For CI Patients
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- The Cochlear Implant
- The Benefits of Cochlear Implantation
- Candidacy
- Device Choice
- Surgery
- Activation and Programming
- Rehabilitation
- Freqently Asked Questions (FAQs)
In order to understand how a cochlear implant works, one must first have a basic understanding of how sound is transmitted in a normally-functioning ear.
How the Ear Works:
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Sounds are transmitted as acoustic waves from the outer ear to the eardrum.
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The sound waves cause the eardrum to vibrate which set the bones in the middle ear in motion.
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The motion of these bones causes the fluid within the inner ear (cochlea) to move. This fluid motion triggers sensory cells (hair cells) within the cochlea to bend and stimulate the auditory nerve.
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The auditory nerve transmits the signal to the brain which interprets and processes the signal as a hearing sensation.
Most profound hearing loss is sensorineural in nature. A sensorineural hearing loss (SNHL) is one in which the outer ear and middle ear are intact and functioning but the hair cells in the inner ear, or cochlea are damaged or absent. Sound waves are lost or distorted and cannot be transmitted through the hearing nerve to the brain. Cochlear implants bypass the damaged hair cells by stimulating the auditory nerve directly.
The cochlear implant (CI) is an electronic device that provides access to sound for those who do not benefit from traditional amplification. A CI consists of an internal and an external device. The internal device is placed inside of the cochlea during surgery. The external device consists of a microphone and speech processor and must be worn on the body/ear.
How the Cochlear Implant Works:
- A cochlear implant works by bypassing the impaired inner ear structures and electrically stimulating the auditory nerve.
- Internal Device – consists of a receiver/stimulator and electrode array that are surgically implanted under the scalp and inside the cochlea (inner ear), respectively
- External Device - picks up the sound and interprets/processes the signal that is sent to the electrodes on the inside
- A microphone picks up sound in the environment.
- The sound is then sent to the speech processor (computer). The speech processor changes the auditory signal into an electrical/digital signal. The digital signal is a code of information based on the features of speech that are critical for speech understanding in normal listeners.
- The new signal is then sent to the transmitter which connects to the internal device by a magnetic connection. It communicates with the internal receiver via a RF (radio frequency) signal.
- The internal receiver/stimulator then sends the new digital signal to the electrodes array placed inside of the cochlea.
- The electrodes then stimulate the auditory nerve.
- The signal is then carried from the auditory nerve to the brainstem.
- The brain must then interpret the electrical code to enable hearing.
The Benefits of Cochlear Implantation
The cochlear implant is a mechanism designed to provide auditory access to sound. It does this by transmitting a signal of auditory information to the auditory nerve. The auditory nerve must carry that signal to the brain, and the brain must then interpret and process the new signal as sound. Because each individual may process the sound differently and at a different rate, the range of benefit of implantation can vary widely. Other factors such as etiology of hearing loss, length of auditory deprivation, and (re)habilitative support to use the CI also influence an individual’s success with a cochlear implant.
Minimum Expected Benefits
Although a wide range of benefits exist, there are minimum expected benefits that we would expect for all CI users to achieve. They are as follows:
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Awareness to Sounds in the Environment
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Detection of sounds in the speech range (not speech understanding)
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Detection of music
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Improved speech reading ability
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Awareness of one’s own voice
With personal motivation and effective training, it is possible for some individuals to achieve even greater success with the cochlear implant; however, the benefits above describe the minimum auditory advantages that one can expect.
With appropriate training, an individual with a cochlear implant may also learn to:
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Understand and use spoken language
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Monitor personal speech to improve clarity and intonation
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Detect and understand the meaning of sounds in the environment
A cochlear implant will most benefit individuals who:
- Have a severe-to-profound sensorineural hearing loss and receive limited benefit from appropriately fit hearing aids
- Receive the implant after only a short period of auditory deprivation
- Possess sufficient motivation and/or a motivated support system (e.g., parents or family)
It is important to remember that the cochlear implant is only a mechanism designed to transmit sound to the auditory nerve. The auditory nerve must be intact to carry the acoustic signal to the brain, where the signal is interpreted as sound. The cochlear implant:
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Does NOT provide normal hearing
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Does NOT guarantee intelligible speech or age appropriate language skills
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Does NOT guarantee educational success
It is the brain that must interpret the sound and provide an individual with speech understanding.
