Across the world, about 50,000 cochlear implant (CI) surgeries are performed each year.1 Patients of all ages with a CI may need to attend upwards of eight to 10 appointments in their first year of implantation.2 Various appointments must happen within the first year of implantation, including speech processor programming, speech perception testing, and auditory skills testing. These appointments are all necessary to monitor the implant and the patient's progress with CI use.3 The sparsity of qualified clinicians and CI centers, which are often located at clinics in larger cities, causes many patients (and their support systems) living in more rural areas to drive long distances for appointments.2 Teleaudiology is one possible way to reduce these burdens on patients with a CI, their caregivers, and their families by allowing patients to attend their various appointments either at a health care facility closer to their home or, in some cases, from their home.
The vast number of appointments required for patients with CIs puts a great burden on these patients as well as their families and caretakers. Beyond the travel time and expenses, there can be lost wages from when patients must take off from work. Children with CIs must miss school for their appointments, while their parents must also take off from work to accompany them.2 Recently, technology has seen major progress with the introduction of technology that can be worn by its user, most notably in smartwatches and fitness trackers.1 CIs are no different: Like other wearable devices, CIs are worn by most users every day from the time they wake up to the time they go to sleep. This population of patients with CIs has shown to be open to the idea of implementing telehealth into their device management routine.1 The purpose of this mini-systematic review was to answer the following question: For patients with cochlear implants, what aspects of their CI mapping, maintenance, and additional services can be completed through teleaudiology rather than in-office visits?
Data sources were collected via a complete search of the CINAHL (EBSCOhost) database. Duplicate studies were automatically removed. Search terms included “cochlear implant* AND” “telehealth OR telemedicine OR teleaudiology OR telemonitoring OR telepractice OR telecare.” Searches included only peer-reviewed research published in English completed and published from January 1, 2008, to October 1, 2019.
The GRADE4 method of critical appraisal was used to determine the quality and reliability of the included studies, which were thoroughly screened via a checklist relative to the design of the study. Inclusion or exclusion was supported based on the reliability and appropriateness of the study design.
As shown in Figure 1, 50 papers were yielded from the initial search, of which 16 were excluded after the first screening. Full-text versions were then reviewed for the remaining 34 papers, and five were found to meet the inclusion criteria. Table 1 shows the key findings from the included studies. Overall, teleaudiology offers many advantages, but it may not be the best option for all patients.1
In one study,5 local and remote CI programming proved to be equally successful. Testing consisted of finding T-levels and C-levels in both remote and in-office settings. Results showed that 69 of the 70 total participants had no statistically significant differences in recorded T- or C-levels from one location to the other. This resulted in similar programming levels of their devices in both appointment conditions.5
Hughes, Goehring, Sevier, and Choi6 studied the use of visual reinforcement audiometry (VRA) for children with CI through teleaudiology. In the study, T-levels were found and compared between both remote and in-clinic locations. The remote condition required the use of a test assistant to monitor responses from the child and to communicate with the audiologist who was in a different location. The study showed that T-levels found via VRA were statistically similar in both locations. It also found no difference between the average amount of time needed to complete in-office versus remote testing. About 82 percent of the parents of the study participants reported that they would choose remote appointments in the future.6
Although testing and programming have proven to be feasible and can be accurately completed from a remote location, some aspects of patient care are more beneficial via in-office appointments. At initial activation, the strength of the magnet must be determined, and the length of the cord must be measured.6 Instruction on how to use the device, along with a demonstration of how to change batteries, is also usually done at this time. Extra equipment for the CI is also given to the patient or the caregiver at the first appointment. Each of these interactions requires the patient and clinician to be in the same location.6
Consistent trends in the literature show that many different aspects of CI management can be achieved through teleaudiology for patients with CIs.5-9 Programming and maintenance, aural rehabilitation and counseling programs, and hearing aid management have all been successfully completed through the use of remote appointments. All studies that established thresholds for CIs found no statistically significant differences between levels found in office and levels found with the patient at a remote location.2,5,6 Furthermore, the studies that evaluated parent and audiologist satisfaction found that those surveyed would participate in remote appointments again if given the opportunity.6,8,9
Despite this convergence of evidence in support of teleaudiology appointments, these may not be appropriate for all patients. It is important to look at each patient as an individual and determine what course of treatment he or she is most comfortable with and what can bring him or her the most long-term benefit. While teleaudiology is technologically a feasible option for audiologists in many different clinic settings, it is important to first look at how it can affect patients with regard to clinical outcomes, safety, and personal privacy.10,11
In conclusion, the results of this systematic review support the use of teleaudiology for CI appointments. Results of in-home appointments have shown to be comparable to those conducted in office. Parents report satisfaction with remote appointments and that they would utilize them when available. Finally, these findings support the future application of teleaudiology to many types of appointments, which is vital not only to patients in remote areas but also in times like the COVID-19 pandemic.
1. Cullington, H., Kitterick, P., DeBold, L., Weal, M., Clarke, N., Newberry, E., & Aubert, L. (2016). Have cochlear implant, won't have to travel: Introducing telemedicine to people using cochlear implants. American Journal of Audiology
, 25(3S), 299-302.
2. Goehring, J. L., Hughes, M. L., & Baudhuin, J. L. (2012). Evaluating the feasibility of using remote technology for cochlear implants. Volta Review
, 112(3), 255-265.
3. Hughes, M. L., Goehring, J. L., Miller, M. K., & Robinson, S. N. (2016). Pediatric cochlear implant mapping via telepractice. Perspectives of the ASHA Special Interest Groups, 1(18), 12-18.
4. Goldet, G., & Howick, J. (2013). Understanding GRADE: an introduction. Journal of Evidence‐Based Medicine
, 6(1), 50-54.
5. Wesarg, T., Wasowski, A., Skarzynski, H., Ramos, A., Falcon Gonzalez, J., Kyriafinis, G., &… Laszig, R. (2010). Remote fitting in Nucleus cochlear implant recipients. Acta Oto-Laryngologica
, 130(12), 379-1388.
6. Hughes, M. L., Goehring, J. L., Sevier, J. D., & Choi, S. (2018). Measuring sound-processor thresholds for pediatric cochlear implant recipients using visual reinforcement audiometry via telepractice. Journal of Speech, Language & Hearing Research
, 61(8), 2115-2125.
7. Goehring, J. L. & Hughes, M. L. (2017). Measuring sound-processor threshold levels for pediatric cochlear implant recipients using conditioned play audiometry via telepractice. Journal of Speech, Language & Hearing Research
, 60(2), 732-740.
8. Goehring, J. L., Hughes, M. L., Baudhuin, J. L., Valente, D. L., McCreery, R. W., Diaz, G. R., &… Abbas, P. (2012). The effect of technology and testing environment on speech perception using telehealth with cochlear implant recipients. Journal of Speech, Language & Hearing Research
, 55(5), 1373-1386.
9. Munoz, K., Kibbe, K., Preston, E., Caballero, A., Nelson, L., White, K., & Twohig, M. (2017). Paediatric hearing aid management: A demonstration project for using virtual visits to enhance parent support. International Journal of Audiology
, 56(2), 77-84.
10. McElveen, J.T., Blackburn, E.L., Green, D., McLear, P.W., Thimsen, D.J., & Wilson, B.S. (2010). Remote programming of cochlear implants: A telecommunications model. Otology & Neurotology
, 31(7), 1035-1040.
11. Eikelboom, R. H., Jayakody, D. M., Swanepoel, D. W., Chang, S., & Atlas, M. D. (2014). Validation of remote mapping of cochlear implants. Journal of Telemedicine & Telecare
, 20(4), 171-177.