Pre-operative evaluation and post-operative rehabilitation for paediatric cochlear implantation Han Demin, M.D., Ph.D. Beijing Institute of Otolaryngology Beijing TongRen Hospital Capital University of Medical Sciences Advances in Deafness Management Hong Kong

Instruction The census of China (local) in 2000 – More than 20 million hearing impaired people, the largest handicapped persons of all the categories. – Universal Newborn Hearing Screening an incidence of 1 to 3 per thousand live births 800,000 children with hearing impairment 30,000 children per year born with hearing loss One of the important factors to impact on the quality of life. Effective early intervention is essential.

Cochlear Implants in mainland of China There are totally around 2500 cochlear implant recipients since 1996 in mainland of China. The age of CI recipients has lowered More clinics are conducting surgery and rehabilitation.

Manufacturers of CI in china According to the CI Recipients in mainland of China (about 2500 cases)  NUCLEUS from Australia  CLARION from America  MED-EL from Austria

Distribution of the external

Distribution of the internal

Distribution of the age

Essential elements of the process Surgical technique Rehabilitation and training Hearing the world Key Necessity Periodic mapping Bridge Accurate evaluation Basis

Audiometric assessment system Psychological and pediatric assessment Auditory and facial nerve monitoring Mapping, rehabilitation Evaluation of hearing aid fitting Speech audiometry study for adults and children Subjective and objective assessment

Researches on Cochlear Implantation Audiological and Radiological researches 1. Investigation of tone vocalization in Mandarin with CI Recipients 2. Available speech materials and to be standardizing in mandarin and rehabilitation procedures for adults 3. Development of the Lexical Neighborhood Test in Mandarin as a speech test for children 4. Radiological study on the abnormal modality of the cochlea in order to improve surgical skills of cochlear implantation

Researches on Cochlear Implantation Clinical applications 1. Investigation of audiometric assessment strategies for patients pre- and post- cochlear implantation 2. Setting up the standard of classification for cochlear malformation 3. Establishing indications for selecting teen-age patients who can benefit from cochlear implantation 4. Cochlear Implantation in abnormal cochlea (Mondini, Large vestibular aqueduct syndrome, etc.)

Pre-operative evaluation Comprehensive audiological evaluation Other tests : language, psychological, mental tests radiological tests (CT & MRI) learning ability tests

Comprehensive audiological evaluation Subjective hearing test （ behavioral test ) Impedance test ABR Auditory steady-state response (ASSR) OAEs Speech audiometry Hearing aid fitting

Behavioral test Behavioral observation audiometry (BOA): under 6 month Visual reinforcement audiometry (VRA): 6 to 24 months Play audiometry (PA) : 2 to 6 years old Also be used to get the threshold for speech reception Not widely used in China and this limits the appropriate candidate selection for cochlear implants

Impedance test Testing the status of the middle ear Rule out conductive hearing losses.

ABR ABR (click induced) can only give thresholds at middle to high frequencies (2000 ～ 4000 Hz) without an accurate estimation of low frequency hearing threshold Tone-burst stimulation can be used to obtain thresholds for each frequency, but takes a long time

Auditory steady-state response (ASSR) Used for children at different ages Main advantage: frequency specificity Each clinic should establish its own normalization data before interpreting the results

OAEs OAE is used to evaluate the function of the cochlea, especially the outer hair cells OAE is not ease to define the degree of the hearing loss

Speech audiometry Available speech materials in mandarin – for adults: the minimal auditory capabilities (MAC) – for children: pediatric speech perception test We are going to standardizing the mandarin materials

Hearing aid fitting Pre-operation Binaurally hearing aid fitting 3-6 months auditory training Aided audiogram, and speech perception testing at the start and end of the trial Compare the results with current average CI results

Current situation of post-operative rehabilitation Rehabilitation Service Rehabilitation and training model Rehabilitation and training approach Factors affecting outcome Psychological education for cochlear implant recipients and parents

Government organizations Private organizations Home based Special schools Hospitals or welfare organizations Rehabilitation Service

Rehabilitation and training model Class model Class plus parents Individual rehabilitation Individual plus parents Individual combing with integrated class mode Intensive training combing with integrated class

Rehabilitation and training approach Auditory verbal training Real scenario verbal training

Factors affecting outcome (1) Auditory detection frequency range Normal delivery at birth is better than at risk factors Infants with normal motor skills are better Onset of hearing loss, late onset is better than congenital Duration of hearing loss, shorter is better More residual hearing is better

Factors affecting outcome (2) Intervention pre-operatively: Early binaural intervention with full frequency range is better Rehabilitation and education history: intensive Age Degree of speech disorder Family and language environment Expectation of parents and recipients

Psychological education for CI recipients and parents Communication between the rehabilitation organizations and the parents Improve teachers’ ability to provide counseling Make friends with the recipients Create an environment for emotional rehabilitation Back to mainstream