Devices improve hearing differently than hearing aids

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.

Electronic hearing devices called cochlear implants can help people with hearing loss improve the ability to understand speech and hear more sounds. Here to tell us about cochlear implants is Upstate audiologist Jeffrey VanTassel. He's part of Upstate's otolaryngology ambulatory care.

Welcome to "The Informed Patient," Mr. VanTassel.

Jeffrey VanTassel: Thank you, Amber. It's good to be here.

Host Amber Smith: Can you start by describing what a cochlear implant is and how it works?

Jeffrey VanTassel: Sure. In the simplest terms, a cochlear implant is an electronic hearing device that works by directly stimulating the nerve in the ear. It takes in sound. There are electrodes implanted deep inside the ear that are adjacent to nerve tissue, and they work by simply, for lack of a better term, zapping our nerve to get us to hear.

Host Amber Smith: So how does it differ from a hearing aid, or do hearing aids do the same thing?

Jeffrey VanTassel: No, hearing aids work in a little bit different manner.

A hearing aid uses what we would consider more of a conventional amplification method. They take in sound, they have an amplifier, much like you'd have in your stereo or in your television, and it takes the sound around you and turns it up to a level that would then be audible for the patient. It then outputs that sound through a speaker, so there's actually a sound coming out of the device.

That differs from a cochlear implant in that the cochlear implant takes the sound in, and it modifies the sound, but there's no speaker, there's no sound that's generated from the device. It generates a pattern of nerve impulses that are perceived as sound by the patient.

Host Amber Smith: So who might need a cochlear implant or benefit from a cochlear implant? Who would be eligible?

Jeffrey VanTassel: Right now, eligibility -- it's usually reserved for people who have very progressed hearing losses.

These are hearing losses that were either very aggressive over a short period of time or may have been systematically changing over long periods of time. And also people who don't derive a substantial level of benefit from their hearing aids. Really, this is a technology that slots in sort of after the patient has had experience with hearing aids, and either has such an extensive amount of hearing loss that hearing aids can no longer provide good listening for them or have had such substantial damage to their system that hearing aids again are not going to be adequate for their communication needs.

Host Amber Smith: Do the implants go in both ears?

Jeffrey VanTassel: Right now, that is actually up to the wishes of the patient and the surgeon. At this time, most insurance companies will certainly support bilateral devices. We will often have that conversation because we do know through a lot of research that listening through both ears provides benefits above and beyond just listening through one ear.

So we will often talk to the patients about their wishes. Do they want to try to use two, or oftentimes, which is more typical, they will try one to see what their level of benefit is. And if they're doing well with it, oftentimes they will then opt to have the second one done.

Host Amber Smith: So insurance will cover this.

Jeffrey VanTassel: Generally, there haven't really been any insurances that have balked at this time. It's been an evolution. I've been doing this at Upstate for, this is my 20th year. I've been an audiologist for 28 years, and when I first started, insurance support for cochlear implants was really sort of a giant gray area. There were some that would. There was some that weren't convinced that it was a beneficial technology.

But as the technology has improved, certainly more and more insurance companies have come on board. And I, in probably in the last five years, I have not noticed any insurance company that would deny support as long as the patient is considered a candidate for the device.

Host Amber Smith: So that includes Medicare, too.

Jeffrey VanTassel: Indeed, Medicare and Medicaid are definitely on board with this.

Host Amber Smith: Now, how long do cochlear implants last? Are they meant to be permanent?

Jeffrey VanTassel: They are. When we talk about the cochlear implants, we have to differentiate between sort of two segments of the device. There is an internally implanted electrode, and then there are external processors that are used to take in the sound and generate the code.

The internal implant -- that is designed to be a permanent implantation. Most of the time, with rare exception, these will last pretty close to a lifetime. Most of the time, the companies will say, "We'll give you a 10-year warranty on this," or what have you. But my experience, honestly, I've been in care of, getting close to 100 cochlear implant patients in my career here, and we've only had to replace two implants out of those.

So they do last a long time. Our impression is that once we implant it, there's going to be a very rare occasion that we'll actually have to go in and replace it.

Host Amber Smith: So you talked about the two pieces, the implanted part and the external part. Are there batteries in the external part?

Jeffrey VanTassel: Actually, the interesting thing that I tend to convey to my patients is that the external part of the device is much like caring for a hearing aid. It's a part that will hook over your ear or attach behind your ear to send the code into the internal array, but it looks a lot like a hearing aid.

