Welcome, everyone, to the IHS webinar, How to Help Your Patients Who Struggle to Hear Better and Love Your Services. I'm your moderator today. I'm Sierra Sharp, IHS's Director of Professional Development. Thank you so much for joining us today. Before we get started, I 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 the screen. Also, this webinar is available for one continuing education credit through IHS. The CE quiz and information about how to receive credit can be found on our website, www.ihsinfo.org, slash webinars. A link to this page has been added to the chat box for you as well. The slides for today's presentation can be downloaded from that same web page. Feel free to take a moment now to do so if you'd like to follow along. Tomorrow, you'll receive an email from us with a brief survey about this webinar. Your feedback is incredibly helpful as we continue to create valuable content for you moving forward. And now on to our speakers. To share some insight on how to have a conversation about cochlear implants and support your patients in their lifelong hearing journey are Meredith Holcomb, AUD, and Donna Sorkin. Dr. Holcomb joined the University of Miami Department of Otolaryngology in June 2019 and is an Associate Professor and the Director of the Hearing Implant Program there. She received her doctorate of audiology from the University of North Carolina at Chapel Hill and spent the first 13 years of her career at the Medical University of South Carolina. She is the immediate past chair of the American Cochlear Implant Alliance Board of Directors, and she serves on the Joint Committee for Infant Hearing. She's also a member of the Advisory Board for Advanced Bionics, MED-EL U.S., MED-EL International, and Hemedina. She's a faculty member for the Institute for Cochlear Implant Training Advanced Audiology Course and serves as a consultant for Cochlear Corporation and ASHA. Donna Sorkin is the Executive Director of the American Cochlear Implant Alliance, which is a national organization devoted to expanding access to cochlear implantation for all who may benefit. She has had a long career in advocacy for people with hearing loss at both for-profit and nonprofit entities. She has served on federal, corporate, and university boards, including the U.S. Access Board as a presidential appointee, the National Institute on Deafness at the National Institutes of Health Advisory Board, and the Gallaudet University Advisory Board. And as you can see, our expert speakers have a lot to cover today. 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 questions, which you can send at any time, in the Q&A box. And now let's get on to our main presentation. Take it away, Dr. Holcomb. Thank you so much. I'm going to share my screen. Okay, hopefully you guys can all see this. A huge thank you to IHS for asking Donna and I to present again. We really love being able to work with your group, and we've learned so much about the needs of hearing instrument specialists that, you know, we hope that ACIA is able to offer some education today that will help you with your patients. One thing that was really cool that we were able to see is when you guys signed up for this course, we received an Excel spreadsheet of all the things that you were hoping to get out of this course. So Donna and I are really excited, and we hope that everything that you're wanting to get out of it, you do. My disclosures are listed here. Many of those things were mentioned very nicely early on. Okay, so and IHS, please let me know if there's any problem with my screen or my slides moving. So, you know, I think we've got to talk about hearing loss prevalence, and anybody who works with hearing loss these days knows that the World Health Organization is predicting hearing loss to rise over the next several decades. And when we look at that, you know, there's a big bubble of people who have mild hearing loss, which are very easily treated oftentimes with hearing aids, but then there are those moderately severe to profound hearing loss patients that still make up a good portion of people who are going to need our attention and likely will need cochlear implantation. And we're not talking about just a few thousand people. We're talking about millions. When we look at the projected increase in prevalence of hearing loss and looking towards 2050, you can really see that disabling hearing loss is going to make up a good number of people in the world. 711 million people are expected to have disabling hearing loss compared to 430 million that were in 2019. That's a lot of people that I think we all can work together to help. So why is it important to treat hearing loss? Well, there's a huge global impact. But when we look at the Americas alone, which I think is more pertinent to most of us, you know, there is an extreme number of problems that can go along with hearing loss being left untreated. Many of those relate to health, comorbidities, education, productivity. And what we want to do with treating hearing loss is to give people their life back and to help them in all aspects of their life, not just from a communication standpoint. From a personal impact, we do know that cognition is certainly modifiable with cochlear implantation and with hearing aids. And mental health is a huge component of why patients with hearing loss need to be treated appropriately. I think all of us are familiar with the communication side of things and the social emotional side of things. But we oftentimes forget about the cognition and mental health. It's very, very expensive for the world and for health care in general for these patients to not be treated appropriately for hearing loss, because they may come into clinics for other things that are going on in their life, health-related issues, that perhaps if their hearing loss was treated, some of those things would not be as pertinent. So when you look at hearing loss and hearing device utilization, what's really striking is the poor utilization numbers for cochlear implants and for hearing aids. Cochlear implants, only about 2 to 12% of patients who need cochlear implants actually have