Cochlear Implants
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Artificial Intelligence – Use in Hearing Healthcare by Bill Shapiro, AuD

December 4, 2018
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Research updates

Bill Shapiro

 

By guest author: William H. Shapiro, AuD, CCC-A – Lester S. Miller, Jr and Kathleen V. Miller Clinical Assistant Professor of Hearing Health, Clinical Associate Professor in Otolaryngology, Supervising Audiologist, NYU Cochlear Implant Center

Artificial intelligence (AI) continues to change the way we live our lives. Gone are the days of traveling across country or even the city with a paper map in hand. Now we only need to tell our smartphones where we want to go and the friendly AI-powered avatar tells us when to turn and how long it will take to arrive at our destination. The same is soon to be true in our work lives as well.

As Brian Kaplan noted in a previous ProNews Blog, artificial intelligence has changed the way medical professionals are working and how they arrive at decisions; the same is true for hearing healthcare. However, the change is proving to be much slower than in other sectors of healthcare.

In 2005, Robert Margolis recounted the history of diagnostic tests in audiology and the how the profession has not kept pace with advanced technology. He quotes James Jerger, who in 1963, stated that most all of the routine audiometric tests conducted could be done by a machine while the audiologists would be consumed with analyzing and interpreting the results. Margolis summarized by stating, “My opinion is that if our profession does not embrace automated testing and drive the process of progress, other professions will do it for us.”1 Over a decade has passed since Margolis’ comments and automated audiometry is still not the standard of care for audiometrics but progress has been made in hearing aid technology.

In 2004, Oticon announced the first use of artificial intelligence in a decision-making feature that compared the outcomes of particular feature combinations to provide the optimal voice-to-noise ratio at any given minute2. This is an example of rapid comparison technology that provides options without taking advantage of a closed-loop machine learning technique.  Fourteen years later in April 2018, Widex introduced the first hearing aid which uses input from the patient via a smartphone app combined with real-life listening situations to employ machine learning to optimize the users hearing experience. Widex reports that the machine learning moves beyond simple decision-making to assist the individual by using data from around the world to benefit all Widex Evoke™ users through big data analysis3. This step in technological advancement encourages audiology to take advantage of more sophisticated artificial intelligence systems to better serve the patients who seek our help.

In a recent study at the University of Hong Kong and Ann & Robert Lurie Children’s Hospital of Chicago, AI has been employed in a novel way to predict language development in deaf children using cochlear implants. A machine-learning algorithm used pre-cochlear implant surgery MRI scans to detect abnormal brain development with a high degree of accuracy, specificity and sensitivity. This provided clinicians with information about how to personalize post-surgery habilitation efforts to help those children develop language skills4. AI provides promise in helping predict outcomes according to this study and AI can also be used to standardize and streamline cochlear implant fittings.

Currently, a clinical study in the United States employs an artificial intelligence engine to help standardize cochlear implant programming through a direct-connect system. Cochlear has licensed technology from Prof. Paul Govaerts of Belgium to evaluate recipient outcomes and clinician and recipient acceptance of a new AI technology. The AI system utilizes a closed-loop system of evaluation measures to provide outcome-driven fitting recommendations based on the test measures in a standardized approach to post-operative cochlear implant programming. The software test module may allow for improved clinician and recipient experience by allowing the testing to be delivered directly to the recipient’s sound processor outside of a test booth.  The AI system provides several options to potentially improve outcomes, based on data across major cochlear implant systems and individual psychoacoustic test measures. These AI recommendations come from comparisons to millions of MAPs and parameter settings which could substantially increase the chances of optimized outcomes while reducing programming time for the recipient and the clinician. Additionally, this evidence-based programming method could provide consistency in programming, outcomes and experience for the recipient whether they see a novice or experienced clinicians.

Hearing aid fittings have used real-ear targets for decades, now we are studying the AI technology to develop target-based fittings in cochlear implants as well. This exciting step into advanced AI use can help move our profession to provide the evidence needed to convince audiologists to try another tool in the toolbox of CI fittings. We are not looking to have an AI-assisted avatar tell us how to program, but as our industry grows and provides services to more patients, we do need to continue to standardize the way we provide cochlear implant technology so that more patients obtain optimal results.

See the references below for more information.

About out guest author:

William H. Shapiro received his Master of Arts degree in Audiology from Queens College of the CUNY in 1978. He received his Doctorate of Audiology from Arizona School of Health Sciences, A.T. Still University in 2007. He has worked at New York University since 1984 where he has been involved with all aspects of diagnostic and rehabilitative audiology, including the dispensing of assistive hearing technology (hearing aids, FM systems). He currently holds the title, Lester S. Miller, Jr.& Kathleen V. Miller Clinical Assistant Professor of Hearing Health, in the Department of Otolaryngology, is Director of FGP Audiology, and is Supervising Audiologist at the New York University Cochlear Implant Center, a nationally recognized center of excellence in the field of cochlear implants. Dr Shapiro has several publications in peer reviewed journals as well as book chapters. He has presented at conventions, both nationally, as well as internationally. He serves on the advisory board of two cochlear implant manufacturers. He is the 2008 recipient of the “Outstanding Clinician Award” received from the New York State Speech, Language and Hearing Association.

