The Dallas Ear Institute Cochlear Implant Team is a group of hearing specialists who provide the highest level of diagnostic, surgical, and rehabilitation services in all areas of cochlear implantation. The staff consists of neurotologic surgeons, audiologists, speech-language pathologists, auditory-verbal therapists, psychologists, and insurance reimbursement specialists.
Over 1000 patients have had cochlear implants placed by our surgeons and are being cared for by our team of specialists. Our program participates in ongoing clinical trials and research projects allowing us to offer current and future technology. Our philosophy is that the decision to recommend a cochlear implant can only be made by a multi-disciplinary team of specialists and a well informed patient or parent.
Patient Testimonial Video
As seen on the popular TV Show "Top Docs of DFW"
Dr. Bob Peters with The Dallas Ear Institute discusses the amazing procedure, Cochlear Implants, that he performs that enables individuals to hear. In this segment we hear the story of Kemper who was born deaf, and now thanks to The Dallas Ear Institute can hear. Truly amazing! (See video below)
As seen on the popular TV Show "Top Docs of DFW"
Dr. Bob Peters with Dallas Ear Institute discusses the amazing procedure, Cochlear Implants, that he performs that enables individuals to hear. In this segment we hear the story of Kemper who was born deaf, and now thanks to Dr. Peters can hear. Truly amazing! (See video below)
How Natural Hearing Works
Before going into details of how a cochlear implant works, it is important to understand the structure of the ear
and how it works.
Sound waves enter the ear canal and impact the ear drum (tympanic membrane). After the ear drum picks up the sound, it transmits sound wave vibrations through the hammer (malleus), anvil (incus), and stirrup (stapes). The hammer, anvil, and stirrup make up the chain of three (3) middle ear bones. The stirrup passes the vibrations to the inner ear fluids within the cochlea. Fluid waves travel through two and a half (2½) turns of the cochlea, bending the cochlea hair cells as it goes by. The hair cells correspond to the frequency of the original sound waves, initiating signals within their corresponding nerve endings prior to sending them to the brain.
1. Sounds enter the ear canal and travel to the eardrum.
2. These sound waves cause the eardrum to vibrate, setting the bones in the middle ear into motion.
3. This motion is converted into electric impulses by tiny hair cells inside the inner ear (cochlea).
4. These impulses are sent to the brain, where they are perceived by the listener as sound.
What is a Cochlear Implant?
The use of cochlear implants for the treatment of severe to profound hearing loss is one of the most revolutionary treatments of our time. The cochlear implant is a prosthetic replacement for the inner ear (cochlea) which was developed over 20 years ago, based on the idea that profoundly hearing impaired individuals have auditory nerve fibers remaining that can be electrically stimulated to produce a sense of hearing. A multichannel cochlear implant is an electronic device developed to restore auditory sensation through electrical stimulation of the auditory nerve for individuals age 6 months and older with severe to profound sensorineural hearing impairment. The stimulation provides a wide range of auditory information needed for recognizing environmental and speech sounds to expand communication ability.
The cochlear implant bypasses damaged parts of the inner ear and electronically stimulates the nerve of hearing. The cochlear implant system consists of two parts:
The internal part consists of wires that are surgically implanted into the cochlea through the skull behind the ear
The external part consists of a microphone, a speech processor (that converts sound into electrical impulses), and connecting cables
Individuals who receive little to no benefit from hearing aids are usually considered to be candidates for a cochlear implant.
How A Cochlear Implant Works:
1. The external sound processor captures sounds, then filters and processes the sounds.
2. The sound processor translates the filtered sounds into digital information, which is then transmitted to the internal implant.
3. The internal implant converts the digital information into electrical signals, and sends them to a tiny, delicate curl of electrodes that sits gently inside the cochlea.
4. The electrical signals from the electrodes stimulate the hearing nerve, bypassing the damaged cells that cause hearing loss, allowing the brain to perceive sound.
