Cochlear Implant Surgery Can Open a World of Hearing

Here’s how we’re working to get this under-used service to more people

The snail-like cochlea of the inner ear is where I’ve spent much of my career. It’s what allows us all to hear -- important to me as a surgeon who works on the nerves that connect the ear and the brain. But for some people, the cochlea is damaged, whether from genetic or environmental causes. Its crucial nerve endings called hair cells don’t function, causing severe hearing loss.

However, over the course of my career, I’ve performed nearly 1,500 surgeries to remedy this problem, implanting a life-changing electronic device that assumes the basic function of a cochlea called a cochlear implant. Even since I assumed my new role as CEO of our health system, I still vividly recall nearly every procedure, including the last one I did. Every surgery is a bit of a journey in miniature. You navigate around the facial nerve in the skull base in a tiny 2- to 3-millimeter window and find what’s called the round window of the middle ear, which is about the size of a needle tip. You then drill into it with a tiny device less than a millimeter around and snake the cochlear implant to ride all the way around the cochlea. All surgeries are technical, but this is technical taken to extremes. And you’ve got to do it just perfectly. When you’re done, the patient is left with a sophisticated system that delivers sound to the inner ear in a different way, bypassing the damaged hair cells to deliver rich auditory impulses directly to the auditory nerve.

But all this technique and precision is, of course, in service of the larger goal – helping our patients restore their hearing. In the last two decades, hundreds upon hundreds of both adults and children have received life-changing cochlear implants here, and our program has now grown to be one of the largest in the country. One of the most gratifying things for me as a clinician has been following my cochlear implant patients’ progress over time. I’ve watched the kids I implanted as babies grow up, with one even becoming a nurse on our staff. And after every successful procedure, I’ve made the short, happy walk to the waiting room to talk to the family: “Your loved one woke up. It’s working.”? It’s brought me such joy that it’s almost immeasurable.

A patient I’ll call Rachel is a great example of how a cochlear implant can be transformational. She came from a family where members developed hearing loss in their early to mid-adulthood, and she followed a similar pattern – developing severe hearing loss in her 40s. Communicating on the job became increasingly difficult, which caused no small amount of stress for her. “I don't think I ever made an error relative to my hearing loss, but it upped the amount of work, and it definitely upped the amount of stress,” she told me. Rachel researched for options almost a year and attended our cochlear implant support group in order to get her questions answered by those who knew best – those with an implant. Her main concern was that a cochlear implant would eliminate any residual hearing she had left in the treated ear – not an unwarranted worry. But in 2015, she decided to go ahead with it. Recently, she conveyed to me, “I would be sunk without it. It's a pretty remarkable thing. I wish more people knew about it.”

And that, in a nutshell, is the problem we’re facing. A cochlear implant can be an almost miraculous medical intervention for so many, but too few are receiving them. We at UH estimate that the worldwide “penetration” of cochlear implants is only 6% -- meaning that of all those who could benefit, only 6% get one.

Why the disconnect? Misunderstanding about who qualifies for a cochlear implant and what’s involved in the surgery plays a big part. Many people still think of a cochlear implant as a niche treatment for a child born deaf in both ears. Few know, in fact, that it can be a solution for adults whose hearing aids are no longer helping or those with only deafness in one ear. And even fewer know that the surgery can be done on an outpatient basis, often in two hours or less.

But here at UH, we’re working every day to get this life-altering technology to more people who need it.

For example, our team is pioneering cochlear implantation using just local anesthesia and mild sedation for older adults who might otherwise be excluded from the procedure -- the only center in our region to do so. This helps us get cochlear implant technology to the growing number of older adults struggling with hearing loss and deafness. Very often, these people who could most benefit from cochlear implants have other medical conditions that make general anesthesia a greater risk. It’s also important to note that cochlear implants are typically covered by Medicare, as well as Medicaid and most private insurance.

We’ve also been involved in pivotal clinical trials that have established an expanded “new normal” about who qualifies for a cochlear implant.

Our research has shown that cochlear implants are?also?highly effective?for patients with residual hearing?(the amount of hearing one has left after experiencing hearing loss) and single-sided deafness. For example, our team at UH reports that an individual with 60% speech understanding?can potentially improve to 90% or higher with cochlear implantation?and audiology training. Patients with single-sided deafness can also benefit.?Research shows that patients?with single-sided hearing?can experience?superior outcomes with cochlear implants compared to hearing aids, as it allows for hearing better in noisy environments and determining where sounds come from – what’s called sound localization.

Other clinical trials?here continue to focus on the potential benefits of cochlear implants?in patients with varying levels of residual hearing.?Our team has shown that if we implant patients with residual hearing and we preserve that hearing, we can improve their speech understanding by 20 percentile points – a huge amount. Knowing this, we’re exploring whether using a specific investigational implant that sends a steroid called dexamethasone inside the cochlea can prevent inflammation and scarring and preserve residual hearing. Another trial is looking at whether an FDA-approved electrode array that gets closer to the neurons in the cochlea can improve outcomes. The closer you are to the neurons, the greater the speech understanding. With this particular electrode, we at UH have been able to demonstrate that that preservation is consistently possible – with better speech understanding and better residual hearing.

Outside the operating room, we’re also tireless in reaching out to professionals in many disciplines who might encounter people struggling with hearing loss. This includes our fellow ENT physicians around the state, private audiologists and the whole community of folks who dispense hearing aids to people. Our team has also created a Center of Excellence in Cochlear Implants that seeks to be as efficient as possible to provide this technology to patients with the least amount of medical/audiologic visits as possible, while maintaining excellent outcomes and disrupt the least possible the life of implantees. Our message is one of collaboration – appropriate given that it takes a multidisciplinary team of surgeons, audiologists, nurses, speech-language pathologists and so many others to get to a good outcome for a cochlear implant patient. It’s partnership in service of the patient.

I have a book under my desk at UH of cards and letters my patients have sent over the years, many of whom have received cochlear implants. It’s probably my most cherished possession – more important to me than any plaque or award. While people write to say “thank you,” I’m most excited to hear about how their life has improved.

Take a patient I’ll call Barb. She was my first cochlear implant case when I arrived at UH from Boston in 2002 – I still remember seeing her on my first day of clinic. She was a wonderful lady. But she – like all the adults in her family -- had a genetic condition that caused deafness past age 35. And like so many others with hearing loss, it was shrinking her world. She was not coming out of the house. She was retreating.

A few months and two cochlear implant surgeries later, she blossomed into the most amazing woman – full of life, full of joy and able to be present for her family. She sends me an email each year on the anniversary of her surgery, thanking University Hospitals for giving her life back. I just received my 23rd such email. What could be better than that?

One of my greatest hopes is that stories like Barb’s and Rachel’s and so many others will multiply as we continue to spread the word about cochlear implants.

If there’s anything I’ve learned from my patients over the years, it’s that communication is connection. We’re fortunate to have amazing technology to help make it happen.