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2016-07-20 11.36 HOPE for Families- Julie Decker

Suite 43, Cleveland House, Cleveland 4163 PO Box 265 Cleveland, QLD Australia 4163 Phone +61 7 3286 3901 http://bradleyreporting.com ABN 71908 010 981

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Transcript:

JACQUI: Hi. My name is Jacqui Cashmore and I have recently

taken over the role that Trudy was doing.

I would like to welcome you today on behalf of RIDBC Renwick

Centre and Cochlear Limited to the first of our 2016 HOPE parents

series lectures.

I hope you enjoy today. Today we have Julie Decker presenting for

us on a parent's guide to Cochlear implant journey. Julie is a sales

clinical manager for the Australian region of Cochlear Australia-

Pacific.

Julie has been involved in the field of Cochlear implants for over 20

years. Her background includes experience working with listening

and spoken language specialists, in educational and early

http://bradleyreporting.com/

https://www.youtube.com/watch?v=I0dt6KsfXfY

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intervention settings. This role enables Julie to draw on her

knowledge of listening and language development, audiology skills

and technical knowledge of Cochlear implants to improve outcomes

for Cochlear implant users and hearing professionals across

Australia.

I want to go through a couple of housekeeping things before I hand

over. This session is endorsed by AG Bell Academy and BOSTES.

So, can you please send through your details after the session so

we can update both of the sites.

It’s being recorded and you will be sent a link to the captioned

recording in a couple of weeks. We have Jason from Bradley

Reporting joining us today. We appreciate their ongoing support.

We want a nice clean recording today, so we will have everybody

muted. If you have any questions, please type your question into

the chat function and I will interrupt Julie and ask for questions. This

is a one-hour lecture, and I will hand over to Julie. Go ahead, Julie.

JULIE. I’ve been asked to speak today on a parent's guide to the

Cochlear implant journey. As Jacqui mentioned, I work for Cochlear

Limited here in Sydney. But in my previous life I’ve worked in quite

a few different clinics around Australia and overseas in cochlea

implants. So, I'm hoping to overview a general journey for families.

I'm happy to take questions at any time. You can type them into the

chat box and Jacqui will pose them or what I might also do is just

stop at the end of each mini section and just ask if there are


questions. I'm happy to take time to answer questions just to make

sure that you get everything out of the session that you’d like.

I'm hoping to cover I guess a broad -- why your child should have

an implant if their hearing loss is significant enough. Some of the

professionals that you will meet on the journey. A very brief

overview of surgery. And then a look at how we begin to listen. And

some research in the area of cochlear implants.

So, let's start at the very beginning. The beginning of the story for

Cochlear is this man here, Professor Graeme Clark, the inventor of

the Australian Cochlear implant.

He developed the implant at the University of Melbourne in the late

60s/early 70s. But for families the journey basically to start was

trying to determine whether there was a presence of hearing loss.

And through that process we have a number of tests that look at

detection. Then we want to move from detection to discrimination

and identification, hopefully to comprehension and communication.

So, we will take a journey through all of those steps.

First, you need to be able to hear something before you can

discriminate it.

We have a number of tests that audiologists conduct looking at

primarily detection but a little bit of overlap into discrimination with

some of the cortical testing. And then some of these further higher

functions that we do to assess comprehension, communication,


identification.

So, the first port of call generally is trying to assess the hearing

system. Our hearing system works by our ear collecting sound

vibrations, channelling it down the ear canal. We have bones in our

middle ear space that conduct those vibrations off our eardrum into

a mechanical movement that adds emphasis to the sound.

That footplate rests up against this bony chamber called the

cochlea. Inside the cochlea is a membranous labyrinth that has the

sensory receptors for hearing floating in fluid.

So, as the footplate move in the base of the cochlea, it creates

movement within the cochlea that stimulates the nerve endings, or

the hair cells, of hearing. That stimulus goes to the hearing nerve.

The hearing nerve sends it up a pathway within the brainstem up to

our brain. So, we have a number of different tests that look at the

different stations along the way.

I'm going to talk about tympanometry a little bit, which looks at the

middle ear space, otoacoustic emissions and bone conduction,

which looks at the cochlea function. The ABR, or steady state

potential, looks at the brainstem activity. The cortical auditory

evoked potentials look at the top of the brain or the cortex. When

you are looking at a pure tone audiogram or speech perception,

you’re really looking at the whole system.

