Cochlear implants offer alternative to traditional hearing aids for some patients

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

People with significant hearing loss who cannot be helped by traditional hearing aids may be candidates for cochlear implants to improve communication and quality of life.

Here to explain how they work is Upstate audiologist Erin Bagley.

Welcome back to "The Informed Patient," Dr. Bagley.

Erin Bagley, AuD: I thank you for having me again.

Host Amber Smith: Now, can you explain the difference between a hearing aid and cochlear implants?

Erin Bagley, AuD: Sure. A hearing aid amplifies sounds in the environment. Without getting too technical, we hear sounds through vibrations in the air, and hearing aids pick up those sound vibrations, amplify them to a particular level that they're set to, to help a person hear those everyday sounds at a higher level.

A cochlear implant works differently. It actually uses electrical stimulation, so it picks up the sounds of the environment, and it changes it to an electrical signal. And it uses tiny, tiny electrodes, implanted in the inner ear, to stimulate the hearing nerve directly. So it bypasses a lot of the typical parts of the ear that we typically would hear with.

Host Amber Smith: So which one gives a person a more clear sound? Which one sounds more natural?

Erin Bagley, AuD: Well, in terms of sounding more natural, a traditional hearing aid would sound more natural because it amplifies sounds and produces them in a way that we're already familiar with, that we already know how to interpret, just at a higher volume, versus a cochlear implant. There is a learning curve with a cochlear implant. People can become very proficient users of cochlear implants, but they do sound very different, especially at first.

Host Amber Smith: So who are hearing aids designed for, and who is best for a cochlear implant?

Erin Bagley, AuD: Hearing aids are typically fit for people with anywhere from a mild hearing loss on up.

We kind of categorize hearing loss into different categories or degrees of hearing loss, and even some people with a very significant, severe to profound, hearing loss may do OK with hearing aids.

Cochlear implants are kind of the end of that continuum. So, as people start to have significantly more difficulty or less benefit from their hearing aids, a cochlear implant may be just the next step on that journey to help them hear better.

Host Amber Smith: Well, you started explaining how cochlear implants work, but I want to ask a little bit more about that. Do they go in one or both ears?

Erin Bagley, AuD: That depends. So some people have a cochlear implant in just one ear. Some people actually have a cochlear implant in one ear and a hearing aid in the other ear. We call that bimodal listening.

And some people have a cochlear implant in each ear. So it really depends on the person's hearing loss. Perhaps they're still getting some benefit from their hearing aid in one ear, and they want to keep using the hearing aid on that side, and then we implant the other ear so that they get the best of both worlds.

So, it really is just a case-by-case basis, whatever is most appropriate for that patient.

Host Amber Smith: Most people who come for cochlear implants, have they tried hearing aids in the past?

Erin Bagley, AuD: Most of the time, and it is a good idea. So, think of it like a muscle that you don't exercise. If you, have, say your arm in a cast, and you're not able to exercise that muscle, when you get the cast off, that muscle on that side would be a little bit weaker than your arm that wasn't in a cast.

So, it's the same thing with hearing. If you have an ear that hasn't been getting sounds, it may take longer to adapt to hearing again in that ear. We want to keep that hearing nerve exercised and healthy as much as possible.

Host Amber Smith: So what are the realistic expectations for what a cochlear implant can and can't do in terms of providing hearing for someone?

Erin Bagley, AuD: The important thing to know is it's not a quick fix. So a lot of people come in hoping that, "You know what? Geez, I'm not benefiting from my hearing aid anymore. I'm going to get this cochlear implant, and it's going to fix everything."

Cochlear implants are wonderful, and there are people who do extremely well with them, but it does take time, so it's just important to be realistic that there is a learning curve. There'll be follow-up appointments and rehabilitation to get used to hearing with that new device in a new way. So I think, No. 1, that's a really important expectation for patients. The other limitations are, it doesn't sound like your natural hearing. Some people can follow speech very well, but music just doesn't sound the same as it used to.

Unfortunately we're just not quite there yet, in terms of technology, to hear music the way that we used to perceive it. So some people report that that's a really big difference between a cochlear implant versus their hearing aids or their natural hearing.

