Cochlear Implants
Stephanie Cordes, MD
Jeffery Vrabec, MD
March 1999
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Background and Introduction
• Djourno and Eyries(1953) - direct stimulation
• House and Doyle(1961) - scala tympani approach
• Simmons(1964) - modiolar stimulation
• House and Michelson - implantation of electrodes
• House(1972) - first available device
• 1984 - multiple channel devices
• 1997 - 20,000 people with cochlear implants
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Basic Science - Technology
• Implantable circuitry and processing system
• Restore activity in the central auditory pathway
• Receive, process, and transmit via electrical stim.
• Directly depolarize auditory nerve fibers
• Internal and external component
• Receiver-stim. - accepts, decodes, transmits
• Speech processor - amplifies and compresses
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Amplification
• Occurs within the processor
• Amplifiers used to increase the signal levels
• Gain of amplifier determines the amount of
increase
• Gain = ratio of output signal level to input signal
level
• Can increase or decrease signal level
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Compression
• Impaired hearing has decreased acoustical
dynamic range - 10 to 25dB
• Linear and non-linear compression
• Gain of amplifier changed so output to input ratio
changes - automatic gain control
• Automatic gain control - keep output voltage in a
certain range
• Wide range of compressor types in use
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Filtering
• Filter on the basis of frequency - 100 to 4000Hz
• Three types: low pass, high pass, and bandpass
• Two reasons for filtering:
– 1) remove unwanted information
– 2) separate bands for independent processing
• Extract frequency dependent features
• Divide acoustic frequency spectrum into channels
• Feature extraction systems - filter F0, F1, and F2
• Multichannel processing refers to multiple filtered bands
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Encoding
• Encoded to transmit to the receiver
• Preserves information and enables information to
get to the auditory nerve
• Analog signal first enters the processor
• One type - changes analog to radio-frequency
• Another - converts from analog to digital
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General Design
• Two configurations of electrodes
• Monopolar and bipolar
• Speech processing strategies
– Nucleus 22-channel implant - SPEAK
– Clarion multichannel implant - CA and CIS
– MED-EL Combi 40-Cochlear implant - CIS
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Patient Selection
• Originally for postlingually deafened adults
• Adult: postlingual, bilateral profound SNHL >95dB
– little or no benefit from hearing aids - 6 months
– psychological and motivational suitability
– aided word discrim. scores no better than 30%
– no upper age limit
• Child: bilateral severe to profound SNHL >90dB
– age 2 or greater, no benefit from hearing aids
– no medical contraindication
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Pediatric Implants
• Intensive auditory training to make sure the
hearing aid would not give the same benefit as an
implant
• Family highly motivated
• Appropriate expectations
• Enrolled in a program for development of auditory
skills
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Audiological Evaluation
• Primary means of determining suitability
• Aided and unaided thresholds obtained
• Hearing aid performance compared to normative
cochlear implant performance
• Not all patients are candidates
• Not candidate if have speech recognition skills
with conventional hearing aids
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Medical Evaluation
• Complete history and physical
• Lab studies as needed to r/o medical disorder
• Evaluate for external or middle ear disease
• CT scan to evaluate cochlea
• Congenital malformations are not
contraindications - except Michel and small IAC
• Psychologic testing
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Surgical Implantation
• Decide which side to place implant
• Facial nerve monitoring
• Mark position of internal component - 1cm behind
• Design a skin flap - c-shaped or postauricular
• Internal device depression created
• Complete mastoidectomy with facial recess
• Cochleostomy anteroinferior to round window
• Quit using monopolar electrocautery
• Place electrodes carefully into scala tympani and secure
internal component
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Surgery - continued
• New bone growth - drill 4-5 mm along basal coil
• Complete obliteration of tympani - use vestibuli
• Complete ossification - drill out tympani
• Cochlear dysplasia - CSF gusher
• Fit external device and antenna 3 weeks postop
• Overall complication rate - 5%
• Most commonly associated with skin and flap
• Unwanted stimulation-eliminate during mapping
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Rehabilitation
• Needs differ depending on auditory experience
before deafness
• Prelingual - auditory and speech training
• Postlingual - auditory for complex skills
• Team approach for pediatric patients
• Develop receptive and expressive language skills
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Results
• No cochlear implant can restore normal hearing
• Variability in outcomes primarily due to patient factors
• Primary goal is improved speech perception
• Postlingual- achieve open-set discrimination earlier
• Prelingual children continue to improve over 2-5 years
• Miyamoto et al.-55 prelingual children, 63% discrim.
• Gantz et al.-54 children, 4 years, 82% open-set discrim.
• Waltzmann et al.-14 children implanted prior to age 3, followed for 2-
5 years, all aspects of hearing improved, oral language, attended
regular school, open-set discrim.
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Conclusion
• Cochlear implants are not experimental
• Cost effective
• Provide high quality of sensation of hearing
• Further research improves implant components
and implant results
• Further expansion of criteria to include patients
with less severe hearing loss, but poor
discrimination
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Case Presentation
• 66 year old female
• Progressive SNHL over several years
• Failed to respond to steroids
• Hearing loss of unknown etiology
• Physical examination: normal except for
hearing loss
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Case Presentation
• Audio shows severe to profound SNHL
bilaterally
• PTA: AD = 93, AS = 90
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Case Presentation
• Hearing aid evaluation was done
• Patient wore AS BTE hearing aid with
minimal benefit
• Needs visual cues to communicate
• Interested in cochlear implants
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Case Presentation- Result
• Preimplant: • Post-implant:
• CNC word list
• CNC word list
– proc.- 50%
– aid- 8% – proc. w/ aid- 58%
– aid w/ visual- 64% – proc. w/ visual- 82%
• Phonemes • Phonemes
– aid- 26% – proc.- 69%
– proc. w/ aid- 77%
– aid w/ visual- 81%
– proc. w/ visual- 91%
• HINT sentences • HINT sentences
– aid- 11% – proc.- 90%
– aid w/ visual- 72% – proc. w/ visual- 94%
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