Cochlear Implants
by Patti Trautwein

What is Normal Hearing? Why a simple and consistent answer is needed

October 29, 2020
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By Patti Trautwein, MA, AuD, Vice President, Product Management & Marketing, Cochlear Americas

Less than 25% of people get their hearing screened annually and more than 37 million (15%) Americans have hearing loss.1-2  Less than 30% of people who can benefit from hearing aids1, 2 and approximately 8% from cochlear implants have them.3 

As an audiologist, this data can be frustrating. There have been tremendous advancements in technology in the last few decades, including more treatment options with devices that are smaller, smarter and deliver better outcomes. Despite these advances, why haven’t the growing number of people with hearing loss accessed treatment?  Recent clinical and market investigations have identified awareness, acceptance, cost and stigma as primary obstacles to adopting hearing devices.4

A recent article by Christopher Spankovich reviewed the history of defining hearing loss using the audiogram versus other measures such as speech or objective measures, explaining how the past five decades encapsulated the rationale for 15- 25 dB HL as the limit for normal hearing.5 Importantly, the author noted strong correlation between pure tone average and perceived hearing difficulty. Most interesting, Spankovich reported that when asking audiologists what normal hearing is, “not surprisingly, you get a variety of responses.” 

How does the variability across clinicians transcend to the general population’s understanding of normal hearing? 

For example, Cochlear’s industry research highlights how people described hearing and noted the variability. Some used words such as mild, moderately severe, significant or deaf, while others used percentages of loss or percentages of hearing remaining.

So, do people know what is normal hearing? The team decided to go out on the street to find out:

Raising awareness of a simple metric, such as 20 dB PTA, for normal hearing may help the general population understand hearing health. Further, it may provide guidance on when to seek clinical evaluation, treatment and even what type of treatments to consider. This becomes increasingly important as the options expand to include over-the-counter devices in addition to hearing aids or hearing implants, making it more important for consumers to get the support of an audiologist or ENT. A simple and consistent metric streamlines to the process for consumers and allied health providers to monitor and act on hearing health, as they are likely to do with other health considerations such as vision or cholesterol.  

Is this a call to action for hearing health care providers to align on the simple answer that the general public can understand?  Please share the video with your colleagues and start the conversation so we can work together to improve access to appropriate hearing healthcare.

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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.

References:

1. Abrahms, H and Kihm, J (2015) MT9 reveals renewed encouragement as well as obstacles for consumers with hearing loss. Hearing Review https://www.hearingreview.com/practice-building/marketing/introduction-marketrak-ix-new-baseline-hearing-aid-market (accessed on Sept 14, 2020)  

2. Quick Statistics About Hearing. (2020, October 2). NIDCD. https://www.nidcd.nih.gov/health/statistics/quick-statisticshearing#:~:text=One%20in%20eight%20people%20in,based%20on%20standard%20hearing%20examinations.&text=About%202%20percent%20of%20adults,54%20have%20disabling%20hearing%20loss.

3. Holder, J., Reynolds, S., Sunderhaus, L., Gifford, R. (2018) Current Profile of Adults Presenting for Preoperative Cochlear Implant Evaluation Trends in Hearing Jan-Dec.

4. Kochin, S. (2007) MarkeTrak VII: Obstacles to adult non-user adoption of hearing aids, he Hearing Journal: April 2007 – Volume 60 – Issue 4 – p 24-51

5. Spankovich, C. (2020) Some observations on normal hearing and hearing loss.  Audiology Today Sep/Oct 2020 pgs. 32-41.

Related Posts
Dr. James Connor Sullivan

Professional perspective: Hear from an AuD and recipient on best practices

February 4, 2021

James Connor Sullivan, AuD, CCC-A, F-AAA, discusses his experience as an audiologist and recipient, as well as the future of the cochlear implant industry.

How did your experience as a recipient draw you to the field of audiology?

Dr. Sullivan: As a child, my family always raised their kids that they would have to go to college after graduating high school. As the only person with hearing loss in my family, I was treated no differently. I went through all of my grade school with bilateral hearing aids, and it wasn’t until college that I became a candidate for a cochlear implant.

Prior to getting a cochlear implant, I actually never wanted to be an audiologist. When I was in high school, I always thought I wanted to work in a theater program working behind the scenes as a lighting technician, so I enrolled into a selective theater program in Oklahoma. It was during my first semester of my undergraduate program that I had a pretty significant hearing fluctuation, making me a candidate for a cochlear implant.

