Alexandra D. Costlow, B.S.
Cochlear Implant (CI) Appointments General Points <ul><li>Implantation requires an ongoing commitment of time and resource...
CI Appointments General Points <ul><li>Each appointment should support a successful implantation process as a whole </li><...
CI Appointments Stages <ul><li>Candidacy </li></ul><ul><li>Surgical Implantation </li></ul><ul><li>Follow-Up Care </li></ul>
CI Candidacy Appointments Review <ul><li>Preoperative assessment should be performed at a CI center staffed with clinician...
CI Candidacy Appointments Review <ul><li>Hearing Assessment, including Auditory Skills Assessment </li></ul><ul><li>Otolog...
CI Candidacy Appointments Hearing Assessment <ul><li>Hearing Assessment by a licensed audiologist  </li></ul><ul><ul><li>D...
CI Candidacy Appointments <ul><li>Auditory Skills Assessment </li></ul><ul><ul><li>“…  Evaluates child’s ability to attend...
CI Candidacy Appointments <ul><li>Otologic Assessment </li></ul><ul><ul><li>Determination of the etiology of the hearing l...
Candidacy Appointments <ul><li>Opthalmology </li></ul><ul><ul><li>Vision plays a critical role in the deaf child’s develop...
CI Candidacy Appointments <ul><li>Psychological Testing </li></ul><ul><ul><li>Screen for psychopathology and cognitive def...
CI Candidacy Appointments <ul><li>Counseling to ensure suitability and motivation to participate in the process </li></ul>...
Device Discussion <ul><li>To ensure that the patient and his/her family understand the motivation and resources required f...
CI Candidacy Appointments <ul><li>Tests performed by the surgeon </li></ul><ul><li>Analysis of the brain and middle and in...
CT Scan of Cochlea http://www.sciencedaily.com/releases /2008/04/080425151819.htm
CI Candidacy Appointments <ul><ul><li>Magnetic Resonance Imaging (MRI) </li></ul></ul><ul><ul><ul><li>Uses powerful magnet...
MRI (at 3 tesla) of Cochlea http://www.vanderveer.org.nz/research/labs/mri.php
CI Candidacy Appointments <ul><li>CAT Scan and MRI </li></ul><ul><ul><li>Analyze the structure (and presence or absence) o...
Surgery <ul><li>The patient is deemed a candidate and decides to go forth with implantation. </li></ul><ul><li>Surgery may...
Review of CI Components <ul><li>Microphone - picks up sound </li></ul><ul><li>from the environment </li></ul><ul><li>Speec...
Surgery <ul><li>The surgeon makes a trans-mastoid facial recess incision </li></ul><ul><li>The surgeon drills into the mas...
Surgery <ul><li>The outer end of the electrode array is fastened to the skull </li></ul><ul><li>The scalp should be thinne...
Surgery Part I <ul><li>http://www.youtube.com/watch?v=x7ltzA0B2X8&feature=related </li></ul>
Surgery Part II <ul><li>http://www.youtube.com/watch?v=I0Z3eKNw2vc&feature=related </li></ul>
Activation and Initial Fitting <ul><li>Days after the surgical implantation of the receiver (just behind the ear) and the ...
Activation and Initial Fitting <ul><li>Audiologist runs standard check  </li></ul><ul><li>of the speech processor </li></u...
Activation and Initial Fitting <ul><li>How is mapping conducted? </li></ul><ul><li>Using speech (subjective) </li></ul><ul...
Neural Response Telemetry http://www.uzh.ch/orl/lea/nrt.jpg
Map Parameters <ul><li>Strategy - Method by which sound is analyzed and presented, which varies by manufacturer </li></ul>...
Activation <ul><li>Cochlear Implant Activation – Captured </li></ul><ul><li>http://www.youtube.com/watch?v=YFBUNJtT39Y&fea...
Follow-Up to Initial Fitting <ul><li>May include several visits over the span of weeks or months </li></ul><ul><li>Why is ...
Follow-Up to Initial Fitting <ul><li>Sample Programming Schedule </li></ul><ul><ul><li>Days 1, 2: Activation of the extern...
Aural Rehabilitation Previous vs. New Listeners <ul><li>Patients with previous experience hearing and listening should be ...
Aural Rehabilitation <ul><li>Teaches the patient how to use the CI and respond  </li></ul><ul><li>to auditory input </li><...
Aural Rehabilitation Activities <ul><li>Adults </li></ul><ul><li>Children </li></ul><ul><li>May focus on social or occupat...
Outcomes of CI Performance Hearing Aid + CI <ul><li>Ching, Incerti, and Hill (2004)  tested 21 adults who used a Nucleus C...
Hearing Aid + CI <ul><li>Litovsky, Parkinson, Arcaroli, Peters, Lake, Johnstone, and Gonqiang (2004)  tested 17 adults and...
Bilateral CIs vs. Unilateral CI <ul><li>Tyler, Gantz, Rubenstein, Wilson, Parkinson, Wolaver, Preece, and Lowder (2002)  e...
Bilateral CIs vs. CI+HA <ul><li>Litovsky, Johnstone, and Godar (2006)  evaluated 20 children (20 use bilateral CIs, 10 use...
Where to Go from Here? <ul><li>CI+HA and bilateral CIs offer benefit over unilateral CI </li></ul><ul><li>Bilateral CIs of...
Deaf Culture The Basics <ul><li>Deaf Culture is linguistically unified through American Sign Language (ASL) </li></ul><ul>...
