1. Cochlear Implants: Where We’ve Been, Where We’re Going
Amber M. Gardner, Ph.D., CCC-A
University of Virginia Health System

2. Early Attempts…
Alessandro Volta – early 1800s became the first to stimulate the auditory system electrically
Two metal rods in his ears (approx. 50V)
“a boom within the head” followed by a sound similar to that of boiling thick soup

3. Early Attempts…
Realization made over the next years that since sound is more of an alternating signal, stimulating with DC wasn’t going to produce an adequate hearing sensation
Duchenne – 1885 – used an alternating current
“the beating of a fly’s wings between a pane of glass and a curtain”
Improving, but not there yet…

4. Early Attempts…
Brenner – 1868 – published study that revealed hearing sensation was better using negative polarity. Also found that a reduction of unpleasant side effects could be achieved with correct placement of the electrodes

5. Early Attempts…
1930s – thermonic valve (vacuum tube) was introduced and this allowed greater precision in electrical stimulation
Wever & Bray (1930)– electrical response recorded near the auditory nerve of a cat was similar (freq. & amplitude) to sounds to which the ear had been exposed

6. Early Attempts…
Gersuni & Volokhov (1936) First to demonstrate that with electrical stimulation hearing sensation still remained after removal of tympanic membrane & ossicles – theorized the cochlea was the site of stimulation

7. Early Attempts…
Stevens & Jones (1939) – Listed several mechanisms that produced hearing when the cochlea was stimulated electrically
Electrical energy could be converted into sound by a direct effect on the basilar membrane that would vibrate maximally at a point determined by the frequency – these vibrations would stimulate the hair cells
Direct stimulation of the auditory nerve produced a crude hearing sensation.

8. Early Attempts…
1940s & 1950s – Researchers began to realize that if more precise hearing sensations were to be produced stimulation of the auditory nerve fibers must be more localized vs. widespread current.

9. Early Attempts…
1950 – Lundberg stimulated the auditory nerve during a neurosurgical operation. Used a sinusoidal current - patient only heard noise.
1957 – Djourno & Eyries – placed a wire directly on the auditory nerve (cholesteatoma surgery). Initially pt. just heard “a roulette wheel” & “a cricket” but was eventually able to differentiate pitch and identify several words.

10. Getting Closer
Doyle et al (1964) inserted an electrode array (4 electrodes) into the cochlea of a deaf patient
Patient was able to repeat phrases
Simmons (1966) inserted an electrode array into the cochlea with more precision (closer to the modiolus)
Patient had ability to determine signal duration length and tonality was achieved

11. Almost There
Early 1970s - Michelson and House - insertion of electrode array through scala tymani driven by implantable receiver stimulators.
1972 – speech processor developed to interface with the House 3M single electrode implant & was commercially marketed.
Single channel devices - very poor speech understanding (especially in open set)

12. Multi-channel Cochlear Implant
Rod Saunders – First multi-channel CI patient (1978)
Courtesy: Cochlear

13. Increasing Channels - Speech
Channels will increase from 1 to 2, 2 to 4, 4 to 8 to 32 – note the improvement in quality.

14. Increasing Channels - Music
First you will hear the song with 4 channels, then 8, then 16, then 32 – finally you will hear the original.
Demo

15. Trends in Candidacy 1985 1990 1998 Today Age of Implantation
Adults age 18 or older
Adults & Children age 2 years or older
Adults & Children age 18 months +
Adults & Children age 12 months +
Onset of Hearing Loss
Postlinguistic
Postlinguistic Adults & Pre/Postlinguistic Children
Pre/Postlinguistic Adults & Children
Pre/Postlinguistic
Adults & Children
Degree of
SNHL
Profound
Severe-to-Profound Adults
Profound Children
Severe-to-Profound Adults, Children > age 2
Profound children
< 2 years old
Adult Speech Scores
(open–set) 0%
40% or less sentences in quiet
50% on sentences in quiet in ear to be implanted, with 60% or less in contralateral ear or binaurally
Pediatric Speech Scores
N/A
Lack of auditory progress,
Less than 20% pediatric word tests
30% or less on pediatric word tests

16. 3 FDA Approved CI Manufacturers
Cochlear – 1985
Advanced Bionics – 1996
MedEl – 2001 (1994 – European release)

17. Speech Processor (1978)
Courtesy: Cochlear

18. Speech Testing (1978)
Courtesy: Cochlear

19. Cochlear – Portable Speech Processor
1980 – 2nd Recipient (George Watson)
Courtesy: Cochlear

20. Nucleus 22 Device
Courtesy: Cochlear

21. Wearable Speech Processor (WSP) 1982
Courtesy: Cochlear

22. From WSP to Mini Speech Processor (MSP) 1986
Courtesy: Cochlear

23. CI22M (Mini 22 Implant) Magnet Flexible receiver antenna 1988
Courtesy: Cochlear

24. MSP to Spectra Introduced in 1988 to go with the CI22M
Courtesy: Cochlear

25. CI24M 1997 Removable Magnet Monopolar electrodes
Telemetry – can measure impedances
Stimulation rates increased
Courtesy: Cochlear

