Cochlear Implants
by Jamie Schwartz

Don’t wait! Consider earlier implantation for your patients

March 7, 2019
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According to the World Health Organization (WHO), 5% of the world’s population, 466 million people, have a disabling hearing loss. They estimate by 2050, this number is expected to rise to over 900 million people or one in every 10 people.1 As the incidence of hearing loss continues to increase, clinical evidence supports early intervention for cochlear implantation. Shortening the duration of hearing loss by implanting before hearing loss progresses to profound within approved indications can maximize outcomes, increase outcome predictability and promote health and quality of life.2 Moreover, as cognitive decline becomes increasingly relevant within our aging population, hearing loss may be shifting from something we cope with and manage to something we recognize and treat.

Many people believe that cochlear implants are only indicated for those with severe to profound hearing loss and only once hearing aid benefit is gone. However, this notion is no longer true due to the expanded adult indications for cochlear implants. Cochlear implants are indicated for treatment of adults with moderate sloping to profound hearing loss. Even the most advanced or best-fit hearing aids may not be enough. In fact, Balkany et. al showed that 20% of hearing aid users are struggling.3 This population may still receive benefit from cochlear implants. Cochlear implants provide an alternative for patients who want to improve their hearing health instead of continuing to struggle with hearing aids or waiting to progress to deafness. For patients who score less than 40% on open-set word tests, there is a high likelihood they will benefit from a CI.4

FactorsCochlear implants can improve quality of life and overall health of recipients. Better hearing with a CI can increase a patient’s overall quality of life, allowing them to regain confidence in social situations. In 19 clinical studies that measured quality of life for adults after cochlear implantation, all reported a significant improvement.5 Hearing health with a cochlear implant could also lead to better overall health. For patients with severe to profound hearing loss, cochlear implantation has been associated with reduced anxiety and depression and improved overall health.6

For seniors, considering cochlear implantation treatment for hearing loss is especially important. As we start to better understand the link between disabling hearing loss and cognitive decline, social isolation and depression, there is growing evidence of the superior outcomes of cochlear implants over hearing aids for people with severe hearing loss (>70dB).7 Cochlear implants may also slow age-related cognitive decline with improvements seen in verbal memory after surgery.8

“A lot of people ignore hearing loss because it’s such a slow and insidious process as we age. Even if people feel they are not affected, we are showing that it may well be a more serious problem.”
– Frank Lin, M.D.

For more details on early intervention and cochlear implantation, please download the Don’t Wait: Health Benefits of Earlier Implantation brochure.

Resources:
1. Data source: World Health Organization, www.who.it/deafness/en/
2. Derinsu U, Yüksel M, Geçici CR, Çiprut A, Akdeniz E. Effects of residual speech and auditory deprivation on speech perception of adult cochlear implant recipients.
3. Balkany et al (2007) Nucleus Freedom North American clinical trial. Otolaryngol Head Neck Surg, 136:757-762
4. Gubbels et al (2016) Can routine office-based audiometry predict cochlear implant evaluation results? Laryngoscope, 127:216-222.
5. Gaylor, BA. Raman, G. Chung, M. Cochlear Implantation in Adults. JAMA Otolaryngol Head Neck Surg. 2018 Mar;139(3):265-72.
6. Manrique-Huarte R et al (2016) Treatment for Hearing Loss Among the Elderly: Auditory outcomes and impact on quality of life. Audiology Neurotology, 21 Suppl 1:29-25.
7. Hoppe U, Hocke T, Hast A, Hornung J. [Longterm Results of a Screening Procedure for Adult Cochlear Implant Candidates]. Laryngo- Rhino- Otologie [serial on the Internet]. (2017, Apr), [cited July 4, 2018]; 96(4): 234-238.
8. Cosetti MK (2016) Neurocognitive Testing and Cochlear Implantation: Insights into performance in older adults. Clin Interv Aging, 11:603-13.
Author

Jamie Schwartz

Jamie is the Associate Marketing Manager in the Product and Professional Marketing Department at Cochlear Americas. Jamie is responsible for ProNews blog content as well as professional social posts and calendars. If you are interested in being a guest author for the ProNews blog please contact Jamie by email at jschwartz@cochlear.com.

