Cochlear implants: who to refer and what to expect when you do Tracey Twomey Consultant Clinical Scientist Nottingham Auditory Implant Programme Chair BCIG

Who can refer? Outlined in NHS England’s Service Specifications for Cochlear Implants D9a https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-d/d09/ GP NHS or private audiology service ENT service Paediatrician

CI candidature Governed by NICE TA166 (January 2009) Unilateral cochlear implantation recommended for: Severe to profound deafness Hearing only sounds > 90 dB HL at frequencies of 2 and 4 kHz without acoustic hearing aids Inadequate benefit from acoustic hearing aids: Adults: a score of <50% on BKB sentence testing at a sound intensity of 70 dB SPL Children: speech, language and listening skills not appropriate for age, developmental stage and cognitive ability Bilateral cochlear implantation recommended for: Children for whom it is clinically appropriate Adults with multisensory impairment (primarily deaf-blind) Outside of these criteria, exceptional request for funding can be made

Referral criteria≠ implant criteria Not always the same Functional hearing is key eg ANSD Evidence of what the child can hear What meaning they can ascribe to sound Contact your CI centre for advice Hints and tips for making a CI referral

British Cochlear Implant Group http://www.bcig.org.uk/ How can we make our website more useful?

There is no upper or lower age limit for referral Assessment: around 40 Implanted: around 280

Other considerations Asymmetry Severely sloping losses Close to borderline Look for overall functional profound deafness Single sided deafness (SSD ) Not routinely funded Current multi-centre trial Severely sloping losses Combined CI/HA (EAS) Limitations to hearing preservation Risk of progression of underlying HL Adults rarely qualify due to NICE BKB criterion Those with no auditory experience / language may be declined

What to do before referral Prompt referral recommended Refer urgent cases immediately Meningitis Sudden onset If possible test >90dBHL, include 2&4kHz BKB at 60dBSPL (adults) Optimised hearing aid trial Manage CHL Begin managing other health needs Contact CI centre for any advice

Patient ‘misconceptions’ Not for congeni-tally deaf Wrong age Not for congeni-tally deaf Funding problems Additional needs Surgery is risky Brain surgery Sounds like a Dalek It will change who I am I will learn to talk Too drastic Long wait Not for me

Professional ‘misconceptions’ Wrong age Not for congen-itally deaf Funding problems Additional needs Surgery is risky Someone else will refer Hearing aids are better Previously declined High/low expect-ations Too drastic Long wait Not for you

Generic CI assessment pathway Initial assessment (audiology) Initial rehab F/U rehab F/U Audiology MDA Surgery Initial SLT F/U SLT Imaging MRI/CT (Psychology) Local assessments

Working in partnership If in doubt, discuss potential referrals with CI centre Collaborative assessment Provide your expertise (HAs, tinnitus, dementia…) Patient-centred, seamless service RTT clocks – under pressure! Joint support (bimodal patients after CI) Give us feedback!