As an avid researcher of everything technology, I turned to the web and anything else I could get my hands on to get any information I could about the cochlear implant process, trying to figure out “what a cochlear implant sounds like.” It very quickly became apparent to me that getting good, reliable and accurate information for young adults about cochlear implants is very difficult.

Most young adults with hearing loss are in an awkward stage of their life (for many reasons). Most young adults are trying to figure out their financial situations, career goals, health insurance coverage, how to pay for hearing technology as they are losing coverage, all in the midst of possibly transitioning out of their pediatric audiology clinic and into their adult audiology clinic with a new provider.

I was young, broke, unhappy with my major as a freshman, unable to afford healthcare or new hearing aids, and my hearing had a pretty significant shift in my hearing and word understanding. As part of the cochlear implant approval process I realized that I had a unique insight that most people rarely get to experience or share with their patients.

The day I got activated with my cochlear implant I changed my major from theater to audiology because CI audiologists get to change our patients’ lives every day. I always knew I wanted to do something that had a true impact in others lives and little did I know how much I’d love getting to do it.

 How has the current global environment changed the way you deliver care?

Dr. Sullivan: COVID-19 has thrown a wrench in 2020. I think that the pandemic has made providers think about each procedure and process, and ensure that what we are doing is beneficial to the patient and to the office as a whole. As part of this review, I believe that we have found some things to increase the efficiency of our clinic to help make a lasting change in the patient experience.

  1. Prior to COVID-19, our clinic utilized primarily paper case histories. We have now moved to all digital, allowing for appropriate triaging of patient appointments and for our clinical assistants to move up appointments as medically indicated.
  2.  As face masks are required in all clinical spaces, we have expanded the use of voice-to-text software throughout our iPads® for our patients with significant hearing loss or language barriers.
  3.  We have added virtual appointments for any and all appointments that have the ability to be conducted virtually, including device selections and counseling appointments.

 How do you empower patients to achieve hearing goals and outcomes?

Dr. Sullivan: We have all of our cochlear implant patients establish care with an auditory verbal therapist to assess their needs and set appropriate goals. From an audiology standpoint, it is important to educate the patient, but not over-educate them on all of the intricacies of their equipment. It is VERY easy to get overwhelmed the first day.

At my activation appointments, I tell the patients that they need to “focus” on three things during their first few days with the device, adding more layers of complexities as I see the patient for their follow-ups.

1.       How to change the battery and put the device on.

2.       Focused listening therapy, at least 20-30 minutes a day.

         My go-to apps are AngelSounds™ and Bring Back the Beat. Later I encourage audiobooks.

3.       Progressing through the progressive MAPs.

I typically set a schedule for when to progress, every two days progress to the next MAP. By the next time I see them they’ll be on the appropriate MAP.

At the end of the day wear time and auditory stimulation is the name of the game. As the patient comes for their follow-ups and they display that they have an appropriate grasp of the first concept, then I’ll add in information like accessories.

Is hearing therapy involved?

Dr. Sullivan: In order to ensure the patient has appropriate access to sound, we always check Ling Sounds during their MAPping to ensure an appropriate MAP has been completed. Once appropriate access to all the Ling Sounds has been established, the patient needs to establish care with hearing therapy.

Hearing therapy is an integral part of our cochlear implant team. As previously mentioned, we have established our patients with our auditory verbal therapist in the area. We also encourage at-home exercises and show them in the clinic to ensure understanding of the tools.

How are outcomes and quality-of-life measured?

Dr. Sullivan: We measure outcomes through the SSQ, the Tinnitus Handicap Inventory (if they have Tinnitus) and the Nijmegen Cochlear Implant Questionnaire. These are administered through an online survey site on an iPad. In addition, we regularly assess our patient’s performance through functional testing with CNC and AzBio (in quiet and in noise as appropriate) testing.

Can you touch on awareness/access to care in the cochlear implant industry?

Dr. Sullivan: It’s no secret that cochlear implants are significantly underutilized by patients who could benefit from them. I think that the 60/60 guideline (Zwolan et al. 2020)1 should really be in every clinician’s mind when conducting any audiological examination.

If a patient has less than or equal to 60% word recognition in either ear, or if their pure tone average is at or less than 60 dB HL for either ear, a clinician should refer the patient for a cochlear implant evaluation. It is important to stress that just because you get evaluated for a cochlear implant, it does not mean you are receiving a cochlear implant. I always look at these appointments as information gathering sessions.

Per Zwolan et al. 2020, if utilized as a screening guideline this screening has a 96% detection rate and a 34% false positive rate.

It is important to educate fellow clinicians, providers in the area and patients about the ever-changing cochlear implant landscape. 

