Exam 1 Flashcards
What impact does HL have when onset is in adulthood
-hearing/speech perception
-psycho-social-emotional
-school achievement
-vocational/economic
What impact does HL have when onset is in late childhood
-hearing/speech perception
-language
-experiential/world knowledge
-psycho-social-emotional
-literacy
-school achievement
What impact does HL have when onset is in early childhood
-hearing/speech perception
-speech production
-language
-experiential/world knowledge
-psycho-social-emotional
-literacy
-school achievement
What impact does HL have when onset is in prelingual-late
-hearing/speech perception
-speech production
-language
-motor skills
-experiential/world knowledge
-psych-social-emotional
-literacy
-school achievement
What impact does HL have when onset is in congenital or early-acquired
-hearing/speech perception
-speech production
-language
-motor skills
-experiential/world knowledge
-psych-social-emotional
-literacy
-school achievement
What year and who first electrically stimulated the temple of an individual who was deaf? What sensation did they feel?
1748 by Benjamin Wilson
Tactile
Who was the first person to ATTEMPT to stimulate an auditory system via electrical stimulation? In what year? What else did they invent?
Allesandro Wolta in 1800
Also invented the battery and volt measurement
Who was the first to record an electrical response from the area of the auditory nerve? Year? Whats did ultimately lead to the discovery of?
Weaver and Bray in 1930 in a cat
Who and what year applied a sinusoidal electrical current during a neurosurgical operation that the patient describes as a sound?
Dr. Lundberg in 1950
Who and what year was an article published describing effects of electrical stimulation of the auditory nerve?
Djourno and Eyris in 1957
Who invented the first implantable prosthesis to stimulate the nerve?
Djouno and Eyris in 1957
Who created their own implantable technology? Who did they partner with to create early iterations of CI technology? In what year?
Dr. William House partnered with Dr. John Doyle in 1961
Who was the first person to place 6 electrodes into modules of a deaf person which first demonstrated the place-pitch theory? What year was this?
F. Blair Simmons from 1964-1966
When was the first single channel CI implanted?
1969
When was the House/3M single electrode device invented? What feature did it have that is no longer used
1969
Percutaneous plug
What year was the Vienna/2M invented?
1980s
What is the difference between House/3M and the Vienna/2M?
House has a single electrode and Vienna has 4
Ineraid/symbion
-Eddington and colleagues
-1970s + 1980s
-6 intra-cochlear electrodes
-4 channels
-percutaneous
UCSF’s 4 channel system
-16 electrodes, 8 pairs, 4 chosen for stimulation
-four external coils using RF transmission
-redesigned into the clarion implant
Who is the father of the Modern Cochlear Implant
Dr. Graeme Clark
What was Dr. Graeme Clark inspired by?
Blade of glass in a snails shell
What developments occurred in the 1980s?
-physicians at UCSF and RTI collaborated to create an 8 channel CI
-single channel system for children
-clinical trials with multi-channel systems in Australia and U.S.
What developments occurred in 1987?
FDA approval of multi-channel devices demonstrating safety and efficacy for adults
What developments occurred in 1990?
FDA for children 2+
What developments occurred in 2000?
FDA approval for children 12 months+
What developments occurred in 2019?
FDA approval for SSD 5+ years
What developments occurred in 2020?
FDA approval for 9 months+
How many manufacturers are there for CIs? Name them
Cochlear corporation
Advanced Bionics
MED-EL
Define cochlear implant
a tool that is designed to detect, convert, code and transmit the salient features of acoustic signals into electrical signals that are delivered to the cochlea
How many components does a CI have? Describe what each consist of
Internal processor- electrode array, receiver/stimulator, retention magnet
External processor- mic, transmitting cables, speech processor, transmitting coil, power supply, user controls
How does a CI work?
- the mic captures the sound
- the processor converts that sound to a digital signal
- that signal is sent through the cable to the coil
- the signal is sent across the skin to the implant where it is converted to electrical energy
- the energy is sent to the electrode array within the cochlea where it stimulates the hearing nerve
Where is the ideal placement with the electrodes?
With the scala tympani
How do CIs and HAs differ?
CI- bypass damaged hair cells and electrically stimulates the nerve directly; converts the acoustic input into an electrical pattern that is transmitted by FM signal through skin to the internal device and delivered to electrodes in the scala tympani; rely on surviving neural elements to be stimulated by direct delivery of current pulses
HAs- acoustically amplify sound through outer and middle ear to stimulate traveling wave in cochlea; outcomes rely on the responsiveness of surviving hair cells
Speech/sound processing strategy
a set of rules used to control the conversion of signals from acoustic features into electrical properties
What are the similarities across the manufacturers?
-transcutaneous communication between internal and external portions
-multi-channel
-some form of telemetry technology
-different speech processing options
-process of programming similar
-cost and warranties
-MRI compatible internal devices (current generation)
-rely on external battery technology for power source
How many electrodes does each manufacturer have?
MED-EL- 12
Advanced bionics- 16
Cochlear- 22
Differences between devices
-appearance
-style and wearing options
-number of implanted electrodes
-mic design
-visual feedback features
-slightly different surgical considerations
-durability
-track record
-bluetooth/accessory compatibility
Who was the founder of Advanced Bionics (AB)?
Alfred Mann
Current AB internal device names and what distinguishes them
Generation is: HiRes Ultra 3D (MRI compatible)
Devices are: HiFocus Slim J (more hearing preservation), Mid-Scala (pre-curved, electrodes are closer)
Current AB external devices
Naida CI M
Sky CI M
Chorus (C1 device)
where M is marvel
Advantages of a t-mic
act as an alternative, pinna advantage, phone placement and sound quality
Charging options for AB
can be rechargeable or battery
batteries used will be 2 675 implant strength batteries and will typically last 2-3 days
What is the biggest CI company?