them. And hearing aids is really not that much better. A little more than 20% of patients who need hearing aids have them. Now, the majority of new hearing aid sales, interestingly, are not to new users, but they're to existing users to upgrade their technology. And the hearing aid utilization in adults with severe to profound hearing loss actually exceeds 70%. So, you know, what's interesting to Donna and I about this is the majority of people who are using hearing loss may actually be better suited with cochlear implants. But there's this huge number of folks who need hearing aids that don't have good access to those either. And so really, you know, it's a global problem. And globally, we're underutilizing these devices for our patients who certainly need to be able to hear better. So what are some reasons for this device underutilization? You know, one reason is that there's really poor awareness of the consequences of untreated hearing loss. We love the fact that your group is wanting to take time out of their busy schedules to listen to us talk about this important topic and to gain better awareness of when to refer patients for a cochlear implant if necessary. You know, there's also a lack of routine hearing screening protocols for adults. There was a big push a few years ago to have an adult hearing screen sort of, you know, not mandated, but suggested for PCP offices and when patients come in to their annual visits. And it was not accepted by the U.S. Task Force. So we're hoping that some of these things can change because oftentimes patients walk around with hearing loss. And as you guys know, it's a very, it's not necessarily a visible problem to other people until the hearing loss gets so bad that they're unable to communicate effectively. And so what we want to do is try to mitigate that problem and get these hearing loss patients treated and appropriately fit with devices as soon as possible. There's also some misconceptions regarding device candidacy, specifically with cochlear implantation. And there's some misconceptions about the risk versus the benefits. Donna's going to speak after me, and she's got such a great story to tell. One little teaser I'll give you is that Donna actually has a cochlear implant herself. So she's going to share with you her journey as a patient and let you know on, let you in on some little tips and things that she has learned along the way. There's also really limited access to specialized healthcare in underserved populations and certain geographical regions. Many of you who work in more rural settings can probably really understand this on a deeper level than some of you who work in urban settings. But, you know, not everybody has good access or convenient access to healthcare and specifically to hearing healthcare. You know, driving long ways with the way gas prices are right now is just not something that everyone can do. So, you know, we're trying to figure out better ways with cochlear implants and with hearing aids to make hearing healthcare more accessible. All of you know this, but let's just do a little reminder of the difference of hearing aids versus cochlear implants. So as you guys know, a hearing aid takes sound from the environment. It really just makes it louder. And, you know, when the hearing is bad enough, that loudness becomes more of a distorted signal for patients, which is why a lot of these patients show up in your office time over time and they say, you know what, the hearing aid is still not helping. I can't hear my wife very well. I can't hear my grandkids. It's very difficult to understand them. And maybe you make changes to the hearing aids. And, you know, as we know from being providers, we're doing everything we can to make sure the hearing aid is fit appropriately. But the patient's still unhappy, unsatisfied, and still, you know, complaining or expressing difficulties. This is really a good example of when you might want to consider referring those patients for a cochlear implant. Oftentimes the patients who are showing up in your office more regularly because they do have complaints, those patients may need to go on for some more specialized testing just to see if there's something else that could, you know, maybe help them along the way. So what about a cochlear implant? So a cochlear implant is very different. A cochlear implant is going to bypass essentially that affected or the impaired area along the hearing pathway. And so the sound is going to be picked up from the outside on a speech processor. And that's going to be sent to the headpiece, which is on the head. And you can see here in the picture that's sticking onto the patient's head. And the reason it's sticking there is because there's a magnet. The magnet is then attached to the internal device. The internal device also has a magnet. Now, the magnet's not necessarily making these parts work. It's just making them stick together and stay together in a more consistent way. So when that sound all crosses over into the internal device, that's sort of when all the magic happens. And the internal device then sends these pulses and stimulations down into the inner ear where the electrode has been inserted. None of this is brain surgery. And that's why I make a big circle on here on the ear. This is ear surgery. It's not close to the brain. It's not in the brain. It is more, I guess, another way to look at it is it's a prosthesis for your ear. So I usually tell patients, you know, it's kind of like if you have a knee surgery, a prosthetic knee, a knee replacement. You know, we're only implanting something into your knee for that surgery. It doesn't mean that your whole leg or your hip or your arms are going to be affected necessarily by the surgery, right? But you hope everything works together so that the patient can walk well again. So it's not that terribly different with a cochlear implant. We're putting something inside the ear and we're stimulating sounds. We're giving the patient a way to hear again where they couldn't hear some of those sounds with a hearing aid. Specifically, high-pitched sounds is really where the biggest benefit compared to