Deaf Culture and Cochlear Implants Conflict of Cross-Cultural Values <ul><li>Child as Recipient </li></ul><ul><li>Impact o...
Deaf Culture and Cochlear Implants <ul><li>Advocates for Deaf individuals </li></ul><ul><ul><li>The National Association o...
References <ul><li>American Speech-Language Hearing Association (ASHA).  Cochlear implants.  Retrieved from  http://www.as...
References <ul><li>Kim, H.J. (1993). Congenital inner ear malformations. Retrieved from  Baylor College of Medicine’s  web...
References <ul><li>National Institute on Deafness and Other Communication Disorders (NIDCD). (2009). Cochlear implants. Fr...
References <ul><li>Tyler, R.S., Gantz, B.J., Rubenstein, J.T., Wilson, B.S., Parkinson, A.J., Wolaver, A., Preece, J.P., W...
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Cochlear Implantation Process, Performance, and Culture

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Cochlear Implantation process, performance, and cultural implications.

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  • Realistically, there may have been a string of appointments that may have lead up to the patient attending the candidacy appointment. Ex: parent-teacher conference, IEP meeting/s, appointments with the audiologist and/or speech-language pathologist It is important to remember this because although this will be the start of the appointment process for the professional, this is likely not the beginning of the appointment process for the patient.
  • Professionals who are familiar with the implantation process from start to finish may be better able to identify both risk factors and strengths for implantation Factors that affect performance- patient motivation, family support, *duration of deafness at age of implantation  neural activity allows neuronal pathways to retain their potential to achieve meaningful integration of prosthetic inputs (Niparko, 2009). Factors that affect perceived benefit- realistic expectations
  • Multimodal Processing Assessment is performed by an occupational therapist to identify subtle motor and/or sensory delays that may interfere with the child’s ability to integrate audition with other senses and into a social context. It is important to look at the big picture. Is implantation safe? Will this patient be a successful CI user? The BL: Look at patient as a whole– are the fit to be a successful CI user?
  • In other words, the hearing assessment has moved away from being “all about the numbers” to being more holistic and functionally-based. Constraints of HA usage: anotia/microtia, no residual hearing, limited manual dexterity
  • A child may have residual hearing, but he/she may not be able to functionally use the residual hearing.
  • Prognostic value of knowing the etiology of the HL is only for ossification of the cochlea (due to meningitis, lues, and trauma) or changes in labyrinthine bone (osteogenesis imperfecta) (Niparko, 2009). Usher Syndrome- deafness of inner ear, gradual vision loss due to retinitis pigmentosa (degeneration of retinal cells), and balance difficulties. Caused by mutation of 1 of 10 genes. Neurofibromatosis II – (MISME = Multiple inherited schwannomas, meningiomas- on meninges, ependymomas- on ependyma, a soft tissue) is an inherited disease that causes the patient to develop these benign tumors, principaly on CN8. They also have eye problems.
  • Waardenburg syndrome- is a group of inherited conditions characterizedby deafness and partial albinism (pale skin, hair, and eye color).Symptoms: Cleft lip (rare); Constipation; Deafness; Extremely pale
  • Knutson, J.F., Johnson, A., &amp; Murray, K.T. (2006) Social and emotional characteristics of adults seeking a cochlear implant and their spouses. British Journal of Health Psychology, 11 (2), 279-292.
  • Psychological testing and Counseling go hand in hand
  • Computerized Axial (Anatomical)- of or relating to the axial bones of the body, which are the skull, vertebral column, ribs, and sternum Tomography- Greek “tomos,” to cut or section
  • Science Daily (2009). Low frequency hearing linked to shape of cochlea, from: http://www.sciencedaily.com/releases/2008/04/080425151819.htm
  • From Van Der Veer Institutefor Parkinson’s and Brain Research (2007) Magnetic resonance Imaging at 3 tesla – The first in New England, from: http://www.vanderveer.org.nz/research/labs/mri.php
  • Cochlear abnormalities- Mondini’s deformity (incomplete or lack of intrascalar septa); Cochlear aplasia (cochlea is a single cavity) Mastoid- stenoisis of the EAC
  • Skin flap designs vary (C flap versus Inverted J flap) and are aided by a mock BTE processor and implant. Cochleostomy is anterior and inferior insertion to the round window
  • http://www.youtube.com/watch?v=x7ltzA0B2X8&amp;feature=related Skin flap measurement and incision Insertion of the transmitter
  • http://www.youtube.com/watch?v=I0Z3eKNw2vc&amp;feature=related Cue before 2:30 Drilling into round window, Insertion of the implant and threading of the electrode
  • The first appointment is about 2 hours, and the patient will return the following day for a 1.5 – 2 hour appointment.
