Implantables Flashcards

Question

What are the theoretical advantages of middle ear implants, and which of these remain applicable today? ( true today)

Answer 1

**Greater Gain:** increased gain prior to acoustic feedback. but feedback risk remains due to enhanced mechanical oscillation. **Avoidance of the Occlusion Effect**: crucial for individuals with external otitis or skin allergies. unaffected by cerumen-related problems. **Improved Comfort:** especially with fully implanted **Higher-Fidelity Sound:** higher-fidelity sound w/less distortion. ***Aesthetic Appeal:*** especially if components are implanted under the skin. (today) ***Continuous Wear:*** Fully implantable allow 24/7 wear, including showering and sleeping, with minimal acoustic feedback risk. (today)

Answer 2

* **Surgical Procedure:** Requires 1-2 hours under general anesthesia, w/ facial nerve injury and infection risk. Complication rates are generally low, but healing time is needed before activation. * **Cost and Insurance:** Higher costs, not typically covered by insurance. PT's out-of-pocket expenses for AuD services. * **Hearing Implications:** Some MEI involve disarticulation of ossicular chain, resulting in maximum conductive hearing loss when inactive. * **Not MRI Compatibile**: Most MEI contain magnets, prohibiting MRI without implant removal. ***Exception***: MED-EL VIBRANT SOUNDBRIDGE allows MRI up to 1.5-tesla without removal. * **Verification Challenges:** REM unfeasible for verifying gain/output settings. b/c MEI don't produce acoustic output in the ear canal, making traditional

Answer 3

**MED-EL VIBRANT SOUNDBRIDGE** allows MRI up to **1.5-tesla** without removal.

Answer 4

Piezoelectric Electromagnetic Electromechanical

Answer 5

Piezoelectric

Answer 6

Pros * **No external power needed** * **strong stability and durable**. Cons * not enough amplification formoderate to severe hearing loss due to their **limited output and narrow bandwidth**

Answer 7

Electromagnetic

Answer 8

Pros: None? Cons: * output is dependent on the magnet to coil distance * increased distance = decreased output.

Answer 9

Electromechanical

Answer 10

Pros: * highest output and widest frequency responses * Not affected by variable output due to changes in magnet to coil distance. (housed together) Cons: * More complex design and more prone to mechanical failure. Small drawback now with modern tech

Answer 11

Partially Implantable * Vibrant Soundbridge * MAXUM Fully Implantable * Envoy Esteem

Answer 12

1. A receiving coil that surrounds a biocompatible magnet 2. An internal processor and stimulator (i.e., the “demodulator”) 3. A lead (the Conductor Link) that delivers electrical current from the stimulator to the transducer 4. Floating Mass Transducer (FMT)

Answer 13

MED-EL Vibrant Soundbridge * **Partially implantable MEI** * Two basic: **External sound processor** (SAMBA 2 audio processor & the MED-EL Vibrant Soundbridge **Implant** * **Electromagnetic Transducer** * Microphone capures sound --> analyzed by digital signal processor--> converted to electrical --> transmitted via electromagnetic to--> processor transmitting coil --> coil recieves and converts to electrical signal --> to implant processor for analysis --> eletrical current down the conductor link --> to FMT (electromechanical) --> coil creats mag field and magnet ossilate wi/FNT

Answer 14

Partially Implantable MEI * An external sound processor known as SAMBA 2 audio processor * The MED-EL VIBRANT SOUNDBRIDGE implant

Answer 15

FMT coupled to the **long process of the incus** * rarely couple to the incus body * for mixed/condutive HL - coupled to round window

Answer 16

* Sound is pick up by the microphones on the sound Processor and analyzed by the digital signal processor * Signal is converted to electrical current and transmitted though the processor transmitted coil * coil recives and converts to electrical signal & delivered to implant * Analysised by implant * travels down conductor link lead to FMT * FMT is magnet and col to create magnetic field (electromagnetic) Sound picked up --> analyzed --> converted to electric --> transmitted through coil--> coil converts to electrocal signal--> delivers to implant ---> analysied --> travel down conductor link lead --.> to FMT--> | Not that important

Answer 17

* CHL * Retrocohlear or Cental Auditory disorder * Tympanic membrane perforation associated w/ME infection * A skin or scalp condition | MEI

Answer 18

An externaly worn Ear Level Sound Processor aka Integrated Processor & Coil (IPC). made up of.. * Micorphone * Digital SIgnal Processor * Eletroomagnetic coil Magnet (house in titanium) * attached to ossicles

Answer 19

* IPC (Integrated Processor & Coil) houses both sound processor & eletromagtic coil * IPC receives sound, amplifies it and convert to electrical current * delivered to electromagnetic coil * as E current travel throough coil it's converted to electromagnetic signal * EM signal moves across the TM and towards MAXUM Magnet * Magnet coupled to neck of stapes * engages in electromagtic virbations and process

Answer 20

* CHL * Retrocohlear or CAPD * Active Middle ear infections * TM perfs w/recurrent ME infection * Disabling tinnitus

Answer 21

Envoy Esteem

Answer 22

Pizeoeletric

Answer 23

Implated in the **temporal bone** 1. Sensor 2. Sound Processor 3. Driver 4. Non-rechargeable lithium - iodide battery

Answer 24

A surgically implanted component that is coupled to a structure in the middle ear and that mechanically oscillates to facilitate stimulation of the cochlea.

