Good afternoon. Welcome, everyone, to the IHS webinar, Fact or Fiction, What to Know about Cochlear Implants Today, sponsored by Cochlear. I'm your moderator, Sierra Sharp, IHS's Director of Professional Development. Thank you so much for joining us today. Before we get started, I just want to share a few housekeeping items with you. Note that we are recording today's webinar, so it can be offered on demand through the IHS website in the future. Closed captioning is also available and can be turned on using the Zoom toolbar as shown on your screen. This webinar is available for one continuing education credit through the International Hearing Society. The CE quiz and information about how to receive credit can be found on the webinar webpage, which is shown on the screen and linked in the chat box for you. The slides for today's presentation can also be downloaded from the same page. Feel free to take a moment to do that now if you'd like to follow along. Following completion of the CE quiz, you'll be asked to take a three-question evaluation. We appreciate your feedback and we use it to create future content for our valued IHS members. Now onto our presenters. Dr. Varun Bharadwajaran is a neurotologist and skull-based surgeon with dual board certifications in otolaryngology and neurotology. He specializes in the management of ear and hearing-related disorders. As a lifelong musician, Dr. Bharadwajaran obtained a degree in music before pursuing his medical career. He fostered his passion for auditory perception by pursuing subspecialty training in otology, neurotology, and skull-based surgery after completing his otolaryngology residency. A Wisconsin native, Dr. Bharadwajaran grew up in Milwaukee before attending Washington University in St. Louis for his undergraduate studies. He received his bachelor's degree with a double major in music and biology there. Dr. Bharadwajaran attended medical school at the Medical College of Wisconsin and completed his otolaryngology residency at the University of Florida. To further subspecialize in ear, hearing, and skull-based conditions, he completed his neurotology fellowship at The Ohio State University. Definitely safe to say he's an expert. Presenting this webinar with Dr. Bharadwajaran is Laura Lassen. Laura is the senior manager for growth channels at Cochlear. She has a bachelor's in speech and hearing sciences from Miami University and received her AUD from Vanderbilt University. She has worked in a range of industry roles, including clinical trainer, territory manager, sales trainer, and regional director for two different hearing aid manufacturers. Her clinical experience includes both private practice and ENT settings, providing diagnostic and hearing aid support for the adult population. As you can see, our speakers have a lot to cover today. And at the end, we'll move on to a Q&A session. On your bottom menu, you'll see icons for chat and Q&A. Try to keep general conversation in the chat box and all your questions, which you can send at any time in that Q&A box. And now we'll go ahead onto our main presentation. Take it away, Laura. Well, thank you so much, Sierra, for that wonderful introduction. So let me get started here. And I want to say thank you as well to Dr. Varadarajan for collaborating with us on this effort. You know, I know, Dr. V, you do so much great efforts within the Sacramento and Northern California market in really getting out, meeting with hearing aid providers and talking to them about cochlear implants and education, and really at the end of the day, collaborating on patients and how you guys can both get them to the best hearing possible and to the best care option for them. So to start, I did want to talk a little bit about our mission at Cochlear because this really is something that rings through for us across the organization. And with events like this and collaborations with IHS, you know, we really look to transform the way people understand and treat hearing loss. And as a part of that, it's really about working with so many professionals across hearing healthcare to understand where cochlear implants fit in. So Dr. V, I'll start with, I know a lot of these statements are things, again, that as you've worked with professionals, you still hear a lot of these myths or, you know, things that, you know, maybe have changed over the years. So excited for you to address them and really ultimately help providers understand how they can talk with their patients most effectively. So to start, I wanted to ask you about this statement. Cochlear implants should really only be considered as the last resort when the patient is receiving little to no benefit from their hearing aids. So what do you say to this one? So thanks so much, Laura, for the, and to the whole Cochlear team for the kind introduction. I'm Dr. Adar Adharajan, for those of you who didn't, who weren't here for that part. This is a great question. And I hear this, you know, this question a lot, you know, when meeting hearing instrument specialists and audiologists and actually other ear, nose and throat doctors as well. This is fiction. This is one of the biggest myths. And it's mostly because it's dated. You know, when FDA approval was granted for cochlear implantation in the 1980s, that's really when this would have been fact. But as cochlear implant technology has progressed, we are able to implant patients with greater degrees of residual hearing. And actually we're getting better outcomes with a cochlear implant if we implant earlier, which we'll show you some data on soon, rather than waiting until they're getting no benefit at all from their hearing aids and they just have severe to profound sensorineural hearing loss. Yeah. And that's where, again, I think, as this audience knows, unfortunately, hearing loss is extremely prevalent, you know, for all the millions of individuals that are impacted by hearing loss. You know, penetration rates, even on the hearing aid side, have really remained in that 30% range. And so we know that it's really undertreated. And the reality when it comes to cochlear implants, I think is that, unfortunately, it's even lower. You know, estimates have that cochlear implants are just about, you know, three to 5% of those that could benefit from that technology. And so, again, I think, hopefully, as an industry, we're continuing to share how hearing loss impacts individuals' lives, and not just the hearing. And we see that in so much research and things like the ACHIEVE study. But I think if we think about, again, the patient journey, really, to hearing loss, that's where, obviously, we have so many great technology options that are out there. Obviously, you know, now we've got OTCs all the way to cochlear implants. And I think what's important for patients and professionals to educate them on is that, obviously, hearing loss, just like other disease states, can have a progression. And so that's where these different technologies fit in, depending on their degree of loss. And that, you know, for some patients, again, they may have moderate hearing loss their entire lives, and hearing aids are the best option. But there's always gonna be that subset of patients who, again, their disease state progresses, their hearing loss becomes worse, and they really need to consider different options. And I think that's where, as, you know, hearing instrument specialists, you know, you guys really see this first and foremost, because they're coming back in with their hearing aids, they're struggling more, that level of communication difficulties becoming greater. So you guys really have such an impact in helping them understand where the technology fits and when they need to look at it. And that's where, unfortunately, I think, you