a hearing aid comes in. Now, that sound's got to get to the brain, right? And so the brain has to interpret all of those sounds, which is why it takes a little bit of time for the patient to get used to the way the implant works. But overall, the brain really works very magically together with the auditory system and with this implanted device. So that's sort of how they're all connected. So when we look at the parts of a cochlear implant, just to give you a little bit of a refresher, number one is called the sound processor. And it looks a little bit like a, you know, big kind of a ultra power hearing aid. And it also but it also has that wire and the coil with the magnet in it that attaches to number two, which is the internal device. Now, the sound processor also has microphones. It has two microphones, actually. So we have directional microphones and a way for speech and noise to be sort of filtered apart from each other in complex listening conditions. And then we also have batteries that power the device. So sometimes I have patients ask me like, oh, my gosh, am I going to be able to take it off? How do I charge it? It's really very simple and not terribly different pair and process of taking care of it than it is from a hearing aid. Now, one of the big questions I saw in the chat or in the Excel spreadsheet that we got about your questions and your concerns is how do you know who's a candidate? So just for making it very simplistic to way to look at it, there's a couple of different ways we look at candidacy. And over time, the candidacy has really evolved. So initially, when implants first came out, they really looked at it as a standard electrode or sort of for someone who has very severe to profound hearing loss in that red shaded region. And then in 2014, they looked at FDA said, you know what, these devices are actually beneficial for people who have normal to near normal hearing in the low pitches. And so that's where you have the A and E candidacy, which is acoustic and electric. Now, this is where it gets a little bit tricky is when you put those two things together. This is now the audiogram shape of who potentially would be a cochlear implant candidate. Some of you may be sort of gasping and thinking, wait a minute, this is taking up three fourths of the audiogram. And while that is true, not everyone who's in this shaded area may need a cochlear implant, but many of them might. And most of them, I would say, would benefit from at least going through the testing to know if hearing aids really are the best option for them. One of the things now that happens with the surgery is it's very atraumatic, meaning a lot of those low frequencies that you see in that purple shaded region up in the normal range. We actually are seeing that after surgery, they still have normal or to near normal hearing in those low frequency regions because of the way the surgery is being done. I actually had someone yesterday that we did her activation, and she had normal thresholds at 250, 125, and at 500, her threshold was at 40 decibels, and that was after surgery. And so, you know, we're really making a lot of progress with how these patients can benefit from using electric and acoustic hearing together. Now, a newer topic is single-sided deafness and asymmetrical hearing loss, and since 2019, we've seen that the FDA has graciously agreed with all of us as researchers and providers that people who can only hear in one ear, they actually do need help hearing in the ear that's affected. And so we're implanting probably about 20% of our caseload now are people who have hearing only in one ear. Fortunately, there's no upper age limit on cochlear implants. That's great news. You know, it's not up to me or to you to decide who is an appropriate candidate for cochlear implants as far as their age. We've implanted people in their 90s, and they've done great with their devices. We've implanted people in their 80s. They've lived to be, you know, 100 and have used their device well. I always remind anybody that's working with hearing loss patients, you know, all our job is is to make sure that they are referred for the appropriate evaluation. It's up to the physician, the surgeon, maybe the cardiologist who manages them. It's up to them to decide if they're appropriate to undergo surgery. And there are some centers in the U.S. that are actually able to perform these surgeries specifically on older adults without putting them under anesthesia. And so instead of putting them under general anesthesia, they are they are basically awake, but they are anesthetized topically. So let's make it even more simple. So you saw the audiogram. Hopefully you guys will print these slides out just to keep at your office. Another way to think about who could be sent for a cochlear implant evaluation is the 60 60 rule. I really love this because it's so simple and easy to remember. Even at University of Miami, where we do about 160, close to 200 implants a year, our team oftentimes forgets who exactly needs to be referred for an implant eval. And so this has been great for surgeons, for trainees, for our audiologists who don't work in the implant space. The 60-60 has really made a difference in who gets referred. So what that means is if you have patients with a pure tone average, 500, 1,000, and 2,000, if they have a pure tone average of 60 decibels or worse, and if they have speech understanding unaided, 60% or worse, they likely need a cochlear implant eval. Oftentimes, these are patients too who are not happy with their hearing aids. And so accompanying the 60-60 if they are reporting that they're struggling with communication, this is a great method of identifying who needs to be referred. For the study that did this, Dr. Zwolan and her group at University of Michigan, they found that applying the 60-60 referral criteria to identify candidates for cochlear implantation actually had a 96% detection rate. So it's pretty good if you use it. Now, bimodal hearing is something that really is a hot topic in our industry, patients keeping a hearing aid on one ear and having a cochlear implant on the other ear. Only about 