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SPECIAL REPORT

Advances in Cochlear and Bone Conduction Implant Technology Runny Ears Hearing Loss – A Challenge But Far From Insurmountable Modern Technologies and the Benefits of Early Action Most People with Hearing Loss Will Benefit From a Cochlear Implant Getting the Greatest Benefit

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Published by Global Business Media


The facts on why to refer your patients

DISCHARGING EARS

What are discharging ears? Discharging ears is known as Chronic suppurative otitis media (CSOM) which is the middle ear and mastoid cavity inflammation of greater than two weeks and differs from the other two conditions in that it results in episodes of discharge from the ear. It may arise as a complication of acute otitis media.

Where in the ear does CSOM hide? Otitis Externa

Otitis Media

Otitis Interna

Middle Ear

How many patients are suffering?

ANNUAL 123,189 CHILDREN

251,791 ADULTS

URGENT!

When should you refer?

> 2 WEEKS DISCHARGING EARS SHOULD BE REFERRED FOR ROUTINE ENT ASSESSMENT

Any postauricular swelling or tenderness, facial paralysis, vertigo or evidence of intracranial infection is shown, arrange urgent assessment or admission with an ENT team

For more information, visit www.iwanttohear.com/uk/CSOM References 1 http://patient.info/doctor/chronic-suppurative-otitis-media 2 Office of National Statistics (ons.gov) 3 https://en.wikipedia.org/wiki/Otitis_media


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

SPECIAL REPORT

Advances in Cochlear and Bone Conduction Implant Technology Runny Ears Hearing Loss – A Challenge But Far From Insurmountable Modern Technologies and the Benefits of Early Action

Contents

Most People with Hearing Loss Will Benefit From a Cochlear Implant Getting the Greatest Benefit

Foreword

2

John Hancock, Editor

Runny Ears

3

Matthew I. Trotter, Consultant ENT Surgeon

Sponsored by

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. © 2016. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Referral Pathophysiology Aetiology Treatment Surgical Management Hearing Loss Summary

Hearing Loss – A Challenge But Far From Insurmountable

6

John Hancock, Editor

Hearing Loss – A Significant and Growing Healthcare Challenge The Impact of Hearing Loss Addressing Hearing Loss

Modern Technologies and the Benefits of Early Action 8 Camilla Slade, Staff Writer

Cochlear Implant Bone Conduction Hearing Aids The Sooner the Better

Most People with Hearing Loss 10 Will Benefit From a Cochlear Implant Peter Dunwell, Medical Correspondent

Older Children and Teenagers Adult Cochlear Implantations Improvements Across the Field of Human Experience Age is no Barrier

Getting the Greatest Benefit

12

John Hancock, Editor

Hearing the World as it is Deciding on and Following on from a Cochlear Implant

References 14


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Foreword C

OCHLEAR IMPLANTATION is a proven and

aetiology and treatment of these conditions and

established treatment for the restoration of

highlights the alternative to the fitting of a conventional

speech perception and communication in severe

hearing aid – the Bone Anchored Hearing Aid (BAHA),

to profoundly deaf people and the provision of

which has become recognised as an excellent addition

hearing to those born deaf… There is no alternative

to rehabilitate the hearing in patients unsuitable

clinical treatment. There is only the default state

for hearing restoration surgery, or for conventional

of remaining deaf.” This summary statement from

hearing aids.

NICE in 2007 in its appraisal of a technology that

In the second piece, we look at the condition of

has brought enormous benefit to thousands of

hearing loss and how it can, if untreated, profoundly

people with hearing loss in the UK and around

degrade the quality of life by limiting opportunities and

the world. But, as with any clinical solution, the

isolation. Next, Camilla Slade addresses cochlear

questions have to be asked as to what it is that is

implantation and bone conduction technologies, how

being addressed and why is that necessary. It is

they differ from previous solutions and how they work

also useful to look at the technology in its wider

to help people with hearing loss to regain a significant

context and to know what benefits it will offer users.

degree of hearing. Peter Dunwell then considers how

And, as the technology, along with clinicians and

a cochlear implant can enhance the lives of those who

beneficiaries’ experience of it advances, it is useful

undergo the procedure and how it can benefit people

to know how that is changing perceptions.

with hearing loss whatever their age.

The opening article in this special report looks at

Finally, we review the case for bilateral as opposed

runny ears and points out that there are multiple

to unilateral implants as well as the factors that need

causes including infections in the external ear canal

to be taken into account when assessing a patient for

or middle ear. It stresses that anyone presenting with

suitability for cochlear implantation.

persistently discharging ears requires investigation

Given the impact of hearing loss on those who have

and management, as runny ears may be as a result

it, a technology that can mitigate that impact makes

of chronic suppurative otitis media (CSOM). The

an important contribution to healthcare.

occurrence of this condition, or of cholesteatoma, often requires long-term support due to effects of the disease and the associated disability of hearing loss. The article goes on to examine the pathophysiology,

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for more than 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Runny Ears Mr Matthew I Trotter MBChB, MRCS, MClinSci, FRCS(ORL-NHS) Consultant ENT Surgeon, Heart of England NHS Foundation Trust, West Midlands (Heartlands, Solihull and Good Hope Hospital)

