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Special Considerations in Pediatric Cochlear Implantation Samuel P. Gubbels, MD, FACS Assistant Professor Director, UW Cochlear Implant Program Department of Surgery – Otolaryngology Waisman Center Conflict of Interest • I have no financial relationships to disclose • I will discuss a non-FDA approved indication for cochlear implantation Topics • Hearing loss in children • CI evaluation in children • Timing for cochlear implantation • One or two ears? • Predicting outcomes in children • Regenerative therapies – Significance for children today www.bcm.edu Hearing Loss • 538 million worldwide with hearing loss3 • Permanent hearing loss in 3 in 1000 newborns5 – Most common birth defect – 12,000 children per year in the US6 • 31 million Americans with hearing loss2 – 10.5% of population – 14% of baby boomers (48-66 yo) – 7% of Generation X (33-48 yo) • $297,000 to $1,000,000 lifetime cost per individual1,4 1Mohr (2000) Int. j. technol. assess. health care 16:1120-1135 2Kochin (2005)Hearing Review 12(7): 16-29 3Stevens et al., Eur J Public Health (2011) Epub 4 Johnson et al., (1993) Seminar in Hearing 14(1):105-119 5 Ross et al., (2008) Trends in Amplification 1291): 27 6 White (1997)Workshophttp://www.infanthearing.org/resources/fact.pdf Hearing Loss in Children • Early intervention leads to better developmental outcomes1 • Progress at age-appropriate rates with appropriate intervention2 • 92% of children with hearing loss have normal hearing parents3 • Parents suspect hearing loss before physicians4 1 2 3 4 Holt & Svirsky, (2008) Ear & Hearing 29(4):492-511 Geers et al., (2009) Journal of Deaf Education 14(3): 371-85 Mitchell and Karchmer, (2004) Sign Language Studies 4(2): 138-63 Harrison and Roush, (1996) Ear & Hearing 17(1): 55-62 Causes of Hearing Loss in Children Figure 3 Environmental and genetic contributions to total congenital SNHL Richard JH Smith , James F Bale Jr , Karl R White Sensorineural hearing loss in children The Lancet Volume 365, Issue 9462 2005 879 - 890 http://dx.doi.org/10.1016/S0140-6736(05)71047-3 Presentation of HL in children • • • • • Failed newborn hearing screening test Head turning to sound in infants Family history of congenital hearing loss Failed hearing screening tests Delayed speech and language development Cochlear Implant Evaluation • • • • Audiological Medical - Otologist Radiological Pediatric patients – Speech and language evaluation – Educational assessment – Social work consult with patient and parents UW CI Program • • • • • • • Audiologists Surgeons Speech Pathologists Social Worker Educational Audiologist Program Coordinator Administrative Assistants • Multidisciplinary conference Cochlear Implant Indications • Bilateral severe to profound sensorineural HL – FDA - 12 months old minimum – Speech discrimination score < 40%* • Sentence level material in best-aided condition • Inability to benefit from hearing aids in 6 month trial • No medical, behavioral or radiological contraindications * Varies depending on insurance status Cochlear Implant Audiological Assessment • Unaided and aided audiogram • Age appropriate aided speech perception assessment – Sentence level tests in best aided conditions • • • • Auditory Brainstem Response (ABR, BAER) Auditory Steady State Response (ASSR) Otoacoustic emissions (OAE) Hearing aid trial period (at least 6 months in length) Pediatric Audiological Assessment • Behavioral Observation Audiometry – Birth to 6 months old • Visual Reinforced Audiometry – 7 months to 2.5/3 years old • Conditioned Play Audiometry – 3-7 years old • Speech Testing Candidacy – Parental Factors • Appropriate expectations • Enrollment educational and rehabilitation programs – Development of auditory and verbal skills • Able to bring child to regularly scheduled training, mapping and follow-up sessions • Motivation to function within community that depends on spoken communication CI Radiological Evaluation • CT versus MRI? – CT – Bone anatomy – MRI – Soft tissue • Congenital • Auditory nerve McClay et al., Arch Otol (2008);134(9):945-952 Auditory Neuropathy • • • • • Sound transmission to the brain in impaired Sound enters the ear normally Poor speech perception abilities Disease of the auditory nerve Cause is unclear – Gene mutation present in some (Otoferlin) • Debate on role of cochlear implantation versus hearing aid usage www.health.state.mn.us CI Radiological Evaluation • CT versus MRI? – CT – Bone anatomy – MRI – Soft tissue • Congenital • Auditory nerve • Cochlear malformation CI Radiological Evaluation • CT versus MRI? – CT – Bone anatomy – MRI – Soft tissue • Congenital • • • • • Auditory nerve Cochlear malformation Skull thickness Otomastoiditis Labyrinthitis ossificans Contraindications to CI • Active otitis media • Absent auditory nerve • Relative Contraindications – Cochlear dysplasia – Labyrinthitis ossificans – Canal-wall down mastoidectomy – Psychiatric disease – Unrealistic expectations – Neurofibromatosis Type 2 CI Components – Internal Device Antenna Magnet Cochlear electrode Receiver stimulator Ground electrode www.cochlearamericas.com CI Components – External Device Magnet Inductive Coil Microphone Speech Processor www.cochlearamericas.com Current Devices in Use Cochlear Nucleus www.cochlearamericas.com Advanced Bionics www.bionicear.com Med-El www.medel.com Immunization for Pediatric Cochlear Implantees • Pneumonia (Streptococcus pneumoniae) vaccination – Routine immunization for all children – Additional vaccinations may be needed for cochlear implantees • Meningococcal and Haemophilus vaccinations as otherwise recommended • UW Cochlear Implant Program – Communicates recommendations with family and assists in coordination of vaccination with pediatrician http://www.cdc.gov/vaccines/vpdvac/mening/cochlear/dis-cochlear-gen.htm CI Surgery • General anesthesia • Outpatient or overnight stay • 1.5 - 2.5 hours • Minimal hair shaving • Operating microscope • Facial nerve monitoring • One month healing time Risks of CI Surgery • • • • • • Device failure Infection Disequilibrium Facial stimulation Facial weakness “Technological” • CI-related risks generally less than 5% – Major complications less than 1% How Well does a CI Work? • Significant improvement in open set speech recognition • Improved quality of life across multiple age groups* – Quality of life assays validated for hearing loss • >219,000 worldwide • Variability exists *Vermeire (2005) Otol Neurotol 26:188-195 Life with a Cochlear Implant • • • • • • Sound quality Batteries Usage Externals MRI Surgical implications When to Implant? • 1 year old minimum – per FDA • Implantation in younger patients safe – Pediatric team, surgical considerations • Developmental window for speech and language acquisition – In absence of normal stimulation1 • 3.5 years maximal brain plasticity • >7 years plasticity greatly reduced 1Sharma, Dorman, Spahr (2002), Ear & Hearing:23;532-39 Cochlear Implantation in Infants • FDA Age requirements – 1970 - Profound HL in adults – 1980 – Children age 2 years – 1990 – Children age 18 months – 1998 – Children age 12 months to adult • Is there additional benefit to earlier implantation (<1 year)? – Do the benefits outweigh the risks of surgery in very young patients? Early Implantation • Connor et al. (2006) – ”Growth burst” after CI* – Lost after 7 y for consonant production – Lost after 3.5y for vocabulary -*Controlled for years of device usage • Robbins et al. (2004)– Percentages of children achieving communication levels equal to normal hearing counterparts** – 12-18 mo 50% – 19-23 mo 25% – 24-36 mo 10% **Infant Toddler Meaningful Auditory Integration Scale Cochlear Implantation in Infants • Safety of cochlear implantation in patients demonstrated in multiple studies – – – – Roland et al. (2010) – 50 children, 5-11 mo Valencia et al. (2008) – 15 pts, 6-11 mo Roland et al. (2005) – 18 pts, 6-11 mo Coletti et al. (2005) – 10 pts, 4-11 mo • All studies emphasize importance of experienced pediatric care providers • • • • Audiological evaluation