Dr. Abby Meyer, Lisa Zagar, AuD; and Mignon Miller, SLP, of the audiology and rehabilitation services programs at Children’s Minnesota join the show to discuss cochlear implants. A transcript of the episode is available below.
Jimmy Bellamy, social media specialist: Thank you for downloading Children’s Pedcast, a conversation about pediatrics. I’m Jimmy Bellamy, and today we’re here to talk about cochlear implants. We have a full house, so I’m going to let my guests introduce themselves, because they’ll do a much better job than me.
Lisa Zagar, AuD: My name is Lisa Zagar. I’m an audiologist at Children’s Hospitals and Clinics and I work with cochlear implants, as well as hearing aids and other hearing loss issues.
Dr. Abby Meyer: I’m Abby Meyer. I’m a pediatric otolaryngologist and so I take care of children from the medical and surgical side with hearing loss and I’m one of the surgeons who does cochlear implants here at Children’s Minnesota.
Mignon Miller, SLP: My name is Mignon Miller and I’m a speech pathologist and I work with children with all types of speech issues, including children with hearing loss and cochlear implants.
Jimmy Bellamy: Thank you guys again for coming here. I know that trying to coordinate just one persons schedule is hard enough here. So to get all three of you here today, I feel fortunate. I want to talk about cochlear implants, because it’s a topic that some people know a little about, others know nothing about and there maybe families out there who have children with hearing loss and want to know more about this, so just on a very surface level, what are cochlear implants?
Dr. Abby Meyer: Cochlear implants are an electronic medical device and they usually replace the damaged part of the inner ear, unlike hearing aids, which makes them louder. Cochlear implants replace the inner part of the cochlea and provide sound signals to the brain and how it works is I can go through and kind of explain actually how it works. So if you look at a child that has a cochlear implant, you’ll often see there’s different varieties, but you’ll see something either on the ear or clipped to the child and then an area that leads to the back of their head. So that’s the external part of the implant. Then there’s also an internal implant that I, as the surgeon, put in and how it works is there’s always a microphone that captures the sound and that sound initially is converted into a digital signal and you’ll see a cord that leads to the part that’s on top of the child’s head and so the signals pass through that coil and then through a magnet, actually. So there’s a magnet on the external device and internal device and that’s how the digital signal is transferred to the two. And so then the internal device converts that digital signal to an electronic signal and as part of the surgery, I implant an actual electrode aural into the cochlea and that electrode aural is then stimulated, as an electrical signal and it’s interesting because the cochlea, which is the hearing organ of the inner ear is organized such that different locations within the cochlea represent different tones – so either a very low pitched tone or a very high pitch tone and anything in between and the electrodes also do that. So depending on what frequency the sound is or what the tone is different areas of that electrode are stimulated, which stimulates the little nerve fibers that are in the inner ear and then that signal is then brought along the hearing nerve to the brain and then the brain interprets that signal as sound and that’s how the patient hears.
Jimmy Bellamy: And because I only went to school for four years, if I word something incorrectly, feel free to let me know. But take me through the process of determining whether or not a child is a candidate for cochlear implants.
Lisa Zagar: It kind of depends on when the child is coming into see us. Typically what happens first is there’s the initial hearing evaluation, which may happen while the child is sleeping through an auditory brain stem response test or if the child’s a little bit older, they might be doing something in the sound booth for us responding for sound. Once the hearing loss is established, the child will be fit with hearing aids and then during that time, we do assessments with speech pathology and with audiology, to see what benefit the child is able to get from those hearing aids. If the child is not receiving significant benefit from the hearing aids, then we start looking at whether or not they would be a candidate for cochlear implants. And that process looks like we do testing with their hearing aids on and with their hearing aids off and then talk about the cochlear implants process. They also see the ear, nose and throat surgeon, to determine if they’re a good medical candidate for a cochlear implants and then we talk a lot with the family. The family is involved in the decision-making process and then we decide from there is cochlear implant the best option for the child? If the family’s goal is for the child to learn speech and language through listening and the child’s hearing loss is so severe that they cannot get enough benefit from a hearing aid in order to do that, then likely a cochlear implant is the best option for the child at that time.
