MedStar Health: Otolaryngology at MedStar Georgetown University Hospital

• Chin lift and neck liposuction

• Michael Hoa, MD (Director)
• H. Jeffrey Kim, MD
• Mary Finkbone, AuD
• Laura Jones, AuD
• Michael Morikawa, AuD
• Melissa Blumgart, AuD

With technical advances in cochlear implant technology, surgery is now available for more qualified patients. The following are the current criteria for adult and child cochlear implant candidates:

Adult criteria

• Moderate to profound sensorineural hearing loss (refers to damage to the inner ear or nerve pathways form the inner ear to the brain)
• Little or no benefit from hearing aids
• No medical contraindications
• Clear understanding of cochlear implantation and end results
• A commitment to the process and follow-up appointments

Pediatric criteria

The Food and Drug Administration (FDA) has approved the use of cochlear implants for children who meet the specified criteria:

• Children at least 9 months of age
• Children with profound (9-24 months) or severe-to-profound hearing loss (2-17 years)
• Children who are healthy enough to have the surgery
• Children whose families are motivated to follow through with auditory verbal rehabilitation therapy and full-time device use
• Younger children:
  • No benefit from well-fitted hearing aids that are worn all of the time, and
  • No progress or change in speech and language development
• Older children:
  • Unable to understand at least 30% of the words with listening-only tests

Patient expectations can be a sensitive and critical issue to address pre-operatively and post-operatively with patients undergoing surgery, family, and friends. Post-operative outcomes for cochlear implant recipients can take many recognizable forms, from sound awareness (detection) at the most basic level to open-set speech recognition (referring to the patient's ability to identify spoken words without prior knowledge of what the word or sentence choices are) in noise.

The patient's perceived benefit largely depends on past hearing history and exposure to amplification and spoken language. We identify patients who developed spoken language before the onset of significant hearing loss as post-lingually deafened. A patient with this hearing background differs from a patient who primarily uses sign language or other forms of manual and visual communication to communicate. Patients who rely on sign language are often described as being pre-lingually deafened, meaning hearing loss occurred before spoken language development. 

In adult populations, post-lingually deafened patients tend to have better outcomes than pre-lingually deafened patients after cochlear implantation.

In pediatric populations, pre-lingually deafened patients who are implanted early in their development (9-24 months), outcomes with cochlear implants may be equivalent to those of post-lingually deafened pediatric patients. However, post-lingually deafened pediatric patients tend to have better outcomes after this early period than pre-lingually deafened pediatric patients after cochlear implantation.

Research has shown auditory verbal therapy and speech-language rehabilitation may improve speech perception outcomes for most cochlear implant recipients. Referral for these services is optional for patients and can be discussed with your audiologist.

Both post-lingual and pre-lingual patients can be excellent candidates for cochlear implantation. Therefore, we review each patient's unique case to provide support options based on the best of our knowledge and expertise.

With three cochlear implant companies manufacturing reliable FDA-approved devices, flexibility exists among the available technology to make the “best” choice for each and every patient. We work equally with all three cochlear implant devices and are equipped to service and program implant from these companies: 

• Cochlear Corporation
• MED-EL Corporation
• Advanced Bionics Corporation

The treatment plan includes the collaboration of the patient's desires with the recommendations of the implant team (surgeon, audiologist, family). All three implant manufacturers have a long-standing history of building and creating reliable speech processors that offer strong patient performance.

They are committed to the functioning of the device for the lifetime of the patient. These manufacturers are constantly seeking to improve the existing technology so as to offer new options to patients while ensuring back-compatibility to the internal devices that may have been implanted years earlier.

A variety of accessories and features come with each of these implants and information on these options will be provided to the patients by your audiologist. You will discuss your personal needs with your audiologist to determine the best implant system to meet the demands of your lifestyle.

We encourage patients to obtain literature from all implant manufacturers as well as visit the company websites online to gain more information about device technology, before engaging in the selection process. We are comfortable with all manufacturers and are willing and able to accommodate patient preferences.

Abnormal cochlear or external ear anatomy will be assessed via CT and/or MRI scan. Your surgeon may provide direction regarding which electrode type will work best for your anatomy, which may influence the device manufacturer choice.

