Rehabilitation of the
Hearing Impaired
FACULTY OF MEDICINE AND SURGERY
Course: EAR, NOSE & THROAT
Lecturer: Prof /Dr. Abdullahi Hussein Abdi
Ass.Lecturer: Dr Hussein Omar Zuke
COCHLEAR IMPLANTS
A cochlear implant is an electronic device that can
provide useful hearing and improved communication
abilities for persons who have severe to profound
sensorineural hearing loss and who cannot benefit
from hearing aids.
A cochlear implant works by producing meaningful
electrical stimulation of the auditory nerve where
degeneration of the hair cells in the cochlea has
progressed to a point such that amplification provided by
hearing aids is no longer effective.
Components and Functioning of a Cochlear
Implant
A cochlear implant has an external and internal
component.
1. External component. It consists of an external
speech processor and a transmitter. The speech
processor may be body worn or behind the ear type; the
latter being preferred.
2. Internal component.
It is surgically implanted and comprises the
receiver/stimulator package with an electrode array.
Sound is picked up by the microphone in the speech
processor.
The speech processor analyses and codes sounds into
electrical pulses.
The processor uses a variety of coding strategies to
deliver meaningful speech parameters from the
acoustic stimulus to the nerve. Examples of such
strategies are simultaneous analogue strategy (SAS),
continuous interleaved sampling(CIS), spectral peak
(SPEAK) and advanced combination encoder (ACE).
Disadvantages of conventional hearing aids
Cosmetically unacceptable due to visibility.
Acoustic feedback.
Spectral distortion.
Occlusion of external auditory canal.
Collection of wax in the canal and blockage of insert.
Problem to use in discharging ears.
The electrical impulses are sent from the processor to
the transmitting coil which in turn sends the signal to
the surgically implanted receiver/stimulator via
radiofrequency.
The receiver/stimulator decodes the signal and
transmits it to the electrode array.
Current day implants are multichannel processors
with the electrode having a linear array of electrode
contacts used to deliver multiple channels of current
to different places along the basilar membrane.
The electrode array which has been placed in the scala
tympani of the cochlea stimulates the spiral ganglion
cells.
The auditory nerve is thus stimulated and sends these
electrical pulses to the brain which are finally
interpreted as sound.
Cochlear implants may be used both in children and
adults.
The following criteria help define candidacy for
cochlear implantation:
1. Bilateral severe to profound sensorineural hearing
loss.
2. Little or no benefit from hearing aids.
3. No medical contraindication for surgery.
4. Realistic expectation.
5. Good family and social support toward habilitation.
6. Adequate cognitive function to be able to use the
device.
Candidates with such hearing impairment may be
defined as prelingual or postlingual depending on
whether they were deafened before or after the
acquisition of speech and language.
In children who have hearing impairment at birth or
early in childhood, early intervention with hearing
aids or a cochlear implant is vital for auditory stimulus.
Auditory deprivation, i.e. lack of auditory stimulus in
the early developmental period causes degeneration in
the central auditory pathways.
This will limit the benefit in terms of speech and
language acquisition following cochlear implantation.
Outcomes of Cochlear Implantation
Factors that predict a successful clinical outcome are:
1. Previous auditory experience (postlingual patients or
prior use of hearing aids).
2. Younger age at implantation (especially for prelingual
children).
3. Shorter duration of deafness.
Multichannel implants are the standard today and
perform much better than single-channel devices.
Postlingual children or adults achieve very good
benefit.
They develop the ability to recognize speech with no
or minimal lip reading or visual cues.
They eventually can also use the telephone.
Evaluation
Thorough evaluation of the patient is very critical in the selection
of candidates for a cochlear implant.
The main purpose is to determine if the patient is medically and
audiologically suitable for an implant.
Medical evaluation through detailed history and physical
examination is necessary to confirm fitness for a general
anaesthetic.
The necessary preanaesthetic tests will be required to be carried
out.
All candidates must be fully vaccinated against meningitis
(particularly Haemophilus influenzae type B, Pneumococcus and
in some areas Meningococcus).
Imaging of the temporal bone, cochlea, auditory nerve
and brain is carried out using CT and MRI.
This is required to provide an image of the structure of
the cochlea and help identify any anomalies or
pathology that may complicate the implantation
process.
Audiological evaluation.
Surgery
Simple cortical mastoidectomy is done first and the short process of
the incus and the lateral semicircular canal are identified. The
facial recess is opened by performing a posterior tympanotomy.
The principle of cochlear implant surgery is to place the electrode
array within the scala tympani of the cochlea.
This allows the electrodes to be in close proximity to the spiral
ganglion cells and their dendrites (that lie in the modiolus and
osseous spiral lamina of the cochlea, respectively).
Surgery is carried out under general anaesthesia and is similar to
mastoid surgery. Once the patient is positioned, prepped and
draped, the position of the device is marked and the incision
planned.
Flaps are elevated carefully so as not to disrupt the
blood supply. Usually, a two-layered approach is
chosen utilizing a flap of skin and subcutaneous
tissue, followed by a second layer of musculoperiosteal
flap.
A pocket is created under the second flap and a well or
recess is drilled in the bone to house the
receiver/stimulator.