  • Standard check checks impedances of contacts of the cochlea to evaluate communication between the internal and external devices (like EA for a HA) Impedance change? Can be caused by ossification of the cochlea Impedance too low? Increase current flow to increase intensity of signal *Level of Comfort and not UCL ** 100% detection
  • Tele = remote, metry = measure At the Cochlear Corporation lecture, we talked about how telemetry determines how much current is necessary for stimulation, how to spread the current, how long the pulses should be, the rate of stimulation, the pulse width, etc…
  • The implanted electrodes deliver stimulus to the auditory nerve, which then elicits a neural response NRT takes about 5 minutes to complete
  • http://www.youtube.com/watch?v=YFBUNJtT39Y&amp;feature=related Pt: “I can’t hear it, but I can feel it” Hears echo of own voice Pt: “Sounds like I’m on helium” – like a chipmunk, robot, duck Pt: “I’m hearing noise, but I just can’t make it out” – muffled and echo-ey Aud: “It’s not making you feel dizzy or nauseous or anything?” Aud adjusts intensity Aud took off the extended filter, which allows for more low frequency emphasis, but it made this pt. hear an echo Aud: None of these decisions are set in stone Aud: Three ways to map: 1. Activate all electrodes at once and use live voice, 2, Activate 4 electrodes as a time and use bursts of sounds to make adjustments, 3. NRI= Stimulate the implant and measure response from the nerve NRI=Neural Response Imaging (telemetry) Fidelity 120 = sound processing option used in difficult listening environments like in a restaurant or on the phone Aud: This is why we set several electrodes and interpolate in between them
  • For children, follow-up appointments will be necessary more often.
  • Carver, C.L. (2007) Cochlear implant mapping: What every CI user and candidate should know.
  • New Listeners will learn that the hum of the refrigerator is normal and can be ignored whereas a siren is a warning signal.
  • BOTH: Identification of alerting sounds Ex: Audiologist plays fire alarm, child identifies that it is a signal to leave the school Ex: Audiologist plays horn, adult recognizes that it is a warning signal for driving
  • Ching, T.Y., Incerti, P., &amp; Hill, M. (2004). Binaural benefits for adults who use hearing aids and cochlear implants in opposite ear. Ear and hearing, 25 (1), 9-21. Diotic- Diotic is the same as binaural, and means hearing one, two, or more, sound sources with two ears, and then making sense of where that/those sound(s) are coming from. Dichotic- Dichotic, on the other hand, refers to the artificially generated state of hearing a different sound with each ear, as when messages are presented through earphones (Trimble, 1931).
  • Litovsky, R.Y., Parkinson, A., Arcaroli, J., Peters, R., Lake, J., Johnstone, P, &amp; Gonquiang, Y. (2004). Bilateral cochlear implants in adults and children. Archives of otolaryngology head and neck surgery, 130 (5), 648-655. Results for bilateral CIs are less robust for children
  • Tyler, R.S., Gantz, B.J., Rubenstein, J.T., Wilson, B.S., Parkinson, A.J., Wolaver, A., Preece, J.P., Witt, S., &amp; Lowder, M.W. (2002). Three-month results with bilateral cochlear implants. Ear and hearing, 23 (1), 80S-89S.
  • Litovsky, R.Y., Johnstone, P.M., &amp; Godar, S.P. (2006). Benefits of bilateral cochlear implants and/or hearing aids in children . International Journal of Audiology, 45 (S1), 78-91.
  • Ching, T.Y.C., Psarros, C., Hill, M., Dillon, H.,&amp; Incerti, P. (2001). Should children who use cochlear implants wear hearing aids in the opposite ear? Ear and hearing, 22 (5), 365-380.
  • Deaf culture has a distinct pattern of social organization
  • In the US, there is a strong legal foundation that establishes parental authority as paramount Cis fail to foster language in children born deaf- Lane, and Bahan (1998) found that mean scores overstate speech perception ablity, children born deaf score close to zero, and high-scorers may derive benefit more from rehabilitation than from the CI itself BUT, this research evaluates only early CI research, only examined very stringent auditory-only testing conditions, used children with an average age of implantation that was over 5, and the children had limited CI use. Socio-cultural genocide because it is “… A general intent to commit genocide can be established, in the absence of a specific intent, from proof of reasonable forseeability” (Lane &amp; Bahan, 1998). Lane, H, &amp; Bahan, B. (1998). Ethics of cochlear implantation in young children: A review and reply from a Deaf-World perspective. Otolaryngology and Head Neck Surgery, 119 , 297-313.
  • Cochlear Implantation Process, Performance, and Culture

    1. 1. Alexandra D. Costlow, B.S.
