Audiology
The North East Regional Cochlear Implant Programme is one of the longest standing programmes in the country.
The programme has expanded over time and now implants approximately 70 cases each year. This includes adults and children, and both unilateral and bilateral operations.
Location and areas covered
The programme is based at The James Cook University Hospital in Middlesbrough, with outstations across the region. ENT consultations and surgeries currently take place at both The James Cook University Hospital in Middlesbrough and at the Freeman Hospital in Newcastle.
For children, specialist speech, language and educational assessments and post-operative therapy takes place virtually with parents at home and staff at nursery and school.
The main areas covered are North Yorkshire, Redcar and Cleveland, Teesside, County Durham, Sunderland, Newcastle, Tyneside, Cumbria and Northumberland. However, we can take referrals from any area. It is important professionals and patients consider the travelling time and cost when deciding which implant centre to refer to.
Team members
The team comprises of ENT surgeons, audiologists, speech and language therapists, hearing therapists, teachers of the deaf, plus administrative support. Each patient is allocated an implant keyworker who acts as the patient’s and family’s professional point of contact within the programme.
Who is suitable for a cochlear implant assessment?
The two main audiological criteria used when considering cochlear implantation are:
Pure-tone audiometric threshold equal to or greater than 80 dB HL at 2 or more frequencies (500 Hz, 1,000 Hz, 2,000 Hz, 3,000 Hz and 4,000 Hz) bilaterally without acoustic hearing aids.
Or
Patients with Auditory Neuropathy Spectrum Disorder (ANSD) not gaining adequate benefit from full time use of bilateral hearing aids. In adults, this is assessed using aided speech discrimination testing. In children speech, language and listening skills are assessed to see if they are delayed and if so, whether communication is developing.
Patients should have a hearing aid trial for a minimum of six weeks with the most suitable aids optimally fitted prior to being referred to the programme, unless hearing aid fitting is contraindicated or the cause of hearing loss is meningitis (see information below).
The above criteria do not necessarily have to be met if the hearing loss has been very recently acquired due to meningitis, see further information on the next page.
Any persistent middle ear fluid should be removed and grommets fitted by the local service prior to referral, and hearing re-assessed unless the patient is post-meningitis, in which case they should be referred immediately.
Pre-lingually deafened adults can be referred if they have been consistent hearing aid users.
For hearing loss acquired due to meningitis, it is appropriate to refer patients with better hearing thresholds so that we can monitor any further changes in hearing thresholds closely and also carry out an MRI or CT scan to determine if ossification is already occurring or progressing.
These thresholds may have been obtained using either objective or behavioural testing. Cases where hearing thresholds are outside of NICE Guidelines criteria but where ossification is occurring, it may be appropriate to implant sooner rather than later. In these instances, the team would decide whether it was appropriate to apply to the exceptions panel in order to obtain funding to implant such a patient.
All patients are assessed on an individual basis and professionals are encouraged to refer patients who may be borderline if felt appropriate.
Suitability criteria used by the implant team
The suitability criteria used by the programme are the NICE guidelines for cochlear implantation. Following assessment patients would be considered appropriate for cochlear implantation if they meet all the following criteria:
- Pure-tone audiometric threshold equal to or greater than 80 dB HL at 2 or more frequencies (500 Hz, 1,000 Hz, 2,000 Hz, 3,000 Hz and 4,000 Hz) bilaterally or with dead regions at these frequencies, or with ANSD.
- Not gaining adequate benefit from hearing aids.
- Medically suitable
Ideally to include a fully developed cochlea with a patent channel for inserting a cochlear implant. Otherwise, implantation may be still possible but with a limited number of electrodes. - Appropriate expectations and motivation of the patient, parents or carers with a full understanding of the process from surgery to rehabilitation.
- Appropriate family support
For children it is essential that the family are committed to establishing and maintaining good cochlear implant use after surgery and understand the importance of a proactive role in the rehabilitation process. The aim is for oral or aural communication. - For pre-lingually deafened children their age is considered
As benefit is usually correlated with age at implantation, It is well documented that children implanted before the age of 12 months have a better chance to develop speech and language on a par with their normally hearing peers. - Those implanted over the age of three years are less likely to develop normal speech and language. However, if a child has recently lost their hearing through an accident or illness, or if they have only recently stopped finding their hearing aids helpful, their age is not so important. This is because their brain is used to receiving and understanding information through hearing.
- Patients having disabilities in addition to hearing impairment is also considered during the assessment for cochlear implantation. For babies and young children, additional disabilities may not have been identified before cochlear implantation and may therefore limit the potential benefit of the implants.
