NICE Guidelines for children and adults with severe to profound deafness (2009)

Severe to profound: Greater than 90dB(HL) from 2-4 kHz without hearing aids

Adequate benefit from HAs:

Adults: 50% or more on BKB sentences at 70dB (SPL)
Kids: Speech, language and listening skills appropriate to age, developmental stage and
cognitive ability

Candidacy:
1. Unilateral CI recommended for severe to profound patients who do not receive
adequate benefit from hearing aids AND
2. Simultaneous bilateral CIs recommended as an option for severe to profound
hearing loss, no benefit from HAs AND
a. Are children
b. Adults who are blind or have other disabilities that increase reliance on
auditory stimuli as a primary sensory mechanism for spatial awareness
3. Acquisition of bilateral implants should be at lowest cost
4. Sequential bilateral CIs not recommended as an option for people with severe to
profound hearing loss
5. CIs considered for paediatrics and adults only after assessment by a
multidisciplinary team. As part of the assessment, patients should have a valid trial
of a hearing aid for at least 3 months (unless contraindicated or inappropriate)

Appointments

IAs IA questionnaire
Psychosocial Questionnaire
Audiogram
Aided FF thresholds

Advise on audiological suitability and next steps

Go through devices and issue leaflets (if patient is suitable)

Meeting with ENT Ensure copies of the following are attached to file:
appt - IA (as above)
- SLT assessment
- VFT/ABR assessment
- Psychology assessment
- MRI etc.
Decision - Would expect similar results from all three
Appointment - Choice will not have any effect on operation or the follow-ups
- All devices have disposable and rechargeable batteries
- Cochlear and AB are starting to bring in wireless devices
- All can plug into audio adaptor
- All have loop, different programs and VC

AB:
- Controls (VC and programs) are on the device, like a HA
- Microphone on top and by ear

Med El:
 - No controls, have to use remote control for this
- Microphone at the front

Cochlear:
- Has both remote control and controls on sound processor
- Microphone at the top
- Two options
o Shorter which will be wireless
o Longer can plug things into it will also be wireless too
- Rechargeable batteries need charging everyday
o Small rechargeable ~ 6 hours
o Longer rechargeable ~ 12 hours
o Disposable ~ 3 days
- Remote will show how much battery power is left
- Will show whether microphone is working
- 4 colours Can also have different covers in other
colours/patterns

Next step After decision appointment, patient is sent letter confirming everything
that has been agreed. Patient has to sign this and return back to WECIP.
Surgery date will be booked once this paperwork has been received

Switch-on 1. Check operation site

2. Discuss expectations
3. Measure impedances: Check for spikes (indicative of short
circuit)
4. Measure thresholds (not necessary for Med-El) and MCLs
5. Turn everything down a bit and then go live
6. Discuss expectations again and let patient go for a wonder
7. Discuss sounds, check comfort, adjust as necessary
8. Go through how to use CI
9. Insurance
10. Listening check homework!

Remap Important to remap in the beginning, even if patient is finding sounds

comfortable because we need to move things along

Qns: How are things going, good things, bad things, etc.
Report Remap as necessary

CUNY:
CI + HA with LR
CI with LR
CI without LR

BKB

Environmental sounds
Review

Testing
CUNY Set to 0
Always show topic
 Best aided (i.e. 2 HAs) with lip-reading
Aided alone (can do R and L aided if necessary)
Lip-reading alone
BKB Set to -10

Environmental -10 (-15)

Med-EL

Remote control: Has to be paired with processor

To pair, place coil over MT button, lift flap to switch off and close to
switch back on.
2 orange lights should flash which means its ready

Rechargeable 1 battery will last about 1 day

batteries:
Drying bricks: Last about 2 months
Use at least once a week

DaCapo: Rechargeable battery system

Non-rechargeables: 3 batteries last about 3-5 days

Coils: D-coil (slimmer) and Coil COMPT+P (bulkier old coil)

Software: Maestro, password: Medel

Leads: Opus II: Navy blue DiB coil, blue lead

Rondo: Same DiB, different lead
Connecting: Connect processor, software will detect device
Check settings along the bottom line, will give an indication of how
patient is wearing device

Connect DiB coil, place magnet on patients head and click measure.
This checks impedances (telemetry)

Fitting screen: To re-map:

Choose most recent map and have a look at the average levels
Create new map and apply average levels
Find MCLs (vary frequency)
Then go back and balance
Keep lock to threshold ticked (thresholds then dont need to be
measured)

Configuration: For programs:

Drop down to change
Repairs: Fill out form to return faulty items
Fill in sheet in Med-El repairs folder (can get repair # from this)

Med-El: Timeline

1994: COMBI 40 is launched.