20% of adult patients have bilateral implants or an implant in both ears. So that's 80% of patients who likely could have a hearing aid on one ear and an implant on the other. The three implant companies in the U.S. have options now available for bimodal hearing. And some of you may have worked in that space where you're managing the hearing aid and someone else is managing the implant. I do think that, you know, in a perfect world, if we could all keep our patients and still manage one ear and maybe someone else manage the other ear, that would be great. The difficulty sometimes with the implanted patients is that the implant and the hearing aid have to be paired together in the implant software in order for the bimodal streaming and some of those bimodal functions to work. So, you know, hopefully, you can make a good relationship with an audiologist who works in cochlear implants close by you and you can have that conversation about how you can both manage these patients effectively. When we think about bimodal hearing as well, you know, we really want to make sure that these patients, even if they only go for the cochlear implant evaluation, you know, we don't have to tell them, hey, you're going to get an implant in both ears. They could still keep the hearing aid on one ear and potentially have a CI on the other ear. And all the research with those two devices together really have been outstanding. And the research suggests that patients do better with those two devices than with a cochlear implant by itself. So, this is just one more quick thing and then I'm going to pass it to Donna. Again, Dr. Zwolan, she put this together as a publication about how to counsel hearing aid users about their candidacy for a cochlear implant. I think this is a great tool. It's something you guys can use in your own practice. But basically, the recommendations are to show the audiogram. And you can use the purple audiogram that I showed you earlier. And you can put the patient's audiogram in that kind of like you would, sometimes we do that for kids, for like a listening audiogram. And you can show them like where their hearing falls within that candidacy criteria. You could also perform testing with their hearing aids on and show them exactly where they're able to hear along the frequency spectrum. With a cochlear implant, you should expect that across the whole frequency, patients are going to hear probably about 20 decibels all the way across into the high frequency. So, if patients with hearing aids are not getting that good access in the high frequencies with their hearing aids, you know, that's a reason to refer them on as well. You can provide them with literature and counseling and then also provide them with websites for the manufacturers. The biggest thing is try to avoid talking about the cochlear implant as if it's a last resort or if, you know, they're too old for it or too medically involved. You know, it's really part of the hearing health care continuum. It's not necessarily the end of the road, so to speak. It's just the next step. So, ultimately, patients really appreciate the recommendation for further testing, even if they're not a candidate. And I'm going to have you now talk to Donna. And Donna is going to give you a little bit more information about why adult CI candidates may not move forward. Thank you so much, Meredith. It's always so thrilling to partner with you and to talk about this from all perspectives. Is everybody able to see this screen correctly? Wonderful. So, I'm going to talk a little bit about this whole issue of why people may not move forward, even when they are a candidate and sometimes even when they know that they're a candidate. And in general, there's a lack of knowledge among hearing care professionals about the candidacy. And this is true all along the care continuum. It's true of hearing instrument specialists. It's also true of audiologists and ENTs and our primary care physicians, who we would hope would let us know that there is this next step that's available, don't necessarily prioritize hearing. I've tried this out with my own internal medicine team, and they really don't have a good sense of what a CI is and when they should be encouraging people to explore it. So, you, all of you, as trusted professionals, have a key role in that advisement process, and hopefully you will take advantage of that and keep your patients happy and connected to the world around them. There are a lot of perceptions and misconceptions and fear. Fear is a big one about cochlear implants, and you have a role in helping people understand what really is involved and what they can expect. Concerns about the surgery are a big one, something I hear very often as a reason for people not going forward. They're fearful about losing their existing residual hearing. Meredith already told you that that has really changed over the years. People don't necessarily lose their residual hearing. They have a perception that they're getting along with their hearing aids. People think that they won't enjoy music. We're going to talk a little bit about that. As someone who was a musician in my early life, I can speak to you about the differences in terms of how a CI processes that sound, but also the incredible benefits that have come. People want to wait for the technology to improve. That's a reason. And then a perception that CI isn't covered by health insurance. So, let's look at all of those and also think about what the research says about those reasons. So, concerns about the surgery. Meredith talked about the fact that this is not brain surgery, and there is sometimes that perception floating around. This is typically performed outpatient, one to two hours. The patient comes in in the morning and goes home in the afternoon unless they have some other issues that need to be watched. But most people, it's an outpatient procedure. And it's safe. It's effective compared to other major issues, other major surgeries. It's very similar. And about two to three percent of people have some sort of a complication. And these are, a major one is sometimes over time, there's a migration of