Sound Start Foundations

2017

Expanding Candidacy
Yetta Abrahams, BA, BHlthSc, MClinAud, MAudSA(CCP)
Senior Manager, Education & Professional Engagement, Asia Pacific

1982 CI candidacy guidelines

Frequency (Hz) X = left
low pitch high pitch
O = right

Normal
soft Aided Testing

s 0% word
understanding
Hearing level (dB)

k
Mild with use of
ch hearing aids
m i a sh
u Moderate

Moderate
to Severe

Severe

loud Profound

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Current indications per TGA (Australia)

CI24RE(CA); CI24RE(ST); CI422; CI512; CI522; CI532

• Bilateral or unilateral moderately-severe to

profound sensorineural hearing loss
• Compromised functional hearing with
hearing aids or would receive no benefit
with hearing aids.
• No maximum age limit

• Children • Adults
– 17 years and younger – Postlinguistic: 18 years and
Pre-op warning: The implant is sterilised using Ethylene older
Oxide (EtO). After the sterilisation process, the residual level
of EtO is suitable for a recipient with a body weight of 7 kg or
greater *
.
– Pre or peri-linguistically
deafened individuals aged 18
years with profound bilateral
sensorineural hearing

* This information is located within the Physician’s Guide for all implant models.

Understanding the difference

Indications for use Candidacy Criteria
Determined by the clinic,
How the manufacturer is allowed to
government, etc.
promote the device after review by
and varies by country
national regulatory authority
May include:
• Moderately-severe • Age specification
to profound • Degree of hearing loss
sensorineural • Percentage of speech perception in
hearing loss the “best aided condition” or based
on the ear to be implanted
• Compromised
functional hearing Reimbursement Criteria
with use of hearing
aids (no benefit with Determined by payers
use of hearing aids) (government, bureau,
insurance review agency,
user/self pay, or those who call
for national tenders)

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Past and current indications

Implanting recipients with

more residual hearing

Bilaterally implanting recipients

Unilaterally implanting recipients

with other disabilities

Unilaterally implanting children with bilateral

profound sensorineural hearing loss

Unilaterally implanting adults with bilateral

profound sensorineural hearing loss

Pre-operative Assessment and Counselling

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Cochlear implant team

• ENT Surgeon • Psychologist

• Audiologist • Neuro-psychologist
• Speech Language Pathologist • Family/Carer
(SLP/ Auditory Verbal Therapist
(AVT)

Candidacy factors and pathway

Cognitive
Audiogram and status
speech Outcomes and
perception expectations

Benefit from Medical

aetiology
hearing aids duration of hearing loss

Pathway →

Audiological ENT Discussion/

Referral
Assessment Evaluation Decision
• Acceptance • Realistic expectations? • Imaging okay? • Cost?
• Denial • What are the goals? • Medically appropriate? • Which ear? Both?
• Curiosity • Is a CI going to provide • Referral to other specialists? • Which implant?
benefit? • Which sound processor?

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Audiology assessment

• Test left and right hearing aid alone and using both
together.
– Recorded phoneme/word – in quiet
– Recorded sentences – in quiet and in noise

• Questionnaires
– Quality of life (HHIA, HHIE, APHAB, CHILD)
– Benefit/satisfaction with use of hearing aids (GHABP, SADL, SSQ,
PEACH, ELF)

• Discussion of goals
– Self-report questionnaire in which help with hearing is required (COSI)

*Consider: Testing in noise at +10 dB SNR if scores in quiet exceed 70%.

Further testing at + 5 dB SNR if + 10 dB SNR score is 70% or higher.

Expectations

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Common parental expectations

• Ability to speak and not have any delays

• Ability to hear like normal hearing peers
• Start school with normal hearing peers
• Develop social skills
• Participate in sports
• Listen to and/or play music
• To not be limited

Adult expectations

• Hear better in one-on-one, group

situations, in noise, etc.
• Resolution of tinnitus
• Talk on the phone
• Help to recover from depression,
embarrassment, frustration and/or isolation
• Become more independent
• Improve ability at work
• Improve communication
• Socialise / pursue hobbies
• Speak to a stranger
• Music appreciation

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Self report measures

A self-report measure may be completed by the adult patient to identify what
is important to them...what will mean the most to them?
E.g The Client Oriented Scale of Improvement (COSI) is a clinical tool developed by NAL for
outcomes measurement. It is an assessment questionnaire for clinicians to use which allows
them to document their client's goals/needs and measures improvements in hearing ability.

