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A cochlear implant is an electronic device that takes over the work of the human
ear in converting sounds to electrical signals that the brain understands as
sounds and delivers them to the brain via the hearing nerve, after fine tuning
the sound much like the graphic equalizer on a music system, via an electrode
array surgically implanted into the inner ear.
Who does it benefit?
Both children and adults who have severe to profound hearing loss in both ears
wherein even wearing hearing aids the person will have difficulty in
understanding normal speech even at very loud volumes, and without the hearing
aids would maybe only detect the loudest shout. New criteria include people who
have lost some frequencies of sound much more and can hear sound when its loud
but cannot understand it (little or no benefit even with hearing aids).
Implantation at a young age is highly recommended because hearing is important
for language development and because research has shown better outcomes for
children implanted at an early age.
Older children and adults with previous speech and language development
generally perform better with a cochlear implant than children with a severe to
profound sensorineural hearing loss in both ears. Age at implantation may be as
young as several months, depending on individual circumstances and local
practices
In what circumstances does it not work?
Since the cochlear implant replaces the part of the ear that converts sound to
electrical signals, it works only if the nerves going to the brain and the areas
of the brainstem carrying the signal and the hearing recognition areas of the
brain are functioning. An analogy would be like using voice recognition on your
phone where the microphone (cochlear implant) works but the cable to the phone
is damaged or software is corrupted and does not work.
How does one detect severe to profound hearing loss in a child or adult?
The subject will not hear important elements of the class discussion including
key context and content without visual cues, will have a smaller or more limited
vocabulary than their same age peers, not hear all the sounds in a word,
commonly leaving off 's', 'ing' and 'ed' in their speech and their writing ,
will have problems pronouncing some speech sounds, particularly those in the
high frequency such as ‘s’ or ‘p’. They will also become very tired towards the
end of sessions that have required intense concentration or were conducted in
noisy environments
Very often, they misinterpret what is said although they 'hear' the speaker’s
voice (they know that someone said something but couldn’t hear clearly enough to
understand what was said)
There is a limited understanding of colloquial language, such as 'pull up your
socks', and in normal conversations , they have difficulty understanding complex
sentences, have poor vocal quality, have trouble explaining their ideas to other
people, and have limited background knowledge and experiences in a range of
areas which can affect learning and social skills.
Who is a candidate for a cochlear implant?
A person who has severe to profound hearing loss in Both ears, has a functioning
hearing nerve which is detected by medical tests, has lived at least a short
while without hearing, has no medical reasons to avoid surgery, has no benefit
from the best hearing aids , and has a good support group at home.
What are the components of a cochlear implant?
A cochlear implant consists of an external device that looks like a hearing aid,
which has the function of capturing sound, tuning the sound like the graphic
equalizer on a music system, using software, and then transmitting the sound
like a radio station to the surgically implanted device.
The surgically implanted part consists of an antenna like a radio antenna which
picks up the sound from the external device , a processor which like a music
system output , takes the sound and sends it to different parts of the electrode
which is implanted In the inner ear , much like a surround sound music system
delivers sounds to different speakers in a room.
The electrode array, which is like Diwali lights, where depending on the
processor different lights at different points on the cable switch off and on in
this case different electrodes switching off and on cause different parts of the
hearing nerve ends to receive stimulation that the brain perceives as sound of
different frequencies.
What has changed in cochlear implants since they were introduced in
India since 1987 at the Jaslok Hospital
External device has become smaller, more light weight, more microphones to pick
up sound and better software with faster processors to process more sound and
give clearer and more focused sound to the patient. Also it has become smarter,
able to send and receive data from the implanted device to diagnose problems and
improve efficiency of sound transmission to the brain.
Implanted device. Has become smaller, more light weight, electronically smarter,
wherein the implanted device can send diagnostic information back to the
external device. Also, it occupies less space and requires less surgical
exposure. The electrode array has more electrodes and is slimmer and less
damaging to the inner ear structures resulting in more information delivered to
the hearing nerve while preserving residual hearing, which has resulted in
better speech and sound understanding even in noisy environments. Also the
materials used have advanced to a stage where the body rarely rejects the
implant.
Surgery has become more precise and less invasive resulting in quicker healing
and shorter hospital stays for the patient.
Sound processing software …has advanced and is still advancing , enabling
doctors after surgery to fine tune the patients hearing and create software
environments wherein even in noisy environments speech and sound understanding
is getting even better all the time .This has resulted in less and less speech
and sound training required after surgery and more natural sounding hearing.
Cost factor… Both surgery and implantation costs are decreasing all the time as
devices are being mass produced and surgical techniques less invasive requiring
shorter surgical times and less hospital stay.