R

UNNY EARS are a problem that is often accepted by patients and healthcare professionals as a social inconvenience; however this is never something that should be ignored. The causes of runny ears are multiple and include infections in the external ear canal or middle ear. The effects can also be serious and troublesome. Runny ears may be as a result of chronic suppurative otitis media (CSOM), a condition that is characterised by discharging ears through a perforated tympanic membrane for at least six weeks. Anyone presenting with persistently discharging ears requires investigation and management. The prevalence of CSOM in UK is estimated to be nearly 1% in the Paediatric population and 0.5% in the adult population. This is a condition that effects many people each year and is characterised by a smelly, discharging ear that also normally causes hearing loss.

Referral Any patient with a discharging ear that hasn’t responded to a course of topical antibiotic drops should be referred for a specialist opinion. Many of these patients will have a local otitis externa (inflammation of the lining of external ear canal), and will require microsuction to clear debris to allow local treatment. However, some will have CSOM and a smaller number will have developed a cholesteatoma. It is the latter two conditions that often require long-term support due to the sequelae of the disease and the disability of hearing loss associated. Patients requiring urgent referral include those with facial paralysis, evidence of post aural tenderness/swelling and vertigo in association with CSOM. Pathophysiology: CSOM occurs following an upper respiratory tract infection that has led to acute otitis media. This progresses to a prolonged inflammatory response causing mucosal (middle ear) oedema, ulceration and perforation. The middle ear attempts to resolve this ulceration by production of granulation tissue

THE IMPORTANCE OF HEARING

and polyp formation. Unfortunately, this leads to increasing discharge and failure to arrest the inflammation so development of CSOM. The common bacteria isolated from microbiological analysis of the discharge include Pseudomonas Aeruginosa, Klebsiella pneumonia and Staphylococcus aureus. Aetiology: Patients are at increased risk of developing CSOM when they have a history of multiple episodes of acute otitis media, live in crowded conditions and attend day care facilities (paediatric population). Patients with craniofacial syndromes including Cleft lip and palate, Down syndrome, Microcephaly etc. are at higher risk, presumably due to the alteration in Eustachian tube function Treatment: Chronic Suppurative otitis media treatment commences with a full assessment of the patient including past history of ear problems. The effect of a discharging smelly ear in conjunction with hearing loss should not be underestimated on the psychological milieu of the patient. CSOM is a debilitating condition that can lead to social withdrawal of the patient. Treatment is first aimed at confirming the diagnosis which, in the presence of a discharging ear, will generally require microsuction in a clinic environment and microbiological analysis. Diagnosis of CSOM is necessary to aid and direct treatment. In those with a perforated tympanic membrane medical treatment directed by microbiological analysis will be the first line of therapy. Granulation and oedema of the middle ear is often seen in patients presenting with CSOM. The first line treatment of a discharging ear will be topical drops including both steroid and antibiotic. Although microbiological analysis can be used to guide treatment; drops should not be withheld whilst awaiting results. Simple precautions such as preventing water entering the ear will aid the treatment of this condition. It is important to rule out Cholesteatoma, keratin in the middle ear, caused most commonly by retraction of tympanic membrane and perforation.

Hearing loss can affect virtually every aspect of a person’s life. Studies show that anxiety and depression are more pronounced among individuals with hearing loss 1 Find out more why patients with discharging ears should be referred today www.iwanttohear.com/ uk/CSOM Reference 1 Helvik AS, Jacobsen G, Hallberg LR. Psychological well-being of adults with acquired hearing impairment. Disability and rehabilitation. 2006 May15;28 (9); 535-45

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Many with CSOM, once treated (either medically or surgically), will have no long term issues with hearing loss but in both groups formal audiological testing is required

HOW NORMAL HEARING WORKS 1 Sound waves travel through the ear canal and strike the eardrum. 2 These sound waves cause the eardrum and the three bones within the middle ear to vibrate. 3 These vibrations are transferred to the fluids in the inner ear – known as the cochlea – and cause the tiny hair cells in the cochlea to move. 4 The movement of the hair cells produces neural impulses which are sent along the hearing nerve to the brain, where they are interpreted as sound.

Cholesteatoma is an erosive process that may cause discharge, hearing loss, tinnitus, vertigo and, if untreated, can progress to facial nerve palsy, meningitis and intracranial complications. CSOM invariably leads to hearing loss and the impact of this on both paediatric and adult patients should not be underestimated. In the initial stage of the condition the hearing loss is due to a conductive element. The Ossicles struggle to amplify sound in an environment of oedema

and inflammation and the situation is exacerbated by the perforated tympanic membrane. Sensorineural hearing loss is also recognised sequelae of disease and can compromise further an already challenging situation

Surgical Management The goal of both medical and surgical management of a patient with CSOM a dry ear that is ‘safe’. Safe means unlikely to develop

HOW A BONE ANCHORED HEARING AID WORKS (TRANSCUTANEOUS/MAGNET SYSTEM) 1 The sound processor captures sound in the air and sends vibrations to the tiny implant. 2 The implant transmits the vibrations through the bone directly to your healthy inner ear.

