Cochlear Implants
by Cochlear Guest Author

Use of Global Adjustments for cochlear implant fittings

October 5, 2021
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By Kyle Longwell, Product Manager – Software and Clinical Care

With the introduction of Custom Sound® Pro fitting software, Cochlear embraces new advances in fitting practice while maintaining support for historical fitting methodologies.

By leveraging ongoing developments in implant technology and clinical data available after 40 years of experience, Cochlear is utilizing data-driven design and automation with an increased focus on the use of Global Adjustments. This contrasts with historical fitting practices, which often focused on per- channel fitting methodologies which can be time-consuming and require sustained recipient attention.

These new fitting approaches are supported by the introduction of new screens and a default workflow in Custom Sound Pro software. These advances also prepare you and Cochlear for the future of ongoing advances in programming and digital healthcare.

What are Global Adjustments?

Global Adjustments are changes to MAP settings which are applied across the entire MAP profile at the same time, rather than on a channel-by-channel basis.

Global Adjustments have been used within Custom Sound software for many years. For example, Global Adjustments have been a key part of the streamlined programming flow (i.e., Shift and Tilt in live stimulation mode) for at least 15 years. These adjustments are typically made in live speech, allowing for patient judgement of MAP comfort and sound quality and are ideal to use as a part of routine programming or for patient control of MAP comfort outside the clinic. However, access to Global Adjustment may be conditional upon the patient’s MAP or implant type.

Let’s take a quick look at the Global Adjustments used within Custom Sound Pro fitting software:

Master volume

Applies a global shift of the entire T and/or C level MAP profile during live speech and is used to set or modify the overall loudness or comfort of a MAP. This saves measurement time and is less taxing for patients than individual channel measurements. The Master Volume level is the average of all C levels for active electrodes in the MAP. Adjustments can be applied to C profiles only, T profiles only, or both T and C profiles. If Thresholds were measured prior, only the C level profile will be adjusted to preserve behavioral T levels.

Bass and treble

Applies a combination of tilt and curvature across the MAP profile in the presence of live speech. Bass adjusts low frequency volume and Treble adjusts high frequency volume and is used to balance sound quality of a MAP in response to patient feedback. Adjustments start at zero and are applied in a gentle curve starting from the most central channel (maximum range -30 to +30 CLs).

Why program using Global Adjustments vs. individual electrodes?

Individual channel measurements are sometimes necessary to obtain quality hearing outcomes, however, with technological advances the need for per-channel measurements across the entire array has reduced.

Some patient factors such as tinnitus, poor concentration, unreliable responses, young age, etc. may restrict a clinician’s capability to perform individual channel measurements in a reliable manner. Additionally, stimulating on single electrodes does not consider loudness summation when all channels are activated in a MAP. After individually measuring C levels, many clinicians globally reduce C levels before going live to compensate for expected loudness summation and as a result, setting loudness globally with live audio may better reflect daily use conditions.

Using Global Adjustments and the default Custom Sound Pro workflow at activation can:

  • Achieve a quick first fit MAP which can be refined later
  • Achieve an easier patient interaction as they acclimate to electrical stimulation
  • Place the focus on achieving MAP audibility and comfort
  • Serve young or less cooperative patients
  • Help avoid over or under-fitting with onscreen guidance provided

After activation, the literature confirms that MAP levels typically stabilize within the first-year post-implant and remain stable over time for both adults and children1-4, so it may not be necessary to re-measure at every follow-up appointment.

This doesn’t mean that C and T levels are not important – there will be times when it is clinically indicated to measure T and C levels during follow up appointments, but the need for frequent re-measurement may therefore be reduced.

Conversely, using Global Adjustments at follow up appointments offers a comfortable and easy task for many patients to perform a quick MAP check to monitor stability. It can also allow focus to be directed towards non-MAPping activities during follow-up sessions.

There will always be some instances when individual channel measurements are clinically indicated and should be performed to ensure optimal outcomes, but clinicians are encouraged, where possible, to start with Global Adjustments and then continue with per-electrode adjustments as needed. Consider Global Adjustments at follow up appointments for:

  • Routine fittings when setting audibility and establishing comfort
  • Optimizing whole MAP sound quality
  • Follow-up MAP checks
  • Serving patients who are uncooperative or unable to reliably perform psychophysics

Learn more about Custom Sound Pro here!

References:

1. Henkin Y, et al. Int. J. Pediatr. Otorhinolaryngol. (2003); Aug 1;67(8):873-80.

2. Gajadeera EA, et al. Ear Hear. (2017); Nov 1;38(6):736-45.

3. Hughes ML, et al. Ear Hear. (2001); Dec 1;22(6):471-86.

4. Incerti PV, et al. Int. J. Audiol. (2018); Mar 23;57(sup2):S27-40.

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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In January 2022, Cochlear received FDA approval to treat patients with single-sided deafness (SSD) with the Cochlear™ Nucleus® System. This approval expands treatment options to include both bone conduction solutions and cochlear implants for these patients.

“This indication allows patients experiencing UHL/SSD to get as close to the normal condition as possible as a cochlear implant restores hearing ability to the ear that has hearing loss. This allows me to provide for my patients so they can get back to the condition that they had been used to before their hearing loss.”