Jimmy Bellamy: If a parent is local here in the Minneapolis-St. Paul area, what would they do in order to get in touch with our hearing loss program?
Dr. Abby Meyer: They can always start by calling our clinic and the phone number for that is 612-874-1292, and they could, you know, schedule or say that we’re interested in cochlear implant evaluation. Another thing that would be helpful too is that most kids that are getting to the point where we’re thinking, you know, is a cochlear implant going to give them more benefit than hearing aids? They have an audiologist who follows them closely and that person could contact us directly, you know leave a message when they call and say, you know this is so and so. I’m an audiologist for so and so. We’re thinking maybe we might be going down the cochlear implant route. Can you call and can we talk about it over the telephone? Is this appropriate or what else do you think we should do? That sort of thing. We’re always happy to talk with, you know, the providers, you know audiologist, school audiologists, I mean anybody that has a vested interest in this child and how they’re doing and certainly a parent too. It’s the simplest thing is to call and make an appointment to just, and even if you’re not to that point where it’s in the immediate future, just having the conversation, okay, well how are we doing? Let’s assess the situation. Are we happy with how they’re doing with their hearing aids? But what do we see down the road? Like what things should we watch for? What kind of changes would make us think maybe we’re getting closer to that point? So you know just because you come and see us, it doesn’t mean we’re going to say, “Oh, you need implant right now.” We can have a conversation and say, “Well, really, how’s the child doing?”
Jimmy Bellamy: Once it’s been determined and we could go through the how a child will receive an implant, what’s it like once that happens? I know there’s a period of time for healing and then activation occurs. Several steps and, I mean, you can take me through the list of them, cause I know there are people who are curious about it.
Dr. Abby Meyer: From an ENT standpoint, a medical or surgical standpoint with the development of the newborn hearing screening process, so children who have very significant hearing loss from birth, they’re identified so young that for a lot of parents it’s this long period of wait and that’s so hard. You know, they’ve known for months that their child has a very significant hearing loss. Their child was fit with hearing aids, as soon we diagnose it and then usually around that six month of age time, the child can start doing behavioral testing in the booth and that really is the gold standard of knowing well how is the child doing with the hearing aids? But that you know, often is you know, four months of time, it just seems to drag and parents are like, “Oh we’re not seeing responses with the hearing aids.” We likely know what the child needs, but just, so it’s hard. But kind of around that time, I feel like then we start to think about bringing them in for the full evaluation. You know speech has been following, audiology’s been following, a lot of times I’ve been following and then we really start to get kind of serious and this is for the kind of classic infant, who has very significant hearing loss.
And then you know, we do things like we get, you know from a medical standpoint, we get imaging. So a CAT scan, MRI scan, cause we have to look at the anatomy of the inner ear and the nerve going from the inner ear to the brain, to say well are all the parts there that we need to actually implant the child and is there anything on the imaging that can give us an idea of maybe how the child would do with the implant or not do? And then the audiologists do their aided testing with the hearing aids on in the booths, hear their responding speech, gets a baseline. Say is there anything else that’s raising a red flag as far as language and speech and that sort of developmental process. And then, you know, once everyone is convinced that this is the right thing to do, then we move forward. Now the child that comes into the system who’s had a progressive loss that can go all over the board, where we say, you know what, that child passed their newborn hearing screen. There was no red flags until a child wasn’t talking, when they were a toddler and to say boy, why isn’t the child talking and they get a hearing test and sure enough, there’s a significant hearing loss. So that routes a little bit different and like a lot of it depends on the severity of the hearing loss and really how the child does, once they’re fitted with hearing aids. So it’s hard to kind of lump everyone’s experience into a classic pathway, because I think with the exception of the infants who are otherwise, you know, typically developing healthy, that are identified really, really young. There’s just so much variability how the children come into the system and see us and how rapidly they move towards an implant, if that’s what they need.
