1. Cochlear Implant Services
B.C. Children’s
Cochlear Implant Services
Ruth Chia
Picture of BC Children’s and roughly where we are located.
B.C. Itinerant Conference
April 3, 2017

2. Cochlear Implantation at BCCH
1988
Today
Program began in 1988 (3 implants) with no designated funding. Dec 2003 received formal government funding.
We have completed over 400 cochlear implants to date
We do approximately 35 cochlear implant surgeries a year
Approximately 250 children are seen for ongoing follow up at BC Children’s Hospital
Began providing bilateral CI in 2008
Updated website: Cochlear Implant Services
Easiest to just do a google search
Website:
Google: Cochlear Implant Services, BC Children’s Hospital

3. Medical Surgical Director
BCCH Cochlear Implant Program
Cochlear Implant Team Members
Dr. Fred Kozak
Medical Surgical Director
Raegan Bergstrom
Clinical Coordinator
Ruth Chia
CI Audiologist
Donna Myer
CI Audiologist
Cindy Gustin
CI Audiologist
Kelly Allison
Social Worker
Dr. Laura-Lynn Stewart
Psychologist
Lorna Gurat
Admin Assistant
Samantha Gill
Technician

4. `83 `98 `94 `89 `02 `97 `05 `09 `13 `16 Change in Technology WSP
ESPrit™
`98
Spectra
`94
MSP
`89
ESPrit 3G
`02
SPrint™
`97
Freedom™
`05
Nucleus 5
`09
`13
Nucleus 6
`16
Kanso
In 34 years how far we have come in technology. From devices worn on the body to devices worn on the ear to devices no off the ear.

5. Cochlear Implant vs. Hearing Aid
Type of stimulation
Site of stimulation
hearing aids pick up sound at the microphone and amplify it and deliver louder sound (acoustic signal) to the inner ear hair cells. Sometimes, no matter how loud the sound presented to the hair cells is, the damaged hair cells can't process the information.
a CI does not make sounds louder, it is not an amplification device. rather it directly stimulates the surviving auditory nerve fibers (beyond the hair cells) with electric current.
Electrical v.s. acoustic
Auditory nerve/spiral ganglion vs hair cells

6. CI Patient Criteria BC Early Hearing Program
Criteria to get a cochlear implant. Youngest we do surgery is around 12 months and the oldest around years of age.
age > 12 months* to 18 yrs
no medical/radiologic contraindications
severe to profound bilateral SNHL
marginal benefit from hearing aids (trial with binaural amplification)
high motivation and appropriate expectations
Enrolment in appropriate habilitation/educational program
Talk about the steeply sloping HL configuration

7. Pediatric Cochlear Implant Consideration
12-23 Months
≥75 dB HL Hz
≥90 dB HL Hz
24-48 Months
≥75 dB HL Hz
For the youngest age group the hearing loss is mostly profound
For the toddler age group it is more severe hearing loss

8. Candidacy – Cases to Consider
Asymmetric Hearing loss can be an appropriate referral to CI
Types of progressive loss where we expect hearing will decrease
Not making expected progress in speech, language, and auditory skill development

9. Candidacy – Cases to Consider
Hearing preservation. Counsel families on the worse case scenario but sometimes we can preserve hearing.
This is an example of potentially using a hybrid processor. (discuss difference between hybrid implant and hybrid processor)
18 year old male
10 – 25 dB HL shift in post-surgery thresholds
Steeply sloping hearing losses
Severe hearing thresholds at 1000 Hz and above
Poor speech discrimination and difficulty performance in noise
Poor access to high frequency speech sounds
Left Ear Pre-CI: LNT words = 32%, Common Phrases 50% quiet, 40% + 10 dB SNR
6 months post LNT words 68% and Common Phrases 80% quiet

10. Bilateral Cochlear Implant Criteria
Rapidly changing based on more evidence we get ..so these are the basic key factors. Meet criteria for unilateral implantation
Simultaneous Bilateral criteria:
bilateral severe-profound SNHL
post-meningitis
deaf/blind
Considerations for Simultaneous vs. Sequential Bilateral
Bimodal Benefit
symmetric vs. asymmetric loss
surgical/anatomical
family choice after counseling of pros/cons

11. Expected Benefits Lack of auditory stimulation : Critical Periods
Many studies have shown that children implanted between months of age achieve better speech perception abilities and language development than children implanted after 2 years of age.
Critical periods for development of central auditory system.
Sharma et al established normal range of P1 latency at different ages.
P1 response was measured in children who received CI at different ages.Children who received CI < 3.5 years had normal P1 latencies Children who received CI > 7 years had abnormal P1 even after years of CI use. Study concludes that optimal period for central auditory development is within first 3.5 years of life.
Cortical Reorganization and cross-modal take over of the auditory regions.
Gap between chronological age and speech and language development age. Will not increase rate of language acquisition.