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Dr. Hunter

Research spotlight with Dr. Hunter: Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program

November 29, 2021

Hear from Dr. Hunter on the latest publication: Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program:

Dr. Hunter

What led your team to perform this retrospective analysis?

The initial motivation was the desire to build our adult cochlear implant database. Our former Neurotology fellow, Dr. Anthony Tolisano, who is now on staff at Walter Reed National Military Medical Center, and I, started building the database several years ago, with great assistance from one of our medical students at the time, Natalie Schauwecker, who is now a PGY-2 Otolaryngology resident at Vanderbilt University. The impetus that led us to explore and ultimately publish our data was that most patients in the database were White, highlighting to us that our practice probably does not represent the entire community we desire to serve.

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

The two most significant insights were that patients who racially self-identified as non-White were more likely to qualify for a cochlear implant, but were less likely to pursue surgery, as compared to White patients. We interpreted this to mean that non-White patients were referred for a cochlear implant evaluation further along in their hearing loss journey since their hearing loss was more substantial.

Further, as a group, while we routinely leave it up to the patient and their family to decide whether to pursue implantation if they qualify, there clearly are variables at play that lead non-White patients not to pursue surgery, arguably in a population who have a greater need for implantation in relation to the comparison group. We cannot exactly control our referrals, but recognizing differences are present in those that pursue implantation, the greater surprise was that we as a cochlear implant center were not addressing those differences. Granted, we did not recognize that those differences existed before we conducted the analysis, but as a health care practitioner, and a cochlear implant center, we wish we didn’t have those differences.

Based on these findings, how do patient demographics play a role in the referral process?

In reference to the specific referral process, patient demographics do not play a role. If a patient needs a cochlear implant evaluation, we are happy to provide that to the patient and referring provider, recognizing before we meet the patient, and potentially even after, we cannot speak to the exact motivation of the patient, family, and referring provider for pursuing the evaluation. We are not the patient or the family. But, speaking for myself, I feel it is our job and expectation to provide as much information to the patient and their family about their hearing loss journey, making sure they understand their rehabilitative options, including cochlear implantation for some patients, which includes a discussion of the surgery, rehabilitative process, and anticipated outcomes. Patient age, gender, race, or residence does not alter my counseling, but I can appreciate that different patients’ opinions may interpret my counseling differently.

As a team at a large university hospital system, have these findings changed your adult care model? If so, how?

Currently, these findings have not directly changed the model. While some cochlear implant referrals originate in our system, most are generated externally. I believe most practitioners in our practice referring patients for cochlear implant evaluations are aware of the data, though I do not know if the findings have influenced them, and I cannot speak for community referrals. Whether our approach in counseling about surgery has changed since learning of this data, and or led to any changes, I do not know. But on the other hand, as healthcare providers, this data has enabled us to reflect internally to try to be more inclusive and open-minded, despite our impressions previously.

Your study mentions 3 areas for identifying healthcare disparities, one of which classified as indication detection.  How does your team support referring professionals to ensure timely referrals and intervention?

I think this is something we can always continue to improve upon. We do not have the resources to support a cochlear implant team coordinator currently, but rely on individual relationships between the cochlear implant surgeon and audiologist and referring providers, whether that be otolaryngologists, audiologists, or any other hearing healthcare provider. Timely referrals are contingent upon a number of factors, but we encourage anyone to contact us directly to help facilitate them.

Any key takeaways that professionals should know?

This dataset and findings only reinforced the original need to step back and look at our practice from a different perspective. I think it is a valuable experience for personal development, but also for practice development, and I would encourage others to explore whether their practice is serving their own interests, as well as their community’s.

To learn more about cochlear implants as a standard of care please visit this website.

Citation:

Tolisano AM, Schauwecker N, Baumgart B, Whitson J, Kutz JW Jr, Isaacson B, Hunter JB. Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program. Ann Otol Rhinol Laryngol. 2020 Apr;129(4):347-354. doi: 10.1177/0003489419888232. Epub 2019 Nov 18. PMID: 31735055.