Jimmy Bellamy: Is there any common, after saying you can’t really put a blanket on every case, is there a common follow up that occurs post-op, as far as whether it be a child and family are expected to come in a certain amount of times per year and is this throughout the child’s lifetime into adulthood?
Mignon Miller: Yes, typically ENT follows them for post-op, after surgery and then they’re usually healing for about a month and then audiology sees them for their initial activation. And then audiology kind of spaces their programming out, because the implant has to be reprogrammed for a certain period of time and kind of fine-tuning if you will, but speech really continues for many years. The children have to learn to listen, using that cochlear implant, because it is an electrical signal, so it’s much different than our own ears, which are 20,000 hear cells going down to 16 or 24 electrodes. So it’s a different signal, so a lot of times the speech pathologist has to be trained in aural rehabilitation and have the child learn to listen using that device and then eventually talk and speak.
Jimmy Bellamy: How do you approach it, because each case is so unique and each child is so unique? I imagine you yourself are learning things as you get each new patient?
Mignon Miller: Every child is different and I think that every parent is different. You know some parents only want their children to learn to listen and talk and therefore, we use very limited sign language and other parents want their children to kind of be more bilingual and have sign associated with the speaking and so we do a mixture of signing and talking and listening. But actually with a cochlear implant, the most important part is the children need to learn to listen and so that part is the same for every child with a cochlear implant.
Jimmy Bellamy: When parents of a child with hearing loss go through the process of cochlear implant do they more often then not learn American Sign Language as well?
Mignon Miller: Well, most hearing-impaired children are born to parents that are hearing. Therefore, most of the parents want to see their child learn to talk. If there is deafness that runs in the family and the parents sign or the grandparents sign, then most often those children are brought up with sign language in their family, in addition to hearing.
Jimmy Bellamy: I’m always fascinated, no matter the topic with where cochlear implants were 10 years ago, what couldn’t be done then that is being done now and then I never ask anybody to predict the future, but where do you think it will be going even in the next five years, what are some things?
Dr. Abby Meyer: I think from a device standpoint, an implant standpoint, it’s pretty amazing where it’s come. So in 1970 it was the first time a multichannel implant was put on the market. So meaning that there were the different electrodes representing different tones, so before that it was a single channel and that’s how it really was developed. So that was, you know, 37, 38 years ago and the devices keep getting better and better all the time. The internal implants, so the part that I put in doesn’t change as rapidly I don’t think, as the processors and the processing strategies and with technology, you know, Bluetooth and all these things and Lisa can talk more about those specifics, but that’s pretty amazing. The good things about those technologic advances in the processors is that, they always make sure that they can be compatible with the earlier implants.
So when your child gets an implant and you say well what about 20 years from now, are they going to be able to use the technology? The general answer is yes, because they know that there’s so many people being implanted today that are still going to be implant users the rest of their life and they make sure that it’s compatible. I think that probably over the last several years, the biggest push of the implants are with the electrodes and making them less traumatic or as least traumatic as they can be, because the idea is, study’s show that if you can preserve acoustic hearing and that’s what typical hearing is acoustic hearing versus electrical hearing. There are significant benefits to having some preserved acoustic hearing. Now for in the adult world, a lot of adults have a very sloping hearing loss, where their low tone hearing is fairly good, even though their high pitch tone is very poor. So even some for those, they’ll use a shorter electrode or this, you know a very technique to try to preserve as much as the hearing is possible, so they can be actually use both and they can problem the device such that it’s like a hearing aid/cochlear implant combination basically.
So you have acoustic and electrical hearing. For children we don’t tend to use the shorter electrodes, but the idea of an atraumatic insertion is still something I think we all strive for. I always tell families it’s not necessary about hearing preservation in a child, who has very little residual hearing and certainly no useable hearing, but it’s about cochlea preservation, because I don’t know what’s going to come out in this child’s lifetime. I mean we’re implanting children you know, sometimes 8, 9, 10 months of age. What’s going to happen in 60 years? I have no idea, but I know that I’d want to try as hard as possible not to limit what they could have during their lifetime, if something comes out that you know, in order for them to be able to utilize that technology, the cochlea structures have to be preserved. I’m going to do everything I can to preserve those cochlear structures as much as possible. And the newer electrodes are finer, a little bit more flimsy so to speak, so they can be inserted theoretically less traumatically, to hopefully keep those structures intact. So I think that’s like the biggest breakthrough from a surgical standpoint and really where us, as surgeons are trying to go and it’s a topic we discuss at our meetings all the time.
