Wisconsin Public Television University Place Waisman Center Day  Melanie Buhr Lawler Cochlear Implants  June 23, 2012 UP732   cc >> I'm an audiologist and a clinical associate professor at the UW department of communicative disorders. I teach the course for our grad students on implantable devices but I come from a clinical background. Prior to coming here in 2010, I spent several years on the cochlear implant team as a pediatric CI audiologist at Children's Hospital, Boston and prior to that I worked with adult CI patients at Mass. Eye and Ear Infirmary in Boston. I have a little bit of experience with both adults and a lot of experience with the child cochlear implant population. And Jennifer Ploch, who will introduce herself next, and myself, are here to give you the look, the clinical look, at what goes on with you, with your family members, with your friends, with your patients on our end. And so I'll let Jennifer introduce herself. >> Good morning, my name is Jennifer Ploch. I work across the street, or down the street, from Melanie. I work at the University Hospital. I see patients both preoperatively and post operatively. 

My experience is primarily with the adult population. We're going to talk together today. Melanie will address more the pediatric issues and I'll try to field the more adult issues of the clinical side of cochlear implantation. >> And we're going to be joined at the end by Michelle Quinn and she's going to cover the speech and language aspect of cochlear implantations. I am going to let her introduce herself at that point.  >> So getting back to your question about how good are these devices. My answer to that is, I think it's as good as the team that you've got working with your child or with the patient. We've talked about this a lot this morning, but you can have a really great device, and you can have a really great surgeon who gets that device in the ear just right. You can have an audiologist who programs that device, but if you don't have the other pieces in place, the device isn't going to work. So we really believe that it really takes a village to make this work and to make it work well. 

So as Dr. Gubbels mentioned, there's certainly surgeon involved, the audiologists involved, speech language pathologists, we have physicians assistants at the University Hospital who deal with some of the medical aspects of cochlear implantation. We have social workers. A really critical piece for the kids are the educational audiologists. We can not send your child to school unless the people at school know about implants and know how to help your child. So, as Dr. Heatley said, we're seeing more and more children kind of enter the mainstream in school. As their mainstreamed, we have regular educational teachers who don't know about hearing impaired children. So we need people in place at the school so when your child says, "Mrs. --, my batteries died." There's got to be someone there to help. Or, "My speech processor keeps beeping and won't stop." The educational audiologists are in place to help with some of those classroom management issues and to help with FM systems. We're fortunate, as Dr. Gubbels said, as we have a cochlear implant coordinator. We have program assistants who help with the insurance piece. 

We can't even get to the operating room until we have insurance approval. And certainly OT, physical therapists, and other professionals along the way as needed.  >> So on the audiology end, once you have your team and you have perspective cochlear implant patients, what do you do, what do we looking for and what tests do we have to do for pediatric cochlear implant candidates. One of the things that has evolved over the years across the country, and certainly in the state of Wisconsin, is that all children now are being screened mandtorially. Their hearing is being tested typically by the time they're released from the hospital. We have pass or a refer for more testing at that point. We're catching a lot of children early whether or not they're found to have a hearing loss, that is permanent and profound, we're finding this out very early. In fact, the goal now across the country is to have every child screened by one month of age, to have a full diagnostic test with an answer at three months of age and have appropriate hearing aids or amplification fit by six months. And I can speak from experience this actually often happens even earlier in many places. One of the tests that we do, we do all sorts of testing when children come in, often after that first screening and but at any point, and one of them is a brain stem response test. 

With a tiny baby, you can't raise their hand and tell you if they hear a sound so we look at brain waves to see how the hearing is functioning. We do other some other objective tests of hearing. Based on the results of that test, if we found that child has a hearing loss, we will fit them with hearing aids and monitor their progress. Of course, we'll refer for all of those other supports and ancillary services that Jennifer was just discussing. Should we find that someone has severe to profound hearing loss, and say they're an infant, or a child, and the family is interested in learning more about cochlear implants, we would refer for an evaluation on a whole cochlear implant team. I'm going to go into a little more detail later about what exactly we're looking at with children in terms of candidacy and how we assess those things. And as Dr. Gubbels mentioned, there's other tests and the surgeon and the imaging that's done at that point. We also want as to look at a behavior test of hearing in children. We want to confirm what we're finding on all of our objective tests where we put a child in a hearing booth or look at their physical responses to sound. That is usually something we can start to assess around seven months of age. 

