Otology, Neurotology, & Hearing Center

Dallas and Frisco, TX
Main Phone: 972-566-7600
Hearing Center: 972-566-7359
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Cochear Implant Program

The Cochlear Implant Team at Dallas Ear Institute is a group of hearing specialists who provide the highest level of diagnostic, surgical, and rehabilitation services in all areas of cochlear implantation.

Cochlear Implant Program

The Dallas Ear Institute Cochlear Implant Team is a group of hearing specialists who provide the highest level of diagnostic, surgical, and rehabilitation services in all areas of cochlear implantation. Our team is made up of neurotologic surgeons, audiologists, speech-language pathologists, auditory-verbal therapists, psychologists, and insurance reimbursement specialists. Our philosophy is that the decision to recommend a cochlear implant should be made by a multi-disciplinary team and a well-informed patient/parent.

Over 1000 patients have had cochlear implants placed by our surgeons and are being cared for by our team of specialists. Our team helps another 100 patients each year receive a cochlear implant. Our program participates in ongoing clinical trials and research projects, allowing us to offer leading technology and stay abreast of advancements.

In the sections below, you will learn about cochlear implants as a treatment option for hearing loss.

WHAT IS A COCHLEAR IMPLANT?

The cochlear implant is a prosthetic replacement for the inner ear (cochlea). It is a small, complex, multichannel electronic device that helps provide a sense of sound through electrical stimulation of the auditory nerve for hearing-impaired and deaf individuals. Though the implant does not restore normal hearing, the stimulation provides a wide range of auditory information needed for recognizing environmental and speech sounds to expand communication ability.

The cochlear implant bypasses damaged parts of the inner ear and electronically stimulates the nerve of hearing. The cochlear implant system consists of two parts:

  • The internal part consists of wires that are surgically implanted into the cochlea through the skull behind the ear
  • The external part consists of a microphone, a speech processor (that converts sound into electrical impulses), battery and some devices also have a connecting cable

HOW DOES NATURAL HEARING WORK?

To understand how a cochlear implant works, it is important to understand the structure of the ear and how it works.

Sound waves enter the ear canal and impact the ear drum (tympanic membrane). The ear drum transmits sound wave vibrations through the chain of three (3) middle ear bones made up of the hammer (malleus), anvil (incus), and stirrup (stapes). The stirrup passes the vibrations to the inner ear fluids within the cochlea. Fluid waves travel through two and a half (2½) turns of the cochlea, bending the cochlea hair cells as it goes by. The hair cells correspond to the frequency of the original sound waves, initiating signals within their corresponding nerve endings prior to sending them to the brain. 

How does hearing work
  1. Sounds enter the ear canal and travel to the eardrum.
  2. These sound waves cause the eardrum to vibrate, setting the bones in the middle ear into motion.
  3. This motion is converted into electric impulses by tiny hair cells inside the inner ear (cochlea).
  4. These impulses are sent to the brain, where they are perceived by the listener as sound. 

HOW DOES A COCHLEAR IMPLANT WORK?

A cochlear implant is designed to bypass damaged or degenerating cochlear hair cells (within the inner ear that correspond to the sound wave frequencies). The hair cells are the "spark plugs" of the inner ear nerve endings. The vast majority of deafness is usually the result of non-functioning hair cells, however, with the nerve endings still purposeful in the majority of those cases, it makes it possible for cochlear implants to work. 

  1. The external sound processor captures sounds, then filters and processes the sounds.
  2. The sound processor translates the filtered sounds into digital information, which is then transmitted to the internal implant.
  3. The internal implant converts the digital information into electrical signals, and sends them to a tiny, delicate curl of electrodes that sits gently inside the cochlea.
  4. The electrical signals from the electrodes stimulate the hearing nerve, bypassing the damaged cells that cause hearing loss, allowing the brain to perceive sound.

How does cochlear implant work


WHAT IS THE HISTORY OF COCHLEAR IMPLANTS?

The use of cochlear implants for the treatment of severe to profound hearing loss is one of the most revolutionary treatments of our time. Cochlear implant technology was developed over 30 years ago, based on the idea that profoundly hearing impaired individuals have remaining auditory nerve fibers that can be electrically stimulated to produce a sense of hearing.

