well I've been told we're running an hour behind so I will rapidly talk about hearing loss and I'm so glad to meet all of you. Um As dr Griffith said I just recently joined P. And I I'm bringing a whole new service line into the providence health care system. So as the third largest healthcare system in the United States there was no neuro oncologist for all of southern California. So I'm trying to basically um bring a service line that can help break the backlog at the university Centers in lateral skull based surgery and cochlear implantation. So we had our first two cochlear implants on monday of this week and we have three more coming up in about 25 patients on the list. So we are often going so let's talk about the management of severe to profound hearing loss. Hearing aids and cochlear implantation. I have nothing related to disclosures regarding this talk. So as we all know in this room, hearing loss is very prevalent in our society. About 30% of adults over the age of 50 suffer from hearing loss, 55% of adults greater than 80. The prevalence doubles every decade of life and it's a third leading chronic health condition Among aging adults. 50 580 million people worldwide are estimated to have hearing loss. I always love this slide because we're doing a little bit better than our historical predecessors have. These are some really creative ways to help with hearing loss but we we hopefully can bring things a little bit more cosmetic these days. So we're doing a terrible job treating hearing loss. Um if you can believe it, only 15% of people who need a hearing aid actually use one in our society. And this is a terrible statistic. Every time I speak about it, it always shocks me. Only about 8% of adults who could benefit from a cochlear implant actually get one. And we really have not moved the needle on this for um the last decade. And so this is part of our mission at P and I is to really make this technology easily accessible in the community. And we recruited Becky Lewis who will be giving a talk. She's a very talented cochlear implant audiologists. We're trying to reduce the backlogs. Um at the academic centers. This is really a technology that needs to move out into the community hospitals. And that's our big push here in Los Angeles. This is another horrible statistic. There is a 7-10 year delay in treatment after the person or family member identifies that there's some hearing loss going on. Becky Lewis is going to talk more about hearing health and brain health. But hearing loss is associated with a wide range of brain health conditions, depression, anxiety, paranoia, insecurity, reduced social activity, social isolation, the ability to produce at work the loss of independence balance impairment and the risk of fall cognitive decline and dementia. This is a huge one that Becky is going to touch on later cardiovascular disease, diabetes and mortality has even been linked with hearing loss. So there's a huge impact on not only the ears but on brain health itself. Um there there is a five times higher association of Alzheimer's disease. There is 32% more likely to be hospitalized. If you have hearing loss 43% of people with hearing loss have kidney disease. There's a three-fold increased risk of falling and depression is very prevalent in folks with hearing loss. So can hearing improvement be improved, can hearing improvement, improve brain health. So, although there's a link can treating hearing loss actually improve brain health and the answer is yes, and Becky's going to talk about that further. So what did we used to do? Um we we used to recommend an audio graham and hearing aids really, whenever the patient complained, so the patient came in complaining. Okay, let's get a hearing test, let's see what's going on. But now we're actually changing the paradigm because we know hearing loss has such an impact on brain health. I have changed my own practice, so I'm starting to implement as dr Griffiths was saying um audio graham screening, you know, usually in the sixties 65 but you know, in the primary care setting, as dr Griffiths have mentioned, we really should be routinely screening for hearing loss and being very aggressive about treating hearing loss early. Um we can treat hearing loss depending on the severity, so mild to moderate hearing loss in general can be treated with the hearing aid but if a patient is struggling with the hearing aid we can't give up. So that patient needs to then be referred on to a place where they can be screened for cochlear implantation. So what are some signs and symptoms other than just the audio gram of mild to moderate loss. So the patient or family member may be complaining that they are now starting to have the inability to hear certain sounds in the environment. Um unable to understand the clarity of speech and really complaining of hearing in background noise. The hearing aids. Um as we all may know just amplify natural auditory pathways. So it uses the entire natural auditory pathway. Now moving into severe to profound loss. What are some of those complaints I can't hear, I can hear but I can't understand. Even in quiet environments. And now even with my hearing aids I hate my hearing aids. They come in they have six pairs of hearing aids in the drawer. Um The family members are saying you know Aunt Sally just won't wear hearing aids. Everybody's frustrated. This is a big sign that they may be a cochlear implant candidate difficult, communicating one on one even within a quiet environment. They're avoiding the phone, they can't understand even with their hearing aids on using the telephone. That's a great screening question in your um offices. They're avoiding social activities are starting to socially isolate and they're really depending on visual cues to understand speech. We've had a huge influx in our practice together with masks going on. This is bringing people out of the woods because they're really not um not realizing how much they've been focusing on patients, lips are people's lips to understand. So what is a cochlear implant? So a cochlear