About the author:

Jacob Hunter is the Dedman Scholar of Clinical Care and Associate Professor in the Department of Otolaryngology-Head and Neck Surgery at the University of Texas Southwestern Medical Center. He is board-certified in Otolaryngology, with sub-specialty certification in Neurotology, having completed his residency at Albert Einstein College of Medicine in the Bronx, New York, and fellowship at Vanderbilt University in Nashville, Tennessee. His research focuses on hearing loss, cochlear implants, and vestibular schwannomas, having been awarded funding to explore the links between hearing loss, social isolation, and cognitive decline. He has published over 80 peer-reviewed manuscripts and contributed to over 10 book chapters. He is currently an Associate Editor, Otology and Neurotology for Otolaryngology-Head and Neck Surgery, published by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, while serving on the editorial board for Otology & Neurotology and Otolaryngology Case Reports.

Dr. Rivas

Interview with Dr. Rivas: Growing a CI program and incorporating new innovations

August 11, 2020

Interview with Alejandro Rivas, MD and new Chief of Otolaryngology at University Hospitals in Cleveland, on growing a CI program and incorporating new innovation including telehealth

By Patti Trautwein, MA, AuD, Vice President, Product Management & Marketing, Cochlear Americas

On June 1, 2020, Alejandro Rivas, MD, joined University Hospitals of Cleveland (UH) as the Chief of Otology/Neurotology, moving from Vanderbilt University Medical Center. Dr. Rivas’s new role includes directing the hospital’s large hearing implant program. I had the pleasure of catching up with Dr. Rivas to learn more about his vision for the program and incorporating the latest innovations in cochlear implants and telehealth.  

PT: You recently made a big transition from Vanderbilt to UH/Case Western Reserve University School of Medicine. Tell us about your new role and the hearing implant program?

AR: The UH program is well established and was started by Dr. Anthony Maniglia, Dr. James Arnold and Dr. Cliff Megerian as well as our Director of Audiology, Gail Murray, PhD.  The program has been supporting 80-120 cochlear implant surgeries per year. We see both adults and children, currently 60/40 split between adults and pediatrics. In addition to myself, Dr. Sarah Mowry is actively implanting new patients. Between August and October, two additional physicians will join so we will have four fellowship trained neurotology surgeons supporting our implant program. We also have over 22 audiologists, six of which are providing care for our cochlear implant patients. We conduct surgery out of three hospitals and have many regional satellite locations for care.  

PT: You transitioned to UH amidst the pandemic. How is your new program scheduling patients? How long does a patient have to wait to get an appointment with you?

AR: During the pandemic we continued to see patients as medically needed with approximately 20% of appointments in clinic and another 50% virtual. Currently, we are back at 90% live appointments and the wait time for an appointment with a cochlear implant surgeon in my group is about one week. We have worked diligently through these last months to assure we have rescheduled any affected patients and are at this point, up to date from a scheduling and procedural perspective.   

PT: What process changes has your hospital implemented for you to continue to offer ear surgeries during these uncertain times? How are cases being prioritized?

AR: We are following enhanced infection control procedures which include social distancing, masking, pre-operative COVID testing and increased sanitization. We have no restrictions currently on elective surgeries and our OR suites are at full capacity. We do not view cochlear implants and many other ear surgeries as elective, given the impact of hearing loss on our patients’ ability to communicate and overall health. Therefore, we have continued to implant CI, safely and carefully, to assure we are optimizing each patient’s overall quality of life and function.  Dr. Megerian, a neurotologist and pioneer in cochlear implants, has been appointed President of the University Hospitals Health System and will assume the role of CEO next year, so we expect hearing health to continue being a high priority.

PT: Considering COVID, how are you counseling patients who may be hesitant or fearful to move forward with a hearing implant now?

AR: I empathize and understand the concern, however COVID may be here to stay and we may not have a vaccine for some time. Hearing loss can incapacitate your life. Hearing aids are not able to provide you the hearing, especially in noise, that you need. Delaying your treatment is not in your best interest as it impacts your overall health, including your ability to communicate. To me, the hospital may be one of the safest places you can go. We have plenty of personal protection equipment (PPE), follow strict infection control measures and test all patients prior to a procedure. Patients with COVID are not treated in the same part of the hospital, which further helps us to maintain excellent infection control measures in the operating rooms. So, there should not be a delay in getting a cochlear implant.