So, ABR testing, auditory brainstem response testing, evaluates


how sounds travel along the pathway up to the level of the

brainstem. Now, this information can be frequency or tone specific

or it can be a broad stimulus. There is also a test called auditory

steady state response, which some children have depending on

where your hearing testing is done, which is frequency specific and

results generally in a plotting of an audiogram-like representation of

your hearing loss.

Otoacoustic emissions are an acoustic response produced inside

the cochlea. So, your ear or your cochlea creates an echo to a

sound it ears. This echo bounces back out of the cochlea and it's

measured by the OAE machine. This gives us information on how

the cochlea is functioning and then how that relates to the ABR to

help us determine the type of hearing loss.

We then have cortical auditory evoked potentials, which are looking

at the top of the brain or the cortex response to sound. Generally

we use speech sounds like ma, ba, ga. This can be done with

hearing aids or without hearing aids, aided or unaided.

We also look at tympanometry when doing these assessments and

we are looking at how well the eardrum is vibrating. So, how is the

movement in the eardrum? If your middle ear space is full of fluid

your eardrum mobility is restricted. And your middle ear and the ear

infection that you have in that space is creating a hearing loss in

some cases.

So, in some cases you can have a hearing loss just by that


blockage or it could add extra loss to something that is happening

at the level of the cochlea. They also do an acoustic reflex

measurement, which is really looking at when you hear a loud

sound there a muscle in your middle ear that pulls on one of the

bones in the middle ear space as a reflex to loud sound, and that

needs information to go up to the lower part of the brain and

back down to create that reflex. So, it's looking at that neural

pathway again. Also, you have to have a certain amount of hearing

sensitivity to be able to elicit the reflex. So, if there is a significant

hearing loss present, the sound that goes in, which if you have

normal hearing, is extremely loud, is not loud enough to create that

reflexive result.

Those are the sorts of things you will have done when children are

young or difficult to test. And they are done by the professional and

their equipment that basically measures those neural responses or

physical responses from the system and don't actually need

participation from the child or the adult or the teenager.

We also look at what we call behavioural testing. That first lot of

tests are what we call objective testing, because essentially it's a

measure of a response as measured through equipment. Versus

behavioural testing, where we are trying to train a response in

response to sound. So, our ability to do that depends on the age of

the child. And we use different approaches trying to look at different

frequencies or pitches and different levels of intensity or loudness.

Sometimes the test will be done through a loud speaker. So, that

means the child is responding to the sound coming from a single


source, and both ears potentially could hear and so therefore any

response we get represents the better ear.

We then move to putting headphones on, which then lets us test

the right side versus the left side. Again, it tests the whole pathway

up to the level of the brain.

We then also have a bone conductor, which is a little hard vibrator

placed behind the ear on the bone, which creates vibration of the

skull, which then measures the pathway of hearing at the level of

the cochlea up to the brain. So it bypasses the ordinary air pathway

that we get through headphones and a loud speaker.

So we as people with good hearing acuity, we hear our own speech

primarily through bone conduction. As we talk, our skull is vibrating.

This is why when you listen to yourself on a tape recorder or

answering machine you sound quite different than you sound to

yourself, because your pathway of hearing it is slightly different. We

do hear through both means, and we need to test both means so

we can try and separate where the locus of the hearing loss is.

So, if your hearing levels with the bone conductor match the

headphones, then it's a sensory loss. Because it's not anything in

the pathway obstructing.

If there's a difference between those, there is what we call a

conductive overlay or a blockage in the hearing pathway. Often this

is treatable, if it's middle ear fluid either by grommets or antibiotics.


If it's something more significant like a cholesteatoma, you may

need to have surgery to resolve it.

When testing kids, we look at doing behavioural observation

audiometry, or BOA, when kids are very young. Basically we are

using different toys or noise makers to try and see if a child reacts.

For most of you, you will know the hooter test, where they squeak

the hooter because we're trying to elicit a startled to loud sound.

As kids get bigger and they can sit up and have head control, we

train them to turn towards a sound source and reward them with

something visual like a puppet. So VROA, or visual reinforced

orientation audiometry, is also known as the puppet test, and really

we are just training kids to look to the sound source, which is

generally a loud speaker, and see the puppet when they hear, and

that helps us sort out frequency specific and intensity specific

information.

