Week 9 Activation and Programming Flashcards
1
Q
what all is included in the post-op physical exam
A
- imaging
- –pre- CT and MRI
- –post= x-ray
- activation day and every appointment after:
- –otoscopy (MEE is common up to 3-6 weeks post-op)
- –incision
- –coil placement
2
Q
how to select a magnet
A
- want to make sure it is not too weak or too strong
- children, women, and elderly have a mostly thin skin flap
- middle aged men and obese patients have a mostly thin skin flap
- dont fall for parent request because they would ask for a strong magnet for their active child–you are the expert
- make sure it is the right strength because if it falls off with pt movement it is too weak but if it snaps on when being held 1/2 inch away it is too strong
3
Q
what are the 4 main steps to programming
A
1) impedance measures
- –deactivate any abnormal electrodes
2) select a coding strategy
3) measure stimulation levels: threshold and USL
4) adjust parameters
4
Q
how to select a coding strategy
A
- generally use the manufacturers recommended (ACE, HiRes Optima, FS4)
- –for adults base it off of trials meaning start with recommended strategy and then if the pt has poor benefit try another strategy and see if it helps
- –for children again start with manufacturer default and then if not improving try to address the issues and can change strategy to so this
5
Q
review of each manufacturers threshold basic
A
- Med-El (THR): highest level not heard 100% of time–generally estimate
- Cochlear (T-Level): lowest level heard 100% of time–measure
- AB(T-Level):lowest level heard 50% of the time–estimate
- —–with kids it can go good to measure threshold across manufacturers
6
Q
review of each manufacturers USL basic
A
- Mel-EL (MCL): loud but not uncomfortable
- Cochlear (C-level): loud but comfortable
- AB (M-level): most comfortable
7
Q
Ways to measure CI threshold in adults
A
- do as you would audiometric threshold
- begin with apical electrodes because normally easier for the pt to perceive
- procedures:
- –ascending-descending
- –count the beeps while altering the # of beeps
- –psychophysical scale
- –estimation
- could use ling sounds ans see it the patient could detect them
8
Q
what happens if the threshold for the CI is set too low
A
T-levels set too low leads to pt having issues with soft levels and general processing of speech signals because a lot of it will end up outside of the electrode range you are trying to stimulate
(below their actual threshold)
9
Q
what happens if the threshold for the CI is set too high
A
T-levels too high leads to pt not having access to soft level sounds
10
Q
what is a t-tail
A
- a problem that is only identified when using a psychophysical scale
- –you keep increasing the level but the pt does not notice a change in loudness level
- —–eventually it will seem louder to them
- —–poses a problem because the pt ends up with a wide electrodynamic range ad then levels will overall be too soft and the pt will have problems with speech sounds
- in cases of t-tail, want to set up the threshold right at the point the loudness perception starts increasing
11
Q
ways to measure CI threshold in children
A
- BOA: breathing, sucking (typically supra-threshold)
- VRA around 6 months
- conditioned play audiometry ages 2+
- activities during the session
- step size would want to be bigger to be quicker and use electrode hopping meaning one apex one basal and middle and s on so even if testing stops you have info from the full range
- within a month post activation: aided soundfield want 30 dB in FL, 25 dB in middle, and 25 dB in high freqs
- can use estimation however large EDR or limited responses to soft sounds means we should measure
- –actually with kids its recommended to measure threshold
12
Q
measuring USL in adults
A
- it is important to not over or under estimate the USL
- procedures:
- –loudness scaling chart
- –global adjustment using live speech and balancing
- –ESRT
- —–measured in up to 85%
- —–0.79 to 0.85 correlation between objective and behavioral USL
- —–performance= actually give better maps than the chart measured USL
13
Q
what happens if you overestimate the USL
A
painful sounds for the pt or discomfort
14
Q
what happens if you underestimate the USL
A
narrow the dynamic range leading to distortion because of more “compression” of the speech into smaller range
- EDR on average is:
- –cochlear= 40-50 CL
- –AB= M-level between 150-250 CU
- –med-el= MCL 10-25 CU
- —–really dont want to go over these set values for the USL
15
Q
measuring the USL in children
A
- procedures:
- –ESRT is generally the best because it does not rely on behavioral responses