Cochlear
Current Cochlear tech for internal devices
-CI612 (contour advanced)
-CI622 (Slim straight); lateral wall
-CI 632 (Slim modioloar)
-CI 624 (Slim 20)
-L24 (hybrid); short array
Current Cochlear tech for external devices
N8 and Kanso 2
Which Cochlear technology is not BTE
Kanso
Charging options for Cochlea
2 675 implant strength batteries and will typically last 2-3 days or rechargeable
Cochlear accessories
partner with resound so the accessories will be resounds
Founder of Med-El
Hockmeirs
Current tech for Med-El internal devices
Synchrony 2 portfolio
-standard
-medium
-compressed
-flexsoft
-flex28
-flex24
-flex20
2 facts about Med-Els internal devices
-no precurved arrays
-longest arrays
Current tech for Med-El external devices
-Sonnet and Sonnet 2 EAS
-Rondo 3
Does Med-El have an off the ear option?
Yes, Rondo 3 and is only rechargeable
Med-El battery
-2 675 implant strength batteries and will typically last 2-3 days
-rechargeable and is the shortest lasting of the manufacturers
Retention aids
for little ears:
-headbands
-pilot caps
-shirt clips
-double-sided tape
Hearing Hour Percentage (HHP)
-(wear time/mean awake time) x 100
-mean wake time is derived from a pediatric sleep meta-analysis
-compared the amount of time the subject had access to sound to the amount of time a typically developing child with normal hearing would have access to sound
What is one of the most important factors with CIs?
Age of implantation
-early implantation is better
-wear time is important too- need to wear it
What tests are part of the pre-op assessment?
-otoscopy
-tympanometry
-OAEs
-ABR (age pending)
-unaided thresholds
-HA verification
-parental questionnaire
-aided speech
CDACI
childhood development after cochlear implantation
Why is the pediatric minimum speech test battery useful?
universal battery in case patient moves, it will have the same candidacy hierarchy which makes it easy to compare
At what level is the pediatric minimum speech test battery set?
conversational level
Post-op tests after implantation
-aided thresholds
-listening check
-unaided thresholds
-parental questionnaire
-speech perception with CI (recommended to be completed at 60)
Aided thresholds
-obtain in the soundfield using warble tones/narrow band noise to avoid standing waves in the soundfield
-want to achieve thresholds between 20-30 dB HL
Auditory skills checklist
-parent survey that addresses different categories
-detection
-discrimination
-identification
-comprehension
LittlEARS
-recommended age birth to 24 months
-parent questionnaire that addresses auditory responsiveness to sound and environment
-yes/no questions
-score: yes is 1 point, looking for the total number of yes responses
Early speech perception: low verbal
-recommended for children age 2-5 years
-closed set task with physical toys/items
-set of 4 items for each level
-often completed for MLV, seated near the child/mouth covered
-three levels: pattern, spondee and monosyllable; each item presented 3 times for 12 total per test level; score out of 12, administer the next level after a score of 8/12
Early speech perception: standard
-recommended for children age 2-5 years
-closed set task with picture cards to point to response
-set of 12 items for each level
-often completed MLV, seated near the child/mouth covered
-three levels of test: patter, spondee and monosyllable; each item presented 2 times for 24 total per test level; score out of 24, administer the next level after a score of 17/24
Pediatric speech intelligibility (PSI) words
-recommended for children 5-7 years
-closed set 20 words present on 5 picture cards containing 4 pictures
-carrier phrase “show me”
-children and point to or repeat the target word
-score: percent positive words
Multisyllabic lexical neighborhood test (MLNT)
-recommended age 2-3 years
-open set, recorded task, 2-3 syllable words
-24 words where the first half is easy words and the second half is hard words
-two unique word lists
-no carrier phrase
-score: percent words correct (easy/hard), percent phonemes correct (easy/hard)
-only 2 lists
Lexical Neighborhood Test (LNT)
-recommended age 2-3 years
-open-set, recorded task, 1 syllable words
-50 words where the first half are easy and second half are hard
-two unique word lists
-no carrier phrase
-score: percent words correct (easy/hard), percent phonemes correct (easy/hard)
Consonant-Nucleus-Consonant test (CNC)
-recommended age 2-5 years
-open set, recorded task, monosyllabic words
-50 words: not normed for use of half-list, each word has 3 phonemes (150 total), pediatric scoring often use a word and phoneme score
-10 unique word lists
-carrier phrase is ready
-score: percent words correct, percent phonemes correct
-developed to provide lists of monosyllabic words with equal phonemic distribution across lists
-each list should have approximately the same phonemic distribution as the English language
Pediatric Speech Intelligibility (PSI) sentences
-recommended age 2-3 years
-closed-set, recorded task
-two closed sets with 5 items each, total of 10 sentences
-carrier phrase is show me
-children point to the target picture
Bamford-Kowal-Bench Sentences: Quiet (BKB)
-open set, recorded task
-16 sentence lists, with 50 total key words
-score-percentage of key words correct
Bamford-Kowal-Bench Sentences in noise (BKB)
-open set, recorded task
-BKB sentences presented with four-talker babble with increasing SNR
Pediatric AzBIO in quiet
-open set, recorded task
-16 sentence lists, with 20 unique sentences with 3-12 words per sentence
-single female talker
-score: present complete 20 sentence list, percent positive words
Pediatric AzBIO in noise
-open set, recorded task
-16 sentence lists, with 20 unique sentences with 3-12 words per sentence
-single female talker- four talker babble at +5 or +10 dB SNR
-score: percent complete 20 sentence list, percent positive words
How long does a typical adult CI evaluation take?
4-5 hours
Unaided testing for CI evaluation
-AC and BC thresholds; it is critical to obtain thresholds from 125 to 8000 Hz to reflect accurate hearing status
-SRT
-recorded WRS via W22, NU6 or CNC
-tymp
-acoustic reflexes
-OAE and ABR when warranted
Aided testing for CI evaluation
-HA verification
-soundfield thresholds from 125 to 8000 Hz to assess functional gain of HA
-speech perception in quiet, noise, individual ears, bilateral/bimodal
Why do we do HA verification for a CI evaluation?