pitfalls Anesthetic considerations Surgical considerations Programming and rehabilitation challenges Early Implantation Summary • Improved receptive and language development when implanted before 1 year • More likely to achieve potential and reduce need for “catch up” period – Auditory perception – Linguistic development • Risk to benefit ratio favorable under appropriate conditions Cosetti & Roland (2010) Trends in Amplification 14(1):46-57 Bilateral Cochlear Implantation • Pro – Speech – Localization – Better ear always implanted – Continued stimulation if one device fails, infected • Cons – Surgical considerations – Vestibular deficit • Risk appears acceptable – Preserving ear for future regenerative strategies • Hybrid Implant – Cost – Healthcare resource distribution Advantages of Bilateral Cochlear Implantation • Speech intelligibility – Advantage in noise more than quiet – Adults – • 56% improvement in speech intelligibility in noise • 21-28% receptive improvement in noise – Children • Sequentially implanted children 21% speech improvement in noise • Postlingually deaf • Prelingually deaf* – *Intelligibility advantage does not require prior binaural experience *Litovsky RY et al. Int J Audiol 2006; 45 (Suppl 1):S78–S91. Advantages of Bilateral Cochlear Implantation • Localization accuracy* • Subjective measures – Unilateral CI 50-67° – Bilateral CI 24-30° – 70% of bilateral <20° • Children** • Adults 1-2 mo after second implant • Children 1-2 years after second implant** *Verschuur CAet al. Auditory localization abilities in bilateral cochlear implant recipients. Otol Neurotol 2005; 26:965– 971. ** Litovsky et al. Ear Hear (2006) 27(1):43-59 – Improved speech in noise and localization – Quality of life measures conflicting on advantage of bilateral CI* • Especially children *Summerfield QA et al. Int J Audiol 2006; 45 (Suppl 1):S99–S107. Predicting CI Outcomes • Predictive factors… – Duration of deafness • Most important factor – Cause of hearing loss – Age when deafness occurred – Prior speech and language skills – Consistent usage of the device – Age at implantation Language Outcomes • Individual outcomes challenging to predict • General findings – Earlier age associated with better outcomes – Children with CI outperform those with hearing aids – Some children acquire language at a rate similar to normal-hearing children – Wide range of benefit observed – Many children with CI achieve literacy skills approaching those of peers • Variability exists Ganek, Robbins & Niparko (2012) Oto Clinics of N. America 45:173-85 Regenerative Therapies for Hearing Loss • Inner Ear Hair cell loss – Approx. 80% of cases • Nerve degeneration follows Scale bars: h - 20 μm; j - 2 μm http://depts.washington.edu/hearing/InnerEar HairCellRegeneration.php Gubbels et al., Nature (2008):455;537-541 Hair Cell Regeneration – Gene transfer • Cell cycle modulators • Transcription factors • Gene replacement – Inner ear stem cells – Cell transplantation • Stem Cells Gubbels et al., Nature (2008):455;537-541 Mouse Atonal Homologue 1 (Atoh1) • • • • “Pro-hair cell gene” Necessary for inner ear hair cell formation Focal point of hair cell regeneration Forced expression of Atoh1 – Multiple in vitro1,2 and animal models3-6 1Woods, C., Montcouquiol, M. & Kelley, M.W. Nat. Neurosci. 7, 1310–1318 (2004). 2Zheng, J.L. & Gao,W.Q. Nat. Neurosci. 3, 580–586 (2000). 3Gubbels, S.P., Woessner, D.W., Mitchell, J.C., Ricci, A.J. & Brigande, J.V. Nature 455, 537–541 (2008). 4Kawamoto., Ishimoto, S.,Minoda, R., Brough, D.E. & Raphael, Y. J. Neurosci. 23, 4395–4400 (2003). 5 Izumikawa, M. et al. Nat. Med. 11, 271–276 (2005). 