What excites you the most moving forward in the CI industry?

Dr. Sullivan: I’m most excited about the expanded access to this life-changing technology. As previously mentioned, I never would have even considered being an audiologist and now I get to work with cochlear implant patients every day. I’m looking forward to the evolution of cochlear implant processor technology and providing access to patients who otherwise would have never received access to this technology.

For more helpful resources, subscribe to the Cochlear ProNews.

About the author: Dr. Sullivan is an audiologist who works in the Houston area with patients who have hearing loss. Dr. Sullivan, also born with a hearing loss, enjoys using both his personal and professional experiences with his cochlear implant and hearing aid to aid in the treatment of his patients. Dr. Sullivan has presented both nationally and internationally on several topics, including Large Vestibular Aqueduct Syndrome, the disorder that resulted in his hearing loss. He is passionate about using his personal experiences alongside clinical knowledge in audiology to help patients across the lifespan and their families who are impacted by hearing loss.   

References:

  1. Zwolan, Teresa A.; Schvartz-Leyzac, Kara C.; Pleasant, Terrence Development of a 60/60 Guideline for Referring Adults for a Traditional Cochlear Implant Candidacy Evaluation, Otology & Neurotology: April 20, 2020 – Volume Publish Ahead of Print – Issue – doi: 10.1097/MAO.0000000000002664

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TIMS

Case study: Intraoperative correction of a CI632 placement using the Nucleus® SmartNav System and TransImpedance Matrix recording

June 21, 2022

By Nauman F. Manzoor, M.D. * and Viral Tejani, Au.D., Ph.D. *

Department of Otolaryngology-Head and Neck Surgery, University Hospitals / Case Western Reserve University School of Medicine

*Co-authors with equal contribution to the write-up

Patient background

An 88 year old female was referred for bilateral progressive sensorineural hearing loss and remote history of left- sided Meniere’s Disease. She no longer had any episodic vertigo but did endorse mild imbalance. She was using bilateral traditional amplification but over the last year had noticed decline in speech understanding. Based on comprehensive audiometric testing, she was a cochlear implant candidate in both ears. Vestibular testing showed left-sided weakness and hence this ear was selected for cochlear implantation. Pre-operative computed tomography (CT) imaging was normal with no cochlear or labyrinthine abnormality (images below). Normal mastoid anatomy and facial nerve course was appreciated. Prior magnetic resonance imaging (MRI) scan was also negative for any retrocochlear lesion.

Device selection / Electrophysiology background

In all standard cochlear implant cases, we use CI632 Slim Modiolar Electrode (SME) for modiolar proximity and good cochlear coverage. While clinical studies indicate a low tip fold-over rate1-5 with the SME, our institution still routinely confirm device placement via electrophysiologic measures and an intraoperative x-ray using a modified stenver view.

While effective, these imaging measures add to the surgical costs, expose patients to radiation (albeit a small amount), and add to the surgery time3. Thus, electrophysiological measures of TransImpedance Matrix (TIM) have been previously proposed and has shown promise in identifying tip fold-over5-6.  Essentially, the TransImpedance Matrix show how voltage is distributed along the electrode array when the cochlear implant is stimulated.

The TransImpedance Matrix tool is available in Custom Sound® and has also been incorporated into the recently created Nucleus® SmartNav platform. The SmartNav platform is an iPad based platform that wirelessly interfaces with the internal CI; it monitors insertion speed and conducts a “Placement Check” as well as impedance and AutoNRT recordings once the CI is inserted.  The placement check is a TransImpedance Matrix recording.

Surgical course

              A standard mastoidectomy was performed and a facial recess approach was used. Round window anatomy was normal, and an extended round window approach was utilized. The electrode array was deployed in a standard manner keeping a co-planar trajectory to the basal turn. After placement, the SmartNav System was used to conduct a Placement Check.  As shown by the screenshot below, the placement check indicated a tip fold-over at electrodes 19-22.

To verify the Placement Check results and obtain more detailed measure, a TransImpedance Matrix recording using Custom Sound was performed.*  These results are plotted in the below figure.  The left axis shows the recording electrode, while the bottom axis shows the stimulating electrode.  In a normal TransImpedance Matrix plot, a dark black / red diagonal line from the lower left hand corner to the upper right hand corner is expected, which shows normal voltage distribution. However, the below figure indicates abnormal voltage spread at the apical electrodes starting around E15-22 (see lower left hand corner plot). For example, when looking at stimulating electrode 22, one can see two peaks (as signified by the red points at recording electrode 22 and recording electrode 15/16).  This signifies that electrodes 15 and 22 are very close to one another due to the high voltage recordings.