A cochlear implant is designed to bypass damaged or degenerating cochlear hair cells (within the inner ear that correspond to the sound wave frequencies). The hair cells are the "spark plugs" of the inner ear nerve endings. The vast majority of nerve deafness is usually the result of non-functioning hair cells, however, with the nerve endings still purposeful in the majority of those cases, it makes it possible for cochlear implants to work.
Saying that a patient is a candidate for a cochlear implant means they should obtain significantly better hearing ability from a cochlear implant than they can from the most optimally fitted hearing aids. Current cochlear implant technology works so well that the candidacy criteria is expanding rapidly. The following are generally accepted candidate criteria.
Age: 6 months or older
Children: Profound hearing loss in both ears
Adults: Severe or profound hearing loss. When tested with optimally fitted hearing aids this means hearing thresholds are over 40db at all frequencies or word understanding scores are less than 50%.
No medical contraindications
High motivation and appropriate expectations
Involved in an educational or training program that emphasize auditory skills and oral communication.
Cochlear Implant Process: Explanation of Evaluation Steps
1. Cochlear Implant Evaluation – This visit will involve extensive soundbooth testing with and without hearing aids. The results of these tests combined with your hearing loss history is used by the audiologist to determine if a cochlear implant is likely to be helpful to you or your child. If so, the audiologist will counsel and educate you about cochlear implants so that you understand all that is involved before you decide to proceed with the rest of the cochlear implant process. (2 hours at The Hearing Center, A107)
2. Otologic Medical Evaluation – The physician at Dallas Ear Institute will take a full medical history, perform a physical exam, and review the hearing tests performed in step 1. If he agrees that a cochlear implant is the best option, the next phase of the evaluations will be scheduled. (45 minutes at Dallas Ear Institute, A103)
1. MRI or CT Scan – It is required that all patients have a scan to evaluate the inner ear anatomy and screen for any brain conditions prior to cochlear implant surgery. Children usually require sedation or anesthesia for the scan, therefore, it is performed in Medical City’s Radiology Department. Adults and older children have their scan performed in a nearby outpatient facility. (45 minutes)
2. Genetics Evaluation (CHILDREN ONLY) – In 80% of children born with hearing loss, the hearing loss is because of a genetic cause. Determining the exact gene that caused the hearing loss is helpful to the physician in understanding the condition. It also helps the parents understand how future children can be affected. Genetic blood testing for hearing loss is now very practical and cost effective. The benefits of testing your child will be discussed. In some cases it may be recommended that your child see a doctor who specializes in genetics. The geneticist will take a detailed family history, perform a physical exam, and possibly obtain a blood sample for genetic testing and later counsel the parents regarding the results. (1 hour)
3. Auditory-Verbal Evaluation – For ADULTS, this assesses (A) the effects of hearing loss in the patient’s listening and speaking skills at home, work, educational and social settings, (B) the possible benefits of a cochlear implant, and (C) the need for hearing therapy or speech therapy after the cochlear implant is activated.
For CHILDREN AND ADOLESCENTS, this assesses the patient’s potential for learning to (A) hear and comprehend spoken language with a cochlear implant, and (B) develop speech to use as a primary means of communication. The roles of the parent and the child’s educational setting are discussed and how they impact the benefit from cochlear implantation.
For ALL patients, the purpose of short or long term therapy is discussed. Adult family members are encouraged to attend the evaluation to learn how to support the patient. (1-2 hours at Hear in Dallas)
4. Neuropsychology Evaluation – For ADULTS, the purpose of the screening is to (A) obtain information regarding overall cognitive, adaptive, vocational, and emotional functioning relevant to preoperative concerns, and (B) assist the individual and their family in identifying and addressing current stressors and other factors which could influence compliance following cochlear implantation.
For CHILDREN AND ADOLESCENTS, the purpose of the screening is to (A) obtain information regarding overall cognitive, adaptive, emotional and behavioral functioning, (B) assist in developing a plan to address skills of compliance and independence relevant to cooperation in rehabilitation, and (C) answer questions, address concerns, and offer emotional and behavior support to enhance preoperative or postoperative rehabilitation.