know, we see this in the penetration rates, and we see this as well in a lot of the surveys that we do with recipients. They're not even aware that cochlear implants really exist and where it fits in. And to what you were just talking about, Dr. V, this has an impact on many things. So, again, I'll let you kind of talk about why early implantation and helping individuals understand where this fits in their journey is so important. Yes, and, you know, if you go back to that slide before this, one thing I'll point out, you know, this is a very good slide, you know, if we think about it linearly, but that's not how hearing healthcare is thought about anymore. Now, the OTCs, yeah, that goes on the left side of this for mild hearing losses, but as we go to the right, you know, even graphs like this, which we don't have things much better than this, but we still have cochlear implants listed in the severe to profound range on that top yellow arrow. Whereas, realistically, we're implanting people with moderate to severe sensorineural hearing loss, where we probably could move cochlear implant a little more to the left on this graph, and we can move on to the next slide here. The number one goal of a cochlear implant is improved speech clarity or improved speech discrimination. And yes, obviously, pure tone average and pure tone thresholds are important as a screener, and there's a clear correlation where you have worse pure tone thresholds for cochlear implant candidates, but the real test of whether or not you're a candidate comes down to speech discrimination. And so, the longer you wait, you know, without appropriately providing that acoustic stimulation, the longer it takes for the hearing nerve, which received that electric stimulation, to learn how to use the implant. It takes longer for the brain to, for it to feel natural, and for them to get the best possible hearing outcome they could get. Now, this goes back to, you know, why we shouldn't wait until patients are totally deaf or severe to profound to implant them. And this graph sort of demonstrates, you know, where their hearing benefit actually ends up versus like how long you wait, and the decibel loss, and decibel loss obviously, you know, refers to pure tones. And so, what we really need to let go of is the fact that we're only basing our decision on pure tone average and look at the speech discrimination as it goes down. And if the speech discrimination is, you know, so significantly affected, and we'll talk about, you know, how and when to refer, we can't put all the weight on, oh, their pure tones are really good, therefore they must be doing well with conventional hearing amplification. And this graph sort of demonstrates how early intervention can actually get a better hearing outcome and better speech understanding and communication for the patient. So, as far as untreated hearing loss, this is something that you are all very well aware of. We know that auditory deprivation and untreated hearing loss can result in a number of sequelae. For example, mental sharpness, mental acuity, cognitive factors, you know, and what's not even listed on here is potentially a risk of dementia, which there's emerging data exploring that. Their ability to work and function day-to-day as normal citizens, their quality of life, day-to-day satisfaction, a loss of enjoyment. There's, I'm sure you're familiar with the data showing that there's a higher risk of dizziness and falls. Geriatric patients can have loss of independence from this. And what I hear a lot in my clinic, lastly here is social isolation. And I'm sure you hear that from the hearing aid front as well. Patients are withdrawn. They're not interacting with their friends, their family. They completely dread social events. These are red flag warning signs that we should be thinking outside of the box from what we've tried already from conventional hearing amplification and that we need to be thinking about the next step. So when do you refer? And so there really are two categories of candidates. It looks like the slide didn't fully load up all the way there. Are you able to see that, Laura? Oh, there we go. It's on my end, yep. Okay, it took, it was like frozen for a second, but there's two categories. There's what we consider traditional candidates. These are patients with bilateral or both sides sensorineural hearing loss. And then there's the other category of patients which are single-sided deafness where one ear is severe to profound and then the other ear is normal or various degrees of hearing loss. We're gonna first focus just on traditional candidates. So this is the run of the mill, presbycusis, gradual, progressive sensorineural hearing loss that you get especially in our elderly patients. And this article by Terry Zwollin who at the time was at University of Michigan, they wrote this article called, that talks about the 60-60 guideline. And this is a guideline on when to refer a patient for a cochlear implant evaluation. And that's where the pure tone average is 60 decibels or worse, or the speech discrimination in the better ear is 60% or worse. And the whole specialty is heading more and more towards the ear to be implanted. So this idea of a traditional candidate needing hearing loss in both ears, obviously Medicare still follows that but our commercial payers are moving away from that too. And we're just looking at each ear independently. But this is a good rough guide on, hey, is this a patient that's approaching cochlear candidacy other sort of subjective measures are, they struggle to hear on the phone, difficulty understanding speech discrimination. I talked about the social isolation and often having other people repeat themselves even with their use of conventional hearing aids. I personally weigh more on the speech discrimination here because a lot of times you can have a lot of low frequency pure tones that are actually pretty good that can skew the pure tone average decibel level. And so if both ears are 60% or worse, it is okay to refer the patient at least just to see how they are to cochlear implant candidacy. And if they're not a candidate yet, they may be at some point in the future, but it also introduces the technology and that's one of the benefits as well of referring even beyond seeing if they could actually qualify for an implant. And this is what I was referring to before. The second type of candidates is single-sided deafness. And we don't have a speech discrimination guideline for this but you can use 40 to 60% or worse as a conservative, or I guess I should say not conservative as a liberal way of saying, hey, this ear is not gonna get benefit from hearing amplification if they're still dissatisfied. But we have pure tone guidelines where, 80 decibel pure tone average or worse, I would even move that up to 70. So severe or worse hearing loss and the better ear can be totally normal. Speech discrimination, ideally less than 50 or 60, but majority of patients I see referred for this have less than between 20 or 40. And that's when I'm seeing them referred, but a lot of times we get them before that and they end up qualifying for cochlear implantation. And so here's another way of talking about the conception of you have to wait until a patient has severe to profound loss. If you first look at the patient on the right, this is what most people would consider a traditional cochlear implant candidate. And that's where we have profound bilateral sensory neural hearing loss. But if you were to compare that patient today with the patient on the left side where, their low frequency losses in the mild range, mild to moderate range, the patient on the left is actually likely to do even better with a cochlear implant than the patient on the right. The greater