Finally we would do a cochlear implant consultation if that the route the family is electing to take that. The goal in most centers, although you've heard, there's variability, is to have a child ready for implantation by 12 months of age. It may vary based on the child, the family, the center, the physical health, insurance, but that is often the goal.  >> So as you can imagine, an adult evaluation is a little bit different. We typically receive referrals from audiologists, from other ear, nose and throat physicians, from family practice physicians. At the UW an adult patient is scheduled for an initial evaluation which lasts about three hours. They spend two hours with an audiologist going over devices, explaining how the system works. We do some basic preoperative testing to see if they would be a candidate for implantation. And then they also meet with the surgeon to determine if they are a medical candidate for cochlear implantation. If insurance, audiologic and medical criteria has been met, we see the patients back a few more times before surgery. 

So there's more testing that needs to be done before surgery. We also like to meet with family members, spouses, children, to spend a lot of time counseling, answering questions, and talking about realistic expectations after implantation. And as Dr. Gubbels mentioned there's imaging that needs to be done and before we can move further we need to have insurance authorization in place. That can be easy, that can be really hard, depending on the insurance carrier. That can waylay us a little bit. So in adults, there's a lots of baseline testing we do. We want to do some middle ear evaluation, we do a basic hearing test to confirm the hearing loss. We do a lot of word recognition testing. We want to see how well people understand speech, both with and without their hearing aids. We need to determine if the hearing aids are providing people with enough benefit. 

If not, then the question is can a cochlear implant provide more benefit. We make sure that the hearing aids are appropriately fit. So another question is, would a different hearing aid provide more benefit. We do otacoustic emission testing. That is a test of cochlear or inner ear function. As Melanie suggested, we do auditory brain stem response testing with adults as well as children. If there are questions about dizziness or balance, we may do some preoperative balance testing. Again, we really try to spend a lot of time with patients and family members talking about expectations, the process, and what realistic outcomes are for their given situation.  >> So we mentioned the testing that we do, whether it is be through brain stem response testing or a traditional hearing test, and because this comes up when we're going to be talking more in detail about candidacy for cochlear implantation, I wanted to quickly run through this graph here called the audiogram. Many of you are probably intimately familiar with what you see on the screen. 

It's a plot we use to graph the softest sounds that an individual can hear. All of us in the room, we could use this to plot our hearing and it would probably it would look different for every single one of us. Even people who have, kind of, the same category of hearing might have a slightly different picture. This is one example. Across the top is pitch or frequency of sound. Starting from low pitch sound on the left side going over to high pitch sound on the right side. Down the long way, on the Y-axis is the loudness of sound, or decibel level, from very, very soft at the top to very, very loud at the bottom. Again, the lines that are plotted on there, the symbols, are a graphical representation of the very softest sounds that the individual can hear. Typically, just as kind of a baseline for you, anything that falls on the 20 line, I don't know if that's visible, right around there, and above all the way across, that's considered to be hearing within the normal or the typical range. So in this case, this individual, and we want to look at the Xs and the Os for the purposes of what I'll be discussing, this individual has a severe to profound hearing loss. 

This would be a typical audiogram or graph of an adult cochlear implant candidate. In some cases, if you see like a little arrow falling off of the symbol, the X or the O, with the arrow on it? That just indicates that even when the sound as loud as the equipment would make it, the individual that was test taking this test could not hear the sound. Maybe they could feel it, but there was not anything audible. That's not uncommon in cochlear implant candidates at some frequencies. So with that audiogram is your background. I want to touch a little bit more in detail. We talked about in throughout the morning so I don't belabor hopefully, but we'll go over in a little more detail about pediatric cochlear implant candidacy. One of the things we look at is the audiogram. There's another very important factor in determining candidacy that we're going to talk about later which how clear, or how understandable, words or speech is. But first to discuss the audiogram, candidacy is slightly different for the young ones, for the 12 to 24 month old population. 

When they get a little older, the candidacy expands a little bit, as you can see. So in the 12 to 24 month range you have the blue plot in the 90-decibels and louder, that's qualifying a child with a profound sensorineural hearing loss. That's the graphical, or the audiogram, criteria. You can have a little more hearing loss in children that get a little older as long as they're not successful with appropriately fit hearing aids. We'll talk a little bit more about how we even look at word recognition in children, but that's something that's really important to look at as well. So in older children, children ages 2 through 17, we want to make sure that even when they're appropriately fit with hearing aids they're not getting benefit. If a child is doing quite well with appropriately fit hearing aids, and this is really variable, then that would be the best route for them. If a child is fit appropriately, using them all the time, getting all of the services that they need to, then a cochlear implant might not be the best choice for them at that point, but it would be something so keep an eye on. Of course, as we keep saying, high motivation and realistic expectations for the family. That's a key factor, especially for children who are not necessarily able to be advocates for themselves. 

