10/31/2013 • No disclosures Cochlear Implants: Where we’ve been, Where we are Colleen Polite, AuD Assistant Director Cochlear Implant Center Otolaryngology Head and Neck Surgery University of California, San Francisco November 1, 2013 2 Objectives • Candidacy Criteria • Cases Warranting Referral • Emerging Indications Poll: I work with CIs in my practice 3 1
10/31/2013 Poll: How many CI candidates have you seen in ... Poll: How many patients have you referred for ... AudiologyNOW 2008 Survey Population Statistics 60 • 1,000,000 potential CI candidates in US • 7.5% of people who could benefit from CI have 50 one 40 • 3% of audiograms met FDA criteria for CI 30 20 10 0 Saw None Saw 1 ‐ 4 Ref'd None Ref'd 1 ‐ 4 Huart, 2009 7 8 2
10/31/2013 Consumer Survey Market • Average time from onset of severe-profound hearing loss to CI = 12 years • Average time from learning about CI and discovering eligibility to surgery <1 year • Almost 80% of CI recipients said they would have gotten a CI earlier if they had known about it ENT-VSL-3.2 Increase the proportion of persons who are deaf or very hard of hearing and who have cochlear implants 9 10 Baseline: 76.8 per 10,000 persons Target: 84.7 per 10,000 persons 10 percent improvement www.healthypeople.gov/2020 11 12 3
10/31/2013 Where we’ve been Bilger Report, 1977 • Benefits lipreading • Environmental sound awareness • Better modulation of voice • Possibilities of improvement 13 14 Where we’ve been Where we’ve been Candidacy: Adult Candidacy: Adult • First outcomes reported pre-op vs. post-op 1985 • Comparisons of HA users and CI users Age: 18 yrs+ • Results on CI outcomes in patients with more Hearing loss: bilateral profound post-lingual hearing pre-op Speech recognition: 0% words or sentences with HAs Hearing aid use: 6 months 15 16 4
10/31/2013 Where we are Candidacy: Adult Candidacy: Adult Today Age: 18 yrs+ Hearing loss: bilateral MODERATE – PROFOUND , post-, peri- or pre-lingual Speech recognition: ≤ 50% on sentences in ear to be implanted and ≤ 60% best aided/contralateral ear Figure 2. Advances in technology and signal processing in cochlear implants have resulted in improved performance outcomes. Shown are group mean scores for CUNY and HINT sentences in quiet and CNC monosyllabic words from multiple sources: Skinner et al. (1994), Skinner et al. (1991);Pijl et al. (2009). Huart, 2009 17 18 Where we are Candidacy: Adult • Speech scores can approximate normal hearers • Near ceiling performance at 3 - 6 months experience • Updated speech battery (MSTB 2011) Gifford, 2008 19 20 5
10/31/2013 Candidacy: Pediatric Candidacy: Pediatric Today 1990 Minimum age: 12 – 23 mos Minimum age: 2 yrs Hearing loss: <24 mos prof HL; ≥ 24 mos sev-prof Hearing loss: profound Communication: 30-40% word or sentence scores Communication: 0% words or sentences with HAs Hearing aid use: 3-6 months Hearing aid use: 6 months 21 22 Candidacy: Pediatric Word Learning • Lower minimum age – Higher communication performance – Higher scores on all language measures Houston, et al. 2012 23 24 6
10/31/2013 Will Older Children Catch Up? Candidacy: Pediatric • More hearing – Children with poorer hearing pre-CI had lower language skills at 3.5 yrs – Accounted for almost 60% of variance in language performance Nicholas and Geers, 2006 Nicholas & Geers, 2007 25 26 Where we are Candidacy: Pediatric Referral Warranted • Reduced HA trial period • Fluctuating hearing loss • Children diagnosed and using hearing aids at the earliest ages experienced longer periods of hearing aid use before implantation. • Children with greater aided residual hearing also experienced longer hearing aid trials before implantation. • These data suggest long periods of hearing aid use prior to cochlear implantation may not always be the most beneficial course of action for young children who may be CI candidates. 27 28 7