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  1. Margolis, R (2005) “Automated Audiometry: Progress or Pariah?” whitepaper prepared for AudiologyOnline.
  2. Schum, D. (June 2004) “Artificial Intelligence: The New Advanced Technology in Hearing Aids”, AudiologyOnline, https://www.audiologyonline.com/articles/artificial-intelligence-new-advanced-technology-1082.
  3. April 2018, “Widex Launches the World’s First Machine Learning Hearing Aids”, press release, https://global.widex.com/en/news/widex-launches-worlds-first-machine-learning-hearing-aid-evoke.
  4. Ann & Robert H. Lurie Children’s Hospital of Chicago. (2018, January 15). Brain imaging predicts language learning in deaf children. ScienceDaily. Retrieved August 6, 2018 from sciencedaily.com/releases/2018/01/180115151559.htm
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In an effort to keep our content fresh and reflective of a diverse industry, Cochlear Americas features a mix of employees and professional partners to contribute to Cochlear ProNews as Guest Authors.

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Cochlear Case Studies – CI632 case with Dr. Sarah Mowry

May 12, 2021

Cochlear Case Studies is a new series on Cochlear ProNews that highlights relevant clinical and surgical scenarios surrounding the latest hearing industry topics and research. We’re excited to partner with professionals to highlight their experiences surrounding specific patients. This first installment features surgeons, their cases and contributing factors for use of different electrodes.

Case Study

A 52 year old male sustained direct head trauma after falling down a flight of stairs. Immediately after the fall he reported no hearing bilaterally and the left side of his face was paralyzed. He was ultimately transferred to our medical center with a diagnosis of bilateral otic capsule violating fractures with the left side complicated by complete facial paralysis and a dural sinus thrombosis (CT images shown, MRV shown). Audiometry obtained five days after the fall demonstrated bilateral profound sensorineural   hearing loss.

On day six after the fall, the patient was taken to the operating room for a left total facial nerve decompression via a translabyrinthine approach. A complete transection of both the 7th and 8th cranial nerves was identified in the fundus of the IAC, thus precluding placement of a cochlear implant in the left ear. He was brought back to the operating room approximately two weeks later (three weeks from the injury) to attempt placement of a right cochlear implant via a transmastoid approach.

The cochlea was visualized through the facial recess. A formal cochleostomy was created anterior inferior to the round window membrane as the fracture did involve the bony niche overhang. The scala tympani did appear to have some inflammation and granulation tissue; therefore, the depth gauge was inserted into the cochlear duct without removal of the stylet. Placement in the cochlear duct was confirmed with intraoperative X-ray. Once the depth gauge was confirmed in the duct and not in either the IAC or the fracture line, the depth gauge was removed and the CI632 Slim Modiolar Electrode was introduced into the cochlea.

I chose the CI632 for its perimodiolar position, MRI compatibility and slim profile to help minimize trauma in this already traumatized cochlea.  Placement in the perimodiolar position was confirmed with X-ray intraoperatively. Electrical testing of the device was then performed (see tracings). The patient did have robust response of the cochlear nerve to NRT on several electrodes but had no response on others. Activation occurred four weeks postoperatively. He had responses in the low to mid frequencies and was able to detect sound and static with speech sounds.  The patient has had his second stimulation is reporting improved detection and a recognition of speech vs noise!

Image 1. Bilateral otic capsule violating temporal bone fractures. The left fracture transected the entire 7/8th nerve complex in the fundus of the IAC precluding implantation of the left ear. The right fracture spared the IAC and the facial nerve but resulted in pneumolabryinth and profound hearing loss.

Image 2. Air in the right cochlear duct.

Image 3. MRV demonstrating decreased flow in the left transverse and sigmoid sinuses.

Image 4. Audiogram from five days after the injury demonstrating profound bilateral SNHL.

Image 5. Depth gauge in the cochlear duct. The gauge was inserted with the stylet in.

Image 6. Intraoperative skull X-ray demonstrating appropriate coiling of a CI632 electrode into the cochlear duct.

Image 7. Screenshot of a NRT obtained on the day of activation demonstrating variable responsiveness across the electrode array. This may represent injury to the cochlear nerve from shearing forces sustained at the time of fracture.

Image 8. Example of NRT from electrode 22.

Image 9. Screenshot of his progressive map at the end of programing. His pulse width was widened to 37 from 25.

Are you a surgeon who has a case study to share? Contact mcoon@cochlear.com for a chance to be featured on Cochlear ProNews.

About the author: Dr. Mowry is an board certified otology/neurotologist who strives to provide excellent clinical care to patients while promoting the education of the next generation of leaders in the field. She treats both pediatric and adult patients who have dis orders of hearing, balance and the lateral skull base. Her interest in cochlear implants as a young medical student has translated in to a career of service to those with hearing disorders. She is also the residency program director for the University Hospitals Cleveland/Case Western Reserve University Otolaryngology department. She enjoys spending time with family, traveling, cooking and exercising.