Lisa Zagar: Just to add a few things kind of from the audiology standpoint of more recent development. More recently in the past few years, it used to be that the child needed to be two years old, before they could have the implant surgery and now we’re implanting at younger ages, even infants. We want to make sure that the child has had a long enough time to try out hearing aids and really give that a good effort, to make sure that they are a good candidate for an implant in that regard, and also so that they’re old enough, so that we can see them perform behaviorally for us for the hearing test and making sure that they’re a good candidate for an implant, but certainly much earlier than two years and we see that with that added time when they’re having access to sounds earlier, we can see better performance that way. And another, one of the bigger, more recent advancements has been getting implanted on both sides, so having an implant in each ear, rather than just having one implant and we see more benefits with that in really difficult listening situations that the child is able to perform better, especially once they get into the classroom, in a noisy classroom or in a really noisy cafeteria, we rely on two ears working together to be able to hear and understand speech better and background noise. So now cochlear implants users that have two side implanting are able to take advantage of some of those listening, advanced listening skills and also, being able to know where sounds are coming from, localizing those sounds relies on, you rely on having both of your ears listening together. So that’s also been a major advancement with cochlear implants, once children are able, children and adults are able to get two implants, we can see a lot of benefit in those really difficult listening situations, by having two implants.
Jimmy Bellamy: Do cochlear implants replace the need for a hearing aid, or is there such a thing as cochlear implant hearing aid combo?
Lisa Zagar: Typically speaking, when we’re talking about children, they would not be wearing a hearing aid and a cochlear implant device on the same ear. Once the child is implanted with a cochlear implants, they would just be wearing the external piece for the cochlear implants. The hearing aid would no longer be useful for them at that point. Sometimes we do have children who maybe have a little bit more hearing on one side than the other and then they might be implanted on one side and wear a hearing aid on the other wide. So that would be a situation where they might be using both devices, but not at the same time for one ear.
Jimmy Bellamy: What is the parents or even the family’s role, after a child has received cochlear implants?
Dr. Abby Meyer: I mean it’s a huge deal to have a child with an implant, to kind of put it simply, it’s a huge time commitment, because there’s a lot of appointments, a lot of a lot of appointments and over time, you know us in ENT, we often kind of fade away. Audiology becomes less frequent, but the speech is really ongoing. So there’s lots and lots of appointments and so for people who live in an area where it’s difficult to get to the Twin Cities or if they don’t have someone whose familiar with cochlear implants and taking care of a child with cochlear implants, it can be challenging and a lot of travel time. Even things like knowing how the parts of that process or knowing about the batteries, how long the barriers last? Can you recharge them? What do you do? How could I troubleshoot if something isn’t working? It’s a lot to know. It really is. It’s a big commitment.
Jimmy Bellamy: And Mignon talk about the elements of speech pathology and the impact it has on a child with cochlear implant.
Mignon Miller: The No. 1 thing I think that parents should know is no matter if your child is hearing or not hearing, you should continue to talk to your child. That is the absolute number one thing. Because there is so much that a child can learn and observe from a, even though they’re not hearing, they can do super segmentals by bouncing the baby on their knee and saying “bah, bah, bah, bah, bah” and that way the child is getting the visual stimulation and also the tactile stimulation by bouncing up and down on the parent’s knee. You can also do with a baby, you can take them and say “ahh” and so you can kind of fly them across the room. And so there’s so much that parents can do very early on, make faces, blow raspberries at your baby, stick out your tongue. Is your baby able to follow some of those commands or those signals that you put forth and especially you know just think about your own child, your baby when they smile. You smile at them and they smile back at you. That is so important for communication to get that back and forth communication very early on and it makes it later on down the road, so much easier when they do get a cochlear implant that all those precursors to speech have already been started.
