From Evaluation and Surgery to Life with a Cochlear Implant

man with cochlear implant

The Eye & Ear Foundation’s May 23 webinar, “From Evaluation and Surgery to Life with a Cochlear Implant,” featured three panelists. A UPMC cochlear implant surgeon, audiologist, and cochlear implant recipient shared their respective expertise.

Emily Kate Feibelman, AuD, started things off by describing acoustic hearing, or how we hear naturally. Sound travels down the ear canal to the eardrum, which vibrates the bones behind the eardrum and moves fluid in the inner ear organ of hearing, or the cochlea.

How Do We Hear?

Inside the inner ear organ of hearing, we have hair cells. Someone who has normal hair cells has pretty normal hearing. Someone who has hearing loss probably has some damage to those hair cells. When the hair cells are triggered, they send a signal to the auditory nerve, which then sends the signal to the brain that sound is occurring. This works better with healthy hair cells.

Hearing aids are typically the first step for someone with hearing loss. This is acoustic hearing, where the sound goes through the outer and middle ear. The hair cells of the inner ear are used to send the signal to the hearing nerve up to the brain. Hearing aids make sound louder.

Cochlear implants, however, utilize a different pathway and are a different type of hearing entirely. This is “electric hearing,” since cochlear implants (Cis) convert sound into electrical signals. The outer and middle ear are not used. The surgically implanted part takes the role of damaged hair cells to send electrical signals to the hearing nerve. There are two main parts: internal and external, and together they convert sound into electrical signals. There is also electroacoustic stimulation with an EAS/hybrid system.

How Cochlear Implants Work

Cis for people with moderate to profound hearing loss involve microphones on a sound processor that picks up sounds. The processor converts them into a digital signal, which is transferred to the implant just under the skin. The implant sends the digital sound signal to the electrode array in the cochlea. The hearing nerve picks up the signal and sends it to the brain, which is understood as sound.

There are two main styles: behind-the-ear, like a hearing aid, and off-the-ear, with everything contained in one device that sits on the magnet site.

Cis for people with residual low-frequency hearing with severe to profound high-frequency hearing loss use microphones on the sound processor to pick up sounds. The processor converts them to a digital signal. The acoustic component amplifies the low-frequency sounds and sends them through the ear canal. The coil transfers the high-frequency sounds to the implant just under the skin, which sends the digital sound signal to the electrode array in the cochlea. The hearing nerve picks up the two signals, combines them, and sends them to the brain, which is understood as sound.

CI Evaluation

Typically, someone goes for their routine hearing test or routine hearing aid appointment, where they will have a full hearing evaluation. Audiologists look at the patient’s daily interactions, like whether they struggle to hear on the phone, have difficulty understanding unfamiliar speakers, withdraw from social events, and often need others to repeat themselves. They employ the 60/60 rule, which looks at two different numbers. One is audibility, which has to be greater than or equal to 60dB in the better ear when it comes to pure tone average to qualify for a CI. The other is speech understanding, which has to be less than or equal to 60% in the better ear on an unaided word recognition score to qualify.

Compiling all of this together determines whether someone should be referred for a CI evaluation.

CI Candidacy

To be a good CI candidate, a person will likely have moderate to profound sensorineural hearing loss and limited benefit with appropriately fit hearing aids. An evaluation appointment – which typically is about two hours – evaluates hearing thresholds with and without hearing aids and evaluates speech understanding with hearing aids. Sentences are tested in different conditions, without background noise and with hearing aids, with increased background noise, etc.

The appointment also includes counseling of CI expectations, risks, and benefits, and information about the different devices. UPMC works with three CI manufacturers: Advanced Bionics, Cochlear Americas, and Med El. The audiologist will talk about all three and let the patient decide which one is best for them.

Additional criteria is used to determine CI candidacy. Main considerations include:

  • Hearing and HA history
  • Cognition – ready to do what they need to do, like auditory rehabilitation
  • Support system
  • Motivation
  • Overall health, i.e. able to undergo surgery safely
  • Appropriate expectations

Health is more important than age. From 2020-2024, the average age of implantation was 63 years old. And at least 26 recipients were 80+ years old.

CI Expectations

A CI CAN allow access to more sounds and provide more clarity than hearing aids (with time and effort). A CI CAN NOT repair permanently damaged hearing nerve/hair cells, or determine which sounds are “noise” and which sounds are the speech you want to hear. Some listening situations will still be challenging.

Activation Day and Early Days

What will a CI sound like on activation day? There is a spectrum, where the sound is described as beeps and buzzes, cartoon-like, robot, or even normal speech with a chipmunk sound quality. Most people will fall in the middle of the spectrum, Dr. Feibelman said.

Activation day is the “worst day.” The goals are to activate the CI and learn about basic device use. The importance of auditory training and being dedicated to rehab will improve chances of success.

People often say at the end of the appointment that the CI already sounds better. It takes a lot of work; it is a different type of hearing, and you have to train your brain to hear in a new way. It does not automatically sound perfect. When it comes to rehab, some people use audiobooks and read along with the book in front of them. Others use a workbook by the manufacturer. It does not matter which method is chosen, Dr. Feibelman said, as long as time is put in with the device and the patient is dedicated to their auditory training.

If someone wears a hearing aid in the other ear, audiologists recommend they continue with that to keep the auditory pathway in use in case they opt to get another CI later on. This is called bimodal hearing. A lot of people are very successful with this.

After activation, there are a lot of appointments in the first year. Following activation, there is a one-month visit, three-month, six-month, and then a one-year. After that, evaluations are done annually or biannually. Each appointment lasts 1-2 hours. During those appointments, reprogramming/mapping is done, along with measuring outcomes. Throughout the whole CI process, there is continued support from the audiologist and manufacturer.