 >> Again, the adult group is a little bit different. As you can see from this graph, adults can have a little bit better hearing in the lower frequencies and qualify for cochlear implantation. The key though is FDA in the U.S. indicates that we have to document limited or no benefit from conventional hearing aids. What that exactly is, in the adult population, adults are tested in a sound booth with sentences. So they are sitting in a sound booth with the hearing aids on. They're listening to a CD, a voice says a sentence and they have to repeat back what they hear. FDA says that on a sentence-level test presented in best aided condition, you have to score less than or equal to 50% of those words correct in the ear to be implanted, less than or equal to 60% in bilaterally, bilaterally or in best aided condition. If you're a Medicare patient or if you have insurance that follows Medicare guide lines, you have to score worse. You have to score less than or equal to 40% of words correct. Test materials, again, are presented 50 dB HL in the sound field. 

So we look at how well people can hear beeps. Raise your hand when you hear a beep, and children we have different strategies. The other key factor we look at is word recognition ability and why we look at that. When we assess word recognition ability preoperatively to establish if a person is a candidate for CI or not. Post operatively we look at it to see how they are benefiting from the device. It can give us information about programming. If test results don't look so good in a sound booth then that can give us information about what we have to change in the map parameters, or the programming, of the speech processor. We track progress over time. So there are patients in the audience today who are cochlear implant users and they will tell you they get pretty tired of doing these sentence tests because we make them do it over and over and over again. But we monitor progress, we try to do it at least once a year with adults so we can just keep an eye on things. 

If changes start to occur, then we start looking at issues with mapping parameters or with the device. It also helps speech pathologists, educational audiologists to know where these children are functioning and how to guide their therapies at school and elsewhere. We certainly use it for data collection for research purposes.  >> So as a pediatric cochlear implant audiologist, a question I got all the time, especially prior to the point at which a child is able to do word recognition testing was, how do you even look at how my child is understanding words, and how early can you even test. Later, how can you even test my child's hearing. So be I'll showing some examples of both of those. It is important to also look at word recognition ability in children. It's part of the candidacy criteria, and as Jennifer mentioned, it's how we track progress over time. I'm going to show some examples of pediatric word recognition testing. There's many tests available, but these are some common tests, and tests I have visuals of. 

One of the tests for the youngest children is called the Early Speech Perception test. This test consists of, not just pictures, but actually objects as well. We can look at word recognition or sound recognition ability even before the child is able to verbally repeat back words. For example, this test has little toys that come with it. One would be an airplane and one a little bunny and you could teach the child that airplane is an AH sound, and you can give them visuals, and visual cues from your face and show them the airplane and teach them to associate a hop, hop, hop, with the bunny. They can feel you say it, see you say it, and hopefully hear you have say it. Then you can take away the visuals and just let them listen for the AH versus the hop hop hop. Then once they can identify the toys, check to see if they are able to, with listening only, tell you the difference in those two patterns. That's a really early skill that's learned on the path of learning to listen with a cochlear implant. The children I'm talking about right now are children who have never really heard sound. 

Maybe they've gotten a little bit of audibility through a hearing aid but there's a lot of children that are implanted at 12 months of age who've never had access to sound. It's really different than an adult that has a lifetime of listening and a remembrance of what sound means. Children who are implanted and get their sound turned on at 12 months, it's like they're ears are a newborn baby's ears and they're starting to learn to attach meaning to sound. We have to tailor the testing that we do to be age appropriate, not just for the child's age but the listening and the hearing age as well. And that test works through kind of a hierarchy or levels of difficulty. But once the child, either with their own age, or with their hearing age, ages out of test like that, we can make the test difficulty a little more challenging. Here's an example of a test that's still for young children, it's just a picture pointing task. This can be done with listening only or with listen and visual cues. Often it's done just through listening. So the audiologist would either play with the recording or say a word and the child would have to identify out of similar words what word they're hearing. 

Once a child is able to repeat backwards and stay engaged in the task because that's another part of it, we want to keep their attention and keep it fun, we can up the difficulty again. So we may then be able to move to repeating back a sentence. Because sentence tests tend to be more easy to understand and hear than a single word, because with a sentence you have context and your brain can help you kind of fill in the blanks if you miss a word hear or there. We have some sentence tests that children can repeat back for us. We can make it even more challenging and move on to have them repeat back single words. It is really important though to choose the right tests for a child. As I mentioned, you might have a 2-year-old that can say words back to you, although most often that's not the case, and you might have a 2-year-old that's still listening for different patterns. So you really want to vary the tests and tailor the test to the child's appropriate level of vocabulary, of listening, of sound experience, and we don't want these tests to be tests of vocabulary. We want all the tests we're doing with children to be familiar words. Parents will sometimes ask if their child can review the list beforehand. 