This evaluation is usually not covered by insurance and requires the patient or parents to pay for the evaluation fee of approximately $150 at the time of the visit. Insurance will not be billed for this evaluation. (1 hour at Dr. Nuche’s office)
5. Videonystagmography (VNG) Balance Testing (ADULTS ONLY) – This test involves a series of balance tests to determine the amount of balance function in each ear. The results of these tests can affect the choice of ear for cochlear implantation and help detect certain patients who may be prone to balance difficulties after cochlear implantation (1 hour at Dallas Ear Institute, A103)
6. Insurance Precertification – Obtaining approval from your insurance company for cochlear implantation can take several weeks. Our insurance department will keep you up to date on the progress of the precertification.
7. General Medical Preoperative Exam by your Primary MD – If you are age 40 or older OR of any age with medical conditions such as: high blood pressure, heart conditions, diabetes, etc., you may need to see your primary care physician for an exam that includes an EKG, Chest X-ray, and general blood tests. 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 cochlear implant surgery.
1. Preoperative Appointment – When (and only when) all of the above steps are complete, a surgery date will be scheduled. Our administrator will call and inform you of your estimated out-of-pocket expenses related to the surgery. The day prior to your surgery, you will meet with your physician to review all of this information and confirm which ear is to be implanted. You will also be given one of two pneumococcal vaccines that are needed, the Prevnar and the Pneumovax, as recommended by the FDA and CDC, unless you are certain you have received them in the past. You may be given these at any point in the evaluation process but they must be given separately 2 months apart. The audiologist will contact you as to which brand of cochlear implant you have decided unless it was decided during the Cochlear Implant Evaluation appointment. (1 hour at Dallas Ear Institute, A103)
2. Cochlear Implant Surgery – The surgery takes approximately 1.5 hours. The majority of patients go home the same day of surgery except infants who often spend on night in the hospital. Further details of the surgery will be discussed with you by your physician and can also be found on our website at www.dallasear.com.
3. One Week Postoperative Check and Cochlear Implant Equipment Orientation – You will return to see your physician one week after surgery to check the incision for proper healing. You will then see the audiologist who will perform electrical checks on the internal implant. She will counsel and educate you concerning all of the external components of the cochlear implant system. You will be sent home that day with all of your implant equipment and instructions to learn at home. You or your child WILL NOT have your cochlear implant activated at this visit. (1-2 hours at Dallas Ear Institute, A103 and The Hearing Center, A107)
4. Cochlear Implant Activation and Programming – Activation usually takes place 3 weeks after surgery. That day you or your child will have the processor programmed and leave the office with the cochlear implant functioning. This is the beginning of learning to hear with an implant. You will be returning to the audiologist for programming of the processor at regular intervals to slowly increase the strength of the implant stimulation. (1 hour at The Hearing Center, A107)
5. Auditory-Verbal Therapy – You will schedule your Auditory-Verbal Therapy to begin sometime after activation. The frequency and duration of your Auditory-Verbal Therapy will be determined by your therapist. (Hear in Dallas)
The surgical placement of cochlear implants has been performed for over 20 years. Newer implant designs and surgical techniques allow us to place these devices with very 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. 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 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 inner ear cochlea without disturbing the ear canal or eardrum. A very small opening is made into the cochlea, and the implant electrode is threaded in as far as possible. Most cochleas can accommodate the complete electrode unless meningitis is the cause of deafness, in which case a partial insertion may be necessary. The incision is closed with hidden absorbable stitches that do not require removal. A Velcro cup dressing is placed on the ear and remains in place for 2 days. Patients usually leave the hospital 3 to 4 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 spontaneously within the first week. Patients are seen in the office 1 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 3 weeks after surgery. Once healed there is practically no visible evidence of the implant’s presence. The incision can tolerate water 3 days after surgery. Sports, exercises and air travel should be suspended for 3 weeks. After that, there are no activity restrictions.
Cochlear implants are extremely reliable. It is expected that a patient will never need to have their implant replaced. Less than 1% of implants have malfunction that requires replacement. Thankfully, if necessary, implants can be surgically replaced without losing any hearing performance. This also means that in the future patients can be upgraded to newer technology if warranted by the expectation of improved performance.