-ensures HAs are meeting targets
Aided test setup for CI eval
-speaker located 1 meter from center of listeners head
-both speech and noise signals for noise conditions are presented from the same speaker (at UNC this is speaker right)
-use recorded speech testing
-administered at 60 dB SPL
Closed-set
-limited number of choices are available to listener
-ex. ESP and four choice spondee recognition test
What is the ideal speech list?
Depends on the patient! Want one that is easier and a bit harder so measure change overtime
Open-set
-unlimited number of choices
-ex. HINT, AzBio, CNC, BKB-SIN
CUNY sentence test
-40 lists of 12 sentences where there are 3 sentences, 4 questions, 4 commands
-carrier phrase is ready
-all sentences of the list relate to a general topic- there is context which makes it easier and is slower and shorter
HINT sentence test
-designed as an adaptive noise noise test
-utilize in clinic with fixed noise
-each list consists of 10 sentences with no ready indicator
-use 2 lists (20 sentence total)
-Ch.1 = signal (EXT B)
-Ch.2 = noise (EXT A)
-background noise may stop and start
AzBio Sentence Test
-4 talkers, 2 male and 2 female
-15 sentence lists
-each list consists of 20 sentences 10 spoken by 2 female talkers and 10 spoken by 2 male talkers
-Ch.1 = signal (EXT. A)
-Ch. 2 = noise (EXT. B)
-limited contextual clues
Spanish AzBio Sentence Test
-4 talkers (2 male and 2 female)
-42 sentence lists
-each list consists of 20 sentences with them split evenly among the speakers
-Ch.1 = signal (EXT A)
-Ch. 2 = noise (EXT B)
-since 2021 use HINT Spanish prior but would have ceiling affects too
-noise has higher frequency because more high frequency speech sounds and not babbled
In what year was it recommended that a set of materials be used to assess the performance of adults with cochlear implants?
1996
What is the minimum speech test battery (MSTB) for adults CI as of 2011?
-1 list of CNC
-1 list of AzBio in quiet
-1 list of AzBio in noise
-1 list of BKB-SIN
-recommended to present at 60 dBA
-recommend SNR of +10 0r +5 for AzBio sentences in noise
-recommend calibration prior to administration of any tests
Changes to MSTB since 2011
-CNC is the primary for clinical determination
-best aided = the score obtained for an individual ear when the patient uses hearing aid that has been optimized for that ear
-sentences in noise should be administered at a level of 65 dBA to represent increased vocal effort
-perform post-op testing only at 3 and 12 month time points rather than 1, 3, 6, 12
What is the cutoff (in percent) if you need to make things easier or harder?
25% to move down, 80% to move up
Testing setup for adult asymmetric/SSD
-speech perception in spatially-separated noise
-AzBio sentence conditions (0 dB SNR)
– speech front, noise front
– speech front, noise to better ear
– speech front, noise to poorer ear
-BKB-SIN conditions
– speech front, noise front
– speech front, noise to better ear
– speech front, noise to the poorer ear
-one speaker at 0 and the other at 90 or 180
In cases of asymmetric/SSD, how do you isolate the test ear?
- plug and muff- earplug inserted into better ear deeply with muff over it and no leakage, adults can expect 38-54 dB SPL of attenuation
- masking noise via insert earphone to better ear- to mitigate crossover from BC (necessary for pre-op evals), common in adult population and utilized in MED-EL SSD clinical trial
- application of masking along with circumaural earphones placed over the better ear
- use of direct audio input
Pediatric CI evaluation appointment flow
-tymps
-OAE/ABR (age/developmental ability)
-unaided thresholds
-aided speech perception
-counseling
Adult CI evaluation appointment flow
-case history
-tymps
-ARTs/OAE
-unaided thresholds
-aided speech perception
-cognitive screener and questionnaires
-counseling
Adult CI candidacy referral sources
-self
-family members
-other CI patients
-hearing health care professionals
-ENT physicians
-family physicians
Adult CI candidacy referral reasons
-not satisfied with current hearing aid technology
-struggles more to hear and communicate with spouse/family/friends
-outreach event
According to the MSTB-3 consensus panel, when do you refer an adult for a CI eval
-60/60: refer if a patient presents with SNHL with unaided PTA of equal to or greater than 60 dB HL and unaided WRS less than or equal to 60% in the ear to be implanted
CI quality of life (CIQOL)
-objective measures or pre- and/or post-implant speech perception may not be in good agreement with subjective assessment of perceived performance and/or benefit
-questions on 6 domains (communication, emotional, entertainment, environmental listening effort, and social)
Speech, spatial, and qualities of hearing scale (SSQ-12)
-rating the difficulty of completing an activity due to HL
-use a ruler to the tenth of a decimal to get the rating
Tinnitus handicap inventory
-helps to evaluate the severity of tinnitus pre and post-op if they complained about it
-tinnitus is common for patients to report when they are CI candidates
-getting a CI may make it better, worse, or no change
During a CI evaluation, what frequency needs to be tested that usually is not?
125 Hz
FDA info on CIs (not FDA CI indications)
-CIs are a class III regulated biomedical device
-must obtain post market approval to ensure safety and efficacy
FDA indication vs. candidacy
-FDA indications vary by manufacturer and insurers, such as Medicare, can have different indications for who can receive a CI
-FDA indications develop following a clinical trial and are part of the devices label
-any changes made after the trial have to be submitted to FDA as a supplement which is a lengthy and expensive process
Traditional Adult CI FDA indications for Med-EL (synchrony and synchrony 2)
-18 years or older
-bilateral sever to profound SNHL (PTA of 70dB or greater at 500, 1000 and 2000 Hz)
-limited benefit from amplification (40% correct or less in best aided listening condition on recorded tests of open-set sentence recognition (ex. HINT sentences)
– is it best aided in noise or quiet?
