Download Cochlear Implants

Cochlear Implants
Perry C. Hanavan, Au.D.
Question
Cochlear implants:
1. Amplify sound
2. Process sounds
3. Both A and B
4. None of the above
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Question
Who has the fundamental right to decide
whether a child should receive a CI?
A. NAD
B. Schools
C. Parents
D. Physicians
E. The State (government)
COCHLEAR
IMPLANTS
Chapter 18
THE
FACTS
CI Manufacturers
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MED-EL
Advanced Bionics
Cochlear
Neurelec
Who Makes the Decision for CI
and
When Should CI for Children with HI?
• Educator of the Deaf? Parents? Physician?
Audiologist? Child? Team? Others?
• Before 1 year, 18 months, 2 years, before 5?
• When person is old enough to make
decisions?
• Never?
CI Factoids
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About 70,000 people worldwide have cochlear implants
About 25,000 people in the United States have cochlear implants
About half of all CI recipients are children
CIs can help an estimated 200,000 children in the United States who do not
benefit from hearing aids.
The demand for CIs is increasing annually by 20%.
About 250 hospitals across the country perform cochlear implant
procedures.
A recent study on cochlear implants demonstrated that special education in
elementary school is less necessary when children have had "greater than
two years of implant experience" before starting school. These children are
mainstreamed at twice the rate or more of age-matched children with
profound hearing loss who do not have implants.
The benefits of a CI to society amount to a lifetime savings of $53,198 per
child.
By the time a child with hearing loss graduates from high school, as much
as $420,000 can be saved in special education costs if the child is identified
and given appropriate early intervention.
CI Study of 181 Children
• Most parents had normal hearing, majority (white) and had more education
and higher incomes than the general population.
• Families tended to be intact with both a mother and a father who involved
their child with CI in family activities on a regular basis.
• Children enrolled in the full range of educational placements available across
the United States and Canada.
• Fairly even distributions of children from public and private schools, special
education and mainstream classes and oral and total communication
methodologies were represented.
• Educational placement changed as children gained increased experience
with a cochlear implant.
• They received an increased emphasis on speech and auditory skills in their
classroom settings and tended to move from private school and special
education settings to public school and mainstream programs.
• Data support the position that early cochlear implantation is a cost
effective procedure that allows deaf children to participate in a normal
school environment with hearing age mates.
Geers A, Brenner C. (2003) Background and educational characteristics of prelingually
deaf children implanted by five years of age. Ear Hear. 24(1 Suppl):2S-14S.
Study of Children in US and CA
• Use of a cochlear implant has had a dramatic impact on the linguistic
competence of profoundly hearing-impaired children.
• More than half of the children in this sample with average learning
ability produced and understood English language at a level
comparable with that of their hearing age mates. Such mature
language outcomes were not typical of children with profound
hearing loss who used hearing aids.
• Use of a visual (i.e., sign) language system did not provide the
linguistic advantage that had been anticipated.
• Children educated without use of sign exhibited a significant
advantage in their use of narratives, the breadth of their vocabulary,
in their use of bound morphemes, in the length of their utterances and
in the complexity of the syntax used in their spontaneous language.
• An oral educational focus provided a significant advantage for both
spoken and total language skills.
Geers AE, Nicholas JG, Sedey AL. (2003). Language skills of children with early
cochlear implantation. Ear Hear. 24(1 Suppl):46S-58S.
Canadian Study
Children with cochlear implants have
increased educational opportunities, with
those children in mainstream and those who
have moved toward mainstream
demonstrating improved progress in speech
perception ability.
Daya H, Ashley A, Gysin C, Papsin BC. (2000). Changes in educational placement and
speech perception ability after cochlear implantation in children. J Otolaryngol.
29(4):224-8.
British Study
• Age at implantation and duration of deafness were found to be
significant predictors of placement two years after
implantation.
• The duration of deafness of children in schools for the deaf or
units was twice that of children in mainstream education.
• Fifty-three per cent of children who were in pre-school at the
time of implantation were in mainstream schools two years
after implantation, whereas only 6% of those who were
already in educational placements at the time of implantation
were in mainstream education.
