COCHLEAR IMPLANTS Chapter 18

1
COCHLEAR IMPLANTSChapter 18

• THE FACTS

2
CI Manufacturers

• Medel
• Bionics
• Cochlear

3
Who Makes the Decision for CIandWhen 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?

4
CI Factoids

• 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.

5
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.
6
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.
7
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.
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.
9
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 30000 to
  200000.
• 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.
  
• The 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.
10
Profound vs. Severe Loss CI

• Highly significant difference between the
  educational placement of implanted children and
  hearing-aided profoundly deaf children
  (plt0.00001)
• 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.
11
CI by 6 Months

• By the 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.
12
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. 18962-5.
13
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 the 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. 18969-73.
14
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.
15
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.
• The 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 Sep28(5)403-18.
16
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 brains auditory system.

17
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.
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Show Video(s)

• 60 Minutes
• Oral Deaf
• Celias Story
• Sound Fury

19
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.

20
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.

21
Seven Steps to CI

• Initial contact
• Pre-CI counseling
• Formal evaluation
• Surgery
• Fitting/mapping
• Follow-up
• AR

22
Roles

• Audiologist
• SLP
• Educator of the Deaf
• ENT

23
Child CI Candidate Criteria

• 12 24 months

• Pediatric

• 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

• Profound bilateral SNHL
• Limited benefit from appropriate binaural Has
• Lack of progress in auditory skill development
• High motivation and appropriate expectations from
  family

24
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

25
A cochlear implant is an assistive technology

• That bypasses the damaged part of the cochlea and
  sends electrical signals to the auditory nerve
  which relays these signals to the brain
• Designed to provide sound detection to a full
  range of sounds to children with severe to
  profound hearing loss who obtain minimal benefit
  from hearing aids.
• With unknown outcomes related to providing a
  child full access to spoken language for
  education and life success

26
Increasing numbers

• Clerc Center- 1999-2000- no students with
  implants
• Kendall,2002- 10 students (8 in candidacy
  process)
• MSSD, 2002- 5 students (varying degrees of usage)
• Nucleus Implants- worldwide
• 1994-10,000
• 1999-26,000
• 2002-36,450
• (Do not have statistics for Advanced Bionics and
  Med-El)

27
Why Are the Numbers Increasing

• Early Identification
• Improved technology
• Changing candidacy requirements
• Lower surgical risk
• Changing attitudes

28
Implant Components

• Three manufacturers of implants commonly used in
  the United States
• Cochlear Corporation (Nucleus)
• Advanced Bionics- (Clarion)
• Med-El
• Surgically implanted components
• Receiver coil
• Electrode array
• External components
• Microphone
• Speech Processor
• Transmitter with a magnet

29
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

30
LEVELS OF PERFORMANCE

• Sound Awareness
• Basic discrimination of sounds
• Voice monitoring
• Understanding environmental sounds
• Understanding single words and/or phrases
• Understands details in sentences
• Understanding connected speech

31
Why are the outcomes different for each child?

• 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

32
Candidacy Requirements

• Who is a candidate
• Age- FDA says 18months, but doing as young as one
  year (some earlier)
• Intact auditory nerve
• Degree of loss- was profound, now increasingly
  more in severe range
• Hearing aid trial was 3 months in many places,
  now not as strict in many Centers
• Issue of who "is not" a candidate
• Centers do not seem to be denying children
  access to this surgery, however many centers
  strongly suggest participation in a full
  mainstream environment in coordination with the
  surgery. Some implant centers may not consider
  "signing" students and families as candidates.

33
Process John's Hopkins Hospital- The Listening
Center

•     Initial consult
• ABR
•   Audiology evaluation (with and
  without hearing aids, may
• take many visits
•    CT scan- looks at anatomy of
  cochlea
•     Promontory test- looks at which ear
  stimulates best to an
• electrical signal
•       ENT consult
•       Rehab consult
•      Outreach with educational programs
• Surgery
• Mapping
• Habilitation/Rehabilitation

34
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

35
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.
•  

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  
During         Shave area         Mastoid bone
uncovered (skin flap)         Carve space for
body of implant         Drill hole to
cochlea         Small opening in cochlea to
insert electrode array        
Incision closed
36
What about insurance

• 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)

37
Mapping/Programming Issues

• Each person has an individual program called a
• Map based on determining threshold levels, and
• maximum comfort levels for each
  electrode.
•    Determine how many electrodes can be
  stimulated
• comfortably
•     Various strategies- one not best for all
  (SPEAK, CIS,
• ACE). Not one program suited for all
  people.
•    Takes multiple sessions to program
•     May initially be uncomfortable
•     Neural response telemetry-Objective measure
  of
• response to electrode stimulation
•    Speech perception errors may be used to
  monitor the mapping (may be difficult due to
  impact of articulation errors, not good for young
  children)

38
Research issues

• Change of research playing field now that
  candidacy requirements have changed
• Much of the research focuses on speech perception
  and speech production
• Age of implantation under 5 indicates advantage
  and ease in spoken language learning, yet still
  variability
• There does not appear to be an age cut off when
  an implant does not appear useful in some way