the receiver electrode array that might require a second surgery. It doesn't happen very often. And we warn people that there is very, very occasionally facial paralysis and infection, and these are much less common. There are short-term effects that affect most people. They affected me. And some dizziness and balance issues, perhaps an increase in tinnitus and a taste disturbance. Everything tasted salty for about a week. But those things do go away. And it's just part of the surgical after effects. We have a lot of resources aimed at patients or for you all on the surgery on our website. So, you might want to take a look at that because it is a common reason that people are hesitant to go forward. The loss of residual hearing, Meredith talked about. And some of this is the fact that very early on, CI surgery meant that patients did lose all their residual hearing in the implanted ear. And that was definitely what I was told. And I had my surgery 30 years ago, and I did lose everything in that implanted ear, but I gained so much more. But that's not the case anymore. And people do retain a good portion of their residual hearing. Sometimes all of it depends on the individual. We now have what's called soft surgery. And the surgeon will make intraoperative adjustments during the insertion of the electrode array, as well as a device, an internal device that's designed to support that goal. So, it's different than it was years ago. And we are able to preserve hearing. And there are also devices that combine CI and hearing aid use in the same ear, which provides even better hearing outcomes and quality of life outcomes. And it's almost always the case that patients gain much more than they lose. And I'm going to show you some examples of that in just a minute. People get used to using hearing aids, and they think they're getting by okay. And I've heard so many people say, well, I'm doing okay with my hearing aids and my assistive devices and captioning and lip reading and a hearing dog. But oh, my goodness, it's exhausting to have all those things going on. I've been there. I've done that. I know how exhausting it is. And so, we do want people to realize there's something else out there that will make it so they don't have to work so hard. And sometimes it's really helpful to just see how poorly they are doing just with their hearing aids and no lip reading. And they're often surprised to learn that, you know, they're getting 20% without lip reading or something like that. And that's, you know, accounting for all that extra work that they're doing. We mentioned that most are using a hearing aid on the contralateral ear. But I think the biggest thing is just a fear of the unknown and not knowing what's going to happen. We did a very important study that led to the expansion of Medicare criteria. And it involved 34 Medicare beneficiaries, median age of 73.6. And their pre-op sentence scores in best dated were 53% bilaterally and 24% in the year to be implanted. And these are sentence scores, AC Bio sentences. 12 months post CI, they went from that 53% to 89% bilaterally and 77% in the CI year alone that had been at 24%. So, big, big change in this population of older adults and important change in their quality of life. And then this study was then submitted to CMS that led to the revision in the Medicare candidacy criteria in September of 2022. So, you know, I think the thing to tell people is instead of continuing to decline, they have the opportunity to really have a major improvement in their hearing and in their quality of life. And this is just to show you what that looks like in a visual format. And those two graphic bars at the bottom, the one on the far left is the bilateral hearing outcome. So, the blue is how people were doing with their two hearing aids post, before they had their surgery. And then six months and 12 months, that's showing you what happened to them post CI. Most of that change did come in the first six months. And then the set of bars, the second set of bars is showing you what happened in their CI year. And so, they went from that 24% of the blue up to 77%. So, huge difference, really important outcome. And people say, I thought I would not enjoy music. And, you know, 30 years ago when I had my implant, I was told I wouldn't like music. And that was because pitch isn't handled well by CIs, and we know that. And people believe that since pitch determines melody, that we won't necessarily like music. But the new conventional wisdom is that in fact, many recipients do enjoy music. And there are some things that people can do to help them enjoy music. One of them is having the words to songs, because it is realistically very difficult to pull the words to a song out with a cochlear implant. It's hard for many hearing aid users to do that. So, having those words really helps. Rhythm with a cochlear implant may be near normal, mine is. And so, certain kinds of music sound better to us. There are ways to practice, know how to listen. And it's just important to keep expectations appropriate. It's not going to be the same. But for me, it was way better than it was before I had my cochlear implant. And the other thing to remember is, you know, music is essentially about enjoyment. You know, when my husband and I go to the theater and go to a musical, there's the environment that we're in, the beauty of the space, what's going on, just being there, wearing perfume for a change, etc. So, it's part of the experience of the moment. And for me, at least, music post the eye was an improvement. Sometimes we hear people say that they're waiting for the technology to improve. But in fact, most of the enhancements that have been made occur via the external sound processor. Meredith showed you what those look like. Now, those processors that I'm showing you there were actually the first four that I wore. It started with one of the body worn ones. And then after about a year and a half, they made tremendous improvements in sound processing. And I got the second one. And then they started in with your level devices. And so I didn't have room to put them all in there. But then plus