Jimmy Bellamy: If you can describe, whether it be the feelings you get or what it means when you have worked with a patient and you’ve seen the progress that’s made and whether it’s he or she comes in for a visit later and it’s not even an appointment, but to visit. Or you just maybe, do you ever stand back and say, “I remember when she was here and now she’s here.” What’s that like?
Dr. Abby Meyer: I mean that happens all the time. It’s; I mean, it really is what makes it special. You know these babies a lot of times you’re meeting them when they’re truly babies and you see the family, they’re petrified, cause lot of them have no hearing loss in the family and here, their perfect baby cannot hear and that it’s so, it’s just, it’s devastating, but then you see how far they come. You see them next time and they’re whipping those hearing aids in like they were born to do it or the first time you seen struggle, to even get them in. And then you know, then it’s we go to surgery and I always tell families, the surgery is like this little blip in time. It’s such a short amount, I think makes them very nervous, appropriately so, cause it is a big deal, but in the whole journey of this child and getting them to the point where they’re listening and talking is such a small amount of time, but then you see them there. You see them afterwards when they’re just healing and then a lot of times, I often don’t see them for a while. So for me, I’m not seeing them week by seek, to see the slow progress. I’m seeing them sometimes months later and you walk in and sometimes the child you know, says “hi,” and you’re like whoa and its; and you see the family, they’re so happy. You know, it was a long road, but they’re so happy they did it. It was worthy it, cause you say it’s; you know, just said it’s such a big deal to have a child with a cochlear implant, because it’s so much work, but I mean you ask families, I think probably almost all of them would do it again, because they see what their child can do and it makes all those miles, all those appointments so worth it. So it’s special. It really is a special thing. I just feel so privileged to be able to be part of it. It’s just – it’s wonderful.
Mignon Miller: And I think in speech pathology, you know, ever parent always comes in saying, “I want them to talk,” and then they talk for the first time and it’s really a magical moment.
Jimmy Bellamy: And I know you don’t get into this for that, but it has to be one of the sweetest rewards to see and be a part of that journey, to be with them by their side and see them make that process and you’re setting them up for the rest of their lives. There’s nothing better than seeing a patient make it through what is often the most difficult time for that child and that family and to see them come out on the other side better, in the sense that their fears have been washed away because of the work that’s being done here.
Dr. Abby Meyer: And you know, I think it’s hard, because we see families that have gone through this, so when you see them initially, you know that they’re going to be okay eventually, but they don’t know that. This is their first time going through it and you just feel for them. Your heart hurts for them, because it’s so hard, but you know they’re going to be okay. You know they’re going to get through it and they’ve going to be glad they did it and but it’s just getting to that point.
Jimmy Bellamy: From your perspective, you know the process and you know things will improve and I think once you, I imagine once you get the family’s trust, it makes everything a little simpler.
Mignon Miller: I think at Children’s, we have an excellent cochlear implant program. We have three surgeons that do surgeries in Minnetonka, St. Paul and Minneapolis. We also have two cochlear implant audiologists that are housed in St. Paul and then we have speech pathology available in Woodbury, Minneapolis, St. Paul and Minnetonka. So it’s a wide variety and parents can go to any one of those sites or give a call and talk and we’ll always work with the family.
Dr. Abby Meyer: And I think we really try to focus on being a team. You know, I’ll see a child in the office and I’m emailing, okay, I saw so and so. This is how things look. Let me know how this goes and we try to really communicate amongst ourselves and truly be a team for children with hearing loss, even, you know, amongst our three surgeons, my two colleagues and I that do this, we’re always, you know, looking at you know, for example CT scans of challenging anatomy, say hey, what do you think about this? What would you do? I mean we really want to be a team and make sure that we’re doing everything we can at the best of our ability to help each child that we see.
