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I've been here for about four >> I'm newyears.-Madison.
I'm a cochlear implant surgeon. I do implants in both adults
and children. I wanted to first take a minute
to thank Ruth, and Theresa --,
out for a minute. and It's a joint effort inpped
organizing this amongst us. January was our first meeting to
think about this meeting and
turnout we have today. it's a pleasure to see the great
thinking about it, I think we're And after so many months of
So thank you all for showing up all vetoday.ased.
I hope it's useful in all regards.
I'm going talk a little bit about the medical aspects of
cochlear implantation.
end to speak a little bit about I novel therapies for hearinghe
loss. And no financial relationships.
I will be talking about the different implants, and I have
no relationships to disclose
while review the devices in with any of brief.nufacturers,
Diane talked, and I'll have a little bit more
than she covered. This is the outline.
I was unaware of how much history and depth Diane would go
in her talk about the history which was wonderful, and so
we can save time by going through the history quickly.
The cochlear implant evaluation.
evaluation itself. There was a question about the
evaluation process. I'll cover those in detail.
And we'll go over the surgery briefly.
And we'll talk about life after a cochlear implantation.
Briefly some of the nuts and
for decisions down the road and btalk a little bit about novelly
therapies for hearing loss. So I think we can move through
this slide given the crowd and
some of the numbers probably your interests and being here
hearing loss is a global health fproblem and both in adults andw
children. And in general, as Dr. Heatley
covered, if we can use hearing
hearing aids. It avoids surgery, and uses
normal acoustic hearing than
provided with cochlear implants. electric hearing that is
cochlear implant candidacy for Essentially, the fundamentals of
receiving limited benefit from a all age ranges are, are they
If we can use hearing aids, we hearing aid.
Cochlear implants as we've should use hearing aids.
already covered so much in the discussed already, and we've
there's going to be large holes in my talk that we've already
gone over.
It's an electrical stimulation I'll try to move through those.
We talked about different manufacturers and the multiple
channels each manufacturer
It's not great evidence that we are able to actually harness the
extra information provided by additional channels from some of
the cochlear implants, and
ceiling effect in about 6 to 8 there is, at least in quiet, a
Essentially beyond six or eight chachannels, you can't getech.
additional benefit, at least in quiet conditions, when we are
testing speech. Again, it's stimulation directly
of the auditory nerve.
that in 2010 the latest numbers we have, it's about 219,000,
people worldwide who
Here's a typical -- internal have been implanted.
We'll go over some of the components of the internal
device in a minute. This is a schematic of what the
electrode going into the cochlea
So again, I'm going to move right through the couple history
slides. I think this one's interesting,
just because it shows the first device Diane mentioned, which
was really this first cochlear implant, is the house
3M device.
implant. It was single channel cochlear
patients got from only one It's remarkable the benefit that
And especially some patients had channel.
one channel. a remarkable benefit from only
about the need to re-implant. If you implant a child early in
life and the need to
Certainly, the thought is that, with a modern cochlear implant,
it can last a lifetime. There's a technological risk, if
you will, that at some
improvement that you want to point there's bound be some
single channel to multiple take advantage of going from a
there's investigations going on to look for totally implantable
cochlear implants.
doing that, and might one consider the risks of additional
surgery to take advantage of
the future, that may be those, of possible.opments in
But again, this is of historical interest again, being
the original cochlear implants. It's also worth the mention I
think that cochlear implants are
one of the levels is that it's fascinating on many levels but
as they do. You think the architecture ofl
the inner ear and how delicate
electrode and have it function it is, that we can put in an
is really remarkable, and it's as well in the inner ear it has
the cochlear implants first were actually telling, when
prominent cochlear implant introduced, there were many very
remember one of the famous surgeons world wide who, I
of advancements in our ability quotations, "there will be a lot
cochlear implants is not to improve people's hearing but
There were implant surgeons who almost got burned a little bit
because they made an early
They were surprised at how well the cochlear implants ended up
functioning down the road.
use. Here are the current devices in
manufacturers and they're very Again, there are three
Here's the external device for similar essentially.