-Eric Lupo, MD Rocky Mountain Ear Center

While this is an extremely important landmark, we want to ensure that professionals have the resources they need to provide the best treatment option for each individual’s unique hearing loss and needs. The first step in the counseling process is to help candidates understand the potential impact of single-sided deafness within their daily lives. While individuals with SSD can function well in relatively easy listening situations, bringing awareness to the disruption in their ability to understand speech in adverse listening situations, their ability to localize sound, and the mental fatigue associated with daily listening efforts, is vital.

Age and duration of hearing loss is a key consideration and starting point for determining the best solution for individuals with single-sided deafness. For children under five years of age, Cochlear offers Softbands and SoundArcs™, non-surgical bone conduction solutions. This is important because early access to improving speech understanding is of highest priority. For children ages five to twelve, Cochlear expands the bone conduction offering with the Baha® Connect and Attract Systems, as well as a portfolio of Nucleus cochlear implant solutions. Finally, for individuals twelve and older, in addition to cochlear implants, the Cochlear Osia® System combines the best high frequency amplification with unique piezoelectric stimulation without a percutaneous abutment.

With regard to cochlear implants, one of the core advantages is the restoration of binaural hearing and improved ability to localize. Candidacy is dependent on the presence of a functioning nerve in the impacted ear and a duration of less than 10 years since the onset of the hearing loss. With acoustic neuroma being one of the leading causes of unilateral hearing loss, the FDA has approved Cochlear to remove the acoustic neuroma contraindication from its labeling.

This ensures that individuals with a functioning nerve, pre- or post-acoustic neuroma removal, can still have a cochlear implant option.

With more options come more decision points. This is why we’re committed to partnering with leading professionals in the industry and developing clinical guidance tools to support you and your patients throughout the journey to better hearing

Please reach out to your local Cochlear Representative to learn more about these solutions and clinical guidance resources.

Read more about the treatment pathway for SSD patients here.

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Cochlear Implant Evaluation Toolbox: Incentives and Obstacles to the Routine Use of Outcomes Measures by Clinicians

May 5, 2020

By Kyle Longwell, Product Manager – Software and Clinical Care at Cochlear

Recent studies1,2 support the notion that patient outcomes don’t only include a speech score – the incorporation of patient-focused satisfaction and quality-of-life metrics within the cochlear implant evaluation toolbox may contribute to a more holistic assessment of candidacy and clinical outcomes following implantation.

Data from the CI532 Clinical Study suggests that patient satisfaction measures may more accurately reflect a candidate’s real-world experience in noise and other listening situations, and should therefore be considered as a standard CI candidacy evaluation tool.1 Professionals can use patient-focused assessments like the Speech, Spatial and Qualities of Hearing Scale (SSQ-12) to inquire about aspects of the patient’s ability and experience hearing/listening in different situations. Also, the Client Oriented Scale of Improvement (COSI) is used post-operatively to document the patient’s goals/needs and measure improvements in hearing ability.

Clinicians who participated in a recent CI532 study feedback gathering session reported substantial change to their viewpoints on the of various metrics as a critical component of CI evaluation battery. Most notably, fewer surgeons and audiologists considered sentences in noise to be a vital evaluation metric, while more now consider patient satisfaction to be a key factor during CI evaluation. Feedback indicates that most clinicians are very likely or somewhat likely to include SSQ-12 in their practice in the future.

Another appointment tool, the COSI test, is an open-ended, individualized measure in which each patient nominates the situations in which he or she would most like to be able to better hear. At the end of a pre-determined time frame, (be that the next appointment or 3-6 months later), the patient rates against a five-point scale the degree of improvement, and the final ability to hear in each of those individual situations.

Further, survey responses from 50 clinicians collected by Dillon and So2 highlight the positive aspects of using COSI to measure outcomes over time:

  • Goals and expectations: Clinicians indicated that they valued the way COSI helped them check on the patients’ goals at the outset of the rehabilitation program. The COSI test:
    • Helped individualize the rehabilitation program which would not have otherwise been possible
    • Assisted the clinician and patient by discussing appropriate device use (i.e. accessories) throughout their visit schedule
    • Provided additional insight into the patient’s expectations from the outset
  • Outcome measure and residual need: Clinicians liked having a measure of success at the end of the rehabilitation program. Participants noted that it brought a sense of closure when appropriate and helped to continually identify areas that may still need work in order to plan future appointments accordingly.
  • Rapport and concern: Clinicians reported that the use of COSI helped convey to the patient that a good outcome could be achieved in situations that are important to each individual patient. It can help foster a greater rapport with patients, demonstrating that the professional is listening to the needs of each patient and documenting their satisfaction more closely. It provides a personal touch and way to track progress.
  • Patient involvement: Clinicians have reported that the use of COSI increases the involvement of the patient, and in turn, the likelihood of a good outcome. It gives the patient some ownership in their participation in the rehabilitation program.

These studies suggest that tools like SSQ-12 and COSI can improve the way professionals deliver care, incorporating more patient-focused satisfaction and quality-of-life metrics in the clinic.

To learn more read the study and watch this Cochlear NEXT Youtube playlist.

References:

  1. Data on file – CLTD5446: Clinical investigation of the Nucleus CI532 cochlear implant
  2. Dillon, H., So, M. 2000. Incentives and Obstacles to the Routine Use of Outcomes Measures by Clinicians. Ear & Hearing 2000; 21; 2S-6S.
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