    2. 2. Cochlear Implant (CI) Appointments General Points <ul><li>Implantation requires an ongoing commitment of time and resources </li></ul><ul><li>The appointment process begins at the candidacy stage </li></ul><ul><ul><li>However, there may have been appointments with related professionals prior to the candidacy stage </li></ul></ul><ul><ul><li>Referral to the audiologist, CI center, etc… </li></ul></ul>
    3. 3. CI Appointments General Points <ul><li>Each appointment should support a successful implantation process as a whole </li></ul><ul><li>“ Progress is not always a straight line” in reference to the implantation process </li></ul><ul><ul><li>The normal series of appointments may be individualized based on the needs of the patient </li></ul></ul>
    4. 4. CI Appointments Stages <ul><li>Candidacy </li></ul><ul><li>Surgical Implantation </li></ul><ul><li>Follow-Up Care </li></ul>
    5. 5. CI Candidacy Appointments Review <ul><li>Preoperative assessment should be performed at a CI center staffed with clinicians offering experience in postimplantation management. </li></ul><ul><li>Clinicians analyze risk-to-benefit ratio through outcome predictors and modifiers </li></ul><ul><ul><li>Factors that affect performance, perceived benefit, and long-term use of a CI </li></ul></ul><ul><ul><li>An assessment of relative benefit aids in the decision-making process and helps in aligning the candidate’s expectations with probable outcomes </li></ul></ul>
    6. 6. CI Candidacy Appointments Review <ul><li>Hearing Assessment, including Auditory Skills Assessment </li></ul><ul><li>Otologic and Medical Assessment </li></ul><ul><li>Opthalmology </li></ul><ul><li>Psychological Assessment </li></ul><ul><li>Language, Educational, and </li></ul><ul><li>Development of Multimodal Processing </li></ul><ul><li>Assessment (for the pediatric/school-aged </li></ul><ul><li>population) </li></ul>
    7. 7. CI Candidacy Appointments Hearing Assessment <ul><li>Hearing Assessment by a licensed audiologist </li></ul><ul><ul><li>Determines a baseline through characterization of </li></ul></ul><ul><ul><ul><li>Residual hearing </li></ul></ul></ul><ul><ul><ul><li>Functional hearing </li></ul></ul></ul><ul><ul><ul><li>Response to amplification </li></ul></ul></ul><ul><ul><ul><li>Changes to Hearing Assessment </li></ul></ul></ul><ul><ul><ul><li>Movement away from hearing sensitivity </li></ul></ul></ul><ul><ul><ul><li>alone </li></ul></ul></ul><ul><ul><ul><li>Instead, consider the patient’s experience with effectively accessing speech with amplification </li></ul></ul></ul><ul><ul><ul><li>Note the constraints of hearing aid usage (Niparko, 2009) </li></ul></ul></ul>
    8. 8. CI Candidacy Appointments <ul><li>Auditory Skills Assessment </li></ul><ul><ul><li>“… Evaluates child’s ability to attend to and integrate sound using conventional amplification” (Niparko, 2009). </li></ul></ul><ul><ul><ul><li>Speech and environmental sounds over a range of frequencies </li></ul></ul></ul><ul><ul><ul><li>Integrate auditory perception with speech production in order to imitate sounds </li></ul></ul></ul><ul><ul><ul><li>Make meaningful associations for sounds from single words to conversation </li></ul></ul></ul><ul><ul><ul><li>Overall, to integrate hearing into communication </li></ul></ul></ul>
    9. 9. CI Candidacy Appointments <ul><li>Otologic Assessment </li></ul><ul><ul><li>Determination of the etiology of the hearing loss helps guide the implantation process </li></ul></ul><ul><ul><ul><li>Ex.: Usher Syndrome patients will </li></ul></ul></ul><ul><ul><ul><li>also have gradual onset vision loss </li></ul></ul></ul><ul><ul><li>Ex.: Patients with Neurofibromatosis II </li></ul></ul><ul><ul><li> who have bilateral acoustic tumors will benefit </li></ul></ul><ul><ul><li> more from Auditory Brainstem implants </li></ul></ul><ul><li>Medical Assessment </li></ul><ul><ul><li>Evaluates patient’s fitness for general anesthetic and mastoid surgery, as well as device programming and postimplantation rehabilitation </li></ul></ul>
    10. 10. Candidacy Appointments <ul><li>Opthalmology </li></ul><ul><ul><li>Vision plays a critical role in the deaf child’s development in that it allows the child to associate meaning with auditory inputs (Niparko, 2009). </li></ul></ul><ul><ul><li>An opthalmology exam can identify visual abnormalities associated with congential sensorineural hearing loss </li></ul></ul><ul><ul><ul><li>Refractive errors and cataracts </li></ul></ul></ul><ul><ul><ul><ul><li>These visual abnormalities can help to </li></ul></ul></ul></ul><ul><ul><ul><ul><li>diagnose etiologies such as Usher and </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Waardenburg syndrome </li></ul></ul></ul></ul>
    11. 11. CI Candidacy Appointments <ul><li>Psychological Testing </li></ul><ul><ul><li>Screen for psychopathology and cognitive deficits </li></ul></ul><ul><ul><ul><li>Mood disorders can cause elevations in depression, social introversion, suspiciousness, social anxiety, and loneliness in adult CI candidates (Knutson, Johnson, & Murray, 2006) </li></ul></ul></ul><ul><ul><ul><li>Cognitive defects can indicate the need for unique rehabilitation strategies </li></ul></ul></ul>
