Monday, 22 July, 2024
HomeOtolaryngologyCochlear implants for adults should be recommended more often

Cochlear implants for adults should be recommended more often

An international group of hearing specialists has released a new set of recommendations emphasising that cochlear implants should be offered to adults who have moderate to severe or worse hearing loss much more often than is the current practice. The group hopes the recommendations help increase usage of such devices, potentially improving hearing and quality of life for millions worldwide.

The consensus statement was developed by a panel of 31 hearing experts representing more than a dozen countries. Dr Craig A Buchman, the Lindburg professor and head of the department of otolaryngology-head & neck surgery at Washington University School of Medicine in St Louis, led the panel.

Unlike hearing aids, which amplify sound for people who retain some ability to hear, cochlear implants help people hear by directly stimulating the auditory nerve. The committee of hearing experts, which includes otolaryngologists and audiologists, said that the estimated 50m people living with hearing loss severe enough to negatively affect quality of life could benefit from cochlear implants. The recommendations also are intended to raise awareness among primary care doctors and other health-care providers who potentially could diagnose hearing loss and refer patients to hearing specialists.

“Even though cochlear implants have been approved by the US Food and Drug Administration since 1985, less than 10% of adults who could benefit from them actually receive one of these devices,” Buchman said. “There may be a misconception that cochlear implants are only for young children born with profound hearing loss. But these devices can be extremely effective for adults who have lost hearing later in life. Adults who have difficulty talking on the phone, for example, are probably candidates for a cochlear implant.”

Buchman also said adults and their doctors may turn to hearing aids because they assume such devices will solve the problem and help avoid what is perceived by many to be a major surgery.

“Cochlear implants can be implanted in an outpatient procedure that typically takes about an hour,” Buchman said. “It’s a safe procedure and highly effective. In addition, hearing aids only work for those who need some amplification. But as hearing diminishes, people start to lose clarity as well. Making unclear speech louder doesn’t help with comprehension – people start to sound like the teacher who mumbles in the Charlie Brown cartoon. At that degree of hearing loss, a cochlear implant is the recommended intervention because it can restore clarity.”

The consensus paper reports 20 statements that the panel of experts voted to include in the document. The recommendations, which were arrived upon following a review of scientific literature on cochlear implants, cover seven categories for adults with moderate to severe or worse hearing loss in both ears. They focus on:
Awareness of cochlear implants.
Best practice guidelines for diagnosing hearing loss.
Best practice guidelines for cochlear implant surgery.
Clinical effectiveness of cochlear implants.
Factors linked to outcomes after cochlear implant surgery.
Relationship between hearing loss, depression, social isolation and dementia.
Cost implications for cochlear implants.

Buchman said another possible barrier to wider adoption is that hearing loss is surprisingly difficult to diagnose. Primary care offices do not always have the specialized equipment used to test hearing, and patients are adept at finding ways to cope with diminishing ability to hear.

“During a one-on-one check-up, it’s actually quite easy for doctors to miss even severe hearing loss,” Buchman said. “Hearing loss can happen gradually, and people may not notice the degree to which they are relying on lip reading and the context of what they can hear to compensate for what they’re missing. But to compensate for lost hearing successfully, they need to have face-to-face interactions.”

“If you are a doctor having a wellness visit with a patient, a simple way to screen for hearing loss is to go to the sink and wash your hands,” he said. “With the water running and your back to the patient, try asking a few questions. If the patient doesn’t respond in that situation, it’s appropriate to start a conversation about hearing loss with him or her and discuss whether formal hearing tests are appropriate.”

Hearing loss has been associated with social isolation, depression and dementia. Though research is ongoing to understand the role of hearing loss in these problems, Buchman and his colleagues said strong evidence suggests that improving hearing can have a significant impact on quality of life.

“Research indicates that hearing loss is the single largest modifiable risk factor for dementia, and cochlear implants can perhaps lessen that risk,” he said. “We hope these recommendations will eventually lead to formal clinical practice guidelines. Such guidelines could increase access to cochlear implants worldwide, address disparities in care, and lead to improved hearing and quality of life for adults living with debilitating hearing loss.”

Importance: Cochlear implants were approved for use in adults in the 1980s, but use remains low owing to a lack of awareness regarding cochlear implantation candidacy criteria and expected outcomes. There have been limited, small series examining the safety and effectiveness of cochlear implantation in adult hearing aid (HA) users with and without mild cognitive impairment (MCI).
Objective: To investigate the safety and effectiveness of a single-ear cochlear implant in a group of optimized adult HA users with and without MCI across a variety of domains.
Design, Setting, and Participants: In this nonrandomized controlled trial, a multicenter, prospective, repeated-measures investigation was conducted at 13 US institutions. The setting was academic and community-based cochlear implant programs. Eligible participants were 100 adults (aged >18 years) with postlinguistic onset of bilateral moderate sloping to profound or worse sensorineural hearing loss (≤20 years’ duration). Fluent English speakers underwent an optimized bilateral HA trial for at least 30 days. Individuals with aided Consonant-Vowel Nucleus-Consonant (CNC) word score in quiet of 40% or less correct in the ear to be implanted and 50% or less correct in the contralateral ear were offered cochlear implants. The first participant was enrolled on February 20, 2017, and the last participant was enrolled on May 3, 2018. The final follow-up was on December 21, 2018.
Interventions: Participants received the same cochlear implant system and contralateral HA.
Main Outcomes and Measures: The primary outcome measure was speech understanding in quiet (CNC word score) using both the cochlear implant and opposite ear HA. Secondary outcome measures included the following: adverse events; speech understanding in noise (AzBio signal-to-noise ratio of +10 db [+10 SNR]) Health Utilities Index Mark 3 (HUI3); Speech, Spatial, and Qualities of Hearing Questionnaire 49 (SSQ49); and Montreal Cognitive Assessment (MoCA).
Results: The median age at cochlear implantation of the 96 patients included in the trial was 71 years (range, 23-91 years), and 62 patients (65%) were male. Three serious adverse events requiring revision surgery occurred, and all resolved without sequelae. By 6 months after activation, the absolute marginal mean change in CNC word score and AzBio +10 SNR was 40.5% (95% CI, 35.9%-45.0%) and 24.1% (95% CI, 18.9%-29.4%), respectively. Ninety-one percent (87 of 96) of participants had a clinically important improvement (>15%) in the CNC word score in the implant ear. Mild cognitive impairment (MoCA total score ≤25) was observed in 48 of 81 study participants (59%) at baseline. Speech perception marginal mean improvements were similar between individuals with and without baseline MCI, with values of 40.9% (95% CI, 35.2%-46.6%) and 39.6% (95% CI, 31.8%-47.4%), respectively, for CNC word score and 27.5% (95% CI, 21.0%-33.9%) and 17.8% (95% CI, 9.0%-26.6%), respectively, for AzBio +10 SNR. Statistically significant and clinically important improvements in the HUI3 and SSQ49 were evident at 6 months.
Conclusions and Relevance: The findings of this nonrandomized controlled trial seem to indicate that cochlear implants are safe and effective in restoring speech understanding in both quiet and noise and improve quality of life in individuals with and without MCI.

Craig A Buchman; Jacques A Herzog; Jonathan L McJunkin; Cameron C Wick; Nedim Durakovic; Jill B Firszt; Dorina Kallogjeri for the CI532 Study Group


[link url=""]Washington University School of Medicine in St Louis material[/link]


[link url=""]JAMA Otolaryngology abstract[/link]

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