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

THE IMPORTANCE OF HEARING

HOW A BONE ANCHORED HEARING AID WORKS (PERCUTANEOUS/ABUTMENT SYSTEM) 1 The sound processor captures sound in the air and sends vibrations to the tiny implant. 2 The implant transmits the vibrations through the bone directly to your healthy inner ear.

the more complex sequelae of this condition including long-term hearing loss, facial nerve paralysis, labyrinthitis and intracranial complications (meningitis or abscess). If, despite optimal medical management, the ear continues to discharge through a perforation, then consideration is given to repair of the ear drum (tympanoplasty). Mastoid surgery is normally only undertaken in those with choleseatoma, but some surgeons will undertake a mastoidectomy in those with mucosal CSOM and perforation to remove granulation to allow an environment to develop that aids healing of the reconstructed tympanic membrane.

Hearing Loss Hearing loss Is normally conductive and due to the active infection, discharge, perforation and reduced mobility of the ossicular chain. Sensorineural hearing loss can also complicate CSOM. When assessing, treating and managing those with CSOM, consideration should be given to audiological rehabilitation. Many with CSOM, once treated (either medically or surgically), will have no long term issues with hearing loss but in both groups formal audiological testing is required. In a patient with medically treated CSOM there is only a small chance that the chronic perforation will heal once the ear is dry. In this group of patients, a hearing aid, if required, may predispose to further episodes of CSOM due the ‘occlusive effect’ of the hearing aids. In this group who require audiological support, consideration should be given to tympanoplasty to close the perforation. Some patients will require ossiculoplasty (reconstruction of the bones of hearing) to improve their hearing

loss where the ossicles are eroded or absent. However, some patients are not suitable for otological surgery. The reasons for this are varied and include operating on the only hearing ear (concern regarding possibility of hearing loss postop), patient health issues or patient choice. Previously if a patient was unsuitable for otological surgery but required audiological support there was little alternative but to fit a conventional hearing aid and deal with the often troubling sequelae of infection and discharge. For many years there has been an alternative to this scenario – the Bone Anchored Hearing Aid (BAHA). This is a titanium implant fixed to the skull requiring a sound processor connection that directly stimulates the inner ear. It is very well tolerated and is an excellent addition to rehabilitate the hearing in patients unsuitable for hearing restoration surgery surgery, and those who experience problems with conventional hearing aids.

Summary CSOM is a debilitating condition. Treatment is aimed at limiting complications and treating symptoms. Surgery is reserved for those in whom medical management has failed. Hearing loss can be improved by conventional hearing aids, surgery or a Bone Anchored Hearing system. Patients with CSOM may have complex audiological rehabilitation needs.

Hearing loss can affect virtually every aspect of a person’s life. Studies show that anxiety and depression are more pronounced among individuals with hearing loss 1 Find out more why patients with discharging ears should be referred today www.iwanttohear.com/ uk/CSOM Reference 1 Helvik AS, Jacobsen G, Hallberg LR. Psychological well-being of adults with acquired hearing impairment. Disability and rehabilitation. 2006 May15;28 (9); 535-45

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Hearing Loss – A Challenge But Far From Insurmountable Tom Cropper, Editor

While hearing loss is a growing phenomenon, available treatments, if applied, can mitigate its consequences for lives

Hearing loss in adults may also be caused by excessive exposure to noise, or by ototoxic drugs, metabolic disorders, infections or genetic factors. Severe to profound hearing loss in children may have a genetic aetiology, or have prenatal, perinatal or postnatal causes

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Hearing Loss – A Significant and Growing Healthcare Challenge Whatever the causes, hearing loss is a significant issue in the UK and it’s set to be a growing one. From 10 to 11 million people have hearing loss1, today (1 in 6 of the population) and Action on Hearing Loss projects that number to rise to 15.6 million by 2035. Of today’s number, more than 900,000 are severely or profoundly deaf with more than 45,000 children being deaf or suffering temporary hearing loss. Age is a factor with more than 70% of over 70 years old and 40% of over 50 years old experiencing some level of hearing loss. NHS (UK National Health Service) England2 explains, “It [hearing loss] will continue to become an even bigger challenge over the next decade as the number and proportion of older people increases and with increasing exposure to workplace and social noise such as MP3 players.” continuing to highlight the wider implications of hearing loss: “5.3 million older people (aged over 65) in England have a hearing loss and this will have a disproportionate effect on their wider physical and mental health, independence and ability to work. Moreover, hearing loss is not just a health issue – it is societal…” There are3 “two main types of hearing loss, depending on where the problem lies: • sensorineural hearing loss – caused by damage to the sensitive hair cells inside the inner ear or damage to the auditory nerve; this occurs naturally with age or as a result of injury; • conductive hearing loss – when sounds are unable to pass from your outer ear to your inner ear, often because of a blockage such as earwax, glue ear or a build-up of fluid from an ear infection, or because of a perforated ear drum or disorder of the hearing bones.”