the degree of residual acoustic hearing, the better they do with a cochlear implant because that hearing nerve has gotten robust stimulation with their hearing aid or whatever hearing device that they're using. So it's not as much of a stretch for it to learn electric stimulation versus the patient on the right. If they've been completely unaided, they're gonna struggle for a while. They eventually will get there and get satisfaction with an implant, but it will take them longer and their performance plateau will not be as high as the patient on the left. Yeah, well, great information. Cause again, I think, I know my team really talks with referring professionals a lot. And this comes up and patients, really not feeling ready to move forward. So I think equipping professionals to talk about, the impact of waiting and that they need to do something earlier. And you kind of mentioned it too in the referring slide, the next step, if someone does kind of meet that 60-60 is really just the evaluation step. And so, they're not going the next day to surgery or anything like that. And it's really, I think, if you think about hearing healthcare as a medical condition, it's helping that patient really get more information, really understand their condition. I think, educated patients are really empowered patients. And so, those are great points, Dr. B. So going on to our next one, and I have to say, I think this is the one that, still we hear so much about, but the statement patients will lose all their hearing when they're implanted. So I will turn this, important topics. I know this comes up a lot to you and how do you kind of address this with professionals as well as with patients? So this is a great question. For the most part, this is fiction and this has, but I will say it has only become fiction in the recent past, in the last 10 to 20 years. And the reason is implant technology has just gotten better. And we can go on to the next slide and I'll talk about why I'm mentioning that. This is a sort of diagram of the cochlea and the cochlea's tonotopic organization. As you all know, the outer hair cells and auditory nerve is organized within the modiolus of the cochlea as it comes in through that spiral, through the spiral ganglia. And the base of the cochlea at the bottom right here, that's where we actually put a cochlear implant electrode in and that is also where the frequencies are highest. And as you spiral up the cochlea to the apical portions of the cochlea, that's where we get to the lower frequencies. And so the nerve spirals up through the modiolus and it sort of hits all of this like a spiral staircase, like keys on a piano. And we lose hearing as we get older, mostly in the high frequencies first, just like the audiograms that you were seeing before. And then we hold onto the hearing in the low frequencies for longer. Now, just based on mechanical trauma, inflammation, and when we open up the cochlea and we put an electrode, that electrode is being threaded up from the base towards the apex. And so a lot of the hearing in the basal turn and the parts of the middle turn of the cochlea are going to be lost if there is a residual acoustic hearing. Now, that's not always the case, but that is the highest risk of losing that degree of hearing loss. Usually, especially the high frequencies, but to be honest, those frequencies are typically already gone or at least non-serviceable. It's really the low frequencies where we're talking about residual hearing, like we mentioned before. Now, with advanced cochlear implant technology, better electrodes, slimmer electrodes, more sophisticated surgical technique where we put it in at the right angle, we have intraoperative tools from cochlear to measure our speed of insertion, our depth of insertion. We are able to save a lot of that residual hearing in the low frequencies in well more than half of patients. Some studies are showing more than 70 to 80% hearing preservation, which is pretty similar to what I'm experiencing in the patients that we intend to save that hearing on. And obviously I have my preference on what electrodes that I want to use for that. But this slide here shows a pre and post-op right-sided audiogram on a patient. And so this is from a referral from a hearing instrument specialist on the left, where in the low frequencies, they have a bunch of that, you know, 250 and 500 Hertz residual hearing. And then we did a bone line after surgery on the patient and that's the audiogram on the right. And that low frequency hearing was completely preserved. You know, they were able to hear it. And this patient then was fit, not only with the cochlear implant processor, but what we call a hybrid kit, where in that same ear, they were getting electric stimulation for the high frequencies and then acoustic amplification, just like a hearing aid for the low frequencies. And they get a more satisfying auditory perception with that, they can appreciate music even better. And overall, they get a fullness in sound that's hard to put in words. I have to describe it as the umami of hearing. We're able to get them that part that you can't quite replace. And this is why we work so hard and there's so much research trying to preserve hearing. And we have another example after this as well. This is another patient, your classic bilateral, this one's actually mild sloping to severe to profound sensory neural loss. And this is even better than that initial, those two comparisons side-by-side audiograms I had, but their speech discrimination was where they were struggling. So we implanted the right side and here's the post-op audio on the right, but a month or so after, and that low frequency hearing is still there. And so they also got a hybrid kit. And so they're really just using the implant for above around a thousand Hertz and everything below that, they're actually getting conventional hearing amplification for. We can go on to the next slide here. And so what do we consider relevant to try to save? And what's worth fighting for as far as a residual acoustic hearing? The graph on the right, the shaded area and the low frequencies, we can see a decline after the implant and 20 to 25 decibels of a drop, but sometimes we don't see any decline. And below 80 decibels, similar to that single-sided deafness threshold, that's where it's like, what's a hearing aid really gonna do for that level? But above that, if we power it enough with the hybrid kit, they can get that hybrid stimulation where we get acoustic stimulation for the low frequencies and electric stimulation for the high frequencies. Thanks for including this slide here. So what has changed in cochlear implant surgery? I've mentioned the electrodes, they're slimmer, they're less traumatic. It's not just the hair cells that we're damaging by opening and violating the cochlea. It's also, the perilymph is being displaced. They can get inflammation within the cochlea. Anytime we do a surgery, there's gonna be inflammation afterwards as part of the healing process that can progress in the cochlea and cause hair cell damage. More stiffer, larger electrodes can actually damage the walls of the cochlea which results in more inflammation. It can impact the blood supply to the hair cells and the hearing nerve as well. I mentioned surgical techniques that has evolved and we're very conscious of how we're putting electrodes in and what speed we're putting them in. I mentioned the previous intraoperative tools and there's obviously ongoing research that's still ongoing and especially at some of the institutions that I've trained at to try to maximize our hearing preservation ability. All right. So obviously, Cochlear Americas, their whole goal is to preserve functional residual hearing and they take