No, we don't really want to look at the list. We don't want them to go through the words necessarily, take it home and study it. We want to make sure that the words that we're testing with the family and with the child are familiar. At this point, from an audiology perspective, we want to look are see how the child is doing, either pre- or postoperatively, with their listening skills alone and not necessarily test those more executive, or higher up, levels of functioning that Dr. Edwards was just mentioning.  >> Adults are a whole lot easier in terms of word recognition testing. They can just repeat back words. Over the years there's been a lot of standardized tests that have been produced and various audiologists will use various tests. If you travel in cochlear implant circles, if you're on forums or are reading, the most recent test that we've used most commonly is it a HINT. It's a hearing and noise test. Cochlear implant patients will talk about that. 

They know what their scores are. They'll talk to each other and say, "how do you score on your HINT? What are your hint scores." There's a newer test battery that's available now that we are utilizing. We've moved away from HINT testing to some newer tests. And the minimum speech test battery for adults has really been a joint effort by all three manufacturers to, I guess in essence, standardize the testing a little bit more across centers and across manufacturers. What was happening was, as the technology improves and as we're seeing better and better outcomes, most of our patients were ceiling out on HINT sentences. They're scoring more than 80 or 85% of words correct, and it made it really difficult to see where the problem areas were. So there are newer, more difficult test materials available. The Consonant-Nucleus-Consonant test is old. It's been around forever. We're using that a little bit more. 

The AZ-Bio sentences are the newer sentences that we use now. And the BKB-SIN is another hearing and noise test that we look at. Dr. Gubbels already reviewed this. Just examples of the various manufacturers' devices.  This me or you? Okay.  >> So this has already been reviewed. Not going to spend a lot of time on the mapping time line, but I'm going to spend some time talking about what mapping is. Mapping is what we like to call programming or setting. What the audiologist in the office, to set the sound of the cochlear implant. Most centers follow a pretty standardized timeline for follow-up mapping. 

As has been mentioned, between the surgery and the initial activation there's no sound. Usually that's for approximately a month, although that varies depending on the patient and the center. We, as audiologists, are really fortunate to be involved in this amazing appointment. I've been very fortunate to be in many of these where we get to turn on the sound for the first time for the patient. Realistic expectations are key here. We don't know what any one particular individual or child is going to hear through their device on day one. You can make a guess but there's no way to know for certain. We want to be sure it's not uncomfortable and that you slowly ease, particularly children, into hearing for the first time. But there are patients at the activation are able to converse. I've gone from typing on a computer screen, to talk or using an interpreter, to face-to-face oral communication with no other support at an activation. 

I've heard, this is with adults, people say that it just sounds like beeps and buzzes and come back several weeks later and they're already making great progress. With children we don't get as much feedback at the activation. I'll show slides of how we test and how we map with children in a little bit. After that initial activation, we hover pretty closely at first. The levels that we set can change in the ear. The perception of sound as someone gets used to that electric-type hearing and having the electrical current stimulate the auditory nerve, that can change over time. And it changes pretty quickly at first. Within the first month, the person might come back, after their activation, two or three times for adjustments. Then it starts to space out. Maybe ever three months. 

Then depending on how things are going with the individual, it will space to maybe six months, and then eventually to annually. This slide is really text heavy. I'm not going to go through every detail on the slide. It's kind of for the professionals in the crowd or people who are interested in the more technical details of what in the world we're looking at on the computer screen when we're setting the maps. As you can see, we look at a lot of different parameters when we're making adjustments to someone's cochlear implant. I'm going to spend the most time talking about the first parameter on here which is the current level, or one manufacturer uses T and C levels, and that's how I'm going to describe it today. So clinical mapping, or programming, really this is what decides what the sound is going to be like. Length of experience, therapy, all of those additional supports help the brain and the ear interpret sound, but the mapping and how the levels are set with device, that's what determines what is going on to the nerve, what kind of electrical stimulation the cochlear implant is providing. We use slightly different techniques to determine these levels for children and adults. One of the primary things that we're setting with the cochlear implant, when you see us pushing buttons or when you think about what a audiologist does, is setting the threshold level of electrical stimulation. 