39
Research issues

• Oral children may have faster gains than TC kids,
  but what about ultimate outcomes?
• CI increases speech and language regardless of
  the modality of language programming provided.
  (U. of Michigan, 2000)
• Children with better communicative interaction
  skills at preverbal level were also most likely
  to have good speech perception and production
  skills three years after implantation. (Tait and
  Lutman, Robinson, 2000)

40
Parents Perceptions and Experiences Gallaudet
Research Institute findings (439 families)

• 52 of families chose an implant to increase ease
  in development of spoken language
• 43 of families perceived a significant increase
  in their childs ability to understand words
• 62 of families continued to use sign language
  support in the home although use of speech
  increased

41
The bottom line

• Outcomes related to development of spoken
  language will be unique for each child
• Educational programming must be designed to
  address the individual needs of students with
  implants

42
CI Guidelines

• In 2002, the FDA lowered the recommended age
  requirement to 12 months of age. While this is
  the FDA-recommended age, this age is not legally
  binding and some hospital centers in clinical
  trials are completing the procedure earlier based
  on expectations of improved outcomes for early
  implantation. In addition, specific circumstances
  may allow for earlier implantation. For example,
  if meningitis is the cause of hearing loss, it
  may be important for the child to be implanted as
  early as possible as this condition causes
  ossification (bone build up) in the cochlea,
  making it increasingly difficult to surgically
  insert the electrode array as time passes. Note
  There may be questions related to insurance
  payment for the procedure if it is completed
  prior to 12 months of age.

43
CI Guidelines

• The FDA states that a child should have a
  bilateral (both ears) profound sensorineural
  hearing loss however, increasing numbers of
  children with hearing loss in the severe range
  are being considered for cochlear implants.

44
CI Guidelines

• Negligible functional benefit (limited open-set
  speech recognition) from appropriate
  amplification is often mentioned as a criterion.
• When such measures cannot be obtained on young
  children, hospital centers make individual
  decisions regarding whether or not a child would
  be able to do well on such tests given documented
  hearing levels and traditional hearing aids.
• There are varied implant center requirements
  regarding the use of traditional hearing aids
  prior to implantation.
• Some centers waive an extended hearing aid trial
  requirement in the interest of time when it is
  clear that the child would perform better with a
  cochlear implant.

45
CI Guidelines

• A child who is failing to progress in speech,
  language, and listening development with
  traditional hearing aids based on parent report
  and educational information may be considered as
  a candidate.
• Family willingness to follow recommendations
  enroll in speech, language, and listening
  therapy and return for follow-up appointments is
  a factor in candidacy.
• Having no medical contraindications to electrode
  insertion or receiver placement is a factor in
  candidacy.
• Educational and home environments that are
  supportive of cochlear implants are factors in
  candidacy.

46
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.

47
Other Factors Non-candidacy

• Some centers may not implant children with severe
  emotional, behavioral, or cognitive delays when
  it is perceived that these characteristics may
  prevent participation in the educational/training
  programs necessary to actualize benefit from the
  cochlear implant.
• Some children obtain substantial access to sound
  from the technology of state-of-the-art digital
  hearing aids or other hearing devices. Without
  surgical intervention, these devices may be an
  equally effective choice for some children.

48
CI Student Placement Options

• a neighborhood or private school with no
  additional supports
• inclusion in a neighborhood or private school
  with supports integrated within the school
  (itinerant teachers, resource teachers, speech
  and language specialists, etc.)
• a self-contained classroom for children with
  hearing loss using
• an oral approach,
• cued speech,
• total communication, or
• American Sign Language,
• a day school for deaf children that uses
• an oral only approach,
• total communication, or
• a bilingual approach (American Sign Language and
  English).

49
Communication Mode

• Manual
• ASL
• Bilingual/Bicultural
• Manually Coded English
• Simultaneous Communication
• Total
• Multisensory
• Aural/Oral
• Multisensory
• Unisensory
• Acoupedic
• Auditory/verbal

50
Sign Language CI

• "Continued use of a total communication approach
  might be the most effective means for
  facilitating language growth in a child with a
  cochlear implant.
• Nonetheless, it is essential that the child be
  exposed to an enriched auditory environment for
  as many hours a day as possible.
• There is a great need for a strong commitment to
  maximize the auditory component with a TC
  approach.
• In addition, it might be necessary for the school
  staff to adjust their expectations and teaching
  priorities, especially if manual communication is
  the focus of the child's educational placement."
• McKinley, A., Warren, S. (2000). The
  effectiveness of cochlear implants for children
  with prelingual deafness. Journal of Early
  Intervention, 23.

51
Spoken Language

• For educational environments that use either
  American Sign Language or other sign language
  systems to be appropriate environments to
  facilitate development of spoken language for
  students with cochlear implants, there must be an
  ongoing commitment of the program to value these
  skills and ensure ongoing opportunities for
  implanted students to develop and use spoken
  language.

52
CI Spoken Language

• While development of spoken language skills
  should be central to whichever communication
  approach is utilized, use of an approach that
  provides a student with support through visual
  modalities in addition to spoken language should
  also be considered

53
Communication Options

• Handout on communication options