Answer 25

* armature (moves) & the yoke (fixed) w/small air spaces between them * Armature is surrounded by wired coils and contains a permanent magnet (yoke remains fixed and does not move) * electrical current is delivered though the coil creating a magnetic field in the amature * fluctuations of field = oscillating magnetic field * creating attract and repel between the armuture and yoke * creating mehcnical energy that is transmistted to the skull when sound processor is coupled to the head.

Answer 26

**External sound processor** * captures acoutics signals, converst to mechnical vibration and delivers the M vibrations to the internal component **Titanium components** * surgically implanted in the skull and used to deliver mechnical vibrations to the cochlea via bone conduction

Answer 27

* Peri-implant infection * Flap Necrosis * Loss of the abutment (infection or trauma) * Osseointegration failure * Skin Numbness * Skin overgrowth over the abutment

Answer 28

**Osseointegrated:** implants require surgically placing an implant screw that integrates with the temporal bone. (bone adheres to screw) **Non-osseointegrated:** implants are attached to the bone of the skull, but do not rely on osseointegration for the function of the device

Answer 29

Skin Drive: Vibrations are transmitted to the bone through the skin via an external drive placed on the skin surface Direct Drive: Vibrations are directly transmitted to the bone through an implanted transducer without the need for skin transmission

Answer 30

**Percutaneous**: Penetrating the skin; this is what people refer to as Baha **Transcutaneous:** Across the skin. vibrations from the soound processor are transmitted across the skin. * keeps skin intect.

Answer 31

Active: Implanted; implant generate vibrations that is directly applied to the bone. (direct drive bone condution). * Optimal BC sound transmission Passive: Transducer is imbeded in the speech processor. Sound processor generates stimultion that is applied from the outside onto the skin. * less optimal, Skin attenuates sound

Answer 32

Percutaneous systems & Transcutaneous systems

Answer 33

* 5 yrs + & 2.5 mm skull thickness * CHL & no benefit from HA's * Mixed HL Mild to Moderate SNHL w/BC thrsholds of 65db or better * for SSD Better ear BC thresholds 20db HL or better (but these imlants are generally able to provide enough stimultion that will allow transfer of the BC signal to the better hearing ear w/mild HL

Answer 34

Skin drive: vibrations are transmitted to the bone through the skin via an external device placed on the skin surface * headband * Softband * adjoin * **Baha attract** * **Sophono**

Answer 35

Direct drive: vibrations are directly transmitted to the bone through an implanted transducer without the need for skin transmission * Baha * Ponto * BoneBridge * BCI

Answer 36

* process in which bone cells attach/adhere to the surface of a metal (titanium) surface. * implants require surgically placing an implant screw that integrates with the temporal bone. * BAHA * BAHA attract * Osia * Ponto

Answer 37

implants are attached to the bone of the skull, but do not rely on osseointegration for the function of the device. * Bonebridge * Sophono

Answer 38

Passive: transducer is imbeded in the speech processor. stimultion is applied outside onto the skin. Less optimal * BAHA * Baha Attract * Sophono * Headband * Softband

Answer 39

Active: transducer implanted, directly to the bone. Optimal tranmission * Bonebridge * BCI

Answer 40

Penetrating the skin; this is what people refer to as Baha. * Baha * Ponto

Answer 41

Across the skin. The vibrations from the sound processor are transmitted across the skin. Keeps the skin intact. * Baha Attrect * Sophono * Headband * Softband * Bonebridge (trans & active) * BCI (trans & active)

Answer 42

Osseointegration refers to the process in which **bone cells attach/adhere to the surface of a metal (titanium) surface.**

Answer 43

* 5 yrs + w/ 2.5mm skull thickness & at least 3mm skin thickness. * BC thresholds of 45dbHL ot better * Best for CHL or SSD w/ normal BC thresholds in better ear (due to any attenuation casued by the skin

Answer 44

A screw is surgically placed and eventually, osseointegrate to the temporal bone; bone cells attach/adhere forming a *biologic attachment*. * **One stage:** implant with the abutment is placed as a single piece in one surgical setting * **Two stages:** the fixture is implanted in the first stage and the abutment is placed after osseointegration has taken place which is usually 3–6 months

Answer 45

* Lower rate of complications at and around incision site * Minimal wound care * Better aesthetics; invisable * Less risk of trauma to implant * Can be activated wi/ 4 weeks of surgery

Answer 46

* Optimal Signal Delivery * Better for PT's w/ sensitive skin * Excellent retention for active recipients * Approved for MRI w/strength up to 3T * artifact/shadow minimized

Answer 47

* higher risk of abutment - related complications (skin overgrowth, infections and granulation tissue) * high risk of loss or truma * high hygiene maintain * 3 to 6 mos waiting btwn surgery and coupling of processor to abutment (allow for osseointegration) * Astheic concerns * Issues w/ attching soound processor when dexterity is a cocern

