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August 2010 
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In this issue :
EURO-CIU European Association of Cochlear Implant Users 16, rue Emile Lavandier L - 1924 Luxembourg Fax: + 352 44 22 25 eurociu@implantecoclear.org |
Message from the EditorA summer newsletter is never easy to produce with everyone away on vacations or planning them. There are only two contributions from member countries this time but we hope there will be more news from other members for the autumn issue. There are several articles of note in this issue. The notes by Ruud van Hardeveld on the International Conference on Hearing Screening are of particular interest, especially the comments at the conclusion about the importance of patient organisations in promoting research and influencing decision making bodies. The initiative by the German Senior League in promoting awareness of age related hearing is particularly noteworthy; they distributed 25,000 leaflets and then turned their attention to getting the media involved in their campaign. While the AHEAD campaign is concerned with hearing loss generally in older people, it is still very important not to allow the needs of those who do not benefit from hearing aids to be forgotten. In the UK the National Cochlear Implant Users’ Association and Cochlear Implanted Children’s Support have been very active producing not only an information CD for all family doctor centres in the country, which is particularly important as the family doctor is normally the first point of contact for a deaf person seeking treatment, but also a booklet for prospective cochlear implant users. Children are not forgotten in this issue and the progress of the Leonardo project will be of interest to all who have their welfare at heart. We also attach a copy of the International Federation of the Hard of Hearing Position paper on cochlear implants. Alison Heath The deadline for the Autumn Newsletter is 1st October 2010. Please send all contributions to Alison Heath at alisonheath71@hotmail.co.uk. If you are sending a photograph Brian would like a copy sent to him direct brian.archbold2@btinternet.com to preserve the quality of the photograph. We can only print one good photograph with each article. Please send us your best one as a jpg image. Please feel free to forward this Newsletter to your colleagues, should they not get a copy of their own. If you would like our Newsletter emailed direct to your own email address, just send an email to Brian brian.archbold2@btinternet.com and we can add your name to the list. EURO-CIU future dates
The World Conference for the Hard of Hearing
The next world conference for the Hard of Hearing will be held in the land of the midnight sun - Norway - 25-28 June 2012. You can make a mailing list registration at the conference website www.ifhoh2012.no Proposals for an International Teenage CI users Meeting 2011
Photo of St John's School for the Deaf, Boston Spa, UK The Ear Foundation is pleased to be able to announce that they have received funding of 3,000 Euros from EURO-CIU for an International CI Teenage Users Summer Meeting in the UK in July 2011. The aim of this event is to bring together groups of teenagers from approximately 10 European countries for a week of shared activities. The funding received has now made it possible to hold this event which will provide a unique opportunity for teenagers to travel internationally, independently of their parents, and to meet with many other CI users of a similar age from different cultural backgrounds. Many requests and comments have been received by The Ear Foundation indicating widespread interest in attending such an event from across Europe. Places will be limited on this occasion but if it is successful then hopefully other countries will organise similar events in the future enabling more youngsters to attend. The plans for 2011 are for 8 groups of one adult and up to four 11-16 year olds from a number of European countries to meet with 10 UK participants at St. John’s School for the Deaf in Boston Spa, North Yorkshire. St. John’s will provide accommodation and meals and there will be five full days of activities. The adult from each group will, along with a number of UK adults, form the staff for the week. A wide variety of activities will be held at the school and there will be at least two trips out to visit York and the great British seaside. Activities over the week will facilitate social development, self esteem and independence with the added opportunity to practise English in a safe environment that supports the communication needs of the teenagers. Ultimately those who attend will have fun and be provided with a rich and memorable life experience. Delegations will be able to arrive over the weekend in time for the activities to start on Monday 25th July morning. The week will end with a party on the evening of Friday 29th July with accommodation being available until Saturday the 30th of July. Each delegation will need to fund their own transport and make a donation towards the overall running of the event. However these exact costs have yet to be decided. We will keep you informed as plans progress and hope to be able to confirm the event soon. If you are interested in attending with a team then please let us know and we can ensure you receive an application form. Jackie Salter The Ear Foundation Jackie@earfoundation.org.uk or Ruud van Hardeveld EURO-CIU erveha@xs4all.nl FROM SPAIN: Professor Graeme Clark is invested Doctor Honoris Causa by the University of Saragossa
