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1 Cochlear Implants: When Hearing Aids Aren t Enough Recorded: October 8, 2013 Presenter: Howard Francis, M.D., Director of the Johns Hopkins Listening Center SLIDE 1: Good evening, thanks for joining us. It s my pleasure to be giving this webinar this evening on cochlear implants; when hearing aids aren t enough. SLIDE 2: And I will be covering these four topics, more or less. First, who should cochlear implant? What is a cochlear implant? The cochlear implant candidacy process and a brief discussion about some the new and potential future developments in the field and also the Listening Center. SLIDE 3: Verbal communication is a very important activity for social participation and can be simply be broken into two components: verbal production or speech production, and speech perception or hearing. Now the vocal tract is composed of the larynx, the pharynx or throat and the mouth, and all the components of these structures are important in generating speech sound. And each speech sound has a unique combination of tones and each tone has its own relative loudness. So you look at the picture here in the right lower corner of this slide, which is a visual representation or spectrogram, as we called it, of an utterance. This specific utterance in this case is Da-Car-Ter. The frequencies are represented by the lines that are oriented horizontally from low frequency to high frequencies. And we see that the relative loudness or intensity of each frequency band is represented by the color, such that lighter colors white in particular represents very loud presentation and softer sounds are represented in blue. And so we see that both intensity and frequency change over time. SLIDE 4: Well this unique representation of a particular speech sound has to be received and interpreted for verbal communication to take place and this occurs when the sound vibrates the molecules in the air eventually vibrates the tympanic membrane, the middle ear ossicles and gets picked up by special sensors in the cochlear which then transmit this information as electrical signals to the brain. SLIDE 5: And within the coil of the cochlear, as shown here if we were take a sliver of this cochlear and we were to examine this under the electron micrograph, we would see three rows outer hear cells and one row of inner hear cells, the so called organ of corti. And these cells are responsible for not only detecting each of these frequencies in that sound, but transmitting it in a code that the brain can interpret. SLIDE 6: In a certain conditions however, on the certain circumstances the cochlear is unable to fully execute this important role. This is an electron micrograph of an individual with a significant hearing loss where essentially all of the outer hair cell are missing at least in the basal turn of the cochlear and the other hair cells in other reasons are not functioning well. And this is a cochlear therefore that (SLIDE 7) is having some difficulties representing the sound that it s receiving for the brain to be able to interpret it. There is a reduction in the ability of the ear to detect the sound you can see sort of a veil over the representation of speech and (SLIDE 8) the speech sounds are distorted.

2 SLIDE 9: Hearing loss is not simply an inability to detect sound and in this regard we can categorize hearing loss from a mild loss to a profound loss, where essentially in a profound setting there is a very little bit of a sound that can be detected, but that is not the entire picture. Hearing aids are very helpful in overcoming a reduction in awareness of sound SLIDE 10: So hearing aids enable the ear to receive a louder representation of that sound, which might overcome the hearing loss if the only problem is with detection. But as we see in this series of images here, they are underlying that difficulty detecting sound is a significant distortion of sound. So an individual with a mild hearing loss shown here progressing to severe/profound loss shown here. We see an increasing distortion and disturbance of the sound, hearing aids are particularly helpful in overcoming the hearing losses associated with these two examples up here, but unfortunately will not overcome the severe distortion that we see in individual with severe to profound hearing loss. This has significant implications in the ability of individuals to participate in day to day social activities that involve communication, and has significant implications in young children and their ability to develop verbal communication, ability to listen and ability to speak. Whereas hearing aids have an important role in less severe forms of hearing loss and can be extremely powerful in helping individuals handle more distorted hearing, significant amounts of lip reading are required in these more severe states. In this scenario, a cochlear implant can be helpful in overcoming the distorted signal, enabling the brain to acquire a signal that it can again differentiate, allowing it to perceive one speech sound from the other. SLIDE 11: The cochlear implant is an array of wires that form electrodes that are placed within the cochlear. They are placed in close proximity to the auditory nerve which in the setting of hearing loss remain silent or is unable to transmit very meaningful signals to the brain. It restores the ability of this nerve to provide meaningful information about what is being said in the environment. SLIDE 12: This technology has two components: it has a fully implanted or internal component, which consists of a simulator placed under the scalp and this simulator supplies electrical signals to those electrodes that we just talked about that are coiled within the cochlear. This internal device receives instructions from an external speech processor via an antenna that transmits radio waves across the scalp. And this antenna is held in place by a magnetic attraction - there are two magnets, one inside the internal device and one within the magnet that holds it in place. There's a microphone that receives information, receive a sounds from the environment, and transmits this to the speech processor placed behind the ear. SLIDE 13-17: It s worthwhile noting that the transformational impact of the cochlear implant technology on our world population was worthy of recognition by The Lasker-DeBakey Clinical Medical Research Award which bestowed their 2013 award to three scientists in the field. These are individuals, Dr. Graeme Clark, Dr. Ingeborg Hochmair and Blake Wilson, are individuals who have been innovators in the field, but they represent scores of individuals who