• The results indicate that children who are given implants early,
before an educational decision has been made, are more likely
to go to mainstream schools than those given implants when
already in an educational setting.
Archbold S, Nikolopoulos TP, O'Donoghue GM, Lutman ME. (1998) Educational
placement of deaf children following cochlear implantation. Br J Audiol. 32(5):295-300.
Cost Effective
• Children with greater than 2 years of implant experience were
mainstreamed at twice the rate or more of age-matched children with
profound hearing loss who did not have implants.
• Also placed less frequently in self-contained classrooms and used fewer
hours of special education support.
• A cost-benefit analysis based on conservative estimates of educational
expenses from kindergarten to 12th grade shows a cost savings of cochlear
implantation and appropriate auditory (re)habilitation that ranges from
$30,000 to $200,000.
• CI accompanied by aural (re)habilitation increases access to acoustic
information of spoken language, leading to higher rates of mainstream
placement in schools and lower dependence on special education support
services.
• Cost savings that results from a decrease in the use of support services
indicates an educational cost benefit of cochlear implant (re)habilitation for
many children.
Francis HW, Koch ME, Wyatt JR, Niparko JK. (1999). Trends in educational placement
and cost-benefit considerations in children with cochlear implants. Arch Otolaryngol
Head Neck Surg. 1999 125(5):499-505.
Profound vs. Severe Loss & CI
• Highly significant difference between educational placement
of implanted children and hearing-aided profoundly deaf
children (p<0.00001)
• No statistically significant difference between implanted
children and hearing-aided severely deaf children.
• Implanted profoundly deaf children who have received their
implants before beginning school have the same profile of
educational placement as aided severely deaf children rather
than aided profoundly deaf children of the same age in the UK.
• This is likely to have significant implications for the future
management of profoundly deaf children and to influence
future planning of educational support services.
Archbold SM, Nikolopoulos TP, Lutman ME, O'Donoghue GM. (2002). The educational
settings of profoundly deaf children with cochlear implants compared with age-matched
peers with hearing aids: implications for management. Int J Audiol. 41(3):157-61.
CI by 6 Months
• By age of 2 years the subject implanted in infancy
achieved scores on the GAEL-P which were
nearly equivalent to those achieved at the age of 5
1/2 years by children implanted at later ages.
• Age-equivalent scores on the Reynell
Developmental Language Scales were achieved by
the subject implanted in infancy and the ability to
discriminate speech patterns was demonstrated
using the Visual Habituation Procedure.
• CONCLUSION: This report demonstrates
enhanced language development in an infant who
received a cochlear implant at the age of 6 months.
Miyamoto RT, Houston DM, Kirk KI, Perdew AE, Svirsky MA. (2003). Language
development in deaf infants following cochlear implantation. Acta Otolaryngol.
123(2):241-4.
Advocating Oral with CI?
• Data from Clarion cochlear implant pediatric clinical trials were examined
retrospectively to uncover trends in candidacy and postimplant benefit
over time.
• In particular, age at implantation, educational setting, and
communication mode were examined with respect to speech
perception performance after implantation.
• The results showed:
1) age at implantation is decreasing,
2) children in oral education programs obtain more benefit from a cochlear
implant than children in total communication programs,
3) children who undergo implantation before 2 years of age show greater
benefit than children who undergo implantation between 2 and 3 years of
age,
4) more younger children are using oral communication than older
children, and
5) more children with good auditory skills before implantation and more
residual hearing are undergoing implantation.
Osberger MJ, Zimmerman-Phillips S, Koch DB. (2002). Cochlear implant candidacy and
performance trends in children. Ann Otol Rhinol Laryngol Suppl. 189:62-5.
TC vs. Oral
• Spoken word recognition improved at a faster rate
in the oral children with early implantation.
• Children who underwent implantation before 3
years of age had significantly faster rates of
language development than did the children with
later implantation.
• The oral children demonstrated more rapid gains
in communication abilities than did children who
used total communication.