Last May 21st, Professor Graeme Clark was invested Doctor Honoris Causa by the University of Saragossa (Spain). To attend the ceremony, which took place in the Paraninfo (the auditorium), the Professor and his wife travelled to Saragossa, Spain. Dr. Héctor Vallés, Director of the Cochlear Implant Program in Aragón, was the main sponsor of the investiture. Because of that, he made a speech praising the work and life of Professor Clark. After that, the Rector gave the degree of Doctor and proceeded to the investiture by the sponsors with the imposition of the cap, which in his case was yellow. Then, Professor Clark made the doctorate oath as required by the Secretary, and it was then that the Rector imposed the Medal and gave him the title of Doctor. Next, the new Doctor Honoris Causa delivered his Master Lecture entitled “The multichannel Cochlear Implant and the mitigation of severe-to-profound deafness”. A lot of cochlear implant users, deaf people and representatives of associations attended to the ceremony. They could understand everything thanks to Federación AICE, which made the live transcription, and ASZA, which provided the sign language interpreters. FROM SPAIN: A Tribute to Professor Clark by cochlear implant users
Since Professor Graeme Clark was in Zaragoza (Spain) because of his Doctor Honoris Causa by the University of Zaragoza, the Spanish Federation of Cochlear Implant Users (Federación AICE) wanted to arrange a meeting with cochlear implant users, so that we could convey our thanks to the professor. With the invaluable help from the University of Zaragoza and Dr. Héctor Vallés, this encounter took place in the Main Lecture Theatre (Aula Magna) on the very same day of the investiture. We wanted the event to be as accessible as possible so the Federación AICE took care of the live transcription and ASZA (Association of Deaf People of Aragón and Zaragoza) provided the sign language interpreters. And, of course, we wanted Professor Clark to understand us, so we hired an English/Spanish interpreter. It was a very moving event. Testimonies from associations and, especially, CI users were touching and very emotional. Everyone wanted to express their gratitude to Professor Clark, saying that he has changed their life. Federación AICE gave him a plaque, made by one of its members and a cochlear implant user. The text on the plaque was as follows: To Professor Graeme Clark on behalf of the Spanish Cochlear Implant Users, in grateful appreciation of his contribution to the development of this technical assistance which has improved our quality of life. Federación AICE. Professor Clark paid attention to everyone and listened very carefully. He said that “I have never had such a warm welcome and I’ll never forget it. It makes me feel that we’re all members from a big family. Your words let me know that all the hard work has been worthwhile”. The event ended with a standing ovation dedicated to Professor Clark, which lasted a few minutes. Then, breaking the protocol, everyone approached to him and asked him for autographs and photos. FROM THE UK: Deaf Awareness Week and a Parliamentary Reception
Photo: John Leech MP with Annie Wilson from CICS (the Cochlear Implanted Children's Support group). The General Election held in May this year resulted in the overthrow of the Labour government, which had held office for thirteen years, and the return of a Conservative majority but not an overall majority so a coalition government has been formed with the Liberal Democrats. There are many new MPs and also the new government has plans for the re-organisation of the health service. However, the guidelines for cochlear implants of the National Institute for Health and Clinical Excellence, published last year are not likely to be affected and will still remain the agreed guidelines for the purchase of cochlear implants by health authorities. All these changes have meant that it is of great importance to keep cochlear implants in the public eye. Every year we have a Deaf Awareness Week and as a part of the activities UKCoD (United Kingdom Council on Deafness), RNID and the National Deaf Children’s Society organised a Parliamentary Reception in the House of Commons. Over 70 MPs and Peers attended the event. There were speeches; and representatives from the deaf charities worked hard engaging with the politicians on the issues that affect deaf and hard of hearing people. Annie Wilson from CICS was there talking to MPs and making quite sure that they understood the benefits of cochlear implants. She also highlighted the fact that provision across the country was uneven and deaf people needed support from their MPs when the services failed them. FROM THE UK: An information CD for General Practitioners (Family Doctors)The National Cochlear Implant Users’ Association (NCIUA) and the Cochlear Implanted Children’s Support group (CICS) have jointly produced a CD aimed at general practitioners (GPs). The aim of this information CD is to educate and drive home the message that a cochlear implant is the only effective device available for the treatment of hearing loss in profoundly deaf adults and children. It seeks to raise awareness of the benefits of cochlear implantation among GPs. The CD includes a video of a cochlear implant operation. It has been distributed to all GP practices in England and Wales. This has happened at a particularly opportune moment as we not only have the NICE guidelines, which recommend the purchase of CIs for children and adults, but also the new government plans to hand back much responsibility for the purchase of health services to the GPs so they are going to be the lynch pin in the system. This was a major project for both organisations involved. It was funded by three CI manufacturers: Advanced Bionics, Cochlear and MED-EL. FROM THE UK: Cochlear implants: experiences of adults and children