6Lumpkin, E.A. et al. Gene Expr. Patterns 3, 389–395 (2003). Atoh1 Generated Supernumerary Bear Stereociliary Bundles P35 Whole Mount Scale bars: h,I 20 um; j,k 2 um Gubbels et al., Nature (2008):455;537-541 Innervation of Atoh1 Generated Hair Cells Scale bars: 10 um Gubbels et al., Nature (2008):455;537-541 Atoh1 Generated Hair Cells are Functional Gubbels et al., Nature (2008):455;537-541 Akil O et al., Neuron (2012) 75:283-293 Gene Transfer for Hair Cell Regeneration • Evidence – Functional auditory hair cells using Atoh1 gene transfer in vivo – Improvements in ABR thresholds of deafened guinea pigs • Challenges – Cochlear access • Damage – Viral delivery • Safety • Distribution – Patterning • Ectopic locations • Effect on hearing Mizutari K et al., Neuron (2012) 77:58-69 Pharmacothereutic approaches • Advantages – Avoid cell-related concerns – Avoid concerns with gene transfer – Large number of compounds • Disadvantages – Toxicity – Side effects – Duration of effect Hair Cell Regeneration – Gene transfer • Cell cycle modulators • Transcription factors • Gene replacement – Inner ear stem cells – Cell transplantation • Stem Cells Why use pluripotent stem cells? • Availability – Approved banks in existence • Consistent and well-defined supply • Malleable Pluripotency • Self-renewing Mouse Embryonic Stem Cells Generate Hair Cell – like Cells Oshima K. et al., Cell (2010); 141(4): 704-716 Mouse Embryonic Stem Cells Generate Hair Cell – like Cells Oshima K. et al., Cell (2010); 141(4): 704-716 Hair Cells from Human Pluripotent Stem Cells • • • • No reports to date Ongoing work in many laboratories Embryonic stem cells Induced pluripotent stem cells – Avoid the ethical debate Neural Differentiation Paradigm Cells: - Human H9 Embryonic Stem Cells (ESC) - Human IMR90-4 Induced Pluripotent Stem Cells (iPSC) Pankratz TM, Zhang SC et al., Stem Cells (2007):25(6):1511-20 Hu BY, Weick JP et al., PNAS (2010):107(9):4335-40 Otic Gene Expression – H9 ESC Neural Differentiation Co-Expression of Otic Markers Chen W et al. Nature (2012) 490: 278-282 Stem Cells as a Novel Therapy for Hearing Loss • Stem cells can generate hair cells in vitro – Multiple types – Rodent – Functional • Challenges in transplantation into the cochlea – Access – Engraftment, integration, functionality Stem Cell Clinical Trial • Houston – Children’s Memorial Hermann Hospital • PI - Dr. Samer Fakhri • Cord Blood • Safety Study • 10 Children • 6wk-18 months • “Post-Birth HL” • IV infusion Regenerative Therapies for HL • When? – Remains unclear • How? – Gene transfer, stem cells, pharmaceuticals – Intravenous, Injections into middle/inner ear – Delivered by a cochlear implant electrode • Where? – Hopefully at UW-Madison! Current Relevance -Should my infant have cochlear implants on both sides? • Candidacy for future regenerative therapies – Electrode trauma – Lifetime of ongoing research in regenerative therapies • Benefits of CI clear – Bilateral • Cellular degeneration over time – Organ of Corti – Auditory nerve – Central networks Summary • Special considerations in children – Candidacy assessment – Multidisciplinary team critical • Advancements in CI in children – Early implantation – Bilateral implantation • Active investigations into novel therapies for hearing loss • Regenerative therapies factoring into current clinical decision making Acknowledgements • Department of Surgery – Otolaryngology • Waisman Center • • • • • Parul Trivedi Cynthia Chow Megan Duffey SuChun Zhang Funding – NIH/NIDCD • 1 R03 DC012432-01 – Institute for Clinical and Translational Research* • Type I Pilot • KL2 – Department of Surgery *The project described was supported by P30 HD003352 and the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011, and now by the National Center for Advancing Translational Sciences (NCATS), grant 9U54TR000021. Thank You! Immunization for Pediatric Cochlear Implantees • Routine PCV13 vaccination • Age 2-5 years - PCV13 X 2 if they have not received any PCV7 or PCV13 previously – If four-dose PCV7 series completed then one dose of PCV13 through age 71 months. • Age 6-18 years - PCV13 X 1, regardless of previous PCV7 or pneumococcal polysaccharide vaccine (PPSV) (Pneumovax®) • One dose of PPSV at age 2 or older, and after completing all recommended doses of PCV13 • Meningococcal and Haemophilus vaccinations as otherwise recommended http://www.cdc.gov/vaccines/vpdvac/mening/cochlear/dis-cochlear-gen.htm