How much does the entire surgery and other related costs add up to?
Implant prices vary from 6.25 to 14 lakhs depending on the make and model
chosen. Investigations and surgery and vaccinations and follow up depend on the
hospital and the package chosen and the class of rooms and amenities chosen. On
an average basic package would be 7.5 lakhs and postoperative rehabilitation of
2 to 4 years depending on the package and implant chosen would be about 50
thousand to 2 lakhs.
Are there any sponsorships available?
Tata trust and Maharashtra Cm sponsor cochlear implants. Government of India has
ADIP scheme for 500 implants per year. Airports Authority of India sponsors
cochlear implants via the CRS initiative. In addition, insurance companies also
sometimes cover the cost if due to congenital deafness. a number of private
charities and trusts also sponsor implants and also some private individuals.
Cochlear Implant surgeons usually can provide a list of the same.
Current scenario of cochlear implants in India
Today there are around 200 state-of-the-art cochlear implant centers across
India, in each major city, with talented professionals and well-equipped
habilitation units for comprehensive management of deaf individuals. The
Cochlear Implant Group of India which was conceptualized 15 years ago based on
the British Cochlear Implant Group, has successfully created awareness regarding
CI and has provided guidelines and support for its propagation and
implementation across the country. Almost 30, 000 implants have been done in
India with one million children still awaiting implants.
Selection Process
Screening of candidates
Adults
• Individuals 18 years of age or older, with Moderate to profound sensorineural
hearing loss in both ears. (severe hearing loss where even very loud sounds are
not heard)
• Limited benefit from amplification (hearing aids) defined by hearing test
scores of ≤ 50% sentence recognition in the ear to be implanted and ≤60% in the
opposite ear or binaurally1
Children (2-17 Years) Same as for adults but including
• Multisyllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test
(LNT) scores ≤ 30%
Children (12-24 Months)
• Profound sensorineural hearing loss in both ears
• Limited benefit from binaural (both ears) amplification
New Important Considerations:
• Remember that many individuals with residual low frequency hearing are CI
candidates and can benefit from CI.
• When appropriate, discuss use of acoustic hearing: Does your patient have a
passion for music? Work in noisy or reverberant environments? What are lifestyle
demands?
• Determine motivation to experiment with hearing aids, in both the implanted
and/or contralateral (opposite side) ears.
• Discuss the opportunity to use acoustic hearing to manage expectations and
rehabilitation options, when appropriate.
Financial Discussions are an important part of the selection as patients have to
afford spares and repairs in addition to the surgery. poor patients are given a
list of charities while the affluent are educated to the expenses and time and
energy postop that will go into the process of rehabilitation. Poorer patients
have options of several government hospitals linked to colleges teaching
audiology and speech therapy , while the more affluent have the option of
availing the same services in corporate and private hospitals
What guarantees do Cochlear implants offer?
Cochlear implants guarantee hearing sound but do not guarantee how well a person
may perform. In addition, implants can be rejected by the body and like all
electronic devices can occasionally fail. companies guarantee devices and
replacements within the guarantee period. However, with new technology these are
uncommon incidences.
Surgery and Post Surgery
Surgery for cochlear implants can be done by any surgeon well versed with
routine ear surgeries. In western countries it is often an outpatient procedure
whereas in third world countries some days of hospital stay is required.
Typically, a two hour surgery. Following the surgery some amount of dizziness
and ringing in the ears is normal. Bandages are removed a few days after surgery
and patient allowed to wash the hair. The implant is switched on when healing is
complete, usually 2 to 4 weeks later when a programming (tuning) is done which
balances the loudness of different frequencies as per the patient.
Surgical complications
usually have to do with surgical technique and include skin over the implant
losing blood supply, improper electrode placement, and rare facial nerve
problems. Minor issues include opening of wound line, infection, facial nerve
stimulation, dizziness, ringing in the ears (tinnitus) All these complications
have simple solutions which are applied when needed.
Rehabilitation
This refers to training the cochlear implant patient to hear sound and
understand speech. electronic sound is different from normal sound. it is like
learning a new language like a small child does from hearing sounds to
recognizing them to being able to identify the source and then to learn
alphabets, vowels, consonants, words, sentences, paragraphs and so on.
Insurance
Quite often Cochlear implants are not covered in India under Insurance- these
often are reported on the following terms for non coverage -
- The hearing loss is on account of congenital disease which is an exclusion in
many policies. Hence any treatment of an excluded disease is also not covered.
- Part of the implant resides outside the ear - the exclusion quoted by
insurance companies is - any external durable or appliance is an exclusion under
the policy.
- There is a specific exclusion in the policy on not covering cochlear implant.
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