Can You Hear Me Now? An update on the latest technology and solutions for hearing impairment Linda S. MacConnell, PA-C ENT Specialists of AZ ASAPA Fall CME Conference ctober, 03 Learning bjectives. Differentiate various types and causes of hearing loss. Treatments for hearing loss 3. Explain how implantable devices could enhance their patient's lives 4. Determine in which patients implantable devices are appropriate Hearing Impairment and Deafness in the USA ~8 million Americans with hearing loss ~700,000 have severe-profound hearing loss ~0% have received the benefit of a cochlear implant Hearing loss is the # birth defect in the US ~-6 per 000 babies are born with a significant hearing loss
Audiometry Decibels (d) and % Strange scale; human ears are incredibly sensitive Range: Fingertip brushing skin to jet engines Smallest audible sound, almost total silence =0d Jet engine is,000,000,000,000 ( quadrillion) x more powerful than smallest audible sound Measures intensity of sound, exponentially 0 X more powerful is 0d, 0 d =00 x more powerful, 000 X more powerful = 30d Comparison of Sounds and Decibels
How Hearing Works: Natural Hearing 3 4 How Hearing Works: Hearing Aid 3 4 Typical Hearing Aids Acoustically amplify sound Require functional hair cells Programmable amplifiers 3
ptimum Hearing is ilateral > Input from both ears means potentially enhanced: Direction of sound Differentiation of sound Quality of sound Hearing Aids vs Cochlear Implants Hearing aids amplify sounds Programmable Rely on surviving hair cells responding ypass hair cells directly stimulating the nerve of hearing 4
ilateral and imodal Hearing Ability to receive input from both ears: ilateral= input to ears imodal= a different mode in each ear, CI+HA How Hearing Works: Cochlear Implant 3 4 Cochlear Implant Children -7: severe-toprofound SNHL Children - years: profound SNHL Adults: moderate-toprofound SNHL 5
Internal implantplaced just under the skin, behind ear External sound processorsits behind ear Sound Processor Headpiece, Transmitter Antenna and Cable Internal Cochlear Stimulator with Receiver Antenna and Electrode Array Cochlear Hearing Loss Sensory receptors, (hair cells) are damaged Some auditory nerves survive Damaged hair cells unable to transmit electrical impulses to surviving nerves Auditory signals not sent 6
Cochlear Implants ypass damaged hair cells to stimulate the nerve directly How a CI Works A sound processor () captures sound with a microphone and converts it into detailed digital information. Digital signals are sent from the headpiece () to the implant, where they are converted into electrical signals. Signals travel to a tiny electrode array(3) placed inside the cochlea. Electrode array sends electrical signals directly to the hearing nerve (4), bypassing damaged cells. These signals are then sent to the brain, where they are interpreted as sound. 3 4 Anna MacConnell CI Photos 7
Who is an adult CI candidate? Limited benefit from HA Difficulty communicating :, even in quiet room Need captions for TV Avoid social activities Depend on lip-reading to understand conversation Trouble hearing on phone No longer enjoy music Pre-implant: CI Candidate Anthem/Wellpoint Criteria (Surg.0004) Unilateralor bilateralimplantationof a U.S. Food and Drug Administration (FDA) approved single or multi-channel cochlear implant is considered medically necessary in an individual with bilateral severe-toprofoundpre or postlingualhearing loss (sensorineuraldeafness), defined as speech reception of 70 (d) or greater, when all of the following criteria are met:. The individual, including those with hearing loss due to meningitis, cannot benefit from conventional hearing devices; and. The individual is free from lesions in the auditory nerve and acoustic areas of the central auditory pathway (nervous system); and 3. The individual is free from otitis media or other active ear infections; and 4. The individual is able to participate in a postcochlear rehab program in order to achieve benefit from the cochlear implant 8
Pediatric Candidacy Criteria Audiometric candidacy ranges: -7 y.o. severe-to-profound SNHL in both ears; -4 mos. profound SNHL in both ears * Test material typically presented @ 60 d SPL Speech recognition criteria* -7 yrs: Limited benefit from binaural amplification trial -4 mos: Limited benefit from binaural amplification trial Who is a pediatric CI candidate?. Little or no benefit from appropriately fitted hearing aids. Parent or teacher reports: 3. Lack of speech and language progress 4. Rarely responds to name 5. Lack of social interaction with children or adults 6. Able to participate in postimplant rehab to achieve benefit from CI Pre-implant: CI Candidate Contraindications* Deafness due to lesions of the acoustic nerve or central auditory pathway Active middle ear infection: Tympanic membrane perforations in the presence of active middle ear disease Absence of cochlear development (congenital) Psychological contraindications Medical contraindications to surgery Unrealistic expectations Disabilities that may limit participation in rehabilitation (differs depending on situation) * Cochlear Nucleus Cochlear Implant System Physician s Package Insert 9
Predicting Success Duration of deafness Mode of communication Commitment / motivation to get a CI Determine candidacy based on word recognition in addition to hearing thresholds Earlier is better but, it s never too late to become an implant recipient How Hearing Works: AHA System 3 4 Cochlear one Anchored Hearing Aid (AHA) Cochlear aha System sseointegratedauditory implant system for individuals*with unilateral profound hearing loss (singlesided deafness), mixed or conductive hearing loss *Implant appropriate for aged >5 years old. Younger children may use the aha Softband system 0
AHA Indications - Conductive hearing loss - Mixed hearing loss - Single-sided deafness Cochlear aha System Direct bone conduction system Adults & pediatrics aged 5 and older Younger children may use the aha Softband system sseointegration (fusion of implant and bone) = 3 mos. for adults, typically 6 mos. for children Fully functional demos can be used in the office Cochlear aha System Proven performance 8 As the air/bone gap increases, hearing aid performance decreases aha System performance is not affected 8 SnikAF et al. (005) Consensus Statements on the AHA System: Where Do We Stand at Present? Annals of RL 4(S). 95:-.