The smallest amount of current that we're putting on to the nerve, and kind of the maximum amount of current the cochlear implant is providing. For the purposes of today, I'm going to call those the T level, or the threshold, and C level, the comfort level. Different manufacturers use slightly different terms to discuss those. One uses M level, and it's defined slightly differently, but it's the same general idea across manufacturers. We can measure those levels of sound through beeps on each individual electrode, or we can play the sound on more than one electrode at once. It sounds kind of like a splatting sound. A cochlear implant user would be able to describe it better than I can. They call it a speech burst, manufacturers call it a speech burst, but it's just stimulating more than one electrode at once with a non-speechlike stimulus. It just putting sound onto a couple of electrodes. We can also make adjustments in live mode. 

Meaning all electrodes are turned on and we are talking and turning the sound up and down before the levels have been set and saved to the processor. With adults, it's pretty easy. We can get feed back from an adult. We can ask them to raise their hand when they hear the beep. Look for the softest beeps. Like you would imagine a hearing test. Sometimes we have adults count the beeps. When sounds are very soft, sometimes you're listening and maybe raising your hand, and not sure if you hear it or not. So sometimes we have people count between one and four beeps and we vary the number, That way we can really get it. Okay, did they hear it or were they maybe just guessing, and we're looking for the point at which those beeps are herd accurately. 

Very, very soft but audible. In terms of comfortable level, the maximum comfort or the loudest level we want to play on an electrode, with adults we can have them tell us. We can use a little rating scale. We can have them rate with a visual scale. Like when you think of a pain scale, how you look at the image of the 1 to 10 and there's a happy and a smiley face, we can do the same kind of thing with rating the level of the sound. We even do that with some children, older children, with a much more simplified rating scale and it tends to work quite well for a rating comfort. Determining threshold levels or the softest sound, a very young child can hear, is a little more challenging with behavior but we do have ways of making measurements. Some of you may have seen a child tested in a sound booth and some of you have seen a child receive cochlear implant mapping. We use a technique called Visual Reinforcement Audiometry with young children. I'm going to show a image of this, because I think there's a lot of mystery about how do you even accurately set the settings for a child. 

I'll get into that in a moment, but that's for the youngest children. When they get a little older we're able to play a little listening game. Visual Reinforcement Audiometry in teeny tiny children, the 12 month old that gets activated at 13 months. They may not know what a sound means, but we're linking the sound that's coming through the implant, we're playing beeps through their implant, and we're teaching them to associate that sound to a turn toward a reinforcer toy. A light, a video, or-- and us getting very, very happy. There's some training involved. At the initial stimulation of a child, we have some objective information, but we're also trying to get subjective information from the child as well. We're spending a lot of time teaching them to associate whatever their, whatever is happening that they're hearing, that they may not even know is hearing at that point, with turning their head and looking at the response. The visual that they're getting is not part of the stimulus, it's actually the reward. Once we establish that they can independently turn their head and get that reward, then we start looking for that measurement at softer and softer levels. 

I'm going to show you really brief video, maybe. I don't have a mouse. A video of that being done for a cochlear implant mapping. Maybe.  >> Is Clark here? >> No, that's okay. I can do it. [inaudible]  We'll see if this works. If not, I can move on. I described it pretty vividly. It's too bad. 

It's during a cochlear implant mapping, so it's pretty cute. It was at a 12 months old's activation that I did in Boston. Unfortunately, I don't think-- Oh, here we go. Her parents put this on YouTube and gave me permission to use it. We might not have sound. I'm just going to-- there's a lot of-- >> You want sound? >> Sure. It doesn't hurt. Oh, are you okay? >> Yeah. >> Okay. I'm just exercising here. 

[laughter]  The thing about this, is we won't be able to hear what she hears anyway. All of the sound during the mapping is coming straight into the device itself. It's not audible generally in the room by everyone else.  >> I'm sorry, I don't know this computer. >> It's okay. Thank you, so much. Okay, I'm going to go back and show it one more time. She's already been conditioned. There was a response where she turned her head, and looked and then she got her reward. There's a computer on the left side of the screen with the mapping going on. 

And all of this time I'm playing beeps and looking for the softest beeps that she's responding to. That was accurate response, so she got the visual reward, she's engaged. We don't want her continually looking at the reinforcer so her mom, or an assist, or another audiologist entertains her She has a cap on to cover her device, because often at activation, the little, teeny tinies like to pull it off. They want to see what in the world is on their head. So it helped to hold it on, and she did really, really well with it and didn't end up wearing it after that. We'll get back to our PowerPoint.  With older children it gets a little more straight forward. We want to keep them entertained and engaged. The more information we can get, the more accurate we can set the maps. We'll do a little game where they wait for a beep, they listen, and when they hear it they put a toy in a pegboard, or a block in a bucket, or a checker in a Connect Four game. 