device, the Advanced Bionics, the Nucland Med-El. cochlear
This is their modern internal implant, with Med-El, and here's
the external for the Advanced Bionics, and again, the Cochlear
Corporation has the most market share world wide and this is the
currently used implant. We'll talk a little bit about
the evaluation process. There's three important
components, three essential components in the evaluation
process.
most important. We've touched on it multiple
times this morning. That's the audiological
evaluation done by the
level of hearing loss we have. audiologists in determining what
for different ages. ThYoung children, as you mightt
imagine, there are more challenges in determining
exactly is there is any residual
better off with hearing AIDS. Whereas in adults it's a littlee
more straightforward on some
changing. The medical evaluation by the
otologist, or cochlear implant
Radiological evaluation as well, surgeon.
scan, some cases a psychological involving a CAT scan or MRI
In children, there's other evaluation.
to consider when we're evaluations that are important
candidacy and how well they'll evaluating a patient for their
The audiological evaluation, do in the future.
one thought that I think is againimportant to say here.d on
Really the advantage we get with
magic of a cochlear implant is cochlear implants and really the
surgically. The implant procedure is
relatively scripted on some levels.
You need flexibility with young children and for different
anatomical variance, but on the whole, thankfully for us, the
anatomy is pretty constant. Most of the procedures, again,
you know what to expect throughout the procedure.
Really the advantages and advancements and the benefit
that patients receive with
what's done with our cochlear implants is due to
patients preoperatively and probably more important after
surgery with the multiple visits
audiologist to optimize the device and it's function.r
Again, the candidacy we've
move through it. already gone over this, so I'll
bit later today. We'll have more on this a little
hearing loss in both ears. Severe profound, sensorineural
the on set of language. TThis is a determination we'reer
using less these days, pre- or
benefit from amplification. Again, these are the two most
important considerations. It's just really from there a
question of how do we demonstrate that audiologically
in different age ranges.
highlight is there has to be Another important thing to
device. reaIn the family that Ruth the
presented, with the parents having 30 years without hearing
loss the expectations for what
cochlear implants are going to they might achieve from their
children when they were implanted, that you can expect
they're going to perform at a much higher level than a person
who's had a prolonged period of hearing loss.
Also, we need to speak to the motivation and commitment of the
patient and the family. This is a critical factor for
getting the best outcomes.
again, there's a lot left in the Assessing this is hard, but
help guide things as far as the leap of faith not using their
hearing aid in the other
Just focusing on using the ear anymore.
period of time, to get cochlear implant, at least for a
to using the cochlear implant tand going away from auditoryd
hearing, and maybe
the road. There's really a commitment and
motivation requirement that we
process that's very important. need to at least mention in the
there are really three major During the medical evaluation,
the cause of the hearing loss, things that we look at,
loss, and then hearing aid the duration of the hearing
You see on the right, a number usage.
hearing loss. For most of them it doesn'tf
actually effect necessarily the candidacy of a patient.
There are some that really will,
meningitis will significantly affect what we might expect
after cochlear implant, and certainly if they have gone on
to develop some -- that some
Thankfully this is infrequent. patients will after meningitis.
time the etiology is not The bottom line is that most of
hearing, doesn't affect the necability to implant.ost
Duration of hearing loss helps
realistic expectations might be. to predict what the
very important. For a patient who hasn't had
hearing for ten years but continued to do what they can
with a hearing aid as opposed to
hearing aids for the last ten years after losing hearing.
We might have different expectations after
their cochlear implant. Any history of infections, be
that acute infections or
more severe infections that we'll see the of temporal bone,
and middle ear infections.
the planning we'll do surgically They'll certainly affect some of
Thankfully, it's an infrequent and how we manage the situation.