Some people have both types, known as mixed hearing loss and, while some people are born with hearing loss, most cases develop with age. The UK National Institute for Health and Care Excellence (NICE) offers more details4; “Hearing loss in adults may also be caused by excessive exposure to noise, or by ototoxic drugs, metabolic disorders, infections or genetic factors. Severe to profound hearing loss in children may have a genetic aetiology, or have prenatal, perinatal or postnatal causes. These include conditions such as meningitis and viral infection of the inner ear (for example, rubella or measles), as well as premature birth and congenital infections. Deafness that occurs before the development of language is described as prelingual, whereas deafness that occurs after the development of language is described as postlingual.”

The Impact of Hearing Loss Put in terms such as those used above, it’s easy to understand the aetiology of hearing loss. As important is the impact of the condition (whatever the cause) on lives “and a loss of hearing or a hearing impairment can have massive implications for speech development”5 (London Health). It seems obvious but hearing and speech are mainstays of communication: an inability to communicate is a disabling condition. The implications are significant for education, employment, social life, mental health and quality of life.

Education Hearing loss is not in any way connected to intelligence but it can cause children to become frustrated and to fall behind their peers in education. Although an American example, Healthy Hearing’s6 statement that, “Hearing


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

loss causes delays in development of speech and language, and those delays then lead to learning problems, often resulting in poor school performance. Unfortunately, since poor academic performance is often accompanied by inattention and sometimes poor behaviour, children with hearing loss are often misidentified as having learning disabilities such as ADD and ADHD…” is an accurate summary of how hearing loss becomes a disability.

Employment The Ear Foundation7 pulling together data from a number of sources, explains that, “Of the 300,000 people of working age with severe hearing impairment, 20% report being unemployed (and seeking work), with an additional 10% reporting that they cannot (seek) work due to an illness or health condition. The 20% figure compares with 6.2% [at the time the report was written] being unemployed in the general working age population… The employment rate for people who identify ‘difficulty in hearing’ as their main health issue was 64% compared with an employment rate of 77% for people with no longterm health issue or disability.”

Social When people struggle to communicate they suffer socially in two ways. First, others might not understand them and will therefore not seek them out or wish to socialise with them. Second, for the first reason and because they can become frustrated and embarrassed at their inability to share thoughts and feeling with speech or to understand others, people with hearing loss might withdraw from social interaction and can suffer loneliness.

Mental Health From loneliness, it is only a short step to depression and other mental health issues. A report for the UK Government’s National Institute for Health Research (NIHR)8 concluded that, “Hearing loss is independently associated with social isolation and depression, and social isolation and depression are associated with cognitive decline.”

Quality of Life (QoL) Each of the above issues and others for which there is not the space here, fall into or overlap with the quality of life impact of hearing loss. According

to NICE (see reference above), while the impact of hearing loss on those born with the condition might not always be bad – they often use sign language from the outset and regard themselves as part of a signing community – “for a child who is born deaf within a hearing family or for a person who becomes deaf and is used to functioning in a hearing environment, deafness can have a significant impact on their quality of life.” Notwithstanding the above, it would be wrong to leave readers with the impression that people with hearing loss face a hopeless prognosis. That is far from the case as increasing and increasingly effective treatments become more and more available.

THE IMPORTANCE OF HEARING

BAHA ATTRACT CLOSE-UP

Addressing Hearing Loss Available treatments will often be tailored to the type of hearing loss so that there are several treatments for sensorineural hearing loss according to severity, including digital hearing aids, bone anchored implants, middle ear implants and cochlear implants. Similarly, conductive hearing loss might respond to medication or minor surgery (especially where the condition is temporary) but can also be treated with more major surgery or hearing aids, including Bone Anchored Hearing Aids (BAHAs). The Ear Foundation (see reference above) advocates using the latest technologies to help those with hearing loss, including, “… for those who are severely or profoundly deaf, cochlear implantation offers the only means of hearing spoken language again.” The Foundation continues to argue against the cost driven approach to cochlear implantation, taking the view that, if the costs of hearing loss (see above; education, employment and mental health) are taken into account, let alone the QoL improvement, cochlear implantation offers excellent value.

Hearing loss can affect virtually every aspect of a person’s life. Studies show that anxiety and depression are more pronounced among individuals with hearing loss 1 Find out more why patients with discharging ears should be referred today www.iwanttohear.com/ uk/CSOM Reference 1 Helvik AS, Jacobsen G, Hallberg LR. Psychological well-being of adults with acquired hearing impairment. Disability and rehabilitation. 2006 May15;28 (9); 535-45

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Modern Technologies and the Benefits of Early Action Camilla Slade, Staff Writer

When the usual paths are not available, new technologies will bypass damaged areas but the sooner they are used, the better will be the results

Cochlear Implantation is suitable for people with severe to profound sensorineural hearing loss, i.e. where their cochlea has been damaged.