*TIM is only available in Custom Sound® EP and requires a regional key and access code.

This was confirmed via an intraoperative X-ray. It does appear that there is fold-over starting and that electrode 22 and electrodes 15/16 are very close to one another.

The electrode was removed, reloaded into the sheath, and the array was reinserted without incident. SmartNav Placement Check was normal.

The TransImpedance Matrix recording was also normal (see below figure).  As previously stated, in a normal TransImpedance Matrix plot, we expect a dark black / red diagonal line from the lower left hand corner to the upper right hand corner.

Intraoperative X-ray was also normal. 

Conclusions

This case study provides proof-of-concept regarding the utility of TransImpedance Matrix recordings (as embedded in SmartNav or as separately available in Custom Sound) in evaluating cochlear implant placement.  Given the low tip-foldover rate reported across the literature for the SME array1-5, large scale studies are needed to generate a sufficient patient sample size to verify the sensitivity and specificity of TransImpedance Matrix recordings in identifying tip-foldovers and compare these metrics to the sensitivity of intraoperative imaging.

Get an inside look on the SmartNav System here!

About the authors:

Dr. Manzoor is a board-certified otolaryngologist and head & neck surgeon with fellowship training in otology-neurotology and lateral skull base surgery. He has expertise in the diagnosis and treatment of a wide range of otologic, neurotologic and skull base conditions. He completed his otolaryngology training at University Hospitals Cleveland Medical Center and completed his fellowship training at Vanderbilt University Medical Center. He is particularly passioned about hearing rehabilitation and strives to deliver cutting edge treatment options for patients with hearing disorders. He is also an avid researcher with 60 peer reviewed publications related to otologic-neurotologic disorders and outcomes.

Viral Tejani, AuD, PhD, is a Cochlear Implant Audiologist and Assistant Professor of Otolaryngology.  He sees cochlear implant patients in the clinic and is also involved with both NIH-funded and industry-funded research. His particular expertise/passions are in cochlear implant psychophysics, electrophysiology, electric-acoustic stimulation, as well as improving outcomes of cochlear implantation. He completed his AuD at University of Maryland and his PhD at University of Iowa, where he remained as an Otolaryngology faculty member until relocating to Cleveland.

References

  1. Aschendorff, A., Briggs, R., Brademann, G., Helbig, S., Hornung, J., Lenarz, T., Marx, M., Ramos, A., Stöver, T., Escudé, B., & James, C. J. (2017). Clinical investigation of the Nucleus Slim Modiolar Electrode. Audiology & neuro-otology, 22(3), 169–179. https://doi.org/10.1159/000480345
  2. Friedmann, D. R., Kamen, E., Choudhury, B., & Roland, J. T., Jr (2019). Surgical Experience and Early Outcomes With a Slim Perimodiolar Electrode. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 40(3), e304–e310. https://doi.org/10.1097/MAO.0000000000002129
  3. Klabbers, T. M., Huinck, W. J., Heutink, F., Verbist, B. M., & Mylanus, E. (2021). Transimpedance Matrix (TIM) Measurement for the Detection of Intraoperative Electrode Tip Foldover Using the Slim Modiolar Electrode: A Proof of Concept Study. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 42(2), e124–e129. https://doi.org/10.1097/MAO.0000000000002875
  4. Shaul, C., Weder, S., Tari, S., Gerard, J. M., O’Leary, S. J., & Briggs, R. J. (2020). Slim, Modiolar Cochlear Implant Electrode: Melbourne Experience and Comparison With the Contour Perimodiolar Electrode. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 41(5), 639–643. https://doi.org/10.1097/MAO.0000000000002617
  5. Shew, M. A., Walia, A., Durakovic, N., Valenzuela, C., Wick, C. C., McJunkin, J. L., Buchman, C. A., & Herzog, J. A. (2021). Long-term Hearing Preservation and Speech Perception Performance Outcomes With the Slim Modiolar Electrode. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 42(10), e1486–e1493. https://doi.org/10.1097/MAO.0000000000003342
  6. Zuniga, M. G., Rivas, A., Hedley-Williams, A., Gifford, R. H., Dwyer, R., Dawant, B. M., Sunderhaus, L. W., Hovis, K. L., Wanna, G. B., Noble, J. H., & Labadie, R. F. (2017). Tip Fold-over in Cochlear Implantation: Case Series. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 38(2), 199–206. https://doi.org/10.1097/MAO.0000000000001283   

SmartNav offers a variety of measurements. These insights are one source of information and do not guarantee clinical outcomes.

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