We can also put a set of headphones on and still use the puppet to

reward them.

As kids get older, around five, sometimes four, sometimes three

depending on the child, we can teach them what we can play

audiometry. That’s the pegboard game, or the model …. So they

hold the toy and they listen and when they hear the sound they put

the peg in and are rewarded for hearing.

We do this with headphones as well as the bone conductor. As they


get older, six, seven, eight, we pop them in the chair like we would

an adult or teenager. We give them a hand-held button, ask them to

press when they hear a sound or ask them to raise their hand when

they hear a sound. Again, we do that with the headphones and the

bone conductor to try to ascertain where the hearing loss is

occurring.

All of this information results in the audiogram, which then the

audiologist describes as either normal, mild, moderate, moderate-

severe, severe or profound.

We have a whole bunch of tests that we do that are looking at that

point essentially of detection: Can you hear sound or not?

What that doesn't tell us really is how well you hear sound. So,

what are you doing with the sound that you can hear? Or if some of

these tests are done with your hearing aids on, how are you

processing, how are you perceiving sound with those hearing aids?

That's when we move to what we call speech perception testing.

Depending on the age of the child, we look at assessing this in

different ways. For young kids often parent or teacher

questionnaires, observation of their speech development and

babble, and response to different sounds usually in a formalised

listening or habilitation session.

For older children we actually ask them to repeat sentence and

words and they will let us know how clear they have heard

something based on their repetition. Obviously if there is specific


speech errors we need to take this into account. So, the older a

child is, the easier it is to do formal speech perception testing.

So, what we really need to know is: how do we take all of this

access -- so what sounds can your child hear -- and actually really

understand what are children doing with the sounds that they

perceive and detect?

We know children learn language rapidly and effortlessly from

babbling to full sentences within the first three years of life. That

acquisition appears quite simple for children with normal hearing.

Because we take 40 distinct elements, or phonemes, sounds of

speech, and build these units into categories, which become words.

So in English, we have 40 different phonemes, 40 different sounds

and we create nearly half a million different words from those.

So, central to learning is the categoral perception which is focused

on the discrimination of acoustic sound. Unlike adults, children,

infants can discriminate between all phonetic units. We are born

with a propensity to hear in our native language. Because for

children your organ of hearing, or your cochlea, is fully formed,

adult size, at three months gestation. So, although the baby is

growing inside, they are beginning to perceive sound from sort of

three months gestation onwards. So they are born with a leaning

towards hearing their own native language but have the ability to

perceive all different sounds. That's where often learning multiple

languages when you are young is a lot easier. We know infants can

discriminate tiny changes at birth and that that is essential to


helping us learn language.

So, we know that hearing loss does impact this innate ability. It

makes things intrinsically harder, makes it harder to perform

discrimination, it's harder to hear. We lose the automaticity of that

hearing response, because we have the presence of a hearing loss.

It becomes a conscious task instead of unconscious. We have to

teach discrimination to children and help them to hear the

differences.

And it reduces the ability to overhear. So, we know we learn

language just by being immersed in a surrounding of sound. And

the presence of a hearing loss reduces our ability to overhear and

learn naturally. So, it reduces our implicit learning as well. It

reduces the redundancy of the information we hear. We are not

hearing as much or as often.

So, this then impacts on cognitive capacity, working memory,

executive function, memory skills, changes our sensory pathways.

This may then result later on in psychosocial implications,

self-esteem, social interaction, connection, pragmatics.

So, the presence of a hearing loss, if left unsupported, can have

significant knock-on effects just beyond the presence of a sensory

loss.

So, we need to I guess identify what access people have, how that


relates to the autometric thresholds. In this audiogram we have a

range of normal hearing, which is between 0 and 20dB. Speech on

average sits around 50 to 65dB and it's quite dynamic in nature. So,

if we have the presence of a hearing loss of a severe nature, so

65dB down here. Normal speech is outside of your range of access,

so you need amplification to increase that so it falls within your

audible range. But then we need to consider what does that access

with the amplification look like?

Because it's audible, does that make it usable? Those differences

in speech which are soft to loud become relevant and salient to our

language learning, our phoneme acquisition and words and so on.