12. Expected Benefits will NOT provide normal hearing
will NOT guarantee intelligible speech or age appropriate language skills
will NOT guarantee educational success

13. Expected Benefits Consistent use is like paving that highway
However, with consistent use of the cochlear implant and ongoing training, the sound the child hears through the implant should become more meaningful and should enhance the child's ability to communicate
Child should be able to detect and discriminate most/all conversational speech sounds

14. (e.g. parent, audiologist, physician, teacher)
Referral to CI Team
From any source!
(e.g. parent, audiologist, physician, teacher)
Candidacy criteria is always changing as we get more evidence based information.
Exceptions to the criteria
If in doubt, contact us

15. Yes No Referral Assessment Team Meeting - Recommendation
Cochlear Implant Candidacy Process
Referral
Assessment
Team Meeting - Recommendation
Yes No
Parental Decision
Alternatives Discussed

16. Cochlear Implant Candidacy Process
Referral- from any source!
Initial interview
Candidacy assessment
Audiological assessment
Social work
Medical workup
(CT/MRI, Genetics, Ophthalmology, Immunizations)
Team Decision
Surgery
Initial Activation
Follow-up programming (“mapping”)
Ongoing assessments
More detailed look at the process

17. FYI
6 weeks post surgery
physical activities. (e.g. no gym or playground)
CI students can participate in most sports but must use appropriate safety gear.
Extreme contact sports (e.g. MMA fighting)
At Science World Van Der Graff machine
Helmets
Static is no longer a real issue.
Van Der Graff is different because of the strong electric charge that could harm the internal implant.

18. Create an Emergency medical procedure handout for the school
Emergency Procedure:
Blow to the head directly on the implant.
Contact the parents
Parents need to contact Dr. Kozak’s office ext. 1.
If you cannot get hold of anyone, call the ENT on call through locating at  
Emergency issues: Call 911: if possible, go directly to the BCCH emergency department, who will then consult with the ENT department.
School should be informing you of the incident. Contact the students CI audiologist.

19. Audiological Follow-up for the 1st year
Intra-operative Testing
NRT
Equipment fitting
3 weeks post surgery
Mapping
Initial Activation (1 month post-surgery)
1 month, 3 months, 9months
Speech Perception Evaluation
6 months, 1 year post implant
NRT – Neural Response Telemetry - records neural activity within the cochlea in response to electrical stimulation from the implant. It provides a quick, non-invasive, objective measure of peripheral neural function. And it’s the NRT test that we routinely use to, first of all confirm the presence of nerve activation, and secondly, to determine the minimal current level needed to elicit a neural response, referred to as Threshold NRT.

20. CI + Remote Microphone Technology (RMT)
Ready for personal RMT
>6 months post implant
Able to report issues with CI
Contact the CI Audiologist to begin the process
We will need to do FM sound booth verification testing to verify readiness
Use the PRP-AO: Request for Equipment- Cochlear Implant Student form
School district authorization signatures
Signed permission to share form.
Fax these forms back to CI Audiologist to complete.
CI Audiologist will send the request to PRP
Equipment to be sent to PRP Audiologist Carrie Siu for set-up.
Most CI students will use Some will need
CI Audiologist will confirm readiness. Some exceptions to doing the FM testing in the sound booth. Additional needs kids. More comprehensive plan needs to be in place.
No direct audio input on the processor they will need to use different remote technology (T coil loop, wireless mini microphone)

21. Why We Need Your Collaboration!
Surgery is only the beginning; learning to listen with a cochlear implant is a lengthy process.
Let us know when a child is not meeting educational expectations. (Red Flags)
Challenge and motivate these kids. Don’t under estimate what they can achieve. Not all issues are due to the hearing loss there still maybe be an underlying language or cognitive impairment.

22. Contact Information
B.C. Children’s Hospital
Cochlear Implant Services - Room 1D20
4480 Oak Street
Vancouver, B.C V6H 3V4
Clinic Phone: ext 5239
Fax:
Raegan Bergstrom ext 7723
Ruth Chia ext 5240

23. Thanks for Your Attention