- —–set USL within 10% below the response
- –loudness scaling chart for kids 8+
- —–there are simpler charts for kids ages 4+
- –observation in younger kids (increase level and see when child starts blinking)
- –live speech
- be careful because over stimulation will make them not want to wear the CI
16
Q
balancing of CI
A
- 80-90% of the DR
- –do the apical electrode first
- –should be done at one week post-activation
- –starting at 7 yrs old, dont do younger children
- –absent ESRT means super important to do because ESRT normally creates a more balanced map than behavioral
- –procedure: ask pt how the perceive loudness of electrode 1 and 2 then move to 2 and 3
- —–always adjust the 2nd electrode so by time you get to the base all electrodes are compared to the apical one
17
Q
sweeping of CI
A
- looking at sound quality, pitch transition, equal loudness
- 100% and 50% of DR
- apical electrode first
- also first visit after activation post balancing
- start apical and go down from there
18
Q
stimulation rate as a parameter adjustment
A
- individual differences in that some people do well with high rate but not everybody
- 900-1500pps is typically the range people fall in
- programs with different rate are used if pt is not improving to see what rate works best for the pt in the real world
- –elderly or neuropathy might need around 700pps or some other slower rate
19
Q
pulse width as a parameter adjustment
A
- amplitude vs width vs rate meaning they are all connected together (limit one another)
- 37 micro seconds is the recommended
20
Q
channel gain as a parameter adjustment
A
- before processing
- can be used with CIS strategies to address small changes
- last resort in n-of-m strategies (cochlear)
21
Q
frequency allocation as a parameter adjustment
A
- really want to see where the frequencies are going especially when you have disabled electrodes because the freqs will be distributed and reconfigured to neighboring electrodes
- want to include high freqs but not too high
- adults 6000Hz, children at least 7000Hz
22
Q
maxima as a parameter adjustment
A
*10-12 means generally 10-12 electrodes selected to be stimulated at any time
23
Q
activation of CI and following appointments general schedule
A
- two-day activation session 2-4 weeks post surgery generally
- one week-post activation appointment
- 2 month post activation appointment
- 3 month post-activation appointment
- regular visits after this
- –these are dependent on the clinic
24
Q
what to do at day 1 of the activation session
A
- importance= introduction to the device and stimulate at comfortable level to provide audibility
- –physical examination
- –magnet strength
- –impedance
- –signal coding strategy and basic parameters (rate,pulse width, maxima)
- —–T-levels
- —–USL (detect or identify the ling sounds)
- —–volume control–potentially full range so they are not overwhelmed
- –counseling topics: realistic expectations, care, use, battery, VC
25
Q
what to do at day 2 of the activation session
A
- physical examination
- –want to look at where the coil is for skin irritation from 1st day of wear to make sure magnet isnt too strong
- impedance
- stimulation level (programs with different levels to serve as adaptation level like on a HA)
- ESRT (only if tolerable)
- ECAP (potentially half of the electrodes on day 1 and the other half on day 2)
- –auditory response telemetry (ART) for med-el, Neural response telemetry (NRT) for cochlear, or neural response imaging (NRI) for AB
- follow feedback but minimally be careful not to change too much because the pt hasnt gotten time to get used to the CI
- –do listen to feedback about non-auditory stimuli
- detect or identify ling sounfd
- counseling topics: care and use (also what family members can do)
26
Q
what happens at the one-week post activation appointment
A
- for adults and older children do soundfield testing (want = 30 dB at 250-6000 Hz)***this is the goal of this appointment
- first things:
- –physical exam
- –impedance
- T-level, USL want to measure again since they are used to it
- –can do an optional 3 week post activation visit for children
- ESRT for the 1st time and ECAP for remaining electrodes
- can create situation specific programs (music, noise)
- counseling: monitoring earphones for fam, assistance devices, dehumidifier
27
Q
one month post activation appointment
A
- sound processor check with monitoring earphones to make sure it is working okay
- aided soundfield (tones and speech)
- –LF= 30 dB; MF and HF = 25 dB
- physical exam and impedance
- t-levels and ESL
- ESRT