So, we need to look at access to speech and then its knock-on to

understanding, because speech is quite dynamic. When children

are very young we have to go on objective information, and we

need feedback from teachers and parents, habilitationists, speech

therapists, all of the individuals who work closely with the children

to understand that relationship between audiometric thresholds and

actual performance, how they are using hearing and accessing

sound.

If your access to sound is deemed to be insufficient, so you don't

have enough access to all of the range of speech to develop I

guess enough access to sound to get language acquisition, spoken

words with clarity, it may be decided that a cochlea implant referral

is the most appropriate next step for you or your child.


So, what is a cochlea implant. Essentially--actually, before I go on

to that, are there any questions that have popped up, Jacqui, and I

will stop and take a breath?

JACQUI: Not as yet. Does anybody want to type any questions into

the chat? No, it doesn't look like it at this stage, Julie.

JULIE: Okay, great. So, a cochlea implant essentially has two

components. It has an internal implant that is placed under the skin

behind the ear, in the bone. And an external sound processor that

is worn on the outside that picks up sound information. So, the

sound processor, microphone, will pick up sound and look at that

sound that's come in. It will look at the frequency content and the

loudness information that is contained in that sound.

It will then determine what electrical stimulation needs to be given

to represent that signal. So, we're taking a really big acoustic signal

and translating it to information that can be processed through a

digital code across 22 electrodes. So, it sends that information to

the coil, which sits with a magnet in it over the internal implant.

They are connected by a magnet. So, this is a transmitter and in

here is a receiver. So it's a little mini radio, FM signal. Sends that

information from the acoustic world across to the implant. The

electronics package of the implant decodes that signal. In the

external code here, there's a battery. So, the amount of power

needed to stimulate is carried over in the code. There is no internal

power source in the implant; it gets all of its power from the external

device.


So, it decodes the frequency information and the power information.

Sends that information down to the electrode array. And the one

amazing thing about the hearing system, as complicated as it is, it's

very organised. It's organised in what we call a tonotopic way; it's

organised in frequency. That organisation of frequency is carried

down the hearing nerve, through the brainstem and even up to the

level of the brain.

Graeme Clark, when he was inventing the implant, realised this and

created an electrode array that goes from low tone, which is the

deepest end, which is the low tones of the cochlea up the top, and

around to the base of the cochlea where the high frequencies sit.

He aligned the electrode contacts to where the nerve endings are.

There is a really good neural to frequency alignment within the

cochlea. And because of that, we can use the plates that the

electrode sits in the cochlea to represent different frequencies. That

information then gets decoded at the level of the electrode array.

The electrical impulses and the intensity of those impulses

stimulate the hearing nerve and sends it on up through the

brainstem to the brain where we perceive it as sound.

So, if you have had heard sound before you start to take your

hearing memory and line it up with that stimulation. If you have not

had hearing before, if you were born profoundly deaf and your

hearing for the first time at six months, you start to create your own

hearing memory through that stimulation.


So, when you go to the implant centre to have your

assessment -- and it may be a centre, it may be part of your early

intervention service or part of a hospital -- you will meet a group of

people. One of those will be the surgeon. They are responsible for

giving you advice, counselling and medical assessment.

You will meet audiologists. These audiologists may be the same

audiologists who did your hearing loss diagnosis or it may be a

different group of audiologists. They again are responsible

for giving you advice, counselling and doing some audiological

assessments on top of maybe the information that you have come

with.

You should meet a habilitationist. They usually have speech

pathology, listening and spoken language backgrounds, teacher of

the Deaf backgrounds, someone who is skilled up in listening and

language learning for kids or for adults in some instances. They are

responsible again for giving you advice, counselling and also those

functional listening assessments. So, how are you using the

hearing that you have and does that match up with the information

that we have?

There may be a social worker on the team. They again will give you

advice, counselling and family support. So, they often help you

navigate the systems of the hospital, the transportation system. And

also help manage the stress that the family are under, basically

working their way through this journey.


There may be other professionals that you meet like a psychologist,

an occupational therapist, a physio. You may meet other medical

doctors like cardiologists or neurologists--anyone who can add

information to that picture to determine whether an implant is the

right intervention for you or your child or also to make sure that

medically it's a safe procedure to undertake.

So, you will have a series of steps that you walk through in that

journey. There will be candidacy evaluation, surgery, activation, the

habilitation process and then maximising the outcomes from the

implant.

