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Opportunities with Implantable Hearing Technologies Douglas D. Backous, MD, FACS Medical Director, Swedish Center for Hearing and Skull Base Surgery Seattle, Washington USA SNI Grand Rounds January 6, 2011

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Plan of Attack <ul><li>Discuss the options for hearing restoration for differing levels of hearing loss </li></ul><ul><ul><li>Introductory talk </li></ul></ul><ul><li>Outline the indications for Baha </li></ul><ul><li>Introduce cochlear implants and auditory brainstem implants </li></ul><ul><ul><li>Indications and outcomes for each </li></ul></ul>

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Disclosures <ul><li>Cochlear Corporation: Surgical Advisory Board </li></ul><ul><li>Medtronics Neurotechnologies: Consultant </li></ul>

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Left bone Right air Left air 100% 100% Right bone Understanding the Audiogram Normal Mild Hearing Loss Moderate Hearing Loss Severe Hearing Loss Profound Hearing Loss

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Left bone Right air Left air 82% 100% Right bone Case 1

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Hearing Aids

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Osseointegrated Implants

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Baha System <ul><li>Detachable Sound Processor </li></ul><ul><li>External Abutment </li></ul><ul><li>Titanium implan t </li></ul>

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Identifying Baha Patients <ul><li>Conductive hearing loss </li></ul><ul><ul><li>Anatomical abnormalities (e.g. atresia) </li></ul></ul><ul><ul><li>Large Conductive Hearing Loss (CHL) </li></ul></ul><ul><li>Mixed hearing loss </li></ul><ul><ul><li>CHL > 30dBHL </li></ul></ul><ul><ul><li>Up to 65 dBHL sensory loss </li></ul></ul><ul><li>Single Sided Deafness </li></ul><ul><ul><li>Normal or Minimal hearing loss on ‘good ear’ </li></ul></ul>

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Right bone Left air 52% 100% Right air Case 2 43 year old female with chronically draining right radical mastoid cavity

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Baha

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Left bone Left air CNE 100% Right bone Single-sided Deafness 61 year old white male with Sudden hearing loss 2 years ago

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SSD Solution with Baha

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Cochlear Implants Cochlear Corporation, Ltd. (Lane Cove, Australia) MED-EL (Innsbruck, Austria) Advanced Bonics (Sylmar, California)

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Left bone CNE CNE Right bone Severe to Profound Hearing Loss 49 year old white male with progressive hearing loss

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Cochlear Implant System An internal implant placed just under the skin, behind the ear 1 And an external sound processor 2

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Tonotopic Organization

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Candidacy Criteria Adults Adults/children 2+ Adults/children 1+ Speech recognition criteria Adults : < 50% sentences in ear to be implanted < 60% bilaterally (best aided condition) Children: <30% MLNT or LNT best aided Frequency (Hz)

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Predicting success <ul><li>Adult considerations: </li></ul><ul><ul><li>Onset of deafness </li></ul></ul><ul><ul><li>Duration of deafness </li></ul></ul><ul><ul><li>Mode of communication </li></ul></ul><ul><ul><li>Commitment/motivation to getting a cochlear implant </li></ul></ul><ul><li>Pediatric considerations: </li></ul><ul><ul><li>Age of the child at implantation </li></ul></ul><ul><ul><li>Aural (re)habilitation </li></ul></ul><ul><ul><li>Family commitment </li></ul></ul>

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Cochleostomy Positioning ← incudo- stapedial joint ↑ ↑ Scala tympani cochleostomy site Prior cochleostomy site (Risk to basilar membrane)

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Proper electrode placement

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Outcomes

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Contraindications <ul><li>Hearing loss of central origin </li></ul><ul><li>Absence of cochlear or VIIIth nerve development </li></ul><ul><li>Medical contraindications to surgery </li></ul><ul><li>Unrealistic expectations </li></ul><ul><li>Disabilities that limit participation in (re)habilitation </li></ul>

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Hearing loss in the U.S. 1.Kochkin, S. The Hearing Review,(2005); July. 2.Blanchfield, B.B.. JAAA. (2001);12: 183-189. 3.Available Mkt- National Institute on Deafness & Communication Disorders (NIDCD) 2004 4. Recipients– Internal Cochlear data Total hearing loss 1 1.6% annual growth rate 32m Potential device candidates 2,3 1 - 1.2 million severe-profound and profound 1 million SSD, mixed and conductive ~2m Total implanted population 4 10% Cochlear Implant /1% Baha <100k

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Auditory Brainstem Implant

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Auditory Pathway

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Indications <ul><li>Neurofibromatosis Type 2 </li></ul><ul><li>Twelve years of age or older </li></ul><ul><li>Implantation may occur during first or second side tumor removal </li></ul><ul><li>Medically and psychologically suitable </li></ul><ul><li>No audiological criteria are indicated </li></ul>

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Nucleus 24 ABI Receiver-stimulator Monopolar reference electrodes Micro-coiled electrode wires Electrode array (21 platinum disks 0.7mm diameter) T-shaped PET mesh Removable magnet Stabilisation PET mesh

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Position of the ABI in the Brainstem

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Main differences: ABI vs. CI <ul><li>Patient has a debilitating disease that is life-threatening </li></ul><ul><li>Precise placement of the array more difficult </li></ul><ul><li>Side effects during activation to be expected </li></ul><ul><li>Surface tonotopicity of CN is not predictable </li></ul><ul><li>Outcomes generally poorer </li></ul>

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Outcomes <ul><li>ABI recipients should experience: </li></ul><ul><li>Detection of medium to loud environmental sounds at comfortable listening levels </li></ul><ul><li>Detection of conversational speech at comfortable listening levels </li></ul>

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Outcomes <ul><li>Over 80% of ABI recipients were able to perceive sound and use the device postoperatively. </li></ul><ul><li>Over 80% of the recipients demonstrated statistically significant improvements in open-set sentence understanding, when using their Nucleus ABI in conjunction with lip-reading </li></ul>

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Conclusions <ul><li>Technological interventions are now available for defects at each level of the auditory pathway </li></ul><ul><li>Indications for Baha continue to increase </li></ul><ul><li>Cochlear implants continue to deliver higher levels of auditory function in people of all ages </li></ul><ul><li>ABI remains the best intervention for NF-2 patients </li></ul>

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Thank you