Cochlear Implants
by Cochlear Guest Author

New evidence supports the performance benefits of ForwardFocus

September 19, 2019
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Nucleus 7

By Amy Donaldson, Professional Education Manager

Your patients now have the freedom to focus on what matters – connecting with others.

Incorporated as a standard feature on the Nucleus® 7, ForwardFocus* is a revolutionary setting that goes beyond the state-of-the art scene analysis and adaptive directional microphones of SmartSound iQ® and allows users to enable maximum focus on what matters most to them. It is specially designed for the most challenging listening environments, such as listening to speech in a busy restaurant. 

ForwardFocus is intelligently designed to attenuate distracting noise from behind the listener, making it easier to enjoy face-to-face conversation and maximizing understanding of speech from the front.¹  It differs from the automated directionality in SmartSoundiQ by providing a more focused listening experience.  In an internal study using roving background noise, an average improvement of 2.9 dB was seen for speech recognition thresholds in noise over the default SCAN** program.1 In that same study, 88% of Nucleus 7 recipients recommended ForwardFocus for use in cafes and restaurants.

Evidence supporting the use of ForwardFocus in challenging listening environments is emerging beyond Cochlear’s internal studies.  A recent study from Germany compared ForwardFocus to BEAM (the directional microphone utilized within SmartSound iQ).2  A significant improvement of 5.8 dB was seen using the ForwardFocus program in 3-talker babble (noise presented from fixed positions of 90°, 180° and 270°), bringing performance closer to normal than with BEAM. 

Using ForwardFocus, recipients demonstrated statistically significant improvement in both conditions of spatially separated noise.1  This can result in an improved and controlled listening experience as rear-facing noise is reduced.

ForwardFocus must be enabled in Custom Sound fitting software before it can be used by the recipient.  This is because in certain situations (for example, if the recipient needs to hear sound from behind), ForwardFocus is not the best option.  Recipients must be instructed on the use of ForwardFocus and should be able to manually enable and disable this feature, something made even easier with the introduction of the Nucleus Smart App for Apple Watch®. This new feature allows for convenience control at their fingertips with a discreet tap. Patients can change programs, see battery status, adjust volume and select audio source, making it easier to use than ever before!

For more information about using ForwardFocus with your patients, please consult the ForwardFocus Clinician Quick Guide.

Encourage your patients to download the Nucleus Smart App now from Apple® App Store or on Google Play!

About the author: Amy Donaldson is an Audiologist and Professional Education Manager for Cochlear Americas.  She received her Master’s Degree in Audiology from the State University of New York at Buffalo and her AuD from the University of Florida.  She was privileged to begin her career as a pediatric audiologist and gain extensive clinical experience in implantable hearing devices at the University of Michigan in Ann Arbor and at the Manchester Cochlear Implant Programme in the United Kingdom.  After working for several years as an Educational Audiologist and Technical Support Audiologist in the hearing aid industry, she returned to hearing implants and Cochlear in 2011.

References

  1. Cochlear Limited. D1376556.CLTD5709 Acceptance and Performance with the Nucleus 7 Cochlear Implant System with Adult Recipients. 2018 Jan; data on file.
  2. Hey M, Hocke T, Böhnke B, Mauger SJ (2019) ForwardFocus with cochlear implant recipients in spatially separated and fluctuating competing signals – Introduction of a reference metric. Int J Audiol, 57(2).

*ForwardFocus can only be enabled by a hearing implant specialist. It should only be activated for users 12 years and older who are able to reliably provide feedback on sound quality and understand how to use the feature when moving to different or changing environments. It may be possible to have decreased speech understanding when using ForwardFocus in a quiet environment.

**SNR-NR, WNR and SCAN are approved for use with any recipient ages 6 years and older who is able to 1) complete objective speech perception testing in quiet and in noise in order to determine and document performance 2) report a preference for different program settings.

The Cochlear Nucleus Smart App is available on App Store and Google Play. For compatibility information visit www.cochlear.com/compatibility
The Cochlear Nucleus 7 Sound Processor is compatible with iPhone, iPad and iPod touch. Apple, the Apple logo, FaceTime, Made for iPad logo, Made for iPhone logo, Made for iPod logo, iPhone, iPad Pro, iPad Air, iPad mini, iPad and iPod touch are trademarks of Apple Inc., registered in the U.S. and other countries.

App Store is a service mark of Apple Inc., registered in the U.S. and other countries.

Android is a trademark of Google LLC. The Android robot is reproduced or modified from work created and shared by Google and used according to terms described in the Creative Commons 3.0 Attribution License.

