About Cochlear Implants
A cochlear implant is uniquely different from a hearing aid. A hearing aid works by amplifying and making the everyday sounds in the environment louder. By increasing the level of the sound, this can often surpass the patient’s threshold for hearing as determined by his/her level of hearing loss and simultaneously improving the patient’s ability to hear and communicate. Traditionally, hearing aids are adequate for patients with mild to moderately-severe sensorineural hearing losses as well as patients with inoperable forms of conductive hearing loss.
Contrastingly however, a cochlear implant is an excellent method of treatment and intervention for patients who have levels of hearing loss in the severe to profound range or those who can no longer benefit from traditional amplification/hearing aids. The cochlear implant is classified by medical terminology as a “neural prosthetic device” similar to a pacemaker or heart defibrillator.
The cochlear implant consists of two distinct pieces; one is an internal receiver/stimulator (surgically implanted) and the second is the external speech processor, which is worn on the outer ear (pinna) and looks similar in appearance to a behind-the-ear hearing aid. Both of these pieces must be present for the system to work for the patient as they are coupled across the skin and through the hair by magnetism. The internal receiver houses a magnet and the external portion magnetizes to the internal connection.
The function of the cochlear implant as well as the surgical process will be fully addressed with each patient at the initial clinical cochlear implant evaluation. Both the audiologist as well as the implant physician are knowledgeable in the process and would be happy to address additional questions you may have regarding this medical procedure.
Adult candidacy criteria can be identified as a patient who suffers from bilateral, severe to profound sensorineural hearing loss and receives limited benefit from traditional acoustic amplification. By audiological classification, these patients are 18 years of age and older, who present with a pure tone average (PTA) of at least 70 dB HL and poor monosyllabic word recognition. These preliminary measurements can be both attained and reviewed at your local audiologist’s clinic. Upon review and counseling, your audiologist can then recommend your referral to the UNC Adult Cochlear Implant Program for further testing and evaluation for cochlear implantation. There is no upper age limit with respect to a potential adult cochlear implant candidate as we are most concerned about the patient’s general/overall health. Lifestyle and health are more important than age.
Personal subjective observations of your inability to hear may include:
- Extreme difficulty hearing and communicating in quiet as well as in noise despite the use of appropriately fit hearing aids.
- Difficulty communicating over the telephone
- Dependency on lip-reading for everyday communication
- Noticeable feelings of loneliness; withdrawing from social activities as a result of your hearing loss
- You feel like you are always stating: “I can hear you, but I just don’t understand what you are saying!!!”
If one or more of these descriptions match your experiences, please call UNC Health Care at 984-974-2141 to schedule a comprehensive cochlear implant evaluation.
Hearing is a complex process that originates in the cochlea; the organ of hearing that is located inside the temporal bone of the skull. The cochlea is a tiny snail shell shaped organ that is comprised of thousands of microscopic sensory cells. These sensory cells work like keys on a piano. Each sensory cell is organized and tuned to match a certain pitch, much like piano keys are. In a normal hearing person, these sensory cells respond to acoustic information in the environment and translate it into a neurological code that the brain can interpret. Understanding of sound happens in the brain; the ears are just the way in. The sensory cells have a very important role in this translation of acoustic information to a neurological code. If any of the sensory cells do not work properly, the information that arrives in the brain will be distorted and incomplete. The listener may have difficulty understanding what is said.
Speech is a complex acoustic signal. When a speech signal makes it to the cochlea, many sensory cells respond. This would be analogous to a sonata playing on a piano. Many keys are being played at once to make rich, full music or, in this case, speech. When sensory cells are damaged and/or missing, incomplete and distorted sound arrives at the brain. Think about how a piece of music would sound when played on an out of tune piano with missing keys. This is comparative to speech coming through a cochlea with damaged and missing sensory cells. When the signal arrives at the brain, the music isn’t rich, full, or even recognizable. The listener has to work even harder to understand what he or she is listening to.
Hearing aids only make sound louder. A loud sound arrives at a damaged cochlea. Louder sounds don’t overcome the damage of the sensory cells. The damage is permanent.
A cochlear implant is not a hearing aid. Rather, it is a neural prosthesis that helps to provide hearing to people with severe to profound hearing loss by bypassing the damaged sensory cells of the cochlea for individuals that cannot make use of the sound amplified by the hearing aid. The patient’s traditional means of hearing, “acoustic hearing,” is then replaced with “electric hearing” through the cochlear implant. From this point forward, a new journey in hearing…begins!
