National Cochlear Implant Programme Beaumont Hospital & Children s University Hospital, Temple Street Bilateral Cochlear Implants Jennifer Robertson, Clinical Specialist SLT Nov 2014
In January 2009 in the UK NICE (National Institute for Health and Clinical Excellence) recommended bilateral cochlear implantation for: children adults who are blind or who have other disabilities that increase their reliance on spatial awareness In July 2014 a programme for bilateral cochlear implantation began in Ireland.
What are the Benefits of Bilateral Sound localisation Listening in noise Ease of listening Cochlear Implants? Two processors mean reduced likelihood of being without sound in case of breakdown All resulting in optimum listening opportunities for developing spoken language
A second cochlear implant will not: Restore normal hearing Resolve additional speech/language or learning problems
What are likely challenges? Perception of sound with the second implant may be poorer due to a longer duration of deafness in that ear The second implant may be distracting and unhelpful until the individual becomes used to it which will take time and perseverance Sound perception might be different from the first implant The risk of tinnitus and balance disturbances Residual hearing in the second ear will be damaged by having an electrode array inserted The operation and its associated risks e.g. Anaesthetic (UK audit major complications 0.9%) Remember: It takes time and practice to get used to the sound and gain good benefit
BY KIND PERMISSION OF MANCHESTER AUDITORY IMPLANT CENTRE Which children may benefit from a second cochlear implant? Red indicators of little or no benefit Long time since 1 st CI surgery (greater than 8 years) No hearing in second ear No hearing aid use in second ear Intermittent cochlear implant use Sign language is the main mode of communication No ability to process auditory information in the second ear Poor attendance at appointments Amber indicators of possible benefit Time since 1 st CI surgery between 5-8 years No or limited hearing or some residual low-frequency hearing in second ear, but no consistent hearing aid use Intermittent cochlear implant use and / or hearing aid use in second ear Sign language is the primary mode of communication Limited ability to process sound in the second ear Every child's case is different and the decision regarding the benefit, if any, a child is likely to receive from a second implant can only be made following assessment Green indicators of significant benefit Short time since 1 st CI surgery (less than 5 years) Consistent or committed cochlear implant user Consistent hearing aid user in second ear if it provides benefit. Proven ability to process oral language Regular attendance at appointments
Who will receive a second cochlear implant first? *All dates and ages from 18 December 2013* Group 1: Children who have had an implant for less than 4 years and are under 5 years old. Within this group those who received their first cochlear implant most recently will be assessed first. (73) Also teenagers aged 16 18 (21) Group 2: Children who have had an implant for less than 4 years and are older than 5 years. Within this group those who received their first cochlear implant most recently will be assessed first. (48) Group 3: Children who have had implant for more than 4 years but are under 10 years old. Within this group those who received their first cochlear implant most recently will be assessed first. (37) Group 4: All the other children and teenagers under 18 on 1 December 2013. Within this group those who received their first cochlear implant most recently will be assessed first. (45) NB: at any time a child may be prioritisedon clinical need
Some Reasons for Prioritisation Older teens Teens who have just turned 16 through to 18 years of age at start of bilateral sequential programme, will be contacted with Group 1. All teenagers will be given an appointment with clinical psychologist. (21) Children with visual difficulties If a child has a diagnosed visual condition and they are not already in Group 1, they will be prioritisedand approached together with Group 1. Clinical Need Individual children may be expedited based on clinical need, based on the decision of the CI team.
