Wisconsin Public Television University Place Waisman Center Day with the Experts  Diane Heatley  June 23, 2012 UP731   cc >> Good evening, everyone, and I'd just like to echo the welcome that the last two have offered. It really is great. I know this is the first time we've done that. The advertising and stuff didn't go out very long ago, and so I'm glad that you are all here to join us. So, I'm a pediatric otolaryngologist, and I'm a clinician, much to Ruth's dismay. I really am not a researcher person. But I've been here since 1992-'93 on the actual faculty, although I did much of my training here as well, and so there's been a huge change in how cochlear implants are viewed in the community, not just the medical community, but the community in general. And it's been a very interesting transition, I'd say, over the years that I'll just talk about a little bit. And, really, the history of cochlear implants is not that long. In 1980, so that's only, really, not that long ago, there was a single channel cochlear implant device. 

And people had been working on this for a few decades prior to that, but the first time it was actually inserted into young children was 1980. Now, prior to that they had tried it in adults. Suddenly they decided, gee, maybe some children have hearing problems too that could benefit from this. Shortly thereafter, a team from Australia developed a multi-channel device that actually was approved by the FDA, and this was a huge, huge barrier because prior to 1984 cochlear implantation was experimental surgery, and as experimental surgery, you didn't get insurance coverage for cochlear implantation, and so there was tens of thousands of dollars worth of money that these patients had to come up with. Lots of bake sales and community dances and all these sorts of things to really help families so that once the FDA approved this device it made great big difference as far as the clinical utility. And this was during my training, so I like to think of myself, I'm not all that old, and so as I was training in ear, nose, and throat surgery, these suddenly became clinically approved. Now, people initially were putting one implant into the ear on the theory that we always want to save that second ear in case better technology comes along later. And, really, the first time people were putting things into both ears was because it wasn't working in this ear. So if there was a problem with the device here, maybe you would get your other ear implanted. And that was the late '80s. 

So, again, not that long ago. And my next slide it will show now that we're really doing this quite a bit more frequently. In 1990, the FDA actually approved, so I said up here they approved this device in 1984 but not for children. This was approved for adults, and not until 1990, so only 22 years ago, was it approved for use in children down to the age of two. So I finished my residency training in '92 and then went down to St. Louis for my fellowship in pediatric ear, nose, and throat. And St. Louis is the home for a center called the CID, which I'm just having a senior moment here, Central Institute for the Deaf, and a big auditory verbal school. And we did cochlear implants when I was a fellow. Almost all were removing the single channel devices, which gave people environmental awareness of sounds but not good speech, and implanting instead these people who had previously had one device with the multi-channel device. So it was a great experience for me. It was very few young children. 

It was more older children who had already been implanted. So then when I came back here to be on faculty, I joined another partner of mine, Mark Pyle, there are three of us here who do cochlear implant surgery. Mark Pyle, who unfortunately isn't here, myself, and now Sam Gubbels, who's been with us for four years. When I came, Dr. Pyle kept the grown ups and I got the children, and then when Sam joined us, he does both. And so it's an excellent team of individuals from a physician standpoint, and then, obviously, the most important people on the team are the audiologists, speech pathologists, educators, all the people who really make sure that these devices we put make a difference in the lives of our patients. So when I came in, really it was a different community for cochlear implants. It had not been embraced, I would say, in Wisconsin. It was made very clear to me by the school district here in the early '90s that they were not interested in supporting cochlear implants. The school for the deaf in Wisconsin was not interested in taking care of people with cochlear implants. We had little brochures in the office, and I would get angry people saying what are you doing, this is wrong, we shouldn't do this. 

Even the research community was very cautious about embracing this technology because of the huge polarizing effect with the deaf community, and that has been such a huge transition and great transition over these years to where we are today and where I think we will continue to go in the future with cochlear implants. But it's important to remember that's really only a 20-year time period. It's a really short period of time that cochlear implants have now become, I think, accepted, celebrated. People have not always felt like they did or like they do now. So a few years into my practice the FDA actually lowered the age of cochlear implantation to 18 months. On-going research again has shown us that the younger we get hearing into congenitally hearing-impaired children, the better they ultimately do in their speech and language outcomes. And the other big thing was at about that time an ear level processor became available. And I don't know if I have a pointer.  Do I have a pointer? I do have a pointer. So this was one of the very early adults who had an old 3M cochlear implant. 

And you'll see that this is his wife and she's talking to him through this microphone, and this big thing was his actual processor for the cochlear implant. So he does have an ear level receiver but it was a body device, and the only way that you heard it is somebody had to have the mic. I did a bad thing? Where's the AV guy? [LAUGHTER] Oh, it came back. I'm just going to put down the pointer. [LAUGHTER] In the upper left, even this, so this was when I was first in practice, and it looks kind of familiar to what you're used to for an implant. You have the magneted device, the receiver behind the ear, but then there's that wire. In that little box there you had to wear on your belt, or for children we often had them as a lanyard or strapped to your back so the kid couldn't rip it apart. But when they came up with just an ear level processor there was a huge, huge advance, and really much of the advances have not been in that internal wire that us as surgeons put in. the operation really hasn't changed. Incisions changed, the device on the inside maybe gets a little thinner, a little prettier, a little easier to insert, but really the external processing, what those computer programs can do, the miniaturization of that has been the huge, huge advance, in my mind, over the years, not just in ease of use for patients with cochlear implants, but in how good the quality of sound is that we're able to get into the ear. 