    12. 12. CI Candidacy Appointments <ul><li>Counseling to ensure suitability and motivation to participate in the process </li></ul><ul><ul><li>Expectations of what the CI can and can not do </li></ul></ul><ul><ul><li>Determination of family and/or social support </li></ul></ul><ul><ul><li>Patient acknowledgement and acceptance of the time and resources required for care a follow-up service </li></ul></ul>
    13. 13. Device Discussion <ul><li>To ensure that the patient and his/her family understand the motivation and resources required for successful CI implantation and use </li></ul><ul><li>May discuss differences between the different implants </li></ul><ul><li>May discuss insurance coverage or funding </li></ul><ul><li>Reiterate that pre-implantation expectations will shape post-implantation success </li></ul>
    14. 14. CI Candidacy Appointments <ul><li>Tests performed by the surgeon </li></ul><ul><li>Analysis of the brain and middle and inner ear </li></ul><ul><ul><li>Computerized Axial Tomography (CAT Scan)/X-rays </li></ul></ul><ul><ul><ul><li>CT scanner x-rays around the circumference of the patient </li></ul></ul></ul><ul><ul><ul><li>Detectors in the CT scanner measure how much x-ray is transmitted through the area of the body of interest </li></ul></ul></ul><ul><ul><ul><li>CT Scan analyzes soft tissue (including organs), bone, and blood vessels </li></ul></ul></ul><ul><ul><ul><ul><li>Is there new bone growth in cochlea due to meningitis? </li></ul></ul></ul></ul><ul><ul><ul><li>3D images of organs are created by stacking slices of images </li></ul></ul></ul><ul><ul><ul><li>New, multidetector scanners scan the body in about 30 seconds </li></ul></ul></ul>
    15. 15. CT Scan of Cochlea http://www.sciencedaily.com/releases /2008/04/080425151819.htm
    16. 16. CI Candidacy Appointments <ul><ul><li>Magnetic Resonance Imaging (MRI) </li></ul></ul><ul><ul><ul><li>Uses powerful magnets and radio waves </li></ul></ul></ul><ul><ul><ul><li>The scanner contains a magnet whose field is ~10,000x greater than the earth’s magnetic field </li></ul></ul></ul><ul><ul><ul><li>Magnetic field causes hydrogen atoms in the body to align in a specific configuration </li></ul></ul></ul><ul><ul><ul><li>Radio waves are projected onto the hydrogen atoms, and bounce back </li></ul></ul></ul><ul><ul><ul><li>Computer records the signal, which is specific to the type of tissue </li></ul></ul></ul><ul><ul><ul><li>MRI more effectively images soft tissues (brain) than does CT </li></ul></ul></ul><ul><ul><ul><li>Single MRI images are also called slices </li></ul></ul></ul><ul><ul><ul><li>The exam usually takes 1 hour or longer, depending on the number of slice being analyzed </li></ul></ul></ul>
    17. 17. MRI (at 3 tesla) of Cochlea http://www.vanderveer.org.nz/research/labs/mri.php
    18. 18. CI Candidacy Appointments <ul><li>CAT Scan and MRI </li></ul><ul><ul><li>Analyze the structure (and presence or absence) of the 8 th Cranial Nerve (Auditory) </li></ul></ul><ul><ul><li>Can identify structural abnormalities of the cochlea and/or mastoid bone that could compromise the surgery </li></ul></ul><ul><ul><li>Can identify space-occupying lesions that result in hearing loss </li></ul></ul>
    19. 19. Surgery <ul><li>The patient is deemed a candidate and decides to go forth with implantation. </li></ul><ul><li>Surgery may involve an overnight stay at a hospital, but generally, it can be performed on an out-patient basis. </li></ul><ul><li>It takes place under general anesthesia and takes 1 to 2 hours. </li></ul>
    20. 20. Review of CI Components <ul><li>Microphone - picks up sound </li></ul><ul><li>from the environment </li></ul><ul><li>Speech Processor - placed behind the </li></ul><ul><li>ear or worn on the body , it selects and </li></ul><ul><li>arranges sounds detected by the </li></ul><ul><li>microphone </li></ul><ul><li>Coil- held in place by a magnet, radio </li></ul><ul><li>waves transmit the coded signal to the </li></ul><ul><li>transmitter </li></ul><ul><li>Transmitter - placed internally , it receives </li></ul><ul><li>signals from coil and converts them into electrical impulses </li></ul><ul><li>Electrode array - placed in the cochlea , it collects impulses from the transmitter and stimulates portions of the auditory nerve (NIDCD, 2009) </li></ul>
    21. 21. Surgery <ul><li>The surgeon makes a trans-mastoid facial recess incision </li></ul><ul><li>The surgeon drills into the mastoid bone in order to access the inner ear </li></ul><ul><li>A depression is created in bone behind the mastoid to accommodate the transmitter (receiver-stimulator) internal device </li></ul><ul><li>The electrode array is threaded into the scala tympani through the round window membrane or cochleostomy (25-30 mm is full insertion) </li></ul><ul><li>The cochleostomy is sealed around the electrode with fibrous tissue </li></ul>
    22. 22. Surgery <ul><li>The outer end of the electrode array is fastened to the skull </li></ul><ul><li>The scalp should be thinned to no more than 1cm to enable stable retention of the magnet </li></ul><ul><li>The incision is closed </li></ul><ul><li>The patient returns in about one week for suture removal </li></ul>
    23. 23. Surgery Part I <ul><li>http://www.youtube.com/watch?v=x7ltzA0B2X8&feature=related </li></ul>
    24. 24. Surgery Part II <ul><li>http://www.youtube.com/watch?v=I0Z3eKNw2vc&feature=related </li></ul>