Host Amber Smith: Will cochlear implants remove tinnitus, or ringing in the ears?

Erin Bagley, AuD: There have been some studies on that. For some people, they do notice their tinnitus much less when they're using their implant because, again, they're getting, they're hearing, they're getting stimulation to their brain, and so they're not as aware of that annoying tinnitus as they were before.

But it's hard to know who is going to have that benefit and who isn't.

Host Amber Smith: How long do implants last for? Are they good for life?

Erin Bagley, AuD: So, there are two parts to a cochlear implant. There's the actual implant part, which is under the skin, and that is ideally there for a lifetime. I have patients that received their device in the late '80s that are still using the same internal device.

We try not to remove and replace that internal if we don't have to because the inner ear is a very delicate organ, but the external processors, those get replaced approximately every five years. And that's the part that's on the outside that looks, in some cases, more like a hearing aid.

And there are some smaller devices now, processors that actually sit off the ear, so, they're a little bit more comfortable to wear. And those last, like I said, about five years.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Erin Bagley. She's an audiologist at Upstate, and we're talking about cochlear implants.

Does Medicare and health insurance cover the cost of implants?

Erin Bagley, AuD: One of the key parts of finding out if somebody is an implant candidate is that we have to do specific testing. So if a person meets Medicare criteria, then yes, Medicare covers 80%. And if they have, like, a secondary insurance or a benefit plan, there may be some additional coverage there.

As far as private insurers, typically, yes, they are covered by insurance. To what degree varies by insurer. We do have to get prior authorization before we move ahead with that process.

Host Amber Smith: What are the potential risks to consider with implants?

Erin Bagley, AuD: Like any surgery, there's always some risks like infection and things like that, although that tends to be pretty low.

Some people do experience a little bit of dizziness right after the surgery that typically goes away pretty quickly. In terms of other risks, there could be a worsening of hearing in the ear that's implanted. That's always a risk of the surgery. surgical techniques have gotten better and better over time.

Some people don't have any change in their hearing, the residual hearing, we call it, or what's left of their hearing after the surgery. But some people do lose more hearing after the surgery.

Host Amber Smith: Does the addition of implants change a person's life in terms of their ability to go swimming or to be able to hear when they're asleep?

Erin Bagley, AuD: So, just like hearing aids, we recommend that people take their implant off at night. The implants have rechargeable batteries, so I always say, "Recharge your batteries." Well, you're recharging, so you're going to it off at night and recharge your batteries. So, in terms of hearing at night, I know many people are concerned about things like hearing the fire alarm or hearing the phone ring or hearing a loved one perhaps in the night.

There are some other technology solutions that we can talk about, or you can talk about with your audiologist, to help with those situations when you're not able to wear your implant. What's really cool is that you can get a waterproof cover so that you can actually wear them swimming or to water aerobics or while you're fishing or boating so that you can still enjoy those activities without worrying about getting your processor wet.

Host Amber Smith: Let's talk about how a person goes about obtaining implants. Do they need a referral from a primary care doctor? Do they go to an ear, nose, and throat doctor? How does that all work?

Erin Bagley, AuD: Typically, the process is a patient is referred here by their primary care physician, to our office. In our office, we do the audiology portion first.

I do some specialized testing with my patients, with their hearing aids, if they have them. And we determine whether or not they meet the FDA and/or insurance criteria for a cochlear implant or implants. If they do, then they would follow up with our neurotologist, Dr. (Charles) Woods in our case, and he would do some more, investigation as to whether they are a good surgical candidate, like doing imaging and making sure they're healthy enough for surgery.

And then we collaborate. And we make sure that we're on the same page. If we are, we go ahead and get insurance authorization, and the patient gets scheduled for the surgery.

Host Amber Smith: So before the surgery, you measure their level of hearing loss, or does it have to be a certain degree before they would qualify for the surgery?

Erin Bagley, AuD: It does. So it needs to not just be a certain degree of hearing loss, but also we measure their word understanding, and we do it in kind of a tricky way. So we measure with their hearing aids, and we measure their word understanding of certain types of sentences, in quiet and also in background noise.