So, in that assessment phase--you will have another audiogram or

specific electrophysiology testing for that testing where the child

doesn't need to cooperate--where we are measuring responses

from the level of the brain stem, the cochlea or the brain. If that

hasn’t already been done in your diagnostic work-up.

Some centres will use electro-choreography, some will use steady

state evoked potentials and some will use tone burst ABR

dependent on the clinic. They will do tympanometry, check the

health status of the middle ear essentially and also do verification

that the hearing aids have been optimised. So, in Australia it's quite

unique; we have generally the diagnostic process happens in a

hospital with paediatric facilities.

Then they are referred to the government organisation, Australian


Hearing, for hearing aid fitting. And then they are referred

sometimes into a new place, cochlea implant assessment.

Sometimes that new place is the paediatric hospital facility that they

started at. But not always.

So, there are a number of different people you meet along the way.

And ideally they are all kind of speaking with each other and

sharing information.

You will also have some medical tests done as determined by your

ear, nose and throat specialist. Generally they do MRI and CT

scanning for all children. Sometimes it’s one or the other just

dependent on access. Then there will be a general medical

assessment to ensure that they are safe for anaesthetic, because it

is a surgery that requires anaesthetic.

This process of assessment generally takes a few sessions with the

various professionals. At the end of the information gathering there

will be generally a group meeting case discussion where all of the

results and potential benefits from the implant will be discussed.

One of the things that has to happen along that journey is choosing

an implant system.

Cochlear system is a Nucleus 6. We have a variety of electrode

options that the surgeon can choose, dependent on the shape of

the cochlea, dependent on perhaps sometimes their surgical

preference, whether they go for a curly array or a straight array.


Implant reliability is important. Not only looking at the reliability at

one year, but over time. We have the best implant reliability of all

manufacturers, and the most number of recipients around the

world.

We also have very sophisticated sound processor technology.

We've been manufacturing implants for over 30 years. And they just

get better and better. So, the technology that is available to us as

hearing aid technology improves becomes incorporated into sound

processors. We have something called SmartSound IQ that

basically analyses the sound situation and automatically sets up the

processor to hear the best.

We also have wireless freedom, wireless accessories that allow us

connectivity to remote microphones, to phone interfaces—and all of

that is done without wires. We have a remote assistance which

allows communication between the processor and the remote. And

the remote and the processor. It goes both directions. If you have a

faulty cable or your battery is running flat, that gets reflected on

your remote. So as a parent you can be very confident about the

status of the equipment that your child is using.

We also have the ability to mix acoustic input through a hybrid

component. We also have an Aqua Plus accessory, which is a

waterproof sleeve so you can swim with your sound processor.

One of the things that is really important is access. So, we know

that on average children are only exposed to clear speech for about


half an hour a day. That is hardly enough to hear the 21,000 words

they need to hear before they start to develop speech and

language. So, it's really important for us that we manage noise. We

know that noise is much more distracting to a child than an adult.

And that actually one of the most difficult things for a child is trying

to listen when there is other sound forces that are speech-like. So,

when there are other people babbling in the background. We know

that kids learn language from hearing it. And they have to have a

greater need for understanding speech that is around them but they

are less equipped to deal with it. They need to hear the speech

around them because they need to hear all of those words before

they can start to develop their own words.

Normal-hearing children listen for around nine months before they

start to form their first words. We know there is lots and lots of

listening that happens before language emerges.

So, we need to set up our processor so they can manage speech

against any competing background noise. And that process of

listening in noise is not just difficult for very young children, it's

difficult for toddlers and pre-schoolers, and it's really not until kids

are teenagers or adolescents that that skill to suppress background

noise and focus in on speech begins to develop.

We know that kids are not little adults, and they do need a better

signal to noise ratio to hear. There was a study done looking at

phoneme discrimination, looking at adults here versus kids. The

difference in the signal to noise ratio--so that is how much louder


does speech need to be than background noise for it to be clear--

about 30 dB. So, 30 dB is essentially the difference between a soft

voice and a loud voice.

We know that they need a much cleaner signal. When you are

looking at listening in noise, we know that ages—this is five to

seven, eight to 12, 13 to 16 and adult. So, teenagers and adults

function pretty similar and can have noise greater than the speech.

