COCHLEAR IMPLANTS GETTING THE FACTS
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COCHLEAR IMPLANTS GETTING THE FACTS

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  • * tool not a cure * it’s a better “hearing aid” * not one size fits all
  • Can’t compare apples and oranges. As younger kids get implants- special needs may not yet have surfaced We can’t assume that the educational program will look the same for all implanted children.
  • When looking at these families, the families obviously want improved use of spoken language. And many do perceive an increase in their child’s ability to understand words, however, It appears that many families continue to use sign. What does this mean
  • As with other children who are deaf, educational programming can not be a one size fits all approach

COCHLEAR IMPLANTS GETTING THE FACTS COCHLEAR IMPLANTS GETTING THE FACTS Presentation Transcript

  • COCHLEAR IMPLANTS GETTING THE FACTS
  • A cochlear implant is an assistive technology :
    • That bypasses the damaged part of the cochlea and sends electrical signals to the auditory nerve which relays these signals to the brain
    • Designed to provide sound detection to a full range of sounds to children with severe to profound hearing loss who obtain minimal benefit from hearing aids.
    • With unknown outcomes related to providing a child full access to spoken language for education and life success
  • Increasing numbers
    • Clerc Center- 1999-2000- no students with implants
      • Kendall,2002- 10 students (8 in candidacy process)
      • MSSD, 2002- 5 students (varying degrees of usage)
    • Nucleus Implants- worldwide
      • 1994-10,000
      • 1999-26,000
      • 2002-36,450
      • (Do not have statistics for Advanced Bionics and Med-El)
  • Why Are the Numbers Increasing
    • Early Identification
    • Improved technology
    • Changing candidacy requirements
    • Lower surgical risk
    • Changing attitudes
  • Implant Components
    • Three manufacturers of implants commonly used in the United States:
      • Cochlear Corporation (Nucleus)
      • Advanced Bionics- (Clarion)
      • Med-El
    • Surgically implanted components
      • Receiver coil
      • Electrode array
    • External components
      • Microphone
      • Speech Processor
      • Transmitter with a magnet
  • How does an implant work?
    • Sound picked up by microphone
    • Electrical pulses of sound signals sent to speech processor
    • Speech processor codes sound signals
    • Code is sent to transmitter
    • Transmitter sends coded sound across skin to internal receiver (via FM transmission)
    • Receiver converts code to electrical signals
    • Electrical signals sent to electrode array
    • Signals recognized as sound by the brain
  • LEVELS OF PERFORMANCE
    • Sound Awareness
    • Basic discrimination of sounds
    • Voice monitoring
    • Understanding environmental sounds
    • Understanding single words and/or phrases
    • Understands details in sentences
    • Understanding connected speech
  • Why are the outcomes different for each child ?
    • Age at time of implant
    • Pre-implant duration of deafness
    • Etiology of hearing loss
    • Residual hearing prior to implant
    • Family support
    • Implant technology/channels
    • Consistency of usage
    • Appropriate programming of device
    • Additional special needs
    • Quality of educational and habilitative environment
  • Candidacy Requirements
    • Who is a candidate:
    • Age- FDA says 18months, but doing as young as one year (maybe some earlier)
    • Intact auditory nerve
    • Degree of loss- was profound, now increasingly more in severe range
    • Hearing aid trial was 3 months in many places, now not as strict in many Centers
    •  
    • Issue of who "is not" a candidate
    •  
    • Centers do not seem to be denying children access to this surgery, however many centers strongly suggest participation in a full mainstream environment in coordination with the surgery. Some implant centers may not consider "signing" students and families as candidates.
  • Process John's Hopkins Hospital- The Listening Center
    •     * I nitial consult
    • * ABR
    •   * Audiology eval (with and without hearing aids, may
    • take many visits
    •    * CT scan- looks at anatomy of cochlea
    •     * Promontory test- looks at which ear stimulates best to an
    • electrical signal
    •       * ENT consult
    •       * Rehab consult
    •      * Outreach with educational programs
    • * Surgery
    • * Mapping
    • * Habilitation/Rehabilitation
  • Deciding which ear to implant-some issues to consider
    • Anatomy (lack of calcification, is there an auditory nerve,
    • malformed/no cochlea)
    • Perhaps one ear accepts electrical stimulation better than other
    • Leave ear with better hearing, implant worse ear, then if not successful can revert back to aiding that ear
    • Implant better ear (opposite argument)- It has already benefited from hearing aid, will more readily acclimate to implant
    • Facial nerve too close to cochlea-may pick other ear
    • If no difference may want it on right- as speech and hearing
    • centers of brain on left
    • Want on right- later for later when driving. Can hear people in the car
  • Surgical Considerations
    • General
    • ·     Usually outpatient, 1-2 hours
    •  
    • ·     Two parts of implant are inserted during surgery- electrode array in cochlea and the implant body placed in mastoid bone. Body holds a magnet that attaches to external components of the implant.
    •  
    After · Usually up and around in 1-2 days ·May be some swelling externally · Warned of some possible nausea from anesthesia ·   W ait 4-5 weeks for all swelling/healing to take place before activation   During ·         Shave area ·         Mastoid bone uncovered (skin flap) ·         Carve space for body of implant ·         Drill hole to cochlea ·         Small opening in cochlea to insert electrode array ·         Incision closed
  • What about insurance
    • Cost of cochlear implant is $40,000-50,000
    • Most private insurance companies are paying for surgery
    • Most of the time Medicaid pays 90-100%.
    • May be problems with insurance related to child being too young based on FDA guidelines
    • Implant manufacturers have special departments to handle insurance related problems and secure payment.
    • Some insurance companies pay for post implant training/mapping
    • Only a few insurance companies pay for upgrades (earlevel) ( may get coupon for upgrade from the manufacturer)
  • Mapping/Programming Issues
    •    Each person has an individual program called a map
    •     Map based on determining threshold levels, and
    • maximum comfort levels for each electrode.
    •          Determine how many electrodes can be stimulated
    • comfortably
    •          Various strategies- one not best for all (SPEAK, CIS,
    • ACE). Not one program suited for all people.
    •          Takes multiple sessions to program
    •          May initially be uncomfortable
    •          Neural response telemetry-Objective measure of
    • response to electrode stimulation
    •       S peech perception errors may be used to monitor the mapping (may be difficult due to impact of articulation errors, not good for young children)
  • Research issues
    • Change of research playing field now that candidacy requirements have changed
    • Much of the research focuses on speech perception and speech production
    • Age of implantation under 5 indicates advantage and ease in spoken language learning, yet still variability
    • There does not appear to be an age cut off when an implant does not appear useful in some way-
  • Research issues
    • Oral children may have faster gains than TC kids, but what about ultimate outcomes?
    • CI increases speech and language regardless of the modality of language programming provided. (U. of Michigan, 2000)
    • Children with better communicative interaction skills at preverbal level were also most likely to have good speech perception and production skills three years after implantation. (Tait and Lutman, Robinson, 2000)
  • Parents’ Perceptions and Experiences: Gallaudet Research Institute findings (439 families)
    • 52% of families chose an implant to increase ease in development of spoken language
    • 43% of families perceived a significant increase in their child’s ability to understand words
    • 62% of families continued to use sign language support in the home although use of speech increased
  • The bottom line
    • Outcomes related to development of spoken language will be unique for each child
    • Educational programming must be designed to address the individual needs of students with implants