Answer 48

* Skin attenutaion up to 20db * insufficient power for BC mild to moderate HL * not MRI cleared above 1.5 T * magnetic plate create artifact and shadowing around the implant area * magnet pressure could aggreavate soft tissue problems

Answer 49

* AC threshfrom 250 - 8k * BC Thresholds 250,500,1,1.5,2,3,4 (mask when possible) * WRS (CNC & Az-Bio)

Answer 50

* Average BC thresholds @500,1,2 & 3 khz candidate if **≤ 65 dB HL** (65 dB HL or better) * Average ABG @500,1,2 & 4khz Candidate if **≥ 30 dB** (ABG is 30 dB or greater) * 5 yrs + (surgical) * Any age (Non-surgical)

Answer 51

* Poor ear: Profound SNHL **≥ 80 dB HL** (80 dB HL or worse) * Good Ear: AC PTA (500,1,2,3) **≤ 20 dB** (20 dB HL or better) * 5+ (surgical) * any age (non surgical)

Answer 52

BCD alleviates the head shadow effect **improving speech recognition** in quiet and in noise when speech arrives from the side of the poorer ear.

Answer 53

efficacy remains **uncertain** with variability in outcomes across studies.

Answer 54

Significant improvement in audibility, speech recognition in quiet and in noise, and localization.

Answer 55

mild BC thresholds typically experience significant **audibility improvements**, while those with poorer thresholds may not benefit as much from BCDs.

Answer 56

* **Functional Gain SF**, Warble tone detection thresholds (500 -6khz) * **Unaided & aided CNC** @65 *dbSPL* speaker 0 azimuth, 1 meter away * Adaptive speech in noise, Aided & unaided. (**QuickSIN**, BKB-SIN) 65dbA signal routed to a speaker 0 and 1 meter away & noise 90 or 180 behind PT * Compare performance between **aided and unaided**

Answer 57

* **Functional gain SF**, Warble tone (500-6khz) * Adaptive Speech in noise aided & unaided **@65dbA** (**quickSIN**,BKB-SIN) * 90 and -90 (270) azimuth * Signal to poorer ear and noise to better ear * Improved SNR between aided and unaided = BCD benefit | (no CNC unlike CHL)

Answer 58

Cochlear Baha * **Baha Connect** * **Baha Attract** * **Osia** Otocon * **Ponto** MED-EL * **Bonebridge** * **ADHEAR** Medtronic * **Sophono** Non-surgical * **Baha 5 Softband** * **SoundArc**

Answer 59

Cochlear Baha Oticon Ponto MED-EL BONEBRIDGE Medtronic Sophono

Answer 60

**Baha Connect** * Osseointergated * Percutaneous * Direct Drive * Passive **Baha Attract** * Osseointegrated * Transcutaneous * Skin Drive * Passive

Answer 61

* Osseointegrated (tioblast) * Percutaneous * Passive * Direct Drive * FDA 12 week gap btwn implantation & connection * activation wi/4-6 wks * MRI compatabile 3T

Answer 62

* Osseointegrated * Transcutaneous * Passive * Sjkin Drive * 4 wks should pass btwn implantation and * MRI 1.5 T

Answer 63

* no movement between parts that wear down over time * excellent hearing performace * slim, smart and robust * powerful and consistent performace

Answer 64

* Non-Osseointegrated * Transcutaneous (completely under the skin) * Active * Direct drive * wireless signal transmission between the SAMBA 2 audio processor and the active implant.

Answer 65

* non-osseointegrated * Transcutaneous * Passive * Skin drive * 45 minute surgery * MRI 3 T

Answer 66

* Non - surgical * Stick, click, hear * Skin drive * passive * Contains an adhesive adapter placed behind the ear coupled to the sound processor and delivers mechanical oscillations to mastoid bone

Answer 67

* ADHEAR * Baha Softband & Sound Arc

Answer 68

A cochlear implant is a device surgically inserted into the ear to help people with severe HL it works by directly stimulting the auditory nerve using electrical signals, bypassing the damaged parts of the inner ear.

Answer 69

The hair cells are damaged. CI bypass this by directly stimulting the auditory nerve with electrodes. The electrodes are inserted into the cochlea. They send electrical impulses that stimulate the auditory nerve fibers indirectly, through the cochlear structures. and

Answer 70

Cochlear Nucleus Advanced Biontics MED-EL

Answer 71

**Labeled:** Manufacturer-defined indications listed in the physician's package insert. **Off-labeled:** Provision of a CI to a patient who does *not* meet the approved indications is often referred to as “off-label” use.

Answer 72

Labeled: when Patient meets the criteria for CI Off -labled: SSD for example in AB - only have label for bilateral

Answer 73

* Well informed about the product. * Base its use on firm scientific rationale and on sound medical evidence. * Maintain records of the product's use and effects.

Answer 74

(9-24 Months) * Profound SNHL in both ears Children (2-17 Years) * Severe to profound SNHL in both ears 18 yrs + * Moderate-profound SNHL, bilaterally. * CNC 60% or less → AzBio Score of 60% or less.