An evaluation for a cochlear implant may include:
- Hearing Test
- A Doctor of Audiology (AuD) will go over your hearing history
- Test your hearing with and without hearing aids
- Test your speech understanding with and without hearing aids
- Counsel you on your test results, make appropriate recommendations based on the results, answer your questions, and review information on cochlear implant technology (if applicable)
- Medical Check
- A Medical Doctor (MD) who specializes in ears will go over your medications and health history
- A scan or x-ray will most likely be done to look at the anatomy of your ear
- The physician will talk about surgery, procedure, and risks
The cochlear implant evaluation requires approximately 3-4 hours of time for the audiologic and medical evaluations.
Patient expectations can be a sensitive and critical issue to address both pre-operatively and post-operatively with not only the patient undergoing the surgery but with the patient’s family and friends. Post-operative outcomes for cochlear implant recipients can take many recognizable forms, including sound awareness (known as detection) at the most basic level to open-set speech recognition in noise, which represents the pinnacle of achievement for cochlear implant users.
The level of achievement that a patient achieves is largely dependent on his/her hearing history and exposure to amplification and spoken language. Patients who developed spoken speech prior to the onset of profound hearing loss are routinely identified as post-lingually deafened. A patient with this background in hearing is different from a patient whose primary means of communication is through sign language or other forms of manual and visual communication. Patients who rely on sign language are often described as being pre-lingually deafened, meaning that the hearing loss preceded his/her development of spoken language.
Research has shown auditory verbal therapy and speech rehabilitation to be viable means for improving speech perception outcomes for most cochlear implant recipients. Referral for these services is optional for each patient and can be discussed with your audiologist as we are supportive of this decision. Both post-lingual as a well as pre-lingual patients can be excellent candidates for cochlear implantation and we review each patient as a unique and separate case. Cochlear implantation is a life-changing experience and we believe in serving all of our patients to the best of our knowledge and expertise.
Cochlear implantation and its benefit to individuals who qualify is a well-documented medical procedure. Medicare along with most major, private insurance companies recognize its significance and typically offer 80-100% coverage of the costs of the surgery and the implant system. Medicaid in contrast does not provide monetary coverage for the implant procedure for those patients who are 21 years of age or older. UNC Health Care does respect and support patients who elect to pay for medical services, such as cochlear implants, through out-of-pocket means.
Each patient is requested to bring copies of their insurance card(s) to the initial cochlear implant evaluation, so that the information can be documented in our medical system. Once candidacy for the process has been determined and a surgery date established, UNC Health Care will take the responsibility of evaluating your insurance and medical coverage for the cochlear implant procedure. Every patient’s medical coverage is unique, which can affect the overall cost of the surgery. Financial counselors are on-hand to discuss your individual insurance plan and your potential out-of-pocket expenses associated with the surgery.
With three cochlear implant companies manufacturing reliable devices, flexibility exists among the available technology to make the “best” choice for each and every patient. We at UNC Health Care work equally with all three cochlear implant devices and are equipped to service and program implant technology from all 3 companies; Cochlear Corporation, MED-EL Corporation, and Advanced Bionics Corporation.
The ultimate decision-making process includes the collaboration of the patient’s desires as well as those of the implant team (physician, audiologist, family). The discussion process most often centers around the following key points:
Device performance and integrity: All 3 implant manufacturers have a long-standing history of building and creating reliable speech processors that offer strong patient performance.
Current Technological Advances: Manufacturers in a competitive market are always seeking to improve on existing implant technology so as to offer new options to the patient and better serve the “implant customer.” With most advances, newer, sleeker, and more efficient processing units become available. The upgrade process is understood and supported by the companies and well as the insurance providers.
Patient Preference: We encourage patients to obtain literature from all the implant manufacturers as well as visit the company websites online to gain more information about device technology, before engaging in the selection process. Visiting with other implant recipients can also provide helpful insight to a potential recipient.