In line with NICE guidance, the North East Regional Cochlear Implant programme offers simultaneous bilateral cochlear implants (for example, both ears implanted during the initial surgery) to children who are clinically suitable.
The family need to be committed to attending additional or extended post-operative audiology appointments due to the additional time needed to programme two implants. There will be some children for whom bilateral implants may not be appropriate, and this will be discussed during the assessment process.
Only adults who are registered blind or who have other physical disabilities that increase their reliance on auditory stimuli can currently be considered for simultaneous bilateral implants.
For some adults and children with better hearing in the lower frequencies, there is an option to implant an electrode which may be able to preserve the low frequency hearing and allow the patient to use an acoustic hearing aid for the low frequencies and the mid to high frequencies can be stimulated electrically. The cochlear implant sound processor is integrated with the hearing aid.
It is possible to apply for funding on an individual basis for a case who does not meet the criteria but are felt suitable for cochlear implantation having completed a full assessment.
When to refer
Post meningitis
Patients who have had severe to profound deafness diagnosed after confirmed or suspected bacterial meningitis should be referred urgently to the cochlear implant programme, with patient consent. This is due to the risk of rapid ossification (bony growth) of the cochlea which may result in cochlear implantation being impossible if left for even a short period of time. The patient will then be fast tracked through the cochlear implant assessment to determine whether they are a suitable candidate.
The local audiology department should arrange for urgent hearing aid fitting in parallel to the referral to the implant centre. However, the patient does not need to have completed a six-week hearing aid trial prior to referral. In addition to this, patients with middle ear fluid do not have to have this resolved or removed prior to referral.
Babies and children
It is recognised that generally the sooner a child is implanted the better the outcomes. Therefore, we would encourage referrals to be made as soon as a child has a
severe or profound loss confirmed.
Newly diagnosed children from the newborn hearing screening programme should be referred once:
- The infant has an assumed loss equal to or greater than 80 dB HL at 2 or more frequencies (500 Hz, 1,000 Hz, 2,000 Hz, 3,000 Hz and 4,000 Hz) bilaterally, in the absence of middle ear fluid.
- They have no middle ear fluid demonstrated by tympanometry.
All other cases
Referrals should be made as soon as the criteria given in the previous section are met, or if the case is borderline. Borderline patients are considered on a case-by-case basis. Such considerations would include concerns regarding the child’s functional ability with hearing aids in everyday life, particularly their educational setting.
How to refer
Referrals can be accepted from audiologists, ENT consultants and GPs. All referrals should be sent direct to the North East Regional Cochlear Implant Programme at The James Cook University Hospital.
The referral should be in the form of a letter with the following details:
- Demographics
Full name, NHS number, date of birth and full address - Best contact telephone number
For patient or parents (often a mobile number) - GP name and address
- Current unaided thresholds, history of hearing loss
(duration, aetiology if known or state unknown, changes over time) - Previous unaided thresholds
If progressive - Copies of any results from Dead Regions testing
- Copies of any previous objective testing
For example’ ABR, OAEs or cochlear microphonic testing - Current hearing aids
Make, model, confirmation they have been fitted with REMs and explanation if REM ‘goodness of fit’ is poor, date fitted, and, if unilateral, the reason why they have not been fitted bilaterally. - Hearing ability with hearing aids
Description and, or speech discrimination testing results. - Any significant medical factors and history
To include any conductive component to loss and any prior surgical or management options considered. - Name of any other professionals involved if known
For example, name of teacher of the deaf, social worker etc. - Named ENT consultant
What happens once a referral is received?
Every referral received by the centre is triaged to see if it can be accepted. This is usually done within two working days of the referral being received.
If it is clear from the referral that the patient is not suitable for assessment (for example, it is a child with ongoing middle ear problem that has not yet been resolved, or hearing aid fittings have never been verified by real ear measures), the referral will not be accepted and an explanatory letter will be sent to the referrer, GP and patient or family as appropriate.
Any referrals received without the necessary information cannot be accepted for assessment by the programme. A request will be sent to the named audiologist at the local audiology department requesting the missing details. Copies will be sent to the referrer GP and patient or family, explaining that the CI (Cochlear Implant) assessment cannot proceed until this information has been received.
If the referral is accepted (or additional information is received as requested) a letter will be sent to the referrer, patient plus all other relevant professionals to confirm the referral has been received and the assessments can go ahead. The name of the implant keyworker will also be given.
Patients will then have a series of appointments to include:
Audiology assessment
Assessment of communication (by a speech and language therapist, teacher of the deaf or hearing therapist, as appropriate)
Educational assessment (children only)
Medical assessment (consultation with ENT consultant)
MRI or CT scan.