Answer 75

**9 - 24 mos:** Profound bilateral SNHL >90db HL at 1,00hz **2 - 17 yrs:** bilateral severe to profound SNHL * Limited benfit from binaural HA's * Lack of progress in development auditory skills with HA's & aural rehab for 3 to 6 mos * 3-6 mos HA trial

Answer 76

* 5 years+ * Normal or nearly normal hearing sensitivity in the better ear; severe to profound SNHL in the poorer ear * Score of 5% or less using CNC; additional recommendations based on MSTB3 you could AzBio 0 SNR.

Answer 77

AHL * 5 years+ * Thresholds 90 dB HL or greater in the ear to be implanted and mild to moderately severe SNHL in the better with a difference of 15 dB HL or more between ears. * Score of 5% or less using CNC; additional recommendations based on MSTB3 you could AzBio 0 SNR.

Answer 78

EAS/Hybrid * 18 years+ * Thresholds of 60 dB HL or better through 500 Hz and 70 or worse for 2000 Hz+ * A score of 60% or less using CNC → a score of 60% or less using AzBio at 10 dB SNR

Answer 79

SSD is defined as **profound sensorineural hearing loss in one ear** and normal hearing or mild sensorineural hearing loss in the other ear.

Answer 80

AHL is defined as **profound sensorineural hearing loss in one ear and mild to moderately severe sensorineural hearing loss in the other ear**, with a difference of at least 15 dB inPTAs.

Answer 81

* bilateral moderate-to-profound SNHL with limited benefit from appropriate HAs. ≤60% correct scores in the best-aided listening condition on open-set sentence cognition tests. * No ME infection, normal inner ear and auditory nerve. * No contraindications to surgery. * The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.

Answer 82

If the child has been diagnosed with Meningitis, they will implant before ossification.

Answer 83

Min: 9 months Max: none, if they if they meet the criteria

Answer 84

Imaging of the cochlea anatomy with CT or MRI to determine: * If it is **possible to insert an electrode array** * Confirm that the **auditory nerve is present and/or normal** * Which **ear** may be **most suitable**

Answer 85

Anatomic * Absent cochlea or cochlear nerve * Neurological damage impeding aud processing * Damaged auditory cortex Medical * Medical conditions preventing surgery * Medical risks of surgery outweight benefits Not a CI candidate * a child who has signifant residual hearing & good HA benefit * Absence of CN 8 * Absence of the labyrinth * 20 + w/prelingual HL * cognitive impairments that would prevent rehab * active external or middle ear infection * allergy ot intolerance to device materials

Answer 86

* Duration of deafness Longer = worse outcomes * Age of implantation Younger = better outcomes * Motivation & support Higher = better outcomes * Mode of communication Listening and spoken language support better outcomes * Etiology Some causes predict better outcomes (e.g., genetic, Meniere’s) * socioeconomic status Higher SES = better outcomes * Preoperative residual hearing Some hearing = better outcomes

Answer 87

60/60 guideline **referal for CI eval criteria** PT's should be referred if * in their better ear they score **60%** or worse on **WRS** unaided * **PTA** in the better ear is **60dbHL** or worse unaided

Answer 88

Before 60/60 audiologists we're not referring patients that needed to be referred due to the fact that they didn’t know the qualification criteria for referral.

Answer 89

* Comprehensive Audiological Evaluation * Hearing Aid Verification * Aided Speech Recognition Testing * Outcome Measures

Answer 90

* to **assess hearing preservation** and **guide post - op** amplification strategy * to **support counseling** by setting expectation about potential HL

Answer 91

* Comprehensive Audiological Evaluation * Hearing Aid Verification * Aided Speech Recognition Testing * Outcome Measures

Answer 92

Comprehensive Audiological Evaluation * Otoscopy * Acoustic Immittance * Air conduction * 125 - 8,000hz w/inserts

Answer 93

Hearing Aid Verification * Choose and fit HA's to optimize WRS performance * Listening check and or electroacoustic test for internal noise or distortion * REM to verify output matches targets * Verify output with a calibrated speech signal at 60/65 dbSPL

Answer 94

Aided Speech Recognition Testing * Speech discrimination score are key for candidacy * Calibrate - very important * Aided Speech recohnition is evaluted w/ the minimum speech test battery (MSTB) * CNC & AzBio (RE only,LE only & bilateral if needed)

Answer 95

Outcome measures * Patient reported outcome measures. * Questionnaires.

Answer 96

* Hearing aids should be fit appropriately to maximize aided speech performance.

Answer 97

Calibration ensures **speech stimuli are presented at consistent, clinically relevant levels**. * Enables reliable tracking of PT's Progress * Outcome measures remain valid & compariable * inaccurate calibration = inappropriate CI referrals (under or over qualified)

Answer 98

SF calibration uses speech simuli Input calibration & Output Calibration

Answer 99

Input calibration – **prevents distortion or clipping of the input signal**

Answer 100

Output calibration – **ensures that speech materials are presented in the SF at the intended level**

Answer 101

* program the CI * Monitor the developemnt of speech perception * provide an indication of auditoy function or how child is usng CI to hear