Ease of Use: Many patients suffer from other health conditions that may complicate the use of certain implant technology. Limited vision and dexterity problems are just a few of the issues that may need to be considered when choosing an appropriate implant system. Both behind the ear (BTE) style devices as well as body-worn controllers for speech processors are among the available options from which a patient can ultimately choose. Demo models of all cochlear implant devices are available in the clinic for patients to evaluate for overall fit and comfort. There are viable options for everyone.
Abnormal Cochlear or External Ear Anatomy: Abnormal cochlear anatomy can be easily visualized and noted by the implant physician at the onset of the evaluation via the CT scan. The physician may have advice and valuable input about a specific “internal” receiver, which may work best with the patient’s anatomy. In the end, this will likely influence the external wearing options for the patient. Similarly, some patients may have smaller external ears and be unable to support a behind the ear (ear level) speech processor, due to the weight and size of the device. Demo models of all cochlear implant devices are available in the clinic for patients to evaluate for overall fit and comfort.
“Bells and Whistles:” The term “bells and whistles” typically applies to hearing aids; however, we also use this terminology to discuss the added features available on external cochlear implant processors. Such features include, directional microphones, T-coil compatibility, “splash-proof” status, FM compatibility, multiple program memories for various listening conditions, rechargeable battery options, and multiple wearing configurations. Please discuss all your personal needs with the audiologist so as to find best implant system for to meet the demands of your lifestyle.
The Importance of Vaccinations in Cochlear Implant Users
Bacterial meningitis is a serious infection of the brain and the fluid that surrounds the brain. Bacterial meningitis is a life-threatening infection. Individuals who have a cochlear implant are at increased risk for bacterial meningitis. Although this risk is small, it is important for children and adults with a cochlear implant to be vaccinated against the bacteria that can gain entry into the brain and commonly cause bacterial meningitis. Two types of bacteria have produced the vast majority of cases of meningitis after cochlear implantation: Streptococcus pneumoniae (“Pneumococcus”) and Haemophilus influenzae type b (“Hib”).
Cochlear implant users and their families should be aware that vaccines against pneumococcus (“pneumo” vaccine) and Hib are widely available. These vaccines strengthen the body’s ability to protect against the common causes of bacterial meningitis. Some infections with pneumococcus are now not treatable with routine antibiotics. This is another reason for being sure to get vaccinated.
There are two types of pneumococcal vaccine, Prevnar® for children being vaccinated when they are less than 2 y of age and Pneumovax® for those being vaccinated when they are over 2 y of age. Prevnar® is part of the routine infant immunization schedule in the United States; therefore all children should have received this vaccine in infancy. It is important to verify that your child has received all doses of their Prevnar® series, and if not, to catch up.
Now that you or your child has a cochlear implant you should verify which vaccines against pneumococcus you or your child has received and obtain additional doses if you are not fully immunized. Age at the time of vaccination will determine which type of pneumococcal vaccine should be received:
- Children under the age of 2 y: Vaccination with the Prevnar® series followed by Pneumovax® when the child reaches 2 y of age. (Pneumovax® is not effective in children under 2 y.)
- If an adult or child did not receive Pneumovax® before their implant surgery, it is important for them to receive this vaccination now.
- The sooner the vaccine is given the sooner you or your child will be protected.
- It is never “too late” after surgery to benefit from Pneumovax®.
- Second doses of Pneumovax: If it has been 5 or more yrs since the initial Pneumovax® vaccine, discuss a repeat vaccine with your physician. A second dose of Pneumovax® may provide additional coverage for some individuals, including young children and adults over the age of 65.
- Children 2 to 4 y of age: Complete the Prevnar® series if not fully vaccinated. Vaccinate with Pneumovax® at least 2 mos after the last Prevnar® dose.
- Children 5 y and older and all adults: Initial Pneumovax® vaccination
Most people receive vaccinations such as Prevnar and Pneumovax from primary care providers such as pediatricians, internists, or family physicians. Further informaiton on the availabilty of vaccinations is available through general medical clinics, sponsored state and local government, and by hospitals. Your cochlear implant center can provide more information.
Pneumococcal Conjucate vaccine 13 (PCV13)
The newest pneumococcal conjugate vaccine (PCV13) protects against the 13 most severe types of the 90 differenct types of pneumococcal bacteria. This is an update to PCV7 and children will need to have their immunizations updated in order to receive protection against the 13 strains.
- Children under two years should receive PCV 13 as a series of 4 doses.
- Children between 2 and 5 years who have not completed the PCV7 or PCV 13 series before age 2 should get one dose.
