We are excited to feature two guest authors on our blog! René H. Gifford, Ph.D. and Jourdan T. Holder, Au.D. will be discussing:

  • why people who could benefit from a cochlear implant are not getting referred to be evaluated,
  • what the referral and evaluation process looks like to get a cochlear implant, and
  • what surgery and rehabilitation after cochlear implant surgery is like.

René H. Gifford, cochlear implant candidacy processJourdan Holder_cochlear implant candidacy process“According to the World Health Organization (WHO), there are approximately 466 million individuals living with disabling hearing loss worldwide (World Health Organization (WHO), 2018). This makes hearing loss one of the top three most common chronic conditions; however, most hearing losses can be at least partly remediated with hearing aids, cochlear implants and other assistive devices. Focusing on auditory implants (like cochlear implants), less than 10 percent of those meeting the strictest cochlear implant candidacy criteria have pursued cochlear implantation (Holder, Reynolds, Sunderhaus, & Gifford, 2018). Further, cochlear implant candidacy criteria is less strict than it once was (Centers for Medicare and Medicaid Services (CMS), 2005), suggesting that an even lower percentage of patients who qualify are benefitting from this technology.

A recent study from our research lab (Holder et al., 2018) sought to answer the question: are we increasing access to cochlear implant technology for a broader population of individuals with hearing loss? In order to answer this question, we compiled data from all of our adult patients (n = 287) who presented to our clinic for a cochlear implant candidacy evaluation between August 2013 and August 2015. Taking a thorough look at the demographics of this population is an important step toward making cochlear implants accessible to more people who are struggling to communicate.

Our results showed that, prior to getting a cochlear implant, 64.8 percent of adults with severe-to-profound sensorineural hearing loss had an average word recognition score of 8.7 percent in their ear being considered for implantation. We then compared these results to previous clinical trials (Balkany et al., 2007; Parkinson et al., 2002) and discovered that our current average word scores are only 5-6 percentage points higher than individuals receiving cochlear implants nearly 20 years ago. This finding suggests that we have much room for improvement if we are to significantly increase patient access to this technology.

In addition to defining the hearing status of our current cochlear implant candidates, we also discovered that out of 287 patients, only 14 (5 percent), did NOT meet candidacy criteria. In other words, nearly 100 percent of the patients being referred for a preoperative cochlear implant candidacy evaluation were, indeed, cochlear implant candidates. This statistic suggests that even at a large university medical center, well-known for cochlear implantation, we are receiving small numbers of referrals, and many hearing aid users that could benefit from a cochlear implant are not being referred.

This trend may result from a lack of continuing education regarding current indications for adults amongst referring providers. Patients who report that their referring provider told them that they were not a cochlear implant candidate have confirmed this speculation. These findings clearly show that cochlear implant professionals and manufacturers must increase education and communication efforts regarding cochlear implant candidacy and outcomes to increase referrals.

Why are cochlear implant candidates not receiving the life-changing technology?

In addition to increasing appropriate referrals, there are various potential reasons why cochlear implant candidates are not receiving this life-changing technology. For years, individuals with sensorineural hearing loss may have been counseled that they had ‘nerve deafness,’ and that there was no treatment beyond power hearing aids. The term ‘nerve deafness’ is a misnomer, as the overwhelming majority of individuals with hearing loss have intact auditory nerves, which are viable for cochlear implantation. Rather, most sensorineural hearing losses originate in the cochlea, which is the snail-shaped hearing organ located inside the temporal bone (https://www.nidcd.nih.gov/health/how-do-we-hear). Indeed, severe-to-profound damage to the delicate cochlear structures renders traditional hearing aid amplification relatively ineffective. Thus, what often happens is that patients give up on their hearing aids and resort to a life of auditory isolation.

Are you a candidate for a cochlear implant?

cochlear implant candidacy processWhile cochlear implants may look similar to hearing aids, they work much differently and do not have the same limitations as traditional hearing aids. Cochlear implants are the standard-of-care treatment for adults and children with severe-to-profound sensorineural hearing loss. In fact, adults with moderate-to-profound sensorineural hearing loss meet candidacy criteria as outlined by both the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS).

If you are an adult with considerable hearing loss and are wondering whether or not you are a candidate for a cochlear implant, consider the following questions pertaining to your listening experience with your current hearing aids:

  • Are you able to talk on the phone without visual cues (such as video calls or caption calling)?
  • Are you able to understand television programs without closed captioning?
  • Are you able to effectively engage in conversations at large group gatherings such as dinner parties?
  • Do you feel that you obtain significant communication benefit from your current hearing aids?
  • Take the interactive quiz here: https://www.cochlear.com/us/ci-landing-page/quiz.html

If you answered “no” to at least two questions above, it is time to see an audiologist for a comprehensive hearing assessment and cochlear implant evaluation. Even if you do not meet candidacy currently, a cochlear implant candidacy evaluation will equip you with valuable knowledge about your hearing health and technology options to help you communicate now and in the future.

What does a cochlear implant evaluation look like?

The typical cochlear implant evaluation will involve the audiologist looking in your ear with an otoscope, and may introduce a small puff of air in your ear canal to ensure that your eardrum is functioning normally. Then you may be given a standard hearing test to document the softest sounds that you can hear at various frequencies or pitches.

