Candidate Selection

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Candidate Selection
Taipei, Taiwan June 2002
Presented by Margaret Cheng
Clinical Specialist - NE Asia
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Selection Aims

• To make realistic recommendations on potential
  benefits for the child based on individual
  assessment
• To carry out the process effectively and provide
  appropriate long term management to maximize
  outcomes
• To optimize the potential for the implanted child
  to improve speech perception and production and
  develop communication skills

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Focus of Selection Procedure

• Establish whether there is a GOOD chance of
  improved hearing using a cochlear implant
• Ensure that there is minimal chance of a
  reduction in auditory ability

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Guidelines for Initial Referral

• Bilateral severe to profound SNHL either
  congenital or acquired
• Aided audiometric thresholds that fall outside
  speech range at 2 kHz
• Limited benefit through consistent hearing aid
  use to facilitate the development of functional
  speech and spoken language

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Considerations which may exclude candidacy

• Lack of auditory nerve integrity bilaterally
• Neurological damage impeding auditory processing
• Medical risks of surgery exceed the expected
  benefits of the cochlear implant

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Additional issues

• Active middle ear disease
• Cochlear abnormalities or ossification
• Developmental disabilities

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Selection Guidelinesfor Adults
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Adult Candidacy Selection Guidelines

• Candidate Category Postlingually deafened adults

• Audiological Selection Criteria
• Best individual ear open set listening score for
  sentences ? 50 under the best aided conditions.

• Special considerations
• The shorter the length of hearing impairment, the
  better the post-op performance.

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Adult Candidacy Selection Guidelines
Candidate Category Prelingually deafened adults

• Audiological Selection Criteria
• Best individual ear open set listening score for
  sentences ? 50 under the best aided conditions.

• Special considerations
• Should communicate orally/aurally and show strong
  motivation to participate in future
  rehabilitation
• Should have realistic expectation to the benefit
  of cochlear implant

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Selection Guidelinesfor Children
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Paediatric Candidacy Selection Guidelines
Candidate Category Children gt 2 years with
congenital loss

• Audiological Selection Criteria
• Best individual ear open set listening score for
  phrase or sentence ? 50 under the best aided
  conditions.

• Special considerations
• Children over the age of 7 with no communication
  system or oral intent may have limited benefit.

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Paediatric Candidacy Selection Guidelines
Candidate Category Infants lt 2 years with
congenital loss

• Audiological Selection Criteria
• Bilateral severe to profound loss confirmed by
  electrophysiological and behavioral testing.
• Minimum 6 months hearing aid use with optimal
  fitting
• Emerging stimulus response skills

• Special considerations
• Emphasis on assessment of pre-verbal behaviour
  and parent-child interaction
• Limited information on formal perception
  assessment

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Paediatric Candidacy Selection Guidelines
Candidate Category Post Meningitis Children

• Audiological Selection Criteria
• Best individual ear open set listening score for
  phrase or sentence ? 50 under the best aided
  conditions.

• Special considerations
• CT scans and other medical investigations are
  used to evaluate the cochlear to determine if
  there is osteogenesis or other damage.

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Paediatric Candidacy Selection Guidelines
Candidate Category Changeover candidates (exp
erienced HA users)

• Audiological Selection Criteria
• Best individual ear open set listening score for
  phrase or sentence ? 50 under the best aided
  conditions.
• Has reached a plateau and CI would give access to
  more speech frequencies

• Special considerations
• Continued post-operative hearing aid use in the
  non-implanted ear is encouraged.

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Paediatric Candidacy Selection Guidelines
Candidate Category Children with fluctuating
and/or progressive loss

• Audiological Selection Criteria
• Thresholds monitored regularly over a 3 month
  period. Unaided pure-tone thresholds deteriorate
  to profound levels and/or aided thresholds above
  2kHz fall outside the speech range

• Special considerations
• Continued post-operative hearing aid use in the
  non-implanted ear is encouraged.

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Paediatric Candidacy Selection Guidelines
Candidate Category Children using total
communication/sign language

• Audiological Selection Criteria
• Children gt 5 must achieve vowel discrimination
  upon completion of the candidacy evaluation
  period
• Children lt 5 must demonstrate oral intent and
  some use of residual hearing in communication

• Special considerations
• Adequate post-operative auditory training is
  required

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Paediatric Candidacy Selection Guidelines
Candidate Category Children with additional
disabilities

• Audiological Selection Criteria
• Bilateral profound loss confirmed with
  electrophysiological and behavioral testing
• Emerging stimulus response skills or consistent
  behavioral patterns to sounds
• Minimum 6 months hearing aid use with optimal
  fitting

• Special considerations
• Complete medical and paediatric assessment
• Emphasis on the development of pre-verbal
  behaviour and parent interaction
• Emphasis on multidisciplinary management

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Selection Considerations

• Patient history, hearing profile and
  communication needs and problems
• Audiological assessment of hearing loss
• Medical/Otological considerations
• Hearing aid optimization/evaluation
• Habilitation support
• Informed consent

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Case Examples
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CASE 1

• 40-year-old lady
• Born with a profound hearing loss in the left ear
  and a moderate hearing loss in the right ear.
• Optimally fit with hearing aid on the right since
  2 years old.
• Attended normal school and developed good
  speech/language skills.
• Hearing in the right ear has deteriorated in
  steps and has reached a profound level. Hearing
  aid does not help anymore.
• Full time clerical job which involves some
  communication with customers.