“Understanding my wife when she talks

to me in the car and when the TV is on.”
“Understanding the speakers at mass –
the women are the most difficult.”
“Understanding my grandchildren when
they are visiting and telling me what they
did in school.”

https://www.nal.gov.au/products/downloadable-software/cosi-and-hauq/

Outcome prediction factors

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Paediatric
outcomes

Prenatal hearing sensitivity

20 weeks
The ear completes
development

27 weeks
Frequencies below 500
Hz are detected

29 weeks
May begin to detect 500
– 1000 Hz

31-35 weeks
Detection up
to 3000 Hz

Development of fetal hearing, Hepper & Shahidullah, Arch Dis Child Fetal Neonatal Ed v.71(2); 1994 Sep

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Language acquisition

5 years 2200 words 9

4 years 1500 words

3 years 1000 words

2 years 200 - 300 words

1 year 20 - 50 words

AGE

• L. Fenson, P. S. Dale, J. S. Reznick, E. Bates, D. J. Thal, and S. J. Pethick, “Variability in early communicative development,”
Monographs of the Society for Research in Child Development, vol. 59, no. 5, pp. 1–185, 1994.
• S. Lorraine, Vocabulary Development: Super Duper Handouts Number 149, Super Duper Publications, Greenville, SC, USA, 2008.

Brain development
Neural connections for different functions
LANGUAGE HIGHER COGNITIVE FUNCTION
Symbols, ideas Critical thinking
Social relationships Reflective thinking
SENSORY PATHWAYS Verbal ability Considered response
Vision, Hearing, Touch
The impact of hearing loss
for infants is far different
from that which occurs in
Number of synapses

adulthood.

Children use their hearing

to learn about the world
around them and develop
communication skills.

First year

INTO ADULTHOOD
Birth Months Years The infant brain has many more synapses than the
adult brain. These connections rapidly increase
after birth, then begin a natural decline as the brain
specializes. Active connections reinforced by
experience stabilize, while weak ones disappear.
Source: C.A. Nelson (2000). Credit: Center on the Developing Child

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Critical/sensitive period
Intervention for severe-to-profound hearing loss
Sensitive period
Age in
years
1 2 3 4 5 6 7 8 9
Optimal for implantation
Suitable for implantation
Age of implantation
Reduced plasticity
Exception for this age range:
X acquired or progressive loss

• 136 normal-hearing subjects

‒ Age range 6 weeks to 20 yrs.
• 107 CI recipients
‒ Congenital hearing loss or severe to
profound hearing loss by age 1 yr.

Sharma, A., Dorman, M. F., & Spahr, A. J. (2002). A sensitive period for the
development of the central auditory system in children with cochlear implants:
implications for age of implantation. Ear and hearing, 23(6), 532-539

Leigh, J., Dettman, S., Dowell, R., & Sarant, J. 2011. Evidence-Based
Approach for making cochlear implant recommendations for infants with
residual hearing. Ear & Hearing, Vol. 32, No. 1, pp. 1-10.

“These guidelines can only

be applied for children
without additional
disabilities and younger
than 3 years of age.”

An unaided PTA (PTA of 500, 1k and 2k Hz ) of 65 dB HL or worse in the better hearing

ear and unaided PTA of 75 dB HL or worse in the ear (to be implanted) offers a 75%
likelihood of improvement with a CI compared to their current benefit with hearing aids.