    25. 25. Activation and Initial Fitting <ul><li>Days after the surgical implantation of the receiver (just behind the ear) and the electrodes (in the cochlea), the patient returns to the CI center. </li></ul><ul><li>An audiologist fits the patient with: </li></ul><ul><ul><li>A microphone (resembles </li></ul></ul><ul><ul><li>a BTE hearing aid) </li></ul></ul><ul><ul><li>A speech processor (may be </li></ul></ul><ul><ul><li>housed with the microphone or </li></ul></ul><ul><ul><li>worn at chest-level) </li></ul></ul>
    26. 26. Activation and Initial Fitting <ul><li>Audiologist runs standard check </li></ul><ul><li>of the speech processor </li></ul><ul><li>Initial activation and programming </li></ul><ul><li>(mapping) of the implant </li></ul><ul><ul><li>Mapping- a set of parameters of electrode stimulation that gives the patient maximum hearing </li></ul></ul><ul><ul><li>Establishment of electrical dynamic range (Level of Comfort* – Threshold** for each electrode) </li></ul></ul><ul><li>May occur over several appointments because the patient will adjust to sound as s/he gains experience with the implant </li></ul><ul><li>Appointments are generally 2 hours, of which 20-30 minutes are spent obtaining T and C Levels (Craver, 2010). </li></ul>
    27. 27. Activation and Initial Fitting <ul><li>How is mapping conducted? </li></ul><ul><li>Using speech (subjective) </li></ul><ul><li>Using tones/beeps/bursts </li></ul><ul><li>(subjective) </li></ul><ul><li>Neural Response Telemetry (objective) </li></ul><ul><ul><li>Telemetry is the remote measurement of various electrical parameters (in our case, through implant feedback) </li></ul></ul><ul><ul><li>Neural Response Telemetry measures the response of the auditory nerve to electrical stimulation via a cochlear implant (The Hearing House). </li></ul></ul><ul><ul><li>NRT takes about 5 minutes to complete (Craver, 2010). </li></ul></ul>
    28. 28. Neural Response Telemetry http://www.uzh.ch/orl/lea/nrt.jpg
    29. 29. Map Parameters <ul><li>Strategy - Method by which sound is analyzed and presented, which varies by manufacturer </li></ul><ul><li>Stimulation - Specifies the difference between active and indifferent electrode mode </li></ul><ul><li>Rate - Pulses per second (frequency) of electrical current </li></ul><ul><li>Pulse Width - Amount of time the electrical current (pulse) is delivered in microseconds (Carver, 2007) </li></ul>
    30. 30. Activation <ul><li>Cochlear Implant Activation – Captured </li></ul><ul><li>http://www.youtube.com/watch?v=YFBUNJtT39Y&feature=related </li></ul>
    31. 31. Follow-Up to Initial Fitting <ul><li>May include several visits over the span of weeks or months </li></ul><ul><li>Why is this such a lengthy process? </li></ul><ul><ul><li>Each electrode in the cochlea is activated </li></ul></ul><ul><ul><li>Each electrode must be programmed and adjusted into the speech processor </li></ul></ul><ul><ul><li>Can create programs for special listening situations </li></ul></ul><ul><ul><li>The patient develops more skill from using the implant, thus more adjustments must be made as skill improves </li></ul></ul><ul><ul><li>Over time, less adjustments are necessary and the patient will return to the CI center every 6 months or annually </li></ul></ul><ul><ul><li>Appointment time can be spent on education and rehabilitation (Craver, 2010). </li></ul></ul>
    32. 32. Follow-Up to Initial Fitting <ul><li>Sample Programming Schedule </li></ul><ul><ul><li>Days 1, 2: Activation of the external equipment, which occurs approximately 4 weeks after surgery </li></ul></ul><ul><ul><li>1 week: Audiogram and reprogramming </li></ul></ul><ul><ul><li>1 month: Audiogram and reprogramming </li></ul></ul><ul><ul><li>3, 6, 9 months: Audiogram, Speech Perception Testing and reprogramming </li></ul></ul><ul><ul><li>1 year: Audiogram, Speech Perception Testing and reprogramming </li></ul></ul><ul><ul><li>Every 6-12 months thereafter: Audiogram, Speech Perception Testing and reprogramming (Carver, 2007). </li></ul></ul>
    33. 33. Aural Rehabilitation Previous vs. New Listeners <ul><li>Patients with previous experience hearing and listening should be counseled that speech will have a different sound quality. </li></ul><ul><li>They may report that CI speech sounds unnatural. </li></ul><ul><li>Patients who are new to hearing sound and speech will need to learn perceive sound and how to respond to it. </li></ul>
    34. 34. Aural Rehabilitation <ul><li>Teaches the patient how to use the CI and respond </li></ul><ul><li>to auditory input </li></ul><ul><ul><li>Listen to an array of auditory stimuli </li></ul></ul><ul><ul><li>Improve speech (expressive and receptive) </li></ul></ul><ul><ul><li>Use speech-reading </li></ul></ul><ul><li>AR Programs </li></ul><ul><ul><li>DASL II </li></ul></ul><ul><ul><li>Speech that Works </li></ul></ul><ul><ul><li>Cottage Acquisition Scales for Listening, Language, & Speech </li></ul></ul><ul><ul><li>The Miami Cochlear Implant, Auditory & Tactile Skills Curriculum (CHATS ) </li></ul></ul>
    35. 35. Aural Rehabilitation Activities <ul><li>Adults </li></ul><ul><li>Children </li></ul><ul><li>May focus on social or occupational skills and/or demands </li></ul><ul><li>Occupation/trade specific vocabulary or communication skills </li></ul><ul><li>Practice communication skills using current events, popular television shows, etc… </li></ul><ul><li>Alerts: car horn, microwave, etc… </li></ul><ul><li>“ Mother May I?” </li></ul><ul><li>Board games: The child advances if he successfully speechreads or can hear and/or repeat stimuli correctly </li></ul><ul><li>Ability to follow directions common to school </li></ul><ul><li>Ability to function in a social setting (ex: playground, cafeteria, sports game) </li></ul><ul><li>Alerts: fire alarm, whistle, etc… </li></ul>
