Fundamental Practices of Programming

Question 1

What is the goal of pre-implant counseling?

Answer 1

To establish a relatively conservative and realistic expectation with the implant and review typical performance at activation while still convincing the candidate that cochlear implantation is in his or her best interests
Strike a balance between conservative outlook and understanding the value of cochlear implantation
To discuss the schedule of audiological, medical, and rehabilitative appointments before and after cochlear implantation, preparing families for associated time and financial commitments
To familiarize patient/ family with the implant hardware
To provide written materials to the patient/family
Implant manufacturers provide written materials covering implantation details, accessible on their website

Question 2

Is establishing realistic expectations one of the most important objectives prior to activation?

Answer 2

Yes
Unfortunately, no matter how thoroughly expectations are discussed, patients and families often are discouraged with performance during the first few days of even weeks of use

Question 3

What are some reasons for patient dissatisfaction with initial cochlear implant use?

Answer 3

The signal from a CI is much different from that of a hearing aid
A period of acclimatization is required for the auditory system to adjust to the new signal
Little or no exposure to sound prior to implantation in most young children have; consequently, a period of auditory-focused speech language therapy normally is required before conversational spoken language skills emerge

Question 4

What is the CI fitting procedure?

Answer 4

Review surgical report
Physical examination
Selecting a signal coding strategy
Streamlined vs comprehensive programming
Measuring stimulation levels
Adjustments to special parameters

Question 5

Is it standard practice for the surgeon to request a post-op x-ray?

Answer 5

Yes, to confirm electrode placement
Audiologist needs to confirm with the cochlear implant surgeon about any intracochlear electrode contacts that are not favorably or fully inserted into the cochlea
Surgeon should inform the programming audiologist of any other pertinent details that may influence programming

Question 6

What should be included in the physical examination on the day of activation?

Answer 6

Perform otoscopy on both ears
Examine skin flap for signs of irritation or infection
Any remarkable observations should be approached cautiously, with the CI surgeon alerted if necessary
Prior to every programming session, visualize the site on which the transmitting coil rests to ensure that the magnet strength is not excessive
Reduce magnet strength, if pronounced indentation and/or discoloration are present

Question 7

How do you determine appropriate magnet strength?

Answer 7

A subjective skill that the clinician may need to perfect over time
It is important to select a magnet strength that is sufficient to prevent the transmitting coil from repeatedly falling off of the recipient’s head
It is more important that the magnet strength is not too great because excessive adherence of the coil may compromise circulation to the skin underneath the coil

Question 8

What can result from prolonged excessive magnet strength?

Answer 8

Skin necrosis under the coil
Potentially leading to skin flap breakdown and requiring reimplantation.
Older children and adults: will typically complain of a headache or a dull discomfort if the coil magnet strength is too strong
Young children may not be able to verbalize any discomfort, posing a greater concern

Question 9

What are the general rules for determining appropriate magnet strength?

Answer 9

The coil should attract to the head but not forcefully pull from the clinician’s hand
The coil should not easily fall off with head movement
However, it should most likely dislodge when the recipient brushes his or her hand against the coil
Young children (6 months to 2 years) and elderly women often need weaker magnet strength due to thin skin flaps
Middle-aged males and obese recipients may require stronger magnet strength due to thicker skin flaps
If redness or indentation is observed between appointments, use lower magnet strength
If the magnet never falls off of the head of an active toddler, then it is likely that the magnet is too strong

Question 10

What are some additional considerations for determining magnet strength?

Answer 10

Unresolved swelling post-surgery may necessitate higher magnet strength at activation
Be aware of cultural considerations in CI coil placement and magnet strength

Question 11

What is a map?

Answer 11

It is not an acronym
It doesn’t stand for anything
It is an individual specific listening program
It is designed for the specific user
Refers to the process of adjusting the electrical stimulation parameters of the recipients device to optimize his/her hearing experience

Question 12

What are the primary goals of programming?

Answer 12

Restore audibility for a wide range of speech sounds — from soft to loud speech
Set stimulation levels to optimize identification of speech sounds
Ensure loudness percepts feel natural for both speech and environmental sounds
Restore normal loudness perception for both speech and environmental sounds

Question 13

Why is it difficult to achieve these goals?

Answer 13

Speech and everyday sounds have a wide range of intensities of ~100 dB, while CI users have a much smaller electrical DR (~ 20)

Question 14

What does a map consist of?

Answer 14

Minimum levels of audibility
Maximum levels of comfort
Programming strategy
Other associated programming options

Question 15

What needs to happen prior to initial activation?