It does have batteries. Now, most of the modern devices have rechargeable batteries, which has been quite a benefit to the patients, so they will get a few batteries when the device is initially programmed, and those batteries can last three to four years before they run out of applicable power. So they just recharge them each night, and every day they'll have a nice, fresh, strong battery to be able to use.

Host Amber Smith: Well, I know with hearing aids, you're not supposed to go swimming with them.

Is that the same with cochlear implants?

Jeffrey VanTassel: I'm going to qualify that answer. Usually we say no. A lot of the treatment of the cochlear implant, as far as how it is exposed to moisture, will be similar to that with a hearing aid. Most of the new devices, they're not specifically waterproof, but they are splashproof, so if you get a little rain on them or what have you, those are good.

But there are a couple waterproof devices that are available from a couple of the manufacturers, and the other manufacturers do have sort of an aftermarket system. It's much like, I call it "Tupperware for your cochlear implant." You can actually insert the implant into a rubber sleeve that will reject the water and it keeps the device sealed, so they will be able to swim with them on, yes.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast, with your host, Amber Smith.

I'm talking with Upstate audiologist Jeffrey VanTassel about cochlear implants.

So what happens to a person's natural hearing ability when the cochlear implants are implanted?

Jeffrey VanTassel: Unfortunately, this is the part that we have to have the real frank conversation with the patients about, because when we implant the electrodes into the ear, a lot of their remaining hearing, unfortunately, does not survive the process. So we have to be very frank with them about the fact that when we go through this process, if, in the rare event that there is some issue that happens, we can't go backwards. Using a hearing aid in an ear that has a cochlear implant in it just will not be effective after the surgery, unfortunately.

Host Amber Smith: So how do you help a patient decide if it's worth trying, if a cochlear implant is good for them, or what do they have to think about?

Jeffrey VanTassel: Well, one of the things we do, we have some very extensive testing that we have to do, first of all, just to be able to demonstrate to the doctors and the insurance companies that this patient is a candidate for the device and would benefit from the device.

Usually it's the results of that type of testing that can really give a good picture to the patient as to where exactly they are in terms of their function, their communication abilities and what type of benefit they may get. We look at the type of benefit they're getting with the hearing aids, and we can contrast that to what we would expect that we can get with a cochlear implant to try to sort of paint a picture for them to see if that step is worth taking.

Host Amber Smith: So if they go with the cochlear implant, if they went to a music concert, for instance, or even just watching TV at home, would that sound different than they were used to hearing it before the cochlear implant?

Jeffrey VanTassel: Generally speaking, it will. There's really two reasons for that.

One reason is, as I talked about earlier, the method that we use to apply the sound to the patient is now sort of an electronic stimulation rather than creating a sound wave, and that comes with some side effects. Now over time, those tend to diminish. At the outset, people will tell me, "Oh, your voice sounds robotic," or "Sounds like a cartoon character" or things like that. But as time goes on, that actually will settle into a more natural type of sound quality. The other thing is that with the cochlear implant, we're able to provide awareness to sounds that the patient had not been typically hearing with their hearing aid. So the quality of sound changes dramatically.

Now, whether or not they can comfortably hear on the television, I usually tell my patients there's a lot of factors that go into that, but if we can get them good, comfortable hearing when they're talking to their friends and family, usually they can hear the television well. But that then depends upon what station they're on, what program they're on, et cetera.

Music, however, that's another can of worms because of the diverse nature of music and how music is performed, how it's generated and things like that. We can't always guarantee that they'll get great perception of music. Most patients will say, "I can listen to music. I understand it. It sounds a little different because the pitches are kind of presented to me in a different way," but most of them understand that music is sort of a secondary benefit of the device, and oftentimes it'll accept a little bit of shifting in that regard.

They still enjoy it, but they will say it's certainly different.

Host Amber Smith: So once somebody decides that they do want to go forward, how do you advise them to prepare for the procedure?

Jeffrey VanTassel: The procedure itself, I usually give them sort of an overview of what the procedure is. The procedure, it's pretty straightforward, but really, as far as preparing for the entire event, it's much like any other surgery.

They'll have to understand they're going to go o into the hospital, they'll have anesthesia. Now, under most normal circumstances, this is an outpatient procedure. They'll go home the same day as long as there aren't any substantial side effects.

