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IMPLANTS
Chapter 18
THE
FACTS
CI Manufacturers
Medel
Bionics
Cochlear
CI Factoids
Canadian Study
Children with cochlear implants have
increased educational opportunities, with
those children in mainstream and those who
have moved toward mainstream
demonstrating improved progress in speech
perception ability.
Daya H, Ashley A, Gysin C, Papsin BC. (2000). Changes in educational placement and
speech perception ability after cochlear implantation in children. J Otolaryngol.
29(4):224-8.
British Study
Age at implantation and duration of deafness were found to be
significant predictors of placement two years after
implantation.
The duration of deafness of children in schools for the deaf or
units was twice that of children in mainstream education.
Fifty-three per cent of children who were in pre-school at the
time of implantation were in mainstream schools two years
after implantation, whereas only 6% of those who were already
in educational placements at the time of implantation were in
mainstream education.
The results indicate that children who are given implants early,
before an educational decision has been made, are more likely
to go to mainstream schools than those given implants when
already in an educational setting.
Archbold S, Nikolopoulos TP, O'Donoghue GM, Lutman ME. (1998) Educational
placement of deaf children following cochlear implantation. Br J Audiol. 32(5):295-300.
Cost Effective
Children with greater than 2 years of implant experience were mainstreamed
at twice the rate or more of age-matched children with profound hearing loss
who did not have implants.
Also placed less frequently in self-contained classrooms and used fewer
hours of special education support.
A cost-benefit analysis based on conservative estimates of educational
expenses from kindergarten to 12th grade shows a cost savings of cochlear
implantation and appropriate auditory (re)habilitation that ranges from
$30000 to $200000.
CI accompanied by aural (re)habilitation increases access to acoustic
information of spoken language, leading to higher rates of mainstream
placement in schools and lower dependence on special education support
services.
The cost savings that results from a decrease in the use of support services
indicates an educational cost benefit of cochlear implant (re)habilitation for
many children.
Francis HW, Koch ME, Wyatt JR, Niparko JK. (1999). Trends in educational placement
and cost-benefit considerations in children with cochlear implants. Arch Otolaryngol
Head Neck Surg. 1999 125(5):499-505.
CI by 6 Months
By the age of 2 years the subject implanted in
infancy achieved scores on the GAEL-P which
were nearly equivalent to those achieved at the age
of 5 1/2 years by children implanted at later ages.
Age-equivalent scores on the Reynell
Developmental Language Scales were achieved by
the subject implanted in infancy and the ability to
discriminate speech patterns was demonstrated
using the Visual Habituation Procedure.
CONCLUSION: This report demonstrates
enhanced language development in an infant who
received a cochlear implant at the age of 6 months.
Miyamoto RT, Houston DM, Kirk KI, Perdew AE, Svirsky MA. (2003). Language
development in deaf infants following cochlear implantation. Acta Otolaryngol.
123(2):241-4.
TC vs. Oral
Spoken word recognition improved at a faster rate
in the oral children with early implantation.
Children who underwent implantation before 3
years of age had significantly faster rates of
language development than did the children with
later implantation.
The oral children demonstrated more rapid gains
in communication abilities than did the children
who used total communication.
Kirk KI, Miyamoto RT, Lento CL, Ying E, O'Neill T, Fears B. (2002). Effects of age at
implantation in young children. Ann Otol Rhinol Laryngol Suppl. 189:69-73.
Teacher Role
Show Video(s)
60 Minutes
Oral Deaf
Celias Story
Sound & Fury
NAD CI Statement
The NAD recognizes the rights of parents to
make informed choices for their deaf and
hard of hearing children, respects their choice
to use cochlear implants and all other
assistive devices, and strongly supports the
development of the whole child and of
language and literacy. Parents have the right
to know about and understand the various
options available, including all factors that
might impact development.
NAD CI Statement
The NAD has always and continues to
support and endorse innovative
educational programming for deaf
children, implanted or not. Such
programming should actively support
the auditory and speech skills of
children in a dynamic and interactive
visual environment that utilizes sign
language and English.
Seven Steps to CI
Initial contact
Pre-CI counseling
Formal evaluation
Surgery
Fitting/mapping
Follow-up
AR
Roles
Audiologist
SLP
Educator of the Deaf
ENT
12 24 months
Severe to profound bilateral
SNHL
MLNT 30% or less in best aided
condition (25 mo to 4 yrs 11 mo)
LNT 30% or less in best aided
condition (5 yrs to 17 yrs 11 mo)
Lack of progress in auditory skill
development
No medical contraindications
High motivation and appropriate
expectations (including children
when appropriate age
A cochlear implant is an
assistive technology:
Increasing numbers
Implant Components
LEVELS OF
PERFORMANCE
Sound Awareness
Basic discrimination of sounds
Voice monitoring
Understanding environmental sounds
Understanding single words and/or phrases
Understands details in sentences
Understanding connected speech
Candidacy Requirements
Who is a candidate:
Age- FDA says 18months, but doing as young as one year
(some earlier)
Intact auditory nerve
Degree of loss- was profound, now increasingly more in
severe range
Hearing aid trial was 3 months in many places, now not as
strict in many Centers
Issue of who "is not" a candidate
Centers do not seem to be denying children access to this
surgery, however many centers strongly suggest
participation in a full mainstream environment in
coordination with the surgery. Some implant centers may
not consider "signing" students and families as candidates.