C

ONTINUING THE theme in John Hancock’s preceding article, that an increasing array of increasingly effective treatments is available for people with hearing loss, this article will focus on two similar but different technology solutions and how earlier action can help younger patients. The two technologies are Cochlear Implantation and Bone Conduction hearing aids and they are different from conventional hearing aids. Conventional hearing aids (analogue or digital) amplify sounds entering the ear so that the wearer can better discern speech and ambient sounds. When people are ‘hard of hearing’ and still have the main parts of their ear still working, albeit at less efficiency, a conventional aid can improve their experience of life without the need for any surgical intervention but for some types of hearing loss, they are not suitable or effective. Cochlear Implants and Bone Conduction hearing aids replace the function of a damaged or absent ear mechanism with a system that turns sounds into electrical impulses transmitted directly to the wearer’s bones.

Cochlear Implant According to the British Cochlear Implant Group9, “A cochlear implant is different because sounds are turned into tiny electrical pulses, which are sent directly to the nerve of hearing. The implant can therefore bypass some of the inner ear structures which are not working…” That’s the technical side of things. Action on Hearing Loss (formerly RNID)10 adds a human aspect; “Cochlear implants can improve people’s ability to hear and understand speech if they can’t benefit from a hearing aid. Cochlear implants enable children who are deaf to learn language, speak intelligibly and perform better at school. Adults are able to communicate more confidently, regain their independence, and stand a better chance of getting a 8 | WWW.PRIMARYCAREREPORTS.CO.UK

worthwhile job.” There follows a brief description of the device… “A cochlear implant consists of: • An internal part: a receiver which is surgically implanted in the mastoid bone behind the ear, with electrodes inserted into the cochlea, part of the inner ear. • An external part: a microphone and speech processor which convert sound into an electrical signal that is sent to the electrodes in the inner ear. These then stimulate the auditory nerve sending a signal to the brain, where it is perceived as sound.” That last part “… perceived as sound” refers to the fact that, as the UK National Institute for Health and Care Excellence (NICE)11 puts it, “The activation of electrodes provides a sensation of hearing, but does not restore hearing.” However, Cochlear Implantation is suitable for people with severe to profound sensorineural hearing loss, i.e. where their cochlea has been damaged.

Bone Conduction Hearing Aids Where there are problems conducting sound waves anywhere along the inner or outer ear (say, as the result of an infection), that is conductive hearing loss and might be amenable to medical treatment but, in more severe cases, will be better treated with a bone conduction hearing aid. Similarly, where the wearer has problem wearing a conventional hearing aid, a bone conduction aid will be beneficial. Action on Hearing Loss12 describes the way they work: “the aid conducts – or carries – sound through the bone in your skull. This process is known as ‘bone conduction’. You hear when the sound vibrations are transmitted directly from the vibrating part of the bone conduction hearing aid through your skull to the cochlea, missing out the outer and middle ears.” A further evolution of bone conduction are BAHAs (bone anchored hearing aids) which are attached to the skull through the skin behind the


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

THE IMPORTANCE OF HEARING

ear (using a titanium screw fitting) and, according to Action on hearing Loss (see above) “People using BAHAs get a better quality of sound and hear more clearly than those with traditional bone conduction aids. Compared with traditional bone conduction hearing aids, BAHAs are lighter and less visible, more comfortable”

BAHA CONNECT CLOSE-UP

The Sooner the Better However, whichever solution is correct for a person with hearing loss, the earlier the solution is installed, the better. Indeed, most solutions can be fitted into patients as young as babies. As the British Cochlear Implant Group13 explains, “Since children are better able to utilize new information than adults, they can also be expected to benefit more from a cochlear implant. A very limited hearing can have a considerable influence on a child’s ability to learn to talk and on overall development. The speech of most children with cochlear implants is of better

quality and more intelligible than their peers using acoustic hearing aids.” NICE agrees (see above). “The NHS Newborn Hearing Screening Programme screens all newborn babies within 26 days of birth for possible hearing difficulties. Babies who at screening are identified as having possible hearing difficulties are referred to NHS audiology services. Those who are then confirmed deaf should receive a hearing aid within 2 months. This initial diagnosis is followed by ongoing support, which includes regular audiological assessment and consideration of the appropriateness of a cochlear implant (usually within the first year).” (Author’s italics). Children implanted by age three can be expected to keep up with their peers in speech and hearing. NDCS14 (National Deaf Children’s Society) explains, “the evidence suggests that the younger a child is when they receive their cochlear implant, the more likely they are to get the most benefit from the device… It is now common for children to be implanted before 12 months of age. Early implantation and support is most likely to achieve the development of speech and language skills in a similar way to hearing children of the same age. The most intensive period for speech and language development is during the first three years of life when the brain develops and builds the neural pathways essential for processing auditory information.” As with almost any healthcare matter, earlier intervention will pay dividends.

