A Step by Step guide to the adult

A Step by Step guide to the adult CI process in NZ. Caroline Selvaratnam Audiologist NCIP University of Auckland

Outline 1. Referral criteria. 2. Eligibility for public funding Vs Suitability for implantation. 3. How do we determine who receives an implant first? 4. Likely outcomes for different client groups. 5. More to be aware of

Eligibility for funding is not the same as suitability for an implant.

Who should I Refer? �For a public referral, clients with 60% or less for CVC words at Pimax (in the better ear for the public program. Privately we would look at any patient who is under performing with well fit aids). �Clients who have had pre-lingual access to sound. �Clients who are well enough to have an operation or deal with the cognitive load that a CI switch on entails. �NZ Citizens/ residents.

An example of a possible CI candidates audiogram. http: //images. google. co. nz/img res? imgurl=http: //www. users. b igpond. com/mnj 144/images/ag ram 83. gif&imgre

PTA

What do I need to do to refer? • Diagnostic hearing test (including bone) • Check the ear moulds. • Make sure hearing aids are appropriately fitted. • If the client does not tolerate aids any where near a prescriptive target, please document the process you have taken to habitulise the client. • Do real ear testing.

Regions in NZ Two CI programs – Northern (Taupo and above). Children (under 19 years): The Hearing House reception@hearinghouse. co. nz Adults : The University of Auckland. ci@auckland. ac. nz Southern – adults and children reception@scip. co. nz

Exceptions to the process? �Meningitis. �Immediately notify the team and send information through as it is collated. �Scans will be arranged urgently and will not be dependent on all other information coming in. �The team may request a hearing aid trial if there is residual hearing, or they may just ask for ear moulds or they may not want either. �Delays can occur if the client is too unwell to make appointments.

The CI Assessment/ reassessment �Has four goals. 1. To determine if a client is likely to do better with a CI than an aid. 2. To determine if a client is eligible for public funding. 3. To make sure that the client has the best access to sound possible while they wait on the funding list. 4. To make sure that the client understands the process and their personal likely outcomes.

Contraindications for CI Implantation �Medical, may not be fit for surgery, anaesthesia. Cochlea may be too ossified from meningitis. Other significant health complications �Auditory nerves not stimulated for a long time, or at all. �Psychosocial, mental illnesses, poor familial support. �Poor auditory input likely (client doesn’t use sound to interact with their world) �Very unrealistic expectations �Poor compliance with previous undertakings, e. g. Hearing aid trial, appointments. �Inability/unwillingness to attend appointments on a regular basis.

Public vs Private eligibility. Public Private Aided hearing in better ear > 60% for sentence material or > 30 % for words. Yes No, we would look at each ear individually and would consider if there were significant dead regions within the cochlear. NZ citizen or resident Yes Doesn’t matter. Medically suitable for surgery and cognitively able to cope with switch on. Yes must be both Appropriate expectations Yes Unlikely to receive benefit No No

Why do we care about well fitted aids? �Clients may have a long wait for funding. �Poor communication can impact on relationships, mental health, work prospects, safety. �Auditory stimulation makes the CI adaptation process easier. �If there is useable hearing, people perform better with an aid on the non CI ear.

CIPAC Score �High scores –Working or looking for work, sudden HL, dependents, vision acuity problems, hearing loss has high impact on quality of life, not able to function with aids etc. �Lower scores – no urgent needs, still able to function with aids, poor auditory stimulation. �Depending on the program clients may be reassesed regularly to determine if their position on the funding list changes. �As of this date the longest that some one has been waiting on the northern funding list is 5 years.

Factors Affecting CI Benefit Permanent - Amount of residual hearing pre-implant - Amount of stimulation of auditory nerves beforehand (all frequencies) or duration of deafness. - Age of implantation - Auditory environment - CI use (all day? ) - Amount of auditory training/rehabilitation - Motivation - Good/Deep insertion achieved? - Pre-lingual, post-lingual - Word discrimination skills - Poor surgical outcome

Expected outcomes for Post Lingually Deaf Adults with normal cognition. • Sound-field thresholds in the 15 -30 d. B range for a well optimised Map. • Ability to hear and identify environmental sounds. • Auditory only hearing for speech in quiet within 1 -3 months. • Able to use the phone in time. • In time able to hear speech in low level noise. • May not have good music perception.

Outcomes for Congenitally Deaf Adults • Expect adaptation process to take 1 -2 years. • Expect non auditory stimulation for some/ all electrodes to start with. • Once client adapts expect access to environmental sounds. • Speech reading will be easier. • No expectation of speech understanding auditory only. • No access to the phone. • No ability to hear in noise.

Post lingually deaf, poor auditory stimulation or APD. �Expect adaptation process to take three to six months. �Non auditory stimulation may occur at some electrodes. �Expect access to environmental sounds. �CI will help with lip reading. �CI will provide help in the absence of lip reading (in quiet) �CI may not provide assistance when in noisy settings. �Phone use may be obtained (if they could use the phone in the past) but assistive devices may be needed.

CI and wireless. • The same as the Resound wireless accessories. • Need to be accessed by a press of a program button on a CI. • Can be connected to a Resound aid on the non CI ear.

Electro-acoustic stimulation or the “Hybrid”. Electro-Acoustic Devices (Hearing aid amplifier connected to the processor). Give better boost in bass sounds if there is residual hearing.

Bilateral CI �Currently not funded for adults but since July 2014 children in NZ receive two implants if it is clinically appropriate. �Improvements seen in �Hearing in noise �Localisation �Many report clarity improvements �May not perceive benefit with �Music �Base sounds

Bimodal Hearing �CI on one ear and hearing aid on the other. �Improvements seen in �Quality of sound and clarity. �Hearing in noise and localisation (although depending on the loss the improvement would be greater with two CI’s). �Music quality.

For audiologists �If there is residual hearing on the other ear it is worth trying an aid! �For prescriptive targets do try Nal 2 (but remember that the fitting is actually binaural). Make sure targets are matched in low frequencies. If the target is below audibility in the high frequencies don’t try and match it. �In most cases frequency compression/ transposition will not work well so if you want it left on verify its benefit with speech testing. �Some aids reaction times will need to be slowed down to match with how fast the Cochlear implant environmental analyser works. �Get to the point where the client feels that neither ear dominates and both work together. Usually this is the point where you will see maximum speech gains.