However, young children need speech to be louder than the noise

signal for them to understand. So, we know that we need a really

good what we call signal to noise ratio.

One of the challenges of all of that is that the world is an extremely

noisy place, there are lots of different sounds around. So, we have

created a sound processor that manages all of that automatically.

We do that with what we call SCAN, which is a scene classifier. It

looks at the sound coming in and makes a judgment of whether it's

quiet out there, whether it's noisy, whether the noise is just

background noise from, let's say, construction or whether someone

is trying to talk over the noise, whether there is music or whether

there is wind. What it does is it picks the settings on the processor

to match that environment that it's identified. This gives the best

signal to noise ratio.

When we look at processors that we have had in the past--this is

our Nucleus 5, which had an everyday setting. So it had a little bit of

noise management but not the sophistication that we have in

SCAN--that we get a 27 per cent improvement of listening to


sentences in noise when we implement that automated scene

classifier, that SCAN functionality. So, we are getting the best

listening we can in noise and we know that that is so important for

kids.

So, the next step, once you have determined what implant the

surgeon is going to use, is the actual surgery. Generally, the

implant is placed under the skin behind the ear. The surgeon

makes quite a small incision, usually directly behind the ear. And

then they open up the space and they open up access into the

cochlea. And thread in that electrode array.

So, the electrode array is quite thin. And it has a very soft tip on it to

facilitate smooth insertion. We want to make sure that there isn't

added trauma into the cochlea when we are putting in implants,

because we don't know what the future will hold. So, the design

principles around the implant are minimal footprint and really

implement soft surgery techniques, so we can maintain the

structures within the cochlea. Because it's highly likely in children's

future that hair cell regeneration or gene therapy or stem cell

therapy may restore some aspects of hearing. We need to stimulate

the hearing pathway so there will be something to connect to, which

is why they need an implant if they have a significant hearing loss.

But it's not going to stop them from having those therapies in the

future. That's often a question people ask, "If I have this now does

that stop me from having hair cell regeneration in the future?" From

all of the surgeons I have spoken with and researchers, there is no

reason to think that that is the case.


Surgeons generally treat it as a low risk routine medical procedure.

There is obviously an assessment for fitness for the surgery. The

surgery is generally an hour to three hours long depending on

whether you have one implant or two. It's done under general

anaesthetic. They don't shave hair anymore. That was the thing

they used to do a long, long time ago. Most people only have a

single night stay in hospital.

Are there any questions people want to ask about the surgery or

about that assessment period?

JACQUI: None have come through as yet, Julie.

JULIE: I will keep going then. After your surgery you have activation

of the sound processor. That sound processor activation can

happen the day you go home from hospital in some instances to a

week to two weeks after surgery, dependent on your clinic and your

surgeon's recommendation.

Generally recipients will continue to wear a hearing aid in the ear

that didn't have the implant surgery. So, they continue to have

some access to sound. At that switch-on, those 22 electrodes and

the implant gets activated for the first time.

Often almost universally in Australia during the surgery there will be

a test of the implant and the nerve's response to the implant. So,

going back to what happened before implant in that diagnostic time,


where they were looking at objective measures to the hearing

system, we do similar objective measures but to the implant

stimulation.

The surgeon has a hand-held remote control that measures a

neural response to sound. And that information, about how much

stimulation from the implant does the ear need to get a neural

response, is passed from the surgeon to the clinic, and they have

that available for your activation. So, generally what they will do is

they will turn the implant on based on those responses they had

from the hearing neural system. And turn it on very softly and

gradually make it louder over time. So, all of the electrodes are

turned on on that first occasion. And the settings are a starting

point. So, it's an early access point. It's not where your levels end

up as your hearing system gets used to hearing. But if there is

sufficient access generally to hear spoken voice. What adults often

say is that over the first week to two weeks it goes a little bit soft

because their system is getting used to it and they need more

stimulation.

So, part of knowing how you are responding initially is that

habilitation phase. So, as the implant gets activated, the

habilitationist, the listening and spoken language therapists or your

teacher will run through some training I guess and language and

listening exposure very similar to what you had before the implants.

But starting again at those very early steps. They may use a variety

of resources that we have available to help them and to also share

with you so you can do work at home.