Lisa Zagar: And I think it’s that’s team approach that helps the children to be, a successful as they can be. As you can imagine, when you’re working with a small infant in audiology and trying to decide what is the softest sound that they’re responding for? Are they able to hear all of these sounds that we need them too? There’s a lot that we do on the programming end that’s very fine-tuning, but you’re asking a lot out of sometimes an infant who is just 12 months or less than two years, it’s a lot of work to ask an infant to do, to get all of this information out of them. So we really rely a lot on that communication with the speech language therapist, the aural rehabilitationist, even the audiologists out there with the schools, all of the parts, all of the professionals working with that child and if there’s something that we’re not seeing in their particular audiology clinic session, we’re looking at well how are they responding for speech? Are they producing all of these sounds? Are they able to respond to them? So we take that feedback and really use it in their programming sessions with audiology as well. It’s very important to us to have that open communication.
Jimmy Bellamy: What do you say to members of the hearing-impaired community who take cochlear implants as going against embracing hearing loss?
Lisa Zagar: This is a question that comes up that parents will ask us sometimes too when they come in, depending on the family and what their goals are. They might come in and ask, “Well if I get a cochlear implant for my child, do I have to stop signing with them?” And our answer to that is always, “No.” We don’t say that you need to stop signing. Our goal for the child is for them to be able to communicate with their family, to communicate with their friends, to encourage academic success. And a lot of communication is going to be a decision for the family and for that child. So certainly signing is a wonderful thing. If a family is going to make the decision to go ahead with a cochlear implant, it is a surgery and it is a big commitment like we’ve talked about. So there certainly needs to be a significant focus on aural rehabilitation and to learn how to use that implant, to listen and to use that implant for what it’s meant for, but you certainly can be using sign language, as well. We never say that you have to stop signing once you get an implant and there might be certain cases, as well where based on anatomy or something else going on with the child where we might think that sign language is a good thing for them to have.
There’s a wide range of performance that we see in children with cochlear implants. Often children who are implanted at very young ages and who get all of the appropriate support services are able to function well in a mainstream classroom, even by the time they reach kindergarten. But there are other children where other things might be going on in that picture for them, where they might rely more on a visual communication mode, along with listening with their implant. We see a wide range in performance there. So certainly not something that we say that you can never be signing with the child again. That’s all really based on the individual family, the individual child and what the choice are made there. As far as your question referring to responses from the deaf community and seeing cochlear implants as a threat, you know, when we’re working with children, we’re really working with the family and the parents and it is a family decision. It’s something that the parents will choose for their child and a lot of families that we see, a lot of them are aware of the deaf community and what’s out there, but a lot of what I hear is that they want to give their child the opportunity to participate in the hearing world and a cochlear implant is a good avenue for them to be able to do that.
And if they want to, they can pursue sign language and deaf culture as well, but a cochlear implant is what gives them access to the hearing world so to speak. And in order for a cochlear implant to be as successful as it can be, it needs to occur, while the child is still very young. So it does rely on a decision from the parents, because if we wait until the child is old enough to make the decision for themselves, we’ve kind of passed the opportunity of where they’re going to really be able to take advantage of that implant. So it’s a big decision for parents to make, but a lot of times what I hear is that they want to be able to give their child opportunities and both, and to really be able to take advantage of that implant it needs to happen young.
Mignon Miller: I think on the speech pathology side of it, we want that child to communicate any way they can. So certainly using sign in the very beginning is an excellent way for that child and I do it with children that aren’t even deaf just for them to communicate. That is our goal is we want them to communicate.
Jimmy Bellamy: Before we go is there anything else you would like to touch on? Anything that you think parents listening would been to know?
Dr. Abby Meyer: Well, I think it’s important for families to know and I think a lot of families do already know this that have a child with hearing loss, but there are so many resources available for support for you and your family. You’re not alone going through this and so I really encourage families to reach out, to some of these organizations such as Minnesota Hands and Voice is a very important one, to be able to have a conversation or meet with other families that have gone on a similar journey with their child. So if you ever need any help with any, even getting resources, you can always call our office too. We really are happy to help anyway we can.
Jimmy Bellamy: I can’t thank you enough for the time. Like I said, getting all three of you together means a lot. So I appreciate it and wish you all the best.
Dr. Abby Meyer, Lisa Zagar and Mignon Miller: Thanks.