implant provides a new pathway for hearing. It basically um bypasses the damaged hair cells of the cochlea and provides electrical stimulation of the auditory nerve electrodes, replace the function of the hair cells. So this is a surgical procedure where we put the electrodes into the cochlea itself. So very briefly I'm just gonna cover who would be a cochlear implant candidate. Um what is the evaluation process? What does the process look like pre imposed surgery and what kind of outcomes can be expected? So one thing I love about my particular specialty is I get to take care of all ages and I can take care of cradle to grave and the youngest cochlear implant I did was in a three month old baby with meningitis. And the oldest patient that I did a cochlear implant Was 102. There's no age cut off. Um as you all know, you can have a spry 102 year old and you can have a very sick, 40 year old. So really looking at the patient and seeing how they're going to tolerate a cochlear implant right now, the FDA just dropped the limit from one year of cochlear implantation for on label use down to nine months. And that that gets lower and lower every few years as we push the envelope for FDA criteria. This is what a cochlear implant system looks like. It has the external processor that a person wears like a hearing aid. And this is the internal device here with the electrode that goes into the cochlear. This is a closer look at what the internal device looks like and the electrode. There are three cochlear implant companies, advanced bionics, which is right here in santa Clarita. You can actually go see a cochlear implant being made. They're handmade. Um and you can see through the glass and what's really neat is a patient can actually meet the person who made their cochlear implant. So they link um I think that's really neat. So I used to take the residents up there to um see how cochlear implants are being made. Cochlear Americas whose is hosting here at our meeting. Make sure to stop by their booth. They are based in Australia but they're american headquarters isn't here in Denver colorado and Medal, which is a european company. This is what the electrode looks like. That goes into the cochlea. They used to be very thick and now we're getting thinner and thinner electrode profiles which really helps us um preserve natural hearing and has been able to open up the criteria for folks that have a normal low frequency hearing loss but really terrible high frequency hearing loss and that's where they really fail using hearing aids. We now can implant those patients due to these narrow profiles of the new electrodes. It isn't a huge bulky thing that you wear on this on the side of your head. A lot of patients are scared about that. If you can believe it now they even just have little discs that fit under your hair with a matched hair color and nobody even knows that you're wearing one. It takes a team to run a cochlear implant program. Becky Lewis is my partner in crime. Um we work very closely together on each and every patient. Um We have also a network of other professionals that we rely on for specific patient um needs speech pathologists, psychologists, social workers, educational liaisons for our younger Children, researchers and of course family and support system is the most important. We already talked about the FDA criteria and we're really expanding the candidacy. We talked about the residual low frequency patients were out also now doing single sided deafness patients. And this will link into my new talk the FDA. Now approved cochlear implantation for people that have normal hearing on one side and have lost all hearing on the other side. I've now been um one of the first in the country to place cochlear implant during acoustic neuroma removal at the time of surgery it's now becoming a national trend. I've done about eight patients. And by and large they're all doing very well, particularly if tinnitus is a major complaint for those patients. So if you see an audio graham like this, which is basically profound loss across all frequencies on both sides. This is an obvious cochlear implant candidate. Um however as I was mentioning before this is also a potential cochlear implant candidate. They have on the right side, complete pretty normal hearing, a little high frequency loss and on the left side pretty terrible hearing. A severe to profound loss with only 4% word understanding. We talked about cochlear implantation with acoustic neuroma removal and what does the evaluation process look like? Well a patient comes in, they get a baseline audio graham, we do imaging MRI and CT scan. We will do special testing using their hearing aids and using um testing and quiet testing and background noise. That's where Becky Lewis and her sophisticated work up um is very necessary. Different insurance companies require different things. Medicare requires different things. So we have to provide that data to them. I look at their overall health history and then we give them vaccination to prevent meningitis. Now that we've provided vaccines for patients or meningitis rates have almost become negligible. And let's just speed along. So the surgery is about 1 to 2 hours. It's usually done in an outpatient setting. Unless the patient is very elderly or sick then I'll keep them overnight. But that's very rare. I usually can do this at R. A. S. C. Um It's a very small incision behind the ear. I make a little pocket under the temporal eschewing muscle. I place the internal device there. I drill bone behind the ear, the master Lloyd bone. I approach the cochlear to make a small hole in the round window and thread the electrode. And so everything up We generally activate the um implant at around 2-3 weeks. Although we're really starting to push the envelope on that Becky. And I were just talking last week that in our patients that live very far away we may even be considering doing same day or next day activations for these folks just to get a baseline map and then perhaps working with local audiologists that want to learn this technique. Um