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

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

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

4. 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.

5. An example of a possible CI candidates audiogram.
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7. PTA

8. 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.
* Remember your basics. It will stop the team requesting more information/ trials and also helps save clients appointments and unnecessary travel.
Speech discrimination with a mixed, conductive or sensorineural loss can be very different. Ok if past tests have shown no underlying hearing but this information is needed for us to determine if aiding is worthwhile.
For many clients it may look as if there is no residual hearing but aids help with lip reading. (Clients reporting on success with lip reading can be varied and do not necessarily match with tests because the ability to lip read depends on the communication tactics used by a partner. These skills can be taught).

9. Complete this form. A referral will not be accepted until this information is provided (or a good reason is given as to why it isn’t provided).
Before we had this form we were still getting all of this information from you but it was often done by our co-ordinator spending all her time chasing it up.
For most clients we would see them for their assessment within one month of getting a full referral.

10. Regions in NZ Two CI programs – Northern (Taupo and above).
Children (under 19 years): The Hearing House
Adults : The University of Auckland.
Southern –
adults and children
Send the form to the correct team.

11. 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.

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

13. 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.
*When considering the first goal, we need to be very confident that a CI is a better choice than well fit aids.
* Age not a contra indicator.
* Intellectual disability not a contra indicator. (As long as proper support networks in place).

14. Public vs Private eligibility.
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
Doesn’t matter.
Medically suitable for surgery and cognitively able to cope with switch on.
Yes must be both
Appropriate expectations
Unlikely to receive benefit No
If a client has had no access to sound in the past they (unaided or aided) they would not be a suitable candidate be it through the public sector or the private sector.
If a client has one CI already, they are assessed in the same way as if they have a HA in the other ear. If the CI is faulty they may be eligible for an implant in the non CI ear but this would be a very unusual case. Typically the public program only supplies one CI.

15. 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.
It is our responsibility to keep people as well aided as possible while they wait.

16. 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 re-assesed 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.

17. 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

18. Expected outcomes for Post Lingually Deaf Adults with normal cognition.
Sound-field thresholds in the dB 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.
* Speech may be audible as early as day 1 or 2, but may not sound natural for a while.

19. 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.
* This is for congenitally deaf who have been aided. For those who have been unaided (or whose hearing has been so bad that the amplification was not enough to provide stimulation) non auditory stimulation may never stop.

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. 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.