10/31/2013 Enlarged Vestibular Aqueduct Audiogram (Pre-Eval) • Most common imaging finding Word Recognition • Excellent candidates for CI RE: 4% – Early referral for patients with progressive/fluctuating loss LE: 84% • Variable outcomes when associated with other PTA cochlear malformations RE: 72 dB HL LE: 105 dB HL • Surgical risk of CSF gusher – Managed intra-operatively – Has no significant effect on speech outcomes (Adunka, et al., 2012) Drop in RE hrg 1 mo ago following head injury Increased tinnitus since drop in hrg 29 Audiogram (CI Eval) Audiogram (CI ) Aided Speech Speech Perception 1 mo CNC AzBio-Q/+10 CNC AzBio-Q/+10 RE: 0% CI: 56% 75% / 32% LE: 60% Speech Perception 3 mos B: 50% 58% / 42% CNC AzBio-Q/+10/+5 CI: 74% 71%/57%/17% CI+ HA: 96% 100%/88%/73% 8
10/31/2013 Where we are Ménie ̀ re’s Disease Referral Warranted • Significant improvement • Fluctuating hearing loss – Even with previous chemical or surgery treatment – EVAS • Results similar to other post-lingually deaf – Meniere’s adults • Asymmetrical hearing loss • Improvement in tinnitus – Implant poorer ear • Most achieve stable hearing – Bimodal listeners Lustig, et al., 2003 33 34 Where we are Auditory Neuropathy Referral Warranted • Fluctuating hearing loss No progress with auditory or language skills • – refer for CI evaluation – EVAS – CI may offer neural synchronization – Meniere’s • Outcomes are variable • Asymmetrical hearing loss – Comparable to SNHL in those without other – Implant poorer ear medical/cognitive issues – ? Contraindicated in hypoplasia/aplasia of cochlear nerve – Bimodal listeners – Counseling is key • Auditory Neuropathy Spectrum Disorder 35 36 9
10/31/2013 Where we are Where we are Referral Warranted Referral Warranted • Fluctuating hearing loss • Fluctuating hearing loss – EVAS – EVAS – Meniere’s – Meniere’s • Asymmetrical hearing loss • Asymmetrical hearing loss – Implant poorer ear – Implant poorer ear – Bimodal listeners – Bimodal listeners • Auditory Neuropathy Spectrum Disorder • Auditory Neuropathy Spectrum Disorder • WRS ≤ 50% • WRS ≤ 50% • Ski-slope hearing loss – Hybrid/EAS – Improved hearing in noise, music quality 37 38 Cochlear Malformations: CI Ski-slope Hearing Loss Candidacy • Not candidate • Candidate – Complete labyrinthine – Common cavity aplasia – Cochlear hypoplasia – Cochlear aplasia – Incomplete partition – Absent auditory nerve – SCC dysplasia – Enlarged Vestibular Aqueduct 39 40 10
10/31/2013 Where we are going Where we are going Emerging Indications Emerging Indications • <12 months • <12 months • SSD/Unilateral – What happens when there is no access to auditory information in the first year of life? – Cognitive mechanisms/language processes – Sensitive periods 41 42 Emerging indications/Expanding Where we are going Criteria Emerging Indications • <12 months • <12 months – Improved phonological skills • SSD/Unilateral – Superior speech understanding – Language skills growth rate similar to normal-hearing peers – Support non-verbal cognitive development (Coletti, 2011) • Risks – Minimalized by experienced pediatric surgeons and anesthesiologists 43 44 11
10/31/2013 Where we are going Success Emerging Indications • <12 months • SSD/Unilateral – Less difficulty hearing in noise – Some benefit for localization – Reduced tinnitus – ? Hearing quality – ? Binaural benefits 45 46 Summary • Patients may have complex issues that need to be fully evaluated in the CI work-up • Early referral of children for CI is best Thank you! • Moderate to profound HL indicates referral • Less than fair WRS warrants referral • Refer any patient with PTA and WRS discrepancy 47 12
10/31/2013 References available upon request • 49 13
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