it very seriously, especially with their electrode development. And you guys are probably not familiar with this, but there's an electrode, the 632 electrode that Cochlear makes. I am able to save hearing with that electrode without even trying. Like I don't even, sometimes there's a low frequency residual hearing is there and not really, it's just above 80. So I'm like, yeah, we don't even worry about it. And I put in this electrode and they, and I put in this electrode and they, it's just preserved and I never even tried. I just sort of mindlessly did the procedure without really paying attention to the nuances of hearing preservation and it still gets preserved. And so they take it very seriously and we do that by selecting electrodes and working on our surgical technique to preserve the inner ear structures and minimize damage, minimize inflammation. I mentioned before a hybrid stimulation. This is what I was talking about, a hybrid kit, where they have this speech processor, that big white piece that is sort of the BTE components. And there's actually a speak unit or a speaker that goes in their ear canal that provides the amplification. The wire that you can see cut off on the left, that goes up to the magnet that couples to the internal cochlear implant stimulator receiver that provides electric stimulation. So the speech processor picks it up and it separates it out. It says, this is gonna go to electric information for the hearing nerve. And this is gonna go for acoustic amplification for their acoustic natural residual hearing. Well, thank you for providing the detail on that because again, I know this residual hearing and the hesitancy from patients to lose their hearing really is a barrier. And I know that's hard for professionals to talk with patients about. So I know having this information helps. And again, I think really helping the patient to understand all they have to gain from hearing better and things like that. I've hung up on, I don't wanna lose this, but I think the more we can talk to patients about how much better they can do and what they can get back by hearing better potentially with an implant, that's a great way I think to really talk to patients when they have this hesitancy. And it's great that again, all that's happening in the industry as a whole is that this isn't a guarantee that they're gonna lose their hearing and we can still maximize it and use it with things like the electric acoustic stimulation. So, well, and again, I know this is another one that as soon as you say implant, if a patient actually knows what it is, that fear of surgery kind of comes in. And so for hearing instrument specialists in particular, again, patients may say, well, I have other medical issues and I can't undergo a procedure and things like that. So how do you address again, concerns about other medical issues and how that would come into play in being able to tolerate an implant procedure? And is this in fact, fact or fiction? A great question. And once again, this is fiction and people, the word medical issues is a very broad term, obviously. And a lot of our patients, if they have some medical issues or they're old, they just assume that they can't get an implant. And that's obviously false. We're doing patients well into their nineties, many patients with other cardiac or pulmonary conditions. The biggest thing is, are they medically fit enough to undergo general anesthesia for a short period of time? And the surgery is not long. The surgery, it takes less than an hour for most of us who are neurotologists at least to do it. And if they're on blood thinners, we try to get medical clearance for them to stop the blood thinner. Sometimes we can't and we still do the procedure with a slightly increased bleeding risk. And there are published protocols now, well-published protocols. And there is a movement to try this in some patients who really are too sick to undergo general anesthesia to do it under moderate sedation. That way they aren't totally asleep. And this is not being done in most institutions, but this is where the future is. And we're gonna eventually have more institutions that are able to accommodate for this. But that being said, it's a short time under general anesthesia and it's very well tolerated. Now, as far as the risks of surgery, this is a nice sort of almost Venn diagram where on the left, all surgery has a risk of bleeding, infections. There's an incision behind the ear with cochlear implants. And so risk of wound infection is there and pain, but pain is actually very well tolerated. The majority of my patients maybe take one or two actual pain pills and the rest of the time they're controlling it with Tylenol and Motrin. And then there's a risk of anesthesia, which we stratify that risk ahead of time and we don't recommend it if we think it's unsafe. The only way to know is by checking it out and getting medical clearance, talking to the patient, seeing what their medical conditions are. Ear surgery in general, not just cochlear implants has a few other risks. Now, there are two risks that are extremely rare, meaning fraction of a percent. One is the facial nerve that provides facial movement travels through the ear and we work around that during any ear surgery. But we do monitor that nerve electrically when we're doing EMG or electromyography during surgery. So it's kind of like the game operation where the machine beeps at you if you get too close to it. And that's why that risk is so low. The second really rare risk is cerebrospinal fluid leak. That's what the letter CSF mean on here. You know, the brain and spinal cord are bathing in a salty solution, a salt water solution called cerebrospinal fluid. And any ear, sinus, you know, procedure, there's working right underneath where the brain sits. And there's definitely a barrier between you and the brain, but in theory it's close. And so anything can happen in any scenario and a fraction of a percent risk of causing a leakage of that fluid. That puts a patient at risk for meningitis. But once again, a leak is actually repairable. There are patients who come in with a leak from other causes and we repair that. And their meningitis is also treatable with antibiotics and all cochlear implant patients actually get a meningitis vaccine. It's actually the pneumonia shot, but that same bacteria can cause meningitis in cochlear implant patients. Also extremely rare, but we make it even more rare by having them get the vaccine. There are two risks that are actually quite common. You know, 20 to 30% of people experience some degree of altered taste on the side of the tongue that we do the implant on. So if it's a right-sided implant, the right side of the tongue can get metallicy or decreased sense of taste or altered taste. It can last months, sometimes up over a year, but at about 10% of people, they do notice it's permanently altered and it is a bit of a nuisance for them. And so I do talk to patients about that. The second is some dizziness. Now we are working on the inner ear. And so any inflammation, it's close to the balance organ. So it's not uncommon to have some equilibrium feeling off, sometimes room-spinning vertigo. That typically goes away in a few days, sometimes up to a week. A very small percentage of people have ongoing issues with this. And those people, we treat them with vestibular therapy or balance PT to help them recalibrate and get them back to functioning normally. And so that's once again, a very small percentage of people actually end up dealing with that. Now, what about biomedical implants in general, specifically, obviously cochlear implants, chances of device malfunction, hardware or software failure, patient dissatisfaction with the way it sounds. And obviously we