Cochlear aha System Titanium implantplaced in the bone behind the ear An external sound processorwhich connects to the implant via an abutment Cochlear aha System aha 3 Sound Processor Picks up sound and converts to vibration System Components Abutment Transfers vibrations from sound processor to implant Implant Titanium - placed in bone behind ear where it osseointegrates and transfers vibrations directly to cochlea via bone conduction AHA System Candidacy Criteria Indications for treating hearing loss with the aha System: Conductive hearing loss Mixed hearing loss Single-sided deafness
Cochlear aha System: Indications > < 5 years of age: Softband only > 5 years of age: Implantation > 65 d HL C PTA > Mixed/conductive hearing loss, single-sided deafness Chronic otitis media Cholesteatoma Congenital atresia Conductive Hearing Loss Candidacy criteria < < < < < Conductive Loss Mixed Loss 3 Single Sided Deafness (SSD) Anthem/Wellpoint Criteria for AHA An implantable bone-anchored hearing aid is considered medically necessary for individuals who meet the criteria specified in either (A) or (), below. A. An implantable bone-anchored hearing aid is considered medically necessary as an alternative to an air conduction hearing aid for individuals five years of age and older who meet both audiologicand medical condition criteria as follows:. Audiologic criteria (must meet one): ilateral implant: Moderate to severe bilateral symmetric bone conductive or mixed (conductive and sensorineural) hearing loss. Symmetric bone conduction threshold is defined as less than: b. 0 decibels (d) average difference between ears (measured at 0.5,,, and 4 kilohertz [khz]), or less than a 5 d difference at individual frequencies (AHA Divino ); or a. 0 d average difference between ears (measured at 0.5,,, and 3 khz), or less than a 5 d difference at individual frequencies (AHA Cordelle II; AHA P00; AHA Intenso ); R Unilateral implant: Conductive or mixed (conductive and sensorineural) hearing loss with pure tone average (PTA) bone conduction hearing threshold better than or equal to 45 d hearing loss (HL) (AHA Divino, AHA P00), 55 d HL (AHA Intenso), or 65 d HL (AHA CordelleII).. Medical condition criteria (must meet at least one): Congenital or surgically induced ear malformations of the external or middle ear canal (e.g., atresia); or Severe chronic external otitis or otitis media; or Tumors of the external ear canal or tympanic cavity; or Dermatitis of the external ear canal, including reactions from ear molds used in air conduction hearing aids; or ther anatomic or medical conditions that contraindicate the use of an air conduction hearing aid.. An implantable bone-anchored hearing aid is considered medically necessary to improve speech recognition in individuals five years of age and older with unilateral sensorineuralhearing loss (i.e. single sided deafness) while the other ear has normal hearing. Normal hearing is defined as PTA air conduction (AC) threshold equal to or better than 0 d HL at 0.5,,, and 3 khz. C. A transcutaneously worn AHA (bone conduction-type hearing aid) utilizing a Headband or Softband is considered medically necessary as an alternative to an implantable bone anchored hearing aid or air conduction hearing aid in individuals who meet the criteria specified in either (A) or (), above, except for the age limitation of 5 years of age and older which does not apply for a transcutaneouslyworn AHA. 3
Conductive Hearing Loss Candidacy criteria < < < < < Conductive Loss Mixed Loss 3 Single Sided Deafness (SSD) Conductive Hearing Loss Aided outcome Unaided audiogram Aided audiogram < < < < < Mixed Hearing Loss Candidacy criteria < Conductive Loss < < < < Mixed Loss 3 Single Sided Deafness (SSD) 4
Mixed Hearing Loss Aided outcome Unaided audiogram Aided audiogram < < < < < Single Sided Deafness (SSD) Candidacy criteria Unaided audiogram x x x x x Conductive Loss Mixed Loss 3 Single Sided Deafness (SSD) Single-Sided Deafness ne ear = sensorineural deafness ther ear = normal Key indications 5
Single-Sided Deafness The purpose of the aha System for SSD is to provide sufficient amplification force to overcome the head transfer function. Eg: Acoustic neuroma Impact of SSD Difficulties adults experience: Hearing in background noise Localization Understanding a person situated on the deaf side Difficulties of children with unilateral hearing loss: Speech and language delay Difficulty paying attention in school Difficulty hearing in noisy environments Difficulty localizing sounds Single-Sided Deafness (SSD) Aided & unaided outcomes Unaided audiogram Aided audiogram x x x x x 6
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