Download Alternative Hearing Technology - International Hearing Society

International Hearing Society
61st Annual IHS Convention and Expo
Alternative Hearing Technology
September 22, 2012
Mark J. Syms, MD, FACS
Arizona Ear Center
Phoenix, AZ
www.arizonaear.com
Background
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Married with 3 children
Born and raised in Philadelphia
Attended Boston College
Jefferson Medical College
Otolaryngology Residency at Tripler
Medical Center in Honolulu
• Otology/Neurotology Fellowship at House
Ear Clinic in Los Angeles
Arizona Ear Center
www.arizonaear.com
• Central Phoenix Location
• Tertiary referral practice – patients from entire
state and adjacent areas
• Disorders of the Ear – the “E” of ENT
• Ear Disorders – Cholesteatoma, Tympanic
Membrane Perforations, Cochlear Implants,
Hearing Loss, Hearing Aids, Implantable Hearing
Devices, Acoustic Neuromas
• Facial Nerve Disorders
• Balance Disorders
Anatomy
Expectations of IMEHD
• Enhanced, natural sound quality, especially in noise
• Reduced feedback and maintenance issues
• Improved fit, comfort, and cosmetics
• Elimination of ear canal occlusion
• Safe surgery that does not adversely affect anatomy
or physiology of the ear
Implantable Middle Ear Hearing
Devices
What are the benefits?
• No occlusion
• No feedback
• Better speech understanding in the presence
of background noise
• More comfortable
• Natural sound
Implantable Middle Ear Hearing
Devices
What are the risks?
Surgery-related risks (partial list)
• Anesthesia effects
• Additional hearing loss
• Taste disturbance
Non-surgical risks
• Unknown long-term effects
Implantable Middle Ear Hearing
Devices
How do they work?
• Sends sound energy from outside the head
to the bones in the middle ear
• Bypasses the ear canal and eardrum (except
Soundtec DDHS)
Implantable Middle Ear Hearing
Devices
Transducer Types
• Electromagnetic
– Electromagnetic fields, when surrounding a
permanent magnet, interacts with the
magnet causing it to move (attract and
repel).
• Piezoelectric
– Electrical energy can be applied to a
ceramic material, causing it to alter its
volume
Envoy Esteem
Envoy
Maxim Hearing Implant
Maxim Hearing Implant
Nd2Fe14B
Magnet
(Neodymium Iron
Boron)
Laser Welded Titanium
Cylinder (1.5 mm x 3.5
mm)
Residual Hearing-Loading Effect
Avg. Change by Air = 4.2dB Avg. Bone change = 1.1dB
Frequency in Hz
.25K .5K
d
B
H
L
0
10
20
30
40
50
60
70
80
90
100
1K
2
3K
4K
6K
PreImplant
PostImplant
Maxim
In-the-Canal Processor
Med-El Vibrant Soundbridge
• Electromagnetic
transducer
• Single point
attachment
• Semi-implantable with
upgradable technology
Symphonix® Vibrant®
Soundbridge™
Vibrating Ossicular Prosthesis™
™
(VORP )
Receives
signal from
external Audio
Processor™ (AP)
Transmits
signal to
Floating Mass
Transducer™ (FMT™)
Floating Mass Transducer™
• Single point
attachment
• Small size
– 2 mm length by
1.5 mm diameter
– 25 mg
Med-El Vibrant Soundbridg
• The FMT™ should be
in contact with the
incudostapedial
joint and parallel to
the axis of motion of
the stapes
• Round Window
Placement
Bone Conduction Hearing
(not only the BAHA)
Aural Atresia
• IF a patient is a candidate,
canaloplasty
• 30-50% revision
• 25-30 dB air bone gap GOOD
result
Bone Conduction Aid
• Uncomfortable
• Poor Cosmesis
• Diminished gain and fidelity
secondary to skin, muscle and fat
Osseointegration
Traditional alternatives
Direct Bone Conduction
• Works independently of ear canal and
middle ear
• Direct transmission gives clear sound
• Preoperative testing possible
• High wearing comfort
• Safe and simple surgery
The Baha System
The
®
BAHA
System
Cochlear™Baha® Product Portfolio
Cochlear™ Baha 3 (BP100)
Baha 3 Power (BP110)
Baha Cordelle II
Top performance, fully
automatic, head-worn,
All-round device
Head-worn power,
Discreet device
Client need:
Super power, body-worn
Ponto Bone Anchored System
 Sound Processors
Standard features
Hole for
safety line
Push button:
•Program selection
•Stand-by/Mute
Coupling
Inlet for
programming
Battery door
Volume
Direct Audio Input connector
control
Microphones
Hearing Aids are Medically Inappropriate for SSD & Some CHL
Inner Ear
Middle
Ear
Outer Ear
Conductive Hearing Loss
One cochlea is completely
impaired = Single Sided Deafness
(SSD)
SSD
Cochlear has normal function but
Middle and/or Outer ear problem
CHL
Hearing Loss Indications
Single Sided Deafness
• Caused by:
–Acoustic neuroma tumors, other surgical
intervention
–Sudden deafness
–Neurological degenerative disease
–Trauma
–Ototoxic treatments
–Genetics
–Meniere’s Disease
Baha System Candidate
Single Sided Deafness
• > 5years of age.