PT: You have been engaged with Cochlear on product development and research for many years now. You are one of the first surgeons to access the new Slim 20 electrode. Cochlear has provided surgeons with a portfolio of electrodes including Slim Modiolar that uses a perimodiolar array to place the electrodes closer to the hearing nerve. How will you use the portfolio to meet the varying needs of your patients? 

AR: I prefer the Slim Modiolar (CI632) for most patients based on research including my own. I will use the new Slim 20 electrode (CI624) in patients with more measurable low frequency hearing; specifically, I reference the hearing levels in the low frequencies to 1kHz.

PT: What would you recommend to a colleague about selecting an electrode?

AR: For surgeons with less experience in cochlear implantation or who will likely only do a few cases per year, I would suggest the Slim Straight or Slim 20 given the ease of handling and placement. The first priority for patient outcomes is an atraumatic placement in scala tympani without disruption of the basilar membrane. 

PT: How often have patients asked you about which electrode you select?

AR: Very rarely, I can think of only a few times. In those cases, I explain as needed my preference for that case and try to make this a decision they simply do not need to be concerned about.

PT: In addition to implant innovations, Cochlear has launched a suite of Remote Care services.  How do you see Remote Care or telehealth fitting into clinical practice today and in the future? 

AR: During the lockdown we saw a dramatic increase in the number of telehealth appointments, upwards of 50%. I see this as something that will continue and be valued by patients here in Cleveland. Overall, patients want to be seen closer to home.  Nothing is closer than telehealth for that purpose.  We are working actively on a UH telehealth CI program to assure patients can access the care they need quickly and efficiently, regardless of where they live. We do have a growing number of satellite offices and it is my intent to have cochlear implant services offered in those locations, but we will still need telehealth services and will need to manage reimbursement hurdles as government policies change. 

PT: How do we overcome the hurdles?

AR: There is an opportunity to reduce the number of clinical appointments required for cochlear implant care. I have a vision to completely transform the surgery and activation process to be more efficient for the CI team and easier on the patient. In my opinion, a same-day surgery and activation is possible with technology and intraoperative measures with tools that can easily be used in the OR by the surgical team. This frees valuable audiology time to manage more challenging clinical cases and new implant evaluations. In two years, this program should see 300 new cochlear implant patients per year.

PT: Cochlear implants have evolved over a 40-year history. Your research as well as that of others consistently demonstrates benefits of cochlear implants over hearing aids for patients with moderate sloping to profound hearing loss over hearing aids.  Yet, far fewer patients get the treatment than the growing incidence of hearing loss. What would you want hearing health professionals and people with hearing loss in your new community to know to improve awareness of this treatment option?

AR: Make it simple to understand by using speech perception in noise. Understanding in quiet is not enough. If a patient cannot hear well in noise (50%) with hearing aids, then recommend they be seen for a cochlear implant evaluation.  

Thank you for your time, Dr. Rivas. Congratulations again on your new role as Division Chief of Otology/Neurotology at University Hospitals in Cleveland. I am glad your transition has been smooth and your vision to grow the program is exciting. On behalf of everyone at Cochlear, we look forward to continuing to partner with you to raise awareness of cochlear implantation in your community, advance product innovation and transform clinical care model to best meet patient needs today and in the future.  

To learn more, subscribe to Cochlear ProNews.

About the author: Patricia’s 25 years in the hearing healthcare industry includes roles in research and clinical studies, product management, education and training, sales and marketing. As Cochlear America’s VP of Marketing, Patricia is responsible for the marketing strategy, communications and public relations, brand ambassador program and product management. Her organization is responsible for positioning Cochlear Americas growth strategy, cultivating opportunities in new and existing customer markets and growing demand for Cochlear’s hearing solutions in the region.

This communication is intended to educate on the experience of other healthcare professionals and is not meant to provide medical guidance. The techniques mentioned in these materials reflect those of the authors, not those of Cochlear.

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