Answer 102

MSTB-3 provides a structured protocol for postoperative testing * **Unaided** audiometric thresholds (125 to 8000 Hz) in the **implanted ear**; this includes AC & BC * **Unaided** thresholds for the **non-implanted** ear (for bimodal listeners) * **Aided soundfield** thresholds for the implanted ear(s) * **Aided speech assessment** * Speech Recognition Testing CNC and AzBio tests under aided conditions * May include comparison between CI alone and CI + HA (for bimodal benefit)

Answer 103

Questionaires to evalute percived benfit and/or quality of life * CIQOL-10, SSQ-12, THI, GAD-7, PHQ-9 (as needed) * Assess QOL, communication, mental health, and patient perception

Answer 104

Postoperative testing at **3 months & 12 months** following implantation for all patients * If performance is **suboptimal at 3 mos** consider additional testing before 12 mos

Answer 105

**CNC** & AzBio

Answer 106

* **Plug and muff** approach, ideal for patients who struggle to process signal from masking noise. * **Masking noise** delivered via insert earphones to the better ear. * **Insert earphone + circumaural headphones**; combines acoustic sealing with masking for enhanced isolation

Answer 107

Normal OAE & Abnormal ABR

Answer 108

ANSD involves disrupted neural synchrony, often at the inner hair cells, auditory nerve, or brainstem. Identifying the site of lesion is critical to: * Predict CI outcomes * Guide appropriate intervention strategies * Rule out non-cochlear causes that may not benefit from implantation The presence of ANSD may influence CI candidacy decisions and postoperative expectations

Answer 109

* Microphone * Digital Speech Processor * Cord, Coil/antenna * Magnet * Power source

Answer 110

Magnet Receiving/transmitting coil Digital signal processor: Stimulator for electric pulse generation Electrode leads Electrode array

Answer 111

* **Magnet**: Maintain connectivity with external hardware * **Receiving/transmitting coil:** Receives data delivered by external transmitter via radio frequency * **Digital signal processor:** Receives signals from the speech processor and converts them into electric impulses. * **Stimulator for electric pulse generation:** Decodes, analyzes, and delivers data to electrode array * **Electrode leads:** Deliver the electric current from the stimulator to the electrode array that is housed within the cochlea. * **Electrode array:**Stimulate the auditory nerve fibers in the cochlea

Answer 112

1. **Microphone** 2. **Speech Processor** 3. **Cord** 4. **External transmitter** 5. **Magnet** 6. **Power source**

Answer 113

1. **Microphone** picks up the acoustical signal and converts it to an electrical signal for input to the speech processor. 2. **Speech Processor** converts a microphone input into electrical stimulation. 3. **Cord** for delivery of electrical data. 4. **External transmitter** to deliver data to the internal receiver (antenna) via radio frequency. 5. **Magnet** to locate and maintain connectivity between internal and external components. 6. **Power source**: Rechargeable or disposable batteries

Answer 114

* A microphone picks up sound from the environment, amplifies it, and converts it into an electrical signal. * The electrical signal is transmitted to the speech processor. The amplitude, duration, and rate of these pulses are controlled by the speech processor. * The speech processor analyzes incoming speech and converts it into digital information * The speech processor sends this digital information to the external transmitting coil. * The external coil transmits both power and digital information through a RF link to the internal receiver/stimulator. * The receiver decodes the digital signal and delivers electrical stimulation pulses to the electrode array implanted inside the cochlea. * The electrodes stimulate the auditory nerve terminals using a series of biphasic current pulses.

Answer 115

(9-24 Months) * Profound SNHL in both ears Children (2-17 Years) * Severe to profound SNHL in both ears 18 yrs + * Moderate-profound SNHL, bilaterally. * CNC 60% or less → AzBio Score of 60% or less.

Answer 116

* 18 years+ * Thresholds of 60 dB HL or better through 500 Hz and 70 or worse for 2000+ Hz * SNHL - No ABG greater than 15db * A score of 60% or less using CNC → a score of 60% or less using AzBio at 10 dB SNR

Answer 117

* **5 years+** * Better ear: Normal or nearly normal hearing sensitivity in the better ear * Poor Ear: **severe to profound SNHL** * **5% or less using CNC**; additional recommendations based on MSTB3 you could AzBio 0 SNR.

Answer 118

* 5 years+ * Poor Ear: profound SNHL * Better Ear: mild to moderately severe SNHL * Difference of 15 db between ears Thresholds 90 dB HL or greater in the ear to be implanted and mild to moderately severe SNHL in the better with a difference of 15 dB HL or more between ears.

Answer 119

* Diagnosis of **bilateral moderate-to-profound SNHL** with limited benefit from appropriate HAs. * **≤60% (or less)** correct scores in the best-aided listening condition on open-set sentence cognition tests. (CNC & AzBio) * **No ME infection, normal inner ear and auditory nerve.** * No contraindications to surgery.

