NOCCCI Educator’s Forum

Cochlear Implant Candidacy and Surgery

Nationwide Children’s Hospital Hearing CenterCochlear Implant Program

D. Richard Kang, MD

Shana Moore, MA, CCC-A

Laura Brown, MSW, LISW-S

August 6, 2010

Cochlear Implant Candidacy Criteria

• 12 to 24 months• Profound SNHL, bilaterally

• Limited benefit from appropriate binaural hearing aids

• Lack of progress in the development of auditory skills

• No medical contraindications

• High motivation and appropriate expectations from family

• 2 to 18 years old• Severe to Profound SNHL, bilaterally

• Speech or Word Recognition 30% or less in best-aided

condition

• Lack of progress in the development of auditory skills

• No medical contraindications

• High motivation and appropriate expectations

Medical Assessment

• Focus on determination of etiologies of hearing

loss, surgical, and anesthetic risk factors

• Radiologic studies – CT scan and MRI

– Cochlear dysplasia (abnormalities)

• Higher risks for complication of facial nerve injury,

endolymphatic fluid leak, less optimal hearing

outcome

– Absent cochlea or absent cochlear nerve

• Contraindication

– Meningitis – labyrinthitis ossificans

Contraindication to Surgery

• Cochlear aplasia

• Absence of Cochlear Nerve

• Family’s inability to commit to prolonged

and consistent program of auditory

rehabilitation

Cochlear Implants in Children:

A Unique Medical Intervention

• Requires Holistic Consideration for Optimal Outcome in

Establishing Spoken Language

– Family support

– Educational options

– Developmental factors

– Audiological criteria

– Medical factors

Francis, Niparko 2003

Multidisciplinary Team

• It is critical to have a group of committed

and dedicated professionals who are able

to offer different perspectives. The team

considers a range of factors that will affect

use and performance of the device, and

ultimately the individual’s level of benefit.

Francis, Niparko 2003

Why a Comprehensive Assessment?

• A cochlear implant is a communication tool, not a cure

for hearing loss

• Multifaceted nature of communication disorder

– Auditory processing, speech production, cognitive ability and

attention

• The candidate and the family must have motivation and

commitment to a prolonged program of rehabilitation to

optimize performance

– implant centers and educational systems should also be

motivated to pursue all avenues of auditory and language

rehabilitation

• Preoperative expectations will shape the postoperative

satisfaction Francis, Niparko 2003

What does a Cochlear Implant Provide?

• A level of hearing that allows for perception of

most spoken language sounds, even when

presented at low levels of intensity

• In post lingual children, it restores access to

spoken language

• In prelingual children, however, the sound

access lacks meaningful language association

Francis, Niparko 2003

Prelingual Hard of Hearing Children

• If given access to sound early enough,

children are able to adapt to, and acquire,

listening skills, verbal comprehension, and

possibly speech, BUT they must have

appropriate, intense long term

intervention.

Francis, Niparko 2003

Language Development with a CI

• An evolving process in this order:

– Sound awareness

– Phases of discrimination

– Recognition

– Identification

– Comprehension and finally

– Intelligible speech production

Francis, Niparko 2003

Progression to Comprehension

• Influencing factors:

– Previous experience with hearing

– Auditory verbal methods

– Age at implantation

– Family and Professional commitment

– Availability of comprehensive postsurgical

rehabilitation

Francis, Niparko 2003

Factors Which Limit Outcomes

• Cognitive disabilities

• Prelingually deafened preadolescent and

adolescent children who primarily

communicate with sign language

• Aversion to social interaction

Francis, Niparko 2003

NCH Cochlear Implant Candidacy Process

• Medical Evaluation

• Audiological (Hearing) Evaluation

• Speech-Language Evaluation

• Developmental Evaluation

– Neuropsychology or

– Developmental Pediatrics

• Social Work Assessment

• Occupational Therapy Evaluation

• Educational Consultation

– School

– Early Intervention, Help Me Grow, Regional Infant Hearing Program

Children’s Implant Profile (2000)

Speech/

Language

Abilities

Multiple

Handicaps

Child

Behavior

Cognitive

FunctionAuditory

Perception

Hearing

Medical/

Radiological

Family Structure,

Support, and

Expectations

Educational

Environment

Chronological Age/

Duration of Deafness

ChIP

score

How a Cochlear Implant Works

Mastoidectomy and Channel

Facial Recess and Cochleostomy

Place Device and Tie Down

Animation of Electrode Insertion

Electrode Insertion

Other Medical Concerns

• Otitis media risk

• Ventilation tubes

• Use of MRI

Cochlear Implant Surgery

When does the child go home?