1. Initial audiology testing and counseling: Extensive hearing testing will be performed in a sound booth with and without hearing aids. The audiologist uses the information combined with the history of hearing loss to assess the potential utility of the cochlear implant. If you are an audiologic candidate, your audiologist will counsel and educate you about cochlear implants. This will help you understand everything involved before you decide to proceed with the rest of the process. You will be given information on the available cochlear implant devices from all manufacturers.
2. Otologic medical evaluation: A cochlear implant surgeon will perform a full medical history and physical exam and a review of hearing test results. If this evaluation is consistent with a cochlear implant being the best option, then the next phase of evaluations will be scheduled.
3. Imaging studies: An imaging study (either an MRI or CT scan) will be ordered and is required for all patients to evaluate inner ear anatomy and screen for any brain conditions before implant placement.
4. Second phase audiology hearing tests: You may need additional audiology testing. Other sentence and word recognition tests performed in quiet and in the presence of background noise enable us to better compare your hearing abilities after cochlear implantation with those prior. If you have not already, you will be asked which cochlear implant brand you have selected.
5. Insurance precertification: Obtaining approval from your insurance company for cochlear implantation can take several weeks and will be performed by the MedStar Georgetown Otolaryngology-Head and Neck Surgery department staff.
6. General medical preoperative exam by your primary physician: If you are age 40 or older and/or if you have other medical conditions (high blood pressure, heart conditions, diabetes, etc.), you may need to see your primary physician for an exam that includes an EKG, chest X-ray, and general blood tests, as indicated, before we can schedule your surgery. Your physician’s office must fax us these results with a note from the physician stating that you are in reasonable condition to undergo the implant surgery. Pneumococcal vaccine, as recommended by the US Food and Drug Administration and Centers for Disease Control and Prevention, can be obtained from your primary care physician (See below).
7. Scheduling surgery: A surgery date will be scheduled when all the above steps are complete. Your physician will review the information and confirm which ear is to be implanted and which device has been selected.
8. Cochlear implant surgery: The procedure takes approximately 2 to 3 hours. The majority of patients go home on the same day of surgery. Further surgical details will be discussed with your physician and found within this section of the website.
9. One-week postoperative check: You will return to see your physician one week after surgery to check the incision for proper healing.
10. Activation and programming, start rehabilitation/auditory-verbal therapy: Cochlear implant activation usually takes place 4 weeks after surgery. At that time, the patient will be fitted with the external parts of the device, which requires programming of the external speech processor by the cochlear implant audiologist. During this process, the patient will begin to hear their first sounds generated by the implant. That day you will have the processor programmed and leave the office with the implant functioning. This is the beginning of learning to hear with the implant. If indicated, you will schedule Auditory-Verbal Therapy to begin sometime after this visit.

The programming of the external speech processor is a procedure that must be repeated one week later and then periodically thereafter. The implant system must be programmed to suit each individual's needs. Each patient's tolerance of sound improves with time. Therefore, the implant stimulation level can be adjusted to suit each patient’s needs. The implant team is committed to working with the implant recipient as long as necessary to ensure optimal benefit from the device.

Meningitis is a possible, albeit very rare, complication of cochlear implantation. However, when present it can cause serious consequences.

Meningitis is an infection of the lining of the surface of the brain. Early symptoms of meningitis include fever, irritability, lethargy, and loss of appetite in infants and young children. Older children and adults may also manifest headaches, stiff neck, nausea, vomiting, and confusion or alteration in consciousness. Physicians are encouraged to consider a diagnosis of meningitis in cochlear implant patients when such symptoms exist and to begin appropriate treatment as soon as possible.

The unusual occurrence of meningitis can be decreased even further through appropriate vaccination. We recommend vaccinations for patients with cochlear implants. Please ask our office staff if you have not received a vaccination recommendation sheet. If you have any issues regarding this issue, please contact your physician.

Based on CDC recommendations, all persons with cochlear implants should receive age-appropriate pneumococcal vaccination with the 7-valent pneumococcal conjugate vaccine (PCV7) (Prevnar®), 23-valent pneumococcal polysaccharide vaccine (PPV23) (Pneumovax®23), or both according to the Advisory Committee on Immunization Practices (ACIP) schedules for a person at high risk.

Because the rate of pneumococcal meningitis is higher in children with cochlear implants and Streptococcus pneumoniae is the most common pathogen causing bacterial meningitis in cochlear implant recipients of all ages with meningitis of known etiology, ACIP recommends the following for persons who have or are scheduled to receive a cochlear implant:

• Children aged <2 years with cochlear implants should receive PCV13 or PCV15, as is universally recommended; children with a lapse in vaccination should be vaccinated according to the catch-up schedule.^4,5
• Children aged 2 to 5 years with cochlear implants who have not received PCV13 or PCV15 should be vaccinated according to the high-risk schedule; children with a lapse in vaccination should be vaccinated according to the catch-up schedule for persons at high risk.^3,4 Children 2 years or older with cochlear implants who have completed the PCV13 or PCV15 series should receive PPV23 ≥2 months after vaccination with PCV7.³
• Persons aged 5 to 64 years with cochlear implants should have received PPV23 according to the schedule used for persons with chronic illnesses, a single dose is indicated.⁵
• Persons planning to receive a cochlear implant should be up-to-date on age-appropriate pneumococcal vaccination ≥2 weeks before surgery, if possible.
• Adults (age 19 years and older) who have NOT had any prior pneumococcal vaccinations need either (1) one dose of PCV20 (Prevnar 20) or (2) one dose of PCV15 (Prevnar 15) followed 8 weeks later by PPV23. A PPV23 booster is required at age 65. Adults (age 19 years and older) who have had prior vaccination only with PPV23 now also need one dose of PCV13 to be given 12 months after their PPV23 shot.