counsel them ahead of time appropriately and they're doing their homework after, practicing with the implants. They're gonna get satisfaction from it if they understand what they're going into. If they're expecting to have hearing like they did when they were in their teen years or 20s, that's not what the goal here is. The goal is to get it so they can communicate again and get their speech understanding back. We talked about the risk of losing some residual hearing. And in the short term, it's not uncommon to have worsened tinnitus because you may be losing some residual hearing or inflammation can cause that. That does get better over time after we turn the implant on and as they start to use it. If anything, tinnitus actually gets better with the use of a cochlear implant. Now, I will say with regards to device malfunction, Cochlear Americas does have actually the best reliability data of all the manufacturers. But overall, the risk is low no matter what. And it's just nice that Cochlear Americas has the best sort of rating for that. And when can we not do a cochlear implant? Absolutely not. Now, medical issues, the general medical issues, those are relative contraindications where we sort of tease it out to see, is it true that we should be able to do this or not? But there are certain situations where we just can't do it at all. And one example on the left here is not having a cochlea. Now, you need a cochlea to put a cochlear implant in. This is a CT scan where it's sort of an axial view. So imagine a patient is lying on a table, their head is going into the screen, their feet are coming out at you, and we're taking sort of bread slices through their head. And this is zoomed in on the right inner ear. And that sort of loop you see in the middle is the horizontal semicircular canal. And in front of it, or I guess on top of it in this diagram, you're supposed to see the cochlea and it's just not there. There's nowhere to put an implant in this patient. Therefore, we cannot offer the surgery for them. The next one is not having a cochlear nerve. Now, the cochlear nerve is the substrate for electric stimulation. That's the whole point of doing this is so we can provide electric stimulation to the cochlear nerve. Now, they have a cochlea. So here you see sort of a cross section. You see sort of like a lumpy structure there in the middle. That's a cross section of the cochlea. But you're supposed to see a little gray line going up there that shows you that there's a hearing nerve that can accommodate that electric stimulation. But if they don't have that, that's called cochlear nerve aplasia or agenesis or hypoplasia. Those patients without a cochlear nerve are not gonna get benefit. And some patients who have deficiency or an abnormally formed cochlear nerve may not get benefit from a cochlear implant either. The next one here is medical intolerance here. And we talked a little bit about that already. If they absolutely cannot undergo anesthesia unless they have access to a surgeon who's able to offer it under sedation, they're not gonna be able to get the implant. And lastly, if a patient just doesn't get it and cognitively they aren't with it, we don't think they're gonna be able to do, to wear it afterwards and practice with it. And just same patients who just aren't really getting the hearing aid. They don't understand the need to wear it to get benefit out of it and change the battery and know when to get it serviced. Those are the same people that we wonder, are they gonna be able to handle working with an implant afterwards? In some ways, it's easier than a hearing aid because it's less fine motor dexterity needed for it. But in other ways, it does, we do want them to understand how the device works and the fact that it takes a while for your brain to understand hearing. It takes weeks, sometimes months for it. And if they just aren't getting it, we don't like to offer the surgery for them. All right, so what about the surgery itself? I mentioned typically, some people it can take up to a couple hours, but majority of routine cases takes well less than an hour. I mentioned the anesthesia part already. Vast majority of patients go home the same day unless there's some medical condition that requires monitoring overnight. Young babies, they keep them overnight and cardiac or heart issues that require monitoring in the hospital afterwards, we sometimes keep them one night so a medical doctor can just make sure that they're safe to go home the next day. Overall, very low complication rate, which I talked about the risks there. I talked about the pain as well. So Tylenol and Motrin around the clock is what I recommend. I do prescribe a narcotic for three days, but most of my implant patients don't need more than like one or two max. There is a dressing that patients wear, like a Velcro or a head wrap type dressing that they keep on for three days, then they remove it. And then they come and see me about a week after, then I clear them to get it activated or get it turned on so they can start learning how to hear again. Yeah, well, again, I know this is the one that comes up and I know you guys in terms of surgeons and even the audiologists, do a lot of counseling with patients around this topic, but it's great for, again, the hearing instrument specialists to really put their mind at ease as maybe they take that next step that this is really become a routine procedure and that there are really low risks. I think those are great things for the audience to share with any potential patients. And I know you brought it up too at the beginning when we started this one, it was just that age factor. I know we don't have it in here in particular, but again, as long as the patient's healthy, they can go through it because at the end of the day, age, we shouldn't say, oh, you're too old to hear. And so I know, again, there are surgeries of patients well into their hundreds because we want them to enjoy and be able to hear for their lifetime, so. Well, okay, going into the cost thing, because I think anytime you talk about new technology or especially if it comes into some sort of surgical type device, patients will have that fear of cost. And for hearing aid patients, they've obviously paid for hearing aids for many years. Obviously, when they're severe to profound patients, they've probably been wearing instruments for 10, 15, 20 years. And so they can have concerns about the costs of taking this next step into the implant. So fact or fiction, patients can expect to have substantial costs associated with receiving a cochlear implant. So what do you say to that one? Yeah, so once again, this is fiction. And actually, believe it or not, it's the other way around. Patients who are audiologic and medical candidates for a cochlear implant, it's cheaper for them than just continuing to buy another set of hearing aids. And the reason is insurance covers it. If we get authorization for it, the surgeon's office should be, has a prior authorization team. If they're a candidate, they submit the data to the insurance. And if you meet Medicare guidelines, they pay for it. And with cochlear, if there's any question about borderline candidates, or if they're worried about their insurance, cochlear has an insurance support team to help with that. And surgeons don't wanna do surgery on people that the hospital doesn't end up getting reimbursed for. And so no one's gonna do it. And then for patients who aren't candidates. And that's also not the right thing to do. We don't wanna do an implant for somebody we don't think is gonna get benefit from it. And we know that they're an audiologic candidate, medical candidate, and cognitively, are they with it enough to do it? We submit all the paperwork forward and we