CI Surgery

It takes a village to have a successful plan for treating someone’s hearing loss with a CI, Dr. Philip Perez, MD, Assistant Professor and surgeon who subspecializes in otology and neurotology. He works closely with the three UPMC audiologists dedicated to CI implantation within UPMC. There is a lot of shared decision making and helping patients through the process because it is a big decision. “It’s such an exciting thing to get to do for people and it’s really just an incredible aspect of modern medicine that this surgery works,” he added.

CI surgery is outpatient, so patients go home the same day. It is done under general anesthesia, so you will need someone to take you home. The surgery is around 3.5 hours. One month of healing is needed before the device is activated. Patients won’t feel or remember anything about the surgery. Dr. Perez sees them a week or two later to check the incision and make sure everything is healing properly.

In surgery, Dr. Perez will shave a bit of hair behind the ear so he can make an incision. The goal is to access the scalp underneath the skin where the internal receiver will be placed. He accesses the bone behind the ear called the mastoid bone and creates a pocket underneath the tight lining of the skull. He drills through this bone to gain access to the inner ear.

The surgery uses high-speed drills that are adapted from dental drills. The surgeon avoids the roof of the ear, which is the floor of the brain, as well as the big vein that drains blood from the side of the head. Once the surgeon has access, a very fine delicate forceps is used to slowly insert the electrode.

Common Questions

People often ask whether they would benefit from a CI. If you are getting to the point where your nerve hearing loss is so severe that even with hearing aids, you are not able to understand speech, a CI may be beneficial. A CI will sound different for each patient, but it never sounds exactly like a natural acoustic ear. It takes time for the brain to learn how to interpret these signals. Patients often describe them as becoming more natural sounding over time.

How old is too old to get a CI? Dr. Perez only operates on adults, but the most common patients are those who have had gradual hearing loss over time and have been using hearing aids. A lot of the older population – people in their 80s and 90s – have years left to benefit from hearing family again and doing the things they want to do; their overall health benefits because of their ability to hear better.

How soon will you be able to hear? It is all about practice, patience, and programming. Dr. Perez tells people that for many, it means a full year of continued improvement. There is room for improvement after that, but it is a long period of training the brain how to hear again. Patients will often have preferred different programs – different settings of programs that slightly change how the device simulates.

What is surgery recovery like? It is not a painful surgery. Plan to take it pretty easy for a week. You will have a sore ear. Strong pain medication is available, but most times people just use Tylenol or nothing at all. For most, it is not an extremely painful surgery and is a relatively short recovery period. They do wait the full 3-4 weeks after for swelling to go down before turning on the device.

The people who do well are the ones who have support from family and friends. If someone in your life is thinking about getting a CI, go to the appointment with them, be another set of ears to take in the information and help encourage them through the process. It will take practice and patience and a strong support system learning to hear again.

CI Clinical Landscape

Three companies have an approved CI device in the U.S. As of July 2022, more than 1 million Cis have been implanted worldwide. In the U.S., roughly 118,100 devices have been implanted in adults, and 65,000 in children. At UPMC, one adult CI surgery is performed a week. There are three dedicated CI audiologists at UPMC, and the program is expanding to streamline access to CI across Western PA.

“We have a great team,” Dr. Perez said. “It’s something that draws people in from far and wide.” He is looking at clustering all the different appointments together to make it easier for people who do not live nearby. This will include potential programming via tele audiology. “It’s an exciting time to be implanting CIs because they’re expanding in what we can offer to different patients.”

The broadening of candidacy for Cis continues to broaden. Early indications meant adults had to be deaf in both ears. Now children can be implanted at six months, adults can have some residual hearing but poor speech understanding, and even single-sided deafness/asymmetric hearing can be addressed this way.

Hearing preservation, sound localization, tinnitus suppression, and music appreciation are all improving. When the electrode of the CI goes into the inner ear, for example, there is inflammation and injury to the inner ear that for many patients means whatever hearing left in that ear is gone. But now surgeons are discovering they are able to preserve some of this natural acoustic hearing. CIs have the tendency to decrease the loudness of people who have tinnitus. And when it comes to music, you are taking the natural ear that has 10,000 keys and collapsing that to 22 keys, so it is never going to be the same. But surgeons are exploring how to optimize people’s ability to enjoy music.

The webinar ended with a presentation by Elena LaQuatra, who lost her hearing unexpectedly at age four to bacterial meningitis. She got a CI in her left ear and is now a news anchor for Pittsburgh’s Action News 4 (WTAE). She is also on the EEF Board of Directors.

After her surgery, Elena went to DePaul School for Hearing and Speech for 3.5 years to learn how to speak and communicate again. From there, she was mainstreamed into the Mt. Lebanon School District. She later got her BA in Broadcast Communications from Point Park University.

Elena called her CI a blessing in disguise because she does so well with it. She admitted that undergoing any type of surgery is intimidating and worrying and worth raising a lot of questions about, however she called the doctors and surgeons phenomenal. It is such a simple procedure now compared to when she had it done 30 years ago. “They are so good at what they do, and the technology is incredible,” she said. “It’s really worth it to go through that process.” 

From personal experience, Elena highly recommended seeking the specialty type of education that she thinks is necessary like an oral school where they specifically teach listening and spoken language skills, as that is part of the process. She advised getting as much information as possible and surround yourself with people who have been through it and are on the other side.

“There’s challenges with living with any type of disability,” Elena said. “For me, it’s minor. I don’t think I missed out on anything because I have the implant or because I’m deaf. I couldn’t imagine my life without it. It is such a blessing to me, my career, the things I’ve done in my life and accomplished. Every aspect of my life would not have been possible without my CI. Every time I say my surgeon’s name, I start crying; he changed my life so many times over for the better.”