A cochlear implant may be of benefit to children and adults with sensorineural hearing loss in both ears that is severe enough to impede speech understanding even with appropriately fit hearing aids. As a rule of thumb, candidates for cochlear implantation have word recognition scores of <50% when using their hearing aids.
Candidacy is determined via an intensive hearing evaluation. The evaluation includes medical, radiological, audiological, psychological, and communication testing. The evaluations enable our Cochlear Implant Team to determine if an individual will be likely to derive benefit from a cochlear implant. Both pediatric and adult candidates must have a minimum of 3-months of experience with appropriately fit hearing aids prior to being considered for cochlear implantation.
Specific criteria for cochlear implantation are determined by age groups:
- Bilateral profound sensorineural hearing loss
- Lack of progress in developing auditory skills
- Realistic expectations of results
- Family or caregiver is proactive with rehabilitation
- IT/MAIS score at or below 25%
Bilateral severe-to-profound sensorineural hearing loss - Minimal benefit from hearing aids
- Lack of progress in developing auditory skills
- Score of 30% or less on LNT word test
- Bilateral severe-to-profound sensorineural hearing loss
- Minimal benefit from hearing aids
- Score of 50% or less on HINT sentence test (quiet) in ear to be implanted and 60% or less in non-implant ear
Cochlear Implant Orientation
Every individual or family considering cochlear implantation must also attend a Cochlear Implant Orientation. The Cochlear Implant Orientation informs candidates and their families of what to expect following cochlear implantation. A realistic expectation of what a cochlear implant can provide is the starting point at which successful use of a cochlear implant may begin.
During the Cochlear Implant Orientation, information is provided on available devices – highlighting the features that can help guide the device choice. As one of the leading implant centers in the United States, The Indiana University Cochlear Implant Program offers the latest technological advances and clinical practices with a full range of device options.
Currently, there are three cochlear implant manufacturers. For information of each of the devices, please visit their respective websites.
Cochlear implantation is performed as outpatient surgery under general anesthesia and typically takes between two and three hours. Surgical access to the inner ear is accomplished with minimally invasive techniques and vigilant monitoring of neighboring nerves, thus allowing for a safe and effective operation and a short recovery time. Cochlear implant recipients are required to stay in the hospital overnight following surgery for post-operative monitoring. If there are no complications, a CI recipient can return home the morning following surgery. Instructions for post-operative Home Care are described below. For additional questions regarding surgery, contact your surgeon’s office:
Dr. Richard T. Miyamoto (317) 274-3556
Dr. Charles W. Yates (317) 944-6699
Post-operative Home Care Instructions
The cochlear implant system is activated after a period of healing (approximately 4-6 weeks after surgery). Recipients have the first opportunity to hear through the cochlear implant at this time. Although the sound quality of the CI is very strange and most individuals do not understand speech through the implant at first, this is the beginning of a new journey with sound.
In order for the CI recipient to hear with the implant, it must be programmed to transmit sounds appropriately for each individual’s auditory nerve. This adjustment occurs in a process called mapping. Audiologists use a computer to measure how the auditory nerve responds to sound at each of the implant’s electrode contacts. This allows the audiologists to determine the most appropriate listening settings for each recipient.
