Programming Cochlear Implants—From a Distance

Hearing loss can be devastating. Children who can’t hear well may experience delayed development and learning difficulties. In the elderly, hearing loss is associated with depression and cognitive difficulties. No matter what your age, not being able to hear instructions or traffic noise, or participate in conversations makes life difficult.

For people with the type of hearing loss that can be helped by a cochlear implant, the device can be transformational, enabling them to participate in activities that previously were inaccessible. But it’s important to realize that cochlear implants are not just a “once and done” surgical procedure.

Like a guitar, a piano, or any musical instrument, these devices must be tuned for optimal function—and re-tuned again and again. If this isn’t done regularly, hearing loss, as well as the loneliness and cognitive decline that are associated with it, can come rushing back.

That’s why remote cochlear implant reprogramming (or tuning) of cochlear implants “is a game changer,” says Douglas Hildrew, MD, a Yale Medicine ENT (ear, nose, and throat) surgeon who treats children and adults with hearing loss.

A cochlear implant works by electrically stimulating nerves inside the inner ear to produce a representation of a sound. In a pre-COVID-19 world, it was necessary for all patients to have their cochlear implant reprogramming sessions in person at a clinic. But recent changes in government regulations have opened up new possibilities. 

Patients now have the option to receive their routine cochlear implant reprogramming remotely. “In just a few months, we have been able to bring our services right to the patient, in the comfort and safety of their homes,” Dr. Hildrew says.

The Food and Drug Administration (FDA) approved remote programming for cochlear implants in 2017, but there were various governmental restrictions and regulations that made it difficult to implement. In response to COVID-19, however, the federal government rapidly removed such barriers. “When social distancing became the new norm, telehealth became king,” says Dr. Hildrew.

Fortunately, because he had already been offering this service at the Veterans Affairs (VA) Connecticut Healthcare System in West Haven long before the pandemic, Dr. Hildrew says he was able to quickly transition towards providing this service to all of his patients. “Since 2017, the VA West Haven has offered a comprehensive cochlear implant and hearing loss telepractice for patients from Maine to the Connecticut/New York border,” Dr. Hildrew says. Recently, this reach has extended nationally.

Without telehealth, it might have been necessary for some of our veteran patients to travel hours for their visit with the VA cochlear implant team, says Dr. Hildrew. “In fact, many people who otherwise would have benefited from such devices were refusing them simply as a result of access issues,” he says. 

The risk for disabling hearing loss increases with age—rising from 25% of people ages 65 to 74 to 50% of those over age 75. However, the vast majority of adults who could benefit from cochlear implants—or any type of hearing aid—never get them.

“It is estimated that only 5-10% of cochlear implant candidates ever get one,” says Dr. Hildrew. “This is largely due to the overall lack of awareness and appreciation that hearing loss has in this country.”

Cochlear implants—and the programming that keeps them functioning—are life-changing for patients, says Meg Narron, AuD, a Yale Medicine audiologist. Hearing loss that goes untreated is associated with anxiety, depression, social isolation, and cognitive decline, including dementia.

“People who can’t hear are very vulnerable, especially now during the pandemic,” says Narron. “This is a population that relies on visual cues. So, at a time when everyone is wearing mask—and you can’t see people’s faces when they are talking—people who are hearing-impaired are compromised. It’s another reason to make sure their cochlear implants are optimized.”

Cochlear implants can provide a better quality of life for two kinds of patients: The first are babies who are born deaf. If they receive one within the first few years of life, they are much more likely to reach key language and hearing milestones, and function better as they grow up. The second are adults with severe hearing loss.

Roughly speaking, people become candidates for cochlear implants when their ability to understand spoken language falls below 50%, Dr. Hildrew says. “When you are understanding less than 50% of what others are saying around you, this means that the majority of what you are hearing is actually hurting you and not helping you. These are the people who are really struggling,” says Dr. Hildrew.

Unlike a regular hearing aid, which amplifies acoustic sounds, a cochlear implant uses a different method. The device has two parts: an external portion that sits behind the outer ear with a transmitter and receiver/stimulator that converts sounds into electric impulses, and an internal portion that is implanted under the skin.

The internal part has an electrode array (with contact points that directly stimulate branches of the cochlear nerve) that collects the electrical impulses and sends them to the cochlear nerve, providing the user with a representation of the sound—and essentially a different way of hearing.

An ear surgeon can perform a cochlear implant in about an hour and a half. (The patient goes home the same day and has a few days of minor discomfort.) After 3 to 4 weeks—when the skin has healed—the device is activated and the patient can begin hearing.

But the initial device activation is just the first step, says Dr. Hildrew. At first, the electrical sounds a patient hears through the implant can be like listening to the “garbled sounds of Charlie Brown’s teacher,” he says. “Our adult patients have spent their entire lives hearing acoustically, with sound traveling through the air from someone’s voice to their ear."

Patients with cochlear implants are instead hearing by way of electronic stimulation. “If perfect hearing is like listening to a live orchestra, a cochlear implant is more akin to hearing only a single instrument. It can be pleasing, but it lacks the complexity,” he says. “The true strength of a cochlear implant is in hearing speech and language. While it may take practice to learn what these new sounds mean, the more you use it, the better you get. Also, the more one works with their audiologist, the more personalized the programming can be. This is why telehealth visits can be so helpful.”

As more people start to resume a life that includes going to an office and, perhaps, traveling, Narron will resume the cochlear implant reprogramming routine she had prior to the pandemic—only with one exception: She will now also offer remote sessions.

Whether done remotely or in person, the process is complex. “We need to synchronize the sounds they are hearing with what they remember those sounds to be,” Narron says. This may mean adjusting the device’s performance to suit the patient’s sensitivity to low sounds or very loud sounds, for instance. “Because we are delivering an electrical current, we work up to it, and that’s really why we have all the follow-up visits,” she says.

Narron makes changes using what can be described as an equalizer bar with sliders that go up and down to control intensity. Each channel is set to a different frequency, and a new patient is started at low levels that are adjusted as they learn to take in a new type of auditory information and begin to tolerate it better.

The patient may wear a hearing aid in their other ear to help them communicate with Narron, who also watches their body language on a video screen for additional feedback.

In addition to programming the implant, Dr. Hildrew and Narron use telehealth visits to counsel patients and make sure they are maintaining their device properly. Once a patient is comfortable with the device and they have settled into a consistent programming strategy, they only need to visit us twice a year, he says.

Patients may need further programming if they are hearing a low-frequency echo, or buzzing or “mushy” sounds, he says. Children are followed more closely, however, because their programming strategy can change more frequently, as developing language is a dynamic process, he says.  

Success is measured, in part, by how patients feels about their hearing, says Dr. Hildrew. “It’s so subjective. Regardless of what numbers we see on our end, my goal is that each patient leaves feeling happy with their hearing and comfortable with what they are perceiving.”

Narron says that hers can be an emotional job. Many patients become tearful when they talk about how improvements to their hearing have made a difference for them—they report being less isolated and lonely, and able to complete simple tasks on their own instead of always relying on other people.

“It’s absolutely life-changing technology,” she says. “Hearing is really the cornerstone of our communication system. When we restore that access to people, the whole world opens up again.”

[Read about Medicare and Medicaid coverage updates for cochlear implants.]