Hearing loss can affect virtually every aspect of a person’s life. Studies show that anxiety and depression are more pronounced among individuals with hearing loss 1 Find out more why patients with discharging ears should be referred today www.iwanttohear.com/ uk/CSOM Reference 1 Helvik AS, Jacobsen G, Hallberg LR. Psychological well-being of adults with acquired hearing impairment. Disability and rehabilitation. 2006 May15;28 (9); 535-45

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Most People with Hearing Loss Will Benefit From a Cochlear Implant Peter Dunwell, Medical Correspondent

Every component that makes up quality of life will be enhanced at every age

The number of older adults with a severe to profound sensorineural hearing loss receiving minimal benefit from hearing aids who could benefit from a cochlear implant is rising due to ageing, awareness of implants among the medical and general population and technological advances

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HILE, AS Camilla Slade explained in her article, there are very good reasons for the earliest possible application of cochlear implantation, that doesn’t mean that the solution won’t benefit people with hearing loss later in life. On the contrary, a successful cochlear implant can significantly enhance many aspects of an older child, teenager, working age adult or older adult’s life.

Older Children and Teenagers According to NDCS15 (National Deaf Children’s Society), “Older children and teenagers may also be candidates for cochlear implants. This includes those who have become deaf after learning to speak (for example following meningitis), as well as those who have a progressive or acquired hearing loss and who now receive less benefit from their hearing aids. Some older children and teenagers may have been assessed for a cochlear implant when they were younger but were found not to fit the criteria to be implanted at that time. As the guidelines have evolved over time, those children who use hearing aids consistently and mainly use spoken language to communicate may now be considered suitable candidates for reassessment.” The Society also emphasises the importance, as children grow into teenagers and young adults, of guiding them into taking increasing responsibility for their implant as part of encouraging them to independence.

Adult Cochlear Implantations “Traditionally, cochlear implants were only offered to adults with a profound to total deafness who received no benefit from conventional hearing aids. However, scientific evidence now indicates that people with significant residual hearing (severe to profound deafness) who obtain some benefit from acoustic hearing aids pre-operatively 10 | WWW.PRIMARYCAREREPORTS.CO.UK

may also benefit greatly from a cochlear implant”16 (NICE – UK National Institute for Health and Care Excellence).

The paper continues to affirm, “The cochlear implant recipient is able to contribute to society, both economically and functionally… performance improvement extends to postlingually deafened adults where benefits are evident in the form of enhanced educational attainments, greater social versatility and robustness, and an increased quality of life.”

Improvements Across the Field of Human Experience In short, improved hearing and the consequent improvement in speech, cognition and ability to participate in life make a very strong case for cochlear implantation in adults of any age. They will be better able to learn and therefore


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

THE IMPORTANCE OF HEARING

to either gain employment and/or improve their employment outcomes. NHS England17 goes as far as to report that, “Those [adults] with severe hearing loss who do not use hearing aids have unemployment rates nearly double those who do.” And it’s the same in social life, the ability to participate that a cochlear implant confers means that adults can continue to enjoy conversation, entertainment and all of those things for which hearing is essential. The lack of that ability can, conversely, have severe negative impact on an adult’s life as the NHS England paper again confirms, hearing loss can, “restrict aspirations and life chances, increase the risk of mental health problems and interfere with peoples’ ability to care for their own and their families’ long term health conditions. This can lead to low achievement, low self-esteem, isolation, loneliness and depression.” Depression is a potential problem for any person with hearing loss and in older people that is even more the case. Recent studies have coalesced around the measurement that older people with hearing loss are 2.5 times more likely to develop depression than those without hearing loss. Also, because older people are more likely to have multiple and complex health issues, there is a group of people in that category who have sight as well as hearing difficulties. The impact of both can be devastating and is even linked to higher mortality rates. So the opportunity to address at least one of a person’s sensory impairments (loss of hearing) with a cochlear implant will offer benefits out of all proportion to the procedure itself. Reporting on a number of studies to assess quality of life in different circumstances NICE (UK National Institute for Health and Care Excellence)18 found, “[nine studies] all of which reported benefits in quality of life associated with cochlear implants. Four studies reported levels of statistical significance and three of these reported

statistically significant benefits for quality of life after cochlear implantation.”

Age is no Barrier Given that age related damage to the cochlea is the greatest cause of hearing loss, older people are a group who should be considered for cochlear implantation. It has the potential to be a significant challenge for the healthcare system (in the UK, the NHS). So it’s not surprising that the NICE Health Technology Appraisal on cochlear implants (see above) concluded, “The number of older adults with a severe to profound sensorineural hearing loss receiving minimal benefit from hearing aids who could benefit from a cochlear implant is rising due to ageing, awareness of implants among the medical and general population and technological advances. A major problem is the impact of a hearing loss on their participation in family and community life, on their ability to communicate with others, and to continue to live independent lives.” We cannot ignore the cost of any technology but, even for elderly people, treatments such as cochlear implantation offer significant cost effectiveness. As the NHS England report (see above) explains, “People with unmanaged hearing loss and either dementia or mental health problems are more likely to go straight to expensive care packages, such as a care home, than would be the case if their hearing loss were effectively managed” One area where a cochlear implant has yielded mixed outcomes is with tinnitus. While there is some evidence that where a second implantation is undertaken it can cause a worsening of tinnitus in some patients, most patients have reported a reduction in tinnitus following the implant. Overall, the benefits to teenagers, adults and the elderly from cochlear implantation are very positive.