A completely new edition of this very popular booklet has been compiled and published by NCIUA. This informative and useful publication is aimed at potential candidates for cochlear implants and their families. It contains an introduction which explains what a cochlear implant is, who may benefit and provides a clear explanation of the process from assessment to switch on. There are eighteen personal stories of cochlear implant users; parents write about their children, teenagers give their stories and adults, young and old, have written about their experiences and how the CI has changed their lives. The 40 page booklet has colour illustrations and photographs of the contributors. The booklet is free and is being distributed mainly through the cochlear implants centres. Copies of the CD and booklet may be obtained from: NCIUA, 70 Sycamore Road, Amersham, Buckinghamshire HP6 5DR; Email: enquiries@nciua.org.uk FROM THE UK: Research from The Ear Foundation
From diagnosis to implantation: what we can learn from parental experience The Ear Foundation recently carried out a study looking at the path from early diagnosis to implantation, from the perspective of parents. Earlier diagnosis of deafness has made earlier implantation more likely; however, it is not clear that the age at implantation has been lowered as a result in the UK as it has been in other countries. We interviewed eleven families of children implanted below the age of 36 months using a semi-structured interview schedule, exploring views on diagnosis, hearing aids fitting and path to implantation. We found that parental experiences and their routes to cochlear implantation were complex and diverse in this sample. The speed at which implantation moved ahead often depended on parental intervention, and whether a child was diagnosed in an audiology service near an implant centre. Some parents wanted the implant referral to obtain a full audiological evaluation, which they felt was not available locally. There was little consensus about criteria for referral for implantation; Newborn hearing screening does not identify all young children who may subsequently need a cochlear implant, and children with early onset progressive losses and Auditory Neuropathy Spectrum Disorder remain at risk of ‘later’ implantation. Listening to parents revealed that early diagnosis does not automatically lead to early implantation: there often remains a reluctance to refer early to cochlear implant centres. Parents in this study in the UK had to drive forward the assessment for early implantation. The study was funded by Cochlear Europe and a booklet about the results is available free from The Ear Foundation: www.earfoundation.org.uk; the study was carried out by Alex Wheeler. Impressions of the International Conference on Adult Hearing Screening in Cernobbio, Italy by Dr Ruud van Hardeveld
Photo - in the grounds of the Conference Centre at Cernobbio (Como) The AHS-conference was organized because the need for Adult Hearing Care is becoming recognized and research in this field is gaining momentum. It is generally agreed that it is time to start planning hearing screening guidelines for adults and the elderly. Scientific literature indicates that screening and early treatment of hearing loss have the potential to significantly improve the quality of life and extent the functional status of adult population. The conference was supported by AHEAD III (Assessment of Hearing in Elderly), an EC research programme commissioned for three years (2008 – 2011). Some interesting results from the programme were reported during the conference. Prof. Probst, discussed the origins of the Age Related Hearing Loss, and expressed his concerns about the steadily increasing mean age of the population and the concomitant increasing number of hearing impaired persons. The life expectancy of the cohort of 65+ increased linearly in the period from 1850 to 2007 from 45 years to about 75 and there is no indication that it will level off. This means that the majority of those being born in this century will live to be 100 years old and more! However, what is being done about the declining functional abilities and senses? Today mobility and independency have already improved, and the same holds for vision owing to cataract surgery. However, an increase in the incidence of dementia and cancer is expected and what about hearing loss? It is noticeable that in the 70+ and 80+ cohorts there are many more hard of hearing men than women, which is partially due to the differences in the hormones of the genders. The decline of central auditory functions as a component of ARHL is becoming increasingly recognized and investigated among others by S. Gordon and Prof B. Schneider. The hearing status of adults is found to correlate closely with cognitive performance. Recent research suggests that the communication difficulties encountered by older adults are largely due to age related losses in sensory perceptual processes. Older adults have to engage their cognitive resources more often and more fully to recover imperfectly heard material, leaving fewer (memory) resources for higher-order tasks involved in speech communication. In stressful situations (work) and background noise, in which listening requires a lot of concentration, a memory deficit can occur. (note by RvH: This holds also for the older CI wearers). The use of hearing aids contribute greatly to the quality of life. This is proved by an economic evaluation showing that screening is very cost effective. B. Weinstein found that hearing impairment is a serious risk factor for fall-induced injuries. She and many other speakers advocate HL screening as first line care. The take up and use of hearing aids is amazingly low, especially in the less developed countries. Worldwide the percentage of hearing impaired persons using an hearing aid differs greatly: Australia 40%, USA 18%, Europe18%, Japan 13%, Russia 