• Normal hearing in contralateral ear.
– Normal hearing is defined as PTA AC
threshold equal to or better than 20 dB at
.5, 1, 2 and 3kHz.
• Functions by transcranial routing of the
signal.
The Baha System for SSD
Clinical Aspects
Single Sided Deafness
• For adults:
– Difficulty understanding in group
conversations, or with noise.
– Difficulty localizing sounds.
– Difficulty understanding a person situated on
the deaf side.
• For children:
– Same difficulties as adults.
– School handicap.
Initial findings
Single Sided Deafness
• Handicap of SSD was
UNDERESTIMATED.
• Complaints of SSD:
– Difficulty understanding speech in noise
– Difficulty hearing sounds presented on the
deaf side
– Unbalanced environment
Personal Hygiene
Simply clean around the abutment with a soft cleaning brush
and gentle soap. This type of cleaning should take place at minimum
2 to 3 times weekly after the area is healed from surgery.
SoundBite
SoundBite Prosthetic Device For Treating
Single Sided Deafness & Conductive Hearing Loss
• Non-surgical bone conduction prosthetic device that transmits sound via
the teeth
• FDA cleared as a prosthetic device for Treatment of SSD & CHL
• Lower cost, lower complication alternative to prevalent surgical
treatment that uses same mechanism of action (bone conduction)
SoundBite Eliminates Surgical Costs and Complications
by Using the Tooth as a “Naturally Osseointegrated” Post
Baha®
SoundBite™
Transducer
Post =
Tooth
Bone
Cochlea
• Simple, non-surgical, non-invasive, and removable
• Superior sound quality:
• Much wider frequency response (500 to 12K Hz ) than
existing hearing devices,
• Microphone location in ear canal takes advantage of
natural acoustics
• Nearly invisible as worn
• Overall treatment cost is lower
• No surgical facility fee, anesthesiology fee, or post-op care
expenses
Cochlear Implants
Hearing Aids
• Presbycusis most common cause of
sensorineural hearing loss
• Hearing aids are and will remain
the best options for MOST patients
• Hearing aids restore volume
Hearing Aids
• Hearing aids in patients with poor
understanding often lead to patient
dissatisfaction
• Hearing aids unable to rehabilitate
understanding problems
• Understanding problems worse in
noise
Technology
• Fit the best technology to best rehabilitate
the loss
• Multiple factors involved in determining
what is best for a patient
Candidacy
There are four main areas of cochlear implant
candidacy to meet and complete.
• Audiologic candidacy
• Medical candidacy
• Psycho/social candidacy
• Insurance authorization
Audiologic Criteria
Pediatric Selection Criteria
Typical Hearing Loss Profile
- Severe-to-profound hearing loss in both ears
- Limited benefit from hearing aids
- In children, plateau in auditory development
with appropriate intervention
Older Children/
Adult Selection Criteria
– Moderate-to-profound hearing loss in the low pitches
and severe-to-profound hearing loss in the mid-to-high
speech pitches
– Can “hear” with hearing aids but cannot “understand”
what is said
- Reliance on lipreading or sign language
- Cannot use the telephone without difficulty
- Speech testing in best aided condition is less than 50%
Wheel of Fortune
_____ _____ _____ _____ _____ _____ _____ _____
_____ _____ _____ _____ _____ _____ _____
With only vowel sounds, it is difficult to
make out the words
_____ O _____ _____ _____ E A _____
I _____ _____ _____ A _____ _____
With consonants only, it is much easier
C _____ C H L _____ _____ R
_____ M P L _____ N T
However, you must first be able to
detect both vowels and consonants
in order to discriminate speech
C O CHL E A R
I M P L A N T
Hearing aids are unable to provide access to both vowel
and consonant sounds due to acoustic feedback, and limit
in high pitch gain.