Kirk KI, Miyamoto RT, Lento CL, Ying E, O'Neill T, Fears B. (2002). Effects of age at
implantation in young children. Ann Otol Rhinol Laryngol Suppl. 189:69-73.
Families of Children with CI
• Children with hearing loss and their families who
sought CIs are not significantly different from
children with hearing impairments whose parents
were not seeking a CI.
• Results provided no support for the notion that
children with hearing loss from families seeking a
CIs for their child evidence more behavioral
deviance than children with hearing impairments
whose parents have not sought an implant.
Knutson JF, Boyd RC, Goldman M, Sullivan PM. (1997). Psychological characteristics of
child cochlear implant candidates and children with hearing impairments. Ear Hear.
18(5):355-63.
Sign vs. Oral & CI (Sweden)
• The aim of the study was to explore patterns of communication between 22
children with cochlear implants (CI) and their parents, teachers and peers in
natural interactions over a 2-year period.
• The children, between 2 and 5 years old when implanted, had used the implant
between 1 and 3.5 years at the end of the study.
• Analyses of videorecorded interactions showed that meaningful oral
communication was more easily obtained in the home setting than in the
preschool setting.
• Patterns of communication between parent-child, content and complexity of
dialogues, quality of peer interactions, communicative styles of adults, and the
use of sign language in communication turned out to be important factors
when explaining the result of the CI on the individual child's development.
• Children with the best oral skills were also good signers.
Preisler G, Tvingstedt AL, Ahlstrom M. (2002). A psychosocial follow-up study of
deaf preschool children using cochlear implants. Child Care Health Dev. 2002
Sep;28(5):403-18.
CI and Auditory Nerve
Three pictures of auditory nerve
tissue (from top to bottom),
showing normal synapses in a
hearing cat, long and flat synapses
in a deaf cat, and like-normal
synapses -- short and curved -- in a
deaf cat treated with a cochlear
implant. (Image courtesy of Johns
Hopkins Medical Institutions)
Research has clearly demonstrated
the ability of cochlear implants in
very young animals to forge normal
nerve fibers that transmit sound and
to restore hearing by reversing or
preventing damage to the brain’s
auditory system.
Teacher Role
• The study examined factors associated with teachers' ratings of functional
communication skills of students with cochlear implants.
• Deaf students living in and around a metropolitan area were surveyed to locate
51 with cochlear implants.
• Teachers rated each student's functional use of the implant, given three
defined ratings.
• Additional information regarding sex, communication option, placement,
home language, rural or nonrural address, etiology, and presence or absence of
an additional disability was gathered.
• The data indicated that students with a known etiology and a rural address,
and who used sign language at home or school, were less likely than others to
use the implant as a primary channel for receptive communication.
• The authors suggest that the teacher's role in implant use warrants more
attention.
Easterbrooks SR, Mordica JA. (2000) Teachers' ratings of functional communication in
students with cochlear implants. Am Ann Deaf. 145(1):54-9.
Show Video(s)
• 60 Minutes
• Oral Deaf
• Celia’s Story
• Sound & Fury
NAD CI Statement
• The NAD recognizes the rights of parents to
make informed choices for their deaf and
hard of hearing children, respects their choice
to use cochlear implants and all other
assistive devices, and strongly supports the
development of the whole child and of
language and literacy. Parents have the right
to know about and understand the various
options available, including all factors that
might impact development.
NAD CI Statement
• The NAD has always and continues to
support and endorse innovative
educational programming for deaf
children, implanted or not. Such
programming should actively support
the auditory and speech skills of
children in a dynamic and interactive
visual environment that utilizes sign
language and English.