We can get really creative. If they like GI Joe, they can get one of those. We tailor it to the child. It's nice to have a big arsenal of toys to keep it entertaining. But some children and adults are not able to give us information with their behavior. Even without the information I was just talking about, we can use some objective tests to set our levels. We've used something through the implant called telemetry. What that is, it's using the device itself, the internal device, to make a measurement of what's happening in the ear and with the electrode. Every time someone comes in, we're measuring what is called electrode impedances and that just gives information on, if the electrodes are on, making a contact, basically if they're functioning. But we also can use the device to make a measurement of where the nerve is responding to sound. 

That's a neural response. All three manufacturers have the capability now, built-in, to do this automatically or semi-automatically with our guidance. We also can make, that third or fourth bullet on the page, something called electronically evoked stapedial reflex thresholds. It's a middle ear muscle reflex in response to stimulation from the cochlear implant. There's a lot of research on the last two bullets on there, the neural response and the reflex threshold, that they correlate with the mapping levels that we want to set with the T and C levels. We're able to use that objective information, either alone or in conjunction with the behavior information to supplement the map or maybe even create a program for someone who's unable to give us any information with behavior. I just wanted-- this is quick. I wanted to show you what we see on our screen. Many of you with cochlear implants in the room have sat in on many mappings and may or may not have seen what we look at. This is just an image of one of the screens we look at with cochlear. 

You can see on the bottom there's a lot of mumbo jumbo in numbers. We care a lot about those. Those are some of the different mapping parameters that we're setting. The red, kind of, chili peppers across the screen, those are those C levels or maximum comfort levels. That's the maximum amount of electrical stimulation being placed on each electrode. In this case, maybe you can see, there's 22 lines and each of those represents an electrode. So what the implant is doing, you all probably know by now after this morning, it's taking all of the sound in our environment and it's diluting it down and allocating, or putting the sound, in different frequency regions on different electrodes. This is just an image of how that's done, from low frequency on the left side, to high frequency on the right side. The red chili peppers are the loudest sounds going on to the electrode and the green little pickles, those are the T levels, and those are the softest signals, or stimulation, that's being provided on each electrode. No two maps between people are the same. 

There's actually something being built into the implants now so that kids can't swap their cochlear implants. Like if you're at a deaf school with a lot of kids with implants, you do not want them getting stimulation that's been set for someone else, because it could be much, much too loud, scary, harmful, and now there's protective features that didn't always exit so they can't swap devices and get stimulation that they shouldn't. It's kind like a fingerprint. Your map is unique to you, just like your hearing test is. Although, I would say, probably within this population, the hearing tests are more similar and the maps much more different. There's a great variability and it really depends on the individual how these are set. This is just another image, a different manufacturer. It happens to be Med-El. I want to show you, it's the same idea, different company, different number the electrodes, but still low on the left side, over to high. This company has 12 electrodes in the cochlea. 

12 electrode pairs actually. And the colored section of the bars represents the threshold and the maximum stimulation on each electrode.  >> So for some patients this can take several months of work. It's not something that happens in one session, certainly for children we might only get one or two electrodes evaluated and they've got to come back again. But at some point, patients go back to the sound booth for testing with their implant done and we do another audiogram. We want to look at how well they can hear across the frequency range now with the speech processor on. So we want to make sure that people have audibility across the frequency range and that they're falling in their range where we would expect them to be and to help their speech perception. So let's go back to the audiogram on the left that Melanie showed you in the beginning of the presentation. Preoperatively this would be a typical audiogram for a cochlear implant candidate. Post operatively we would expect people to start responding better somewhere between the 20 and 30-35 dB range would be a pretty typical result across manufacturer. 

So the implant does not provide normal hearing. Most people still function with some degree of hearing loss even with their speech processor on. But you can see typically patients may fall preoperatively around 100-decibels and then hear somewhere between 20 and 30. So we can typically restore, you know, 80-plus decibels of hearing which is pretty miraculous. I'm not going to spend a whole lot of time, Dr. Gubbels really covered this, the factors affecting performance. It's been covered this morning. Realistic expectations. There are some people who can hear and understand speech when the device is initially activated. More commonly, that does not happen. That speech develops over time and it depends on the patient, depends on length of deafness, etiology of the hearing loss, but quality of sound improves with time. 