three after that. And this means you are able to upgrade without needing another surgery. In most cases, insurance does cover this, there will be copays. Sometimes depending on insurance, there won't be copays. There have been times when I had was double insured. And so I didn't pay any copays. But over time, what I have seen happen with those processors is changes in the size. And you could see that the configuration, I went from a body worn to an ear level to a smaller ear level. There are in fact, processors that are actually on the head off the ear. There's a larger wrap of sound now that we are seeing. Just a quick story about that. When I had my first, I guess, five processors, I could not hear an owl in the far part of our property. It was just a sound that was too far away that I wasn't picking up. And my son just was so anxious for me to be able to hear the owl with my cochlear implant. And then one of my later processors did allow me to hear the owl. So it had a bigger grab of sound with that processor. So that's, you know, hearing an owl, you may say, that's not much. But it's representative of the changes that occurred in my ability to hear in different settings. We all have seen people walking around with white earbuds in their ears for Bluetooth. And while we're not going to wear white earbuds, we do have Bluetooth for the phone for TE and for computer access. And I love it for my phone. So that's really great. And improved noise programs. And I find sometimes when I'm in a noisy place and I'm with people of my age group who have some declining hearing that I'm hearing sometimes better than they are in noise. So that's another important change that has occurred. People sometimes think that there is no insurance coverage for cochlear implants. It's a very common question that we get into the American Cochlear Implant Alliance. People want to know how much it costs. But in fact, unlike hearing aids, most of the time cochlear implants are covered. 90% of the time private health insurance plans cover Medicare, Medicaid for children everywhere and for adults in most states are covered. The VA, TRICARE, Affordable Care Act plans cover. And again, there are co-pays just as there are for other health interventions. And we have a lot of information about that on the AC Alliance website on the whole issue of insurance. So let's talk a little bit about me. People like to hear about the personal experiences that people have. So in 1992, I was really progressing with a hearing loss that had started very minimally in childhood. I had a normal hearing through 4,000 and then it went down after that. And then when I was in college, my hearing started to change and I was doing things looking back, probably didn't even realize that I was doing it. I would always sit in the front of a large lecture room in college and I just kind of intuitively knew how to situate myself in a room. Hearing aids I was using, but they weren't helping me towards the end very much at all. I had a very steeply sloping audiogram. And in that timeframe, remember those were analog hearing aids. So not really able to help me with a hearing profile that looked like mine. I was not working in this field. I'm actually trained in public affairs and was working really without any accommodations in a high communication job. So it was extremely challenging. The ADA was beginning to impact us in terms of our societal perspectives about disability. So that was good. Big one, no internet. Just think how we all communicate now with texting and with email and looking for information. So all of that was missing and I got along without that. Social events were very, very challenging for me. And at that point, there was not much awareness about CI as there is now. So I really felt I was going to have to reinvent my life and not even do the same things that I had been doing. So what helped me move forward and why? As I said, I wasn't getting much help from hearing aids. I was exhausted all the time. I remember that for sure. I had a lot of challenges at work and in social settings. I didn't have the ability to talk on the phone at that point. So that was really, really hard for me. And my hearing aid dispenser suggested that I explore CI. So it was her. Her name is Susan and she was the one that suggested that I look at this. And she provided names of patients who had gotten CIs and she supported my journey throughout. And I've never forgotten that. I have sent her dozens of patients over the years. My internist helped me find a CI center because remember, I couldn't go on the ACI Alliance website and click on the map to see where there was a center. He even called the surgeon. I had fantastic family support and friends who really cheered me on. So that was all really important. So here I am in my first job in this field, the organization that's now called Hearing Loss Association of America. I'm in my office there and you can see my body-worn processor on my waistband plugged into the telephone, which I used really in an unlimited way. The outcomes at that time were more variable than they are today because people were tending to wait longer and have a lot more of a hearing loss, much more profound than is the case now. And we know that shorter periods of deafness and more residual hearing actually result in better outcomes. So that was important. And key impacts for me then and now were in work, in social and family interactions and my ability to go to social events with my husband and not have to prepare for a week in advance about who I was going to see and what to ask them and how to carry on a conversation in that kind of a setting. My general health, because of reduced stress, was improved for sure and continued benefit from the technology with all of those improvements that I've talked about that have happened over the years. And this all occurred without additional surgery. So really this has given me unlimited opportunities to contribute to this field and to travel really all over the world to support other countries that are wanting to expand availability of cochlear implants for people that need them. And I feel like