Over that first three months, the therapy and then programming or

review mapping, some people call it, continues to adjust those

electrical levels to the individual hearing nerve’s needs. As progress

is made with speech and language and listening, eventually those

levels plateau and they stay relatively stable and then there is a

less frequent review. We know that generally there is a rapid

change in the first three to six months and then a pretty stable

access to sound that happens after that.

So, what does that mean? Well, that means we now have access to

information, and we are hoping that children start building that

matrix to knowledge and understanding and language development

and speech development. So, we're going from now we have

improved the access to information--generally with a cochlea

implant you have access to soft speech, medium loud speech, loud

speech, the whole gamut. So, you are not missing part of the signal

in a quiet environment in particular if you are across the dinner

table or something like that.

So, we know listening is really important. That if we listen to a book

a day, we speak a book a day, we read a book a month and we

write a book a year. So, we listen much more than we talk, write or

read. So, listening is important and having that access to sound is

important, which is one of the reasons it's important to get in and

provide implants early. If your child is at school, there is extra

technology or even preschool--riding in the car with you--we have

technology to continue to support access in the form of our Mini


Mic2-plus, a remote microphone that the teacher or parent wears

and it streams wirelessly to the processor, so it means that you can

have an optimal signal to noise level at all times.

There is also a function where you can put it on a table and it goes

into like--what do you call it when you have a meeting? A meeting

mode. There you go.

So, we do know that when we look at listening alone in quiet, even

having the voice at this distance versus this distance--I hope you

can see that--improves access. In quiet and as noise gets louder

and louder, access improves. So this level here, in 65dB of noise,

which is around the average early primary, preschool room noise

level, we get speech perception outcomes that are actually similar

to children with near normal hearing. The use of these assistive

devices continues to improve access and also improve access over

distance.

So, generally as distance increases our access decreases, sound

drops off. However, with wireless technology that access to sound

remains steady.

One of the key things we know in research as well is that children

with profound deafness experience better outcomes when they are

implanted with a Cochlear implant as early as 12 months of age.

So, a group down in Melbourne, the University of Melbourne, the

Hearing CRC, and a number of their hearing partners conducted a

study looking at long-term communication outcomes for children


receiving Cochlear implants younger than 12 months.

So, they grouped their kids into five groups. Before 12 months is

group 1. Group 2 is between 13 and 18 months. Group 3 is 19 to 24

months. Group 4 is 25 to 42 months.

So, that is two to three and a half. And then they looked at three

and a half up to 72 months, which is six years of age. So, we have

very young to prep or kindy depending on what state you live in.

And they looked at speech perception. So what is access to sound

and how are kids performing on the open set tests where you are

just asked to repeat.

When they measure it in terms of phonemes, so the correct number

of sounds repeated. If the word is ‘cat’ and the child says ‘cat’ you

get three out of three. If the child were to say ‘ca’ with no T on the

end they get two out of three. So the score is out of 100 per cent.

That's what this here is.

For these young kids--groups 1 and 2—the phonemes, they are

around 85 per cent correct. Down as the group gets older they are

sitting just under 70 per cent. So still a huge improvement off the

pre-operative state, but better listening skills for younger children.

The same again if you look at that in terms of words. They are

understanding about 60 per cent of words, when they are implanted

before 18 months versus being implanted older, where it drops

down to 45 to 38 per cent.


Then when you look at sentences--so that is generally the ‘clown

had a funny face’, and it's scored by the number of words correct.

You need language to be able to pull together the missing

components and fill in the gaps.

If you were implanted younger, again, your outcomes on these tests

are better than if implanted later. We know that has to do with the

plasticity of the hearing system. By the time children are four, if you

are not using your hearing system other factors start to take over

components of that hearing system and you are not as flexible.

By the age of 7, any flexibility in the system begins to shut down,

and it's much more difficult to stimulate the auditory pathway as you

get older. If you have had a total profound, severe to profound

hearing loss. If you have had hearing and your hearing has

changed, those pathways have been stimulated and that window is

very different to if you have been born with a severe to profound

hearing loss.

How does that translate again--this is open-set speech perception

again. We are getting better results younger on. They also looked

at language outcomes. They looked at the Peabody picture

vocabulary test, and looked at kids that were school age. This dot-

dashed line here and here and this solid line in the middle is the

normal range.

You can have a normal range of one standard deviation below to


one above. So, this is where 60 per cent of children--hang on.