Traditional Adult CI FDA indications for Cochlear (profile and profile plus)
-18 years or older
-pre, peri or post-linguistic SNHL
-moderate to profound hearing loss in the low frequencies and profound hearing loss in the mid to high frequencies
-limited benefit from amplification (50% or less correct on recorded open-set sentence recognition in the ear to be implanted and 60% or less in the best aided condition (opposite ear or binaurally)
Traditional Adult CI FDA indications for AB (ultra 3D)
-18 years or older
-post-lingual onset of severe or profound HL
-bilateral severe to profound SNHL
-limited benefit from amplification (50% of less correct on recorded test of open-set sentence recognition)
EAS adult CI FDA indications Med-EL (synchrony and synchrony 2)
-normal hearing to moderate SNHL in low frequencies (thresholds no poorer than 65 dB HL up to and including 500 Hz) with severe to profound mid-to-high-frequency hearing loss (no better than 70 dB HL at 3000 Hz and above) in the ear to be implanted
-CNC word recognition score in quiet in the best-aided condition 60% or less, in the ear to be implanted and in the contralateral ear
EAS adult CI FDA indications Cochlear (hybrid-L24)
-18 years old or older
-thresholds greater or equal to 60 dB HL through 500 Hz and greater or equal to 70 dB HL for 2000 Hz and higher
-60% or less on CNC word recognition scores in the ear to be implanted with 80% or less in the contralateral ear
Does AB have a separate indication for EAS?
No, but that does not mean you cannot use it
What five things go into determining a traditional adult CI candidate?
-audiogram
-medical
-lifestyle/demographics
-hearing history/etiology
-speech recognition
Why should CNC list be used instead of AzBio for traditional adult CI evaluation?
CNCs have less context compared to AzBio, because of this it shows what the auditory system is doing on its own and its less impacted by the ceiling effect
Medical evaluation for an adult CI candidate
-medical exam and history review (previous surgeries, medical conditions that prohibit surgery)
-imaging (CT scan and/or MRI) to diagnose potential disease in the temporal bone, evaluate the tissues, determine cochlear anatomy and potential electrode choice
-minimum medical work-up (EKG, chest x-ray, blood work, CBC, PTT, chem 7, FTA-ABS)
-pre-op assessment by anesthesiologist
-chronic health conditions (diabetes, heart disease, stroke, hypertension and emphysema) rarely prohibits implantation but it must be considered
Common post-op complications
-pain at incision (pain medication)
-dizziness/vertigo (supervision in post-op period to prevent falls); this may be impacted long term which is rare but possible
-constipation (stool softens pre-op)
-tinnitus
-loss of residual hearing in the implanted ear
Uncommon post-op complications
-wound hematoma
-infection
-facial nerve paralysis
-perilymphatic fistula
-device migration (maybe due to head trauma)
-device failure
Timeline and process for adult CI candidate
Activation happens 3-4 wees after surgery. Programming and fine-tuning occurs duirng follow-up appointments at the 1 month, 3 month and 12 month
Additional candidacy considerations
-is there residual hearing to substantiate staying with traditional amplification or to warrant a hearing aid trial (3 months or greater)
-does patient perceive benefit from amplification in identifying environmental sounds or understanding speech in conversation
-would the patient achieve greater, equal or lesser outcomes with an implant as compared to the hearing aid?
-do the benefits outweigh the risks (assess for each patient)
Candidacy considerations for a traditional adult CI candidate- which ear?
-does the patient have a poorer ear?
– residual hearing vs. speech perception
-history of hearing loss of each ear
-history of traditional amplification in each ear
-are both ears anatomically viable for electrode insertion
-patient preference
-*ear that has worn a HA will do better
Candidacy considerations for a traditional adult CI candidate- medical?
-no medical contraindications
-cochlear patency (ossification of one/both cochlea)
-cochlear anatomy- ex. Mondini/EVA/common cavities
-genetic disorders- ex. osteogenesis imperfecta
-CNS concerns
-temporal bone fractures
-revision
Candidacy considerations for a traditional adult CI candidate- social?
-motivation level (who is initiating the appointment? willingness to return for follow-up appointments)
-support system (communication partner, does the patient need a caregiver in the home post-op? is the patient at risk for falling during the post-op recovery period? transportation to/from clinic)
-realistic expectations (expectation questionnaires- patients with lower pre-op CI performance expectations show higher post-op QoL)
-emotional state (acceptance of hearing loss, death of a spouse, mental health, loss of independence, alcohol abuse)
-desire to communicate and interact in a hearing world (retired/employed? social activities? hobbies/interests?)