Because a cochlear implant utilizes electrical sound
energy, more like our body’s natural nerve impulses, there
is access to all of the pitches of speech.
TWO main aspects to understand
with the transition from hearing aids
to a cochlear implant
• #2 Hearing aids
• Cochlear Implants
– Provide amplified sound
to hair cells in the organ
of hearing. Sound will
only be as clear as the
cochlea itself.
– Transmit sounds directly
into the cochlea bypassing the distorted hair
cells.
– “Goes through the
hearing loss”
– “Goes around the
hearing loss”
Clarity
• Hearing aids are unable to provide a
“clearer” signal of speech to your brain due
to distortion in the cochlea.
• Only a cochlear implant can improve
speech clarity and understanding. This does
not happen over night, but it does improve,
the more a patient uses and practices with
the device. (aka all waking hours).
Mechanics of the
Cochlear Implant
External Parts
• Microphone
The microphones serve to
detect sound and filter
sound to the processor.
External Parts
• Processor
The processor interprets sound, as
programmed during a patient’s
mapping and programming session.
This dictates the speed at which
sound is processed and the manner
in which electrical energy will
activate the electrodes.
External Parts
• Cables
The cables serve to transmit sound
from the processor to the
headpiece coil.
External Parts
• Coil
The coil transmits the sound
from the external device to
the internal hardware.
• Magnet
The magnet pulls the
external and internal
hardware together so they
may communicate
External/Internal Parts
• Radio Frequency
The communication of sound from
the external device to the internal device
occurs via radio frequency.
assigned to CIs.
Internals Parts
• Internal hardware
The internal hardware
sends the programmed
electrical energy to the
electrodes.
Frequency Distribution
2000 Hz 
500 Hz 
 ≥4000 Hz
Internal Parts
• Electrodes
The electrodes
send electrical
pulses to spiral
ganglion cells
within the cochlear
which in turn
stimulate the
nerve.
THREE MANUFACTURERS
YOUR CHOICE
Arizona Ear Center believes in the patient’s right to
choose which device is best for them.
Appropriate expectations…..
……….EQUALS SUCCESS
Completing the process of a cochlear
implant
• Evaluation and consultations
• Demonstrating understanding of the
commitment and desire to hear better
• Completion of the evaluation check-list
• Insurance authorization
• Surgery scheduling
Minimally Invasive Incision
Implant Well
Mastoidectomy
Inferior
(feet)
Superior
(top of head)
Posterior (table)
Left Ear
• Ear canal
(auricle flipped
anteriorly)
• Mastoid tip used
as initial drilling
landmark
Facial Recess
Superior
Inferior
(feet)
(top of head)
Posterior (table)
Left Ear
• Facial recess is a
triangle within a
triangle
• Facial recess
boundaries:
– Fossa incudis superiorly
(middle ear / incus)
– Facial nerve posteriorly
(motor innervation to the
face)
– Chorda tympani nerve
anteriorly (a branch of
the facial nerve, taste)
Facial Recess
Left Ear
• Visualization of the
stapes
• Visualization of the
facial nerve and chorda
tympani
Facial Recess
Left Ear
• Incudostapedial
joint
• Incus points to the
round window
• Promontory
denotes the
external surface of
the cochlea
Cochleostomy Right Ear
Anterior (nose)
Superior
• The cochleostomy
is created anterior
and inferior to the
round window.
(1.5 and 1.0
diamond burrs.)
(head)
Inferior
(feet)
Posterior (table)
Cochleostomy
Electrode Insertion
Electrode Insertion
Minimally Invasive Cochlear Implantation
Minimally Invasive Cochlear Implantation
Paradigm Shift
• Best care involves DIRECT
cooperative care between hearing
healthcare provider and otologist
• Remove primary care as “middle man”
• Elimination of economic competition
Hearing Healthcare Providers
• Provide the best patient care
possible
• Highest level of patient satisfaction
• Economically viable practice
Arizona Ear Center
Paradigm Shift
• Project most advanced technology
to all regions of Arizona
• Provide hearing aids and service
LOCALLY
Arizona Ear Center
Paradigm Shift
• Local care is the best care
• Enhance hearing healthcare
provider’s practice with cutting
edge technology
Arizona Ear Center
Paradigm Shift
• Provide referral forms to hearing
healthcare providers
• Arrange for needed referral on
behalf of the patient
• Correspondence to hearing
healthcare providers
Arizona Ear Center
Paradigm Shift
• Refer patients for evaluation – not
implantation
• If 100% of referred patients receive an
implant, you are not sending all of the
possible candidates
• Patient exploration of technology
enhances your practice and reputation
Questions?