This summer, Hearing Review interviewed Dr Ingeborg Hochmair, worldwide CEO and founder of cochlear implant-maker MED-EL, Innsbruck, Austria. Joining the conversation was Dick Collette, president and CEO of MED-EL USA, based in Durham, NC. Hochmair and Collette discussed the latest trends in cochlear implants, as well what might be on the horizon.
HR: Tell our readers about the latest cochlear implant trends that you’re seeing today. Smaller? More discreet, attractive?
Hochmair: One of the things we’re focusing on is longer battery life. So, we have just introduced a smaller audio processor that runs on two batteries instead of three batteries without compromising battery life. That was something that was made possible through what’s called the D-Coil, which is a more efficient coil for the transcutaneous link through the skin. That processor, the Opus 2XS, is now the smallest, lightest, and thinnest processor in the cochlear implant industry.
Collette: In terms of trends, although we’re keeping up with the hearing aid trends in trying to go smaller, lighter, and more power efficient; from a cochlear implant perspective, the major trend is to minimize trauma to the cochlea when you introduce the electrode of the cochlear implant, so that you preserve the residual structure and capability. As we speak today, we’re in the middle of clinical trials for a new technology, called electric acoustic stimulation (EAS), which is a combination of a cochlear implant for the high frequencies, and an acoustic amplification hearing aid, which is specialized for lower frequencies. EAS is an investigational device in the United States, but the combination, based on the European experience, may improve speech understanding in noise, the quality of the sound, music appreciation, and the ability to pick up different musical instruments, because you’re getting signals from both low frequency acoustic cues, as well as high frequency through the implant. The whole field of minimum trauma with cochlear implants is an emerging area.
We’re just coming back from the big CI2012 conference in Baltimore, and I’d say that 50% of all the papers that were presented addressed atraumatic cochlear implants and hearing preservation. It’s all of a sudden exploded on the mainstream of cochlear implants. I’ve been to six of these conferences 6 years in a row, and I was amazed by how many scientific papers were on hearing preservation and atraumatic cochlear implants. MED-EL was actually the pioneer in this area.
HR: Can you explain that further?
Hochmair: There are two topics, really. One is that some surgeons, or more of them, are able to preserve residual hearing in traditional implant users, such that the patient, even with long electrodes, can hear their alarm clocks still after surgery, and even more than that. There’s also EAS that’s being researched in the United States and has been approved in Europe for quite some time, which potentially could expand the indication to people with more low frequency hearing, and adds the hearing aid component in the same ear.
So, between those two groups, we have a lot of patients who have preserved hearing in the cochlear implant field, as more and more surgeons are able to preserve the hearing through the use of very soft and flexible electrodes that are designed to be atraumatic, or cause as little trauma as possible during insertion into the cochlea. It’s important to preserve as many of the delicate structures inside the inner ear as possible. Because who knows about children who now get an implant at about the age of 1 year? Today, they have a life expectancy of maybe 80 or 90, or 100. Nobody knows what future technologies might come up to help them. So you want to not generate an obstacle to use these future abilities for those children. So, our goal is to preserve these structures of the inner ear to the highest extent possible.
HR: And that’s one of the features of the FLEX electrodes—your latest product approved here in the United States, correct?
Collette: Yes, we’ve just received FDA approval on our new FLEX electrodes, which are the most atraumatic electrodes on the market today. They’re specifically designed to minimize trauma to the cochlea when you do an electrode insertion.
HR: Tell us about your perspective on the relationship between audiologists and ENTs today, and bringing more awareness about the CIs and the benefits.
Hochmair: The vast majority of children born deaf or with considerable hearing loss do get a cochlear implant today. The growth in the cochlear implant industry is mostly with older adults. So we are trying to increase awareness, irrespective of any relationship with the audiologists and the ENTs, so that hearing aid dispensers are really trying to inform the public about hearing implants by the Internet and by other means. I think by having cochlear devices perform better and better, it automatically happens that their benefits are getting more and more known to any possible candidates. And there are in fact so many people who should wear a hearing aid and don’t wear a hearing aid for whatever reason, who we should inform and who we are trying to inform about the existence of this technology.
HR: How is MED-EL addressing hearing better quality of music through cochlear implants?
Hochmair: We have a coding strategy called “Fine Structure Processing.” We’re continuing to work on further improvements for the fine structure coding of the sound signal. It’s coding of the fine structure element of the sound signal that helps with music.
Collette: Also, we should note that Fine Structure Processing is not approved for pre-lingual children in the United States.