Candidacy considerations for a traditional adult CI candidate- health > age
-centers are routinely implanting elderly patients (>65 years old)
-many adult recipients fall in the age range of 75+ years old (the oucomes, regardless of age, are generally one in the same ex. brain plasticity, benefit from CI, anethesia time)
-chronic health conditions such as diabetes, heart disease, stroke, hypertension rarely prohibit implantation
Risks
-general risk with any surgery: post-surgery pain, scarring, bleeding, infection, risks with general anesthesia
-risks with any ear surgery: numbness/tenderness around ear, neck pain, facial nerve injury/paralysis, taste change, perilymph/CSF leak, dizziness/vertigo, tinnitus, blood/fluid/infection at or near surgery site
-risk with CI: loss os residual hearing in implanted ear, meningitis, facial nerve stimulation, inflammation/extrusion, device migration, device failure
Benefits for a traditional adult if they receive a CI
-improved speech understanding in both quiet and noise
-identification of sounds
-quality of life: social opportunities, employment opportunities, access to television and telephone, increased confidence, ease of communication, richer relationships with friends and family, music appreciation)
8 factors that influence outcomes
-onset of HL (age, sudden or progressive)
-duration of HL
-how long without sound or stimulation (consistent HA use)
-status of the cochlea (cochlear malformation, ossification of cochlea, neural HL)
-mode of communication (spoken vs. sign)
-appropriate expectations (commitment to process)
-support system from family and friends
Reasonable expectations for pre-lingual patients
-sound detection
-identification of sounds
-closed-set word identification
-some open set sentences
Reasonable expectations for post-lingual patients
-obtain all levels of sound detection and identification
-closed set words and phrases
-complete open-set recognition at both sentence and word levels with average scores of: 72% sentences in quiet and 56% words
Average CI outcomes for average CI patients
-CNC- 51%
-AzBio in quiet- 67%
-AzBio SNR+10- 52%
Average CI outcomes for better performing CI patients
-CNC words- 69%
-AzBio in quiet- 90%
-AzBio SNR+10- 73%
Average CI outcome performance for EAS patients
-CNC words- 43%
-AzBio in quiet- 74%
-AzBio SNR+10
-AzBio SNR+5- 36%
Realistic Expectations
-progress with CI does not happen every night
-different from normal hearing
-different from HAs
-most progress with a cochlear implant is made during the first 6-12 months after initial activation
-communication with CI recipients can provide more accurate perspective and expectation for candidates
Who is on the aural rehab team for CI recipients
-audiologist
-SLP
-patient, family, friends
What does aural rehab involve
-understanding the difference between sounds and whole words
-understanding new sounds that have been heard before
-reading aloud and following someone else’s speech while they read aloud
-learning when to change settings to improve understanding
-learning how to set up the phone to work with implant
-learning how to enjoy music
Aural rehab tasks
-speech tracking- use topic-oriented paragraphs, favorite literature-books, magazines, newspaper
-start a small, closed set task and expand- days of the week, months of the year, numbers
-common phrases- assess the patients lifestyle and choose phrases that are meaningful
-computer software- sound and way beyond (cochlear), the listening room website (AB), hear at home or auditrain (Med-El)
What can help after a CI implant with getting used to it?
-listening to audiobooks/podcasts
-read-a-louds with a communication partner
-read out loud to yourself
-have a conversation with someone with a known topic
-listening to music
What are some potential benefits of EAS?
-speech perception in noise
-enhanced music appreciation
SSD Adult CI candidacy Med-EL indications (synchrony and synchrony 2)
-5 years and older with profound SNHL on open ear (greater of equal to 90 dB HL at 500, 1000, 2000, 4000 Hz) and normal (up to 15 dB HL at 500, 1000, 2000 and 4000) to mild SNHL (up to 30dB HL at 500, 1000, 2000 and 4000) in other ear
-limited benefit from amplification (5% or less on CNC words in quiet when tested in ear to be implanted alone)
-one month experience with CROS HA or relevant device without subjective benefit
SSD Adult CI candidacy Cochlear Indications (Profile and Profile plus)
-5 years and older with severe to profound SNHL in one ear (PTA at 500 Hz, 1000, 2000 and 2000 greater than 80 dB HL) and normal or near normal hearing (PTA at 500, 1000, 2000, 4000 Hz less than 30 dB HL) in the contralateral ear
-limited benefit from amplification (5% or less on CNC words with unilateral HA)
Asymmetric Adult CI candidacy Med-EL indications
-5 years older with profound SNHL in one ear and mild to moderately severe SNHL in the other ear, with a difference of at least 15 dB in PTA between ears
-limited benefit from amplification (5% or less on CNC words in quiet when tested in ear to be implanted alone)
-one month experience with CROS HA or relevant device without subjective benefit
FDA criteria for children CI candidates for Med-EL
-12 months to 17 years
-profound SNHL specified as 90 at 1000 Hz
-Lack of progress in auditory skills with habilitation and amplification provided for at least 3 months
-3-6 month HA trial without previous fitting; waived if ossification
-less than 20% on MLNT or LNT
FDA criteria for children CI candidates for Cochlear
Children age 9-24 months
-profound SNHL
-limited benefit from binaural amplification
Children 2-17
-severe to profound SNHL
-limited benefit from binaural amplification
less than or equal to 30% on MLNT or LNT
FDA criteria for children CI candidates for AB
Children 12 months to 17 years
-profound bilateral SNHL greater 90 dB HL
-use of HAs for 6 months for children 2-17 or at least 3 months for children 12-23 months. HA use waived if evidence of ossification
-children age 4 or less, failure to reach auditory milestones or less 20% MLNT at 70 dB SLP
-children older than age 4, less than 12% on PBK words or less than 30% on open set sentences at 70 dB SPL
FDA criteria for children CI candidates for Med-El
-children 5 years and older
-unilateral profound hearing, PTA greater than or equal to 90 dB HL and aided CNC word score less than or equal to 5%
-normal to mild hearing in contralateral ear
What happens at a CI eval for a child?
-ENT- medical workup, MRI and/or CT scan
-Audiologist- unaided thresholds (behavioral or objective), verify HAs, aided speech perception (age-appropriate tests, CNC when possible)
-SLP- speech and language eval, collaboration with other services
What is insurance covering for CI?
-children 12 months and older
-FDA labeled device
-no contraindications for surgery
-confirmed diagnosis of severe to profound SNHL (greater or equal to 70 dB HL) in the ear to be implanted with the exception of children with ANSD
-limited benefit from 3 month HA trial (defined by test scores of less than or equal to 40% in the ear to be implanted using age-appropriate speech perception measures
When to refer for a CI eval?
-any newborn with NR ABR should be referred to “center of excellence” by 3 months old
-any child with a SNHL and PTA between 65-8- HL for consideration
-any child with SNHL and PTA greater than 80 dB HL should be referred quickly
-aided SII is less than 65
-any child with aided word recognition skills or spoken language development that do not match pure tone thresholds especially in cases of ANSD
Timeline for early implantation
-NBHS at birth
-ABR, HAF, medical eval, early intervention 2-4 months old
-behavioral testing, early intervention, CI eval 5-7 months old
-implantation, early intervention 7-10 months old
Does a comorbidity preclude cochlear implantation?