As new CI recipients learn and gain hearing experience with their implant, the auditory pathway begins to adapt to the new stimulation. An individual’s map settings need to be changed as this adaptation occurs. Through reprogramming and fine-tuning, our audiologists are able to optimize the CI recipients’ perception of sound. Map adjustments that are made as the auditory pathway is adapting serve to enhance the quality of the perceived sound for the CI recipient. The following rehabilitation schedules are recommended for optimal CI performance:
Pediatric CI Recipients
- Initial Stimulation (occurs over a 2 day period)
- 2-weeks post initial stimulation
- 1-month post initial stimulation
- 3-month post initial stimulation
- 6-month post initial stimulation
- 1-year post initial stimulation
- Every 6-months until child is 5 years old
- Annual evaluations
Adult CI Recipients
- Initial Stimulation (occurs over a 2 day period)
- 1-month post initial stimulation
- 3-month post initial stimulation
- 6-month post initial stimulation
- 1-year post initial stimulation
- Annual evaluations
Rehabilitation/Speech Therapy Services
The electronic stimulation provided by the cochlear implant is very different from acoustic hearing. Because of this, it requires a significant amount of adjustment and rehabilitation before a recipient can learn to use the implant with success. Although the cochlear implant can provide access to sound, understanding what that sound is and means takes more that just detection. Rehabilitation provides a structured model for learning to identify new sounds and to associate meaning with these sounds. Rehabilitation to facilitate the development of auditory and spoken language skills is available for both adults and children. Our speech therapists have extensive experience in auditory training and spoken language development specifically for individuals with hearing-impairment. They also communicate closely with the implant audiologists to determine an individual’s specific progress and rehabilitation needs.
The task of choosing a communication option for the recipient of a cochlear implant is an important one. Families may choose from a variety of options to facilitate the recipient’s auditory development, communication skills, and academic needs. Visual languages include: American Sign Language (ASL), Cued Speech (i.e., hand cues are used in combination with natural mouth movements to make all sounds of spoken language appear different), and Total Communication (i.e., combines oral speech, speech reading cues, and a signed language system). Communication options that aggressively develop listening and speech skills empower auditory-verbal or auditory oral techniques. These options develop auditory skills, articulation, and language through the maximized use of residual hearing. Recipients and families choosing an auditory-oral or auditory-verbal approach must understand that an auditory learning environment must be created. It is crucial that sound becomes a meaningful part of life and communication.
Obtaining a speech-language evaluation and participating in ongoing, intensive speech-language therapy is vital to the recipient’s success as an oral communicator. Speech-language evaluations should be comprehensive in nature and assess the following abilities:
- speech perception skills
- receptive and expressive vocabulary
- receptive and expressive concept development
- receptive and expressive connected language skills
- use of grammatical morphology
- speech/articulation skills
To ensure that the recipient is making adequate gains towards becoming a successful cochlear implant user, a speech and language evaluation should be conducted on an annual basis by a certified speech-language pathologist with expertise in the field of cochlear implants and auditory development. Recipients interested in obtaining more information regarding speech and language evaluations and treatment should contact the Speech and Hearing Department at Riley Hospital for Children at 317-944-8868 or 702 Barnhill Drive Indianapolis, IN 46202.
Frequently Asked Questions (FAQs)
Will my insurance cover a Cochlear Implant?
The best way to find this out is to contact your insurance company directly and ask if your policy covers the procedure. You should investigate your insurance carrier’s reimbursement policy for potential restrictions placed on the center site, surgeon, and the amount of follow-up services required. It may be helpful to determine out-of-pocket expenses that are unique to your carrier and policy. Once you are identified as a candidate for the cochlear implant, we will help you secure prior authorization and/or appeal claims that have been initially denied.
How much will my insurance pay?
We are unable to provide you with exact numbers as each policy/insurance company can be different. Please contact your insurance company directly and have a good understanding of your policy. Cochlear implants are performed on an outpatient basis.
How much money will I be required to pay?
We are unable to provide actual amounts as there is no way for us to know what each insurance plan covers at time of surgery. Also, surgery amounts, as well as various surgical services, can change. You need to be aware of your deductible, co-pay, or co-insurance, obligations prior to going into surgery.
Do I need a referral or authorization for surgery?
Prior authorization should be obtained for every patient prior to surgery being scheduled. Your surgeon’s office will work with you to obtain prior authorization from your insurance company. They will obtain any referrals that are needed for the procedure, and if your insurance company denies the procedure, your surgeon’s office will also work with you to appeal the decision or to find alternative funding options, if available. The surgery will not be scheduled until payment for the procedure has been established.
