Cochlear Implants
by Cochlear Guest Author

How upgrade technology can lead to better hearing

January 12, 2021
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By Jolie Fainberg, AuD, Cochlear Implant Program Director at Atlanta Institute for ENT

With 34 years of cochlear implant experience, Dr. Fainberg discusses upgrading patients to the latest Nucleus® Sound Processors.

What is your current role and what do you love about it?

I am an audiologist at a busy private ENT clinic in Atlanta, Georgia. We have a pediatric ENT, four adult ENTs and we just hired a neurotologist. I love my job because in the 29 years I have worked in Atlanta, I have watched hundreds of cochlear implant (CI) kids grow up. I get to follow them through their journey to develop hearing, speech and language – I become part of their family! Cochlear implants are the most exciting technology. There have been so many changes in this industry and it only gets better.

What do you consider the biggest changes in sound processor technology affecting your Cochlear™ Nucleus upgrade patients and why?

The addition of Bluetooth® streaming technology has had the biggest impact. Everyone loves to stream their music and have the convenience of using the phone directly to their CI. Nucleus Smart App is also a great addition. Patients have more control over their sound processor overall. They can make their own adjustments as needed and change programs more easily. Next, the Hearing Tracker and Find My Processor features have been lifesavers for many patients, particularly parents of young children.  Parents have found their kid’s CI in some pretty amusing places!

How has counseling your upgrade patients evolved with today’s sound processors?

I counsel my patients to really evaluate the benefits of a new sound processor prior to upgrading, as insurance companies have specific guidelines about approving upgrade. Insurance companies can be stricter about approving upgrades. Many require that the current sound processor is not functioning before they will approve the upgrade. This is challenging as I don’t want my patients to be without sound while we wait for approval.

The technology continues to improve in leaps and bounds. Although an upgrade to new sound processor can provide a smaller device, new technology options, etc., the real benefit is the improvement in hearing. I could be the best MAPping audiologist in the world, but there are limitations to technology that cannot be changed with MAPping. When new devices are released, the better sound quality and offer of better hearing transcends any MAPping changes I can make on old technology. I wish the insurance companies understood the hearing benefit our patients get when they upgrade. They might make it easier for patients to get new technology.

What features of the new sound processors do you feel improve hearing outcomes?

Here are a few features:

  • SCAN* (the industry’s first automatic scene classifier) has been beneficial to many of my CI users. For long term recipients, it takes a week or two for them to get used to it. After a period of adjustment, SCAN helps with changes in the hearing environment without having to adjust their CI.
  • Many of my patients have liked ForwardFocus** for restaurants and one-on-one conversations. 
  • I recommend the Mini Microphone 2+ for all my patients. It helps in so many situations such as the car, restaurants and college classes.
  • The Aqua+ wear options~ have been fun for many of my patients who have never been able to hear while swimming or playing in the water.

What are the biggest differences you’ve seen in your patients after an upgrade?

First and foremost: better hearing! I have dozens of stories where patients have heard things with their new sound processors that they never heard before. One patient told me that after she got her upgraded device and was walking with her dad to their car, she asked him: “What’s that sound?” He said, “I don’t hear anything.” They continued walking and then she realized, the sound was her footsteps. She had never heard them before. Another time, a young man received an upgrade after more than eight years and tearful at how clear the sound of the new sound processor was! The newer technology offers hearing that cannot be realized no matter what we do to an older device. That’s why we upgrade our phones and computers!

Would you highlight a success story about one of your earliest implanted Cochlear Nucleus 22 patient (adult and/or child)?

One of my N22 patients who was implanted at two years of age in 1992 just graduated from nursing school and works as a nurse. Because of the COVID precautions, she wears a mask all day at work. In addition, she is a unilateral CI user, as many of our early CI kids were only implanted on one side. She successfully navigates this difficult listening situation. I have a large number of N22 patients still using their original internal device successfully. These patients are all adults now and having a CI has not stopped them from doing whatever they wanted.

How do you counsel your patients on which Nucleus Sound Processor is right for them?

I show both options to my patients and review the highlights of each device. The decision between Nucleus 7 and Kanso® 2 is highly polarizing! Patients either want one or the other. Many of my patients who received their CIs very young do not want the drastic change from behind-the-ear to single unit sound processor. Other patients are really excited about getting a single unit CI and get the sound processor off their ear!