Initial consult
ABR
Audiology evaluation (with and without hearing aids, may
take many visits
CT scan- looks at anatomy of cochlea
Promontory test- looks at which ear stimulates best to an
electrical signal
ENT consult
Rehab consult
Outreach with educational programs
Surgery
Mapping
Habilitation/Rehabilitation
Surgical Considerations
General
Usually outpatient, 1-2 hours
Two parts of implant are inserted during
surgery- electrode array in cochlea and the
implant body placed in mastoid bone. Body
holds a magnet that attaches to external
components of the implant.
During
Shave area
Incision closed
After
Usually up and
around in 1-2 days
May be some
swelling externally
Warned of some
possible nausea
from anesthesia
Wait 4-5 weeks
for all
swelling/healing to
take place before
activation
Mapping/Programming Issues
Research issues
Change of research playing field now that
candidacy requirements have changed
Much of the research focuses on speech
perception and speech production
Age of implantation under 5 indicates advantage
and ease in spoken language learning, yet still
variability
There does not appear to be an age cut off when
an implant does not appear useful in some way
Research issues
Oral children may have faster gains than TC kids,
but what about ultimate outcomes?
CI increases speech and language regardless of
the modality of language programming provided.
(U. of Michigan, 2000)
Children with better communicative interaction
skills at preverbal level were also most likely to
have good speech perception and production
skills three years after implantation. (Tait and
Lutman, Robinson, 2000)
CI Guidelines
In 2002, the FDA lowered the recommended age
requirement to 12 months of age. While this is the
FDA-recommended age, this age is not legally
binding and some hospital centers in clinical trials
are completing the procedure earlier based on
expectations of improved outcomes for early
implantation. In addition, specific circumstances
may allow for earlier implantation. For example, if
meningitis is the cause of hearing loss, it may be
important for the child to be implanted as early as
possible as this condition causes ossification (bone
build up) in the cochlea, making it increasingly
difficult to surgically insert the electrode array as
time passes. Note: There may be questions related
to insurance payment for the procedure if it is
completed prior to 12 months of age.
CI Guidelines
The FDA states that a child should have
a bilateral (both ears) profound
sensorineural hearing loss; however,
increasing numbers of children with
hearing loss in the severe range are
being considered for cochlear implants.
CI Guidelines
Negligible functional benefit (limited open-set speech
recognition) from appropriate amplification is often
mentioned as a criterion.
When such measures cannot be obtained on young
children, hospital centers make individual decisions
regarding whether or not a child would be able to do
well on such tests given documented hearing levels
and traditional hearing aids.
There are varied implant center requirements
regarding the use of traditional hearing aids prior to
implantation.
Some centers waive an extended hearing aid trial
requirement in the interest of time when it is clear that
the child would perform better with a cochlear
implant.
CI Guidelines
A child who is failing to progress in speech, language,
and listening development with traditional hearing aids
based on parent report and educational information may
be considered as a candidate.
Family willingness to follow recommendations; enroll in
speech, language, and listening therapy; and return for
follow-up appointments is a factor in candidacy.
Having no medical contraindications to electrode
insertion or receiver placement is a factor in candidacy.
Educational and home environments that are supportive
of cochlear implants are factors in candidacy.
Not CI Candidates
a child that does not have the eighth nerve
(auditory nerve) which carries sound from the
cochlea to the brain as determined by a CAT
scan (x-ray) and/or Magnetic Resonance
Imaging (MRI) during the candidacy process.
a child who has significant residual hearing
levels and receives good benefit from
traditional hearing aid devices.
an oral approach,
cued speech,
total communication, or
American Sign Language,
Communication Mode
Manual
ASL
Bilingual/Bicultural
Manually Coded English
Simultaneous Communication
Total
Multisensory
Aural/Oral
Multisensory
Unisensory
Acoupedic
Auditory/verbal
McKinley, A., & Warren, S. (2000). The effectiveness of cochlear implants for
children with prelingual deafness. Journal of Early Intervention, 23.
Spoken Language
For educational environments that use either
American Sign Language or other sign
language systems to be appropriate
environments to facilitate development of
spoken language for students with cochlear
implants, there must be an ongoing
commitment of the program to value these
skills and ensure ongoing opportunities for
implanted students to develop and use
spoken language.
Communication Options
Handout on communication options