Hearing loss can affect virtually every aspect of a person’s life. Studies show that anxiety and depression are more pronounced among individuals with hearing loss 1 Find out more why patients with discharging ears should be referred today www.iwanttohear.com/ uk/CSOM Reference 1 Helvik AS, Jacobsen G, Hallberg LR. Psychological well-being of adults with acquired hearing impairment. Disability and rehabilitation. 2006 May15;28 (9); 535-45

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Getting the Greatest Benefit John Hancock, Editor

Ensuring that implant recipients enjoy a real quality of life improvement following their operation

Putting aside the technical aspects, improved localisation of sound sources, improved speech perception and improved functional hearing will all contribute to avoiding the social consequences from loss of hearing

Hearing the World as it is As long ago as 2007, the National Institute for Health and Care Excellence (NICE)19 identified that there were a number of benefits to be gained for people with hearing loss who were fitted with two (bilateral) rather than just one (unilateral) cochlear implant. “These benefits include the ability to localise sound, improved listening in quiet and in background noise. These binaural benefits are due to the head shadow effect (listening with the ear with the most favourable signal to noise ratio), binaural redundancy (listening when the information is the same in both ears) and binaural squelch (the improvement in signal to noise ratio when listening with two ears)… There has been evidence to show that patients implanted bilaterally can benefit from some of these binaural advantages.” In its 2009 guidance on ‘Cochlear implants for children and adults with severe to profound deafness’, NICE20, referring to a number of studies on the topic, was even more specific, “Benefits were reported for auditory and speech perception outcomes with bilateral cochlear implantation. In the five studies that reported levels of statistical significance, three reported statistically significant improvements in the ability to identify the direction from which a sound is coming with bilateral cochlear implants. In addition, two studies reported statistically significant improvements in speech perception in noisy conditions with bilateral cochlear implants.” Binaural benefits for children Summing it up, the National Deaf Children’s Society (NDCS)21 confirms, “It has been shown that children perform better with two implants rather than one alone.” This includes performance in education which, in turn, will significantly impact on later life chances. Back to NICE (see ref 19 above) “If profoundly deaf children have a unilateral implant, and are unable to use the contra-lateral hearing pathway due to insufficient

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residual hearing in the contra-lateral ear, they cannot benefit from any binaural advantages. This may jeopardise their potential academic achievement. Hence, the only alternative for profoundly deaf candidates is to offer bilateral implants, as this is the only way to allow them to benefit from binaural hearing.” A more practical reason to undertake a bilateral implant in a child and as early as possible is to avoid catastrophic consequences should a unilateral implant fail. NICE (see ref 19 above) explains this as, “Firstly, the individual would return to profound deafness after a lifetime of hearing through the implant. Secondly, the only alternative would be to implant the contralateral ear which would have had a long period of auditory deprivation. Research has shown that duration of profound deafness is negatively correlated with outcome.” But, putting aside the technical aspects, improved localisation of sound sources, improved speech perception and improved functional hearing will all contribute to avoiding the social consequences from loss of hearing (see previous articles). Binaural benefits for adults Adults will gain many of the same benefits as children from bilateral implantations. It will improve sensitivity to their surroundings and localisation – ability to discern from where a sound emanates. It will also improve their ability to hear and understand speech and to vocalise so that they will be much better equipped for employment and social involvements. That, in turn will address issues of loneliness, isolation and consequent depression or worse.

Deciding on and Following on from a Cochlear Implant When deciding on the suitability of a person with hearing loss for a cochlear implant, as well as the usual good practice of a medical examination to ensure that a patient is fit to have surgery,


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

THE IMPORTANCE OF HEARING

there are a number of factors to consider. NICE, in its guidance (see ref 20 above) suggests, “… in clinical practice a person’s hearing is assessed not just by audiological tests, but also by a functional test of hearing, specifically their ability to perceive speech in quiet conditions with acoustic hearing aids… decisions about the appropriateness of cochlear implants should take into consideration a person’s functional hearing and the benefit they gain from acoustic hearing aids.” It will also be important to manage a patient’s expectations as to the outcome. Hearing will not be exactly as it would be naturally. In its FAQs on the subject the British Cochlear Implant Group22 explains how the clinician supervising the implant will “During the speech processor tuning… perform certain tests to find out when a patient experiences acoustic signals as being unpleasantly loud. The speech processor is then adjusted so that no acoustic signal reaches this point. There may be other sounds that are not found to be ‘pleasant’ due to their nature (e.g. baby crying) but these should not be uncomfortably loud.” Patients and their families, in the case of children, must also be made aware

of the lifetime commitment of maintenance and care that will be incumbent on them and, especially for the family, that if the wearer removes the speech processor, for instance when going to sleep, they will still be deaf. In the time since commercially viable cochlear implants first appeared in the early 1980s, considerations as to suitability to receive implants has evolved as the technical specification and performance of the devices has developed and as the understanding of their capabilities has grown. Referring to these factors, the 2007 NICE technology appraisal (see ref 19 above) said, “This has obviously resulted in an increase in the range of candidates to include the prelingually and congenitally deaf, and those with greater hearing sensitivity. Other groups, such as those with additional needs and auditory dyssynchrony have also become successful candidates.” None of this should deter clinicians of candidates from proceeding with a cochlear implant but sensible understanding of the whole picture will ensure a better and more sustainable outcome. And that, in turn, will make the implant a real benefit.