For some people it can take over a year like Dr. Litovsky said. Telephone use is also not automatic. That is something that some people really have to work on. There are some patients who are not successful using the telephone with their cochlear implant. Music perception can also be a really difficult hurdle for a lot of people some people think music sounds good with their speech processors, others don't agree. Can take a lot of training, a lot of dedicated time to get music perception down. There are support groups. The Hearing Loss Association of America, we do have a Madison chapter. And that is open to parents, adults, so there's a good group right here in Madison. The Association of the Late Deafened Adults. 

There's a lots of pediatric groups on-line. You can find forums and circles on-line to join. All manufacturers now have published self-directed listening, practice, so things you can do at home that have been great. Cochlear produces Hope, Sound and Way Beyond. Some of the other manufacturers all have their thing. Hearing Journal, there's telephone programs, and now Cochlear too is moving towards Apps that you can download on your computers and phones. You can do a lot of work, therapy work, from wherever you are. Even if you're a Nucleus patient, go to the Med-El or to the AB website. If you go to the manufacturer's website, they're all there and they all have really good stuff. Self-directed listening is great and it's helpful but it's not always the answer. 

A lot of people need more help from a speech therapist and so Michelle Quinn is going to talk to us a little bit more about postoperative rehab and habilitation.  >> Thanks Jennifer. Thanks for your attention. My name is Michelle, I work here at the Department of Communicative Disorders and have had the privilege of working with individuals with hearing loss for about 30 years. In my career, what is possible for individuals because of this amplification option has changed how treatment occurs and although this is the last topic of the morning, so thanks for your patience, it is not the least. And in fact, for those individuals who make the commitment to work with professionals who have specialty expertise, in this area, it makes a lasting impact and may be something that contributes to the differences we see in patients who have cochlear implants. So what is aural rehabilitation? How it looks and how long it lasts varies if you are a person who had hearing before and the device can interface with your brain's auditory memory, versus if you are a child who is listening for the first time after 12 or 13 months, or two or three years, of making sense of the world with your other senses. Therefore, for children who are developing their spoken communication skills, having relied very much on touch and vision, the process is often longer. We don't always know what the prognosis is until two to three years after the child has been mapped. In general, to answer the gentleman's question of what do we usually say to folks, is with the data collected from around the world, most children will make month progress compared to typically developing children. 

Many, however, will not. That may be because of the schedule of therapy they receive, it may be because of the cochlear implant has not been mapped by someone with enough experience, or, unfortunately, but often, because two of out of five children with hearing loss will are other disabilities, the fact they're not making month to month progress may be a red flag that that child may have other difficulties that contribute. Certainly what expectations you, as the patient, and your family, brings are going to affect your motivation and are going to effect, kind of, what you're going to highlight in the treatment for aural rehab. First you're going to want to learn to listen to sounds and patterns that you have not heard before. It's the most intense and often the most structured portion of aural rehabilitation for adults. For adults they often want to minimize their communication difficulties and once their frustration is reduced, they may decide not to continue therapy. Some, however, will report even if certain other aspects of their communication do not improve that they're thrilled with having gotten a cochlear implant because it reduces the effort for them to be able to successfully speech-read and their spouses or significant others or children or employers will report to us that benefit of having many less communication breakdowns when using a cochlear implant. One of the things that I enjoy doing with my graduate students is educating people in their workplaces and in their schools and those of you in Wisconsin should take advantage of looking at the DPI outreach website for working with professionals who serve children who are deaf. And then finally, there are people who want not just to have the device and have it work okay, they want to be able to optimize all of their communication interactions. These are the people who come in with a star mentality and tend to want to continue therapy for a longer period of time than maybe even their insurance providers will allow. 