    36. 36. Outcomes of CI Performance Hearing Aid + CI <ul><li>Ching, Incerti, and Hill (2004) tested 21 adults who used a Nucleus CI-22 or CI-24 and either unilaterally or with a Ha set to NAL-NL1 and loudness-balanced to the CI. They found that CI+HA users, compared to unilateral CI or HA users, had better: </li></ul><ul><ul><li>Speech perception in noise on dichotic and diotic listening conditions </li></ul></ul><ul><ul><ul><li>Subjects who performed better in speech perception also had benefit in localization and functional performance in everyday life </li></ul></ul></ul><ul><ul><li>Horizontal localization </li></ul></ul><ul><ul><li>Functional performance in everyday life evaluated by a functional performance questionnaire </li></ul></ul><ul><ul><li>All subjects showed binaural benefit in at least one measure </li></ul></ul>
    37. 37. Hearing Aid + CI <ul><li>Litovsky, Parkinson, Arcaroli, Peters, Lake, Johnstone, and Gonqiang (2004) tested 17 adults and 3 children with one CI and then bilaterally. </li></ul><ul><li>Adults localize better with 2 bilateral CIs </li></ul><ul><li>Adults perform better hearing speech in noise with bilateral CIs when the noise is in the poorer ear </li></ul><ul><li>Children perform better on localization and speech recognition with bilateral CIs, but not remarkably </li></ul><ul><ul><li>One child did better with a unilateral CI and two children had better speech recognition when noise was presented to the ear that was implanted first </li></ul></ul>
    38. 38. Bilateral CIs vs. Unilateral CI <ul><li>Tyler, Gantz, Rubenstein, Wilson, Parkinson, Wolaver, Preece, and Lowder (2002) evaluated 9 post-lingually deafened adults using the Cochlear Corporation C24M implant for speech in quiet, speech in noise, and localization ability. </li></ul><ul><ul><li>Bilateral CIs showed a significant advantage over CI in th better ear for speech in quietand for speech in noise (located at 0 degrees azimuth) for 4/9 subjects </li></ul></ul><ul><ul><li>When CI was added to ear ipsilateral to noise, a significant advantage was noted for 4/7 subjects </li></ul></ul><ul><ul><li>3/7 subjects could discriminate noise at 45 degrees with one CI, but 7/7 could with bilateral CIs </li></ul></ul><ul><ul><li>Conclusion: Bilateral CIs offer advantage, especially when for ear contralateral to noise </li></ul></ul>
    39. 39. Bilateral CIs vs. CI+HA <ul><li>Litovsky, Johnstone, and Godar (2006) evaluated 20 children (20 use bilateral CIs, 10 use CI+HA) in their ability to hearing in quiet and in noise, and to localize sound. </li></ul><ul><ul><li>Both groups have similar speech reception thresholds </li></ul></ul><ul><ul><li>Improved localization and speech thresholds with bilateral CI group compared to CIHA group </li></ul></ul><ul><ul><li>Individual variability suggests that some children perform as well as normal hearing children while others do not </li></ul></ul>
    40. 40. Where to Go from Here? <ul><li>CI+HA and bilateral CIs offer benefit over unilateral CI </li></ul><ul><li>Bilateral CIs offer benefit over CIHA (Litovsky, Johnstone, & Godar, 2006). </li></ul><ul><li>HA should be programmed to NAL-NL1 Rx for adults and then adjusted on an individual basis (Ching, Incerti, & Hill, 2004). </li></ul><ul><li>Facilitate bimodal amplification by setting stable maps and then adjust HAs (Ching, Psarros, Dillon, & Incerti, 2001). </li></ul><ul><li>Should further investigate the differences in success with bilateral CIs between adults and children ( Litovsky, Parkinson, Arcaroli, et al., 2004) </li></ul><ul><li>Should determine why some children are more successful with CIs than are others (Litovsky, Johnstone, & Godar, 2006). </li></ul><ul><li>Many complicating factors to CI success </li></ul>
    41. 41. Deaf Culture The Basics <ul><li>Deaf Culture is linguistically unified through American Sign Language (ASL) </li></ul><ul><ul><li>ASL is not a manual translation of English </li></ul></ul><ul><ul><li>ASL has its own syntax, morphology, and vocabulary </li></ul></ul><ul><ul><li>ASL does not have a written correlate </li></ul></ul><ul><li>Deaf individuals share an identity based on a culture rather than a medical diagnosis </li></ul><ul><li>“ Deafness, particularly when early in onset, confers a life experience that is radically different owing to a systematically different language base not shared by the majority of hearing culture” (Niparko, 2009). </li></ul>
    42. 42. Deaf Culture and Cochlear Implants Conflict of Cross-Cultural Values <ul><li>Child as Recipient </li></ul><ul><li>Impact on Deaf Culture </li></ul><ul><li>Parental Authority- Hearing parents who implant deaf children are viewed as “ill-founded” and “ill-fated” in their decision </li></ul><ul><li>Deaf do not view deafness as a disease, and it is unethical to operate on a healthy child </li></ul><ul><li>CIs fail to foster language acquisition in children born deaf (Lane & Bahan, 1998). </li></ul><ul><li>Socio-cultural genocide </li></ul><ul><li>Undermines the survival of Deaf culture </li></ul>