Answer 15

Selecting a signal coding strategy

Question 16

What are some considerations for selecting a signal coding strategy?

Answer 16

Research has shown that some recipients perform better with one signal coding strategy over another
Start with the manufacturer’s recommended strategy; most recipients perform very well with the manufacturer’s recommended signal coding strategy
Focus on setting optimal stimulation levels first (they greatly influence outcome) before adjusting secondary programming parameters or trying a difference coding strategy
If the patient is still struggling after one month of use, you may attempt to try different stimulation rates within the recommended coding strategy
If issue persists, you may evaluate whether alternative signal coding strategies provide improved performance - consider providing them with multiple programs to try in real-world settings

Question 17

What are streamlined signal coding strategies and programming platforms?

Answer 17

Manufacturer developed
Created to address the increasing number of recipients and poor reimbursement rates for CI mapping (making it financially infeasible to spend a great deal of time with each patient)
Focuses on a few electrodes and uses this information to apply it to the remaining electrodes

Question 18

What is comprehensive programming?

Answer 18

Involves determining stimulation levels for each electrode contact in the array

Question 19

What happens when stimulation levels are appropriately set?

Answer 19

The cochlear implant recipient should experience a wide range of loudness experiences across various input levels (soft to very loud)
These experiences should be similar to what people with normal hearing would experience for the same sounds

Question 20

What are the two types of stimulation levels?

Answer 20

Upper stimulation levels
Minimum levels of audibility

Question 21

What are minimum stimulation levels?

Answer 21

The lowest level of electrical stimulation required at each electrode to provide audibility
T levels allow the recipient to hear the softest sounds of speech and the environment

Question 22

Does the exact definition of minimum stimulation levels vary across manufacturers?

Answer 22

Yes
Advanced Bionics: lowest amount of electrical stimulation a user can detect with 50% accuracy; T levels; can be locked to 10% of the DR
MED-EL: highest level at which a response is not obtained; THR; an be locked to 10% of the DR
Cochlear: the minimum amount of electrical stimulation the recipient can detect 100% of the time; T levels

Question 23

Does a larger dynamic range indicate better performance?

Answer 23

Yes
The larger the DR, the better the sound quality

Question 24

What is the procedure for setting the t-levels?

Answer 24

Assessment of T-levels often begins on a LF channel presented at a level that is clearly audible, but not uncomfortable
T-levels should be based on responses acquired in the ascending direction to ensure audibility of soft acoustic inputs and to avoid T-tail
Step size for ascending and descending presentations varies initially - larger step sizes are recommended for the first few appointments to accommodate potential changes in response levels

Question 25

What are the different approaches for setting the T-level?

Answer 25

Traditional threshold measurement Count the beep method Psychophysical loudness scaling Threshold estimation

Question 26

Why can assessment of precise T-levels be difficult at initial activation?

Answer 26

Recipients are not accustomed to the signal from the implant It may have been a long time since a recipient has heard any kind of auditory signal at a particular frequency (or they may have never heard at a certain frequency) Recipient may be experiencing tinnitus or internal noise within the auditory system, which is difficult to discern from the programming stimulus

Question 27

Can improperly programmed T-levels lead to negative consequences?

Answer 27

Yes If set too low, the recipient will not have adequate audibility of low-level or soft sounds If set too high, the recipient may experience excessive ambient noise and a reduced electrical dynamic range

Question 28

What are upper stimulation levels?

Answer 28

The max electrical stimulation level of sound that the recipient can comfortable tolerate at any given time

Question 29

Does the definition of upper stimulation levels vary across manufacturers?

Answer 29

Yes Advanced Bionics: most comfortable; M levels MED-EL: very loud but comfortable; MCL Cochlear: loud, C levels

Question 30

What are the procedures for setting the upper stimulation levels?

Answer 30

Psychophysical loudness scaling - Pt is asked to indicate the loudness percept of the stimulus by pointing to a loudness scale chart; clinician gradually increases the level if programming stimulus until the Pt reports that it is comfortably loud Global increase while the user listens to speech - upper stimulation levels will be set where speech and environmental sounds are most comfortable; clinician may choose to tilt or provide decrease or increase in LF or HF of the array to address Pt complaint

Question 31

What are some considerations for setting the upper stimulation levels?