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CASE 1

• Assessment result
• Audiometry
• Bilateral profound to total hearing loss
• Open-set sentences under best aided condition
• Audition alone 12
• Lipreading alone 78
• Lipreading audition 98
• CT scans
• No abnormality of cochlea on either side
• No contraindications to CI surgery

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CASE 1

• Is she a good candidate for cochlear implant
  surgery?
• Which side should be implanted?
• What are the most important issues that need to
  be discussed with this patient?

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CASE 2

• 25-year-old lady
• Bilateral profound hearing loss due to suspected
  meningitis at the age of 10 years.
• Tried hearing aids when she was young but did not
  get benefit and quit using them.
• Developed good speech and language with good
  lipreading skill.
• Attended normal school and works full time with
  minimal communication needs.

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CASE 2

• Assessment Results
• Audiometry
• Bilateral profound hearing loss
• Speech Recognition under best aided conditions
• Audition alone 0
• Audition lipreading 60
• CT scan reveals no anomalies
• No contraindication for CI

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CASE 3

• Is she a good candidate for cochlear implant
  surgery?
• If yes, which side should be implanted?
• What are the most important issues that need to
  be discussed with this patient?

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CASE 3

• 38-year-old man
• Developed a total bilateral hearing loss
  following meningitis at the age of two.
• Attended school for hearing impaired children and
  uses total communication.
• Fitted with binaural hearing aids at 3, but quit
  using them at 14 because of limited benefit.
• Uses sign language with very limited speech
  production.
• Works as a storeman.

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CASE 3

• Assessment results
• Audiometry
• Bilateral total hearing loss
• Sentence scores with the best aided condition
• Audition alone 10
• Lipreading alone 12
• Lipreading audition 14
• CT scan revealed no anomalies on either side
• No contraindication for CI surgery

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CASE 3

• Is he a good candidate for cochlear implant
  surgery?
• What are the most important issues that need to
  be discussed with this patient?

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CASE 4

• 2 years 5 months girl
• Diagnosed with bilateral profound hearing loss at
  14 months of age
• Etiology unknown
• Fitted binaurally with powerful aids at 15 months
• Attends auditory-verbal therapy. Has remarkable
  progress and has developed a small vocabulary.

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CASE 4

• Assessment Results
• Audiometry
• Bilateral profound hearing loss (behabioral
  testing)
• No response at 90 dBnHL with click ABR.
• Hearing aid evaluation
• Useful aided hearing up to 1500 Hz, bilaterally
• Videotaped interactive play sessions
• Good pragmatic skills and early auditory
  behaviour.
• Formal speech perception testing not possible.
• CT scans
• Normal cochlea on both sides
• No contraindications to CI surgery

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CASE 5

• 16 years old male
• Born with bilateral, moderate to severe hearing
  loss and fitted with hearing aids from 2 years
  old
• Good use of hearing aids, attended normal school,
  developed normal speech and language with minor
  speech errors
• Hearing deteriorated to a severe to profound loss
  when he was 10 years old. Hearing aids no longer
  helpful.

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CASE 5

• Assessment results
• Audiometry
• Bilateral profound hearing loss
• Hearing Aid Evaluation
• Aided thresholds showed useful hearing to 1500 Hz
• Sentence scores
• Audition alone 18 (R), 6 (L), 20 (Both)
• Lipreading alone 74
• Lipreading Audition 98 (R) , 96 (L), 92
  (Both)
• CT scan
• Normal cochlea on either side
• No contraindications to implant surgery

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CASE 6

• 2 years 4 months old male
• Diagnosed to have profound to total hearing loss
  at 2.
• Tried hearing aid for 3 months but no benefit.
• Babbles but no intelligible speech.
• Lives very far away from the clinic and parents
  show limited knowledge on CI.

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CASE 6

• Assessment Results
• Audiometry
• Soundfield audiogram shows bilateral profound to
  total hearing loss
• Click-ABR showed no response at 90 dBhHL
• Speech/language abilities
• Babbles but no intelligible speech
• Developed some gestures and good pragmatic skills
• Hearing Aid evaluation
• Optimal fitting but no speech information is
  accessible.
• CT scans
• Normal cochlea
• Medical assessment
• History of middle ear infection on the right.
  Normal on the left.

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CASE 6

• Is he a good candidate for cochlear implant
  surgery?
• If yes, which side should be implanted?
• What are the most important issues that need to
  be discussed with this patient?