well optimised Map.
• Ability to hear and identify environmental
sounds.
• Auditory only hearing for speech in quiet
within 1-3 months.
• Able to use the phone in time.
• In time able to hear speech in low level
noise.
• May not have good music perception.
Outcomes for Congenitally Deaf
Adults
• Expect adaptation process to take 1-2 years.
• Expect non auditory stimulation for some/ all
electrodes to start with.
• Once client adapts expect access to environmental
sounds.
• Speech reading will be easier.
• No expectation of speech understanding auditory
only.
• No access to the phone.
• No ability to hear in noise.
Post lingually deaf, poor auditory
stimulation or APD.
 Expect adaptation process to take three to six months.
 Non auditory stimulation may occur at some
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electrodes.
Expect access to environmental sounds.
CI will help with lip reading.
CI will provide help in the absence of lip reading (in
quiet)
CI may not provide assistance when in noisy settings.
Phone use may be obtained (if they could use the
phone in the past) but assistive devices may be
needed.
CI and wireless.
• The same as the
Resound wireless
accessories.
• Need to be accessed by a
press of a program
button on a CI.
• Can be connected to a
Resound aid on the non
CI ear.
Electro-acoustic stimulation or
the “Hybrid”.
Electro-Acoustic
Devices (Hearing aid
amplifier connected to
the processor). Give
better boost in bass
sounds if there is
residual hearing.
Bilateral CI
 Currently not funded for adults but since July 2014
children in NZ receive two implants if it is clinically
appropriate.
 Improvements seen in
 Hearing in noise
 Localisation
 Many report clarity improvements
 May not perceive benefit with
 Music
 Base sounds
Bimodal Hearing
 CI on one ear and hearing aid on the other.
 Improvements seen in
 Quality of sound and clarity.
 Hearing in noise and localisation (although
depending on the loss the improvement would
be greater with two CI’s).
 Music quality.
For audiologists
 If there is residual hearing on the other ear it is worth trying an
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aid!
For prescriptive targets do try Nal 2 (but remember that the
fitting is actually binaural). Make sure targets are matched in low
frequencies. If the target is below audibility in the high
frequencies don’t try and match it.
In most cases frequency compression/ transposition will not
work well so if you want it left on verify its benefit with speech
testing.
Some aids reaction times will need to be slowed down to match
with how fast the Cochlear implant environmental analyser
works.
Get to the point where the client feels that neither ear dominates
and both work together. Usually this is the point where you will
see maximum speech gains.