Cochlear Implants
by Weston Adkins

Clinical Programming Series: Population Mean

October 28, 2024
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  • Approximately 5 minutes to read
  • Learning objectives:
    • Understanding population mean
    • Implementing population mean at activation
    • Optimizing patient experience and performance

Think of the last time you had a patient come in for their activation, and as soon as they sat down, their loved one immediately pulled out their phone to record, not wanting to miss those first few moments of hearing with their cochlear implant. Understandably so! It is an exciting moment in the patient’s journey towards better hearing.

However, that excitement has traditionally been met with the clinician letting the loved one know that a few measurements need to be taken first. “This will take several minutes, and then we will Go Live,” I used to tell my patients and their families. They would stop recording, put their phone back in their pocket, and settle into their chair with a little less wind in their sails.

Cochlear’s population mean reimagines this traditional activation workflow to meet the patient’s expectation for their activation.

What is population mean?

Population mean is one of several MAP creation methods available in Custom Sound® Pro fitting software. As its name suggests, it is an average MAP that was derived from an analysis of around 15,000 de-identified MAPs. It is electrode specific, so no matter what electrode your patient has, population mean has you covered.1 It features a large range of 46 clinical units between Threshold (T) and Comfort (C) levels, a feature that is associated with better performance in both quiet and in noise.2 In the population mean workflow, Custom Sound Pro displays a shaded target region that guides the clinician to where C-levels land for 68% of patients.

How do I use it?

First, navigate to “Adjust > Select MAP > Create > Population mean” to create a population mean MAP. Then Go Live by selecting “Continue on air.”

Population mean starts at low stimulation levels that are likely inaudible to your patient. While talking to the patient, gradually increase the Master Volume – both the T- and C-levels together – of the population mean MAP. Continue talking with them while they listen and experience their first moments hearing with their cochlear implant. Hopefully their family member was quick with the record button!

Set the overall volume of the MAP to “Loud” since we know the patient will quickly adjust to their new hearing.

How do I personalize the population mean MAP for my patient?

During activation:

After your patient has had a few minutes to listen with their cochlear implant, the next step is to personalize their C-level profile. Sweep across the array at C-level using bands and adjust as needed to ensure all bands are “Loud” to the patient. This accounts for any differences in the individual patient’s C-level profile.

At activation, we recommend an informal assessment of audibility using Ling sounds, for example. If results of the audibility assessment warrant, T-levels can be measured, especially if the patient is a good reporter and able to handle that level of listening task.

During the optimization phase (within 90 days of activation):

For most patients, T-levels are measured at their first optimization follow up visit. Measuring T-levels facilitates ideal audibility in the sound room, which is known to facilitate optimal patient performance.2 Since T-levels are generally stable after the optimization phase and have a range in which they can be set to provide good outcomes, we recommend T-levels be reassessed only as indicated by audibility or the patient’s sound quality concerns.3,4

Consider also utilizing objective measures to cross check the MAP. Neural Response Telemetry thresholds (tNRT) are known to be between T and C-levels of a MAP of the same pulse width.5 Electrically-Evoked Stapedial Reflex Thresholds (eSRT) are known to be approximately 15 clinical units above C-levels.6,7 Both tNRT and eSRT can give the clinician confidence that the patient’s MAP is set appropriately.

How does population mean benefit my patient?

Population mean creates an easier activation experience for patients and enables a quicker Go Live. It allows the patient’s first experience hearing through their cochlear implant to be meaningful, live speech. Contrast that first hearing experience with traditional workflows where the patient first listened for distant beeps of various pitches to measure T-levels.

Population mean focuses on performance. Research studies have shown that C-levels impact a patient’s performance more than T-levels.8 With this in mind, the population mean workflow prioritizes optimizing C-levels then refining T-levels. We continue to recognize the importance of well-set T-levels and the excellent audibility they provide – they are now measured in an appropriately prioritized programming sequence.

Wrap-up

Population mean was derived from an analysis of around 15,000 de-identified MAPs exported from clinic databases.1 Cochlear’s population mean workflow enables a patient-centered activation experience with a quicker Go Live. It has built-in MAP features that start the patient down the right track and is ready to be personalized based on a combination of your patient’s hearing experience and objective measures.