When we're coming up with goals for spoken communication success, it might be in different areas or facets of communication that I like to call domains. We might help the person with a cochlear implant now that they can access sound, make meaningful what those sound patterns are. We may want to work on speech at the sound level, at the word level, or if I'm speaking rapidly in a New York accent, maybe I need to learn to monitor how quickly I talk so you don't need to say to me, "what did you just say?" Okay. Language has to do with both understanding and producing symbols in either speech or in writing or in sign language, which some individuals will choose, and then finally people with cochlear implants may want to have someone to talk about the differences that the cochlear implant makes that disappoints them, in terms of quality of life, and learn if some of the patterns that contribute to that are just part of being a human adult or child because communication difficulties exist for all of us, not only for people with hearing loss. So then just briefly, since I know we're running out of time, the area of hearing, we usually start with individuals with an implant learning to recognize environmental sounds. This afternoon you'll hear a family of panelists who will talk about children not learning the sounds that a cow and duck make but the objects that make sounds within the home for their child. For adults we might help them, if they have a severe or profound hearing loss, and get their implant, to learn to interpret and use inflection and stress, both to understand what I think is most important in the sentence, or to be able to use that stress to help not talk in a monotone voice. In terms of speech, adults often ask us, "now that my hearing loss has worsened, am I too loud, are my sounds sounding distorted to you as a speech therapists? I'm worried that my speech is slurred and I'm wondering if strangers can understand my spoken sentences with ease." This fear of adults is usually not the main area of being a communicator that's affected by an acquired hearing loss, a slow process of having heard fine and then losing your hearing. For children, however, making the link between listening and speech is a very critical component of aural habilitation. We basically want to teach the child to be their own personal speech pathologist coach. 

So we want them to be able to listen to what somebody says to them, talk back and compare. "Did I match what the adult just said." Learning to develop that auditory speech feedback loop allows the child or the adult with the cochlear implant to guide themselves to make sure that their speech output is it as precise as it needs to be. That, as case for hearing children, it's a process that might take three to five years. Really the area of communication that most people with hearing loss feel affects their quality of life is being able to understand. I've listed here, and you can read along, you'll see how many of those first bullets have the words that understanding and face-to-face communication is often eased by getting the correct kind of amplification for your hearing loss. Whether that's a hearing aid or a cochlear implant. Being able to understand words said in a context, about a topic you do or do not know, may be at a level at which you would like some training. Being able to understand, as Jennifer said, on the phone. And what type of clarification strategies you can use when you don't understand, is probably the main way that we, at the UW Speech and Hearing Clinic, serve adults even a year or two after their implant has been mapped. Finally an area of quality of life and there are families who will come to us asking us just to have conversations in which we try to help identify what do they really value, is it reading and writing, is it being able to continue to bowl and hear what your teammate says, is it a worry about how the cochlear implant will look? There are no stupid questions, only human questions, that we like to discuss at this time. 

Certainly, we are trying to tap what is your social, emotional well-being, and we need you to have appointment time where you can share that information. For children, they need friendship access to meet other individuals who are using the same kind of devices, to learn that not everyone that wears a device has the same life path and to help them pursue their own. Their own may include appreciating music, and so I'm delighted to hear that we might be a site for the hybrid implant, because that device has been shown to allow patients who want to appreciate music to be better able to do so. Another aspect of aural rehabilitation that sometimes adults want to veer from, because they're afraid of the top word counseling. Counseling is really our time to listen to you. When we listen to you, we try to hear if what matters to you is something going on the in current context, and if do you or it not have the information to know about what might be some of the future communication demands, particularly for those of you who are raising children. In working with children, I am proud that my clinical colleagues both at Goodnight Hall and here at Waisman Center, take what's called an eclectic, or we're not going to shove it down your throat, approach to working with children. Some children are able to experience success as listeners if they're structured. Some don't want or need structure because they won't sit still. A semi-structured approach of some give and take. 

You get to decide the topic, but I as the adult get to help shape how you respond as a listener. Some children are natural learners and it may be the gentleman who spoke about his daughter, he may have a natural learner, who can do the auditory feedback loop all on her own, but that might be a learning style that she brings to bear from the time she got her cochlear implant map. Those of us who serve children want to help move them as needed between structure, semi-structure, and a natural listening situation, so that they can listen as naturally, as effectively, and as accurately as possible. Finally, for the older children, young adults, sometimes for an older adult who is wanting to just be able to say to their spouse, "would you quit talking to me when you've got the dish washer on from the kitchen." Learning how to advocate for one's self so you're not making the problem worse but really helping people look at you as a whole person rather than just in terms of your hearing loss is another area of counseling. There's various intervention approaches as listed here. We might work with the parents, one on one, in group therapy. And the way that the therapy is delivered and the focus can change. A take home message for families in the audience is do reach out to those of us who like to provide treatment at any point in your listening journey, whether it's before the time of the surgery, close to the time of mapping, or in the years ahead. In closing, I would say all of us have had the experience of being given a gift at the holiday time that we know somebody has re-gifted. They were given it, it was wrapped up nicely, but they didn't use it. 

Those of us who do aural rehabilitation want you to use the gift of combining the device, the brain of the person who has the hearing loss, and the professionals and family members who love you, so that you can be the communicator you want to be. Thank you for your listening and we're open to questions. [applause]