Age of Research

In the early years of development, cochlear implants were very experimental. No one knew what the effects of electrical stimulation of the inner ear would be. It was apparent that a "sense" of hearing occurred with this stimulus. However, a great deal of experimentation would be needed to determine whether this could be used to restore useful hearing.

Questions included:

  • What is the best way to "code" the complexities of sound into electrical pulses?
  • Did it matter where the electrodes were placed inside the inner ear? 
  • What is the optimal number of electrodes? 
  • Would it work in children as well as adults? 
  • What are the effects of long term electrical inner ear stimulation on the hearing nerves and brain, especially in children?

Age of Acceptance and Expansion

With the advent of multichannel implants, particularly the Cochlear Nucleus 22, it soon became apparent that very useful hearing could be provided through electrical inner ear stimulation and could be done safely, even in children. As processing strategies became more advanced, even better hearing performance was achieved. For the first time in history, the prosthetic restoration of a human special sense was taking place. More and more patients of all ages could now benefit from this technology. The question of whether or not cochlear implants work was clearly answered with a yes.

Now the only question remaining was how well can they be made to work?

Age of Refinement

In the late 1990's, new processing strategies, miniaturization of the processors, and advancement of postoperative aural rehabilitative therapy improved rapidly. The Cochlear Nucleus 24 was approved for implantation in children 12 months of age or older as it became apparent the younger a deaf child is implanted, the sooner the child will assimilate language. Implant performance improved so dramatically that adults who had some residual hearing but were performing sub optimally with hearing aids became potential cochlear implant candidates. Some adults were achieving word recognition over 90% with the implant.

  • Advanced Bionics
  • Cochlear
  • MED-EL

Today

There are over one million deaf individuals (those with profound hearing loss) in the United States. Over four times that number have severe hearing loss. Four thousand children are born deaf each year.

Outcome studies have shown cochlear implants to be one of the most cost-effective medical treatments of our day in terms of the long-term impact on a recipient’s quality of life relative to their cost, far greater than coronary bypass surgery or kidney dialysis. Children with at least two years of cochlear implant experience are placed in mainstream normal hearing classrooms at twice the rate of hearing-hearing children without implants. This saves the educations system up to $200,000 in cost from first through twelfth grade. It costs $40,000 dollars to implant one child during infancy to the age of three years. Statistics show that for every one dollar spent on cochlear implants, society saves $25 in specialized services. This calculates to one million dollars in savings per child implanted.


WHO IS A COCHLEAR IMPLANT CANDIDATE?

Individuals who receive little to no benefit from hearing aids are usually considered to be candidates for a cochlear implant. In other words, a cochlear implant can be considered when significantly better hearing ability can be achieved from a cochlear implant compared to the most optimally fitted hearing aids. Current cochlear implant technology works so well that the candidacy criteria is expanding rapidly. The following are generally accepted candidate criteria.

  • Infants: 6 months or older with profound hearing loss in both ears
  • Children: 2 years and older with severe to profound hearing loss in both ears 
  • Adults: 18 years and older with moderate to profound hearing loss in both ears
  • Limited benefit from optimally fitted hearing aids with speech understanding test scores less than 50%. 
  • No medical contraindications
  • High motivation and appropriate expectations 
  • Participation in an educational or training program that emphasizes auditory skills and oral communication

WHAT IS THE PROCESS TO BE EVALUATED FOR A COCHLEAR IMPLANT?

If you are interested in learning if a Cochlear Implant evaluation is right for you, the first step is to send us your hearing healthcare records.  Instructions on how to send us your records for consideration are outlined in the Cochlear Implant Initial Steps document.

Download PDF - Cochlear Implant Initial Steps

Cochlear Implant Process: Explanation of Evaluation Steps

PHASE I

1. Cochlear Implant Evaluation – This visit with the cochlear implant audiologist will involve extensive soundbooth testing with and without hearing aids. The results of these tests combined with your hearing loss history is used by the audiologist to determine if a cochlear implant is likely to be helpful to you or your child. If so, the audiologist will counsel and educate you about cochlear implants so that you understand all that is involved before you decide to proceed with the rest of the cochlear implant process (2 hour appointment at The Hearing Center, A107).