What is happening now? Each child is being called for a 1:1 appointment with the team: Medical review Audiology review PTA for unimplantedear may be required Possible SLT review Liaison between ICTOD & VTOD/school Possible meeting with clinical psychologist, especially for older children and teenagers Team discussion with parents
Important Dates! Monday 21 st July first bilateral simultaneous Wednesday 23 rd July first bilateral sequential Between July and November 2014: 15 children have received bilateral simultaneous CIs 20 have received a second sequential CI 5 more sequential CIsplanned before end of year It may take up to four years to complete the bilateral roll out Group 1 (incl older teens) aim to complete assessments by April 2015 Group 1 (inclolder teens) aim to complete surgeries by Dec 2015
This is going to take time!! Funding for additional staffing has been secured but not all staff are in place yet Please be patient! We are also very short of space and this may impact on availability of appointments
UK National Audit Bilateral Paediatric Cochlear Implantation DevyanneBele, Helen Cullington, Julie Brinton (Southampton, UK) Gerard M. O Donoghue (Nottingham, UK) http://bilateralcochlearimplants.co.uk/results
Outcomes-2 nd Ear Cochlear Implant Use Yorkshire Auditory Implant Service n = 78
Outcomes-Categories of Auditory Performance Yorkshire Auditory Implant Service L6 49% L3 7% L4 22% N = 45 L6 65% L7 3% L4 13% L5 19% N = 37
Category of Auditory Performance (CAP) Category of Auditory Performance Pre 6m 1yr 2yr 3yr 4yr 5yr 7yr 10yr 7 Use of telephone with known speaker 6 Understanding of conversation without lip reading 5 Understanding of common phrases without lip reading 4 Discrimination of some speech sounds without lip reading 3 Identification of environmental sounds 2 Response to speech sounds e.g. go 1 Awareness of environmental sounds 0 No awareness of environmental sounds
Summary of Outcomes Yorkshire Auditory Implant Service Two non-users Two thirds of children have achieved open-set sentence understanding using the 2 nd implant alone by 12 months Functional listening ability improves over time Localisation ability Listening in background noise
UK National Audit Bilateral Paediatric Cochlear Implantation DevyanneBele, Helen Cullington, Julie Brinton (Southampton, UK) Gerard M. O Donoghue (Nottingham, UK) http://bilateralcochlearimplants.co.uk/results
Data Collection Data collected over a 3 year period: 2010-2012 1001 children: 465 sim, 536 seq 4 test intervals Interval Pre CI 1 Yr Post 2 Yr Post 3 Yr Post SIM SEQ Tested with HAs Tested with CI or CI + HA Both CIs Both CIs Both CIs Both CIs Both CIs Both CIs
Cochlear Implant Centres 1. Belfast 2. Birmingham 3. Bristol 4. Cambridge 5. Cardiff 6. Great Ormond St 7. Guy s and St Thomas 8. Manchester 9. Middlesbrough 10. Nottingham 11. Oxford 12. RNTNE 13. Southampton 14. St George s All children who received bilateral CIsbefore the age of 18 yrs SIM (simultaneous)-children who received both CIson the same day (465) SEQ (sequential)-children who received 2 implants at different times (536)
Taken from UK Bilateral Audit
Taken from UK Bilateral Audit
Taken from UK Bilateral Audit
Outcomes Four different measures Performance measures Rating scales Parental questionnaire Surgical Outcomes
Key Findings Simultaneous: More long term followup required CAP and SIR improve significantly after each year of use of implants BLSP= Bilateral Listening Skills Profile ATT= Automated Toy Test Sequential: After 1 year of second CI use: Localisation significantly better ATT noise centre significantly better BLSP having second CI made significant difference to all measures except speech production
Parental Questionnaires Summary Of children implanted simultaneously 91.6% wore both CIsall the time, and 8.4% some of the time. Of children implanted sequentially 85.3% wore both CIs all the time, 13.4% some of the time and 1.3% never. Both groups parents reported improved Q of L, but it took longer for this to become apparent for the sequential group, and was most evident if there was <4yrs between CIs. When asked would they recommend bilateral/seqci 97.1% of parents in the Simgroup said yes, and 2.9% said maybe. 94.1% of the parents in the Seqgroup said yes, 5.1% said maybe and 0.8% said no.
What about surgical/medical complications? See Steve Broomfield s presentation on Bilateral Audit website 1.8% of planned bilateral surgeries became unilateral Major complications 0.9% No deaths, no permanent facial nerve palsies Over 2 year follow up period 0.6% device failures
Recent Publications (courtesy of Prof. O Donoghue, Nottingham) Sarantet al, 2014 (Aus.) Ear & Hearing BiCi: better vocab and language; faster acquisition Hess et al, 2014 (US) Ear & Hearing Variability Mainstream + parental engagement+ high socioeconomic group : normal Sparreboom, 2014 (Holland) OtolNeurotol Sequential: maturation possible after prolonged unilateral CI use Gordon 2013, (Canada)Front Psych Reduced period deprivation enhanced normal-like brain activity Unstimulated brain: degradation, Best: 1.5 year interval Bartov2014 (Israel) J Speech Lang Hear Res Bimodalsbetter at song recognition