What have your patients been most excited about with the Kanso 2 Sound Processor?

They love the convenience of no cables or other parts to worry about. They like that the sound processor is off their ear. Many male recipients find it more aesthetically pleasing and less noticeable.

What innovations do you think will drive the CI industry forward?

In a post-COVID world, I think the capability to offer remote care like more complex remote programming will be in our future. The added benefit to this is the ability to offer better hearing healthcare services to patients living far away from a CI center.

Read more about upgrade technology here and watch this AudiologyOnline course!

About the author:

Jolie Fainberg is an audiologist with 36 years of experience. Her primary interests are pediatric audiology and cochlear implants for children and adults. She received her BA in Speech and Hearing Science at the University of California, Santa Barbara, her MA in Audiology at the University of Tennessee, Knoxville and her AuD from AT Still University. She participated on the original FDA clinical trials for all three cochlear implant companies. Her research has focused on pediatric audiology, pediatric cochlear implants, cochlear implants in special populations, diagnostic techniques for difficult to test infants and children, and brain plasticity in children. In 1992, she developed and established the pediatric audiology and cochlear implant program for Egleston Children’s Hospital at Emory University (now Children’s Healthcare of Atlanta).  She is a Clinical Instructor in the Department of Otolaryngology at the Emory School of Medicine and an Adjunct Professor at A. T. Still University Post Professional Doctor of Audiology program. Currently, she works at an ENT practice doing pediatric diagnostic testing and cochlear implants in adults and children.

The Bluetooth® word mark and logos are registered trademarks owned by Bluetooth SIG, Inc. and any use of such marks by Cochlear is under license.

The Cochlear Nucleus Smart App is available on App Store and Google Play. For compatibility information visit www.cochlear.com/compatibility

*SNR-NR, WNR and SCAN are approved for use with any recipient ages six 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.

**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.

~The Nucleus 7 Sound Processor with Aqua+ is water resistant to level IP68 of the International Standard IEC60529. This water protection only applies when you use a Cochlear Standard Rechargeable Battery Module or Cochlear Compact Rechargeable Battery Module. The Kanso 2 Sound Processor is dust and water resistant to level of IP68 of the International Standard IEC60529. The Kanso 2 Sound Processor with Aqua+ is dust and water resistant to level of IP68 of the International Standard IEC60529. This water protection rating means that the sound processor with the Aqua+ can be continuously submerged under water to a depth of up to 3 meters (9 feet and 9 inches) for up to 2 hours. The Aqua+ accessory should be used when participating in prolonged water activities.

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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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Related Posts

Clinical Programming Series: Population Mean

October 28, 2024
  • 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.

FUN5339 ISS1 JUN24 Care Model on a PageDownload

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

Dr. Laure Pratesi

Aural rehabilitation in practice with Dr. Pratesi

December 14, 2021

Laura Pratesi, AuD, discusses the importance of aural rehabilitation and how she puts it into practice.

What is the value of aural rehabilitation for your adult patients?

Aural rehabilitation is immensely valuable. I recommend it to patients at just about every stage in their hearing wellness journey. I explain that aural rehab is like “physical therapy for the brain.” Whichever skills the patient wants to strengthen or develop, we create a treatment plan and a goal to work towards. I use certain speech in noise tests (such as the QuickSIN or AzBio), as well as questionnaires such as COSI, APHAB, HHIA, HHIE, as benchmarks, to track their progress. 

Data shows that aural rehab is important for adult patients – how do you implement into practice?

Pre-COVID, we were working on developing a weekly in-person group therapy session. I think that patients can learn so much from each other, knowing there are others in the same boat. Group therapy would also give patients the opportunity to listen to lots of different voices (male and female, accent variations, loud and softer talkers, etc.). COVID-19 certainly changed our plans and brought an additional level of complexity as masks hamper lipreading and distort speech signals while quality degrades over distance. We were not sure how to overcome this. So during this time, I have focused on working with patients individually, and having them complete homework by themselves or with family members. 

At what point in the treatment process do you bring up rehab? For whom?

I bring up aural rehab from just about day one. In private practice, if patients are at my office, it is because they notice they are struggling. They have acknowledged that there is an issue, and they want to get to the bottom of it. I listen carefully to their symptoms and concerns. Even patients whose test results fall into the “normal” range may not be performing as optimally as they would like. For some patients, their challenge may have more to do with auditory processing than anatomy and physiology, but that does not mean that their struggles are not real, and do not need to be addressed. If a patient is in front of me with a complaint, then I will work with them to find a solution to their problem!