The worlds first multichannel high rate CI
8 channels with the CIS speech coding strategy with high stimulation rate
Comprises a 31mm long flexible electrode for coverage of the entire length of the
cochlea

1996: COMBI 41+

Provides 50,000? Pulses per second

1997: COMBI 41+ with split electrode for cases of cochlear ossification

1999: TEMPO+ BTE speech processor

Consumes 90% less power than a body work processor

2004: PULSAR Cochlear Implant

providing future-ready electronics in an optimised ceramic housing

2005 DUET speech processor

Also: The EAS (electric acoustic stimulation) first implanted

2006 1. OPUS family of audio processors The first switch-free processor design featuring an
easy-to-use remote control
2. SONATA Cochlear implant which features an especially small titanium housing
3. FLEX series of electrodes Especially designed for preserving the delicate cochlear
structures during implantation
4. Finehearing technology providing fine structure information

2007 FLEX EAS CE-marked approved for treatment of partial deafness

Launch of DaCapo rechargeable battery system

2008 Further development of EAS

2010: MAESTRO Cochlear implant system introduced

Consists of CONCERTO implant, the thinnest implant with titanium housing
CONCERTO implant provided with optional pins for easier fixation
MAESTRO software 4.0 features new coding strategies: FS4 and FS4-p

2011: The long FLEX 28 Electrode Array introduced to provide stimulation of a maximum
number of nerve fibres for the best possible hearing experience
Introduction of Mini Battery Pack for the OPUS 2

2012: OPUS 2XS Battery Pack: Making the OPUS2 the smallest and lightest BTE
 Introduction of the BONEBRIDGE

2013: RONDO (revolutionary-all-in-one-design)

Introduction of FORM electrode arrays, designed to overcome technical difficulties
associated with fluid leakage common in cases of incomplete partition and hypoplasia
Med-Els Cochlear Implant systems are CE_marked for the indication of SSD for adults
and children

CIS: Continuous Interleaved Sampling

Cochlear

CP810 batteries: Standard rechargeable

Batteries box: Compact rechargeable
Disposable

For more powerful settings rechargeable batteries only

Mic covers: Change mic covers every 3 months

Software: Custom Sound 4.0

Thresholds & MCLs Present = J
Up in increments of 5
Run sweep once completed HF to LF and LF to HF
Check balance
Test thresholds: Up 5, down 10
Turn

1994: Spectra processor upgrades for Nucleus 22 users. This utilises SPEAK strategy, an
improved speech coding strategy providing fuller, richer, more natural sound

1997-1998
1. The first implant capable of performing Neural Response Telemetry used to provide
an objective measurement of the hearing nerves response to electrical stimulation
(NRT)
2. SPrint: Powerful bodyworn speech processor. SPrint technology is based on a
powerful Digital Signal Processor. The first MRI-safe implant up to 1.5 Tesla

1998 1. ESPrit The first multi-channel BTE processor

2. Nucleus 24 CI released: Offers technical advancements including an electrode
designed to provide more direct stimulation. Also includes the removable magnet for
MRI and the Nucleus-standard titanium casing

1999 2000
Nucleus ACE speech coding strategy developed. Designed to customise sounds by
combining the benefits of pitch information of the SPEAK strategy, with the higher rates
of stimulation offered by the CIS strategy

2000 1. Nucleus 24 Contour perimodular electrode array is introduced

2. ESPrit 22 BTE speech processor released: The fourth upgrade for Nucleus 22
recipients

2002 1. Nucleus 24 Contour Advance is introduced: Unique Softip feature designed to protect
the delicate cochlea structures
2. ESPrit 3G introduced as part of the new Nucleus 3 system: The new BTE speech
processor is compatible with Nucleus 24 implants. ESPrit 3G is the first speech
processor with a built-in telecoil

2003 2004
New ESPrit 3G for Nucleus 22: This processor is the fifth upgrade for earliest Nucleus
recipients
2005 Nucleus Freedom system. Offers input processing technologies designed to emulate
natural hearing and is the industrys first water resistant sound processor

2008 Nucleus Freedom available for Nucleus 22 implant recipients

2009 Nucleus 5 system released with the CP810 sound processor and the first ever remote
assistant
Advanced Bionics:

Software: AB soundwave 2.2

Telemetry: Automatically carries this out
Naida CI Q70 2 microphones, 1 at the top of the ear, 1 near ear canal

Clear voice: We tend to go for medium as standard. Reduced constant

background noise, only kicks in if there is background noise
Low: -3dB
Med: -6dB
High: -12dB