Answer 120

Anatomic * Absent cochlea/cochlear nerve * Neurological damage impeding auditory processing * Damaged auditory cortex Medical * Medical condition(s) preventing surgery * Medical risks of surgery exceed expected benefits Not a CI candidate * A child w/significant residual hearing levels and receives good benefit from HAs * Absence of the VIIIth cranial nerve * Absence of the labyrinth (Michel’s Aplasia) * > 20 yrs patient with prelingual deafness who has never acquired speech * Cognitive impairment that would prevent adequate rehabilitation (dementia) * Lack of adequate support to ensure attendance at activation and programming sessions * Active external or middle ear infections * Known allergy and/or intolerance of device materials

Answer 121

* **Anatomy** abnormality; nerve or cochlea related) * one ear accepts **electrical stimulation** better * Implant the **worse** hearing ear **OR** Implant **better ear** (opposite argument)- It has already benefited from hearing aid, will more readily acclimate to implant * Implant by the patients **dominate hand** * Facial nerve too close to cochlea- may pick other ear * If **no difference may want it on right (speech and hearing centers of brain on left)**

Answer 122

* **Duration of hearing loss and deafness:** Longer durationof deafness = worse CI outcomes * **Age at implantation:** Poorer outcomes in elderly Pt's ↑Age = ↓Outcome Success * **Preoperative hearing status** FDA Indicated PTA does not implant performance * **Etiology:** Pt's w/ Sudden Idiopathic HL, MD, genetic → better outcome TBI,ANSD, acoustic neuroma → poorer outcomes

Answer 123

*referred* for CI eval if... * Better hearing ear → **60% of less on WRS** * HL *PTA* in Better Ear → **60 db HL or worse** (unaided)

Answer 124

* **Preoperative**: goal is to find out if the **patient is a candidate** * **Postoperative**: goal is to determine the **outcome** or the **success** of the implantation

Answer 125

Detailed counseling is vital before cochlear implant activation. * **establish a relatively conservative and realistic expectation** * **review typical performance** at activation * **Strike a balance** between conservative outlook and understanding the value of cochlear implantation. * **discuss the schedule** (audiological, medical, & rehab appt pre and post implantation,) * **familiarize patient/ family** with the implant hardware * provide **written materials**

Answer 126

Strike a balance between **conservative** outlook and **understanding the value** of cochlear implantation.

Answer 127

Helping the patient and family to **establish realistic expectations** is one of the most important objectives prior to activation. * 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.

Answer 128

1. Comprehensive Audiological Evaluation 2. Hearing Aid Verification 3. Aided Speech Recognition Testing 4. Outcome Measures

Answer 129

Speech coding strategies condense the incoming signal into a form suitable for transmission while maintaining the important info

Answer 130

* Hearing aids should be fit appropriately to maximize aided speech performance. * properly fit and programmed to ensure accurate aided results can be obtained

Answer 131

**Microphone** picks up & amplifies sound → converts to electrical signal → to **speech processor**, SP analyzes & converts to digital info → external transmitting coil → Power & Digital info through RF link→ **internal receiver/stimulator**, decodes digital signal → **electrical stimulation** to electrode array (cochlea) → Stimulates **Auditory Nerve** w/ biphasic current pulses → amplitude, duration, and rate of these pulses are controlled by the speech processor.

Answer 132

speech coding strategy determines how the **auditory signal is processed and delivered to the auditory nerve.** * Takes the acoustic signal and transfers it to an electric signal * condense the incoming signal into a form suitable for transmission while maintaining the important info

Answer 133

* Feature-extraction strategies * Waveform strategies (taking the red line (envelope))

Answer 134

Extract spectral information (formants), and uses it to generate the stimulus to the electrodes. * Limitation: no significant improvements on consonant recognition scores

Answer 135

F0/F2 Strategy: Only Extract fomant frequency and F2 F0/F1/F2 Strategy: More successful than F0/F2 based off WRS scores

Answer 136

Extracts formants (F0/F1/F2), but also HF information (800 - 4000 Hz) - showed some improvement but not enough. * Limitation: it tends to make errors in formant extraction, especially in noise

Answer 137

**HiResS and HiResP** * Clinical trials showed HiRes led to better speech recognition | Variants of CIS

Answer 138

In the map, you specify channels, there is frequency range (bands), ex: 100-300 which is transferred to the more apical threshold. * If the contact is stimulating that frequency region and another, it leads to distortion. * More channels/electrodes, better spectral resolution. You are getting more frequency specific. * **improving channel interaction = improving speech quality** * Decreasing channel interaction = increases quality * Less electrodes = less channel interaction

Answer 139

* CIS-based strategy, known as Fine structure Processing (FSP). -- Extracts spectral, envelope, and fine temporal structure information from the input signal. * N-of-m strategies are more spectral and amplitude based.

Answer 140

* The ground electrode is placed under the temporalis muscle (outside the cochlea). * When current is sent to an electrode inside the cochlea, it flows through all tissue between it and the ground electrode. What it flows through determines impedance, due to attenuation from body tissues. * Result: Wide spread of current → less focused stimulation.

Answer 141

* The ground electrode is an electrode on the electrode array (inside cochlea) * Uses two electrodes within the cochlea—one as active and one as ground. * Current flows only between these two electrodes, stimulating a smaller area and allow for more selective stimulation * has not proven useful and is rarely employed. * Result: More focused, selective stimulation → but not commonly used due to poor outcomes.