3 since the very first implant placed by Dr. Bill House in 1961 and then again in 1969 have really brought us to where we are. SLIDE 18: And the result, as a result, of this hard work we now have three robust companies that have FDA-approved devices that we implant here at Johns Hopkins. SLIDE 19: Going back to speech processing, we talked about the microphone receiving information, sound information from the environment and transmitting this to the speech processor. This sound then is in real-time filtered and the component frequencies and their relative volumes are detected and are analyzed. And each frequency of importance to the detection of that speech sound is then assigned to a particular electrode within the cochlear. The cochlear is arranged from low to high frequency, sort of like a piano that has been coiled on itself. With the electrodes near the base being responsible for high frequencies and those near the apex - or the tip of a coil - responsible for transmitting low frequencies. And so we see how these sounds can then be transmitted in a tonotopic frequency specific way to the auditory system. SLIDE 20: And as an example here is another visual representation of a word choice. Where we see high frequencies on top, the low frequencies below and the louder sounds are brighter colored. Look at how that shape of the actual utterance of the word choice compares to what is produced by the speech processor of a cochlear implant. SLIDE 21: We see that they re not identical, but there is a significant similarity in overall shape of the sound and the relative brightness or loudness of the individual frequencies. And this is really what prosthetic hearing is about; it s about providing for the brain very specific speech information that it can used in daily communication and language learning. SLIDE 22: So how does the internal device, how is it placed? It does require surgery. It s a two to three hour procedure that is performed on an outpatient basis, all of our patients here at Johns Hopkins go home the same day and they are happy to do so. We do have a hospital if there is a need for someone with special health requirement to be admitted. This is done of course under gentile anesthesia it is safe, it s well tolerated. After two hours of recovery one can go home. Incision is well hidden behind the ear and under the hairline. SLIDE 23: Four to six weeks later, the external device is placed and activated and programmed to optimize the hearing experience. Now the process of hearing with an implant is a work in progress it s a journey and immediate benefit is not always acquired, it takes really several weeks, to months for the brains to literally wrap itself around what it s experiencing. There is a process of becoming aware of what matters and what the sounds mean, and it is quite encouraging to see over those first three to six months marked improvements in an individual s ability to participate in communication and in a child s ability to listen and learned language. SLIDE 24: Who would be considered a cochlear implant candidate? In general the presence of relatively severe to profound hearing loss that is sensory in nature and occurs in both ears would be first important criterion. We use in adults speech perception scores with hearing aid

4 in place - that is best aiding condition - to determine if objectively if someone might benefit from a cochlear implant. Recent changes in guidelines by the Food and Drug Administration have now made it possible for individual with significant amount of hearing to in fact avail themselves to the benefit of a cochlear implant. In other words, an individual who is missing 60% or less I m sorry, 40% or more of their speech of what they are hearing would become a candidate; that is scores of 60% or less. Medicare still follows the previous guidelines which would require 40% to speech discrimination or less. SLIDE 25: Here is an individual audiogram an audiogram is a graph that describes the level of hearing acuity by ear so the right ears right ear is represented by the circles, the left ear by the crosses. Low tones to high tones, normal hearing would be anything between 0 and 25. We see that this individual has significant hearing loss in fact, profound severe to profound hearing loss. With a hearing aid there is some improvement in hearing acuity but speech discrimination remains very poor in this individual. After the cochlear implant we see that this hearing acuity can become like a mild loss and in fact in some frequencies, is a border line normal. But what about speech clarity which is after all why we doing the cochlear implant. SLIDE 26: Well here is a summary of outcomes in a group of individuals at Johns Hopkins where we have the average speech discriminations score with the hearing aids in place before surgery somewhere around 30% and this is the best aided condition. At three months we immediately see or quite quickly see that on average there is a doubling of this ability to perceive sound and this is perception without any ability to lip read. Now we see that this continues to improve over time and even beyond a year, and so on average there is marked improvement in hearing ability anywhere ranging from improved ability to read lips to actual ability to use a telephone and not be dependent on reading lips. SLIDE 27: Our mission statement I thought was worthwhile mentioning here it is to bring meaningful sound to the lives of individual who are deaf or hard of hearing through a partnership of medicine research technology, rehabilitation and advocacy. Underlying this mission at the Johns Hopkins Listening Center is a commitment to ensuring that we maximize the ability of this technology to improve people s lives and we accomplished this through the services that we provide and we do provide comprehensive services and also through our efforts to advance the field. SLIDE 28: Starting with the pediatric cochlear program implant program, this multi-disciplinary and comprehensive approach first requires that we carefully coordinate our services with early diagnosis and intervention services. We want children that receive implants at our center to be ready to fully benefit, and also we want to prepare their social environment, their parents, their care providers to be prepare to also be their best advocates and best teachers. We are committed to a period of auditory, speech and language rehabilitation for a year at our center or with collaborators, and we feel that it is critical that we do more than simply provide high quality surgery and high quality audiological programming. We want the resulting sound perception to lead to significant language development and success. We are committed to