Ultrazoom: For noisy environments

Autosound: Dynamically adapts to listening environment, automatically

adjusts volume levels to optimise hearing

Able to store up to 5 user-selectable programs

Universal headpiece Includes a coil that transmits sound signals and power to the implant as
well as a magnet well that houses the magnets
AB myPilot Controls to manipulate program, volume, sensitivity, source-specific
listening checks and zoom control
Also provides status and battery checks
ComPilot Phonak ComPilot can be set up to be used with CI
Connects wirelessly to bluetooth

Mapping: Stimulate to switch on

When mapping, make sure you have HiRes Optima S strategy selected

1996 FDA approval for the Clarion cochlear implant with pre-formed electrode for use in
adults
Clarion sound processor is the industrys first multi-program processor with unique
single headpiece design, independent volume and sensitivity controls and nothing on
the ear

1997 Approval to market Clarion for use in children

S-Series sound processor is released

2001 CII Bionic Ear implant and HiFocus electrode, capable of being upgraded through
software programming for advancing hearing performance with additional surgery

CII BTE and Platinum BTE approved for release

2002 1. Launch in Europe of the HiResolution strategy providing full spectrum delivery with
high rate of stimulation for better temporal definition
2. Launch of the T-Mic microphone

2003 1. HiRes 90K implant launched with a new surgical design

2. Auria sound processor and new programming software (SoundWave) launched

2006 1. Launch of the Harmony HiResolution Bionic Ear System

 2. Launch of the HiRes Fidelity 120 sound processing

2007 Launch of The Listening Room, a free online resource for developing listening skills

2009 1. AB acquired by Sonova Holding AG and begins working with Phonak

2. Launch of the Processor Direct program for faster processor returns

2010 Launch of ClearVoice processing strategy

 BAHA

Older Cochlear abutment

Same as current Oticon abutments
Can be used for both Oticon and Cochlear devices

Snap coupling:
Oticon: Sits on outside
Cochlear: Sits on inside
Newer Cochlear abutment
Can only be used for Cochlear devices

Most patients will have the older abutment type but there will be some patients (implanted
between late Nunez/early Broomfield time) that will have the newer Cochlear abutment and so
can only be upgraded to a Cochlear BAHA. So will need to check this

Be careful when fitting Oticon as this may pinch skin that is too close. If this is the case then
patient will need to see ENT or consider changing to Cochlear processor

Cochlear BAHA BAHA 4.0

Batteries P13: Lower powered devices
P675: Higher powered devices
Devices Analogue:
Divino (mild HL) Has Left and Right
Intenso (moderate HL) Same model for L and R

Digital
BP100 Replaced Divino in 2009
BP110 Replaced Intenso
Both universal 3-pin
Loop stick is different different pin configuration to Oticon and old
BAHAs

BAHA 4 Replaces BP100

BP100/110 Centre button is on/off and progs

Hold down for on/off
Quick press for progs
Can have up to 3 programs
VC: Either side Button above socket = louder, button below = quieter
No automatic setting

Change covers (have gortex membrane) about every 3 months

Patient will get spares when first fitted
Replace the entire cover
BAHA 4 Looks exactly the same as the BP100 but has a wireless symbol on it
Wireless
Buttons are harder so less prone to wear
Can have 4 programs
 No L and R but computer will program so that VC is not confusing like
the BP100: VC up = front, VC down = back
pure sound IQ is the new automatic adaptive setting
Change cover every 3 months like with the BP100
FOC with BAHA 4 At the moment, if ordering BAHA 4, patient can also have a choice of
accessories

1. Remote Control
2. Phone clip
a. Connects via Bluetooth to mobile
b. Aux input
c. Can download appt so can be used as a remote control
3. Wireless mini microphone
a. Acts as an external microphone so can use in lectures,
with TV, etc
b. Aux input
4. TV streamer

Can have up to 5 devices streaming to the same processor

Leads Special Cochlear leads (in BAHA case)

Loop Need to attach little black stick to BAHA for this

Connect Select which device you are using

Click satellite button to connect
Choose based on fitting software for new fit or based on sound
processor to read current settings
Selection Adult, mixed, demo
For proper fitting Do feedback test: Can use this on old BP100/110 and BAHA 4
For IA Can go straight to BC direct
BC direct For performing hearing test through BAHA
Place BAHA behind ear
Use arrow keys and spacebar to present
Can use PT or WT
Automatically plots as you go
Check all in-between frequencies
Fine Tuning Adjust gain at a speaking level to make sound comfortable for patient
Nb! It is very usual for sounds to be different to standard HA
Finalise Save session