Any history of surgery, tubes in consideration.
surgeries for more significant the ear, fore-infection, and
as I mentioned, or skill-based problems, like cholesteatomas,
into our decision-making tumors, will certainly factor
the surgery. technically, how we do
that may have been be needed. Patients who have with syndromic
conditions, like
previous surgery in the area, or neurofibromatosis, or have had
These are conditions that we shunts for hydrocephalis.
we're doing the cochlear implant certainly want to factor in as
None of them would tell us we couldn't do it but would require
some additional planning. And then general medical
clearance for cochlear
A patient's cardio-pulmonary implantation.
what state they're in, if they profile, their heart, lungs,
any other, maybe congenital, had a previous heart attack or
risk, anesthetic risk. heart abnormalities, bleeding
wound healing. And really important is
can see with cochlear implants One of the complications that we
As with any implant, as Diane mentioned, with a hip or an
implant anywhere implanted in a human body, there are always
risks of infection and other
We must really focus on wound healing problems so patients who
are heavy smokers, uncontrolled diabetes, patients on
steroids for autoimmune disease.
need to factor this in These are things we'll
surgery a bit as far as what we ado planning our incision andr
some other maneuvers during surgery to help give us
the best chance of wound
So that's the medical healingevaluation.oblems.
Again, we mentioned audiological
evaluation radio graphically to elook either with a CAT scan or
MRI scan and determine if the inner ear looks implantable.
Generally we do a CAT scan and
is open and looks that tnormal otherwise.cochlea
In patients who've never had
MRI scan. hThe reason we do that, mostan
important thing we need to
evaluation is there an auditory identinerve present.ening
Here we see an MRI scan,
an MRI scan that can highlight and a certain technique of doing
You'll see this darkened area here is the hearing nerve as
it's traversing from the brain
This is the cochlea right here. And clearly we can tell in this
patient there is an auditory
We'll use this type of nerve present.
particularly young children who ehave never had hearing tos,
determine if there's an auditory
therefore if an implant seems a nereasonable thing to do.ne
Most of the time we use a CAT scan in the majority of patients
though, which is a more limited study but still gives us the
information that we need. We also want to account for
inner ear malformations, or other disease in the middle ear
or mastoid bone that may
process as part of the complicate the implantation
The next step, essentially at this point we've evaluated and
determined that a patient is a
most important part of the candidate, audiologically, the
contrary indications medically process, and that there are no
that we're going to or have problems surgically.cate
From there then, we submit to insurance.
The question came up on who pays
That's an important issue. for cochlear implants.
implant candidacy on many levels Our criteria for cochlear
Most of the private insurers is based upon insurers.
who's a candidate based on CMS criteria, you can think
of as Medicare and Medicaid who set standards for the medical
industry as far as when something is paid for and
when it's not.
implants. It's an expensive venture, so
they have strict criteria that
When we write the letter for we must meet.
show that they've demonstrated prior authorization we have to
criteria in order all theto be implanted.quisite
This process, unfortunately,
hear back from an insurer, sometimes is only a few weeks to
Sometimes there's an appeal sometiinvolved.longer.
It depends. As Diane mentioned earlier,
we're fortunate in Wisconsin, I think overall we have very good
healthcare coverage and we're more fortunate than many other
communities as far as how much
of battles to get covered for we haa cochlear implant.e sort
We still have our troubles here and there.
That consideration aside, we
implant, or are we going to hpursue implants on both sides.o
We also have to decide which
Here at UW we carry the Med-El device to implant.
Different centers may cover all three, some carry just one
device. But that discussion is
ultimately made, that decision
patient, primarily in discussion is ultimately made, by the
different pros and cons of each with our auddevice.ts about the
Many of them are very similar.
to some bells and whistles, as It does come down on some level
appears, the external processors, sometimes guarantees
on the device or a warranty for a period of five years.
One of the companies offers that currently.
Sometimes it endings up being small things which determine
that. Similarly, when choosing which
side, in some patients, it's very clear.
They haven't had hearing in one ear for 20 years, whereas
the other ear they've heard well
and now they're a candidate. from and it's slowly progressed
do the ear that's their better We're going to obviously want to
predict they'll do better with a hearing ear because we can
is healthier. In other patients, it's a wash.
Both ears have had a vary similar history and the decision
will be made by their handedness
left handed, and sometimes other sometimes, are they right or
this decision. small factors which will make
evaluation, we covered most of Again, the pre-surgical
the primary care physician often the main elements, a visit with
clearance. is involved for preoperative
any surgical procedure, there Diaare risks involved withith
cochlear implantation.
of the bigger ones we see. Device failure is probably one
device just stopping working all It can come in the form of the
That's what we call a hard together.
longer working at all, or what's failure, where it's just no
Slowly the device may start clmalfunctioning on certaine.
levels. We think there are different
things happening with the device
types of failures. with these two different
what's the chance you might have If you look across the board,
implant? a failure with the cochlear
are somewhere between 1 and 4%. I thInfection is a risk.ates
It's probably 1 to 2% at some point in somebody's life that
they could have an infection. Thankfully, most of the time if
there's an infection, it can be treated with antibiotics.
There are some cases where it's severe enough that the device
would have to be removed. We'd wait for the infection to
clear and we'd have to replace
If that occurs, most of the time the device.
re-implantation with a good outcome, but obviously there's
two surgeries involved and
That is a risk, as with antibioany device.-forth.
Facial nerve stimulation or facial nerve weakness, an
inherent part of placing a
to be comfortable around, and very close to, the facial nerve.
You may have seen a patient with
where there's a facial droop. a That's the facial nerve.y
In cochlear implantation we have
It's an inherent part of the to be very close to that nerve.
Thankfully, it's very uncommon surgery, so there is risk to it.
nerve, but, again, it's a part that we have problems with that
A risk of dizziness is possible, of the surgery.
had dizziness before and more common if a patient has
And as I spoke to earlier, implantation.
involved. therThe patients who got therisk
original house 3M device, when the multi-channel device
became available, they wanted to have that, so that was a
number of re-implants that
The same thing might happen in occurred.
The surgery itself is done under the future.
It's an overnight stay in a gethe hospital.tic.
Sometimes, it's done as an
It depends patients to patient. It can be about two hours
on average. There's really minimal hair
shaving for the incision
It's all done under a operating microscope that looks like this.
This is one of the monitors,
that I just mentioned that we use during the surgery.
There are multiple different
would say this is probably types of incisions we use, but I
This the patient and their nose is up here, the top of the head,
the feet up this way here's the back of the head.
This is with the ear folded forward and there's an incision
like this, what we call a lazy-S
It's probably the most common. incision, behind the ear.
like and the essential Here's what the device looks
cochlear implant. This is the brains of the
internal-- this is the part that's completely implanted
underneath the scalp. This is the receiver stimulator
where most the important
goes on. processing of the device
cochlear electrode that gets This coil right here is the
You can see this particular device coils upon itself..
Doesn't come like that, it comes
the box but when we put it in straithe cochlea, it coilsut of
upon itself.
to put under some of the Here's another electrode we have
There's a magnet here in the muscle here.
device, and that's to help hold on the external portion of the
device which I'll get to that in
And this is an antenna, which you can think of as essentially
receiving the power and sound signals from the external device
that are transmitted through
The surgery itself, I'm not going to spend a lot of time on,
but essentially after the incision, if you feel behind
your ear the lump of bone right behind your ear, we have to
remove a bit. That's called the mastoid
process.
get deeper down to where we're We have to get though that to
and we can make what's called a at the ocochleostomy. cochlea
This is a critical part of this surgery, what's called a
facial recess, where we're
Again, it's key that, for a closuccessful outcome, thate.
we're very close to it and also respect it, obviously.
The facial nerve runs right in
of a millimeter of it there anduring surgery.fractions
Here's the view we have when
This is the innermost of the we're about to make--
here's what's called the round three hearing bones, the stapes,
hole into the cochlea right here, what's called a
cochleostomy, and then insert the electrode.
Here's a picture of a small burr, small drill that we use to
make the hole prior to
ear. implanting an electrode into the
of important things involved. There's a dressing that's on for
a day or two. Immunization Diane covered.
The CDC has recommendations that
The last revision was in 2010 with new recommendations for
vaccination for patients with cochlear implants.
Essentially there's one bacteria
with cochlear implants and most thpeople now are immunized fort
this particular bacteria, but there are new vaccines
coming available. It's important part of what we
do to search people's vaccination records and make
sure that we're adhering to the standards set forth by the CDC
for cochlear implantees.
meningitis in somebody who has a As there is a higher risk of
who doesn't. cochlear implant than somebody
much lower than it once was even about 10 or 15 years ago.
After surgery there's minimal restrictions as far as the kind
of standard things as far as an incision would go.