see what the insurance says. And then if they approve it, they'll pay for it. Now, depending on what state you're in, Medicaid may or may not cover it. So commercial insurances, this is a diagram, this is graph here of cochlear implants, bone conduction implants, and hearing aids. And as you can see here, the trend is hearing aids are sometimes less covered than cochlear implants. Now, it's not a fair comparison because hearing aids is obviously way more candidates for them than cochlear implants. So insurance is not gonna pay for something that there's a lot of people wanting it. But cochlear implants, if you're a candidate for it, and if anything, our criteria are too strict, most insurance plans cover it. And at least in California, Medicaid does cover it. Where I was practicing before in Colorado, they didn't. And then Medicare, they have their own guidelines for it and they'll cover it as well. Yeah, and I think too, on the insurance side, I know obviously there's the evaluation component. So again, insurance will cover again that more extensive hearing test that they would go through in order to qualify as well as just even the console to talk to the surgeon, as well as the device. So again, they cover obviously those multiple visits. And one thing I know that we don't highlight on here though obviously when the patient gets implanted, there's the surgical costs and the device. And for the device, there's the internal component, which is that electrode array and then the external. And as patients reach usually about five years, they are eligible for upgrades to the external components. So just like hearing aids for cochlear, we're always advancing the microphone systems and noise reduction and all the things that make hearing easier with the implant. And insurance will cover those upgrades as well and we help patients in terms of submitting to insurance to get coverage for the upgrades to those external components as well. So just something for the audience to be aware of that once they're implanted, again, this usually the insurance cover will cover up multiple areas for the patient moving forward. So going on to our next one, the majority of cochlear implant users will continue to use a hearing aid in the opposite ear and can benefit from advanced technology like audio streaming for calls and TV. So what's your experience with patients using a hearing aid still? So we finally have something that's true. Some patients who have severe hearing loss on both sides, those people we implant both sides and they get hearing implants on both sides, but majority of patients, if they're getting some benefit from a hearing aid on at least one ear, and even if not, we still try to implant the worst ear and this is the surgeon dependent, but the reason I like to do that is they can continue to use a hearing aid on the opposite ear until that cochlear implant ear catches up or does even better than the opposite ear and then we'd talk about a second implant. Now, that being said, that implies that they are able to get benefit from advanced technology, audio streaming, telephone calls, television, obviously the ReSound hearing aids, for example, pair with the Cochlear Americas device and they can talk to each other and make it easier for patients. Everybody knows the benefits of binaural hearing. I'm not gonna go to bimodal yet because bimodal here we're implying binaural hearing where electric in one ear and acoustic in the other ear, but it's the same as, we're essentially getting them binaural hearing once they're implants up and functioning, but the three big ones are binaural summation, binaural squelch and eliminating of the head shadow. Now, sound localization is huge. They get 3D hearing back. They're able to understand better speech understanding in quiet and in background noise and that's what we're measuring in the post-op period as they learn to continue to use their implant. Improved sound quality, improved functioning in real life environments like restaurants and conference rooms at their workplace, better quality of life and actually better music perception as well. We can go to the next slide here. So patients with using two facilities, let's say you take a group of cochlear implant candidates and they're appropriately fit hearing aids and then you decide to implant just one ear in those patients. All of these factors in the lab, all of these quality of life, hearing satisfaction measures, for example, overall hearing performance, satisfaction, understand what they're saying on TV, conversations in the group, hearing and background noise, music appreciation and use of a telephone. We see dramatic improvements with bimodal hearing, meaning an implant in one ear and a hearing aid in the other ear by magnitudes of 9% up to almost 10 times the amount of improvements. And that's the biggest one is their satisfaction with their hearing performance. Yeah, and I love the satisfaction slide because again, how a patient feels that they're doing can help someone maybe with a hearing loss can help someone maybe move forward. So for providers to talk to them, we see huge satisfaction jumps for patients that move forward again with a bimodal is really important for them to highlight. And just so the audience is kind of aware for cochlear and Dr. B had mentioned it, but we have a great partnership called our Smart Hearing Alliance with Resound. And so technically when we say bimodal, it's really, again, just electric stimulation on one side and acoustic on the other. So any hearing aid could be used in a bimodal setup, but there's a lot of benefits in, you know, using a Resound device in the opposite ear. This way, again, if the patient's been used to streaming, using apps and all that technology that's out there, they can continue to take advantage of that. And, you know, as we move into the next generation of Oracast and that kind of Bluetooth technology, again, our devices have the N8 is Oracast ready as well as I know Resounds. And so helping these patients continue to get the best of what technology offers. And so if you have patients, again, that are maybe moving down this road, you can always look for what devices are compatible either on Cochlear's website or as well from Resound to know, you know, what might be the best option for that other ear. And this is a great way to, I think, just to highlight that this is how, again, you can still be involved in their care just because they're seeing an implant audiologist maybe for that side. Many of these patients still need local care for their hearing aid. And so, you know, coming back to you as their dispenser that they've worked with for so long to continue to provide that instrument for them. All right, well, I know we're only coming up on a couple minutes, but this is such an important one and this is outcomes. And so factor fiction, outcomes are really variable for patients and most won't do better than they are with their hearing aids. I know we have to talk about this one, Dr. V, so I'll give you a couple minutes. Factor fiction on this one. So good, good question. Half of this is true and half of this is false. And so the part that's fact is the fact that it is variable and that's true with any surgery, with any hearing intervention we do, including hearing aids, you know, it's gonna be variable and that's part of our job is to screen patients to make sure that their hearing before surgery is bad enough that they have a significant percentage chance of improvement in hearing afterwards, not only objectively, but subjectively. They should feel it's better. And so the cochlear implant eval is not just testing. So in the eval, an audiologist has them wear hearing aids in the best aided condition and presents them sentences or words and