2. Otologic Medical Evaluation – The physician at Dallas Ear Institute will take a full medical history, perform a physical exam, and review the hearing tests performed in step 1. If he agrees that a cochlear implant is the best option, the next phase of the evaluations can be scheduled (45-minute appointment at Dallas Ear Institute, A103).
You will also be advised to sequentially obtain two pneumococcal vaccines, the Prevnar and the Pneumovax, as recommended by the FDA and CDC, unless you are certain you have received them in the past. They must be given 2 months apart. If you have never had them, you should start this sequence immediately.

PHASE II

1. MRI or CT Scan – It is required that all patients have a scan to evaluate the inner ear anatomy and screen for any brain conditions prior to cochlear implant surgery. Children usually require sedation or anesthesia for the scan; therefore, in their case, it is performed in Medical City’s Radiology Department. Adults and older children have their scan performed in a nearby outpatient facility. A CT or MRI scan of the head that has been performed in the recent past can be evaluated to see if it is adequate for our purposes.

The physician’s medical assistant will instruct you on how to schedule you or your child’s scan (45 minutes).

2. Genetics Evaluation (CHILDREN ONLY) – In 80% of children born with hearing loss, the hearing loss is because of a genetic cause. Determining the exact gene that caused the hearing loss is helpful to the physician in understanding the condition. It also helps the parents understand how future children can be affected. Genetic blood testing for hearing loss is now very practical and cost effective. In some cases, it may be recommended that your child see a doctor who specializes in genetics. The geneticist will take a detailed family history, perform a physical exam, and possibly obtain a blood sample for genetic testing and later counsel the parents regarding the results.

3. Auditory-Verbal Evaluation – For ADULTS, this assesses (A) the effects of hearing loss in the patient’s listening and speaking skills at home, work, educational and social settings, (B) the possible benefits of a cochlear implant, and (C) the need for hearing therapy or speech therapy after the cochlear implant is activated.

For CHILDREN AND ADOLESCENTS, this assesses the patient’s potential for learning to (A) hear and comprehend spoken language with a cochlear implant, and (B) develop speech to use as a primary means of communication. The roles of the parent and the child’s educational setting are discussed and how they impact the benefit from cochlear implantation.

For ALL patients, the purpose of short or long term therapy is discussed. Adult family members are encouraged to attend the evaluation to learn how to support the patient.
You will need to contact HEAR in Dallas at 214-282-9238 or linda@hearingimpaired.com to schedule your 1-2 hour appointment.

4. Neuropsychology Evaluation – For ADULTS, the purpose of the screening is to (A) obtain information regarding overall cognitive, adaptive, vocational, and emotional functioning relevant to preoperative concerns, and (B) assist the individual and their family in identifying and addressing current stressors and other factors which could influence compliance following cochlear implantation.

For CHILDREN AND ADOLESCENTS, the purpose of the screening is to (A) obtain information regarding overall cognitive, adaptive, emotional and behavioral functioning, (B) assist in developing a plan to address skills of compliance and independence relevant to cooperation in rehabilitation, and (C) answer questions, address concerns, and offer emotional and behavior support to enhance preoperative or postoperative rehabilitation.

This evaluation is usually not covered by insurance and requires the patient/parents to pay for the evaluation fee of approximately $150 at the time of the visit. Insurance will not be billed for this evaluation. You need to contact Dr. Nuche at 972-490-8834 or sarahnuchephd@gmail.com to schedule your 1 hour appointment.

5. Videonystagmography (VNG) Balance Testing (ADULTS ONLY) – This test involves a series of balance tests to determine the amount of balance function in each ear. The results of these tests can affect the choice of ear for cochlear implantation and help detect certain patients who may be prone to balance difficulties after cochlear implantation. You need to contact Dallas Ear Institute at 972-566-7600 to schedule your 30 minute appointment (A103).

6. General Medical Preoperative Exam by your Primary MD – If you are age 40 or older OR of any age with medical conditions such as: high blood pressure, heart conditions, diabetes, etc., you may need to see your primary care physician for an exam that includes an EKG, Chest X-ray, and general blood tests. Your physician’s office must fax us these results with a note from the physician stating that you are in reasonable condition to undergo the cochlear implant surgery.