Cedric Pritchett

Research spotlight with Dr. Pritchett: Racial and Insurance Inequalities in Access to Early Pediatric Cochlear Implantation

October 18, 2021

Hear from Dr. Pritchett on the recent publication of Racial and Insurance Inequalities in Access to Early Pediatric Cochlear Implantation:

What inspired you to research this topic?

In the state of Florida we have a rich depth of diversity in culture, ethnicity and language. Nearly 40% of the children with hearing loss in our program have parents whose primary language is Spanish. We were desirous of understanding whether in this diversity, disparities existed.

What surprised you the most? What insights from this study were the most compelling to you and your team?

I was most surprised to learn heritage from African descent was the most predictive factor in delay to early implantation. Black children were less likely than White or Hispanic children to be implanted by two years of age (and even less so for one year of age). Demonstrating in the state of Florida, it is not unexpected for implantation of children with public insurance to occur later than children with commercial insurance; however, I did not expect to find racial background was more important than insurance status. In our study we discovered a Black child with commercial insurance was less likely to be implanted early than a White child of any insurance status—commercial, public, or self-pay, or a Hispanic child of commercial status; and with nearly the same likelihood as a Hispanic child with public insurance. In other words, the only children who were less likely to be implanted later than a Black child with commercial insurance were Black children with public insurance.

Have the findings from this study changed your team’s approach to managing children with severe to profound hearing loss? If so, how?

Realizing the existence of unequal odds for early implantation in our patient population has informed, but not changed our practice. Our team remains dedicated and intentional in our approach to provide timely access to sound in general, and cochlear implantation in particular for our children with hearing loss.

Your study references the importance of a multidisciplinary team. Can you tell us a little bit about how your team is structured? What has made your team successful?

Recently we reviewed our program’s outcomes measuring time to implantation based on several factors including race, insurance status and preferred spoken language of our patients’ caregivers. We were pleased to see such times were similar comparing the different categories within these variables. Our team has included a neurotologist, pediatric otolaryngologist, two implant audiologists, two speech pathologists/auditory verbal therapist, a pediatric nurse practitioner, a registered nurse, a licensed clinical social worker, an implant coordinator and clinical assistant. We have been very fortunate to have the presence of a dedicated social worker and several members of our team who are fluently bilingual (Spanish), including one implant audiologist and at one point both speech pathologists. These assets in our program have provided crucial insight into our families’ needs and perspectives, and then supported our program’s band width to address them.

Any key takeaways that professionals should know?

We recognize our children are the future, but this is especially worth emphasizing in the context of children with hearing loss disabilities/disadvantages. We understand children are typically dependent participants in the care they receive. Pediatric care is best delivered in a multidisciplinary team. A team involving clinicians and therapists, but also educators and family members. Our teams should be prepared to investigate at the least, and ideally mitigate the underlying challenges to optimal care our children-patients encounter.

Read more on this topic here!

Citation:

Liu X, Rosa-Lugo LI, Cosby JL, Pritchett CV. Racial and Insurance Inequalities in Access to Early Pediatric Cochlear Implantation. Otolaryngol Head Neck Surg. 2021 Mar;164(3):667-674. doi: 10.1177/0194599820953381. Epub 2020 Sep 15. PMID: 32930656.

About the author:

Dr. Pritchett is a Pediatric Otolaryngologist- Head & Neck Surgeon with Nemours Children’s Health System at the Nemours Children’s Hospital in Orlando, FL.  His scope of practice includes a range of pediatric otolaryngology conditions with particular interest in pediatric otology and hearing loss. He is a cochlear implant surgeon, presently serves as Medical Director of both the Nemours Children’s Hospital’s Cochlear Implant Program and Section of Audiology, and is an affiliated Associate Professor in Otolaryngology at the University of Central Florida’s College of Medicine. Dr Pritchett received his Medical Degree and Master’s in Public Health from The Ohio State University in Columbus, OH. Residency in Otolaryngology-Head & Neck Surgery was completed at the University of Michigan, in Ann Arbor, MI, and fellowship in Pediatric Otolaryngology at Northwestern University’s Ann & Robert Lurie Children’s Hospital of Chicago. Dr. Pritchett is a member several professional societies including the Academy of Otolaryngology – Head and Neck Surgery, and is a fellow of the American Society of Pediatric Otolaryngology, and the American Academy of Pediatrics. He has served as a reviewer for several journals, including the Laryngoscope, Otolaryngology-Head and Neck Surgery, and International Journal of Pediatric Otorhinolaryngology. He is the author of a number of articles and enjoys sharing his knowledge with training healthcare professionals from all backgrounds. He has been married for over 20 years, and has two wonderful daughters. He enjoys traveling, reading, is attempting to become a photographer, and looking to become more involved in mission work.

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