Google Play and the Google Play logo are trademarks of Google LLC.

Author

Cochlear Guest Author

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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Science Spotlight: Electrode Tip Area and Scala Tympani Shapes Impact on Cochlea Health  

June 6, 2023

Morphometric Analysis and Linear Measurements of the Scala Tympani and Implications in Cochlear Implant Electrodes1 

Fujiwara RJT, Ishiyama G, Lopez IA, Ishiyama A. 

Research tells us that placement of an electrode within Scala tympani (ST) during cochlear implant surgery is desirable over placement in Scala vestibuli or a translocated array because it may lead to better performance outcomes.2,3 While we know placement in Scala tympani is desired, what about electrode positioning within that Scala? By analyzing the cross-section of 10 different electrode arrays as compared to the area of the ST at multiple points of insertion in human temporal bones, Fujiwara et al have shed new light on the impact on cochlea health in the delicate apical region.

Key Findings

  1. Scala tympani assumes an ovoid shape throughout the basal turn and, within the middle turn (360-450 degrees), develops into a triangular shape with its perimodiolar height greater than its lateral wall height. 
  2. At >360 degrees, perimodiolar height (0.71mm Mean, 0.23mm SD) was significantly greater than lateral wall height (0.53mm Mean, 0.21mm SD). This trend continued towards the apex with lateral wall height decreasing at a faster rate than perimodiolar height.
  3. The changing shape of the Scala tympani in the apex may be more likely to lead to translocation, fibrosis or osteogenesis with electrodes with larger cross-sectional tip areas due to higher insertion forces required for complete insertion
  4. Increasing amounts of new bone formation have been positively correlated with a degree of intracochlear insertional trauma, which may lead to worsened postoperative audiological outcomes.

Discussion

The study analysis results suggest that an ideal scenario for avoiding trauma occurs when the electrode has the smallest possible tip volume measurement, avoids the basilar membrane and is not inserted past the point at which ST height becomes too shallow. Now why is this important as it translates to the overall health of the cochlea?

This ideal scenario can have a positive impact on cochlea health in several important ways. Impeding the basilar membrane’s function may negatively impact hearing performance which is important to avoid. The deeper the lateral wall insertion, the more likely the electrode will cause trauma1. Blood supply to the cochlea primarily lives within the lateral wall4, and lateral wall electrodes with larger cross-sectional tip volume may require increased insertion force. The impact on the lateral wall may introduce a blood supply resulting in increased immune response to that foreign body4,5,6. 

The modelling of a fibrotic sheath or osteogenesis response demonstrates fibrosis or new bone growth around the electrode5. If the electrode is abutting the basilar membrane, the fibrotic sheath or bone growth may further impede its function4. The positioning of lateral wall electrode arrays results in fibrous tissue and new bone growth emerging between the electrode array and the spiral ganglion cells whereas this reaction occurs on the back side of perimodiolar electrode arrays. This reaction may be responsible for lower and more consistent impedances as well as reduced current levels required for stimulation on perimodiolar electrodes.7 

 Fig 1. Re-modelling of the cochlea occurs after implantation which may negatively impact cochlea health. Peri-modiolar electrodes provide additional benefits promoting long term cochlea health by avoiding certain issues that impact lateral wall electrodes.

This analysis would indicate that best outcomes may be achieved with electrode arrays of smaller volume that avoid both the basilar membrane and the most apical region of the ST where it is most shallow. In the chart below1 we see that lateral wall vs Peri-modiolar height is similar up to about 180 degrees. Beyond that point however, the lateral wall height begins to decrease at a faster rate than perimodiolar height.

Table from Reference 1

Looking at the height of ST in a perimodiolar position, Cochlear™ Nucleus® electrodes are both positioned further away from the basilar membrane and have more tolerance for ST height to accommodate an atraumatic insertion. Specifically looking at the Slim Modiolar electrode, it’s mean cross sectional area of ST was 12.51% (SD, 2.78%) compared to other manufacturers electrodes with 22.34% (SD, 4.97%) for Midscala, and 32.16% (SD, 7.16% for Helix respectively. Among lateral wall electrodes, the CI622 occupies 7.82% (SD, 1.74%); FLEX24, 13.40% (SD, 2.98%); and SlimJ, 12.78% (SD, 2.84%).

Avoiding trauma during cochlear implantation helps promote long term hearing outcomes through structural preservation. Further minimizing the impacts of implanting a foreign body into the cochlea can provide long term benefits over the patient’s lifetime. The Slim Modiolar electrode not only offers performance benefits over lateral wall electrodes7, but the unique design offers the additional benefit of providing an atraumatic insertion to further promote the long-term health of the cochlea.

