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

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Presentation on theme: "Cochlear Implants: Where We’ve Been, Where We’re Going Amber M. Gardner, Ph.D., CCC-A University of Virginia Health System."— Presentation transcript:

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 Alessandro Volta – early 1800s became the first to stimulate the auditory system electrically Two metal rods in his ears (approx. 50V) Two metal rods in his ears (approx. 50V) “a boom within the head” followed by a sound similar to that of boiling thick soup “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 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 Duchenne – 1885 – used an alternating current “the beating of a fly’s wings between a pane of glass and a curtain” “the beating of a fly’s wings between a pane of glass and a curtain” Improving, but not there yet… 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 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 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 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 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 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 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. 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. 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 – Lundberg stimulated the auditory nerve during a neurosurgical operation. Used a sinusoidal current - patient only heard noise – 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 – 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 Doyle et al (1964) inserted an electrode array (4 electrodes) into the cochlea of a deaf patient Patient was able to repeat phrases Patient was able to repeat phrases Simmons (1966) inserted an electrode array into the cochlea with more precision (closer to the modiolus) 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 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. Early 1970s - Michelson and House - insertion of electrode array through scala tymani driven by implantable receiver stimulators – speech processor developed to interface with the House 3M single electrode implant & was commercially marketed – 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) 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. 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. 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 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 Adults & Children Degree of SNHLProfoundProfound Severe-to-Profound Adults Profound Children Severe-to-Profound Adults, Children > age 2 Profound children < 2 years old Adult Speech Scores (open–set)0%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/A0% Lack of auditory progress, Less than 20% pediatric word tests Lack of auditory progress, 30% or less on pediatric word tests

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

17 Speech Processor (1978) Courtesy: Cochlear

18 Speech Testing (1978) Courtesy: Cochlear

19 Cochlear – Portable Speech Processor 1980 – 2 nd 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 Magnet Flexible receiver antenna Flexible receiver antenna Courtesy: Cochlear

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

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

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

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

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

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

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

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

32 Advanced Bionics 1.0 – 1994 (adults) 1.0 – 1994 (adults) 1.2 – 1996 (adults), 1997 (pediatrics) 1.2 – 1996 (adults), 1997 (pediatrics) CII ~ 2000 CII ~ 2000 Courtesy: Advanced Bionics

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

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

35 AB – BTE Speech Processors Platinum BTE 1998 CII BTE 2000 Auria & Harmony 2003 & 2006 Courtesy: Advanced Bionics

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

37 MedEl Internal Devices Combi 40+ Introduced 1996 Combi 40+ Introduced 1996

38 Pulsar CI 100 and Sonata Pulsar – September 2005 (Ceramic Housing) Pulsar – September 2005 (Ceramic Housing) Sonata – September 2007 (Titanium Housing) Sonata – September 2007 (Titanium Housing) Magnet fixed Magnet fixed 38 Courtesy: MedEl

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

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

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

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

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

44 Hybrid/EAS European & trial data indicates patients are performing significantly better with EAS than CI alone or HA alone European & trial data indicates patients are performing significantly better with EAS than CI alone or HA alone Noted especially in music & speech in noise Noted especially in music & speech in noise Points to consider Points to consider Risk of damage to residual hearing acuity during original insertion of electrode array 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? 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 Internal Components Rechargeable battery (lithium ion) Rechargeable battery (lithium ion) Microphone (subcutaneous) Microphone (subcutaneous) Speech processor Speech processor External Hardware External Hardware Battery recharger Battery recharger On/Off On/Off Volume/Sensitivity Volume/Sensitivity

46 TIKI

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

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

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

50 Thank you


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