And we may even start implementing virtual mapping which basically we send the patient chords that they can hook up to their computer away to download a program on their computer. Um There are even programs we can virtually go into their computer with our elderly population. We may need to download the programs for them and then um we can actually do some of the programming um at their home. So these are all things that we're investigating to really push the frontiers to offer better service for folks and um have a greater catchment area for our new cochlear implant center here in southern California. Um all of the devices now RMR I compatible. This means the patient can go in the machine safely. However with that magnet in place there's still scatter artifact. So I personally always get a baseline M. R. I. Especially on my older folks because that's the only time we're going to get a clear picture of the brain um before I put that magnet in. But it is safe now with all the the each company is safe to go in the M. R. I. Um if you've ever been, if you if you know, I don't know if we can offer you to come in and see an activation with one of your patients. It's very moving. I don't know if you've seen with um sort of the kids on Youtube when they've never heard before, but actually in our older population, if they've been isolated for a long time, it's a very similar moving experience promised myself, I'm never gonna cry and I usually always cry when I'm in there. Um and it's it really does change people's lives the sound quality. You know, the brain is an amazing organ. The sound quality really does change with neural plasticity. So the first activation and Becky can talk more about the specifics of this sounds like helium or mickey mouse or robotic and with lots of rehab using speech rehab. Usually I recommend um there are lots of programs but really if you just get a book, get audible, read the book. Have audible hour after hour, after hour talk talk talk to your family And loved ones that you recognize your voice. You know what their voice sounds like over months. Um you know 3-6 months their brain will slowly acclimate and the neural plasticity will take over. So um treating hearing loss improves relationships, improves confidence, improves mental health improves independence, improves energy level, improves employment opportunity. There's just not a lot of downside. Who does the best with cochlear implants. So the age of onset of deafness is very important. The age of the time of implantation. Hearing loss, duration, residual hearing um the cause of the hearing loss, other health issues and really setting those expectations for patients. Um Just in the To be considerate of our time and I'm sure everybody is very hungry. Um so basically my main message is let's get our patients connected in one way or the other hearing AIDS if they're not doing well. We'd love to see your patients and then for a little plug here we're having a walk for hearing June five P and I has a team, we're bringing our our friends and family really to just raise awareness of hearing loss in our society. So if you'd like to be a part you can join our P. And I team and be there for hearing loss. Are there any questions about cochlear implants or hearing loss? Yes you said yeah boy. What what does the patient that I could hear? I mean normally before lost their hearing and now they hear a human voice again. Beck you wanna you wanna grab that? This is Becky's every every day all day long. This is true. I'm the audiologist that works with the very talented Courtney Volker. Um So for patients that have lost their hearing we really counsel them heavily before they get their cochlear implant that it does take time, patience and practice. So the first day it's that patients might hear static beeps, they might hear squeaky sort of quality of speech or they might actually hear really well. So there's the whole gamut of situations that can occur. And a lot of the the risks are the factors that dr Volker discussed before implantation um kind of play a role here. So patients are really good candidates. Usually they do a little bit better right out of the gate than patients who have been deprived auditory stimulation for a long period of time. So I don't know if that answers your question but typically patients don't hear like they did before. We can't say that right out of the gate they're gonna hear and understand words. But if we give them the right tools usually optimal outcomes are achieved by three months post implantation and they can even get better Even at six months post um and with more practice they can continue to improve. But usually we can tell them by three months we can see significant gains agreed liberating is a visual access. Visual cues are always important. And even, you know, in noisy environments they're still going to struggle a little bit. And that's why these manufacturers have come out with other technology that come with the cochlear implant to help in these noisier places too. Dr. Volker We also have one virtual question for you. I can read that one off, it says do you have resources for cheap hearing aids for patients, any organization sites etcetera? So, you know, hearing aids are always a problem regarding the cost. We have a hearing aid recycle program in our clinic and that is really great people turn in their hearing aids when they get a cochlear implant. Also if they've graduated onto another type of hearing aid, we make sure to keep those hearing aids recycle those hearing aids. We also have the venice family clinic that we have made a big push to have a hearing aid program there that are free. Um but you have to have special criteria to be at the venice clinic. Um Anything else Chester that we can offer folks? It's it's tough. You know, there's there's a big push to decrease the cost of hearing aids, but unfortunately it's not one size shoe fits all and it's it will Maybe actually turning people off their hearing AIDS because there is a rehabilitative process of tuning the hearing aid of uh you know the internal