it was a tremendous gift for me that I now want to help others also receive. So Meredith and I have put together some great resources for you and your patients. There's an article in the Hearing Journal that Meredith wrote with a physician colleague by Common Miss, some of the same things that I talked about. Our website, of course, including the Find a Cochlear Implant Clinic, which is on that top right part of the website, plus just tons of resources that people may want to access. We have a lot of resources that are really good for someone who's just starting on their journey that talks about the steps to a cochlear implant and questions. We do Tuesday talks once a month that are designed for people who are outside of the cochlear implant field and especially for adults and parents who may benefit. And then we have videos on the CI surgery. We have stories for specific audiences. And one of our favorites is an interview I did with Lou Ferrigno, the incredible hulk, about his experience in getting a cochlear implant. And then I want to just also mention this wonderful Facebook page that's called Cochlear Implant Experiences and has excellent moderators who ensure that people stay within the principles of the Facebook page, an opportunity to talk to others and ask questions. There's no brand pushing or bashing. And someone does have to request entrance from the moderators, but then it's all open, and the CI companies all have wonderful resources on their website. So I'm going to end there with the IHS one-year membership to ACI Alliance that we hope you'll take advantage of and join us and get more information. It's free, and we want to just support you any way that we can. Thank you so much, Donna and Dr. Holcomb. Your presentations were so wonderful, full of great knowledge to share with our attendees today. We have a few minutes for some questions. Dr. Holcomb, if you want to come back on video, you're welcome to do that now. As a reminder to our attendees, you can go ahead and enter your questions into the Q&A box at the bottom of your screen. We'll take as many as we can in the time remaining. Our first question is from Cheryl, and I think I'll try to say if I think it's better for Dr. Holcomb or Donna, but you guys can totally jump in as well. So the first question from Cheryl is, how can I find out which implant centers will do the CI surgery without doing general anesthesia? Do you have any information on that, a list, or is there some type of resource for that? Yeah, so the only one that I'm familiar with who's doing it routinely is Dr. Rowland at NYU. We at University of Miami have explored this option, and our anesthesiologists have not been terribly excited about it yet, but I do think that it is something that bigger academic institutions are all exploring. So, you know, that's the only one I know about for sure is in New York. Great, thank you for that. Next question is from Dr. Paul Sobol, and he actually has a little bit of a two-parter question here. So the first part of the question is, why wouldn't you, or maybe would you, implant binaurally if there's a symmetrical sensory neural hearing loss in the implantable range rather than doing one CI and one hearing aid? I can take that one. So ultimately, we recommend a cochlear implant for any ear, if it's both ears or one ear, any ear that would fit into that range. Now, many patients decide that they want to do only one ear at a time, and then oftentimes with Medicare patients, Medicare will only allow us to do one surgery and then the other surgery later. Some patients, as you wouldn't surprise, won't surprise you, they think, well, you know, one device will be enough for me, so they try that, and maybe they're satisfied, and then they decide not to get the second one. But it's elective, so, you know, we can recommend both ears, but sometimes they just don't choose to do it. Is there, and this is the follow-up question, is there any data on the outcomes for one versus two CI, or it sounds like maybe there aren't, maybe there isn't a big enough sample size to really have data on people with two? No, there's huge data, bilateral is always better. So two ears, if possible, if it's possible to do two ears with either two implants or an implant and a hearing aid, those results are going to be better than if you have just one cochlear implant alone, and the really the biggest benefits are in speech understanding and noise, music appreciation, and then knowing which way sounds are coming from, and so while those things may not be able to, we don't have a number that we can show in our sound booth or our audiology testing, the outcomes are substantial when you look at both ears. It sounds really similar, like, you know, our kind of frame of reference at IHS is fitting with two hearing aids instead of one, and it sounds like those benefits of binaural hearing really carry whether we're talking about hearing aids or cochlear implants. Thank you. The next question is from Thomas. Thomas is a hearing aid specialist, and he says, as a hearing aid specialist, how can I improve on the quality of my services in terms of care to a post-CI patient, especially when following up with a patient in a hard-to-reach place? You know, I think the biggest thing that we can all do as audiologists and hearing instrument specialists when we're supporting our patients who have gone the cochlear implant route is to do just that, continue to support them, to advocate for their journey. You know, if you have a relationship with the CI audiologist that they're working with, perhaps you can be that sort of middle person to communicate some of their needs, or if, you know, you can access the patient easier than the cochlear implant audiologist, you know, maybe there are some tips that we can give you as well for troubleshooting, and then, you know, just continuing to give a consistent message that any positive performance or significant change in hearing and understanding is good. I can say that in my case, my audiologist continued to support my hearing aid service on my contralateral ear, and I was using an FM system at that point, and she supported