The impact on cochlea health is critical to a lifetime of hearing performance. Visit our website to explore additional data on outcomes with the Cochlear Nucleus System.

References:

  1. Fujiwara RJT, Ishiyama G, Lopez IA, Ishiyama A. Morphometric Analysis and Linear Measurements of the Scala Tympani and Implications in Cochlear Implant Electrodes. Otol Neurotol. 2023 Mar 8. doi: 10.1097/MAO.0000000000003848. Epub ahead of print. PMID: 36893208.
  2. Holden L, et al. Factors Affecting Open-Set Word Recognition in Adults With Cochlear Implants. Ear & Hearing. 2013;34(3):342-360
  3. Shaul C, et al. Scalar localisation of peri-modiolar electrodes and speech perception outcomes. The Journal of Laryngology & Otology. 2018;132(11):1000-1006.
  4. Bester C, et al. Four-point impedance as a biomarker for bleeding during cochlear implantation. Scientific Reports. 2020;10(1).
  5. Somdas M, et al. Quantitative Evaluation of New Bone and Fibrous Tissue in the Cochlea following Cochlear Implantation in the Human. Audiology and Neurotology. 2007;12(5):277-284.
  6. Verberne J, et al. The Effect of Scala Tympani Morphology on Basilar Membrane Contact With a Straight Electrode Array: A Human Temporal Bone Study. Otol Neurotol. 2017 Jan;38(1):47-53.
  7. Holder JT, et. al. Matched Cohort Comparison Indicates Superiority of Precurved Electrode Arrays. Otol Neurotol. 2019 Oct;40(9):1160-1166.

girls listening to music laying on ground

Clinical Quick Tips: A closer look at accessory mixing in the Nucleus® 7 Sound Processor

December 26, 2017

By guest author: Dave Catlett

Dave Catlett

The Cochlear™ Nucleus® 7 (CP1000) sound processor gives recipients the ability to connect wirelessly to a wide variety of audio sources in several ways.

It is the first and only Made for iPhone (MFi) cochlear implant sound processor that lets recipients wirelessly connect to Apple® iOS devices and stream music, phone calls and more. In addition, Cochlear’s True Wireless™ technology, including the Mini Microphone 2 and 2+, the Phone Clip and the TV Streamer, allow for reliable, untethered connectivity to the sounds that recipients want to hear.

For dynamic FM use, Nucleus 7 processors are also compatible with Phonak’s Roger™ 20 integrated FM receivers. And, as always, a built in telecoil is available and can be used to interface with a variety of telephones, neck loops and looped environments, as found in some theaters, churches and meeting rooms.

All of these technologies are designed to help improve hearing performance and recipient experience in even the most challenging environments.

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The Nucleus 7 sound processor provides recipients with an unprecedented level of control over mixing ratio, which is the amount of input presented to the user from accessory/telecoil input in relation to the processor microphone input. For example, the default pediatric accessory mixing ratio is 1:1 meaning that their streaming Mini Mic 2+ and their processor microphone are presented with equivalent loudness, allowing for good awareness of environmental sounds near the recipient as well as the target input from the remote mic.  This differs from the adult default accessory mixing ratio of 2:1 which results in a 6dB attenuation of their processor mic while streaming, so the accessory signal is given more emphasis. The mixing ratio is set by the audiologist using Custom Sound® 5.0 and can be varied from ratios of 1:1 through 6:1 (with increasing processor mic attenuation) or even accessory-/telecoil-input only.

Clinical Quick Tips

In previous generation processors like the Nucleus® 5 and Nucleus® 6, recipients could change their mixing ratio using the remote assistant. The Nucleus 7 sound processor allows for much greater control of this mixing using the Nucleus® Smart App and, if sensitivity control is enabled, using the iOS Accessibility menu or ‘triple-click’ Accessibility shortcut.