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https://www.outcomes.nal.gov.au/

About The LOCHI Study

The LOCHI study is a population-based longitudinal study that prospectively evaluates the development of a group of Australian children with hearing
loss as they grow up. This study is unique in its inclusion of children whose hearing loss was diagnosed through either Universal Newborn Hearing
Screening (UNHS), or standard care; and all of whom access the same post-diagnostic services provided by the national audiological service provider,
Australian Hearing. This means that their results can be fairly compared, whenever and wherever their hearing loss was discovered.
This study addresses the following research questions:
Does Universal Newborn Hearing Screening (UNHS) and early intervention improve the outcomes of children with hearing loss at a population level?
What factors influence the outcomes of children with hearing loss?
Can early performance predict later outcomes of children with hearing loss?
This study is partly supported by the US National Institutes of Health and the HEARing CRC.

Participants (n = 451)

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CI predictor variables
• Age at first HA fitting
• Age at CI activation
• 4FA hearing loss
• Higher cognitive ability
• Higher maternal
education
• Oral communication
mode

• Additional disabilities
– This should not be viewed as
a reason to not pursue
implantation for a child.

Better open-set word recognition

Before
5 years Cochlear implant use by prelingually deafened children: the influences of age at implant and length of device use.
Fryauf-Bertschy H1, Tyler RS, Kelsay DM, Gantz BJ, Woodworth GG
J Speech Lang Hear Res. 1997 Feb;40(1):183-99.
.

During Higher speech production and language scores

pre- The Age at Which Young Deaf Children Receive Cochlear Implants and Their Vocabulary and Speech-Production
Growth: Is There an Added Value for Early Implantation? Connor, Carol McDonald; Craig, Holly K.; Raudenbush,
school Stephen W.; Heavner, Krista; Zwolan, Teresa A., Ear and Hearing: December 2006 - Volume 27 - Issue 6

Faster rates of receptive vocabulary and

Before language development as well as superior
2 years expressive language abilities
Language Development in Deaf Infants Following Cochlear Implantation, Richard T. Miyamoto, Derek M. Houston,
Karen Iler Kirk, Amy E. Perdew & Mario A. Svirsky, Acta Oto-Laryngologica, Volume 123, 2003 - Issue 2

Best outcomes in terms of language acquisition,

Under 18 speech intelligibility and spoken language, followed
by children implanted at less than 30 months
months Early Identification and Cochlear Implantation: Critical Factors for Spoken Language Development, Dianne M. Hammes, MA,
Mary Willis, MS, Michael A. Novak, MD, Danielle M. Edmondson, MA, Lee Ann Rotz, MA, and Jean F. Thomas, MS Annals of
Otology, Rhinology & Laryngology2016111:5_suppl, 74-78

Profound Experience better outcomes when

hearing implanted by 12 months of age
loss Communication Development in Children Who Receive a Cochlear Implant by 12 Months of Age, Leigh, Jaime; Dettman,
Shani; Dowell Richard; Briggs Robert, Otology & Neurotology: April 2013 - Volume 34 - Issue 3 - p 443–450

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Adult
outcomes

Post-lingual
Retrospective review of 12-month post-operative speech perception performance of
adults implanted at the Eye and Ear Hospital, Melbourne, Australia.

Leigh, J., Moran, M., Hollow, R., Dowell, R.C.

(2016). Evidence-based guidelines for
recommending cochlear implantation for
postlingually deafened adults. Intl Jour of Audiology,
early online: 1-6.

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Post-lingual

Given these outcomes, cochlear implantation can be

confidently recommended for post-lingually deafened adults
who obtain up to the following (in the ear to be implanted):

Open-set Open-set Open-set

phoneme word sentences

55% 26% 61%

Using these criteria offers a 75% chance of
improvement in the ear to be implanted.

Leigh, J., Moran, M., Hollow, R., Dowell, R.C.

(2016). Evidence-based guidelines for
recommending cochlear implantation for
postlingually deafened adults. Intl Jour of Audiology,
early online: 1-6.

Pre-lingual vs Post-lingual
Outcome of cochlear
implantation in adults
with long-term hearing
asymmetry.

Post-lingual
There is no significant
difference in outcome if you
implant the better or poorer
ear.

Pre-lingual
Patients will obtain more
benefit if the better ear is
implanted.

Boisvert, I., McMahon, C. M., Dowell, R. C., & Lyxell, B. (2015). Long-Term
Asymmetric Hearing Affects Cochlear Implantation Outcomes Differently in
Adults with Pre- and Postlingual Hearing Loss. PLoS ONE, 10(6).