5 supporting parents and their efforts to be the primary language teachers of their children and in helping this children transition successfully to educational settings, both pre-school and kindergarten and beyond. SLIDE 29: As part of our commitment we have joined five other centers in the United States in a first of its kind a prospective study of child hood development after cochlear implantation a study that has been NIH funded and has been ongoing for about the last decade. SLIDE 30: We have studied on longitudinally 180 children with a cochlear implants with a mean age of about 2 years, about half of whom are a girls, and we have compared their progress with that of 97 normal hearing children of similar age and gender. SLIDE 31: And I am just going to quickly summarize the primary findings after the first three years and here I ll focus on language results and this can be found in the public available literature in a paper by Niparko et al in the Journal of American Medical Association. One of the most important findings in the study was that greater rates or faster rates of improvement in verbal language are realized in children who are implanted younger, even a few months delay in the age at implantation can lead to life long delays in language. SLIDE 32: And so here I am showing you the individual plots the plots of the individual children in this case in red, these are children who are implanted younger than the age of a year and half. We compare their progress, we see a lot of variability there but we compare their progress to that of a group of (SLIDE 33) implanted between 18 and 36 months of age and another group (SLIDE 34) implanted at older ages and we see that there is even more variability the longer we wait, when we compare all of these children with implants to the (SLIDE 35) group with normal hearing in terms of language development relative to time. SLIDE 36: If we summarize this figure, we see that compared to the trajectory of language learning by normal hearing children, children implanted before the age of 18 months have smaller delays to begin with and almost the same rate of improvement in their language development. We see that as implantation occurs that the older ages we see more delays and we see slower gains. So these children never really catch up relative to the hearing peers, they are nevertheless benefiting from the device and acquiring significant verbal language relative to candidates who do not choose to pursue a cochlear implants. SLIDE 37: Additional findings from the study was that faster rates of improvement in verbal language were experienced if children were implanted with some residual hearing, if they were some hearing present, these kids tended to have faster rate of improvement. We also saw a better language development when parent-child interactions were observed to be more engaging and more language rich. Finally as seen in really in other aspects of our communities we see that socio economic advantage place children at some additional benefit in term of their language learning. SLIDE 38: In our effort at the Listening Center to also impact the development of the reading skills in our implanted children, we have studied their reading performance relative to their language delays and we see that children with the strongest who are the strongest readers has