6% and China 1-2%. Nonetheless the development of the hearing aids as (expensive) high tech communication devices continues. Details about a very interesting initiative of the German Senior League (DSL) together with the University of Berlin (UKB) were given. They run campaigns to promote awareness of the medical and social needs of the aging population. In February 2010, 25,000 brochures for professionals about ARHL were distributed. The second stage of the campaign to increase the awareness of the media about ARHL started in May with press releases being sent to the media, newspapers and radio/TV, all over Germany. The contributions concerning Cochlear Implantation were few in number and brought no new insights. Prof. Grandori will welcome any initiative and/or suggestions from EURO-CIU or other patient organizations for continuation of the AHEAD program. Patient organizations can make a big contribution towards the realization of screening programs and influencing decision making authorities of the need to take action. AHEAD III brings the hard of hearing into a broader context and makes it clear that we, as European patient organizations, should take responsibility for enhancing the effort by supporting this kind of (research) work on a national and EC level. EUROPEAN UNION LEONARDO DA VINCI PROJECT
Photo: members of the committee hard at work. FEAPDA (European Federation of Teachers of the Deaf) is one of five partners working together on the project. The partners comprise FEAPDA and the Universities of Oxford Brookes, Malta, Leuven in Belgium and the Sensory Inclusion Service of Telford and Wrekin. Its purpose is to develop competencies for teachers of the deaf which would be applicable across the continent of Europe, with the over-riding aim of reducing the exclusion of deaf children from educational opportunities through appropriate support and intervention from teachers of the deaf. The project is half way through its two year life span and has now reached the stage at which we are ready to make some initial moves towards consultation. In order to demonstrate the evidence of need, the partners have built up a picture of the prevalence of deafness across Europe and the numbers and qualifications of teachers of the deaf, including highlighting those areas where there is not specialist training at all. At the last meeting of the first year, which took place in Malta, we developed a draft set of competencies for the first round of consultation. We decided to approach colleagues from the widest possible range of people including teachers of the deaf, trainees, teacher trainers, parents and young people themselves. We also determined on the use of focus groups which would allow small groups of respondents to meet together to discuss the document. The interaction between the groups would allow new ideas to emerge and be explored. Therefore we decided to try to trial the competencies through a questionnaire and to arrange focus groups in time to get significant data to consider at the next meeting. We decided to ask respondents to rate each one on a four point scale. These would be categorized as follows:
This, it is hoped, will produce a range of competencies from those felt to be utterly essential – core competencies – for those who work with deaf children and young people in any way, including those with cochlear implants, of course, to those which are peripheral and do not need to be part of the core skills and attributes of the teacher of the deaf. We also decided to ask respondents to choose the ten or so most important from each group of competencies. We left Malta pleased that the first year’s work had gone to plan and that we had developed a robust set of draft competencies to start work on. (Please note that a longer, illustrated version of this report will appear in the September 2010 issue of the British Association of Teachers of the Deaf (BATOD) magazine.) FROM ADVANCED BIONICS: Advanced Bionics launches Bionic Ear Association™ in the UK
Earlier this year, Advanced Bionics launched the Bionic Ear Association (BEA) in the UK. The BEA is a support network dedicated to improving the quality of life of individuals with severe-to-profound hearing loss by providing valuable information, education, awareness and guidance on cochlear implants. The BEA has been in operation in the United States since 2001, and its expansion to the UK is part of the Advanced Bionics commitment to helping others to Hear and Be Heard. If you and your users are interested in cochlear implants, and would like to contact an AB User, connect to one of our dedicated Mentors today on www.advancedbionics.com/UK If you and your users wish to find out more about cochlear implants, please visit www.HearingJourney.com , the place to chat and share stories about cochlear implants and hearing loss. FROM ADVANCED BIONICS: AB Harmony Listening Check™ - check a child’s Auria™ or Harmony™ sound processor
The Harmony Listening Check is a new tool from Advanced Bionics (AB) that enables parents and teachers to easily check a child’s Auria or Harmony sound processor, or the naturally placed T-Mic™, by doing a quick and easy listening test. The Listening Check can also be used to verify that FM equipment is working properly, such as the dynamic FM systems from Phonak, which wirelessly connect to Harmony using the iConnect™ earhook. With the new Listening Check included as part of the paediatric Harmony kit, everyone can be confident that young children are hearing their world with AB and Phonak. For further information please contact Advanced Bionics Europe Tel: +33 (0)3 89 65 98 00, e-mail: europe@advancedbionics.com or visit www.BionicEar.eu FROM COCHLEAR: Breaking ground with Cochlear™ Nucleus® 5
Only Nucleus CI systems utilise all three dimensions of sound to optimise hearing performance in noise. Listening is a complicated process that relies on the brain being able to recognise and interpret constant fluctuations and minute differences in the sounds around us – differences in intensity, spectral shape and origin. The Cochlear™ Nucleus® 5 System breaks new ground in hearing performance, making use of all these different dimensions of sound to enhance the listener’s hearing performance – particularly in noise. Nucleus 5 combines sophisticated single microphone signal processing algorithms with dual microphone technology to deliver the best possible hearing experience. Outstanding single microphone technology The Freedom™ and the CP810 Sound Processor operate two independent automatic single microphone processing algorithms: Automatic Sensitivity Control (ASC) preserves a positive signal to noise ratio – even in loud listening conditions, and ADRO® optimises audibility and comfort in dynamic listening conditions across the whole frequency spectrum. Both processing strategies have long proven their effectiveness1, 2, 3. The combination of both processing strategies substantially improved hearing in noise over and above ADRO alone4 and outperformed an otherwise comparable group of users of a contemporary competitive cochlear implant system5. However, in real life, sounds do not come from a single speaker alone, but are spatially distributed. Sophisticated dual microphone technology takes advantage of this, and further improves hearing performance in more real-life conditions – beyond what is possible with single microphone processing alone. Users of single microphone systems cannot reach their optimal hearing potential. Yet, premium microphone technology is only the first step to breaking performance barriers. Optimised hearing in various real-life situations A suite of dual microphone technology optimises hearing performance in various real-life conditions. Standard directional is active in the Smart Sound Everyday programme. This setting is good for quiet or windy environments and when there is no specific sound source to listen to. Zoom, which is new in Nucleus 5, is used in the Smart Sound Noise programme. Zoom is a great choice for situations when the desired signal is relatively stationary and remains in front of the cochlear implant user, and noise is behind the listener and is not moving. It is also an excellent choice for situations where the user can (re-)position himself or herself so that the noise is behind and the speaker in front. Beam™ is active in the Smart Sound Focus programme. Thanks to precisely calibrated microphones, Beam in CP810 is approximately 5dB more effective than in Freedom. The adaptive directionality produces a maximum sensitivity towards the front. The direction of maximum suppression adapts for maximum attenuation of the currently most dominant noise coming from the back. Beam in the Focus programme works well when the implant user is listening to TV and, for example, children are playing behind him or her in the same room. FROM COCHLEAR: Cochlear™ Nucleus® 5 System scoops top design award
The world’s thinnest and strongest cochlear implant with a slim and superbly performing sound processor – Cochlear™ has been awarded one of the world's most prestigious design awards for its breakthrough Cochlear™ Nucleus® 5 System. The highly coveted red dot award: product design is granted for outstanding, creative, innovative and high-quality products. This year, the Cochlear Nucleus 5 System has won the product design award 2010 for the world’s thinnest and strongest cochlear implant, a slim and sophisticated sound processor with a range of new benefits, including an automatic phone detection feature, software upgrades with significant improvements in functionality, and the first ever hand-held “remote assistant” for day-to-day system management. Striving to deliver on its brand promise, Cochlear is proud to receive this distinction in recognition of its efforts and as an endorsement of its state-of-the art devices – ergonomically designed for patient wearing comfort. “To receive such an important international design award is a great honour for us,” said Dr Chris Roberts, CEO of Cochlear. “Effective innovative design, like we have achieved with Cochlear Nucleus 5, brings together significant technological advances with our users’ own requirements to provide an effective and enjoyable way of hearing now, and always.” Established in 1955, the red dot design awards are considered among the most significant in the world. Last year, more than 12,000 award submissions were made from 60 countries. FROM MED-EL: Introducing the latest generation of the MAESTRO™ Cochlear Implant System
Photo: eye-catching MED-EL balloon at the Stockholm conference
The world’s smallest and lightest titanium cochlear implant was presented by MED-EL Medical Electronics at the international CI 2010 conference in Stockholm. The new CONCERTOTM cochlear implant is part of the MAESTRO 2010 system. Founder and CEO Ingeborg Hochmair personally introduced the system in Stockholm. “We are really proud to present the latest generation of MAESTRO, the best performing cochlear implant system on the market,” said Hochmair. “Every newly developed component of the system – the CONCERTO Implant, the OPUS 2 processor, the MAESTRO System Software – is the result of intensive research and development.” The components of the MAESTRO 2010 system The core of the MAESTRO 2010 system is the new CONCERTO cochlear implant. It is the world’s smallest and lightest implant with titanium housing. It is 25% thinner than its predecessor and is designed for minimally invasive surgical techniques. An essential part of every cochlear implant is the electrode array. MED-EL offers not only the largest selection of electrode