Cochlear Implants
by Cochlear Guest Author

Cochlear Clinical Quick Tips: Confirming the Auditory Response Intra-Operatively

May 4, 2017
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Providing peace of mind and additional confirmation during cochlear implant surgery with the Nucleus CR220 Intraoperative Remote Assistant.

 

For a new Cochlear™ recipient and their family, knowing that the cochlear implant is functioning as their surgeon and audiologist expected, and that the auditory nerve is responding to stimulation, can be reassuring. For the audiologist and surgeon, knowing that electrode impedances are appropriate, and that AutoNRT® thresholds were measured provides confidence that the surgical procedure was successful. In the past, a laptop with Custom Sound®, a programming pod, and associated cables were required to obtain this information – and it was typically in the purview of the audiologist to take time out of his or her schedule to complete the testing. To address these challenges, Cochlear partnered with surgeons and clinicians to expand the capabilities of the industry-first bidirectional remote assistant to provide this valuable information more quickly, and by anyone in the operating room. Using the CR220 Intraoperative Remote Assistant means obtaining confidence that all electrodes are functioning, and that the auditory nerve is responding to stimulation, has never been easier, faster or more efficient!

 Below is some helpful information to know when working with the CR220 Intraoperative Remote Assistant:

  1. Before using the CR220 in the operating room for the first time, you can learn how it works via the onboard Practice Mode. Simply press and hold the OK button, press the down arrow to highlight Practice Mode, and press OK. Be sure to explore the screens accessed by pressing the right side arrow before, during and after testing. You may wish to turn off the Beeps on Remote under Settings before starting your practice session.
  2. The operating range between the CR220 Remote Assistant and the CP810 processor is up to 6 feet.
  3. For simplicity, the CR220 uses the same intraoperative AutoNRT® parameters as Custom Sound®
    1. Stimulation rate of 250Hz
    2. Measurement starts at 170 current level (CL), after a conditioning stimulus of 230 CL for each electrode.
    3. All 22 intracochlear electrodes are measured starting with Electrode 22, followed by Electrode 1, 11, 6, 16 and so on.

Note: AutoNRT has a high success rate of obtaining threshold NRT (T-NRT) on 93 percent of electrodes, which is better than any other cochlear implant objective measure.1

  1. The CR220 Intraoperative Remote Assistant has clear, simple messages to inform you of any actions you may need to take during testing. Below are just two examples.

          a. If the connection to the internal device is lost, the following will be shown on the CR220’s display screen:

  • A prompt to ‘Reconnect coil to Implant.’ You will have five minutes to reconnect, otherwise the test session will conclude.  If this occurs, you can initiate a new session to collect your data.

          b. After pressing the OK button to pause AutoNRT while it is running you will see:

  • Resume AutoNRT: the device will simply continue testing from where it was paused.
  • View Results: use the arrow keys to see the acquired NRT profile or individual NRT traces.
  • Either Cancel AutoNRT or Finish AutoNRT If you cancel AutoNRT before three electrode measurements are completed, the Auto NRT Cancelled screen will display. Press the OK button to return to the NRT: Electrodes screen to re-start. If you stop AutoNRT after three or more electrode measurements are completed, you will have the option to Finish AutoNRT.

We hope that using the CR220 Intraoperative Remote Assistant enhances your confidence in surgery, reduces your clinical load and complexity, and enhances your clinic efficiency.

If you would like to learn more about the CR220, please visit our one-hour (CEU available) Audiology Online course using the following link:

*van Dijk, B., Botros, A., Battmer, R., Begall, K., Dillier, N., Hey, M., Lai, W., Lenarz, T., Laszig, R., Morsnowski, A., Muller-Deile, J., Psarros, C., Shallop, J., Weber, B., Wesarg, T., Zarowski, A. & Offeciers, E. (2007) . Clinical results of AutoNRT: A completely automatic ECAP recording system for cochlear implants. Ear and Hearing. 28:4, 558-570

©Cochlear Limited 2017. All rights reserved. Hear now. And always and other trademarks and registered trademarks are the property of Cochlear Limited or Cochlear Bone Anchored Solutions AB. The names of actual companies and products mentioned herein may be the trademarks of their respective owners.

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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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Related Posts

Clinical Programming Series: Electric-Acoustic Stimulation

November 18, 2024
  • ‌Approximately 5 minutes to read
  • Learning objectives:
    • Understand the benefits of EAS
    • Understand EAS candidacy
    • Understand current EAS programming parameters

What is Electric-Acoustic Stimulation (EAS)?