So, in the late '90s, so, again, only 20 years or 10 years after it had been approved for use in children, we began to use bilateral implantation only because we wanted to make the hearing better and to see if we could improve people's ability to localize sound in space, understand hearing in noisy environments as opposed to just we're putting in a second one because your first one really didn't do it for you. Only 12 years ago we now have an approval down to age 12 months. So once you're one year old, the FDA says that we can put an implant. Now, some people do implant much younger. I don't, not a lot younger, but I know there are people down to age four to six months who are implanting very young children at surgeon's discretion. So it's a little bit off label but there are probably times when it's appropriate, and, who knows, we may be moving toward that younger and younger. It's really can we evaluate the child and be sure that it's the right thing to do. That's the thing in my mind. We don't want to put in an implant if other forms of amplification will do the job. One thing along the history that I think it's important for all of us to remember is this is a device that's implanted into the human body, and it has certain risks. 

Any implanted device, whether it's a new hip or an implant in your ear, there's a risk of infection associated with all of those things. And in the early 2000s we realized that people with cochlear implants had a higher risk of meningitis than the general population. Now, people with inner ear malformations have a higher risk anyway. But nonetheless, it's very important to keep in mind that vaccination for meningitis is recommended for all of our implant users. The vaccine schedules, it seems, those of you with school age children know, it changes all the time. Every time you go to the pediatrician there's a new vaccine for this, that, or the other. My recommendation to my implant kids: any time somebody offers you a meningitis vaccine, please get it. And that's true for adults as well. Just because we want this device to be in, to work, to not cause problems but to, instead, help. So, there's currently three implant manufacturers for children, just so you know. 

The cochlear device was that 22-channel device that came out of Australia Med-El has something called a Combi device, and then Advanced Bionics has a Clarion device. So there is some choice in manufacturers. The devices are all a little different. Cochlear has the longest history in children, and that's the one that I personally use. I know there's a few kids on the panel today who are my patients. They have cochlear devices. So, how many have we put in? I'm looking for a clock here. Oh, there it is. I'm fine. How many people really have cochlear implants? And the closest or the most recent statistics I could find are actually December 2010, but they said 219,000 people worldwide had cochlear implants. 

And in the United States, it's about 71,000 people. 42,600 adults, 28,400 children. So that means it's about a one-third/two-thirds thing. And children they counted as under 18 when they got implanted. So that's one out of every 3,000 people in the United States, which is a reasonably big number considering this really is technology that's only been around and approved and mainstream for only a few decades. Now, I was at a Lego convention last week with my 13-year-old in Chicago, and just walking through this I saw two people with cochlear implants. One was a child, one was an adult. One child in my son's classroom at school has bilateral cochlear implants, and I think we're seeing them more and more and more. Another child in that school, although not in my son's class, I know I did an implant on. And so I think the whole community feeling that this is not something we want to embrace has changed. 

The schools embrace it. They see the children doing beautifully. It's just a different world now than it was even 20 years ago when I went into practice. And then just a few statistics about our last 10 years here. So 10 years ago is when the computers started keeping track of things, and so that's why I have 10 years of data here. In 2002, which is at the very beginning, actually didn't start until about September. Although I was reading in the notes about Sharla, one of our panelists, and so this is, the pictures on the screen here, red are the adult implants that we've done and blue are the pediatric ones. So one of those 2002s, Sharla, was you because it was the end of 2002 that you got your implant. But you can see that for 200 implants, again we mirror the national statistics. We have about 25% who are done in children and about 75% who are done in adults. 

And 2012, the last year, again we're only six 6 months into it. And so I think you can see a progression that we are doing more and more, and that has to do with many things including the work of our colleagues here at the Waisman Center, Dr. Gubbels joining our team, but also I think the community and support of everybody in Wisconsin and in Madison to embrace this technology as something that's great for families. For the children, I was just curious about this, I've done 50-some implants over 10 years, and how old were those kids? And you can see there was a couple that I've done under the age of one but just barely. And then one- and two-year-olds so that about half of the children that we have implanted have been in that congenitally deaf in children who we try to get the device in as soon as we can in order to really have them mainstreamed at school so that when they enter kindergarten, these kids you would never know that they were born hearing-impaired. And for me, just one second, for me... >> Could you sharpen that please. It's blurry. >> Could someone sharpen that please. >> I don't think I can. >> Okay. 

>> I'm sorry. >> Maybe read some of the numbers. >> So there was under one we have two children, and then it's eleven one-year-olds, nine two-year-olds, I didn't implant anybody who was three, so any three-year-olds in the audience who need an implant, let me know. [LAUGHTER] Four four-year-olds, two five-year-olds, one six-year-old. So it's sort of in the between two and four in the adolescents and then a few teenagers, and these were children who had lost their hearing later in life. So they had hearing and lost it because, I think, if you're congenitally deafened and we wait that far, the results really are not as good by any means. The younger the better. So this was hearing impairment from any ideology, whether you were born with it, you developed it, but it really, as a clinician, cochlear implantation is one of the really great, it really gives you a great feeling as a doctor to have a child who's hearing-impaired and really give him back that sense, truly one of the five senses of hearing, and be able to watch him or her grow and develop into a child who's integrated into the hearing community with their parents, able to participate in school, participate in life and all the things that everybody was anticipating he or she would before they lost the hearing or found out that the hearing was absent. So, that is all the information that I have for you guys today. I'm happy to answer any questions if you guys have anything for me because I know I'm running early, and if there's anything you want to know, I know my son is now, he has a concert this morning down on campus and so I'm going to be ditching after this talk. 

And so if you have anything you want to talk to me about, this is your opportunity to do so.