How does an aural rehab program impact your practice?

I believe focusing on aural rehabilitation means that our clinic is working to treat the whole person. We cannot just fit a set hearing aids or a cochlear implant and call it a day. When the brain has been deprived of certain sounds (sometimes for decades), it’s going to take time to learn how to hear and process again. I was born with hearing loss myself, and I did not hear much in my left ear for the first 20+ years of my life, until I got a hearing aid. I remember the time it took to get adjusted to hearing my refrigerator humming and my clock ticking. I was about two years into wearing my own hearing aids until I could tolerate them at the full volume recommended for my hearing loss.

Even now, if I switch between old and new technology, or change between hearing aid brands, it takes about 2-3 weeks for my brain to adjust to the differences. It only makes sense that it will take time for others to adjust as well. Factors to consider include the patient’s duration of deafness, pre- or post-lingual on-set of hearing loss (i.e. before or after speech development) and interventions used to date. As a provider, and as someone with hearing loss, I think it’s important we address the person as a whole. Many are seeking better access to sound and greater ease with communication. Why would we not want to try to address those concerns?

How has Cochlear™ CoPilot been integrated into your program?

Cochlear CoPilot has been an effective addition to my aural rehab tool box. It has previously been a challenge to find quality, affordable solutions for my patients. There have been programs that have been discontinued, others that are not cost effective, some that are cumbersome or not intuitive. I love how the lessons build off of each other, and the tasks gradually become more complex. If the beginning tasks are too easy, you can jump ahead. If the exercise is too hard, you can go back and work on the skill set that builds up to it. You can focus on names or numbers or street addresses or whatever. I found the exercises to be applicable to real conversations and real interactions.

How have your patients used and benefited from Cochlear CoPilot?

I think that any kind of listening exercise can be beneficial, but I love that patients can stream directly to their processor/hearing aid, or can turn one side off and work an individual ear at a time. It’s been very easy to get the app downloaded and installed for my patients. I set aside a few minutes of their appointment time to go over and practice some of the first lessons. Everyone has found it very simple and easy to use, and not intimidating at all. My patients like the streaming aspect the most – and that they can do the exercises anywhere at any time. I try to get patients to commit to at least one hour a day of dedicated aural rehab time. Snagging 10-15 minutes here or there, they can accomplish that easily! 

Download Cochlear CoPilot for free from the Apple® App Store®.

About the author:

Laura Pratesi, Au.D. is owner of Citrus Hearing Clinic LLC in Clermont, Florida. Dr. Laura received her Bachelor of Science in Communication and Sciences Disorders with a concentration in Human Development from Auburn University in 2008, and her Doctor of Audiology degree from Auburn University in 2012. During her time at Auburn, she had the opportunity to work in a variety of clinical settings including in a school system, hospital system, VA facility, ENT practice, private practice, and assisted living facilities. She has extensive experience in working with both pediatric and geriatric populations, as well as veterans.

Audiology is not just a profession for Dr. Laura, but also a calling. Diagnosed with a progressive hearing loss at age 5 years, she was first fit with amplification by her classmates while at Auburn University. Having struggled with untreated hearing loss for years while falling into care gaps, Dr. Laura is passionate about proper identification, diagnosis and intervention of hearing and balance disorders for patients of all ages. 

Dr. Laura has been featured as a Woman of the Year for 2020 by Orlando Magazine, a HearStrong Champion, was a part of the Docs with Disabilities campaign by the University of Michigan, and was featured on multiple podcasts, including Orlando Lady Boss. She is a Fellow of the American Academy of Audiology, has her CCC-A from ASHA, is a member of the Academy of Doctors of Audiology, and is a member of the Florida Academy of Audiology. Since April 2021, she has been a member of a FLAA Task Force charged with updating Audiology Statutes in the state of Florida. At her practice, she does contract work for the Veteran’s Administration, the Department of Vocational Rehabilitation, the Lake County School System, and the Social Security Administration. She resides in Central Florida with her husband, their five year old son, four cats, and two hermit crabs. In her free time, she is a volunteer at Clermont First United Methodist Church, and the former Publicity Chair board member of the Moonlight Players community theater (on hiatus due to Covid-19).

For compatibility information visit www.cochlear.com/compatibility

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