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Pre-lingual vs Post-lingual
Change in health status
Speech perception (psych, social, well being)

Post-lingual candidates gain more benefit = Post-lingual

compared to those who are pre-lingual.
= Pre-lingual
Raghunandhan Sampath Kumar , Deborah Mawman , Divyan Sankaran , Christine Melling , Martin O'Driscoll , Simon M. Freeman , Simon K. W. Lloyd (2016)
Cochlear implantation in early deafened, late implanted adults: Do they benefit? Cochlear Implants International Vol. 17, Iss. Sup1.

Age effect

Speech recognition
results before and after
implantation for the
different age groups

Earlier age of
implantation is
associated with
greater audiologically
measureable benefit.

Young = Middle aged = Geriatric =

≤55 years 56 – 69 years ≥70 years

Katrien Vermeire, Jan P. L. Brokx, Floris L. Wuyts, Ellen Cochet, Anouk Hofkens, Paul H. Van de Heyning. Quality-of-life benefit from
cochlear implantation in the elderly. Otol Neurotol. 2005 March; 26(2): 188–195.

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0 - 16% = No handicap
Age effect 18 - 42% = Mild-Moderate
44%+ = Significant
The HHIA is a
self-report
handicap
measure.

**Remember:
audiometric
measures
alone do not
describe a
patient’s
reaction to their
hearing loss.

Young = Middle aged = Geriatric =

≤55 years 56 – 69 years ≥70 years

Katrien Vermeire, Jan P. L. Brokx, Floris L. Wuyts, Ellen Cochet, Anouk Hofkens, Paul H. Van de Heyning. Quality-of-life benefit from
cochlear implantation in the elderly. Otol Neurotol. 2005 March; 26(2): 188–195.

Questions we have to consider…

Medical Audiological Candidate
Anatomy and physiology Residual hearing Age (paediatrics)
Number of spiral ganglion Duration of deafness (e.g. Expectations (what does
cells > 25 years will impact due the candidate of family
to auditory deprivation) want/expect?)
Other conditions (e.g. Auditory experience Commitment and family
health conditions, (have they ever had good support
syndromes, psychological) speech perception?)
Infection Pre/post lingual deafness Listening opportunities
Structural and functional Wearing hearing aid or Speech and language
status of the cochlea or other device milestones/abilities
cochlear nerve
Which ear? Or bilateral? Motivation
Listening goals

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SSD impact

• Difficulty understanding speech

in noise and/or reverberation

• Reduced localisation ability

• Loss of summation and

integration

• Reduced spatial balance

Common complaints regarding UHL

• 70-93% report high degree of hearing difficulty, regardless of age

– (Coletti et al. 1988; Ruscetta et al. 2005; Priwin et al. 2007; Wie et al. 2009)
• 54-84% report tinnitus
– (Mo et al. 2002; Quaranta et al. 2004; Priwin et al. 2007; Wie et al. 2009)
• 12-41% need of additional educational assistance in children
– (Bess & Tharpe 1986; Bovo et al. 1988)
• 22-35% increased rate of grade failures
– (Bess and Tharpe 1988; Brockhauser et al. 1991; Cho Lieu et al. 2004)
• 25% out of work several years after onset
– (Wie et al: 2009)

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Treating Both Ears as Standard of Care

• The significance of unilateral hearing loss

– In a study of 60 children with unilateral hearing loss1:
> 35% had failed at least one grade in school
> 50% showed some difficulty in the educational process
– Studies show that children with unilateral hearing loss require better listening
conditions to perform as well as their normal hearing peers2

1 Bess FH, Tharpe AM. Case history data on unilaterally hearing-impaired children. Ear & Hearing
1986;7:14-9
2 Ruscetta et al. Speech recognition abilities in noise for children with severe-to-profound unilateral
hearing impairment. International Journal Pediatric Otorhinolaryngology 2005;69:771-9.