And that's the No. 1 thing a lot of people complain about, is that they do OK one on one, but they really struggle when there's background noise. So we want to really measure that and make sure that we're looking at different aspects of how someone is hearing before we make that decision.

Host Amber Smith: So, how do you tell patients to prepare for this surgery?

Erin Bagley, AuD: On their end, once we determine that they are a candidate, like I said, they usually have imaging and as long as that looks good, in preparation for the surgery itself, there's not a lot that they need to do leading up to the surgery. The hard work really comes after.

Host Amber Smith: Where does the surgery take place? Is it in the office, or is it in the hospital?

Erin Bagley, AuD: It's in the hospital. It is outpatient for most of our patients, so the surgery is a couple of hours, and then they typically go home the same day.

Host Amber Smith: And then what is recovery like?

Erin Bagley, AuD: For the most part, patients complain of just a little bit of pain at the incision site, which usually, feels better fairly quickly. They may have a little bit of dizziness after the surgery, but typically they recover pretty well and pretty quickly.

Host Amber Smith: Now the implants are not activated immediately, right? There's some time that lapses between the surgery and when they're activated?

Erin Bagley, AuD: Correct. So we usually wait four weeks from the time of the surgery until the day of activation, because we want to make sure that everything is healed up nicely before we add anything to it.

In that meantime, the patient sees the surgeon just to make sure that the surgical site is healing well and just to check and see if they have any other concerns, like I said, then typically they're cleared at that point to come back for their activation in four weeks.

Host Amber Smith: Now, once the activation takes place, I wanted to ask you about the audiologist's role in that, and then that's when the hard work begins, right?

Erin Bagley, AuD: It is. That's when the fun begins on my end, too. It's really great to be able to guide patients through this experience.

The surgeon does their job in the operating room and immediately after, and then the audiologist really takes over from there to do a lot of the work with the patient. I spend a lot of time with my patients, especially in the beginning, going over how to care for their device, how do we have to set their device, and it sounds very different than anything that they've heard before. So, we take our time to go through fine tuning and refining how things sound and helping patients relearn to listen with the implant and relearn what things sound like again, and also helping them along the way with everything from the fit of the device to accessories.

There are accessories that can pair with the implant. Patients can get phone calls right to their implant, or they may have a microphone that a loved one can wear to help them hear better when there's background noise so that their loved one's voice goes right to their processor.

So I help the patient and their family learn how to use all of those tools to really maximize their hearing.

Host Amber Smith: Is there anything a person can do to improve their chances that the implant is going to really restore their hearing for them?

Erin Bagley, AuD: Yes. I always tell patients, wear it consistently all day, every day.

You want to get used to all those little sounds. It's a noisy world, and sometimes patients forget that because they haven't heard their shoes squeak on the floor, and they haven't heard their dog's toenails on the floor, or the refrigerator running. They haven't heard leaves rustling. So the more you can wear the device all day, every day, and relearn what all those sounds are in your world. And also talk to people, as much as possible.

My patients that are more actively engaging with others tend to progress more quickly than patients who are a little more introverted, maybe live alone and don't interact with people on a day to day basis as frequently. So for those patients, we talk about other things if they do live alone, like audiobooks or podcasts, or other ways to be listening to speech and practicing.

And, I just too wanted to add that there have been some great new developments, in just the last year. Traditionally cochlear implants were for patients that had a significant hearing loss in both ears. And now the FDA (Food and Drug Administration) has approved certain devices for patients with single-sided deafness, or who have deafness in one ear and normal or near normal hearing in the other ear. In the past we've had some limited options for those patients to help them hear better, but now those have been approved and the research is really promising for those patients. I think it's going to be a really good thing. It's just more patients that we can help.

Host Amber Smith: Dr. Bagley, thank you so much for taking time to tell us about cochlear implants.

Erin Bagley, AuD: Oh, you're welcome. Thank you for having me.

Host Amber Smith: And I want to point out that a transcript of this interview is available on our website at upstate.edu/informed.

My guest has been Upstate audiologist Erin Bagley. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.