-no
-approximately 1/3 of our active CI patient population has an additional diagnosis (ex. CMV, CHARGE)
-counseling is vital for realistic expectation
-redefine success with a CI- improved connection with environment, family members, enjoy music
Verification methods
response of the hearing aid should be measured for a variety of input levels to estimate the audibility of speech and ensure that the maximum output does not exceed prescribed levels
Validation
in order to validate benefits and/or assist with fine-tuning, every child should receive an outcomes assessment after amplification is provided. whereas verification serves to ascertain that prescriptively appropriate amplification is provided, outcome assessment checks that amplification needs of individual children are met
What HAs pair up with Cochlear
Resound
What HAs pair up with AB
phonak
FDA criteria for children with SSD for CI for Med-El
- children 5 years and older
unilateral profound HL, PTA greater than or equal to 90 and aided CNC word score of less than or equal to 5
-normal to mild HL in contralateral ear
FDA criteria for children with SSD for CI for Cochlear
-children 5 years and older
-unilateral severe-profound HL, PTA greater than or equal to 80 and aided CNC word score less than or equal to 5% or 10% on age appropriate test
-normal to mild hearing in contralateral ear
At the CCIC who is typically on the team caring for the child?
-educator
-surgeon
-other professionals
-audiologist
-LSLS therapist
-parents and family
Radio frequency link
the internal and external part use this to communicate using near-field
Electromagnetic induction
process of varying an electromotive force to produce a current by varying the magnetic field flux across the conductor
Telemetry
-process of delivering information and power via electromagnetic induction
-transmission of data
-bidirectional- communication to and from the internal device
-backward telemetry- from the internal device to the coil, speech processor, remote control or programming computer
-provides information about the status of the electrodes array and how it responds when being stimulated
-enables features like device identification and feedback on device function
-allows for estimation of battery life
CI mapping
-goal is to direct the current by establishing the rules that will determine how fast, how much and in what manner the current will be delivered
-efficiency in speed and use of power is critical for seamless use, accurate coding and delivery of sound and satisfactory listening
-the audiologist is controlling the delivery of current through the programming software
Voltage
-represents potential difference applied across a circuit that will drive current through a circuit
-electromotive force or electrical pressure
-the excess of electrons located at the battery negative terminal will be attracted to the deficiency of electrons located at positive terminal
-the greater the voltage, the greater the force that is driving the charges together
-always measured between two points
Current
-amount of electrons moving/flowing through the circuit
-measured in amperes or amps for short
Charge
-number of particles present (electrons or protons), measured in Colombs
-product of current amplitude and pulse width
-small charge = quiet, large charge = loud
-stimulus charge is defined by the pulse width and current amplitude; an increasing amplitude or widening width will deliver more current which will give the perception of increased loudness
Resistance/impedance
-measurement of the opposition to the flow of current in an electrical circuit, described in Ohms
for CIs, this can tell us about the integrity of the electrode lead, electrode contact and the return electrode
-a small amount means the circuit is closed but a large amount means an open circuit
Ohms law
-describes the relationship between voltage (V), which is trying to force charge to flow, resistance (R), which is resisting that flow and the actual resulting current (I)
-V = I x R
Basic components of a CI electrical circuit
-the signal generator in the internal processor- current source or output circuit
-the active electrode lead and contact
-the ground, indifferent or reference electrode (the ground is necessary for the extra energy to go somewhere)
What does T stand for in AB and Cochlear and what does THR stand for in Med-EL in regards to current delivery?
Current level
What are the three types of stimulation modes?
-monopolar
-bipolar
-common ground
Monopolar
-active electrode intracochlear, referent electrode is outside the cochlea
-may be more than one referent
-wider spread of current
-most commonly used
-most efficient battery life
Common ground
-current takes path of least resistance
Bipolar
-both active and referent electrode are intracochlear
-can be adjacent electrodes or far apart
-can include multiple electrodes
-physical separation determines the spread of current
Why do modern CI systems utilize monopolar as the default over bipolar?
-less current to achieve same perceptual loudness (more nerve fibers recruited with less current since the field of stimulation is greater)
-less differences in levels from one electrode to the next- we are able to interpolate which saves time
-improves battery life
-in most cases, monopolar electrode coupling does not result in facial nerve stimulation
Channel number
-describes a discrete frequency range over which sound is analyzed for eventual delivery to an electrode contact
-defined by analysis bands (band pass filters with slight overlap between neighboring channels)
-true number of channels depends on electrode selectivity and patient physiology
-interaction between the implant system and the patient determines channel viability
-electrodes that stimulate the same neural elements and produce the same percept are not unique channels
-virtual channels can be created by steering the current between electrodes (current steering)
-the ability to steer current between physical electrode contacts in order to deliver added spectral information
-AB advertises that this helps with hearing in noise, music appreciation, hearing environmental sounds and understanding tonal languages
Impedance telemetry
-measure of electrode function, stimulability and compliance
-unit of measurement of the ohm
-high impedance means low conductivity
-low impedance allows for good conductivity or high compliance
-needs to be tested at the beginning of each appointment
-electrodes that are very high in impedance, open circuits, or shorted together will be identified
-can be affected by hormone changes
Impedance telemetry findings
-“normal” electrode impedance value does not necessarily imply that all is well
-may be affected by recipients hormonal levels
-may preset as unusual loudness growth, odd pitch percepts, no auditory sensation
-persistent fluctuations may be attributed to- changes within the cochlea, change in integrity/properties of cochlear fluids and tissues, fault in cochlear implant
Compliance telemetry
-measure of capacity of electrode to conduct current
-reciprocal of impedance
-ideally an increase in current level produced an increase in loudness percept, unless there is poor compliance
-compliance issues limit loudness growth and may require adjustments in pulse width or simulation mode to overcome
Speech processing strategies
rules that define how the incoming acoustic speech signal will be analyzed and coded
How do you determine which speech processing strategy is optimal for a patient
likely depends on residual hearing, integrity of the auditory system and previous experience
What are the two speech processing strategies?
