Dr.

Supreet Singh Nayyar, AFMC

2010

Cochlear Implantation
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Introduction
 A cochlear implant is a surgically implantable electronic device that convert sound signals into electrical impulses which then directly stimulate the cochlear nerve bypassing the damaged cells of the cochlea In the past deaf person had to learn to cope to live as normally as possible in the absence of hearing It was accepted that means of educating deaf children was sign language utilizing visual system For the adult deafened later in life, deafness entailed learning lip reading Cochlear implants radically changed the outlook for profoundly deaf adults and children It can provide sufficient hearing sensations to enable most deafened persons to continue communicating using speech and can provide opportunity for the children born deaf or deafened early in life to use speech as their primary means of communication Deafness typically results from lost or dysfunctional cochlear hair cells And a resultant lack of synaptic activity that occurs between hair cells and auditory nerve afferents However large reserves of viable nerve fibres remain in the auditory nerve which remain excitable Cochlear implants generate auditory perceptions by receiving, processing & transmitting acoustic info via electric stimulation Electrode contacts implanted within the cochlea serve to bypass non functional cochlear transducers and directly depolarize auditory nerve fibres.

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Historical Aspects
 1790 - Alessandro Volta  inserted a metal rod in each ear and then subjected himself to approximately 50 volts of electricity sensation of sound of thick soup boiling

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Dr. Supreet Singh Nayyar, AFMC

2010

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Benjamin Franklin has also been attributed to have suggested that electricity would be used to produce sound 1953 - Djourno and Eyries – Placed an electrode directly on the eighth nerve in a patient undergoing surgery for cholesteatoma  patient reported hearing sounds like crickets or a roulette wheel. He was able to distinguish simple words and noted improvement of his speech reading ability. 1961 - House and Doyle – implanted single electrode in cochlea via scala tympani 1964 - Simmons - placed electrode through promontory & vestibule directly into modiolar segment of auditory nerve House and Michelson – refined the clinical applications of implantation of electrodes & stimulation of eighth nerve 1972 – House -first commercially available device with single electrode and wearable speech processor 1984 - multiple channel devices by Clark & co workers – 22 channel by Nucleus 1994 – Nucleus 24 device – recognition of speech without contextual clues 1997 - 20,000 people with cochlear implants 2010 - > 110,000 Implantees worldwide

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Basics of cochlear implant
1) Microphone  Picks up sound  converts to electric wave form

2) Speech processor    Alters the electrical signals to emphasize the speech signals Divides the signals into components for various electrodes Uses speech processing strategies o Earlier  CA (Compressed Analogue Processing)  MSP (Mini Speech Processor)
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Dr. Supreet Singh Nayyar, AFMC

2010

o Now  CIS (Continuous Interleaved Sampling)  SPEAK (Spectral Peak Extraction)  Advanced combination encoder Two types o Body worn o Behind the ear

3) Transmitter coil  Transmits the signal to implanted coil without the need for any wires passing through the skin 4) Receiver coil   Implanted into bone of skull behind the ear Receives signal and the signals are decoded and converted to different electrical voltage depending on different frequencies and this is relayed to the electrodes

5) Electrodes   Usually placed within the cochlea inside scala tympani Earlier single electrode. Now multiple (24) electrodes

Types of Cochlear Implants
 Based upon  Speech processing strategies CIS, SPEAK  Analog vs digital encoding  Single vs. Multiple channels  Number of electrodes  Monopolar or bipolar stimulation

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Dr. Supreet Singh Nayyar, AFMC

2010

Candidacy Categories
Candidacy categories

Pre Lingual

Post Lingual

Peri lingual

Primary Candidates - Not acquired language by any other means of communication

Secondary Candidate – Have used another mode of communication (usually sign) to develop language

Change over candidate – Have developed auditory skills using a hearing aid

Patient Selection
 Adults  Severe or profound hearing loss with a PTA ≥ 70 dB hearing level  Use of appropriately fit hearing aid or a trial with amplification  Aided scores on open set sentence tests of < 50%  No evidence of central auditory lesion or lack of an auditory nerve  No evidence of contraindication for surgery in general and cochlear implant in particular

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Dr. Supreet Singh Nayyar, AFMC

2010

Paediatric  Age – 6 months to 17 yrs old  Profound Sensorineural hearing loss (unaided pure tone average thresholds of 90 dB HL or greater)  Minimal benefit from hearing aids which is defined as < 20-30% on single syllable word tests, or for younger children lack of developmentally appropriate auditory milestones measured using parent report scales  No evidence of central auditory lesion or lack of an auditory nerve  No evidence of contraindication for surgery in general and cochlear implant in particular

Assessment & Investigations
 History  Onset, duration & cause of hearing loss (eg. congenital, meningitis, trauma)  Whether hearing aid has been useful  Mode of communication or any usable speech  Language level  Any other major health problem  Peri natal history  Any developmental delay  Past otological history  Ear infection  Ear surgery  OME Examination  Any congenital stigmata  Abnormal behavior  Status of EAC, TM, ME  Nose throat  Gen Exm Psychological evaluation  To assess  Child’s verbal & non verbal intelligence e.g. Autism
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Dr. Supreet Singh Nayyar, AFMC

2010

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 Attention & memory skills e.g attention deficit disorders  Visual – motor integration Paediatric evaluation Speech Therapist Lab – CBP, RFT, LFT Radiological  Xray - PNS, Mastoids  HRCT Temporal Bone  Narrow IAC – contra indication  Congenital abnormalities of otic capsule  Wide vestibular Acqueduct  Labyrinthitis Ossificans  Demineralization in severe otosclerosis  MRI Temporal Bone  Visualize 8th nerve  Wide vestibular aqueduct  Determining whether scala tympani with partial ossification or fibrosis contains perilymph PTA Impedance Audiogram Speech Discrimination Electrocochleography Otoacoustic emissions BERA

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Dr. Supreet Singh Nayyar, AFMC

2010

Final Assessment Meeting
   Results are explained Likely benefits outlined Ear selection in adult

No response to acoustic stimulation in one ear

Yes

No

Select other ear

One of the ear will benefit from hearing aid

Yes

No, none ear will benefit from hearing aid

Both will equally benefit from hearing aid

Choose other ear

Choose better ear

Handedness Patient preference

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Dr. Supreet Singh Nayyar, AFMC

2010

Surgery
 Basically o Cortical mastoidectomy o Limited post tympanotomy o Insertion of array of electrodes Steps o Post aural Incision  ‘C’ shaped – now avoided due to risk of poor flap healing  Vertical incision placed behind attachment of pinna, crosses mastoid cavity anteriorly, upper end at least 3 cm above pinna  adequate exposure o Cortical mastoidectomy with overhanging edges – useful for containing electrode array o Limited post tympanotomy thru facial recess o Incus & superior bridge of bone left intact o Round window niche exposed o Well created in skull posterior to incision conforming to shape of implant o Tunnel drilled to carry electrode from implant to antrum to round window o 0.7 to 0.8 mm fenestra created antero inferiorly to round window o Electrodes are inserted gently thru this cochleostomy to prevent buckling o All active electrodes plus a few stiffening rings are inserted o Temporalis muscle piece used to seal the fenestration o Post tympanotomy and attic are also obliterated with muscle o Electrodes are kept away from any site where facial nerve is exposed o Wound closed in two layers

Complications  Complication rate only 5%  Most common problems o Wound infection and wound breakdown  Rarely o Extrusion of the device o Facial nerve injury o Bleeding o CSF leaks o Meningitis  Device-related complications o Intracochlear damage o Slippage of the array o Breakage of the implant o Improper or inadequate insertion
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Dr. Supreet Singh Nayyar, AFMC

2010

o Stimulation of the facial or vestibular nerve by stray electrode Long term o Hearing deterioration after long use o Fluctuation in hearing – viral flu o Perilymph fistula o Device breakdown o Extrusion of electrode array from cochlea o Extrusion of implant thru scalp o Numbness/ neuralgia over scalp o Loss of taste o Non use of device

Switching on of the Device
   External processor fit 3-4 wks after implantation Audiologist maps out the stimulation threshold for maximum comfort levels If implant doesn’t work on initial switch on, following possibilities o Electrode array is misplaced  X-ray mastoid, preferably Modified Stenver’s view should be obtained o No spiral ganglion cell survival  Implant evoked brain stem potential is helpful o In pre lingual children, difficulty in recognizing response o Device is not functioning  Electrode integrity test can be performed

Assessment of Benefit
 Adults o Evaluation of benefits largely focused on measuring gains in speech perception o Assessment is performed using multivariate analysis  Subject variables – age of onset, etiology, pre operative hearing, survival & location of spiral ganglion cells, patency of scala tympani, cognitive skills, personality, visual attention, motivation, auditory memory Device variables – processor, implant, electrode geometry, electrode number, speech processing unit

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Dr. Supreet Singh Nayyar, AFMC

2010

o Test modalities       Children o Substantial auditory gain are apparent in children implanted with multichannel devices o The range of improvement varies widely between children & will depend heavily on duration of use o Range of levels of speech perception are tested     Simple awareness of sound Pattern perception Closed set speech recognition Open set speech recognition Closed set testing & sentence tests Open set (auditory alone) tests of words & sentences HINT (Hearing in noise test) Capabilities for understanding speech in noise can be assessed by altering signal to noise ratio MSTB ( Minimum Speech test battery) –facilitates comparisons CNC (Consonant/Nucleus/Consonant) tests – Monosyllabic words with equal phonemic distribution

Results
     Improved speech perception is the primary goal of cochlear implants Various studies carried out show that multiple channel implants provide significantly higher levels of performance In children case control studies were carried out to bring out implant benefit relative to unimplanted controls Classification of children according to hearing levels & abilities can provide a common ground for comparison According to this, hearing aid users are classified according to pure tone thresholds Unaided thresholds o Gold 90 to 100 dB at 2 of 3 frequencies o Silver 101 to 110 “ o Bronze >110 “ In general gold category  Boothroyd’s considerable residual hearing These are compared to implantees It is seen that after 2 years of implant experience  Mean speech intelligibility scores of
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www.nayyarENT.com

Dr. Supreet Singh Nayyar, AFMC

2010

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implanted children surpass those of silver hearing aid users & 10% those of gold users Hence increased benefit with increased duration Improved speech reception in children implanted between 2-3 yrs of age relative to children implanted at an older age Rehabilitation team o Speech language pathologist o Paediatric audiologist o Implant audiologist o Psychologist o Social worker o Parents o School support Programs of rehabilitation provide hierarchic approach o Sound detection o Discrimination o Identification o Comprehension Choice of communication methodology o Programs that focus on development of spoken language are indicated o Include  Oral aural approach  Oral verbal approach o Elimination of visual cues o Programs that fail to emphasize auditory input may exert an inhibitory effect o Sign language programmes are not appropriate Signal processing with noise cancellation for better speech understanding in noise MRI facilitation with implant Multichannel devices with non simultaneous stimulation of multiple electrodes  cuts out channel interaction Binaural cochlear implantation

Rehabilitation

Recent Advances
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