that as well in terms of both the hearing aid and also using it with my cochlear implant. So, I continued to have a relationship with her, and she was great throughout. Great. Thank you so much, Donna. And the next couple of questions I have here are for you. The first one, Donna, is from Dr. Paul Sobel. Did you have any problems medically from your CI surgery or the follow-up procedures to switch out your processors? So, I only had one CI surgery, and the processors that I had, the seven processors that I have had throughout my CI journey, all work with that existing internal device, and that's really important for everybody to understand. One surgery that's designed to last your lifetime, and then all of the companies design the external device to work with the same internal device. I don't expect to ever have another surgery. So, really good question. Thank you for asking that. Yeah. Thanks for clarifying. Also next, I think, would be a great question for you, Donna. Rodrigo asks if you can describe what are the differences in sound between normal hearing, hearing with a hearing aid, and hearing with a cochlear implant? Yeah, that's a great question. You know, initially, things did sound different for me. You know, it took a little time to get used to the new sound. Some people talk about things sounding like Mickey Mouse. I didn't have that. It just took me some time to get used to what I was hearing and being able to discriminate. And initially, for me, what I was hearing was out of sync with what I was seeing. It was like there was this delay thing that was going on. And it just, I think it just takes, Meredith talked before about how your cochlear implant is working, the sound you're getting from that is working with your brain, you know, and I'm sure you all have heard the expression, you know, you hear with your brain, your ears are just the way in. And it just took some time for my brain to learn to use that new signal. And over time, what happened was things sounded very natural to me. People that I had known from before I lost my hearing, which in my hearing went very quickly, sounded the way I remember them to be my mom and my husband and my friends. My son sounded different because he had changed from a you know, little boy to an eight year old boy, you know, so his voice was different. But but sounds were voices were very similar. And people do have a voice. If you call if I know you and you call me on the phone, and I pick up, I'll know you from your voice. When I sit around a table, and people talk, I know who's talking based on their voice. You know, I think sometimes what takes a bit of time is figuring out what some of the environmental sounds are that you hear, and, you know, connecting that. But over time, what happens is you learn what that sound is, and you connect up the dots. So it's just, you know, I think it, it, for me, at least, you know, it's it sounds, it's sounds are very natural. Music does sound different, you know, and a very complicated symphony orchestra does not sound the way I remember it to be. I was a I was a bit of a musician in my teens, I played classical guitar. So that does sound different to me. Music that's, that has a strong beat, that's more simple, that doesn't have a lot of instruments tends to sound the best for me. And and so that is probably the biggest difference. I still love music, you know, and I certainly hear it better than I did at the end when I had so little hearing that was usable. Sierra, I'm having trouble hearing you. Yes. I mean, while Sierra is getting her mic back, I may answer one question that I saw come in, which was a great question. Julie had a question about speech testing and candidacy. And she said that I mentioned speech testing results below 60% was part of candidacy. Is this in quiet? Could it also, could you also perform speech testing in noise? And would they still be a candidate if they perform worse in noise? That's an excellent question. So when I was talking about the 60-60 guideline, that's for referring your patients. And it's just using 60% or worse on the unaided hearing, speech understanding. So like with a NU6 list or whatever testing you do for your word recognition score. Now, when we do the aided testing, to look for candidacy, we do, Julie, oftentimes test in quiet and in noise. And depending on if we're following FDA indication, if we're having to go by insurance indications, we may use a combination of quiet and noise testing, or we may just use quiet testing, but that's an excellent question. But just the 60-60, remember is PTA, unaided PTA of 60 dB or worse, and then unaided word recognition score of 60% or worse. Those patients should likely be referred for a cochlear implant evaluation. Thank you so much. I'm going to try one more time. Can you hear me? You're good. We can hear you. Thank you for letting me know that you couldn't hear me. Thank you so much for stepping in to answer that question, Dr. Holcomb. It's the one I was about to ask you. And that is all the time that we have for today. Thank you so much to Dr. Holcomb and Donna for your partnership and sharing this valuable presentation today, how to help your patients who struggle to hear better and love your services. To get in touch with our presenters, you can email them using their email addresses on the screen. As a reminder, for information on receiving a CE credit for this webinar, you can visit the IHS website at www.ihsinfo.org slash webinars. Also keep an eye out for the feedback survey you'll receive tomorrow via email. We ask that you do take a few moments to answer some brief questions about the quality of today's presentation that will help us as we develop future content. Final reminder, IHS members can sign up for the free one-year membership to the American Cochlear Implant Alliance. Log into your IHS member account and visit the list of member resources to get started today. Thank you again so much for joining us today. We'll see you at the next IHS webinar.

IHS webinar

patients

hearing loss

cochlear implants

speech understanding

early intervention

60/60 rule

misconceptions

insurance coverage