    43. 43. Deaf Culture and Cochlear Implants <ul><li>Advocates for Deaf individuals </li></ul><ul><ul><li>The National Association of the Deaf </li></ul></ul><ul><ul><li>The World Federation of the Deaf </li></ul></ul><ul><ul><li>This cross-cultural conflict is without a resolution that is morally valid (Lane & Bahan, 1998) </li></ul></ul><ul><ul><li>Research is needed to determine why some children with CIs are successful in the hearing world and other are not </li></ul></ul><ul><ul><ul><li>Clinical trials </li></ul></ul></ul><ul><ul><ul><li>High quality, generalizable results </li></ul></ul></ul>
    44. 44. References <ul><li>American Speech-Language Hearing Association (ASHA). Cochlear implants. Retrieved from http://www.asha.org/public/hearing/treatment/cochlear_implant.htm </li></ul><ul><li>Carver, C.L. (2007). Cochlear implant mapping: What every CI user and candidate should know. </li></ul><ul><li>Children’s Hospital and Health System. (2010). Cochlear implantation clinic. Retrieved from http://www.chw.org/display/PPF/DocID/25735/Nav/1/router.asp </li></ul><ul><li>Ching, T.Y., Incerti, P., & Hill, M. (2004). Binaural benefits for adults who use hearing aids and cochlear implants in opposite ear. Ear and Hearing, 25 (1), 9-21. </li></ul><ul><li>Ching, T.Y.C., Psarros, C., Hill, M., Dillon, H.,& Incerti, P. (2001). Should children who use cochlear implants wear hearing aids in the opposite ear? Ear and Hearing, 22 (5), 365-380. </li></ul><ul><li>Contradica. (2007, November 26). Cochlear implant activation – captioned [Video file]. From http://www.youtube.com/watch?v=YFBUNJtT39Y&feature=related </li></ul><ul><li>Dillier, N. (2010). Illustration of the setup for intracochlear recordings of electrically evoked compound action potentials (NRT, Neural Response Telemetry). From http://www.neuroscience.ethz.ch/research/sensory_systems/dillier/index </li></ul>
    45. 45. References <ul><li>Kim, H.J. (1993). Congenital inner ear malformations. Retrieved from Baylor College of Medicine’s website http://www.bcm.edu/oto/grand/111193.html </li></ul><ul><li>Knutson, J.F., Johnson, A., & Murray, K.T. (2006) Social and emotional characteristics of adults seeking a cochlear implant and their spouses. British Journal of Health Psychology, 11 (2), 279-292. </li></ul><ul><li>Lane, H, & Bahan, B. (1998). Ethics of cochlear implantation in young children: A review and reply from a Deaf-World perspective. Otolaryngology and Head Neck Surgery, 119 , 297-313. </li></ul><ul><li>Litovsky, R.Y., Johnstone, P.M., & Godar, S.P. (2006). Benefits of bilateral cochlear implants and/or hearing aids in children . International Journal of Audiology, 45 (S1), 78-91. </li></ul><ul><li>Litovsky, R.Y., Parkinson, A., Arcaroli, J., Peters, R., Lake, J., Johnstone, P, & Gonquiang, Y. (2004). Bilateral cochlear implants in adults and children. Archives of Otolaryngology Head and Neck Surgery, 130 (5), 648-655. </li></ul><ul><li>MedLine Plus. (2008). CT scan. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003330.htm </li></ul><ul><li>MedLine Plus. (2008). Head MRI. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003791.htm </li></ul>
    46. 46. References <ul><li>National Institute on Deafness and Other Communication Disorders (NIDCD). (2009). Cochlear implants. From http://www.nidcd.nih.gov/health/hearing/coch.asp </li></ul><ul><li>Niparko, J. (2009). Cochlear implants . Baltimore, MD: Lippincott, Williams, and Wilkins. </li></ul><ul><li>Nussbaum, D. (2003). Cochlear implants: Navigating a forest of information … one tree at a time. From Gallaudet University Laurent Clerc National Deaf Education Center’s website http://clerccenter.gallaudet.edu/Clerc_Center/Information_and_Resources/Cochlear_Implant_Education_Center/CI_Navigating_a_Forest/What_is_a_Cochlear_Implant/Cochlear_Implant_Candidacy.html </li></ul><ul><li>Science Daily. (2009). Low frequency hearing linked to shape of cochlea. Retrieved from http://www.sciencedaily.com/releases/2008/04/080425151819.htm </li></ul><ul><li>Tbhbc. (2009, April 14). Cochlear implant surgery part 1 (without sound) [Video file]. From </li></ul><ul><li>http://www.youtube.com/watch?v=x7ltzA0B2X8&feature=related </li></ul><ul><li>Tbhbc. (2009, April 14). Cochlear implant surgery part 2 (without sound) [Video file]. From </li></ul><ul><li>http://www.youtube.com/watch?v=I0Z3eKNw2vc&feature=related </li></ul><ul><li>The Hearing House. Glossary of terms. From http://www.hearinghouse.co.nz/information+for+parents/glossary+of+terms </li></ul>
    47. 47. References <ul><li>Tyler, R.S., Gantz, B.J., Rubenstein, J.T., Wilson, B.S., Parkinson, A.J., Wolaver, A., Preece, J.P., Witt, S., & Lowder, M.W. (2002). Three-month results with bilateral cochlear implants. Ear and Hearing, 23 (1), 80S-89S. </li></ul><ul><li>University of Maryland Medical Center (UMMC). (2010). Maryland hearing and balance center: Cochlear implant program . Retrieved from http://www.umm.edu/otolaryngology/cochlear.htm#noE </li></ul><ul><li>U.S. Food and Drug Administration (FDA). (2009). Medical devices: Cochlear implants. Retrieved from http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/CochlearImplants/default.htm </li></ul><ul><li>Van Der Veer Institute for Parkinson’s and Brain Research. (2007). Magnetic resonance Imaging at 3 tesla – The first in New England. Retrieved from http://www.vanderveer.org.nz/research/labs/mri.php </li></ul>
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