Seven Steps to CI
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Initial contact
Pre-CI counseling
Formal evaluation
Surgery
Fitting/mapping
Follow-up
AR
Roles
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Audiologist
SLP
Educator of the Deaf
ENT
Child CI Candidate Criteria
Pediatric
• Profound bilateral SNHL
• Limited benefit from
appropriate binaural Has
• Lack of progress in auditory
skill development
• High motivation and
appropriate expectations from
family
12 – 24 months
• Severe to profound bilateral
SNHL
• MLNT – 30% or less in best
aided condition (25 mo to 4 yrs
11 mo)
• LNT – 30% or less in best aided
condition (5 yrs to 17 yrs 11 mo)
• Lack of progress in auditory skill
development
• No medical contraindications
• High motivation and appropriate
expectations (including children
when appropriate age
Adult CI Candidate Criteria
Pediatric
• Moderate to profound SNHL
• 50% or less – sentence recognition – in ear to be implanted
• 60% or less – sentence recognition – in opposite ear or
binaurally
• Pre-linguistic or post-linguistic onset of moderate to profound
SNHL
• No medical contraindications
• A desire to be a part of the hearing world
Why Are the CI Numbers
Increasing?
• Early Identification
• Improved technology
• Changing candidacy requirements
• Lower surgical risk
• Changing attitudes
How does an implant work?
1. Sound picked up by microphone
2. Electrical pulses of sound signals
sent to speech processor
3. Speech processor codes sound
signals
4. Code is sent to transmitter
5. Transmitter sends coded sound
across skin to internal receiver
(via FM transmission)
6. Receiver converts code to
electrical signals
7. Electrical signals sent to
electrode array
8. Signals recognized as sound by
the brain
Why are the outcomes different for
each child?
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Age at time of implant
Pre-implant duration of deafness
Etiology of hearing loss
Residual hearing prior to implant
Family support
Implant technology/channels
Consistency of usage
Appropriate programming of device
Additional special needs
Quality of educational and habilitative environment
Deciding which ear to implant-some issues
to consider
• Anatomy (lack of calcification, is there an auditory nerve,
malformed/no cochlea)
• Perhaps one ear accepts electrical stimulation better than other
• Leave ear with better hearing, implant worse ear, then if not
successful can revert back to aiding that ear
• Implant better ear (opposite argument) - It has already benefited
from hearing aid, will more readily acclimate to implant
• Facial nerve too close to cochlea-may pick other ear
• If no difference may want it on right- as speech and hearing
centers of brain on left
• Want on right- later for later when driving. Can hear people in
the car
Surgical Considerations
General
· Usually outpatient, 1-2 hours
· Two parts of implant are inserted during
surgery- electrode array in cochlea and
the implant body placed in mastoid bone.
Body holds a magnet that attaches to
external components of the implant.
During
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Shave area
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Mastoid bone uncovered (skin flap)
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Carve space for body of implant
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Drill hole to cochlea
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Small opening in cochlea to insert
electrode array
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Incision closed
After
· Usually up and
around in 1-2 days
·May be some
swelling externally
· Warned of some
possible nausea
from anesthesia
· Wait 4-5 weeks
for all
swelling/healing to
take place before
activation
What about insurance
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Cost of cochlear implant is $40,000-50,000
Most private insurance companies are paying for surgery
Most of the time Medicaid pays 90-100%
May be problems with insurance related to child being too young
based on FDA guidelines
• Implant manufacturers have special departments to handle
insurance related problems and secure payment.
• Some insurance companies pay for post implant
training/mapping
• Only a few insurance companies pay for upgrades (ear level) (
may get coupon for upgrade from the manufacturer)
Not CI Candidates
• a child that does not have the eighth nerve
(auditory nerve) which carries sound from the
cochlea to the brain as determined by a CAT
scan (x-ray) and/or Magnetic Resonance
Imaging (MRI) during the candidacy process.
• a child who has significant residual hearing
levels and receives good benefit from
traditional hearing aid devices.
Mapping Cochlear Implants
• Threshold (T) awarness/detection
• Comfort (C or M) Levels
• Loudness Balancing (judge relative loudness of signals
presented to different electrodes)
• Pitch Ranking (ability to discriminate pitch from one
electrode to the next, basal to apical end)
• During mapping process, "T" and "C" levels of each
individual electrode on CI internal electrode array (the
spiral located inside the inner ear or "cochlea") are
adjusted for the user to hear wide range of sounds that one
is typically exposed (soft to loud).
Mapping
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YouTube CI Mapping
YouTube CI Mapping II
YouTube CI Map of 8 mo old
YouTube Ling 6 with CI