Time to Rethink Cochlear Implantation for Adults
Caregivers should feel confident in referring patients who could benefit from implants, but it is important to do so early.
Historically, cochlear implants have been treated as a last-resort option for adults with profound hearing loss. However, Erika Woodson, MD, FACS, Medical Director of the Head and Neck Institute’s Hearing Implant Program at Cleveland Clinic and Sarah Sydlowski, AuD, PhD, MBA, Audiology Director of the Hearing Implant Program (HIP), believe caregivers need to reconsider implants for adults who still have residual hearing. Caregivers should feel confident in referring patients who could benefit from implants, but it is important to do so early since patients with residual hearing who receive implants earlier have better outcomes than those who get them as a last resort.
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“We really empower our local hearing health providers to recognize and refer these patients,” says Dr. Woodson. “We’re doing more evaluations, and far more implant surgeries, since our local ENTs and audiologists have seen what a difference early candidate identification makes.”
Cochlear implants are usually recommended for adults when their hearing aids no longer provide enough benefit. This implies that the patient may be relying on lip-reading or other cues to get by face-to-face, but may be performing much worse on the phone, or when the speaker is behind a mask. Patients can qualify if they still have residual hearing, even if they still have one good ear. “We probably have about a 50% hearing preservation rate if someone comes in with partial hearing loss, which is among the best-reported hearing preservation rates,” says Dr. Sydlowski.
During the outpatient procedure, an electrode array is inserted into the cochlea and it essentially takes the place of the sensory cells that would normally send sound on to the auditory nerve. Rather than just making sounds louder, this direct stimulation may help make speech clearer. Many patients continue to use a hearing aid in the other ear in addition to their cochlear implant.
As cochlear implant technology has improved and become better understood, clinicians realized that offering an implant earlier resulted in better outcomes. When a patient has profound hearing loss before the procedure, the nerve has gone through a deprivation period before being re-stimulated with the implant. Earlier implantation reduces or eliminates that deprivation period and leads to a better outcome for the patient. Patients identified early do well because their residual hearing speeds up their brain’s learning curve.
“We used to wait until both ears had very significant hearing loss,” says Dr. Sydlowski. “Our whole approach to this has now changed, but referring providers may not have realized this. So, we want to help raise awareness among these referrers about the benefits of early implants to ensure that we’re helping patients as soon as they could benefit from the procedure.”
Although cochlear implants are used across the lifespan, people tend to only associate them with infants and older adults. While these patient populations have success with implants, working-age adults often get overlooked as candidates.
“These folks are some of our most successful patients. But our best-performing groups actually tend to seek out implants the least because they don’t realize they could be candidates,” says Dr. Sydlowski.
Results from an internal study at Cleveland Clinic’s Head & Neck Institute suggest a couple of reasons for these missed opportunities. One finding indicated that referring providers weren’t necessarily clear on who could be a good candidate for cochlear implants.
“Patients who could benefit can be in the prime of their life—young and middle-age adults who are skilled at using modern technology to ease their life,” explains Dr. Woodson. “Surgeries can be safely performed on children as early as nine months old and in adults as old as … well, there is no age limit on hearing better.”
Another finding from the internal study was that referring providers may have mistakenly equated a referral for implant evaluation with a recommendation to actually get the procedure done. However, a referral just means that a patient will be assessed for how well their hearing aids help them listen. To alleviate these concerns, the Cleveland Clinic Hearing Implant Program has taken steps to clarify which types of patients make the best referral candidates and to remind clinicians that a referral is just the first step in the evaluation process.
“We’ve emphasized that this is about giving patients an opportunity to see whether this is an option, not about sending them to the operating room,” explains Dr. Sydlowski. “Not all candidates referred for evaluation will receive an implant. But for those who do, the results can be life-changing, and the patient may end up actually trusting their referring provider more to make the right recommendations in their future visits.”
She notes that Cleveland Clinic is seeing an uptick in patients who are referring themselves because of increased awareness of the device. “They’re frustrated by how they’re hearing and are looking for other options,” says Dr. Sydlowski. “That’s great when it happens, but we ultimately don’t want patients to have to rely on self-referral.”
Dr. Sydlowski believes the process of how patients are identified as candidates must also be revised. FDA guidelines advocate use of full sentences in hearing tests as part of candidacy criteria. However, this might not be an effective way to identify candidates.
“There’s good evidence that we should just use individual words, because if you hear ‘The dog chewed on a ____,’ you could probably guess stick or ball or something,” Dr. Sydlowski explains. “But if you just hear the word ‘stick,’ there’s nothing to give you a clue. There’s a push now to identify candidates based on their hearing of words, not sentences, which is what we often use here at Cleveland Clinic.”
“Cleveland Clinic emphasizes advanced testing criteria that reflects the real world listening challenges—hearing aid benefit assessed by single word understanding,” says Dr. Woodson. “All options to improve hearing will be considered in the evaluation, up to and including implants”
Evaluation focused on single words also can facilitate better understanding of which sounds a patient is actually hearing and which sounds he or she is missing. However, because new research may expand beyond the established guidelines, issues with insurance coverage can emerge. “Sometimes we will determine that a patient will benefit from an implant, but then the insurance company will not authorize the procedure by saying the patient doesn’t meet their criteria,” says Dr. Sydlowski. “Fortunately, insurance coverage is expanding to include these individuals. The HIP team also advocates strongly in cases where the insurer’s candidacy criteria is outdated with current practice.”
Another issue is the infrequency of testing patients’ hearing with their hearing aids. Aided speech recognition testing (in which the patient repeats the words or sentences they hear while wearing hearing aids) is commonly administered as part of a cochlear implant evaluation. However, an audiologist who is not working with implants should still incorporate this measure into their routine practice.
“In my opinion, we should always be measuring how much benefit hearing aids are giving a patient,” says Dr. Sydlowski. “As soon as we determine the patient isn’t getting enough benefit, we should start thinking about implants as another option. Cochlear implant surgery should not be viewed as this scary thing to be avoided. It should be a tool that’s embraced as soon as possible.”