In 2017, the Purdue University Audiology Clinic added a cochlear implant (CI) component to its clinical education program to meet a rising need for CI services in rural Indiana and enhance the training of doctorate of audiology (AuD) students at the clinic (Hearing Journal. 2017;70(11):10). Patients, audiologists, and surgeons in central Indiana had previously noted the community's inadequate number of CI audiologists. This shortage was not only a disservice to patients in need of care, but it also limited the students’ clinical experience with this patient population and CI technology. While Purdue AuD students received academic preparation in cochlear implantation, their clinical experience had previously been gained via off-site externships on the third year of the four-year program. Expanding CI clinical services on campus has enabled students to work with CI technology earlier in their education, and provided them with a chance to explore CIs as a possible area of interest for their future clinical practice. Additionally, their classroom education was enriched with clinical application through clinical faculty lectures, guest lectures by CI recipients, and hands-on experience.
The clinic's CI journey started in 2015 with one patient who would eventually become the clinic's first pediatric CI patient. From initial diagnosis to hearing aid fitting, referrals for early intervention services, and ultimately a CI, this patient served as a textbook case of collaboration between parents, hearing care professionals, and AuD students. This case study outlines important factors in timing, communication, and advocacy that may help others effectively incorporate clinical CI services into their AuD programs.
At 3 weeks
Patient Care (PC): This patient was referred to the clinic after her newborn hearing screening. At the age of 3 weeks, she was diagnosed with profound bilateral sensorineural hearing loss. This was the patient's second diagnostic evaluation that served as the confirmation of the hearing loss. Per our clinic's protocol, she was referred to a pediatric ear, nose, and throat (ENT) physician for medical evaluation. Additionally, following the guidelines set forth by the 2007 Joint Committee on Infant Hearing, she was referred for genetic and ophthalmologic evaluations and early intervention services.
Student Learning (SL): Student participation included testing, observation of the extensive and sensitive counseling, and assisting in report writing and documentation of the hearing loss to the state.
At 5 weeks
PC: The patient received a medical evaluation and subsequent medical clearance from the ENT physician, and returned to our clinic to get ear impressions and order hearing aids.
SL: Students observed the case history and counseling, ordered hearing aids and ear molds, and assisted with ear impressions. We learned that the ENT physician had discussed the option of getting CIs in the future with the patient's family who was receptive to this.
At 6 weeks
PC: The clinic received official notification that early intervention services were in place for the patient. The First Steps of Indiana, an early intervention program, funded the patient's assessment and hearing aids. A parent advisor had been in contact with the family, and speech and language therapy services were in place with the goal of introducing sign language and promoting oral communication.
SL: Students had the opportunity to communicate with the professionals, write reports, and observe the follow-up process.
At 7 weeks
PC: The patient was fit bilaterally with hearing aids. The family had expressed the desire to have CIs as the ultimate plan of treatment, but they understood that the hearing aid fitting was a step toward this goal.
SL: Students actively participated in the pre-fitting process, verification during fitting, and counseling on care and expectations. They also made recommendations for follow-up.
From 7 weeks to 9 months
PC: Over this approximately seven-month period, the Early Listening Function test was administered to the patient multiple times at home with the parents. Speech and language therapies were also done multiple times per week. Additionally, we started doing visual reinforcement audiometry (VRA) tests, remade earmolds every six weeks to two months as needed, and checked the patient's hearing aids frequently. The patient also had several appointments with the ENT physician and underwent a CT scan at the age of 6 months.
SL: Several students saw the patient for the appointments described above. Students were able to fit and verify new earmolds, participate in testing, and listen to the ongoing conversation about CIs.
At 9 months
PC: The patient underwent surgery for bilateral CIs. Research has shown that greater expressive and receptive language growth is seen in children implanted under 12 months of age than in those implanted between 12 and 24 months of age (Ear Hear. 2007 Apr;28(2 Suppl):11S).
SL: A third-year AuD student completing an externship at the implant facility was able to observe the surgery.
At 10 months
PC: The CI was activated at the off-site facility. An audiologist and off-campus student from Purdue University were present during the activation as well as at follow-up appointments.
SL: The student learned about CI activation and professional collaboration.
At 2 years
PC: The patient's primary audiology care was transferred back to the clinic. Assessments and adjustments were performed as needed.
SL: Students participated in the planning, testing, and follow-up sessions.
At 2 ½ years
PC: Hearing assessments and mapping revisions continued every six months at the clinic. The patient continued to receive speech and language therapy and at the chronological age of 2;4, scored as 2;9 on a receptive language assessment and 2;4 on an expressive language assessment.
SL: Students continued to actively participate in all the patient appointments. One student presented this case in a grand rounds format in a clinical course, thereby sharing learnings from this case with more students.
PC: Effective and clear communication was key to providing the patient with high-quality and timely CI services. An example is when the parents clearly expressed their goals for the child's long-term communication development with all professionals involved, which enabled them to be connected with the resources they needed and wanted for their child.
SL: Just as effective communication was vital to the patient's success, it was also critical in establishing the CI program and enhancing student education. The audiologists served as a communication hub as they relayed information to the pediatrician, ENT physician, audiologists at the implant facility, and speech-language pathologists. It was important that all parties involved were kept updated on the status of the patient as she progressed and that everyone shared his or her piece of information with the other professionals. In addition, it would have been a missed opportunity to not share the success with this pediatric CI patient at our clinic with other students in the AuD program.
PC: The parents of the patient advocated for their child to receive the best care. From the beginning of their journey, they pushed for an early diagnostic appointment, an earlier appointment with the ENT physician to obtain medical clearance, earlier implantation, and early intervention services that were available. Their remarkable advocacy for their child led to implantation prior to the age of 12 months. They also shared their experience with other parents in various avenues.
SL: Establishing a CI program in a university clinic takes time, communication, and patience. It also requires having and asserting your voice. Despite having challenges in increasing the CI patient load and addressing billing roadblocks, the importance of advocating for these patients in the clinic should not be understated for its positive impact on student clinical education.
At present, the CI recipient has been meeting age-appropriate speech and language developmental norms. Nearly 50 graduate students have had direct clinical experience with this patient, and a far greater number of students have had the opportunity to learn from guest lectures on this patient's case and from case presentations by students who actively engaged with this patient. Overall, this case shows the positive impact of incorporating CI services in clinical education.