CIS (continuous interleaved sampling) and n of m
Which manufacturer uses what speech processing strategy
Med-El and AB is CIS
Cochlear is n of m but can use CIS
CIS (continuous interleaved sampling)
-always electrical pulses being presented, current amplitude is the only thing changing
-channels are stimulated in rapid succession (every electrode will get a turn but are stimulated one at a time)
-samples the intensity presence of the signal across the frequency range or within each channel
n of m
-signal is broken down
-pick out the electrodes that have the most important information then those are the ones that are stimulated
ACE
-cochlear
-uses n of m
-22 channels
-usually stimulating 8-10
HiRes
-AB
-CIS
-16 channels
-higher stimulation rate
-can be paired or sequential (paired means 2 are being stimulated at the same time which is why the rate is faster)
Electrical threshold level
perception of soft sound
Electrical comfort level
amount of current to provide increased loudness perception to the point of most comfortable loudness
AB intensity domain
lowest amount of electrical stimulation a user can detect with 50% accuracy (t-level)
Cochlear intensity domain
minimum amount of electrical stimulation the recipient can detect 100% of the time (t-level)
Med-El intensity domain
highest level of electrical stimulation at which is response is not obtained (THR)– finding threshold and going under it
Intensity domain- upper stimulation level
least amount of stimulation a recipient can detect when electrical signals are delivered to indicual electrode contacts
-AB most comfy listening level (m-level)
-Cochlear loud (C level)
-Med-El max comfy level (MCL)
What manufacturer specific programs affect loudness
-threshold and comfort levels
-pulse width (time of biphasic pulse)
-input dynamic range (want threshold around 20-30 and comfortable around 60-90)
-volume
-sensitivity
Frequency boundaires
-normal hearing 20-16,000
-implant system 70/350-8000
-typically the number of filters is equal to the number of electrical channels
Frequency assignments
-cochlear- 22 active electrodes with 2 extracochlear gounds; 22 most apical (low pitch) and 1 most basal (high pitch)
-AB- 16 active electrodes with 1 extracochlear ground; 16 most basal (high pitch) and 1 most basal (low pitch)
-Med-El- 12 active electrodes with 1 extra cochlear ground; 12 most basal (high pitch), 1 most apical (low pitch)
Rate of stimulation
-number of biphasic pulses that delivered to an individual electrode contact within one second
-fixed in speech coding strategies and variable in others
-faster rates may provide more temporal information but may tax the neural system (stimulating the nerve with pulses results in a highly synchronous compound response from all nerve fibers in the surrounding area of the electrode contact then they all go into refractory period at the same time)
-faster rates typically result in higher pitch perception
-faster rates provide temporal summation and typically a louder perception
Is a faster or slower stimulation rate better?
-depends on the auditory system
-there are advantages to faster rates like it could allow for the processing of fine temporal cues
-but higher rates use more battery life
Sequential stimulation
-biphasic pulses occur one after another in rapid succession
-may result in less channel interaction
Simultaneous stimulation
-several channels stimulated at the same time
-virtual channels is a concept derived from simultaneous stimulation
-independent current sources are needed to do simultaneous
Other map/program parameters
-volume and sensitivity control/enabling
-input processing by microphone function (directional, omnidirectional, beam)
-noise reduction features
-sound enhancement
-enabling and setting mixing ratios
Contributors to bone conductive hearing (5)
-sound radiating into external ear canal (osseotympanic mode)- influences BC hearing sensitivity for frequencies below 1 kHz
-middle ear ossicle inertia (interntial mode)- influences the mid frequencies
-compression of cochlear walls (compression/distortion mode)- very high frequencies
-pressure transmission from the CSF (nonosseous mode)- very low frequencies
-inertia of cochlear fluids- greatest contributor to health of the auditory system
Audiologic indications for a BAHD for CHL
-CHL component of the hearing loss greater than 35
-HL show better outcomes with BAHD compared to traditional HA
Audiologic indications for a BAHD for MHL
-CHL component is greater than 30-35 but HL is less than 65
-no more than mild to moderate SNHL
-there is less benefit as bone thresholds begin to exceed a mild degree
Audiologic indications for a BAHD for SSD
-normal hearing in the good ear (PTA ideally 20 or better)
-contralateral re-routing system
What frequencies are primarily affected by the head shadow effect?