Electric-acoustic stimulation (EAS) is a system that utilizes viable postoperative low-frequency hearing thresholds in combination with electrical stimulation for cochlear implant patients. EAS systems are underutilized and have the potential to provide not only better outcomes, but a better patient experience. Manipulation of additional parameters when fitting EAS can provide an even better experience for our patients overall and should be more often applied. 

A brief history of EAS

‌In 2013 the Cochlear™ Nucleus® Hybrid L24 CI system was the first of its kind to receive FDA approval. The Nucleus 6 Sound Processor was capable of providing EAS, giving patients with residual low-frequency hearing the ability to utilize a combined listening experience. As further advancements in both surgery and technology continue to progress, so does the ability to preserve low frequency hearing. Utilizing the EAS system, when appropriate, provides additional benefits compared to traditional electric stimulation.1 Benefits of EAS are improved speech understanding, improved music recognition, improved localization, decreased listening effort, access to binaural low-frequency cues, and providing a more naturalistic sound quality.1,2,3,4,5

Who could be a candidate for EAS?

EAS should be considered for patients who have preoperative thresholds of less than or equal to 60 dB HL through 500Hz. “Functionally aidable” is a term commonly used to describe hearing loss that may receive benefit when fit with an appropriate hearing aid. The recommendation for fitting EAS is for those with low frequency thresholds less than or equal to 70 dB HL postoperatively. 

How do I program a sound processor with an acoustic component?

‌ The utilization of earmolds can be beneficial when fitting a patient with EAS. Clinicians have options when fitting the acoustic component, including domes, however, in the cases where the patient utilized a custom-fit earmold, utilization of this mold with the EAS system can provide better retention, additional comfort, proper venting, increased low frequency sound quality, and address feedback concerns. Should the patient not have a custom earmold, one can be ordered from an outside manufacturer, or the patient can be fit using an appropriate dome. 

The default boundaries for the acoustic component should be set less than or equal to 866 Hz, while the cochlear implant frequency boundaries should be set less than or equal to 438 Hz. This reallocation of lower frequency boundaries may provide additional performance or sound quality benefits, especially in noise2,3 and may also provide the patient with a more natural and preferable listening experience.4 Further manipulation of these boundaries may provide additional benefit. 

‌A study conducted by Gifford et. al, revealed significant speech recognition and subject listening difficulty benefit in those who utilize EAS3. This study showed the less overlap in cutoff frequencies between acoustic and electric stimulation, resulted in better outcomes, with the highest outcomes achieved when the low frequency cutoffs were set closest to the audiometric thresholds. Overall, significant benefits were observed in speech recognition and subjective listening ease for individuals using bimodal and optimally aided EAS conditions, as opposed to those with only a CI. Furthermore, individuals benefited from a low-frequency cutoff program, showing significant improvement in speech recognition and subjective listening difficulty vs the default program.²

For additional information on programming using an acoustic component, check out our Electric-acoustic stimulation (EAS) fitting flow guide.

FUN1979 ISS2 JUN23 EAS Programming GuidelinesDownload
  1. Dunn, C. C., Perreau, A., Gantz, B., & Tyler, R. S. (2010). Benefits of localization and speech perception with multiple noise sources in listeners with a shortelectrode cochlear implant. Journal of the American Academy of Audiology, 21(01), 044-051. 
  2. Gifford, R. H., & Stecker, G. C. (2020). Binaural cue sensitivity in cochlear implant recipients with acoustic hearing preservation. Hearing Research, 390, 107929.
  3. Gifford, R. H., Sunderhaus, L. W., Dawant, B. M., Labadie, R. F., & Noble, J. H. (2022). Cochlear implant spectral bandwidth for optimizing electric and acoustic stimulation (EAS). Hearing Research, 108584.
  4. Parkinson, A. J., Rubinstein, J. T., Drennan, W. R., Dodson, C., & Nie, K. (2019). Hybrid music perception outcomes: implications for melody and timbre recognition in cochlear implant recipients. Otology & Neurotology: Official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 40(3), e283. 
  5. Shim, H., Kim, S., Hong, J., Na, Y., Woo, J., Hansen, M., & Choi, I. (2022). Differences in neural encoding of speech in noise between cochlear implant users with and without preserved acoustic hearing. Hearing Research, 108649

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Cochlear implant access: Are we making progress? (By: Jourdan Holder and René Gifford)

July 25, 2018

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Guest authors: Jourdan T. Holder, Au.D. and René H. Gifford, Ph.D.