26. Spectra to Sprint 1997 Increased number of program slots
More flexibility
Courtesy: Cochlear

27. Esprit
1998
First BTE processor from Cochlear
Courtesy: Cochlear

28. Esprit 3G
2002 (24 users)
2004 (22 users)
Courtesy: Cochlear

29. Freedom 2005 - New internal & external devices
Same processor for BTE, bodyworn options
New “Smart Sound” features
Courtesy: Cochlear
Courtesy: Cochlear

30. System 5
Launched Sept. 8, 2009
Internal device – thinner, but same technology platform
External – thinner, more water resistant, autophone, 2 way remote control
Courtesy: Cochlear
Courtesy: Cochlear
Courtesy: Cochlear

31. Advanced Bionics History
Company started by Al Mann in 1993
received FDA approval for adults
received FDA approval for pediatrics

32. Advanced Bionics 1.0 – 1994 (adults)
1.2 – 1996 (adults), (pediatrics)
CII ~ 2000
Courtesy: Advanced Bionics

33. HiRes 90k 2003 Titanium (vs. ceramic) housing Removable magnet
Courtesy: AB

34. AB – Body Worn Processors
Courtesy: Advanced Bionics
S-Series ~ 1999
PSP~ 2001

35. AB – BTE Speech Processors
Courtesy: Advanced Bionics
Auria & Harmony & 2006
Platinum BTE
1998
CII BTE 2000

36. MedEl History 1975 - Hochmairs begin development of cochlear implant
Multi-channel CI implanted in Vienna
MedEl is founded
Industry first BTE speech processor (trials)
European approval of MedEl system
FDA approval of MedEl system
FDA approval of MRI compatibility (.2 Tesla)

37. MedEl Internal Devices
Combi 40+ Introduced 1996

38. Pulsar CI 100 and Sonata Pulsar – September 2005 (Ceramic Housing)
Sonata – September (Titanium Housing)
Magnet fixed
Courtesy: MedEl 38

39. Tempo+ Speech Processor (1999)
Lightest BTE Processor
Up to 9 Programs
One processor – multiple wearing options
Courtesy: MedEl 39

40. Opus 2 Speech Processor 2007 Ergonomic switch free design Wireless FM
Fine Tuner – bilateral support, volume, sensitivity & telecoil switches
Courtesy: MedEl

41. Future Directions Greater number of bilateral recipients
Hybrid/EAS cochlear implants
Totally implantable cochlear implants

42. Bilateral CI Benefits Insurance Coverage - class action law-suits
Improved localization
Improved speech in noise performance
Insurance Coverage - class action law-suits

43. Hybrid/EAS EAS - Electric-Acoustic Stimulation Combination of CI & HA
High frequency information - shorter electrode array
Low frequency information - HA (typically mild to moderate HL)
Still in clinical trials in US
Approved in Europe (2007)
All 3 companies still in US trials
MedEl Duet
Courtesy: MedEl 43

44. Hybrid/EAS
European & trial data indicates patients are performing significantly better with EAS than CI alone or HA alone
Noted especially in music & speech in noise
Points to consider
Risk of damage to residual hearing acuity during original insertion of electrode array
What is the course of action if hearing acuity changes and HA is no longer beneficial - additional surgery with new/standard array?

45. Totally Implantable Cochlear Implant (TICI/TIKI)
Internal Components
Rechargeable battery (lithium ion)
Microphone (subcutaneous)
Speech processor
External Hardware
Battery recharger
On/Off
Volume/Sensitivity

46. TIKI

47. Totally Implantable Cochlear Implant (TICI/TIKI)
Benefits
No external parts
able to “hide deafness”
no cables, mics... to break
Able to hear 24hrs a day (in shower, while sleeping...)

48. Totally Implantable Cochlear Implant (TICI/TIKI)
Disadvantages
Larger internal device - more surgical time/larger incision
Battery will have to be replaced (approx. 6yrs)
Replace only battery or entire device?
Hear “body noises” (breathing, swallowing). Some people are unable to adjust to these.

49. TIKI Results 3 patients implanted Melbourne
Able to have “invisible hearing” or use 3G processor
Hearing acuity
TIKI - Mild to moderate HL (improving to mild HL after 6 months)
3G - Hearing WNL
Speech discrimination - CNC Lists
TIKI - 33% (Improved as compared to pre-op)
3G - 77%

50. Thank you