arrays, but also the softest and most flexible arrays on the market. These arrays ensure that the integrity of the delicate structures of the inner ear is maintained during surgery. This is especially important for children who may receive multiple implants within their lifetime. Gentle implantation is essential for the preservation of natural, residual hearing. The second part of the system is the OPUS 2 audio processor. The OPUS 2 is the smallest and lightest audio processor available and is now up to 50 % more energy efficient. The processor can be used continuously for up to 90 hours with the same set of zinc air batteries. New colours are also available, including four colours especially developed for children. Users can now select from 12 colours in total making the easy to use OPUS 2 even more attractive. MAESTRO System Software 4.0 is the third component of the system. It offers over 40 new features as well as a new, intuitive user interface. Audiologists and CI experts benefit from more efficient fittings as well as the ability to provide personalised changes to fit the unique needs of individual users. For more information, please contact: MED-EL Worldwide Headquarters FROM NEURELEC: some helpful hints
Cleaning and drying your sound processor. In summer, your behind the ear processor may be exposed to strong humidity, moisture and perspiration. With time, humidity can lead to premature oxidation of the electronic equipment that could cause malfunction. Drying your sound processor will help you to ensure long life to your system and a maximum of comfort. Therefore, it is very important to take good care of your processor and to clean it every day. Drying your system is simple! Various systems exist. Neurelec’s drying system, compound of gel sachets and a tiny box, is very handy. Tiny, it can be taken in a bag, and used anywhere, at anytime. Before you put the external part in the box, remember to clean it properly with anti-bacterial and anti-fungal impregnated wipes or solution. The latter will help to eliminate dust and sweat residues. Patients with an earpiece exposed to wax are strongly recommended to often wipe the loop. Contact Neurelec or its local distributor for more information. Get your system insured against loss or damage. Your Neurelec cochlear implant is under warranty: 3 years for the external part and 10 years for the internal part. The warranty does not protect against loss or accidental damage. Getting your cochlear system insured will help you to protect your asset against loss, robbery, accidental damage or for repairing or replacing when your warranty runs out. Different coverage is offered by insurance companies. Get in touch with Neurelec’s local distributor for more information and advice on specialized companies to insure cochlear implants or hearing aids. A quick reminder... Over the summer, it is always nice to spend time beside water... Neurelec would like to remind you on these points:
International Federation of Hard of Hearing: Position Statement: Cochlear Implants
Background A cochlear implant is an electronic device that can help in providing a sense of sound to persons who are deaf or severely hard of hearing. The implant consists of an external receiver/processor that sits behind the ear and an internal part consisting of an electrode array placed surgically within the cochlea. An implant does not restore normal hearing; instead it can give a useful representation of sounds and enhance speech comprehension. According to the Food and Drug Administration (FDA), as of April 2009 approximately 188,000 patients worldwide have been implanted 1. Over the last 30 years cochlear implants have developed from a speculative laboratory procedure to an accepted clinical practice. Initially, cochlear implants were primitive, single channel devices that could convey only the most salient speech cues (the duration and relative intensity of the speech wave). At first, implanted people were mainly those who were deafened as adults, and had no residual hearing. The limited benefits possible with this generation of implants – improving overall speech reading skills and auditory "coupling" to a sound-producing environment were of sufficient value so as to encourage continued research on the device. Early studies demonstrated that cochlear implants were beneficial in enhancing speech reading skills; however, apart of exceptional cases, cochlear implants could provide little or no open-set speech perception. Over the years, cochlear implants have benefited from the remarkable advances occurring in microprocessors and miniature electronic circuitry. The primitive single channel cochlear implants have been superseded by complex multi-channel devices. This development enabled the processor to closely mimic the spectral envelope of a speech input. In addition, processing algorithms were added translating this information into electrical stimulation at various sites of the electrode array. There are currently a number of implant brands on the market. These implants generally function in a similar manner, based on the same basic principles, yet at the same time have their unique features and characteristics. All current devices provide multichannel stimulation, use communication between the external hardware and the internal receiver, incorporate telemetry (which enables monitoring of the integrity of the intracochlear electrodes) and utilize advanced speech processing strategies. Current devices contain inbuilt telecoils and, therefore, are compatible with assistive listening devices such as FM systems. Some devices have directional microphones and offer additional features that are thought to assist in reducing the disturbance of background noise. Ongoing research is being conducted into ways to further improve the functioning of cochlear implants in noise and other environments, and to improve its ability to process music. Research is continuously underway into ways of preserving residual hearing during cochlear implantation especially in those candidates who have significant residual low frequency hearing; such devices aim to combine hearing aid and cochlear implant technologies. Over the last years there has been an increasing tendency towards bilateral cochlear implantation, so much so that in many centres this is now becoming almost standard clinical practice for patients who meet the relevant criteria. Much research has been conducted on this subject and there have been numerous studies that have shown the significant benefit of both simultaneous and sequential bilateral implantation in both adults and children. As postlingually deafened adults are concerned, results to date clearly indicate that such individuals generally receive a significant degree of benefit from an implant, with most of these people demonstrating substantial improvement in auditory alone speech perception. Research has shown that there are number of significant factors that contribute to the outcome of such individuals such as duration of profound loss, level of residual hearing, aetiology, use of hearing aids. Over the years criteria for implantation of this group has changed significantly. As mentioned earlier, only adults with profound to total hearing loss were originally considered candidates. Currently adults with moderate to severe hearing loss are also being considered. In the case of adults with significant residual hearing, the decision to implant is based not only on their absolute hearing thresholds, but more importantly on their aided speech perception scores which gives a stronger indication of the level of difficulty they may experience in everyday communication and as such, their potential to improve with a cochlear implant. When dealing with the cochlear implantation in congenitally hearing impaired adults and older children, results are much more varied and individual than postlingually deafened adults. Although many have reported enhanced detection of environmental sounds, as well as improved speech reading ability, and even some auditory alone speech recognition, other individuals have reported little to no benefit and have subsequently become non users. As with postlingually deafened adults, there are various factors that affect outcomes in this group, including age of onset of hearing loss, age at first hearing aid fitting, duration of profound loss and communication mode. For example, an individual who has employed sign language as their primary communication mode is likely to experience limited benefit from a cochlear implant. Similarly the duration of profound deafness may give an indication as to the extent of auditory deprivation and the ability of the auditory pathways to make use of electrical stimulation. Results in this group are highly variable, highly individual and highly subjective. For example, 0% speech perception scores may be clinically seen as unsuccessful, but for the same individual the increased awareness of environmental sounds may be highly advantageous and could be subjectively viewed as a highly successful outcome. The decision of both postlingually deafened and congenitally deafened adults whether to have cochlear implant must be fully informed and the clients are to be aware of possible outcomes as well as the possible risks involved with the surgery and thereafter. Regarding children, the age at which a child is considered for cochlear implantation has decreased significantly over recent years. This is based on research showing that the earlier a child is implanted the more likely they will be to develop normal speech and language with minimal delay compared to normal hearing peers. This is based on research showing that the earlier the implant, the greater impact it has on speech development. This decision, made by the parents should also be an informed decision, based on the consequences of the implantation in the long run. Based on the current research, the results with children can be broken down into two groups. The first group of children are those who were born with normal hearing, but who developed a severe to profound hearing loss sometime after birth. The best candidates in this group are generally those who have had the longest period of normal hearing, as well as the shortest period from the onset of the profound hearing loss to the date of implantation. The results with these children indicate that the implant gives them immediate access to important speech features, which they can demonstrate by imitating most phonemes and combinations of phonemes through audition alone. Sustained auditory language training is necessary, as with training and experience, most of these children are capable of comprehending speech through the auditory channel alone. Those whose training program does not emphasize auditory learning continue to make auditory progress, but not at the same rate as those that receive adequate training. The second group of children are those with congenital hearing losses. When implanted, these children do not display the same auditory responsiveness as the children in the first group. Lacking an auditory memory, the goal with these children is to help them develop auditory awareness. Unlike the first group who simply need their previous auditory memory status restimulated, this second group of children must be taught to be aware of sounds in the environment, to "scan" for auditory events, and to listen and to imitate incoming speech sounds. Progress is slower than the first group, but what research and clinical observations are making increasingly evident, is that given an appropriate auditory language training program , auditory progress does continue. The most recent observations suggest that after several years of experience and training, this group of children may reach the same auditory developmental level as that of the first group. Policy recommendations A: Preamble IFHOH recognizes cochlear implants as a "Hearing Aid", the currently final step in a continuum which began with a cupped hand behind the ear, leading to non-electronic ear trumpets, various forms of electronic hearing aids, and acoustic signal processors of all kinds. Future technology may include; other types of implants to more central auditory brain structures, the application of stem cell research, the regeneration of inner ear hair cells or other, not yet conceived possibilities. Conceptually and functionally all of these devices have had the same purpose – to improve oral communication – and cochlear implants are no different. As with other such devices the employment of cochlear implants depends upon the needs, expectations and evaluation of the involved individual. In accordance with the principles of the U.N Convention on the Rights of Persons with Disabilities (2006), assistive technologies enhancing full participation and inclusion in society should be made available. Recognizing the importance of such devices for the development of people with hearing loss in all aspects of life, IFHOH encourages all states to establish health programs providing hearing rehabilitation to all, including the supply of hearing aids, cochlear implants and other assistive devices. B: Adults 1. IFHOH recommends that all adults with severe / profound or total hearing loss, congenital or acquired, be considered potential candidates for a cochlear implant. The hearing loss must be of sufficient degree, that even when aided, speech perception through audition alone is limited. The decision as to whether to undergo cochlear implantation must depend upon the informed consent of the individual involved and also upon recommendation by a health care professional (i.e. audiologist and ENT specialist). 2. The key prerequisite is information. All cochlear implant candidates must be fully informed of the entire process including the pre-operative investigations, the surgical procedure, and the post-operative program. Only those surgical facilities which offer a satisfactory range of pre- and post-operative services should be considered. 3. IFHOH recommends that persons contemplating cochlear implantation be evaluated and implanted in a centre with demonstrable expertise. Factors to consider are the experience of the centre, the nature of the pre-operative evaluations, the frequency of the routine follow-up evaluations, and whether an Aural Rehabilitation program is recommended and conducted. When in doubt, the person with a hearing loss should obtain a second opinion. 4. IFHOH recommends that individuals be eligible for two cochlear implants when necessary and that nation states should establish health programs to make this possible. C: Children 1. As a general rule, the decision to implant should be made as soon as possible after an acquired hearing loss has been diagnosed, and as early in the child’s life as possible for those with congenital hearing loss. No child should be considered a candidate unless he or she undergoes a significant trial period with appropriate conventional amplification followed by appropriate assessments to determine their ability to maximise any residual hearing. As a general rule, children who have severe to profound hearing losses, who show limited access to the speech spectrum with appropriate amplification are considered candidates for cochlear implantation. This decision should not be made solely on absolute audiological measurements, but should be made in combination with the speech therapist’s report regarding the child’s functional progress. 2. The final decision regarding a cochlear implant must be made by a child’s parents. The responsibilities of the professional team involved in the implant process are to provide the parents with all the information they need to make such a decision. The full range of possible results must be explained, including explicit comments that the procedure does not replace the ear (as many parents think) or produce normal hearing. It is reasonable to use the average accomplishments of children who have been implanted to date a legitimate prognostic marker. 3. The ability of a child to benefit from a cochlear implant is directly related to the adequacy of the subsequent educational program. If audition is not intensively and continually stressed in the training program, it is less likely that the full potential benefits of the implant can be realized. 4. As yet there is not enough information on the ultimate social and psychological consequences of implanting a young deaf child. We do not fully know how implantees will feel about the procedure when they are young adults, as they begin making their own decisions regarding their future. Judging from experiences to date with severely and profoundly hearing-impaired children who utilize conventional amplification techniques, there will be no unanimity of responses. Some will resent the "imposition" of a prosthetic device upon them; others will bless their parents for making the decision. This updated policy paper is based on a former policy paper of IFHOH. Valuable contributions and changes were made by Ricki Salomon (Israel), Ruth Warick (Canada) and Marcel Bobeldijk (Netherlands) and edited by Ahiya Kamara and Gaby Admon-Rick (Israel) 1 National Institute of Deafness and other Communication Disorders (US) – Web Site. IFHOH c/o Hörselskadades Riksförbund; Box 6605, SE-113 84 Stockholm, SWEDEN |
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