Answer 142

Monopolar (MP): * Ground Outside cochlea * Broad (through many tissues) * Selectivity Less selective * Commonly used Bipolar (BP): * Ground Inside cochlea (another electrode) * Narrow (limited between two electrodes) * More selective * Rarely used (not very effective)

Answer 143

Active Middle ear effusion may delay cochlear implant surgery and has been reportedly associtaed with reduced hearing during episodes of Otitis media or negative middle ear pressure.

Answer 144

Take advantage of the **place-to-frequency coding mechanism** used by the normal cochlea. Scala tympani over the scala vestibuli becuase... * Larger diameter accommodates the electrode array better * Allows insertion below the fragile cochlear duct and in close proximity to the SG cell bodies * Closer proximity to the round window during surgical insertion * Less intracochlear trauma and better preservation of residual hearing * Leads to better implantation outcomes and reduced postoperative vertigo

Answer 145

* **Larger Diameter** * Allows **insertion below cochlear duct & close to SG Cell Bodies** * Closer to **Round window** during insertion * **Less intraccohlear trauma** & better preservation of resiudual hearing * **better outcomes** & reduced post op vertigo

Answer 146

* Each pulse is equal-sized negative and positive phases, **designed to deliver no net charge through the electrode at the end of the pulse** * This charge balancing avoids the accumulation of charge that could produce toxic tissue reactions

Answer 147

**Charge-balanced biphasic pulses** in CI stimulation * each pulse is equal-sized negative and positive phases designed to deliver no net charge through the electrode at the end of the pulse * This charge balancing avoids the accumulation of charge that could produce toxic tissue reactions

Answer 148

CI's do not replicate * Spontaneous firing rate: * Phase Locking * Stochasticity

Answer 149

Spontaneous firing rate * Spontaneous activity helps **maintain sensitivity and supports coding across a wide dynamic range**. - CIs do not do this

Answer 150

* Cochlear nerve fibers fire at the same point in each sound wave cycle, but due to their refractory period, individual fibers cannot respond to every cycle, so groups of fibers collectively encode sound frequency and pitch up to about 4000 Hz.

Answer 151

Spontaneous firing rate * Spontaneous activity helps **maintain sensitivity and supports coding across a wide dynamic range**. - CIs do not do this

Answer 152

* Random but phase-related firing of individual cochlear nerve fibers. * This randomness across fibers allows neighboring groups to collectively encode the temporal structure, frequency, intensity, and duration of sounds through the volley principle, **enhancing the auditory system's ability to represent complex acoustic signals**.

Answer 153

FALSE Success of CI is surprising because even multichannel CIs cannot replicate the spectral analysis that occurs in the cochlea. * CIs bypass the frequency selectivity of the basilar membrane and replace it by a more coarse division of the audible spectrum. * CI do not replicate Spontaneous firing rate, Phase locking and Stochasticity

Answer 154

1. Basal turn cochleostomy 2. Round window membrane 3. Extended Round Window cochleostomy

Answer 155

* **drilling through the promontory** directly into the basal turn of the scala tympani - avoiding the hook area of the most proximal basal turn * Correct placement of the cochleostomy is critical for avoiding damage to inner ear structures. * An attempt should be made to limit the amount of bone dust within the cochlea to prevent new bone formation.

Answer 156

* RWM is partly hidden behind a ridge from the promontory, which limits visability of RWM during surgery. * The facial recss is used in posterior tympanotomy to impant array * major boundaries of the FR are the facial nerve (FN) and chorda tympani (CT)

Answer 157

FR is triangular space created by drilling between: * chorda tympani anteriorly * facial nerve posteriorly * incus superiorly identify the facial nerve but not to expose it. It is usually possible to spare the chorda tympani. * used as entrance for RWM electrode insertion

Answer 158

* In the RW approach, the membrane's orientation directs the electrode **upward, inward, and forward**. * The crista semilunaris further **pushes it toward the osseous spiral** lamina. * To ensure smooth entry into the scala tympani, surgeons **drill part** of the **posterior round window lip and crista semilunaris.**

Answer 159

Soft surgery refers to cochlear implantation techniques designed to **minimize intracochlear trauma, preserve residual hearing**, and **optimize electrode placement** within the ST relative to SGNs.

Answer 160

Goal is to reduce disruption to delicate cochlear structures such as the **basilar membrane, osseous spiral lamina, and modiolar wall**. It focuses on * Preventing blood and bone dust entry * Using steroids * Careful surgical site selection * Minimizing perilymph leakage and suctioning * Controlling insertion depth

Answer 161

* Preventing blood and bone dust entry * Using steroids * Careful surgical site selection * Minimizing perilymph leakage and suctioning * Controlling insertion depth

Answer 162

* **Facial N Injury**: FN Palsy or paralysis * **Alteration of Taste**: metallic taste * **Infection**: Bacterial meningitis * **Dizziness**: tinnitus or vertigo * **Wound dehiscence / Flap necrosis** aggressive thinning of flap - Most serious compication & Requires device removal. * **Early device failure** * **CSF leak (gusher)**: CSF leak in CI

Answer 163

* Extrusion / Exposure of Device * Displacement of electrodes * Late device failure * Otitis media * Meningitis

Answer 164

TRUE It is can be a late complication post implantation

Answer 165

* Lateral Wall Trauma * Osseous Lamina Fracture

Answer 166

One of the **most commonly** reported types of insertional damage . Lateral wall trauma may occur in several ways * When the basilar membrane is involved, often torn at lateral wall & can cause **penetration of the electrode into scala media.**

Answer 167

* Osseous lamina fracture would sever the dendrites of spiral ganglion cells eventually leading to **ganglion cell degeneration in the affected area.**

Answer 168

* Slow Decline * Uncommon * declining performance, aversive symptoms such as a popping or shocking sensation or intermittent function * only be confirmed by removal,examination & identification

Answer 169

Reimplantation with another device * Relief of symptoms following reimplantation of a new device strongly supports the diagnosis.