Clinical quick tips

Default pediatric mixing ratio (1:1) settings as seen in (from L to R) Nucleus Smart App, iOS Accessibility menu and iOS Accessibility ‘triple-click’ shortcut

When streaming is active, users can make adjustments to the accessory/telecoil input and the sound processor mic independently and therefore create mixing ratios that can differ greatly from the programmed setting. This can be done in several ways:

  • In the Nucleus Smart App, both ‘Mini Mic Volume’ and ‘Microphone Volume’ (Nucleus 7 sound processor) can be increased or decreased from their default setting to provide the recipient with more emphasis or attenuation on either or both inputs. These are based on a scale from 0 (no sound) to 20 (+12 dB additional gain above the default sensitivity setting of 12). Mixing changes can be made using the Nucleus Smart App regardless of whether sensitivity control is enabled, or not, on the Nucleus 7 sound processor.
  • If sensitivity control is enabled by the clinician in Custom Sound® processor settings, then the iOS Accessibility menu allows users to adjust the ‘Mini Mic Volume’ and the ‘Hearing Aid Mic Volume’ on the Nucleus 7 via sliders that range from 0% to 100%. These controls can be found via Settings -> General -> Accessibility -> Hearing Devices (iOS 10) or MFi Hearing Aids (iOS 11).
  • Also if sensitivity control is enabled, a quick triple-click of the iOS device’s home button brings up additional sliders to control ‘Stream Volume’ from the accessory and ‘Mic’ volume meaning the Nucleus 7. This is the same percentage range of 0-100% as seen in the Accessibility menu.

Both the app and the MFi controls allow adjustments over a range of 21 steps from 0-20 or 0-100% respectively, and each step up or down results in an increase or decrease of 1.5 dB in gain on the input source’s signal.  So recipients can choose to emphasize or attenuate sounds from their accessories and Nucleus 7 sound processor in whatever mix they feel appropriate in their listening environment.  It is important to note that any changes made by the user to their mixing ratio will remain in effect only until the CP1000 is powered down, after which it will return to the setting programmed by the clinician in Custom Sound.  So if a recipient is consistently changing their mixing ratio to one that differs from this default, their clinician should consider adjusting the mixing ratio in Custom Sound to reflect the user’s preferred settings.

This chart shows equivalent ratios as seen in Custom Sound, the Nucleus Smart App and iOS:

Clinical quick tips

Mixing ratio controls in the Nucleus CP1000 processor is just one example of the many ways that Cochlear’s latest technologies provide both simplicity and depth of control to our Nucleus 7 recipients.

About our guest author: Dave Catlett, Au.D., CCC-A, FAAA, Regional Clinical Training Manager

Dave Catlett is a Regional Clinical Training Manager for Cochlear Americas covering the Southeast and Atlantic regions.  In this role, he provides clinical training and mentorship for Cochlear field staff as well as developing and presenting clinical trainings for Cochlear’s professional partners.  He earned his Masters in Audiology at UNC Chapel Hill and his Au.D through the University of Florida.  Prior to joining Cochlear in 2005, David spent several years as a clinical audiologist at UNC’s pediatric cochlear implant program.

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The Nucleus 7 Sound Processor is compatible with iPhone 8 Plus, iPhone 8, iPhone 7 Plus, iPhone 7, iPhone 6s Plus, iPhone 6s, iPhone 6 Plus, iPhone 6, iPhone SE, iPhone 5s, iPhone 5c, iPhone 5, iPad Pro (12.9-inch), iPad Pro (9.7-inch), iPad Air 2, iPad Air, iPad mini 4, iPad mini 3, iPad mini 2, iPad mini, iPad (4th generation) and iPod touch (6th generation) using iOS 10.0 or later.
Apple, the Apple logo, iPhone,and iPod touch are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc.
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©Cochlear Limited 2024. All rights reserved. ACE, Advance Off-Stylet, AOS, Ardium, AutoNRT, Autosensitivity, Baha, Baha SoftWear, BCDrive, Beam, Bring Back the Beat, Button, Carina, Cochlear, 科利耳, コクレア, 코클리어, Cochlear SoftWear, Contour, コントゥア, Contour Advance, Custom Sound, DermaLock, Freedom, Hear now. And always, Hugfit, Human Design, Hybrid, Invisible Hearing, Kanso, LowPro, MET, MP3000, myCochlear, mySmartSound, NRT, Nucleus, Osia, Outcome Focused Fitting, Off-Stylet, Piezo Power, Profile, Slimline, SmartSound, Softip, SoundArc, True Wireless, the elliptical logo, Vistafix, Whisper, WindShield and Xidium are either trademarks or registered trademarks of the Cochlear group of companies. The names of actual companies and products mentioned herein may be the trademarks of their respective owners.

 

This material is intended for health professionals. If you are a consumer, please seek advice from your health professional about treatments for hearing loss. Outcomes may vary, and your health professional will advise you about the factors which could affect your outcome. Always read the instructions for use. Not all products are available in all countries. Please contact your local Cochlear representative for product information.

 

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