Below are instructions to follow prior to surgery:
Once the surgery date is scheduled, the patient will have a pre-operative appointment for an examination by a Dallas Ear Institute physician the day before surgery followed by pre-admission at the surgery center, which includes a brief tour of the surgery center, lab work, paperwork, and further instructions for surgery arrival time the following day.
It is advised that no aspirin, aspirin products, Motrin, or Ibuprofen be taken two weeks prior to the surgery.
Any signs of illness or temperature that may occur prior to surgery must be reported to our office immediately.
If given prescriptions, have them filled prior to surgery.
Take NOTHING by mouth after midnight the night before surgery unless given specific instructions otherwise. This includes foods, liquids, or medications.
Note: The anesthesiologist will call you at home the night before surgery, therefore please be sure you give us the phone number where you can be reached the night before surgery.
Patients usually leave the hospital 3 to 4 hours after surgery is completed. Listed below are some factors to consider for the recovery process:
Pain will be expected and may be 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, however, this usually resolves spontaneously within the first week.
Patients are to return to the office one (1) week after the surgery for a follow-up visit.
After the follow-up visit, most patients are able to return to work or school.
During the healing process, sports, exercise, and flying should be suspended for approximately 4 weeks
After the healing period, patients can expect minimal visible evidence of the implant's presence and there will be no activity restrictions.
Activation of the Device
The initial activation of the device and placement of the external equipment is performed 3 to 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 audiologist. During this process, the patient will begin to hear their first sounds generated by the implant.
The programming of the external speech processor is a procedure that must be repeated one week later and then periodically thereafter. The reason for this is because 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 work with the implant recipient as long as it is necessary to ensure optimal benefit from the device.
Reliability and the Future
Cochlear implants are extremely reliable. In fact, less than 1% of implants have required replacement due to a malfunction. Therefore, patients can be assured they should not expect they would need to have their implant replaced. If it becomes necessary for the implant to be replaced, it can be done without any impact on the hearing performance. This is encouraging since it means patients can have their implants upgraded to newer technology in the future if it will prompt an improvement in the hearing performance.
Recipients vary greatly in the amount of benefit they derive from the cochlear implant devices. The outcomes can be broken down into three (3) groups.
Group 1 Congenital or infancy onset hearing loss.If a child born deaf is detected soon after birth, fitted with hearing aids in the first year of life, and subsequently obtains a cochlear implant by age 2 to 3 years (the earlier the better) there are great expectations for this child to obtain excellent auditory and oral communication skills with a cochlear implant. This requires intensive speech therapy for several years after the implant is placed to achieve these results. It is reasonable to expect such a child to enter mainstream classrooms upon starting the 1st grade and to not have the hearing impairment be a significant limiting factor in the child's ultimate educational and occupational goals. Children in this group are considered excellent candidates for a cochlear implant.
Group 2 Adult Onset Hearing Loss: Adults who grew up with normal hearing or at least hearing adequate enough to learn to speak proficiently, and subsequently have their hearing deteriorate to a severe level are considered excellent candidates for cochlear implants. These patients adjust to the implant very rapidly (usually within a few months) and require only short term therapy. With practice and patience these individuals experience great improvement in face to face communication. Many can learn to talk on the telephone. There is great improvement in environmental sound awareness. Background noise still creates a challenging communication environment.
Group 3 Older Children and Adults Born Deaf: Any child greater than 5 years old up through adulthood who was born deaf and spent many years with very poor hearing is a challenging cochlear implant candidate. The success of cochlear implantation in these cases is affected by many factors: oral speech training and skills, dependency on manual communication (sign language), and motivation of the individual and parents to obtain improved auditory and spoken communication skills. The advisability of cochlear implantation in these individuals must be determined on an individual basis.
Placing a cochlear implant in both ears has now become a standard of care for children and adults who meet certain candidacy criteria. The rationale for and benefits of bilateral cochlear implantation are complex. The Dallas Ear Institute is world renowned for its research in this field. Our surgeons and audiologists will discuss this possibility as part of your or your child’s comprehensive plan for restoring the best hearing possible in both ears.