While meningococcal vaccinations are recommended for all preteens and teens, the CDC does not recommend routine meningococcal vaccination, specifically for younger children and adults with cochlear implants. Data do not suggest that people with cochlear implants are at increased risk for meningococcal meningitis. Hence the reason why CDC does not recommend meningococcal vaccination specifically for people with cochlear implants.⁵

References:

1. CDC. Pneumococcal vaccination for cochlear implant candidates and recipients: Updated recommendations of the advisory committee on immunization practices. MMWR. 2003;52:1-2
2. Reefhuis J, Honein MA, Whitney CG, et al. Risk of bacterial meningitis in children with cochlear implants, USA 1997-2002. N Engl J Med 2003;349:433-43.
3. CDC. Risk of bacterial meningitis in children with cochlear implants. August 8, 2022. Accessed March 14, 2023. https://www.cdc.gov/ncbddd/hearingloss/meningitis.html
4. CDC. Preventing pneumococcal disease among infants and young children. MMWR. 2000;49(RR09):1-38.
5. CDC. Cochlear implants and vaccination recommendations. January 27, 2022. Accessed May 4, 2023. https://www.cdc.gov/vaccines/vpd/mening/public/dis-cochlear-faq-gen.html

The surgical placement of cochlear implants has been performed for over 40 years. Newer implant designs and surgical techniques allow us to place these devices with few complications and excellent cosmetic results.

The procedure is performed in a day surgery unit, with most patients going home the same day. General anesthesia is administered in the operating room, and a small amount of hair behind the ear is shaved, if necessary. An incision is made in the crease behind the ear, which makes the scar very inconspicuous once it has healed.

A pocket is created under the skin to accommodate the internal receiver-stimulator portion of the implant. This part of the implant has a very flat design so that it will not produce a noticeable deformity.

An opening is then made into the air-filled bone called the mastoid. This mastoidectomy allows us to access the cochlea without disturbing the ear canal or eardrum. A very small opening is made into the cochlea, where the implant electrode is threaded as far as possible. Most cochleas can accommodate the complete electrode unless there is a cochlear abnormality, which may result in a partial insertion.

The incision is closed with hidden, absorbable stitches that do not require removal. A mastoid dressing is placed on the ear and remains in place for 1 to 2 days. Patients usually leave the hospital 2 to 3 hours after surgery is completed. Pain is mild-to-moderate for 1 to 2 days and can be controlled with oral pain medicines. Some patients experience imbalance for a few days after surgery, but this resolves within the first week.

Patients are seen in the office one week after surgery to check the incision. Most patients are able to return to work or school at that point. The initial activation of the device and placement of the external equipment is performed four weeks after surgery. Once healed, there is minimal visible evidence of the implant’s presence. The incision can tolerate water 3 days after surgery. Sports and strenuous exercises should be suspended for 3 weeks. After that, there are no activity restrictions.

Cochlear implants are extremely reliable. A patient can expect never to need to have their implant replaced. Less than 1% of implants have a malfunction that requires replacement. Thankfully, implants can be surgically replaced if necessary without losing hearing performance. This also means that in the future, patients can be upgraded to newer technology if warranted by the expectation of improved performance.

Examples of external components from the three manufacturers are seen below:

The surgical placement of cochlear implants has been performed for over 40 years. Newer implant designs and surgical techniques allow us to place these devices with few complications and excellent cosmetic results.

The procedure is performed in a day surgery unit, with most patients going home the same day. General anesthesia is administered in the operating room, and a small amount of hair behind the ear is shaved, if necessary. An incision is made in the crease behind the ear, which makes the scar very inconspicuous once it has healed.

A pocket is created under the skin to accommodate the internal receiver-stimulator portion of the implant. This part of the implant has a very flat design so that it will not produce a noticeable deformity.

An opening is then made into the air-filled bone called the mastoid. This mastoidectomy allows us to access the cochlea without disturbing the ear canal or eardrum. A very small opening is made into the cochlea, where the implant electrode is threaded as far as possible. Most cochleas can accommodate the complete electrode unless there is a cochlear abnormality, which may result in a partial insertion.

The incision is closed with hidden, absorbable stitches that do not require removal. A mastoid dressing is placed on the ear and remains in place for 1 to 2 days. Patients usually leave the hospital 2 to 3 hours after surgery is completed. Pain is mild-to-moderate for 1 to 2 days and can be controlled with oral pain medicines. Some patients experience imbalance for a few days after surgery, but this resolves within the first week.

Patients are seen in the office one week after surgery to check the incision. Most patients are able to return to work or school at that point. The initial activation of the device and placement of the external equipment is performed four weeks after surgery. Once healed, there is minimal visible evidence of the implant’s presence. The incision can tolerate water 3 days after surgery. Sports and strenuous exercises should be suspended for 3 weeks. After that, there are no activity restrictions.

Cochlear implants are extremely reliable. A patient can expect never to need to have their implant replaced. Less than 1% of implants have a malfunction that requires replacement. Thankfully, implants can be surgically replaced if necessary without losing hearing performance. This also means that in the future, patients can be upgraded to newer technology if warranted by the expectation of improved performance.

Examples of external components from the three manufacturers are seen below: