10/15/2013. Disclosures (Dr. Backous) United States Hearing Loss Projections

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1 Diagnostic Pearls for Hearing Evaluation: Intersting Cases Disclosures (Dr. Backous) Douglas D. Backous, MD, FACS Medical Director, Swedish Center for Hearing and Skull Base Surgery Seattle, Washington USA Cochlear Corporation (Surgical Advisory Board) Medtronic Neurotechnologies (Consultant) SOHN Annual Meeting Vancouver, BC September 29, 2013 Agenda for our time today Indications for hearing preservation in cochlear implant surgery Role of advancedaudiology diagnostics in planning hearing loss reconstruction Role of middle ear implants Methods of newborn hearing screening and early intervention Hearing Loss Prevalence More than 31 million people in the U.S. Increased from 16.4 million in 1984 Prevalence has increased by 9.9% ( ) Tripled since 1973 Adults >70 years old 33% have hearing impairments Less than 25% with intervention Kochkin, S., The Hearing Review, 7:2005 Maciosek, MV., Am Jour Prev Med, 1:2006 United States Hearing Loss Projections INITIAL SCREENING PRIOR TO DISCHARGE (UP TO 2 SCREENS IN HOSPITAL) PASS REFER PASS OUTPATIENT RESCREEN W/ PEDIATRIX (1 screen) REFER FOR DIAGNOSTIC EVAL Special Care or high risk babies with refer go straight for medical/audiological evaluation MEDICAL SCREEN AND AUDIOLOGY DIAGNOSTIC EVALUATION PASS Recall for behavioral testing by months of age if risk factors for late onset CONFIRMED PERMANENT HEARING LOSS REFERRED FOR FULL MEDICAL EVALUATION AND FOR FITTING OF AMPLIFICATION Kochkin, S., The Hearing Review, 7:2005 1

2 Device Implantation Rates: USA Total hearing loss 1 1.6% annual growth rate 32m ~2m Potential device candidates 2, million severe-profound and profound 1 million SSD, mixed and conductive Total implanted population 4 <200k 10% Cochlear Implant /1% osseointegrated 1.Kochkin, S. The Hearing Review,(2005); July. 2.Blanchfield, B.B.. JAAA. (2001);12: Available Mkt- National Institute on Deafness & Communication Disorders (NIDCD) Recipients Internal Cochlear data Tonotopic Organization Basal Middle Apical Cochleostomy Positioning Prior cochleostomy site (Risk to basilar membrane) Scala tympani cochleostomy site incudostapedial joint Low freq. Mid freq. High freq. Round Window Insertion 1.7 mm Potential Benefits from Preserved Cochlear Structures Improve perception of high-frequency speech information Maintaining residual low-frequency hearing may provide extra fine-structure Canal of the modiolar vein MUSIC: Better impression of MELODY Better in noisy situations Spatial hearing improved Helge Rask Andersen, Uppsala, Sweden Ø mm 2

3 Available Electrodes CI and HA Programming Hearing Aid Cochlear Implant 100 Hz 1 khz 10 khz Hybrid Results (12m CNC Words) Hearing preservation over time Percent Correct CNC Words Preoperatively vs. 12 Months Implanted Ear Bilateral Condition Matched Pre and Post HA Ipsilateral Pre Hybrid Post Bilateral HA Pre Combined Post p<0.001 p< % 22% low frequency PTA (in db) months Standard+RW(n=4) FlexSoft+RW+IV (n=5) Flex Soft+RW+IV+IT (n=13) Flex EAS Adult (n=6) Flex EAS Pediatric (n=5) Unilateral Bilateral N = 79 N = Case Zero Electrical stimulation Drug delivery Future electrodes will include drug delivery 3

4 10/15/2013 Middle Ear Factors Stapes surgery Chronic ear surgery Normal Tympanic membrane Normal middle ear mucosa Good middle ear pressure equalization Intact malleus, incus and ligaments Quaternary lever mechanism preserved Tympanic membrane altered Middle ear mucosa disrupted Middle ear pressure equalization abnormal Ossicles may be disrupted Ligaments diseased or removed Lever mechanism altered Ossicular ligaments The Ideal prosthesis Model calculation an ideal prosthesis Ossicular articulations/joints Middle ear mechanics Coupled tightly to stapes head Placed on TM near the umbo Designed with a head-size of 2-3mm Protected against the TM by a small cartilage chip Adapted to proper length +/-0.5mm I/S Joint Erosion Retracted tympanic membrane Prosthesis should be aligned for max energy transfer Middle ear mucosa thickened Adequate or dysfunctional middle ear pressure equalization Usually have; Intact malleus, stapes tensor tympani tendon, stapedial and incudal ligaments Lever mechanism preserved 4

5 Stapes Superstructure Eroded Malleus Intact Use if sensible Malleus not present Footplate to Drum with cartilage Gently pack middle ear Can be done in a single stage Verify healthy footplate Austin B Stapes Superstructure Eroded and Footplate Disrupted Seal oval window Perichondrium, cartilage, or fascia May need to stent packing with prosthesis from malleus Ossicular reconstruction Malleus to footplate TORP from cartilage on oval window to cartilage on drum May need to be staged Case 1 Case 1 38 Korean female with right-sided ear fullness Chronic unsteadiness, left ear pressure She hears her voice in the left ear and hears her eyes move 20 db conductive loss on the right/ normal left Normal acoustic reflexes Pathophysiology Case 1 5

6 Case 2 Fibrous Dysplasia Right air Left bone Right bone Left air Discrimination Right Left Pre-op 100% 100% Post-op Case 3 39 year old hispanic male with declining hearing in both ears No longer has use of his right ear Large drop in left hearing in 12/2010 Still using HA No vertigo Case 3 < Right air > Left air Discrimination Right Left Pre-op CNE 60% Post-op Case 3 Case 3 6

7 Right Cochlear Implant 56 year old male with a progressive hearing loss now getting less benefit from his right hearing aid Right air Right bone Left air Acoustic reflexes: 52% 100% Present left, absent right SDS Right: 42% Left: 92% Advanced Otosclerosis Case 5 43 year old female with chronically draining right radical mastoid cavity Right air Right bone Left air SDS Right: 58% Left: 88% 52% 100% Osseointegrated devices Mixed Hearing Loss 7

8 10/15/ Baha portfolio Cochlear continues to shape the future Cochlear Baha BP100 Baha BP110 Baha Cordelle II 2012 Client need: Top performance, fully automatic, head-worn, All-round device Client need: Head-worn power, Discreet device Client need: Super power, body-worn With the introduction of the Cochlear Baha BA400 Abutments, Cochlear will once again improve patient outcomes by reducing the need for soft tissue reduction The Cochlear Baha 3 System set new standards for implant stability. Symphono Sound Bite Conclusions Science is challenging hearing restoration techniques More emphasis on conservation methods New competition in each class of prosthesis Similar to dental retainer Works with fillings, root canals, implants Sealed, Wireless Rechargeable battery 47 8

9 Thank you 9