There's a one month period where
heal up after surgery, and then there's multiple visits with our
audiologist over the next 6 or
After that there's annual electrode checks and re-mapping
visits with our audiologist.
with the device or the wound Should there be any problems
attention that we re-connect and obviously, there's medical
about. address any issues that may come
here's the magnet on the outside Here's the external device,
hold this part of the device as I spoke of earlier helps to
the implanted portion of the directly opposed underneath
Here's the coil or external antenna.
The microphone of this device is
is the speech processor. right up here and this
that Diane was showing. Initially it was a box this size
with the giant microphone and now it's been miniaturized
to this.
it's likely we have a completely In the next five to ten years,
That's probably, to one question implantable device.
possible in the next five or ten that came up, and that's
There's significant challenges years.
microphone that we need to to overcome with regard to the
horizon and an active area of addrinterest as well.n on
What is it like?
covered by the panel that we're Thilucky enough to haveely
this afternoon. But number one, the sound
quality is different with a cochlear implant than it is with
acoustic hearing. As with a hearing aid, there's
challenges with batteries and recharging the device and
changing batteries, and that's
cochlear implant. Most patients who have a
cochlear implant will use it
That's not true for everyone. Most of the studies generally
show that patients who get a
There are occasional problems cochwith externals.e it.
They can be damaged or if they
something like that they need to happen to drop into the sink or
That we'll have to help patients work through.
There are some implications after a cochlear implant, for
you and your healthcare,
Number one is if somebody needs an MRI scan, they have to have
the magnet part of the device removed and that requires a
separate incision.
approved. Unfortunately the MRI scanner
that we use is really not a modern MRI scanner.
For all intents and purposes, if
after a cochlear implant, ya surgery will need to ben
required to remove the battery, have the MRI scan, and replace
battery-- I'm sorry, not the battery,
the magnet. I apologize.
Have your MRI scan and then replace the magnet afterwards.
It can be done very safely, but obviously there's an additional
infection risk with each
There's also an implication for other procedures you might have.
One of the tools we use enterontively, surgically, can
damage a cochlear implant.
have after a cochlear implant, So any surgeries that one may
there's one present. the surgeon needs to know that
One minute, okay. I'm running out of time
here. Well, I think-- I did want to
get to a couple of things and I may run over.
Five more minutes, great. We were going to talk a
minute about predicting cochlear
I think we're going to cover implant outcomes.
so I'm going to skip through a this later in some of the talks
I wanted to show here briefly the hybrid cochlear implant.
Moving on a little bit
future. Ruth talked about the hybrid
cochlear implant, which combines
implant. a hearing aid in a cochlear
the high frequencies and then one continues to use hearing aid
for the middle and low
Diane mentioned there's not a lot that has changed for
cochlear implant surgery through
pushes surgically in one of the thefinesse part of cochlearig
implants is trying to preserve
that's present. anIf there's a little bit ofg
residual low frequency hearing, and certainly essential to this
strategy of a hybrid cochlear implant is how atraumatic, or
how delicately, we can do the surgery and place the implant so
as not to destroy any residual
I'd say that's one of the biggest developments surgically,
is trying to prefect our
hearing. techniques into preserving
device. Here is the external device for
it, which looks just like a cochlear implant otherwise, but
here is the hearing aid component of it.
We were involved in a clinical
hoped to be as we were a little late to join it, with the hybrid
cochlear implant, but the advantages of this strategy are
improvements in speech, noise,
If I had to predict, I think in the next ten years, this is a
device we're going to be hearing
There are so many patients that have a high frequency hearing
loss that this applies to.
there's going to be a large When number of people that FDA,
potentially might be candidates for this.
So I'll move kind of through
covered most of them. I want to speak just for a few
minutes about regenerative
hair cell regeneration. Most people here are probablyr
familiar with-- In the majority of cases, 80% of
the time when we lose hearing,
ear that we lose. itThis is what they look like.er
There's three rows of outer hair
and these are within the cells and one row of inner,
otherwise. cochlea, not hair cells like
their hair cells are lost. When a chicken loses hearing,
looks like. ThiBut with time they're ear
regenerated.
mammals, when we lose our Hohearing, this is the normals,
cochlea, this is after loosing
noise for example, there won't our hearing from too much
That's why hearing loss is be any regeneration.