- Children between the 2nd and 6th birthdays who have a cochlear implant should get 1 dose of PCV 13 if they received 3 doses of PCV7 or PCV13 before age 2, or 2 doses of PCV13 if they received 2 or fewer doeses of PCV7 or PCV13.
- Children ages 6-18 who have a cochlear implant should receive a dose of PCV13, even if they have previously received PCV7.
Further information is available from this CDC handout: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv13.html
TIMELINE of Pneumo Vaccines:
Cochlear implant users and their families should also be aware that vaccinations do not eliminate the risk of meningitis. Children and adults with cochlear implants who develop a middle ear infection (otitis media) or a fever of uncertain cause should seek medical treatment and monitoring until the infection resolves. Infections in a child or an adult with a cochlear implant should be taken seriously. Untreated middle ear and other infections may spread to produce meningitis.
In addition, if an ear with a cochlear implant develops a discharge from the ear canal, or produces unusual ear symptoms or a watery nasal discharge, it is important to have that ear examined by the cochlear implant surgeon or another suitably experienced ear surgeon.
Cochlear implantation is a commonly performed medical procedure at UNC Health Care as we operate on greater than 200 adult and pediatric patients annually at our medical center, and we currently care for over 2000 patients between the adult and children’s’ program at UNC. We have over 30 years of cochlear implant experience at UNC.
In the case of cochlear implantation, a rather delicate and challenging procedure, it is important that you the patient consider the experience and knowledge of the medical staff and clinical associates when selecting your cochlear implant center.
The surgical steps to this procedure may include:
Pre-operative blood work and counseling with the medical staff
CT scan to review cochlear anatomy.
Surgery performed on an out-patient basis with the possibility of an overnight stay or 23-hour observation period, depending on individual health concerns.
2-3 hour surgery under general anesthesia.
Placement of a surgical bandage over the implant site to remain secure for a healing period of 5-7 days post-operatively. At this time, hair washing should be avoided.
Return appointment to the UNC ENT clinic for removal of surgical bandages and scheduling of appointment for initial activation of the cochlear implant. It is important to note that the recipient will not be hearing through the implant upon completion of the surgical procedure. He/she will have to return to the clinic for this first stimulation of the external equipment to begin the hearing process. This appointment is scheduled approximately 2-4 weeks from the date of surgery.
Post-operatively, all patients will be provided antibiotic medications as well as pain relievers if needed.
Restrictions of heavy lifting, straining and strenuous exercise will be limited to the patient for approximately 1-month following implantation.
Following surgical implantation, the patient will return to the clinic within 1 week for removal of the external white bandage. At this time, the patient will be seen by the implant physician to evaluate how the patient is healing and to determine the successive appointment for initial activation. This is the second appointment where the patient will receive the external equipment associated with the implant and begin to engage in the hearing process.
The patient will be seen approximately 6-8 times (clinical visits to UNC Health Care) for treatment and programming associated with the implant during the first year of implantation. Following the first year of stimulation, it is recommended, the patient return for annual follow-up visits for maintenance of equipment and evaluation of performance.
At each clinical visit, the patient will undergo speech perception testing to evaluate his/her progress and benefit in hearing with the implant. Additionally, the patient will be “mapped,” meaning that the external equipment will be adjusted to the patient’s needs and auditory perceptions. Each clinical session is approximately 2 hours in length based on the necessary procedures that must be achieved. Our goal is to provide each and every patient with quality care as well as maximum benefit in hearing with his/her cochlear implant.
At initial activation, the patient may experience a number of sensations and sounds, ranging from “electrical beeps” to recognition of voices and spoken words and speech. All of these reports and experiences are normal and will represent a transition over time to a more improved and comfortable listening signal to the patient. The entire implant procedure is a process in evolution for each patient. Both time and patience make all the difference in hearing well with the implant! It usually takes a patient 6-12 months of consistent use and stimulation with the implant before achieving the maximum level of benefit and success.
Every patient is unique and different, and some patients may need longer than 6 months of use and training before achieving full benefit. With consecutive mapping sessions and clinical visits as well as commitment to the implant process, the patient will begin to notice significant improvements in hearing through the implant, beginning with the date of initial activation.
Are you ready to join us at the UNC Adult Cochlear Implant Program?