we see how they score. That's the objective part, well, sort of objective part of the test. But we also see what the patient's goals are. Like I said, the expectation has to be realistic. They're not gonna get totally normal, natural hearing from a cochlear implant. And there's really nothing that's ever gonna restore that for them in today's technology. But the goal is to get better speech understanding. Now it does sound natural over time and at some point it clicks as they keep using it and it does sound natural and they don't even think about it anymore. But there's a small percentage of patients who don't quite get to that point where they can't even, they don't even think about how it's different. I talked about how we need to make sure that they have a good enough chance. I want a more than 95% chance that they're gonna do better with a cochlear implant than they do with a hearing aid. So patients who are truly borderline, sometimes I'll tell them to wait. Patients who are just in the cusp of candidacy, there are places out there who will just throw an implant in them. And a lot of those patients do very well. But I want the odds to be really, really high. Our job as surgeons is not just to do surgery and do implants to treat hearing as a global sort of view. And that includes recommending continued hearing aid use when indicated. Or continued hearing aid use when we can't 100% confident say that you're gonna be doing better with it. And that's part of the long conversation I have with these patients when I meet them. And so what other factors should we consider? Do they get it? I mentioned that before. The medical factor we talked about. Do they have support, any family support? Do they live with somebody? Do they have people to talk to, not even just about what's going on, but just about anything at all and get auditory input for their cochlear implant to train their brain? Do they have any source of auditory input other than just watching television to learn how to use the cochlear implant? What sort of social structural support do they have around them? Now, there is a bell curve of cochlear implant performance. And this is actually a good segue to the slide. The top of the bell curve is still a very good outcome. They get around 60% understanding or better at the top of the bell curve. And that's sort of why we wait until it's less than that before we consider candidacy. And so this graph on the left shows pre-op and post-op CNC words, and we have a significant improvement from before pre-op up to 61% with a cochlear implant alone. And not everyone gets to that point because obviously there's a bell curve of performance, but the people who are getting below that are usually starting much worse. Like I mentioned before, the earlier you implant, the better. It's really the ones who end up on the far right side of the bell curve are the ones that were implanting earlier, the ones who fully get it, who are working with oral rehab afterwards. Those are the people getting 9,500% word understanding, sentence understanding. On the right side, we have sentences in background noise. And also even with plus 10 dB SNR, they're getting significant improvement from 15% up to 43%. Now, pre-op, look at 15% CNC, 15% azBio sentences. That is well less than candidacy criteria, which is 60-60 criteria, right? Well, 60% azBio sentences is actually when we recommend a cochlear implant surgery. And then we recommend referring when they have 60% speech to scrim or worse. The CNC words is well below that. Now, the azBio sentences, at least with background noise, is well below that as well. So if you imagine how well these patients are doing, imagine the ones that were implanting earlier, they're landing much higher on this graph as far as peak performance once they're really rolling with their cochlear implant. Does that make sense? Yeah, absolutely. And then again, I know, obviously, we typically see those big jumps in performance within that first one to three months is typically where, again, if the patients are working at it, and then the CI centers do the post-op testing, that's usually the largest improvement is seen, but it's not ends at that point, right? They continue to get improvement over time, usually within that first one to two years, which, again, I think when you see some of these numbers of how patients can perform and where they are before, I mean, this is really, for me, how patients get back to being able to function within their daily life with their implant now, where, again, they're starting to pull back when they can't do these things, so. Yeah, and I actually like this graph a lot because it shows that it's not just the first year, the brain's plastic, and it continues to get incremental gains even after using the implant for over a year. And I know a cochlear implant surgeon who has a cochlear implant himself who is three years in, and he's still noticing slight nuances, for example, when he goes to the symphony. He's like, oh, I can get the violins better this time than I did last time. And so there's still subtle changes that can happen over time. Yeah, yeah, and it's getting them back to what they can do. Well, I know we're kind of up on time, but I did wanna allow you just kind of final thoughts for this audience of dispensing professionals and how you would leave this for them. Yeah, so the first thing is, you are the first line responder. You're like the EMS for hearing. And so if you aren't gonna advocate for the patient's hearing for when we think they're potentially ready to start talking about a cochlear implant, probably nobody is unless they start going to see other hearing instrument specialists or audiologists who are comfortable enough to counsel them on this topic. It's very easy to get comfortable with this topic. There's very easy guidelines to memorize, and it's hard if you don't have a good relationship with a surgeon locally. And I like to have great relationships and I communicate with my local hearing instrument specialists and audiologists. Not everybody has that where they are. And so it's tricky to be like, oh yeah, you might need a surgery, and then you send them off to a stranger, versus if you have someone that you can bounce ideas off of a surgeon or an audiologist, that you can bounce ideas off of and be like, hey, is this reasonable to refer? If you don't have that, Cochlear is there for you. And you can use their local representation to help guide that decision-making. Now, that being said, let's say you refer a patient over and they are not a candidate or they're borderline and they end up not getting the surgery. The whole goal of you referring them was not for them to come out and getting a surgery. The goal of you referring is essentially you're advocating for their hearing. You're saying you're dissatisfied. We've done what we're supposed to be doing from a treatment standpoint. Let's just see how close you are really to what the next step is. And if they are a candidate, then excellent. They may decide to do it. And a lot of times you're the hero coming out of that because I've had patients tell me this is their hearing instrument specialist was the first and only person who suggested this technology and they got their entire life back because of it. And they like are still giving them gifts and stuff because it's the only person that you ever told them they should consider doing this. But if they don't get it, that's no big deal, right? Because you introduced them to the technology. They may not be a candidate now. They may be a candidate in the future. And overall, the conversation has been started because like I said, the hearing health has changed where we're not just waiting to do these on people with profound hearing loss. It's