6 the least language delay. We have also identified that the reading behaviors in the home can significantly impact both language and reading, or at least there is an association. And we have taken this new knowledge into our rehabilitation program and we are using this information to help parents overcome some of the delays that we seen in children that are implanted late or may have other socio economic disadvantages. We believe that if we can teach parents how to read in an engaged fashion with their children that we will have even better results with the cochlear implant. SLIDE 39 SLIDE 40: Now turning to our older group, the other end of the life s spectrum, older patients adults have some of their own unique risks or concerns as well. Age related changes that have been found to be associated with hearing loss include declines in social engagement and social networks, which has implications both in general health status and even survival. We also see that this increasing isolation that accompanies hearing loss and can accompany aging even without hearing loss can be associated with increasing cognitive declines. Furthermore, hearing loss in the elderly can place them at increased risk of physical decline as well and an increase rate of falls has been reported in these individuals. SLIDE 41: We have quite an extensive experience with cochlear implants in older adults. And we have found that age does not prevent one from benefiting from this device in fact there are comparable gains in speech perception to those experienced by younger adults. There is however some increase variability in outcomes the longer that someone waits to pursue implantation and the more severe the hearing loss is and so we feel it s important to try and minimize the duration and severity of hearing deprivation or sound deprivation to really maximize the benefit of the cochlear implant. SLIDE 42: We asked the question how does the outcome of implantation compare depending on which criteria you used for candidacy? We compared two groups, one group that fulfilled the new FDA-extended criteria these are individuals with more hearing than the old criteria in fact allowed and another group that have less hearing and in fact meets the current Medicare criteria and we see that there s much more consistently better outcomes (SLIDE 43) in the group with more residual hearing; in fact about 10 percentage point higher than the other group. This is not to say that individuals with very poor hearing cannot benefit from cochlear implant. No, this is the group for which this device was designed, but this is also to point out that individuals with some hearing, some residual hearing, can also benefit and need not wait for their hearing to be almost gone to avail themselves to this technology. SLIDE 44: So our approach to cochlear implantation in older adults is to encourage early referral for cochlear plantation. Residual hearing, if it s still presented, should not prevent one from pursuing this technology. There are negative consequences of hearing loss, certainly related to physical, cognitive and other areas, and that want to try to minimize those negative effects. We promote bi-modal listening - we promote placing a cochlear implant in the worse hearing ear and the continued use of hearing aid in the opposite ear. And we want to collaborate and frequently collaborate with our community audiologist in accomplishing this, so an individual does not need to feel that they are giving up their community audiologist for the listening centers, we believe that one can benefit from both technologies and from both sets of

7 professionals. Auditory rehabilitation has a role and we are providing this to all of our implantees including adult patients. SLIDE 45: So sort of wrap up by just wanted to highlight little bit more some of the discovery processes that we are pursuing at the Johns Hopkins Listening Center. We are very fortunate to have a large team of committed individuals, individuals committed not only to excellence in terms of clinical service but in advancing the field through research. I have already talked a bit about what we ve done in terms of language learning and educational outcomes in children and this work continues. We are also conducting work that with the goal of advancing communication function and overall quality of life in older adults and you ve already heard a little bit about that. And finally understanding and advancing music appreciation and the cochlear implant. SLIDE 46: I should point out the work of Dr. Frank Lin one of my colleagues who is currently conducting two prospective studies looking at outcomes in older patients and I refer you to our website for more information. SLIDE 47: I also want a point out the work of Dr. Charles Limb who is really interested in understanding how sound or how music is perceived and appreciated in cochlear implant users. Music may provide a tool by which we can get closer to the goal of perfect hearing restoration for the hearing impaired if we can figure that out. SLIDE 48: I want to thank you for your attention and I want to also thank with a colleagues with whom I work at the Listening Center and hope that you have an opportunity to meet them sometime if you need our services. Thank you. QUESTION & ANSWER SESSION I think we have some questions already, and I am going to take the first one here or read it to you. Are there circumstances or conditions when people would not benefit from or should not receive cochlear implants? The first requirement for a cochlear implant is that there is a cochlear present and a nerve connecting that cochlear to the brain. There are conditions in which neither may be present, or one or the other maybe missing. And this is the reason why imaging is performed - CAT scans or MRIs as part of the candidacy process to be certain that this is in fact a feasible line of action. There may be other circumstances and a range of grey zones that, that s sort of black and white now if there are several grey zones and too many to go into here. But I think the most important thing is that the expectation for what this technology can provide needs to be reasonable and needs to be reasonable relative to what is possible for this technology to provide. So an individual who has never communicated verbally, for example, because they have been deaf since childhood who's now an adult, it would not be reasonable to expect that the cochlear implant would enable them to communicate verbally. Unless