But the one thing that's very important that they understand is that when we do the surgery, they're unable to hear in that ear. We have to let the surgical site heal. There's a lot of swelling, there's stitches, and we have to let the scar tissue form on that side because we have to place a device right where the surgical site is, and we can't do that right away for fear of irritating the site and causing a lot of healing problems.

So there's typically a four-week delay between the time they go through surgery and the time we're able to activate their implant. And they have to understand that in that four-week period, they will not have hearing in that one ear, or, in a more dramatic case, if they have bilateral implantation, they won't be able to hear out of either ear for that four weeks.

So they need to prepare to be able to have some sort of alternative communication available, or a method to communicate with people for that short term before we get them activated.

Host Amber Smith: Do you have people who want to do both ears, but will space it out sothat they don't lose hearing for four weeks, essentially?

Jeffrey VanTassel: I do. That's a very big consideration for a lot of patients, is they don't want to feel like they've become disconnected from their environment for that period of time. So oftentimes they know that it is a feasible option to do one, and then within a period of time do the second one.

And they oftentimes feel more comfortable, yes, saying, "I'll do the one, but then I can use a hearing aid in my other ear, which will allow me to have that connection to my environment, to my friends, to my family, so I won't feel that's such a great loss for that month while I'm healing from the surgery."

Host Amber Smith: So after that month, is it a second procedure to have the external part put on, or how does that go?

Jeffrey VanTassel: It's not a procedure per se, it's more like fitting a hearing aid. They would come into my office, I give them a thorough overview of what all the components are, how they work, and how the patient will operate them on a day-to-day basis.

We then show them how to place the device. The device is very simple. Like I said, it looks like a hearing aid. It's magnetic, so you place it on your ear, and there's a magnet that sticks over the implant that we put under the skin, and then it's just a matter of pursuing programming to start to get them to hear well. So, there are no other very in-depth medical procedures that are required.

It's more of just teaching them how to use the device, and then teaching them how to hear again.

Host Amber Smith: So I've seen dramatic videos of babies that are born unable to hear. And when they get the cochlear implant, it opens a new world for them, essentially. But these are generally people who are older and have been able to hear ...

Jeffrey VanTassel: Uh-huh. Right.

Host Amber Smith: ... it's probably not as dramatic, or does it sound different enough that they are surprised?

Jeffrey VanTassel: It can be.

And I'll say one thing. Those videos on YouTube are great because you see children that smile and giggle and stuff, but that's not always the case. That's sort of our little behind-the-scenes secret.

Most of the time, a child that hasn't heard before is absolutely petrified of sound that they don't understand. So oftentimes, because I do work with pediatrics and I do work with older patients, oftentimes when we activate a child, they cry for quite a period of time before they start to settle in and understand that all of a sudden they're hearing sound around them.

But that, I tell the parents, that's a very positive thing because I've changed their perceptual scheme. Now they understand that there's something else here that they have to work with.

Now, with older patients, they have a history of hearing that they can fall back on, so they can immediately start to listen and make comparisons to what they think it should sound like and things like that.

So the reactions can span a sort of a wide range. There are certainly patients that will come in thinking that when I activate the device, everything's going to fly right back to really good. And they don't on day one. It's just the reality of the situation. It takes practice and training to really get your hearing back.

So they'll sort of be a little skeptical, but there are number of other patients that even on Day One, are just like, "I can see where this is going, and I'm already extremely excited," so, it's very rewarding regardless of what the reaction is because I know that I've taken them a big step forward in their hearing health.

Host Amber Smith: Now, do they stay in contact with you if they have questions or issues that come up after the cochlear implant's done?

Jeffrey VanTassel: Absolutely. I provide long-term care for all my patients. Part of the cycle, especially when we're trying to get them to be able to hear, is I will see them almost on a monthly basis or every few weeks to really start, (and) keep, fine-tuning the device as they start to get used to it and to provide them with good sound.

But even when they're sort of settled in, I typically see my patients every six months to a year, almost like our eye care, just to make sure that they're doing well, that there's not any outstanding issues, and that their equipment is functioning well and doesn't need any sort of mechanical attention.

So yeah, I keep in very close contact with my patients.

Host Amber Smith: Well, I appreciate you making time for this interview, Mr. VanTassel.

Jeffrey VanTassel: Certainly. It's been my pleasure.

Host Amber Smith: My guest has been Jeffrey VanTassel. He's an audiologist at Upstate.

"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.

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