gonna happen at some point for them if they're already struggling with speech discrimination. The cochlear implant eval, we use the ones who are not candidates at baselines for future tests. We haven't come back in one or two years. And they trust you. I'm glad you talked about it. And a lot of times, another thing I wanna bring up is if you send a patient out, they shouldn't just be swallowed up by whatever system is doing the cochlear implant. You continue to have a relationship with that patient. They're probably not gonna do a simultaneous, bilateral cochlear implant. They're probably gonna be continuing to recommend a hearing aid for the other ear. So you're doing that in tandem with the implant. They can see you for the hearing aid and they can see the implant institution for their cochlear implant. So the relationship with you and the patient is not supposed to end for some of these people you've been following for years. Yeah, very well said. And I know we'll turn it over here to Sierra, but my final thoughts is that, again, to this audience, you don't have to have all the answers. And really, Cochlear is here to help you. If you have specific patients where you say, I don't know who to send them to in my area, you can connect them with us. We can let them know who's closest, who provides services. We have information brochures you can keep in your office and are always willing to kind of chat one-on-one to help you as a professional help your patients more. So always feel free to reach out. And I know IHS will share their information, but we did wanna get to some questions. So I hope there's some that are coming in the chat and I'll turn it back over to Sierra. Thank you. Thank you so much, Laura and Dr. Varadarajan. As you said, let's go ahead and take a few questions in the couple of minutes we have here. First question is from Mark about kind of the bimodal option for hearing that you discussed. Will cochlear implant technology work together with Beltone hearing aids? This also, you know, you could stand it, I think maybe any manufacturer there, are there known limitations on which hearing aids can pair with cochlear implants? Yeah, so again, technically you could use a Beltone device for that bimodal setup. The patient just wouldn't be able to access kind of the streaming components into both ears or utilize the one app. So they could use the cochlear app to control the cochlear device and then the Beltone app to control the hearing aid. But absolutely again, that's still gonna provide them that technical bimodal setup. Right, great. Thank you. Next question here is from Haley. Do patients need to have extensive oral rehabilitation after they receive an implant and or what do you tell them about what the involvement of rehab is or what they should expect? That's a good question. Now, very few patients need what you could consider to be extensive oral rehab. The majority of good candidates, a lot of times just get good outcomes just by wearing the implant and living their life. They just wear it every day, all day and they just take in auditory sounds, you know, and their brain does the work for them. Now, if they wanna go a little faster and you know, those patients will do rehab, you know, listening exercises. They work with the audiologist about to learn about, you know, other ways of training their brain. For example, you know, flashcards with their spouse or significant other. They can do closed and open set words, sentences. They can try practicing hearing different things in their house and their environment. But some people who are a little slower to pick it up do have to do oral rehab and that can be formalized in an outpatient setting as well. But the majority of patients are not needing that degree of oral rehab. Yeah, that's right. I would say technology has come so far. There's so many apps and things like that that patients can use. And one component to that just to highlight is that, you know, sometimes talking to someone who's been through the cochlear implant process and what they had to do from rehab can help. And so Cochlear has a whole network of volunteers that we can help, again, someone who's looking at this, talk to someone who's been through it so that they can, you know, kind of get that perspective from someone who's been through the process. So we can always help connect them to understand the rehab afterwards as well. That's great. Thank you. I have a follow-up question from Beth about the question about hearing aid connectivity. Are there specific hearing aids that are compatible with implants to allow the streaming benefits? If so, do you know which hearing aids those are? Yes. So this is where, as the technology changes for ReSound and then we come out with new processors, I have to tell you, your best resource, if you're ever wanting, because if I say it today, in six months from now, new launches are going to happen. It's outdated. Exactly. Exactly. So I always encourage everyone, you can go to Cochlear's website as well as ReSound and look for device compatibility with Cochlear to see what is the latest so that they can take again if they have the ReSound device from the bimodal streaming and the bimodal app. So that's kind of your best option. Again, since this changes so quickly on both of our sides for technology. Perfect. Thank you. And last question, who do we reach out to to find the best implant specialist in our particular geographic area? How would our audience members find that information? Yeah, so there's a lot of great resources. First, you can reach out to my team at amem at cochlear.com. But if you also go to Cochlear's website, we have a provider kind of search so you can put in your zip code to see who is kind of in that area. Again, sometimes talking to my team, we might know someone who is closer or things like that that may not show up on there. Most of them are. So that's a great resource. I know ACIA, which is the American Cochlear Implant Alliance also has kind of a search engine to help provide information on who's in your area. But that's absolutely something that we can help you with at Cochlear and help understand who's around you to help your patients better. Anything else you'd mention, Dr. B, I'm forgetting? No, other than if you're in California, I'm in Sacramento and I see people from all over the state and Nevada and we have a huge encashment area. And it's not that hard to find somebody as long as you're close to some major city in the area. Yeah. And as care models continue to change, I think that's where, sometimes they may have to go a little bit farther for the surgery, but then follow-up visits can be done more locally too. So, talking to patients that, just get started in the process is always important because sometimes there's remote options, there's ways to make the follow-up care easier in the long-term. So I know we didn't get to highlight that in particular, but something to make patients aware of. That's great, thank you so much. All right, well, that is all the time that we have for today. Thank you so much again to Dr. Bharadwajan and to Laura Lassen for this valuable presentation, Fact or Fiction, What to Know about Cochlear Implants Today sponsored by Cochlear. As Laura said, to get in touch with our presenters, you may email them at amem.cochlear.com. And a final reminder, information about how to receive CE credit can be found on the webinar page, which is linked in the chat box for you. Thanks again for joining us on today's webinar, and we look forward to seeing you on the next one. Have a good day.

webinar

International Hearing Society

Cochlear

cochlear implants

Dr. Varun Bharadwajaran

Laura Lassen

bimodal hearing

insurance coverage

oral rehabilitation

implant specialist