7. Insurance Precertification – The insurance precertification will begin once your MRI has been reviewed by your physician at Dallas Ear Institute. Obtaining approval from your insurance company for cochlear implantation can take several weeks. Our cochlear implant insurance coordinator will be working diligently to obtain insurance authorization. Once your insurance provides authorization, our office will call to inform you of your estimated out-of-pocket expenses related to the surgery.

PHASE III

1. Ordering Equipment/Scheduling Surgery – When all of the above steps are completed, your audiologist will contact you to confirm which brand of cochlear implant you have chosen and will order your equipment. Once this step is completed, the medical assistant will contact you to schedule your surgery.

2. Preoperative Appointment – The day prior to your surgery, you will meet with your physician to review your surgery, your selected brand and confirm which ear is to be implanted. At this appointment, you will be provided the day/time of your future Postoperative Check and Cochlear Implant Activation (1 hour at Dallas Ear Institute, A103).

3. Cochlear Implant Surgery – The surgery takes approximately 1.5 hours. The majority of patients go home the same day of surgery except infants who often spend 1 night in the hospital. Further details of the surgery will be discussed with you by your physician.

4. One Week Postoperative Check and Cochlear Implant Activation – You will return to see your physician one week after surgery to check the incision for proper healing. You will also see your audiologist for programming of the cochlear implant. You will leave the office with the cochlear implant functioning. This is the beginning of learning to hear with an implant. You will be returning to the audiologist for programming of the processor at regular intervals to slowly increase the amount of implant stimulation. You will also be counseled and educated on the external components of the cochlear implant system. (2 hours at Dallas Ear Institute, A103 and The Hearing Center, A107).5.

Once you know the date of your Activation appointment, you will need to contact Linda Daniel at HEAR in Dallas at 214-282-9238 or linda@hearingimpaired.com to schedule your therapy session. Therapy will begin sometime after activation of your cochlear implant.

Download PDF - Cochlear Implant Process to take with you 

Download PDF - Cochlear Implant Process “Map”


WHAT IS INVOLVED IN COCHLEAR IMPLANT SURGERY?

The surgical placement of a cochlear implant has been performed for over 30 years. Newer implant designs and surgical techniques allow placement of these devices with very few complications and excellent cosmetic results.

The procedure is performed in a day surgery unit with most adult patients going home the same day. General anesthesia is administered in the operating room and a small amount of hair behind the ear is shaved. An incision is made in the crease behind the ear, which makes the scar very inconspicuous once it has healed. A pocket is created under the skin to accommodate the receiver-stimulator portion of the implant. This part of the implant has a very flat design so that it will not make a noticeable deformity. An opening is made into the air-filled bone called the mastoid. This mastoidectomy allows us to access the cochlea (in the inner ear) without disturbing the ear canal or eardrum. A very small opening is made into the cochlea. The implant electrode array is threaded in as far as possible. Most cochleas can accommodate the complete electrode array unless meningitis is the cause of deafness, in which case a partial insertion may be necessary. The incision is closed with hidden absorbable stiches that do not require removal.

Cochlear implants are extremely reliable. It is expected that a patient will never need to have his/her implant replaced. Less than 1% of implants have malfunction that requires replacement. Fortunately, if necessary, implants can be surgically replaced without losing any hearing performance.

INSTRUCTIONS TO FOLLOW PRIOR TO SURGERY:

Once the surgery date is scheduled, the patient will have a pre-operative appointment for an examination by a Dallas Ear Institute physician the day before surgery followed by pre-admission at the surgery center, which includes a brief tour of the surgery center, lab work, paperwork, and further instructions for surgery arrival time the following day.

  • It is advised that no aspirin, aspirin products, Motrin, or Ibuprofen be taken two weeks prior to the surgery. 
  • Any signs of illness or temperature that may occur prior to surgery must be reported to our office immediately.
  • If given prescriptions, have them filled prior to surgery.
  • Take NOTHING by mouth after midnight the night before surgery unless given specific instructions otherwise. This includes foods, liquids, or medications. 
  • Note: The anesthesiologist will call you at home the night before surgery, therefore, please be sure you give us the phone number where you can be reached the night before surgery.