70 per cent of kids fall generally in this range. So, they are looking

at where kids fall based on the age at implant.

The younger you are the more kids are populating that normal

range. Some of these older children are falling in the normal range

but not as many. A lot of that is due to the fact that you need

experience to learn language, and your amount of time you weren't

learning language is greater. And your starting point then is

delayed.

So, the longer you wait, the more difficult it is to close the gap you

have because you haven't had access to sound.

Basically, they concluded that they should provide implants for

children with significant hearing loss before 24 months of age to

optimise speech perception, which is listening, and then to facilitate

speech production accuracy before 12 months of age as well as to

enable language acquisition.

So younger is better. That is also supported by Teresa Ching's

longitudinal study looking at the outcomes of children with hearing

impairment, or the LOCHI study.

Do you have any questions about that before I go on to potential

benefits of bilateral implants? I only have three slides. And then

open it up completely for questions. I haven't seen anything pop up.

So I might press on and then we can regroup at the end, if we like.


One of the questions people often ask is: should my child have one

implant or two? Essentially, that question is answered by the

degree of hearing loss in both ears. If they are similar or whether

they are dissimilar.

Basically, we know that having two ears hearing, that we can

integrate the input from both ears, and that sound is presented to

and perceived in both ears, and that we may have different binaural

hearing. So, that is using our two ears we could have two hearing

aids, two Cochlear implants, a Cochlear implant and a hearing aid

or we might have a hybrid and a hearing aid--there are a few

different combinations to stimulate both ears.

So, the recommendation is to stimulate both ears, because there is

a number of reasons why it gives you improved hearing in noise,

improved hearing in quiet and it reduces that auditory deprivation,

so that amount of time where you are not being stimulated. It gives

you ease of listening. You are less fatigued. You always get the

better ear performing. You have more balanced sound. You are

more aware of sound and the environment. It gives you better

opportunities for overhearing--if one side is having trouble then the

other side can still hear. It also is interesting that it gives you

increased opportunity for employment or mainstream school, and

gives you improved expressive and receptive language.

Objectively, it helps you localise. So, it helps you localise on a

horizontal panel as well as up and down and front to back

differentiation. It gives you perception of distance better. It helps


with what we call the head shadow effect. If you have noise on one

side and hearing on the other side, if all of the noise is to your

good-hearing ear, this ear has to try harder to hear because your

head is in the way. Hearing through both ears helps with that. If you

get binaural squelch, you need input from both ears to kind of

suppress the background noise, and you get more redundancy and

a boost from hearing through both ears. You get an oomph in

loudness.

We do know if you have one implant, you can tell the side that the

sound is coming from. But it's quite a broad angle that you can hear

on. You can know it's from the left or the right. But if you add a

second implant, that window of localisation narrows significantly.

So, it's much easier to localise when you are hearing through two

implants versus one.

So, this is that head shadow effect. So, if you have noise over here

and speech over here, by adding hearing through both ears you

have always got one ear facing the speech. And so you actually are

going to get a more favourable signal to noise ratio when you are

listening in noise. And by having the two ears combined, you

actually are going to get a boost in your hearing in noise

performance compared to either ear on their own.

Also, the University of Melbourne have looked at doing studies in

regards to educational outcomes, parental stress, language and

everyday hearing situations. And there are benefits seen for

children with bilateral implants in all of those areas compared to the


cohort that were age matched with unilateral implants. So, we do

know that not only from a hearing point of view do you hear better

but it's actually having educational and language outcomes effects.

So that brings me to the benefits of bimodal hearing, which

basically are increased speech intelligibility, binaural redundancy,

improved localisation and improved functional performance.

What should you do next? If you are thinking about an implant by all

means speak with your RIDBC habilitationist or teacher or if you are

in a different early intervention group speak to your professionals

there. Feel free to contact our customer service if you just want an

information pack. The contact details are there.

I will stop talking and take questions, if anyone has any. I have

talked for almost a whole hour, I apologise.

JACQUI: Thanks, Julie, for a really informative presentation. Are

there any comments or questions for Julie? If you would like to type

"no" into the chat box if you don't have any questions that would be

good. (pause) Julie, we --

JULIE: Still awake?

JACQUI: We have a question from Elizabeth saying you have had a

well spoken presentation. Clarified quite a lot for her. So that was

good and she says thankyou.

JULIE: Thank you.

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