Answer 31

Recipients differ in what they initially will tolerate The clinician must balance the importance of an optimal cochlear implant program with the prevention of overstimulation in the early stages of implant use Maximum level of stimulation that a recipient will tolerate is likely to change over the first few months of cochlear implant use Many users reach optimal performance after several weeks Some may need gradual adjustments over several months to reach an optimal upper-stimulation level Few are comfortable with appropriate upper-stimulation levels in the first days or week of use

Question 32

What are upper stimulation levels critical for?

Answer 32

Preventing sounds in the environment from being uncomfortably loud Supporting speech recognition and sound quality Enabling prelingually deafened children to monitor their own voice and develop intelligible speech

Question 33

What happens if the upper stimulation level is set incorrectly?

Answer 33

May lead to overstimulation Which may cause discomfort, poor speech recognition, reduced overall sound quality, an aversive reaction to CI, poor overall outcomes especially in children relying on auditory feedback for speech development

Question 34

What is loudness balancing?

Answer 34

Map optimization Should be conducted at upper-stimulation levels for two channels at a time (or at 80% of the upper stimulation level for Med-El recipients) Typically begins with the most apical channels and progresses toward the basal end For recipients who have a difficult time tolerating high-frequency stimuli, conduct loudness balancing from the basal end toward the apical end It is important to stress to the recipient that he or she should attend to the loudness of the signal and not to the pitch of the signal When conducting loudness balancing, the adjustment to the stimulation level always should be to the second electrode in the pair because the first electrode is balanced to the preceding electrodes in the array

Question 35

Why do we perform loudness balancing?

Answer 35

Aims to ensure equal loudness at upper-stimulation levels in order to optimize speech recognition and sound quality by maintaining the typical loudness/intensity relationship that exists for different phonemes Uneven loudness levels between high and low frequencies may lead to the perception of fricatives being significantly louder than vowels, reducing speech recognition If one electrode has a much louder C level than others, it may dominate overall loudness perception, leading the recipient to adjust the volume control for comfort, resulting in suboptimal levels for the remaining electrodes

Question 36

What is sweeping?

Answer 36

Sequential presentation of the programming stimulus across all electrode contacts in the array, starting from the apical end and ending at the base

Question 37

Why do we perform sweeping?

Answer 37

Conducted during the early stages of implant use or when the user experiences sound quality issues or nonauditory side effects (facial nerve stimulation) Three objectives: measuring sound quality (not performed at every mapping session), determining appropriate pitch transitions, and confirming equal loudness across all channels

Question 38

Does Med-El offer an anatomy-based fitting?

Answer 38

Yes The goal of this is to reduce the spectral mismatch through imaging Identify where each electrode contact is in each individual cochlea post-operatively Use that information to apply place-specific map with individualized center frequencies for each contact that is a closer match to the natural frequency-place Just have to pull the file of this mapping into the patient file in the software

Question 39

Does Med-El have the longest electrode array on the market?

Answer 39

Yes

Question 40

What might counseling a patient include?

Answer 40

Discussion of device proper use and speech processor basic functionality, such as attaching the coil, charging batteries, adjusting volume, and changing programs, sensitivity…etc Discussion of device care and maintenance of all components of the external equipment (i.e., processor, cable, coil, battery, remote, etc.) Discussion of different programs provided (if applicable) and when they should be used Discussion of importance of aural rehabilitation Discussion of consistent device use and realistic expectations Set a goal of full-time use of the device (10+ hours per day)

Question 41

When can you tell if the map is right for the patient?

Answer 41

Allows the user to access quiet spoken language while not exceeding levels of comfort Users are expected to wear the device consistently for a minimum of 10 hours per day User should be able to hear ≤ 30 dB HL User should be able to detect/repeat all Ling sounds (ah/ /oo/ ee/ /sh/ /s/ /m/) User should be able to hear to at least 30 feet (Carol Flexer) Expect user to be able to overhear (incidental listening) User should be able to tolerate loud sounds

Question 42

How do you evaluate progress of patients?

Answer 42

Varies depending on the duration of device usage by the patient Up to one month: Informal speech perception measures (e.g., common phrases, numbers, Ling sounds). One to three months: CNC words in the implanted ear and in the everyday listening condition. Optional: AzBio Sentences at 65 dBA with a +10 dB SNR in the everyday listening condition and patient-reported satisfaction measures (e.g., SSQ, CI-QOL)

Question 43

What is the maintenance phase?

Answer 43

Pts should enter this when successful optimization is reached - SF threshold better than 30 dB, 10+ hours/day with datalogs, post-op CNC of 56% or better in the implanted ear or the score has improved by at least 20% If the patient has not yet met these milestones or if other concerns exist, they can remain in the optimization phase for further support (seeing if the map is right and evaluating progress)