Objective assessment

• Speech perception testing in noise

– Requires minimum 2 speaker set up
• Speech & Noise in front
• Speech in front, Noise from behind
• Speech to impaired side, Noise to “hearing” side
- Signal to noise ratio (SNR) fixed?
• SNR +5 typical of average classroom
- Adaptive procedure/ SRT
• What is expected from normal hearing?

• Speech perception testing in quiet

– Speech to impaired side in quiet

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Functional Assessments - Adults

• Utilise your own goal setting based on practice for hearing aid clients to
determine which device you will recommend - CROS, Baha, CI or no
intervention
• Speech, Spatial and Qualities of Hearing Scale (SSQ)
• Abbreviated Profile of Hearing Aid Benefit (APHAB)
– Ease of Communication
– Reverberation
– Background noise
– Aversiveness
• COSI Goals
• Localisation?

Functional assessments– Paediatrics

• Speech, Spatial and Qualities of Hearing Scale (SSQ) for children

– Modified separately for parents, children (over 10) & teachers
– 3 sections
• Speech: speech understanding in quiet, noise, groups, on phone
• Spatial hearing: perception of position, movement and distance of sound sources
• Qualities of hearing: identification of sounds and voices, ease of listening, segregating sounds

• Other questionnaires for parents and teachers

– S.I.F.T.ER.
– PEACH/TEACH
• Speech and language progress – multi-disciplinary approach.

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Pre-implant Trial

• What device
– Baha sound processor on softband or SoundArc
– CROS aid
– Air conduction hearing aid

• Who fits the trial device

– Within clinic trials or liaise with Australian Hearing or other Hearing Aid
Provider (for CROS)

• Length of trial
– Clinic protocols vary from 2 weeks to 3 months

Clinical recommendations
Baha vs Cochlear implant
• Not satisfied following a
• Long-standing SSD Softband trial
• Satisfied following a Softband • May consider the potential for
trial partially restored binaural
hearing

• Benefit from sound awareness

• Marked perceived problems
on the affected side and does
with speech understanding in
not anticipate true binaural
noise over an extended time
hearing

• Does not have an intact 8th n. SSD

or patent cochlea • Viable 8th n. and patent
cochlea
• Intact 8th n. and patent cochlea
but not ready to undergo • Intractable tinnitus
significant surgery

• Motivation to consider surgical

intervention
• Lower cost option
• History of Meniere’s with loss
of residual hearing

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Candidacy factors and pathway

Cognitive
Audiogram and status
speech Outcomes and
perception expectations

Benefit from Medical

aetiology
hearing aids duration of hearing loss

Pathway →

Audiological ENT Discussion/

Referral
Assessment Evaluation Decision
• Acceptance • Realistic expectations? • Imaging okay? • Cost?
• Denial • What are the goals? • Medically appropriate? • Which ear? Both?
• Curiosity • Is a CI going to provide • Referral to other specialists? • Which implant?
benefit? • Which sound processor?

Disclaimer
• The contents of this presentation is intended as a guide for information purposes only
and does not replace or remove clinical judgement or the professional care and duty
necessary for each specific recipient case. The information has been prepared with
reference to the best information available at the time of preparation. However, no
assurance is given that the information is entirely complete or accurate in every
respect. Clinical care carried out in accordance with this presentation should be
provided within the context of locally available resources and expertise. This
presentation does not address all elements of standard practice and accepts that
individual clinicians are responsible to:

• advise recipients of their choice and ensure informed consent is obtained prior to
delivering care
• provide care within scope of practice, meet all legislative requirements and maintain
standards of professional conduct
• apply standard precautions, and additional precautions as necessary, when delivering
care
• document all care in accordance with mandatory and local requirements

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Cochlear, Hear now. And always, and the elliptical logo are either registered trademark or trademarks of Cochlear Limited. Baha is a
registered trademarks of Cochlear Bone Anchored Solutions AB.

This content is meant for professional use. If you are a consumer, please seek advice from your medical practitioner or health professional
about treatments for hearing loss. They will be able to advise you on a suitable solution for your hearing loss condition. All products should be
used only as directed by your medical practitioner or health professional. Not all products are available in all countries. Please contact your
local Cochlear representative

D1258839 ISS2 AUG18 © Cochlear All Rights Reserved.

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