Oticon Oticon Medical

Batteries
Leads Standard Oticon leads
Devices Ponto Pro: BC thresholds of 35dB or better
Ponto Pro Power: BC thresholds of 45 55 dB

Ponto Plus: Same as Pro but wireless

Ponto Plus Power: Same as Pro but wireless
Controls VC on the side
Prog button is the big button on the front
On/off: Battery drawer
Can also have mute function but does still use battery
Extra Right and Left are different
 Curves toward the fitted ear, microphones positioned differently on R
and L models

4 colours

BAHA Attract Only available at the moment for patients with BC thresholds of
35dB(HL) and better

Magnet = BIM 400 (BAHA Implant Magnet)

Rather than abutment outside, place magnet under skin
Uses same processors (suggest using power device as vibrations are
buffered by soft tissue)

Surgery is the same but rather than punching hole, place magnet under
skin
Underside of magnet Medical neoprene which acts as a buffer. If too
tight, can cause rubbing and sores/skin necrosis

Advantages:
Aesthetically better (if angle is correct!)
If hearing deteriorates, magnet can be removed, hole punched and
abutment put in

Sephono BC thresholds of 35dB(HL) and better

Also magnet based

Magnet placed under skin, attached via 4 surgical screws

If hearing worsens, cannot remove 4 surgical screws as they would have

integrated to the bone

Initial Assessment

1. Patients should have questionnaires sent to them with their appointment letters
2. In appointment:

Questionnaire

Discussion Check expectations/understanding of the process/questions from

patient

HA use Discuss, GHABP/GHADP as appropriate

Otoscopy
Audiogram (with 3 and 6 kHz AC and BC). Do BC on both sides to take account of
interaural attenuation

Aided FF thresholds Use warble tones SF HI (0.5 4kHz incl. 3 kHz)

with current HA(s)
Aided FF speech WRS SF-HI
testing Start at 70dB(HL) Repeat x2 if 100%
Then go down in 10dB steps until score = 0

Program demo BAHA BAHA: BAHA 4.0

on headband Oticon: Oticon Medical
Program, BC direct and adjustments then save
Aided FF thresholds Record FF PTA and speech test with BAHA, same as before
and speech

3. Were looking for results that are at least as good as with HAs in
4. For SSD with BAHA on dead ear, it is difficult to show improvement in testing (lack of
localisation testing) so send patient away for a home trial (6 weeks)
5. If patient is suitable and would like to take BAHA away for home trial, book them back in
after 6 weeks for FUP
6. Issue booklets for current device options

7. Explanation of BAHA:
a. Sound transmitted through bone to inner ear
b. Demonstrate what BAHA looks like
c. Operation can take 45 mins 1.5 hrs
d. Implanted bit screwed in
e. Show what bits will be visible
f. Go through what happens in operation
g. Risks to hearing: operated area is well-removed from hearing structures so
should not affect hearing
8. After operation:
a. Healing cap with padding
b. Titanium implant starts to fuse with bone
c. Need to wait about 6 weeks before fitting processor
d. Hygiene After everything has healed, can shower, etc. as normal
9. Devices:
a. Two manufacturers
b. Digital, programmed through computer
10. Problems:
a. Risk of infection minimised by surgical technique but infection is still possible if
i. Implant and abutment do not fuse with bone. This is usually due to
infection in bone or around the abutment
ii. Very rare
11. If patient has the operation and does not want to proceed:
a. The external part can be unscrewed and skin will heal over
b. Internal part cannot be removed
12. Hygiene issues:
a. Special brush issued to brush the site NOT the same as a childs toothbrush
b. Need to brush every day
Admin for IAs Hy, HA use, etc. in report
Results etc. attached

CC: Steve Broomfield

Med file
PN
Ordering stock Email Vanessa
BAHA files Appointment checklist (inside front cover)
History sheets
ENT letters
BAHA IA questionnaires
FF audiogram form
ABS word lists
Speech audiogram form

BAHA appointment schedule:

Initial assessment

Home trial for SSD and depending on circumstances

See for ENT review (4th Monday of the month) if appropriate

If suitable for surgery, this will be arranged by ENT
We should be informed of date

Fitting appointment: About 6 weeks post-op

6-8 weeks: 1st review appointment

Aided FF thresholds
Aided FF speech
Use as baseline and can fine tune
Add to approx date on P/L for 12 month review

12 month review: Same as above

Book further annual review if necessary or advise patient to contact for further assistance as
required. Consider upgrading in 5 years if there is an upgrade available

BAHA files: