http://www.washingtonpost.com/wp-dyn/content/article/2006/01/09/AR2006010901541.html
Increasingly, Wired for Sound
New Technology, Guidelines Extend Reach of the 'Bionic Solution' to Hearing
Loss: Cochlear Implants
By Ranit Mishori
Special to The Washington Post
Tuesday, January 10, 2006; HE01
One afternoon in 1999, Denise Portis's son Christopher fell and hurt himself
badly. But Portis didn't answer his cries. The reason: She couldn't hear
him. Since age 27, she'd been living with a profound and progressive hearing
loss, its cause unknown. She thought she'd adapted. Then the incident with
Christopher "shook my world," the Frederick woman recalls.
She already was using two hearing aids, but she knew she needed something
else. A while later, she got it: a cochlear implant -- a needle-sized
electrode surgically placed under the skin at the base of the skull, behind
the ear.
Last July, several congressmen and guests of the Congressional Hearing
Health Caucus watched a video of the results. As a technician switches on
the device, amazement lights up Portis's face.
Then Christopher, now 14, said, "Hi, Mom."
Portis, 39, bursts into tears.
"The last time I really heard him clearly," she recalled later, "he was in
kindergarten and he still had a little-boy voice."
Growing numbers of Americans appear to be joining Portis in opting for the
"bionic solution" to hearing loss. Med-El, one of three leading implant
manufacturers, estimates market growth at 15 to 20 percent a year. According
to the Food and Drug Administration (FDA), approximately 13,000 adults and
10,000 children had received implants as of 2002, the last year for which
data are available.
Several factors suggest growth could accelerate. In April the Center for
Medicare and Medicaid Services expanded implant eligibility criteria. Some
researchers are recommending "doubling up" -- getting an implant in each ear
-- for better results. Meanwhile, the devices are becoming smaller and more
reliable, while implant surgery is growing faster and easier: It is now
usually done in a few hours as an outpatient procedure. A hybrid device
being evaluated by the FDA -- a digital hearing aid coupled with a cochlear
implant and speech processor -- is designed for people with hearing loss too
severe for effective use of hearing aids but too good for standard cochlear
implants. Some experts predict that could double the number of people who
would benefit from implantation.
Implants are becoming almost trendy: Rush Limbaugh has one; so does former
Miss America Heather Whitestone McCallum. Hip-hop singer Foxy Brown, who
recently disclosed her hearing loss, is considering joining the ranks of the
cochlear implanted, too.
Some of the growth is attributable to the aging of the baby boom generation,
some to improved newborn screening for hearing deficits. Even infants under
12 months can now benefit from implants, according to a recent article in
Pediatrics. New evidence, reported this month in the journal Proceedings of
the National Academy of Sciences, suggests that the earlier a
hearing-impaired child receives a cochlear implant, the better.
And the market appears ripe. A 2003 editorial in the New England Journal of
Medicine set the number of potential U.S. implant candidates at 1 million.
An estimate by the National Institute on Deafness and Other Communication
Disorders (NIDCD) puts the figure at seven times as many.
Faking It
Unlike a hearing aid, a cochlear implant doesn't just amplify sound. "It
works totally differently," said Richard Miyamoto, chairman of the
Department of Otolaryngology --Head and Neck Surgery at the Indiana
University School of Medicine and president-elect of the American Academy of
Otolaryngology.
In normal hearing, the outer ear collects sound (a car alarm, a child's
voice, a dog's bark) and sends it into the middle ear. There, sound waves
bounce off the eardrum, go through tiny bones and reach the inner ear, where
fluid waves carry them to the cochlea -- the snail-shaped organ that is the
ear's hearing center. Here, tiny "hair cells" convert sound waves'
vibrations into electrical impulses. The auditory nerve transmits those
impulses to the brain, which interprets them and recognizes them as distinct
sounds. Sensorineural hearing loss -- the most common kind -- occurs when
hair cells are damaged or destroyed by infections, drugs and inflammatory
conditions, among other causes.
A cochlear implant, said Miyamoto, takes the place of a defective inner ear.
Bypassing the damaged hair cells, the device detects sound waves and sends
them as electric impulses to the brain.
By the time Denise Portis went for a cochlear implant evaluation at the
Listening Center at Johns Hopkins Medical Center in Baltimore, she had
little residual hearing left to amplify.
"I was born a hearing person, and [grew up] hearing all the wonderful things
in the world around me," she recalls, "and I was no longer this person."
Over the years, she had learned to "fake it," said her husband, Terry, who
is executive director of the Bethesda-based Hearing Loss Association of
America (formerly Self-Help for Hard of Hearing, or SHHH). She resorted to
tricks like reading lips and interpreting speakers' facial expressions.
Terry would see "the nod, the smile, the 'I-understand-what-you're-saying'
expression " used by many who lose their hearing, he said, "but they're
missing something."
For Portis, too, faking worked only up to a point. Gradually, she dropped
out of activities in her community, church and children's school -- feeling
some of the isolation and depression that often accompanies hearing loss.
She felt increasingly distanced from her family.
"Imagine only hearing parts of words and about 30 percent of a sentence,"
she said. "I couldn't go to a movie with my family and hear very much of it.
I was unable to hear in church. I couldn't go get ice cream with friends and
talk about how exasperating teenagers were. I couldn't listen to the radio
or CD player. The doorbell, phone ringing and dryer buzzing were all sounds
that I read about, but could no longer even place in my memory of how they
sounded."
As it happens, the decline in Portis's hearing coincided with advances in
hearing restoration. Since the first cochlear implant was approved by the
FDA in 1984 and the first child's version approved in 1990, the devices have
evolved from analog to digital, from single electrode to multiple electrodes
with improved speech-processing. New types also allow researchers to
externally manipulate the "coding strategies" used to translate sound into
the signals the implant sends to the cochlea.
Learning to Hear
Many with hearing loss assume they're not implant candidates based on what
they were told years ago. They don't know that candidacy criteria have
broadened, said Gail Whitelaw, president of the American Academy of
Audiology.
Portis underwent a battery of tests to identify any reversible causes for
hearing loss (such as certain infections, drugs and inflammatory conditions)
or other conditions (for example, a damaged hearing nerve) that would rule
out an implant.
Absent such contraindications, said Terry Portis, a person is generally
eligible for implantation if he/she can identify no more than 50 percent of
key words in spoken sentences with a best-fit hearing aid in the poorer ear
and 60 percent or fewer of the key words with such a hearing aid in the
better ear.
In April, Portis was put under anesthesia for the nearly two-hour procedure.
The total cost of the implant, including evaluation, surgery, the device and
post-operative rehab, which is considered essential, was around $40,000. Her
insurer, CareFirst BlueCross BlueShield, covered the surgery and follow-up
care, but not the required pre-surgical psychological evaluation. Many
health plans cover cochlear implants, although they often place limits on
rehabilitation.
The sound of her son's voice wasn't the only thing that changed for Portis.
Implants change sounds in general -- an important point for patients to
understand. You will get hearing back, said Whitelaw, but probably not all
of it, and not the way you remember it. Users will, in most cases, need to
"learn" how to hear with the implant.
No one can predict how well the device will work for any given person. "The
question really is how hard the person will work to learn to use the
device," said Miyamoto.
Rehab initially involves programming, or "mapping," the device: Sound
signals are sent to the implant user, who responds when he hears them. The
audiologist adjusts the device to reflect the lowest level at which signals
are detected.
Audiologists and speech pathologists continue to work with the user
long-term. Hearing generally improves with time and practice. In children,
the process may be more involved, as many have to learn how to speak and
produce intelligible sounds.
Portis speaks of getting her hearing back as being a kind of rebirth.
"I have learned that our microwave beeps when you punch in a cooking time,
and that my coffee maker gurgles and burps while making coffee. The sound of
my dog's pant is worth the doggie breath and if I leave my implant on while
reading in bed, I've discovered my husband does still snore."
"I am hearing new things every day," she said. "And, I wonder, when will
Christmas be over for me?"
Ranit Mishori, a family practice resident at Georgetown
University/Providence Hospital, wrote recently for the Health section about
soaring kidney disease rates in the District
Implants: Who Qualifies?
As technology improves, eligibility criteria for cochlear implants are
changing. Current Medicare guidelines -- often consulted and adopted by
insurers -- stipulate:
For Adults
Severe to profound sensorineural hearing loss in both ears
Functional hearing nerve
Intact cochlea
Minimal or no benefit from hearing aids
Healthy enough to undergo surgery
Realistic expectations and commitment to follow-up and aural rehabilitation.
A score of 60 percent or less in the most common speech-recognition exam,
called the Hearing In Noise Test (HINT).
For Medicare beneficiaries, a HINT score of 40 percent or less.
Reimbursement may vary among different health plans.
For Children
Age 12 months or older
Profound sensorineural hearing loss in both ears, with thresholds of 90 dB
or greater, for children under age 18 months
Small or no benefits from hearing aids
Functional hearing nerve
Healthy enough to undergo surgery.
Realistic expectations and commitment to an intensive rehabilitation.
http://www.washingtonpost.com/wp-dyn/content/article/2006/01/09/AR2006010901532.html
Age Barriers Soften for Cochlear Implants
Tuesday, January 10, 2006; HE05
At both ends of the age spectrum, the market for cochlear implantation is
expanding.
For children, the Food and Drug Administration has lowered the age limit to
one year -- it was two years in 1980 -- on the strength of studies showing
early implantation aids in the development of oral communication. Richard
Miyamoto, president-elect of the American Academy of Otolaryngology, has
implanted kids as young as 6 months old in clinical studies.
"Right now a significant portion of people receiving [cochlear implants] are
children who are born deaf," he said. These children, he added, have been
shown to be "pretty much age-equivalent" in their speech and language with
their peers. "They hear and you'd hardly know they're deaf."
The age range is also expanding at the other end. Sixty-five used to be the
cutoff, but in recent years groups such as the Hearing Loss Association of
America have fought to raise that limit. They often encounter what the
association's executive director, Terry Portis, calls "some attitude" from
providers and third-party payers about the value of implanting older
individuals.
"We actually ran across that attitude in the federal bureaucracy," he said.
"Like, 'What does a 72-year-old man really need a cochlear implant for?' "
Older people sometimes raise the question themselves, he added. "I've lived
my life and my hearing's gone," Portis said they tell him, "so I'm just
content to be by myself.'"
But many studies suggest cochlear implants provide meaningful improvement in
the quality of life of older individuals. A recent study in the journal Ear
and Hearing showed big improvements in "communication, feelings of being a
burden, isolation and relations to friends and family." There was also a
"reduction in the degree of depression and anxiety."
"It's the quality of life, it's independence, it's the ability to talk to
your daughter and understand what they're saying," said Portis. "Talking to
your children and your grandchildren. Life is not over because you're 72
years old."
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