Bring the excitement of hearing into the activation earlier. Try population mean at your next activation appointment. Check out our “Adult Cochlear Connected Care model quick guide” for more information.

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1 – Maruthurkkara, S., & Bennett, C. (2024). Development of Custom Sound® Pro software utilising big data and its clinical evaluation. International journal of audiology, 63(2), 87–98. https://doi.org/10.1080/14992027.2022.2155880

2 – de Graaff, F., Lissenberg-Witte, B. I., Kaandorp, M. W., Merkus, P., Goverts, S. T., Kramer, S. E., & Smits, C. (2020). Relationship Between Speech Recognition in Quiet and Noise and Fitting Parameters, Impedances and ECAP Thresholds in Adult Cochlear Implant Users. Ear and hearing, 41(4), 935–947. https://doi.org/10.1097/AUD.0000000000000814

3 – Dornhoffer, J. R., Khandalavala, K. R., Zwolan, T. A., & Carlson, M. L. (2023). Preliminary Evidence to Support a De-Escalated Cochlear Implant Programming Paradigm for New Adult Recipients: A Systematic Review. Journal of clinical medicine, 12(18), 5774. https://doi.org/10.3390/jcm12185774

4 – Busby, P. A., & Arora, K. (2016). Effects of Threshold Adjustment on Speech Perception in Nucleus Cochlear Implant Recipients. Ear and hearing, 37(3), 303–311. https://doi.org/10.1097/AUD.0000000000000248

5 – Di Nardo W, Ippolito S, Quaranta N, Cadoni G, Galli J. Correlation between NRT measurement and behavioural levels in patients with the Nucleus 24 cochlear implant. Acta Otorhinolaryngol Ital. 2003 Oct;23(5):352-5. PMID: 15108484.

6 – Holder JT, Henry MR, MacDonald AE, Gifford RH. Cochlear Implant Upper Stimulation Levels: eSRT vs. Loudness Scaling. Otol Neurotol. 2023 Oct 1;44(9):e667-e672. doi: 10.1097/MAO.0000000000003988. Epub 2023 Aug 23. PMID: 37621113; PMCID: PMC10637929.

7 – Holder, J.T. 2022. The Role of eSRT in Device Programming. Maximizing Performance in Cochlear Implant Recipients: Programming Concepts. New York, NY, United States.

8 – Martins, K. V. C., & Goffi-Gomez, M. V. S. (2021). The influence of stimulation levels on auditory thresholds and speech recognition in adult cochlear implant users. Cochlear implants international, 22(1), 42–48. https://doi.org/10.1080/14670100.2020.1822495

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Importance of aural rehabilitation following cochlear implantation

August 6, 2020

By Dr. Aaron Moberly, Neurotology Fellowship Director, Department of Otolaryngology – Head and Neck Surgery at the Ohio State University

Cochlear implants (CIs) restore a sense of hearing to adults with moderate-to-profound hearing loss. However, broader restoration of communication function requires more than just restoring hearing. Understanding speech through a CI depends on the ability of the “listening brain” to make sense of the degraded auditory input provided through the CI. Fortunately, most adults who receive CIs are able to make sense of this degraded input, but it can take up to two years of practice listening with a CI to reach a plateau in speech understanding. Moreover, for some patients, the process of re-learning to understand speech through a CI is rapid and comes naturally as a result of daily listening, but many (if not all) benefit from intentional, focused aural rehabilitation.

The broad variability in speech understanding among adult CI users and the variable duration of time required to adapt to the degraded input clearly point at differences among individuals in how their listening brains are processing the sound. Even with very similar auditory input through their CIs, individuals’ brains may process the speech information differently, based on differences in previous language knowledge and basic cognitive functions like working memory, processing speed, inhibitory control and nonverbal reasoning. The traditional clinical and research focus of the field has been to try to optimize the quality of the signal coming through the CI by reprogramming the device, or by recommending use of listening accessories. However, it is likely that in many (if not all) cases, there are measures we as clinicians can take to speed up or optimize the way a listener’s brain makes use of the input, particularly through focused aural rehabilitation.