 

Jourdan Holder

Rene Gifford

 

According to the World Health Organization (WHO), there are approximately 466 million individuals with disabling hearing loss (World Health Organization (WHO), 2018). This makes hearing loss one of the top three most common chronic conditions; however, most hearing losses can be at least partly remediated with hearing aids, auditory implants, and other assistive devices. Focusing on auditory implants, less than 10% of those meeting the strictest cochlear implant (CI) candidacy criteria have pursued cochlear implantation (Holder, Reynolds, Sunderhaus, & Gifford, 2018), despite CIs being named the most successful neural prosthesis (Lasker Foundation, 2013; Wilson & Dorman, 2008). Further, CI candidacy criteria is less strict than it once was (Centers for Medicare and Medicaid Services (CMS), 2005), suggesting that an even lower percentage of patients who qualify are benefitting from this technology.

A recent study from our research lab (Holder et al., 2018) sought to answer the question: are we increasing access to CI technology for a broader population of individuals with hearing loss? In order to answer this question, we compiled data from all of our adult patients (n = 287) who presented to our clinic for a CI candidacy evaluation between August 2013 and August 2015. Taking a thorough look at the demographics of this population is an important step toward making CIs accessible to more people who are struggling to communicate. Our results showed that 64.8% of adults presented with severe-to-profound sensorineural hearing loss, and the average word recognition score prior to CI was just 8.7% for the ear being considered for implantation. We then compared these results to previous clinical trials (Balkany et al., 2007; Parkinson et al., 2002) and discovered that our current average word scores are only 5-6 percentage points higher than individuals receiving CIs nearly 20 years ago. This finding suggests that we have much room for improvement if we are to significantly increase access to this technology.

In addition to defining the hearing status of our current CI candidates, we also discovered that out of 287 patients, only 14 (5%), did NOT meet candidacy criteria. In other words, nearly 100% of the patients being referred for a preoperative CI candidacy evaluation were, indeed, CI candidates. This statistic suggests that even at a large university medical center, well-known for cochlear implantation, we are receiving conservative referrals, and many hearing aid users that could benefit from a CI are not being referred. This trend may result from a lack of continuing education regarding current indications for adult CI amongst referring providers. Patients who report that their referring provider told them that they were not a CI candidate have anecdotally confirmed this speculation. These findings clearly show that CI professionals and manufacturers must increase education and communication efforts regarding CI candidacy and outcomes to increase referrals.

In addition to increasing appropriate referrals, there are various potential reasons why CI candidates are not receiving this life-changing technology. For years, individuals with sensorineural hearing loss may have been counseled that they had “nerve deafness” and that there was no treatment beyond power hearing aids. The term “nerve deafness” is a misnomer, as the overwhelming majority of individuals with hearing loss have intact auditory nerves, which are viable for cochlear implantation. Rather, most sensorineural hearing losses originate inadult CI the cochlea (https://www.nidcd.nih.gov/health/how-do-we-hear). Indeed, severe-to-profound damage to the delicate cochlear structures renders traditional hearing aid amplification relatively ineffective. Thus, what often happens is that patients give up on their hearing aids and resort to a life of auditory isolation.

While CIs may look similar to hearing aids, they work much differently and do not have the same limitations as traditional hearing aids.  CIs are the standard-of-care treatment for adults and children with severe-to-profound sensorineural hearing loss. In fact, adults with moderate-to-profound sensorineural hearing loss meet candidacy criteria as outlined by both the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Administration (CMS).

 

When counseling your CI candidates, Dr. Holder and Dr. Gifford offer the following suggested language with candidates (and referral resources):

If you are an adult with considerable hearing loss and are wondering whether or not you are a candidate for a cochlear implant, consider the following questions pertaining to your listening experience with your current hearing aids:

  • Are you able to talk on the phone without visual cues (such as video calls or caption calling)?
  • Are you able to understand television programs without closed captioning?
  • Are you able to effectively engage in conversations at large group gatherings such as dinner parties?
  • Do you feel that you obtain significant communication benefit from your current hearing aids?
  • Take the interactive quiz here: https://www.cochlear.com/us/ci-landing-page/quiz.html

If you answered “no” to at least two questions, it is time to see an audiologist for a comprehensive hearing assessment and CI evaluation. Even if you do not meet candidacy currently, a CI candidacy evaluation will equip you with valuable knowledge about your hearing health and technology options to help you communicate now and in the future.