Hearing loss can affect virtually every aspect of a person’s life. Studies show that anxiety and depression are more pronounced among individuals with hearing loss 1 Find out more why patients with discharging ears should be referred today www.iwanttohear.com/ uk/CSOM Reference 1 Helvik AS, Jacobsen G, Hallberg LR. Psychological well-being of adults with acquired hearing impairment. Disability and rehabilitation. 2006 May15;28 (9); 535-45

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ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

References: 1

Action on Hearing Loss http://www.actiononhearingloss.org.uk/your-hearing/about-deafness-and-hearing-loss/statistics.aspx

2

NHS England https://www.england.nhs.uk/wp-content/uploads/2015/03/act-plan-hearing-loss-upd.pdf

3

NHS Choices http://www.nhs.uk/conditions/Hearing-impairment/Pages/Introduction.aspx

National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ta166/resources/cochlear-implants-for-children-and-adults-with-severe-to-profound-deafness-82598378568901

4

5

London Health http://www.londonhealth.co.uk/hearing-speech/effects-of-hearing-loss.html

6

Healthy Hearing http://www.healthyhearing.com/report/52433-How-hearing-loss-affects-school-performance

7

The Ear Foundation http://www.earfoundation.org.uk/files/download/869

8

National Institute for Health Research http://www.hearing.nihr.ac.uk/images/uploads/docs/Dawes_et_al_PPLOS_ONE_(2015).pdf

9

British Cochlear Implant Group http://www.bcig.org.uk/assessed/cochlear-implant-work/

10

Action on Hearing Loss http://www.actiononhearingloss.org.uk/your-hearing/about-deafness-and-hearing-loss/cochlear-implants.aspx

National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ta166/resources/cochlear-implants-for-children-and-adults-with-severe-to-profound-deafness-82598378568901

11

12

Action on Hearing Loss http://www.actiononhearingloss.org.uk/~/media/AAC39F0209614E7D8874B076333CE86A.ashx

13

British Cochlear Implant Group http://www.bcig.org.uk/assessed/faqs/

14

National Deaf Children’s Society file: http://www.ndcs.org.uk/search_clicks.rm?id=10910&destinationtype=2&instanceid=475434

15

National Deaf Children’s Society file: http://www.ndcs.org.uk/search_clicks.rm?id=10910&destinationtype=2&instanceid=475434

16

National Institute for Health and Care Excellence (NICE)

17

https://www.nice.org.uk/guidance/ta166/documents/joint-submission-from-the-british-academy-of-audiology-baa-the-british-cochlear-implant-group-bcig-and-entuk2

NHS England https://www.england.nhs.uk/wp-content/uploads/2015/03/act-plan-hearing-loss-upd.pdf

National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ta166/resources/cochlear-implants-for-children-and-adults-with-severe-to-profound-deafness-82598378568901

18

19

National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ta166/documents/joint-submission-from-the-british-academy-of-audiology-baa-the-british-cochlear-implant-group-bcig-and-entuk2

National Institute for Health and Care Excellence (NICE) https://www.nice.org.uk/guidance/ta166/resources/cochlear-implants-for-children-and-adults-with-severe-to-profound-deafness-82598378568901

20

21

22

National Deaf Children’s Society file: http://www.ndcs.org.uk/search_clicks.rm?id=10910&destinationtype=2&instanceid=475434 British Cochlear Implant Group http://www.bcig.org.uk/assessed/faqs/

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The facts on why to refer your patients

DISCHARGING EARS

What are discharging ears? Discharging ears is known as Chronic suppurative otitis media (CSOM) which is the middle ear and mastoid cavity inflammation of greater than two weeks and differs from the other two conditions in that it results in episodes of discharge from the ear. It may arise as a complication of acute otitis media.

Where in the ear does CSOM hide? Otitis Externa

Otitis Media

Otitis Interna

Middle Ear

How many patients are suffering?

ANNUAL 123,189 CHILDREN

251,791 ADULTS

URGENT!

When should you refer?

> 2 WEEKS DISCHARGING EARS SHOULD BE REFERRED FOR ROUTINE ENT ASSESSMENT

Any postauricular swelling or tenderness, facial paralysis, vertigo or evidence of intracranial infection is shown, arrange urgent assessment or admission with an ENT team

For more information, visit www.iwanttohear.com/uk/CSOM References 1 http://patient.info/doctor/chronic-suppurative-otitis-media 2 Office of National Statistics (ons.gov) 3 https://en.wikipedia.org/wiki/Otitis_media


ADVANCES IN COCHLEAR AND BONE CONDUCTION IMPLANT TECHNOLOGY

Notes:

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Primary Care Reports – Advances in Cochlear & Bone Conduction Implant Technology – Cochlear Limited  

Advances in Cochlear and Bone Conduction Implant Technology

Primary Care Reports – Advances in Cochlear & Bone Conduction Implant Technology – Cochlear Limited  

Advances in Cochlear and Bone Conduction Implant Technology