Once all the appropriate assessments have been completed, a full report will be sent to the patient and all relevant professionals. Cases that fall into the criteria will be discussed by the team and the patient and, or family informed of the outcome.
If cochlear implantation is not recommended, the patient may additionally have an ENT consultation at which the decision will be shared and the patient will have the opportunity to discuss this decision. Following the ENT consultation, a report will be sent out to the patient plus all relevant professionals explaining the decision, plus recommendations for future management.
The aim of the programme is to complete all the assessments, make a decision as to whether an implant is recommended and proceed to implant surgery within 18 weeks of referral.
However, there are a number of reasons why a patient may be ‘actively monitored’ for a set period as part of the assessment process (for example, when having a hearing aid trial or if not currently fit for surgery), and this would add a delay. In addition, delays can occur if the advice of another specialist outside the team is needed.
If at any time during the assessment it becomes obvious that the cochlear implantation is not suitable (for example, unaided thresholds are too good), or if the patient does not want to proceed, the assessment may be terminated.
If the same patient wishes to be reconsidered at a later date, a new referral is needed. If the patient is discharged, a report will be sent to the referring professional.
The role of the local audiology department – pre-implantation
During the assessment period, the referring centre will need to supply the patient with hearing aid batteries, earmoulds and provide hearing aid maintenance, as appropriate. However, unless advised otherwise, it is not necessary for the patient to be reviewed by the local centre whilst the assessment is taking place.
If a patient under assessment attends their local centre requesting a hearing aid adjustment, please contact the implant centre first for advice, as some adjustments could add a delay to the assessment process.
Testing during the assessment period may indicate that different hearing aid settings or different hearing aids are needed; the CI audiologist will contact the local audiologist to discuss this and a joint agreement would be made regarding ongoing management.
If a child is found to have middle ear fluid during assessment at the cochlear implant centre, arrangements will usually be made for grommets to be inserted by the implant centre. If there are to be any changes to this for an individual patient, the local centre will be advised.
The role of the local audiology department – post implantation
Once a patient has been implanted, they will be seen on a regular basis by the cochlear implant team.
In the first few months they will be seen on many occasions, but less once the implant is programmed fully and the patient is progressing well. After 12 months post-implantation, if they are doing well and there are no concerns, the patient will then be seen on an annual basis.
At switch on, the patient will be advised to return their hearing aid to their local audiology department.
Unless contra-indicated, a unilaterally implanted patient should continue to wear a hearing aid on the non-implanted side, and the responsibility for the provision and maintenance of this aid remains with the local audiology department. This aid should be fitted as usual, using an appropriate prescription formula and verified using real ear measures.
It may be necessary to adjust the settings of the aid so that the patient feels it is ‘balanced’ with the cochlear implant, and this should be done on an individual basis using patient feedback.
If there may be benefit in setting the contralateral hearing aid in a particular way, the CI audiologist will contact the local audiologist to discuss this further and agree ongoing management jointly.
Post implantation, the cochlear implant centre does not carry out further unaided hearing tests, so this should be carried out by the local audiology department as required in order to maintain the non-implanted side.
If the patient wishes to try a compatible bimodal hearing aid, this will be fitted by the cochlear implant centre and the patient advised to return their contralateral hearing aid to their local audiology department.
The provision of batteries for the cochlear implants are supplied by the North East Regional Cochlear Implant Programme, for patients who have been implanted by the centre. The cost of this is covered by the maintenance fees received from the commissioners.
We are not able to supply batteries to patients implanted elsewhere unless formally transferred (see later section). The local audiology department should continue to provide batteries for the contralateral hearing aid.
Transferring an existing cochlear implant user to NERCIP
If a cochlear implant recipient moves into the local area, they can request their care be transferred to NERCIP. The patient must have an implant which can be supported by the North East Regional Cochlear Implant Programme and be entitled to NHS treatment. Please note we do not currently support all brands of implants.
To formally transfer a patient from another implant programme to NERCIP, the Standard Procedure laid out in British Cochlear Implant Group’s Best practice guideline: Transfer of patients between UK cochlear and auditory brainstem implant services should be followed.
Contact us
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Patient experience
South Tees Hospitals NHS Foundation Trust would like your feedback. If you wish to share your experience about your care and treatment or on behalf of a patient, please contact The Patient Experience Department who will advise you on how best to do this.
This service is based at The James Cook University Hospital but also covers the Friarage Hospital in Northallerton, our community hospitals and community health services.
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