- VC (make it limited for adults and generally disable for children unless they are still having loudness tolerance problems
- additional programs for troubleshooting if needed (stimulation rate change, coding rate change)
- fine-tune based on feedback
28
Q
when to start regular follow ups for both children and adults
A
- for adults do a three month postactivation (if needed) and then regular follow ups after
- for children do a two and three month postactivation and then regular follow ups after
29
Q
goals of regular follow up appointments
A
- any minimal changes needed
- confirming appropriate progress
- monitoring device functionality
30
Q
when to do follow ups for adults and what to do
A
- do every 6 or 12 months
- procedure:
- –aided soundfield (tones and speech)
- ——LF= 30 dB; MF and HF =25 dB
- –sound processor check
- –physical exam and impedance measures
- –t-levels and USL, ESRT
- –fine-tune based on feedback
31
Q
regular follow ups for children when and what to do
A
- perform every 3 months
- –after 2 years of experience or reaching 7 years old then can go to every 6 months
- procedure:
- – aided soundfield (tones and speech)
- –low frequencies = 30 dB ; MF and HF= 25 dB
- –sound processor check
- –physical examination and impedance measurement
- –t-levels and ESL, ESRT
- –fine tube based on feedback form parents
32
Q
what to do for follow ups for patients with bilateral implantation
A
- longer appointment time
- children: two day appointments (eval then programming)
- try to match parameters (rate IDR, and freq allocation)
- binaural loudness balancing (summation)
- –possible protocols:
- —–live speech with global adjustments
- —–warble tone/NBN (500 and 2000Hz) at 90 and 270 degree azimuth
- aided for each ear and binaural is necessary to look for interference
33
Q
post-implant assessment of acoustic hearing status in the implanted ear
A
- should be done prior to CI activation
- –look for residual hearing
- –gives a baseline for monitoring
- –for children, post-op audio testing is recommended at or shortly after activation
34
Q
post implant assessment of acoustic hearing status of the non implanted ear
A
- regular hearing check (annually)
* proper HA care and verification should be completed
35
Q
measuring CI aided audiometric thresholds after implant
A
- adults–CI mapping to achieve aided sound field thresholds of 20-30 dB HL
- children–CI mapping to achieve aided sound field thresholds of = 30 at LF and = 25 at MF and HF
- –if thresholds are below 15 dB this is bad because allowing too much background noise in making it harder for speech in noise
- individual ears need to be evaluated seperate
- bimodal patient
- –make sure to do proper HA verification with PMM
- microphone check= want to make sure processor is working okay, do this before testing with the implant
36
Q
test set up for adults and children for post implant audiological eval
A
- adults= loudspeaker at 0 degree azimuth
* children= loudspeakers placed at 45 or 90 degrees azimuth (because VRA)
37
Q
stimulus for testing post implant audio with CI
A
- frequency-modulated tones (warble tone because in the soundfield)
- narrowband noise will also work
- **this is why you cant do puretones=because soundfield
38
Q
speech recognition testing post implant
A
- use same minimum speech test battery (MSTB)
- –at 60 dB A
- –postop assessments at 1, 3, 6, and 12 months and annually after that
- –CNC (1 list)
- –BKB-SIN (1 paired list)
- –AzBio at +10 dB SNR
- —–if AzBio >60% then do it at +5 SNR
- testing condition should be consistent for comparisons
39
Q
speech recognition testing post implant for children
A
- more difficult to test, so priortize protocol to complete the most important testing 1st
- the tests here are ordered easier to tougher and each set has different levels of difficulty
- –auditory discrimination: early speech perception (ESP)= pattern perception
- —–ESP- 2 is a test of words discrimination
- –word recognition:closed set (NU-CHIPS, WIPI) moving to open set (MLNT, LNT)
- –sentence recogniton: HINT-C, BabyBio, AzBio
- –sentences in noise: BKB-SIN, HINT-C at +5 SNR, BabyBio at +5 SNR, AzBio at +5 SNR
40
Q
post-op subjective evals for adults
A
- administer the same questionnaired that were administered immediately pre-implant
- –APHAB (abbreviated profile of hearing aid benefit)
- –COSI (client oriented scale of improvement)
- –NCIQ (Nijmegen Cochlear Implant Questionnaire)
- –CIFI (cochlear implant function index
41
Q
post-op development of auditory skills in children
A
- auditory questionnaire, parental report, and SPL assessment will tell about this
- administer the same questionnaires that were administered immediately pre-implant