HR: Do you see a time in the future when music will sound the same?
Hochmair: There’s certainly a trend [of improvement]. How far we can get, I’m not sure. But there are two categories of users. Some implant users think that music is not comparable to how it sounded before, but there are also users who enjoy music very much via the cochlear implant. There are a few active musicians who continue being active musicians.
For example, we’ve recently had an implant user who is an active singer and has studied music. It was a very interesting case because she was deaf on only one side due to meningitis, and received a cochlear implant in the deaf ear. She said it changes her impression of sound and also music from “black and white” to perceiving it “in color.” She described an event where she was performing on stage, and then her batteries went dead. Suddenly, she said she was not able to distinguish any musical instruments anymore and couldn’t make use of what she heard from her neighbor singing. With such users, we learn so much about music perception, and it helps us to further improve the speech coding or the sound coding to get better music enjoyment. [Editor’s note: MED-EL later clarified that implantation of unilaterally hearing-impaired patients is currently not FDA approved in the United States for any cochlear implant system. The singer was based in Europe.]
Collette: One other thing I want to point out. It’s common, but you really can’t lump all cochlear implants into one big pile. Short electrodes force the brain to have to remap the electrical impulses because the electrodes are not located where some tones would normally be presented. The cochlea is somewhat set up like a piano keyboard, where the high frequency is at the base and the low frequency is at the apex, and we believe in using the whole cochlea to stretch those tones out. MED-EL has always had as long an electrode as we possibly can, and—this is scientifically proven—a longer electrode maps closer to the natural tonotopic arrangement of the cochlea. So if you were to rank the fundamental core technologies, regardless of the electronics, a longer electrode is going to be more able to match what you remember because your brain doesn’t have to remap the natural tonotopic orientation of the cochlea. So, not all CIs are alike when it comes to music appreciation.
HR: What about telecommunication technologies these days? How are they being integrated with cochlear implants?
Hochmair: It’s really the front end processing of hearing aids that’s entering the cochlear implants, as well as telecommunications as far as it concerns connectivity to other devices that you want to connect to. So that’s having more and more influence in our field. That’s true for the cochlear implants, as well as other hearing implants. But in addition, for example, implementing rehab material on mobile platforms will be a big advantage for our field. We’ve developed a lot of rehab material in many different languages.
HR: Tell us more about these materials.
Collette: If you look at the high end digital hearing aids and their front end digital signal processing, and then if you look at your mobile phone in terms of all of the apps and interconnectivity, it just makes intuitive sense that those two are going to merge. Cochlear implants are going to leverage that. What we see in the very short term is that you will soon be able to put rehabilitation and training materials on a smart phone. So, with wireless technologies, you can imagine someone going through practice drills—sound practice drills, music practice drills. All that could work with a wireless connection between your cochlear implant and an app that might be on a laptop, mobile phone, or iPad. In fact, I just saw an iPad that had a piano keyboard that you can make sound like you were playing the piano. If you can do that, then certainly, with wireless connectivity, you could get it to where you’re hearing and playing. So that’s where the future’s going to be. It’s going to take a while to get there, but you can see those are all going to come together.
HR: What is the durability of cochlear implants these days? How long do they last and have to be replaced with another procedure?
Collette: The implant itself is warrantied for 10 years. A lot of implantable medical devices use 10 years as a benchmark. We think that they’re going to go longer than that, but you don’t really know because the human body is such a hostile environment for an electronic system. The externals are getting better and better, so they have been warrantied for 3 years. MED-EL just announced a 5-year warranty on external equipment, which is the longest in the industry. Generally, most American insurance companies will pay to have the externals replaced at 5 years and the implantable portion replaced after 10 years.
HR: What about back compatibility?
Hochmair: We have 15 years of legacy support. In 1994, we had the first MED-EL implanted, and you will see those same patients today with newer and the latest sound processors.
HR: How else will cochlear implants change over the next 5 years?
Hochmair: I think they’ll get more and more ergonomic. The ergonomics concern the end users of the device, as well as everybody who works with them: the audiologists, the surgeons, and so on. So, we focus on the workflow and the process in every aspect. The procedures also have to become more teachable. It should be easier to teach new people entering the field on the surgical procedures, on the fitting procedures, the diagnostic procedures, and the therapy procedures. We also have to make it easier for the users to use these devices and have a longer battery life, improving the way they get refitted, perhaps via remote fitting. That is also a new trend. So, in the next 5 years, everything should become easier to use, and also smaller and more power efficient. —TV