Aural rehabilitation

 Aural rehabilitation approaches – ideally interdisciplinary approaches among the surgeon, audiologist and speech therapist – comprise a combination of sensory management, instruction on device use, counseling and auditory training.  Often, the auditory training component takes a backseat due to logistical issues of time in clinic and billing limitations for audiologists. Patients are frequently left on their own to choose audiobooks or find a useful online training program, which likely does not provide the necessary tailored approach to address their individual rehabilitative needs. Moreover, many individuals do not use any particular active training methods at all, which likely limits or slows their progress post-implant. By emphasizing the importance of auditory training, and by providing a more comprehensive and individualized treatment plan that specifically incorporates training, professionals can support faster and better recovery of communicative functions for adults with CIs.

Auditory training programs

Auditory training programs come in several general forms, from helping the listener learn to identify very basic speech sounds (vowels and consonants) to recognizing complex speech passages in noisy situations. In all cases, the purpose is to encourage the brain to interpret the incoming speech signals more accurately and efficiently. Over the last few years, with the field’s improved understanding of the complex functions of the listening brain, an emphasis has been developed on “auditory-cognitive training.” This method combines various forms of speech perception training with exercises that focus on improving cognitive processing of speech, such as simultaneously exercising working memory or improving processing speed and efficiency. Although studies are only beginning to examine the impact of this broader approach to training on speech understanding, early results are promising, suggesting a powerful means of helping optimize the functioning of a CI user’s listening brain.

About the author: Aaron C. Moberly, MD, works at the Wexner Medical Center at The Ohio State University. He is an assistant professor in the Department of Otolaryngology – Head and Neck Surgery and Neurotology Fellowship Director in the Department of Otolaryngology – Head and Neck Surgery.

For further information about aural rehabilitation, download Cochlear’s adult home-based hearing therapy manuals and subscribe to Cochlear ProNews.

This article expresses the experience and opinions of Dr. Aaron Moberly.

Counseling on Cochlear™ Electrodes

September 10, 2024
  • Approximately 5 mins to read
  • CochlearElectrodes.com learning objectives:
    • Learn about the significance of electrode selection in cochlear implants
    • Understand the differences between perimodiolar and lateral wall electrodes
    • Understand how to use the electrode model to learn about insertion approaches and educate candidates on electrode types

At Cochlear, we believe that technology is at the center of what gives each patient the opportunity to reach their full potential in hearing and in life. Cochlear is committed to partnering with you to understand and support your expertise to deliver the best possible care for your patients.

One important aspect of a cochlear implant that can have a significant impact on performance outcomes is the type of electrode selected. Cochlear is the only manufacturer with a full suite of electrodes to ensure that you have the optimal electrode for whatever a patient’s individual needs might be.

Understanding the differences between perimodiolar and lateral wall electrodes is critical to selecting the appropriate array for each patient. Therefore, we’ve created CochlearElectrodes.com to be your Cochlear™ Nucleus® implant information center, with content focusing on electrodes, receiver stimulators, innovation timelines, reliability information, surgical resources and more.

One new tool that can be utilized for counseling is our electrode interactive 3D insertion model. Complete with pop up guides and insights, this model can help you or your patients better understand the differences in Cochlear’s electrodes to select the right device for that patient.

For Surgeons, this insertion model can be used to learn about:

  • Various insertion approaches and considerations for each electrode array
  • Key insertion steps and instruments needed
  • Design intention of the electrode arrays
  • Comparison of size and insertion position across arrays

For Audiologists, this insertion model can be used to:

  • Assist with counseling the differences between perimodiolar and lateral wall electrodes
  • Guide discussions on why a surgeon might chose one array over another
  • Visual aid to explain basic cochlea anatomy
  • Brochure to easily locate insertion model and can send candidates home with a reference to the insertion model

For Candidates, this model can:

  • Educate on the differences between perimodiolar and lateral wall electrodes
  • Reduce fear of surgery by better understanding what happens in the OR
  • Explain the differences between electrodes
  • Self-paced learning- can review information after counseling appointment

The decision to move forward with a cochlear implant has quite a few factors: multiple manufacturers, implant type, electrode type, sound processor technology, and so much more. Cochlear has built this model with the intention of aiding the education about our electrode portfolio to help counsel patients to the device that is right for them.

Ask your local rep about our CochlearElectrodes.com handout to have easy access to this interactive model in the clinic. You can keep the half-page brochure on hand or send candidates home with the brochure to explore electrodes on their own for self-paced learning.

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Visit www.CochlearElectrodes.com for more information about Cochlear’s implant portfolio.

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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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