AFTER SURGERY/RECOVERY:

Adult patients usually leave the hospital 3 to 4 hours after surgery is completed. Listed below are some factors to consider for the recovery process:

  • A Velcro cup dressing is placed on the ear and remains in place for 2 days.
    Pain will be expected and may be mild-to-moderate for 1 to 2 days and can be controlled with oral pain medicines. 
  • Some patients experience imbalance for a few days after surgery, but this usually resolves spontaneously within the first week.
  • The incision can tolerate water 3 days after surgery.
  • Patients are seen in the office 1 week after surgery to check the incision.
  • After 1 week, most patients are able to return to work or school. 
  • Sports, exercise and air travel should be suspended for 3 weeks.
  • Once healed, there is practically no visible evidence of the internal implant's presence.

ACTIVATION OF THE COCHLEAR IMPLANT

The initial activation of the device and orientation to the external equipment takes place about 1 week after surgery. At that time, the patient will be fitted with the external parts of the device, which requires "programming" (also known as “mapping”) of the external speech processor by the audiologist. During this process, the patient will begin to hear his/her first sounds generated by the implant.

The programming of the external speech processor is a procedure that allows the implant system to be set to suit each individual’s needs. As an individual’s tolerance of sound improves with time, the implant stimulation levels can be adjusted. Recipients should be committed to returning for programming sessions frequently in the beginning of the process then bi-annually or annually thereafter. The Cochlear Implant Team is committed to continuing to work with each implant recipient to ensure optimal benefit from the device.


As seen on the popular TV Show "Top Docs of DFW"

Dr. Bob Peters of the Dallas Ear Institute, discusses the amazing technology of the cochlear implant and how it can help adults that have lost their hearing. Lynn tells her story about how the cochlear implants and Dr. Peters have changed her life. (See video below)

 

As seen on the popular TV Show "Top Docs of DFW"

Dr. Bob Peters with The Dallas Ear Institute discusses the amazing procedure, Cochlear Implants, that he performs that enables individuals to hear. In this segment we hear the story of Kemper who was born deaf, and now thanks to Dr. Peters can hear. Truly amazing! (See video below)


WHAT BENEFITS CAN BE EXPECTED FROM A COCHLEAR IMPLANT?

Cochlear implants are amazing, but they are not magic. They are only the beginning of a long, persistent journey toward the hearing world.

If our Cochlear Implant Team has determined you are a candidate for a cochlear implant, this means that with the proper programming, hearing therapy, and time, you should receive more hearing benefit from a cochlear implant than you are currently receiving from a hearing aid. As a group, individuals with a cochlear implant are pleased with the benefit they receive.

Today, many cochlear implant patients are able to understand speech in multiple situations, talk on the phone and some may experience some degree of music appreciation; however, many patients persist in having difficulties understanding conversations in a group or in the presence of background noise. Other patients may be limited to face-to-face conversation and relying on captions when watching TV. Despite good overall success, outcomes with cochlear implants have wide variability that are attributed to many factors, including but not limited to age, hearing aid use, duration of hearing loss, residual hearing, amount of speech acquired before the onset of hearing loss, cognitive abilities, patient/family personality and motivation, patient/family involvement and commitment to follow-up programming and hearing therapy appointments. Due to the these many factors, it is impossible to predict any patient’s adjustment to the device, length of time it takes to achieve worthwhile hearing, percentage of hearing improvement, or amount of hearing therapy needed.
Our highest performers took 6-12 weeks to adjust to the cochlear implant and did not need long-term hearing therapy. Others patients needed weekly, long-term hearing therapy. Many patients find the first few weeks or months to be disappointing, discouraging, and sometimes depressing. It is important to anticipate this potentially frustrating adjustment period so that you will continue to work hard with your cochlear implant and persevere with the programming and hearing therapy.

Most patients do not recognize speech from the cochlear implant after it is turned on/activated. Instead, patients report hearing “chirps”, “beeps”, “slow drawn-out talking”, “unrecognizable talking”, “high pitch sound”, “rushes of air”, etc. With consistent use of the cochlear implant, programming, hearing therapy, and daily at-home listening practice, gradual improvement is expected. Progress in speech understanding can be measured with the passing months and even after 1 year of cochlear implant use.

The cochlear implant improves hearing but does not provide normal hearing. Sound quality and speech understanding will improve over time, not immediately. Things may not sound like you remember. Music quality may be poor.