The typical CI evaluation will involve the audiologist looking in your ear with an otoscope, and may introduce a small puff of air in your ear canal to ensure that your eardrum is functioning normally, and a standard hearing test to document the softest sounds that you can hear at various frequencies or pitches. In addition to these standardized assessments, the audiologist will also verify your current hearing aid settings, which involves placing a very small tube-like microphone in your ear and measuring the sound output from your hearing aids. If your hearing aids are not programmed according to your hearing loss specifications, the audiologist will either reprogram your hearing aids or program stock hearing aids to complete the remainder of the testing. The next part of the CI evaluation focuses on your speech understanding while wearing your hearing aids. Various words and sentences will be presented from a loudspeaker placed in front of you, and you will be asked to repeat what you hear, guessing if needed. This part of the assessment is often the least favorite for the patient because the tasks can be difficult, and some patients may feel defeated because they cannot complete the task. Although this assessment may be bothersome, it is necessary to determine your candidacy for a CI and to document your hearing difficulties in order to seek insurance coverage.

Should you be identified as a CI candidate, your audiologist will then provide you with a comprehensive overview of the function and the wearing options for your CI. At this point, you may be seen by an otolaryngologist or ear, nose, and throat (ENT) surgeon. The surgeon may complete a thorough evaluation of your ears and review radiographic images (CT and/or MRI scans) of your temporal bone to characterize the cochlear and auditory nerve anatomy. At this point, the audiologist and surgeon may work together to determine if a CI is right for you. The surgeon will also explain the outpatient CI procedure. The typical CI surgery takes just one to two hours under general anesthesia. It is an outpatient procedure, meaning that under typical circumstances, you will return home the same day as the procedure, and the typical recovery time for adults is generally about 2-5 days. For additional information about the CI surgery, please see: https://www.acialliance.org/page/Surgery.

Following surgery, your new hearing journey has just begun! Similar to an orthopedic surgery, your ear will require ‘physical therapy’. You will work closely with your audiologist and practice daily listening exercises to increase your performance and train your brain to listen with your new CI. It is certainly not an immediate or perfect fix, but the first step is to consider a candidacy evaluation to see if a CI could improve your hearing and overall quality of life.

About our Guest authors:

Jourdan Holder, Au.D., is a clinical and research audiologist with the cochlear implant team at Vanderbilt University Medical Center. Dr. Holder obtained her undergraduate degree from The University of Texas at Austin and her AuD degree from Vanderbilt University. She currently serves adult and pediatric cochlear implant patients in the clinic in addition to completing her PhD in Vanderbilt’s Cochlear Implant Research Lab under the direction of Dr. René Gifford.

René Gifford, Ph.D. is an Associate Professor at Vanderbilt University and Director of the Cochlear Implant Program and the Cochlear Implant Research Laboratory at the Vanderbilt Bill Wilkerson Center. Her research has been funded by the NIDCD for over 10 years and focuses on combined electric and acoustic hearing including basic auditory perception, spatial hearing, and speech perception. She has nearly 70 peer-reviewed papers and is the author of the book entitled “Cochlear Implant Patient Assessment: Evaluation of Candidacy, Performance, and Outcomes.”

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Balkany, T., Hodges, A., Menapace, C., Hazard, L., Driscoll, C., Gantz, B., … Neely, J. G. (2007). Nucleus Freedom North American clinical trial. Otolaryngology – Head and Neck Surgery, 136(5), 757–762. https://doi.org/10.1016/j.otohns.2007.01.006
Centers for Medicare and Medicaid Services (CMS). (2005). CMS Manual System, Pub 100-03, Medicare National Coverage Determination, Subject: Cochlear Implantation Transmittal 42. Baltimore, MD: Department of Health & Human Services, Center for Medicare and Medicaid Services.
Holder, J. T., Reynolds, S. M., Sunderhaus, L. W., & Gifford, R. H. (2018). Current Profile of Adults Presenting for Preoperative Cochlear Implant Evaluation. Trends in Hearing, 22, 233121651875528. https://doi.org/10.1177/2331216518755288
Lasker Foundation. (2013). 2013 Lasker Awards. Retrieved from https://www.laskerfoundation.org/awards/show/modern-cochlear-implant/
Parkinson, A. J., Arcaroli, J., Staller, S. J., Arndt, P. L., Cosgriff, A., & Ebinger, K. (2002). The Nucleus 24 Contour Cochlear Implant System: Adult Clinical Trial Results. Ear and Hearing, 23(1 Suppl), 41S–48S. https://doi.org/10.1097/00003446-200202001-00005
Wilson, B. S., & Dorman, M. F. (2008). Cochlear implants: A remarkable past and a brilliant future. Hearing Research, 242(1–2), 3–21. https://doi.org/10.1016/j.heares.2008.06.005
World Health Organization (WHO). (2018). Deafness and hearing loss. Retrieved from https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss
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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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