– After surgery the child will stay in Recovery for

a few hours

– The child may stay overnight at the hospital

with a parent

• What will the child look like after surgery?

– Small incision behind the ear

– Bandage around the head

Nationwide Children's hospital

Normal

Hearing

Severe

Hearing Loss

Profound

Hearing Loss

Source: Tools For Schools Advanced Bionics

Typical Cochlear Implant

Aided Responses

When will the child hear?

• The audiologist will “turn on” the cochlear

implant approximately 3 weeks after

surgery

• Post Audiology appointments are frequent

immediately after implantation, and

quarterly thereafter

Nationwide Children's hospital

Red = OOC channels

Levels as tool tip: shows

you the current level at

which voltage limit is

reached

Objective Measure

•Neural Response Telemetry NRT/ NRI for young children or patients inexperienced with sound. Almost all patients fit in this category.

•Action potential recordings

•Neural Responses help set mapping levels needed for individual hearing

•Reinforce hearing responses to practice conditioning

Behavioral Mapping

T thresholds =

This is where the processor turns on

C or M levels =

Setting of full volume on processor

What are T-levels?

• Threshold level - The lowest

level of electrical stimulation

required at each electrode

• Allows the recipient to hear the

softest sounds of speech and

the environment

What are C-levels?

• Comfort level - The maximum

electrical stimulation level of

sound that the recipient can

comfortably tolerate at any

given time

• Prevents sounds in the

environment from being

uncomfortably loud

T and C Levels

• All active electrodes will have a

T and C level

• T and C levels are

individualized

• Recipients cannot trade

processors!

Who will be responsible for

troubleshooting?

• Daily troubleshooting

• Designate one person

• Listening check

• Ling sounds

• /ah/ /ee/ /oo/ /s/ /sh/ /m/

• Keep in school for emergencies

• Non rechargeable batteries

• Cochlear implant troubleshooting kit

BTE-to-Bodyworn Conversion

Different Controllers

Identical Main Modules

The Splashproof Design Challenge

Displays

Replaceable

Batteries

Connectors

Controls

High density

electronic

assembly

Microphones• Vulnerable elements

Nucleus 5 Sound Processor

CoilReplaceable magnet

Upper button

Lower button

Earhook

Processing Unit

Accessory socket cover

Battery module

Replaceable coil cable

Battery module lock

Battery cover lock (2ZA battery module only)

Accessory socket

Electrostatic Discharge

•Follow guidelines to protect against ESD damage:

– Have child wear processor with cords inside clothing

– Use dryer sheets or anti-static spray

– Avoid static producing clothing (e.g., polyester, fleece, synthetic fibers)

– Ground yourself before touching child or implant

– Use a humidifier

– Use ESD mats

– Avoid plastic play equipment (OK if speech processor is removed)

– Avoid touching static electricity generators (Van der Graff generators, TV, computers, etc.)

Copyright restrictions may apply.

Niparko, J. K. et al. JAMA 2010;303:1498-1506.

Developmental Trajectories of RDLS Raw Scores of

Comprehension and Expression Grouped by Age at Baseline

Summary

• Cochlear implants in children provide

levels of hearing that allow perception of

most spoken language sounds, even when

presented at low levels of intensity

• To achieve verbal comprehension and oral

speech, it requires a multidisciplinary team

of dedicated and committed professionals

who support a committed family

Future

• Mapping strategies

• Totally implantable device

• Hybrid in children

• Infusion channel

– Cochlear hair regeneration

Questions?

Thank you for joining us today!