dynamics of it. Uh patients come back uh an average of 4-7 times after they buy a hearing aid to meet with the hearing aid audiologist to tune their hearing aids, Make sure the mold fits, make sure it's comfortable where they learn how to use it. Um You know buying them the FDA was approving over the counter hearing aids that people could buy and um maybe that will be good for a mild loss but the more complicated one it will be complicated loss will be more difficult. Um So it's it's um unfortunately it's a it's a it's an evolutionary process and you really have to because it's not your natural sound, you know you're spoiled your whole life with natural sound. Hearing aid only amplifies a narrow band band of sound. Um So it is it is a challenging problem. Um I don't think a cheaper hearing aid, maybe a better uh solution? I think a cheaper hearing aid with support which is a better solution. But we haven't gotten there yet. Is that would you say that Becky? Is that reasonable? That cochlear implants and hearing aids are a medical benefit. So you can find you have to find those hearing aid providers or those audiologists that um except medical but they are a benefit. You know one of the mass, the largest hearing aid dispenser. United States Costco and I'll tell you that it does work for some of the patients but we see more of the patients where it doesn't work. Um They don't really have a good support structure. The ideologists furnished the hearing aids and then they're off on their own and it's not it's it is a process to get a hearing aid actually to fit into work properly. So I don't know what the answer about cheaper and better is they except accessible this government vis a vis no for calculator implants too. So every V. A. Um Some VHS in the United States have a neuropathology contract. Um I am not sure actually Amanda do you know if our are via here but not this one so long beach Loma linda. Um And then there are some V. A. Choice programs where the patient could receive surgery in their own community. No for years all my acoustic neuroma patients have been operated on at house and is our wonderful neurosurgical team now doing them here. Yeah so we um this is one of the reasons I joined this practice is we have an excellent neurosurgery team. Doctor Barca Darien has been my main um colleague on that because you know p. And I has done a really great job with the anterior skull base work but they've really been needing for for decades now. A partner in neuropsychology partner to come in and work on the lateral skull base? Acoustic neuroma says meningioma is of the skull base. I was trained at house and my mentors gave me the go ahead to to make the leap to come join this group and grow that aspect of the program. Yeah. So there's no acoustic neuroma program in southern California for the providence health care system. And that's one of the reasons why I'm here. Yes the answer is yes. Long winded. Yes. For Children born without hearing. Um The the great advantage is that there is a memory, there's no plastic memory of sound and flax and adults. So especially with the asymmetric hearing loss where you have normal hearing on one side the cochlear implants do so patients could do so well. And those patients hate symmetric hearing loss. Really become disabled because it's like having a brick wall that's put on you. They don't they have balance issues, equilibrium issues, um uh social issues with this acute loss of hearing. Uh Really we had no other uh we had baja therapies which is a bone anchoring device. But really the cochlear implant is a great advent for those patients and to prevent a neuro degeneration. Yes I have one more a sudden. So if you have hearing in one ear and you have your cochlear implant. When you wake up from the surgery. Does it distort the hearing. And the good ear once and then the brain then is the brain is able to assimilate the new sound of the cochlear implant to the to the mimetic sound on the opposite side. Wouldn't you agree with that? That they they rehab. Yeah. Three. She agrees. Alright. Yeah I'm standing between you and lunch and very aware of that. We actually have one more virtual question. Go for it. So hold on. Hearing loss dressed up outside. Great question. So for bilateral hearing loss is the implant only on one side. So a lot really sadly um You know this is a good plug for my little patient rio rio I implanted here when he was a baby and he showed up to my office recently looking like that he told me he'd like to be a cochlear implant surgeon. And to my knowledge I don't know in the world if there is a cochlear implant surgeon that has cochlear implants and I said if anyone can do it you can. So for babies that are born deaf um we do usually simultaneous bilateral and sadly we are very far behind in pushing that in the adult population. A lot of insurance companies only allow us to do one side or sequential Medicare. We can you know Medicare is very strict criteria. The three of us are going to um a C. I A which is our american cochlear implant alliance a national conference and just next week in Washington D. C. Where we are really trying to push the federal government to um relax on their terrible criteria. So a lot of times we are limited by the um, insurance companies. Also, patients are very afraid as an adult to, to lose any little even if they're terrible. They have profound loss. Their word understanding is horrible, but it's all there clinging to and they're very afraid so oftentimes I will do one side and they're so happy and then that becomes their better ear and they're, they're like, how quickly can I get the other one done? And then unfortunately we're kind of back to the insurance and some insurance. Let me do the other one. Some say one is good enough. We're very behind on advocating for our our profound loss adults. The Unfortunate reality is Medicare has given to guidelines one in 1979 and the last one was 2003. There's been no update in almost 20 years to the Medicare Guidelines. So, um, um, well, hopefully that will change
Related Presenters