8 potentially they lip read and there are number of others circumstances. But I think that's the answer that I ll give and I moved on to the next questions. Does having a cochlear implant require any changes or precautions with regards to security monitors such as those in secure areas and airports? And the answer to that is that like any other implantable device whether a hip or otherwise it would be advisable to carry a card that indicates why it is that a device might be detected by a metal detector, for example. However the device will not be hurt by the security procedures that are typically used it in the airport or other facility. Are there any restrictions with regards to MRIs or any other medical test or procedures? This is an important questions as well and all are important, but this is one did have not mention. There is a magnet within the internal device and this magnet can interact with the larger magnetic field of an MRI. For this reason anyone with cochlear impact must consult with their surgeon and implant center prior to perusing any MRI or magnet related diagnostic testing. It is possible to obtain an MRI but depending on where the MRI is taking, of which region of the body, depending on the type of implant they are special steps that must be taken prior to the testing. Furthermore the use of certain cautery in surgery should be avoided and this again can be discuss with one surgeon. Are there any restrictions with regards to swimming, snorkeling or scuba diving? There are no restriction regarding exposure to water, the external device though in most cases should be removed. New devices are coming onto the market that are water resistant or at least water tolerate. The internal device is completely internal so one can swim without external device. However scuba diving poses some additional potential risks in that pressure changes within ear could transmit around electrode into the inner ear and so in general we do not recommend scuba diving with a cochlear Implant. Is there a suspected etiology of why people need implants or have sensorineural hearing loss? There is a very long list of possible causes of sensorineural hearing loss. In young children the incidents of hearing loss in United States is somewhere about one in 500 children born in the country have some form of hearing loss in both ears and in the majority of cases this is in fact due to a genetic mutation that has be gone undetected. Less so now than in the past in this country but in other countries, we see that certain infections can cause deafness, rubella, measles, and mumps. Fortunately our immunization programs have lowered the incidence of this problem. The use of certain medications also can put one at risk. Older individuals may have a genetic predisposition to progressive hearing loss, or a life time of exposure to loud sound could also accelerate that process. Exposure to certain medications may also put one at risk for progression of hearing loss.

9 What is that earliest approved age for implantation in the United States? The Food and Drug Administration has given us guidelines that would essentially keep restrict us to implanting at the age of 12 years or older in terms of children 12 months excuse me, 12 months or older one year or older. There is no upper limit and in terms of age. We will implant younger than one year of age in very restricted settings, most specifically in infants who have been become deaf by meningitis and are at risk of the cochleas becoming filled in by bone. Following meningitis the cochlea can become ossified making it difficult or sometimes impossible to place the electrodes within the cochlear and within proximity to the auditory nerve. And in those instances we would not want to wait, we would proceed with implantation before 12 month of age. The other question is At what age do we implant at Johns Hopkins? and I think I answered that question. We try to get as close to 12 month as possible based on our data the younger the better. Do we perform bilateral cochlear implants? Yes we provide bilateral cochlear implants. We tend to however provide this in the sequential fashion usually separated by three to six months. Our reason for doing so particularly in very young children is that we believed that a short procedure committed to getting the first implant in properly and then activated is the priority and that a longer procedure in a very young child may potentially have associated risks. In circumstances though, such as meningitis where we are worried about ossification of the inner ears, we will perform a simultaneous bilateral cochlear implant in that setting. You mentioned that children with residual hearing do better with cochlear implants. I was under the impression that the process of implanting the electrode actually destroys some other residual hearing, hence the requirement the candidates have severe to profound hearing loss. Is this not the case anymore? This is a very timely question. First of all I should say that our ability to preserve hearing in an implanted ear has markedly improved through developments in the electrode design but also in the surgical technique that we use. However, even in settings where the hearing is lost during the placement of the device, we find that as we saw in some of the slides that, the access to speech is markedly improved and we even see within three months a doubling of the speech discrimination and speech perception following cochlear implantation. So there is trade off, but what we think is made possible by implanting an ear with residual hearing - or an individual through with residual hearing in at least one of the ears - is a brain that is wired to take a new electrical stimulus and converted into significant communication abilities. The FDA has recognized this and for this reason has extended the criteria for implantation to include individuals with residual hearing. My question is about the process of getting used to the implant. What does it sound like? I ve been told by my patients that there is a mechanical sound, a bit of a mechanical sound to it, almost a bit robotic sometimes. In the earlier days, my patients used to tell me that it would