high
Medical indications for a BAHD
-skin allergies and chronic ear drainage (HA and/or EM can aggravate the OE or canal)
-congenital malformation of the pinna (placement behind the pinna or in the canal not always an anatomical option
-ear canal stenosis
-previous ear surgery (canal closure, chronic mastoiditis, CWD mastoidectomy)
-syndromic HL (Down syndrome, Goldenhar, Treacher Collins)
Percutaneous devices
-cochlear baha connect (baha 5 super power less than 65, baha 6 max less than 55)
-oticon ponto
Passive transcutaneous options
-cochlear baha attract
-medtronic sophono alpha 2
Active transcutaneous options
-Med-El bonebridge
-cochlear osia
Difference between active and passive transcutaneous
-passive- generates vibrational stimulation through the skin to bone; holds the vibrating sound processor in place and applies pressure to the skin
-active- processor transmits sound to the implanted coil; vibrational stimulation directly to the bone
Nonsurgical options for BAHD
-cochlear baha softband/sound arc
-Med-El AdHear
Osseointegration
a direct structural and functional connection between ordered, living bone and the surface of a loud carrying implant
Components of an adult BAHD candidacy eval
-case history
-COSI, IOI-HA, THI questionnaires
-immittance testing
-unaided testing (pure tone and speech audiometry)
-aided testing
-counseling
-device selection
Sound processor set up for BAHD audiological eval
-demo device typically programmed ahead of time based on previously obtained BC thresholds (could also program via BC Direct where you do a hearing test in the software with the patient wearing the sound processor)
-patient tries the device on via testband/softband
-complete aided testing in the soundfield via speaker
Unilateral CHL/MHL BAHD eval
unaided
-AC pure tone thresholds 125-8000
-BC pure tone thresholds 500-4000 including 3000
-WRS in each ear with appropriate masking
aided soundfield
-NBN 250-8000 with contralateral masking
-speech perception (unaided versus aided quicksin at signal to the front and noise to the better ear)
Bilateral CHL/MHL BAHD eval
unaided
-AC pure tone threshold 125-8000
-BC pure tone thresholds 500-4000 including 3000
-WRS in each ear
-NBN 250-8000 with contralateral masking
-speech perception (unaided versus aided quicksin at 0 degree azimuth)
SSD BAHD eval
unaided
-AC pure tone thresholds 125-8000
-BC pure tone thresholds 500-4000 including 3000
-WRS in each ear with appropriate masking
aided soundfield
-NBN 250-8000 with contralateral masking
-speech perception (unaided versus aided quicksin at signal to the front and noise to the better ear)
Audiologic eval counseling
-realistic expectation (no improvement in localization, may hurt speech perception)
-medical considerations (MRI compatibility, surgical procedure, risks of skin irritation and overgrowth around abutment)
-device selection
-costs
-timeline for activation and follow-up
Advantages of percutaneous
-direct contact with the skull, which means more efficient signal transmissions across frequencies without the impedance of the skin
-superpower option has a larger fitting range then transcutaneous options
-great retention
-minimal MRI shadow
Disadvantages of percutaneous
- increased potential for adverse skin reactions
-visible post that is more at risk to be damaged by head injury
-3-6 month waiting period for activation
Transcutaneous advantages
-lower rate of complications around implant site
-minimal wound care required
-no visible post (aesthetic)
-less risk of head injury causing damage to the osseointegrated fixture
-can be activated within 4 weeks of surgery
Transcutaneous disadvantages
-MRI shadow
-magnet pressure may irritate the skin
-magnet strength is limited and not always strong enough
Cochlear BAHA system indications
-5+years old
-SSD- AC PTA or better ear 500-3000 less than 20
-CHL/MHL- BC PTA 500-3000 less than 55 for BAHA 6 max; BC PTA 500-3000 less than 65 for BAHA superpower
-bilateral- symmetric bone, less than 10 difference between ears for PTA or less than 15 difference at individual frequencies
Piezoelectric effect
-the ability of certain materials to generate an electrical charge from mechanical stress
-pierzoelectric layers expand and contract to send vibrations through to the cochlea
Benefits of piezoelectric stimulation
-thinner implant, minimal drilling
-more gain/power in the higher frequencies
-no movement between parts that can cause wear over time
Osia system indications
-5+ years old
-SSD- AC PTA of better ear 500-3000 less than 20
-CHL/MHL BC PTA 500-3000 less than 55
-bilateral candidates- symmetric bone conduction thresholds, less than 10 difference ears for PTA or less than difference at individual frequencies
Osia sound processor
-single 675 implant battery will last 22-35 hours
-user control button
-average of 12 dB more gain in high frequencies compared to percutaneous systems
-made for iPhon with capability for direct streaming
-MRI compatible for 1.5 and 3 Tesla with sound processor removed
Ponto 5 mini fitting range
-12+
-SSD- profound SNHL in one ear and AC PTA of contralateral ear 500-3000 less than 20
-CHL/MHL- BC PTA 500-3000 less than 45
-bilateral- symmetric bone conduction thresholds, less then 10 difference between ears for BC thresholds at 500-4000 (not 3000) or less than 15 difference at individual frequencies
Bonebridge fitting range
-12+
-CHL/MHL- BC less than 45 in PTA of 500-4000 (not 3000)
-SSD- BC less than 20 in the contra ear in PTA 500-4000 (not 3000)
Mel-El Bonebridge
-2 screws on either side of the transducer rests in the mastoid bone cavity and is floating
-flexible transition between the receiver coil and the floating mass transducer which allows it to bend up to 90 degrees in either lateral direction
-completed osseointegration not required to have been completed prior to activation (2-4 weeks)
-MRI approved for 1.5 Tesla only
Samba2
-single 675 implant plus battery lasts 8-10 days
-direct bluetooth streaming only through the samba2go accessory
Med-El ADHear
-all ages
-no pressure on skin needed
-sound converts to vibrations in the processor then transmits to the bone via the adhesive adaptor
-not typically covered by insurance
-up to 2 weeks of battery life with single 13 battery
-unilateral or bilateral CHL- BC less than 25
-SSD- BC less then 25 in the contralateral ear
BAHD verification
-verifit 2 skull simulator with DSL-BCD prescriptive targets
-the electronic coupler simulates the mechanical impedance of the human head
Advantages of BAHD
-nothing inside the ear
-more comfortable then an ear mold
-does not require a pinna or ear canal
-unaffected by ear drainage
-BAHDs do not need to be re-adjusted if AC thresholds fluctuate because prescribed gain is based off of bone conduction thresholds
Disadvantages of BAHD
-limited benefit if BC thresholds exceed 65
-BC thresholds do typically change over time with aging and/or disease progression
Why BAHA instead of CROS for SSD
-BAHD is worn off the ear on one side while a CROS requires devices on both ears
-BAHD wireless streaming can be mixed with the environmental mic but for a CROS to wirlessly stream sound the CROS mic must be turned off
-BAHD can be covered by insurance and for a CROS few insurances have HA benefit for patients 21+ years old
-BAHD bypasses OE and ME to send a clearer/crisper sound directly to IE, but a CROS device in a normal hearing ear will disrupt the natural acoustics of the ear (monaural spectral cues)
What has research shown when comparing BAHD and CROS?
-BAHD sends a clearer, crisper sound directly to the inner ear and does not need to overcome any kind of occlusion effect
-BAHD provides better speech understanding in noise than CROS hearing aids
-higher level of user satisfac