In addition to these standardized assessments, the audiologist will also verify your current hearing aid settings, which involves placing a very small tube-like microphone in your ear and measuring the sound output from your hearing aids. If your hearing aids are not programmed according to your hearing loss specifications, the audiologist will either reprogram your hearing aids or program loaner hearing aids to complete the remainder of the testing.

The next part of the cochlear implant evaluation focuses on your speech understanding while wearing your hearing aids. Various words and sentences will be presented from a loudspeaker placed in front of you, and you will be asked to repeat what you hear, guessing if needed. This part of the assessment is often the least favorite for the patient because the tasks can be difficult, and some patients may feel defeated because they cannot complete the task. Although this assessment may be bothersome, it is necessary to determine your candidacy for a cochlear implant and to document your hearing difficulties in order to seek insurance coverage.

Should you be identified as a cochlear implant candidate, your audiologist will then provide you with a comprehensive overview of the function and the wearing options for your cochlear implant. At this point, you will be seen by an otolaryngologist or ear, nose, and throat (ENT) surgeon. The surgeon may complete a thorough evaluation of your ears and review radiographic images (CT and/or MRI scans) of your temporal bone to characterize the cochlear and auditory nerve anatomy.

At this point, the audiologist and surgeon will work together to determine if a cochlear implant is right for you. The surgeon will also explain the outpatient cochlear implant procedure. The typical cochlear implant surgery takes just one to two hours under general anesthesia. It is an outpatient procedure, meaning that under typical circumstances, you will return home the same day as the procedure, and the typical recovery time for adults is generally about two to five days. For additional information about the cochlear implant surgery, please see: https://www.acialliance.org/page/Surgery.

Following surgery, your new hearing journey has just begun! Similar to an orthopedic surgery, your ear will require ‘physical therapy.’ You will work closely with your audiologist and practice daily listening exercises to increase your performance and train your brain to listen with your new cochlear implant. It is certainly not an immediate or perfect fix, but the first step is to consider a candidacy evaluation to see if a cochlear implant could improve your hearing and overall quality of life.”

To hear from people who have Cochlear Implants and how the technology changed their lives, visit YouTube.com/CochlearAmericas.

If you are battling hearing loss and looking for treatment options, learn more about cochlear implants at Cochlear.com/US/CochlearImplants.

About our guest authors:

Jourdan Holder, AuD, is a clinical and research audiologist with the cochlear implant team at Vanderbilt University Medical Center. Dr. Holder obtained her undergraduate degree from The University of Texas at Austin and her AuD degree from Vanderbilt University. She currently serves adult and pediatric cochlear implant patients in the clinic in addition to completing her PhD in Vanderbilt’s Cochlear Implant Research Lab under the direction of Dr. René Gifford.

René Gifford, Ph.D. is an Associate Professor at Vanderbilt University and Director of the Cochlear Implant Program and the Cochlear Implant Research Laboratory at the Vanderbilt Bill Wilkerson Center. Her research has been funded by the NIDCD for over 10 years and focuses on combined electric and acoustic hearing including basic auditory perception, spatial hearing, and speech perception. She has nearly 70 peer-reviewed papers and is the author of the book entitled “Cochlear Implant Patient Assessment: Evaluation of Candidacy, Performance, and Outcomes.”

Balkany, T., Hodges, A., Menapace, C., Hazard, L., Driscoll, C., Gantz, B., … Neely, J. G. (2007). Nucleus Freedom North American clinical trial. Otolaryngology – Head and Neck Surgery, 136(5), 757–762. https://doi.org/10.1016/j.otohns.2007.01.006
Centers for Medicare and Medicaid Services (CMS). (2005). CMS Manual System, Pub 100-03, Medicare National Coverage Determination, Subject: Cochlear Implantation Transmittal 42. Baltimore, MD: Department of Health & Human Services, Center for Medicare and Medicaid Services.
Holder, J. T., Reynolds, S. M., Sunderhaus, L. W., & Gifford, R. H. (2018). Current Profile of Adults Presenting for Preoperative Cochlear Implant Evaluation. Trends in Hearing, 22, 233121651875528. https://doi.org/10.1177/2331216518755288
Lasker Foundation. (2013). 2013 Lasker Awards. Retrieved from https://www.laskerfoundation.org/awards/show/modern-cochlear-implant/
Parkinson, A. J., Arcaroli, J., Staller, S. J., Arndt, P. L., Cosgriff, A., & Ebinger, K. (2002). The Nucleus 24 Contour Cochlear Implant System: Adult Clinical Trial Results. Ear and Hearing, 23(1 Suppl), 41S–48S. https://doi.org/10.1097/00003446-200202001-00005
Wilson, B. S., & Dorman, M. F. (2008). Cochlear implants: A remarkable past and a brilliant future. Hearing Research, 242(1–2), 3–21. https://doi.org/10.1016/j.heares.2008.06.005
World Health Organization (WHO). (2018). Deafness and hearing loss. Retrieved from https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss
Cara Lippitt
Cara Lippitt is the Senior Manager, Social Media Strategy at Cochlear Americas. Cara is inspired by the stories of the recipients that she is able to tell and the incredible journeys they have taken. Cara was born and raised in Colorado and adores the mountains, snow and the world of musical theatre.