10 be like a Donald Duck sound. But I think that there is as tremendous diversity in terms of the experience and the quality of the sound is different from acoustic hearing with the hearing aid. But the clarity and the ability to access individual words is what people find most compelling. Is it easier or harder for a person who still has hearing in the other ear who continues to use a hearing aid on that side to get used to the implant on the other side? Initially there is a process of getting used to the implant and the quality of hearing, but our goal is to really used both ears, to benefit from the improve speech perception and speech discrimination on the implanted side while still continuing to benefit from a hearing aid on the other side, giving the individual as close to a three dimensional access to sound as possible. And this has been shown to improve the ability to understand speech in the presence of background noise, as well as indentify where sounds are coming from in several individuals. There is an adjustment but in the end these are some of the happiest patients that we have. If someone has near normal hearing in one ear, but next to no hearing in other ear, will they be candidate for Cochlear Implant for the poor ear? This is a great question. It depends on how much hearing is present in the normal ear. The individual says near normal, I would think probably not a candidate. There needs to be two circumstances, number one a progression of hearing loss in the better hearing ear, and a moderate at best hearing loss in the better hearing ear. In that setting we sometimes will put an implant in deaf ear in anticipation that this is an individual who needs to adjust to this new form of listening while they are losing their hearing in the other ear. But at this time the food and drug administration has not approved the use of a cochlear implant in the setting of unilateral deafness. We are interested in studying the use of implants in this scenario and there is some growing literature internationally to suggest that it may have a role, but there s still more work to be done. What are the risks involved with the surgery? Important question because like any other surgery there are potential risks. As I said it's a safe and well tolerated procedure, but there are some errors of vulnerability, the facial nerve, the taste nerve, the brain. These are all within the vicinity of the surgeon s work and fortunately the risk of injury to the facial nerve is in our hands 1 in a 1000 or less risk of that. The risk of meningitis is very, very low again, less than 1 in a 1000 although we do required that everyone is appropriately immunized against the most common organism that can disassociate with meningitis in the setting of cochlear implants and we require this before going to surgery. The most common complaint is a slight change in the way that food taste on that side of the tongue, about 1 in 20 individuals will experience a slight change in that function which improves over time. I understand that one must participate in therapy to be able to hear with a new cochlear implant. I'm in my 70s, how difficult is it for an older person to learn to use the implant? There is a work involve there is no question. Like a lot of things in life, you get more out of it the more you put into it. This is a new way of listening and one has to really focus on trying to

11 associate what you are hearing with what s happening around you in terms on communication. And it helps to have a coach help you through that process and that's how we run the rehabilitation process in adults. We are coaching you in this process. Does it involve some work? Yes it does, but if you are willing and you stick with it you see significant gains that are meaningful. As a woman I'm concerned about my appearance. Will the mechanism show? Women with a lot hair and ability to style it appropriately can in fact completely go without their implant being noticed, the device speech processor is like a BTE, a behind the ear device, placed behind the ear. And the magnet it can be hidden under the hair line and this is much more difficult for us guys with short hair. In fact I think you d be surprised that how easily this can be hidden. I constantly have to change the batteries in my hearing aids now. What maintenance is there with the Cochlear Implant? The power for the implant is supplied by the batteries in the external processor. Fortunately, thank goodness, we don't have to change any batteries on the internal sides, so there is no need to re-operate and remove the device or do anything maintenance wise from that perspective. But the speech processor will have magnets that have to be either recharged or purchased and placed. The devices made by the three different companies have different features in this regard and this is an important part of the candidacy process. We bring you in for 90-minute discussion of what the implant is and how it applies to you, and we at some point during this process discuss the features that you can use to make a decision about which implant you might want to pursue if you want to go this route. If I have my surgery at Hopkins can I go elsewhere, closer to home, for follow-up care? If you are an adult the answer is typically yes, but there are some caveats. We feel very strongly that the first several months of activation and programming and tuning of the device are best done in the home institution. However we have had made some exceptions, depending on who was available closer to your home, their level of experience, training. As it relates to children, we are particularly careful to make it clear that we really hope that your child can spend a year, or as close to a year as possible, with us, coming to work with our rehab therapists to maximize his or her language development. We are increasingly collaborating however with rehab therapists and audiologists in the community in the region to make these services available closer to home. But this would require case by case kind of discussion. What actually happens during the therapy to learn how to use the implant? Well there is quite a bit of teaching individuals what a takes to communicate. It's not only about listening, it s about communications of which hearing and listening is part of it. Our rehab therapists on the team are extremely well versed in coming to this from an holistic perspective. Homework is set and certain skills are built upon over time. I think that the details required for

12 this exceed what we have time to discuss, but for children it would require a weekly interaction. For adults who already speak and know how to communicate, this could be a muscle less frequent kind of process. I have poor balance which I was told may be due to inner ear issue, will a cochlear implant help? The cochlear implant will not impact vestibular function or balance function. Fortunately it rarely impacts it in the negative way and it almost never helps if there is already a poor vestibular functions at present. So the goal of this intervention is not to improve balance. The same could be asked about tinnitus or sounds phantom sounds that you hear. Cochlear implant cannot be guaranteed to help this either although it has been shown to reduce the level of tinnitus in many patients. Well unfortunately that's all the time we have again I want to thank you for your attention and wish you all the best evening. Bye-bye. To learn more about the Johns Hopkins Listening Center, visit or call