5 Common Myths of Cochlear Implants : The Hearing Journal

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Cochlear Implant Surgery

5 Common Myths of Cochlear Implants

Zeitler, Daniel M. MD; Holcomb, Meredith AuD

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doi: 10.1097/01.HJ.0000795656.75870.51
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Despite decades of scientific research and innovation to successfully provide electrical stimulation to the inner ear for restoration of hearing loss, significant misunderstanding and misinformation surrounding cochlear implants (CIs) continues to exist. Early results of multicenter trials concluded that CIs were safe and beneficial to patients, which helped dispel some of the debate among the scientific community. However, these results were often not available to the lay public, and specifically to those with hearing loss who could benefit from CI technology. Even in the last 20 years, while the efficacy of CIs has been proven through well-designed and rigorously conducted trials, and indications for implantation have expanded to include children younger than 12 months and children and adults with unilateral hearing loss, many myths remain about cochlear implantation. As a result, many patients who may benefit from CI technology decide not to pursue implantation, while others may never learn of the opportunity to improve their ability to communicate. We decided to discredit five common myths about cochlear implants to share with patients.

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Myth 1: My insurance will not cover cochlear implant surgery.

CIs are recognized as the standard treatment for patients with moderate-to-profound sensorineural hearing loss (SNHL) who are unable to benefit from optimally fit hearing aids. Despite recent media and cinema portrayals that CIs are not covered by insurance, more than 90 percent of commercial health plans and managed care organizations currently provide coverage benefits for CI surgery and related services (candidacy evaluation, hospital costs, physician’s and surgeon’s fees, internal and external equipment, and postoperative programming and (re)habilitation). 1 Additionally, Medicare, TRICARE, the Veteran’s Administration, and several other federal health care plans all provide coverage for CIs. Due to specific provisions written in federal law for Medicaid, all state Medicaid programs must provide coverage for CIs in children 21 years and younger, but coverage in adults is optional and varies by state. 2 For those insurance plans that require prior authorization, it is usually the CI center that takes responsibility for obtaining authorization before proceeding with surgery.

Myth 2: Cochlear implant surgery involves complicated brain surgery.

There is no brain surgery involved in cochlear implantation, and the surgeon is not near the brain or cranial cavity during the procedure. A small incision is made behind the ear (usually 3-4 cm in length) to house the receiver-stimulator portion of the implant beneath the skin of the scalp. The surgeon will drill the mastoid bone (the hard bone behind the ear) to access the middle ear and insert the electrode array into the cochlea (inner ear). The overwhelming majority of CI surgeries are performed as an outpatient, same-day procedure, and only a small percentage of very young children or very old or infirm adults may spend the night in the hospital. Cochlear implantation is extremely safe in experienced hands with a major complication rate of < 2%, but as with any surgical procedure, there are risks. 3 Some of these risks are transient and minor (vertigo/dizziness, altered taste, pain, and swelling at the incision site), while others can be more severe (wound infection, facial nerve injury, ear drum perforation, and device failure). Despite the risks, CI surgery has been proven to be extremely safe in the very young (< 12 months) and the elderly (> 80 years). 4,5 All potential CI patients should have a thorough evaluation by a multidisciplinary care team to mitigate these risks when possible, as well as have an informed discussion regarding the possible risks and potential benefits of surgery.

Myth 3: Cochlear implants are only for patients with profound hearing loss.

CI candidacy has evolved over the past decade to include patients with single-sided deafness (unilateral hearing loss), asymmetrical hearing loss, and normal low-frequency hearing. These “non-traditional” CI candidates have been shown to perform well with their CIs and, in many cases, perform as well or better than their “traditional candidate” counterparts. 6–8 It is also becoming increasingly common to perform CI surgery on the poorer ear and allow the patient to use a hearing aid in their better ear (bimodal hearing). As such, many CI surgeons now perform off-label cochlear implantation for adults and children. 8 Likewise, improvements in CI electrode design and atraumatic surgical technique have contributed to improvements in post-operative hearing preservation and objective outcomes, including music appreciation and speech understanding in quiet and in noise. 9,10 To ensure the best possible outcome, it is recommended that all adults and children unable to benefit from traditional amplification be referred to a CI center for a complete evaluation before they are profoundly deaf. 11,12

Myth 4: A cochlear implant will restore my hearing to “normal.”

Listeners without hearing loss can hear in the -10 to 20 dB HL range. For patients using a CI, typical CI-aided detection thresholds are in the 20-30 dB HL range, or the equivalent of a mild hearing loss. Depending on the complexity of the listening environment, CI users may still experience some difficulty with speech understanding in quiet and, more often, in background noise. Assistive technology like remote microphones may be necessary to help with communication and can often improve satisfaction in complex listening conditions. While CI recipients will not have “normal” hearing, they should achieve significant improvements in audibility, speech recognition scores in both quiet and noise, and quality of life following cochlear implantation. 13–19 Nevertheless, it is important for clinicians to set realistic expectations and appropriately counsel patients pre-operatively so they can understand the difference between acoustic hearing and hearing with a CI. The CI journey is not a quick fix to hearing loss and requires active participation from the patient, family, and support team.

Myth 5: I am too old to get a cochlear implant.

Over the last 50 years, the average life expectancy in the United States has continued to rise. Currently, the fastest growing age demographic is the over 80-year-old group, and more than 80% of this group has some degree of hearing loss, some of whom qualify for cochlear implantation. 20,21 Often, audiologists, hearing instrument specialists, and other health care providers may limit referrals for CI evaluations for this population out of concern that they are “too old” for CI surgery. In the past, concerns have been raised that the elderly population would demonstrate poorer performance with their CIs due to factors such as longer durations of deafness, decreased social/occupational interaction and stimulation, declining central auditory processing abilities, and diminished auditory rehabilitation potential. 19 Additionally, it was presumed that the elderly population would be at higher risk for anesthetic and surgical complications due to the higher prevalence of medical comorbidities and poorer cardiovascular health. In reality, there is no upper age limit for cochlear implantation. In fact, several studies over the last decade have shown the risk of adverse surgical events in the elderly population is comparably low to their younger peers, and multiple studies have shown that CI surgery is safe in septuagenarians, octogenarians, and nonagenarians. 20,22

Objectively, CI in the elderly population has proven to be highly effective with postoperative hearing performance outcomes similar to those seen in younger adult recipients. One recent study reported a median improvement of 53 percentage points on sentence comprehension testing in CI recipients over the age of 65 years (from 24% pre-operatively to 77% at 1 year post operatively). 23 Furthermore, older adults with a CI are able to improve their speech comprehension in complex listening environments (such as in background noise) in a similar timeframe as younger adults. 24 Just as importantly, there are significant improvements in overall and hearing-related quality of life in elderly CI recipients that result in objective outcomes that mirror those seen in the general population among the same age group. 23,25

In summary, cochlear implantation is a proven, effective treatment for significant hearing loss when hearing aids are no longer effective. Given the multitude of improvements noted post implantation, any child or adult who exhibits communication difficulties with appropriately fit hearing aids should be referred to CIs center for a complete evaluation with a multi-disciplinary team. While myths around CI technology, surgery, and outcomes continue to exist, the abundance of evidence-based benefits of CIs clearly dispel the untruths.

References

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