As stated above, recipients can vary greatly in the amount of benefit they derive from a cochlear implant. The outcomes can be broken down into 3 groups.

GROUP 1

Congenital or infancy onset hearing loss: If a child who is born deaf is identified with hearing loss soon after birth, fitted with hearing aids in the first year of life, and subsequently obtains a cochlear implant by age 2 to 3 years (the earlier the better) there are great expectations for this child to obtain excellent auditory and oral communication skills with a cochlear implant. This requires intensive speech therapy for several years after the implant is placed to achieve these results. It is reasonable to expect such a child to enter mainstream classrooms upon starting the 1st grade and the hearing impairment not be a significant limiting factor in the child's ultimate educational and occupational goals. Children in this group are considered excellent candidates for a cochlear implant.

GROUP 2

Adult Onset Hearing Loss: Adults who grew up with normal hearing or adequate hearing to learn to speak proficiently, and subsequently have their hearing deteriorate to a severe level are considered excellent candidates for cochlear implants. These patients adjust to the implant very rapidly (usually within a few months) and require only short term therapy. With practice and patience these individuals experience great improvement in face to face communication. Many can learn to talk on the telephone. There is great improvement in environmental sound awareness. Background noise still creates a challenging communication environment.

GROUP 3

Older Children and Adults Born Deaf: Any individual older than 5 years old of age who was born deaf and spent many years with very poor hearing is a less ideal cochlear implant candidate. The success of cochlear implantation in these cases is affected by many factors such as oral speech training and skills, dependency on manual communication (sign language), and motivation of the individual and parents to obtain improved auditory and spoken communication skills. The advisability of cochlear implantation in these individuals must be determined on an individual basis.


WHICH DEVICE SHOULD I CHOOSE?

We are often asked by patients and parents, "Which device should I choose?"
Our answer is always the same: "Any of them."

Our Cochlear Implant Program implants all 3 manufacturers (Advanced Bionics, Cochlear, MED-EL) and we solicit the patient’s and parent’s involvement in choosing which cochlear implant to use. On rare occasions, a patient may have a medical reason requiring the choice of one implant over another. The majority of patients are encouraged to make their decision based on their subjective preference for the appearance of the external processor or confidence in one device over the other as they have networked with other implant recipients. If the patient/parent has no preference concerning which implant to use, we can choose by alternating between the manufacturers.

Each of the cochlear implant devices are excellent devices with comparable electronic capabilities made by stable, well established companies. The specific technical information on each device has very little to do with how well a patient will ultimately "hear." Rather, patient performance with a cochlear implant is determined more by "patient specific" factors (age, duration of hearing loss, amount of speech acquired before the onset of hearing loss, educational setting, amount of time with the implant, how hard patients and parents work in therapy after the implant, etc.). It is crucial that patients/parents place their focus on these issues and not expect the device to guarantee a good outcome.


SHOULD I WAIT FOR FUTURE TECHNOLOGY INSTEAD?

We are also frequently asked, "Should I wait for future technology before proceeding with cochlear implant surgery."

The answer is, "Absolutely not."

The current generation of cochlear implants provides excellent auditory detail and can be upgraded to better technology in the future if warranted. The duration of significant hearing loss before implantation and conversely the amount of time an individual has been using an implant are two major determining factors in hearing performance. Each day, each month, and each year without an implant is time lost towards auditory integration and speech acquisition, especially in children who have a limited "window" of opportunity to obtain maximum benefit from an implant.


DO PEOPLE GET TWO COCHLEAR IMPLANTS?

Placing a cochlear implant in both ears has now become a standard of care for children and adults who meet certain candidacy criteria. The rationale for and benefits of bilateral cochlear implantation are complex. The Dallas Ear Institute is world renowned for its research in this field. Our surgeons and audiologists will discuss this possibility as part of your or your child’s comprehensive plan for restoring the best hearing possible in both ears.

Download Rationale for Bilateral Cochlear Implantation in Children and Adults 

Download Importance of Age and Post-Implantation Experience on Speech Perception Measures in Children with Sequential Bilateral Cochlear Implants

Download Worldwide Trends in Bilateral Cochlear Implantation

Download Presentation at AAA 2010



Links

  • The Dallas Hearing Foundation - A nonprofit organization whose mission is to help provide medical, rehabilitative educational, and research funding.