For many decades there's been a push for hair cell regeneration
and progress is being made. There are three approaches that
have been taken.
deliver genes that we know are One is the thought that can we
hair cells into the inner ear iand make new hair cells, oncef
they've been lost.
Another approach is, there are We'll call that gene transfer.
lives in the inner ear, at least is population of stem cells that
Can we harness the stem cells ithat are already present in an.
inner ear in some way to
with hair cells once they've repopulate the inner ear
And the third approach, can we been lost.
off a shelf, some type of stem take stem cells, if you will,
that can make any cell in the body, and turn them into hair
cells and transplant them and have them ingraphed into the
inner ear, into the cochlea, and
Those are three approaches being function.
We'll move a little, with time taken.
The initial approach, the gene limits here, through this.
in research with previously. transfer approach I was involved
in that we know of some of the The approach has shown promise
regenerate hair cells. most important genes to
might have even read about, which is called math one, or
ATOH1.
control gene. When it's turned on, a certain
tissue knows to make a
It's a very potent gene in the hair cell.
hearing. interest of regenerating
player in this approach. It's the probably the foremost
this gene into an inner ear at a We've shown that with delivering
make extra hair cells. very early stage, we can
three rows of outers, and here's Here's a normal cochlea with
We characterize those hair cells to show that they be
seem to be doing the things that
Most importantly, when we record from them, which shows
actually their true function, they're working like hair cells
when we make new ones in the
Also we've shown that they can inner ear.
They can attract nerves rootlets communicate with the brain.
This is a promising advance and there's been more beyond this.
With the gene transfer
there's some evidence that this tecpotentially can be used inand
animal models.
application to humans, but it's really one of the most promising
approaches that we're continuing
approach for hearing to work on, a gene transfer
The other approach I'm going to skip to, but one I'm actively
involved with here at the Waisman Center.
As Teresa covered earlier,
role with regard to stem cell UW-Madisonresearch.a prominent
The Waisman Center, on the sixth
nucleus of neuro stem cell floor, is really kind of the
Not only the research I'm doing with regard to stem cells and
their applications in the inner ear and hair cell regeneration,
but also for other neuro
for vision loss. degenerative diseases and also
of researchers here at the There's a clustering
some of these labs if you would Waisman Centelike.d we can tour
In my lab upstairs we're working
stem cells that can make any with the strategy of can we take
in culture, the signals that cell in the body and give them,
a dish. Then can we potentially transfer
those cells to an animal and
ingraft in an inner ear and restorrestore hearing.hem to
What you're seeing on the right here is, when we take stem cells
that can make any cell in the body, and we culture them the
right way, we can make cells
would be present in the brain, that go on to form neurons like
cells expressing an inner ear and smarker called Pax-2.e are
What that tells us is that we're
making a hair cell. sWe haven't made it in cultures
all the way into making a hair
about halfway there in cell, but I like to think we're
We've given these cells important initial signals to
point them in the right direction to where we hope
to ultimate will be.
we continue to address. Can we make human hair cells in
the lab?
and are there inner ear stem cells in the ear already
that we can use to replenish? With regenerative therapies,
when will they come about?
knows the answer to. This is the question that nobody
I would like to think it's as close to as five to ten years
away, but I think that's
We can't base our decisions, probably optimistic.
with regard to what we have now. as Ruth touched on,
now and what works well. We have to go with what we have
I think waiting for hair cell regeneration, it's an open ended
question at this point. And then how, I covered some of
the different approaches, and then where hopefully, we'll have
a part in it here at UW-Madison.
Cochlear implants, as we Here's my summary slide.
this morning, are playing an discussed, on multiple talks
The candidacy evaluation increasing role.
goals and risks are relatively is comprehensive, the surgical
There's not a lot of variability scripted and well known.
There's research into improvements in cochlear
implants that's ongoing here on campus and elsewhere.
And also there's active investigations into regenerative
therapies for hearing loss. I want to acknowledge the
Waisman Center and
couldn't be here with us today. Again, thanks to Teresa, for all
her efforts with organizing things today, and Kerry
McConnell is the coordinator of our cochlear implant program
here at the UW, and I wanted
in having this come to fruition. to acknowledge her efforts
I'm not sure I have time Thank you very much.
[applause]