Answer 170

* Device Malfunction * easily confirmed with the available assessment tools * Symptoms: ↓Hearing performance & integrity testing shows malfunction

Answer 171

Electrode impedance is a measure of the **opposition to electrical current flow across an electrode when a certain voltage is applied** * Opposition to flow

Answer 172

* Idenify electrode failure * Verification of voltage compliance * Monitor electrode function * Evaluate intraoperative to post op changes * Changes across follow ups

Answer 173

**Definition**: incomplete path for current to flow, or a discontinuous circuit. **Causes**: * Broken electrode contact * Broken lead wire * ossification/buildup * air bubble **Impedance** * HIGH * 30+ kohms

Answer 174

**Definition**: low resistance between two points in a circuit that differ in potential which typically are separated by higher resistance → increase in current flow **Causes**: * kinked or curled array * Excessive distortion or tension on the electrode array. * Electrode lead wires that are touching within the electrode carrier due to damaged insulation. **Impedance** * Low * less than 1 (0 or 0.5)

Answer 175

**Definition**: relatively low resistance resulting in increased current flow, but still higher impedance for a true short circuit. **Causes**: * small tears or fractures in the silicone surrounding the electrode **Impedance** * Low * altering the impedance * zigzag pattern

Answer 176

**Open circuit** * Broken electrode contact * Broken lead wire * ossification/buildup * air bubble

Answer 177

Partial short circuit * small tears or fractures in the silicone

Answer 178

Short circuit * kinked or curled array * Excessive distortion or tension on the electrode array. * Electrode lead wires that are touching within the electrode carrier due to damaged insulation.

Answer 179

* **disabled** but re-evaluated after a period of implant use. *

Answer 180

TRUE Due to accumilation around electrode away

Answer 181

may or may not be disabled, depending on the **extent** to which **performance is affected**

Answer 182

CIs have constant current determined in the software, and the amount of voltage (coming from the battery) changes based on the **impedance of the electrode.**

Answer 183

The **voltage is limited by the battery** - this is called voltage compliance * Using a battery with higher voltage capacity can help avoid reaching the compliance limit. 0 once you reach compliance limit - you cannot increase any more.

Answer 184

Ohm’s law Voltage (V) = Current (I) X Resistance (R)

Answer 185

* Speech recognition and sound quality may be reduced. * Loudness may be unbalanced across the electrode array. * The user may experience non-auditory effects, such as facial nerve stimulation, due to maximum current amplitude.

Answer 186

* Impedance lowest at the time of surgery * After surgery impedance increases due to inflammation * Steroid use during surgical insertion reduce fibrous tissue growth and lower impedance. * Once the implant is stimulated, impedance typically decreases over time. * Impedances should remain stable one to three months post-activation

Answer 187

Impedances should remain stable **1** to **3** months post-activation

Answer 188

* **electrode contact** * **electrode lead that is coupled to the contact** * **Surrounding medium**, including: Cochlear fluids Surrounding tissues Electrolytes Macrophages Proteins

Answer 189

EC is presentation of low-level current to each electrode to remove air bubbles, protein buildup, and so forth.

Answer 190

* Prior to testing in the operating room * At initial activation * At a programming session preceded by a prolonged period of nonuse * When activating electrodes were previously disabled and reactivated

Answer 191

* Cochlear: Custom Sound * Advanced Bionics: SoundWave * MED-EL: Maestro

Answer 192

Custom Sound

Answer 193

Sound Wave

Answer 194

range of acoustic inputs that are mapped to the user's electrical Dynamic range

Answer 195

Lower IDR → Threshold of electrical stimulation.

Answer 196

Upper IDR → maximum electrical stimulation level

Answer 197

lower end = 20 to 30 dB SPL

Answer 198

Upper end = 65 to 85 dB SPL

Answer 199

* Controls the microphone gain in the sound processor. * Adjusts the input signal level before frequency analysis. * Works to shape how acoustic signals are mapped into the user’s electrical DR. * ↑ sensitivity allows softer sounds to be included in the mapped input range, while ↓ sensitivity excludes lower-level sounds.

Answer 200

Frequency allocation table controls **how frequencies are delivered across the active channels**.

Answer 201

* They can also choose from four frequency allocation tables based on different psychoacoustic models. * Current methods include anatomy-based assignment. * **If an electrode is turned off, its frequencies are reallocated to remaining active electrodes**.

Answer 202

**High stimulation rates improve access to fine temporal details in sound. =** Enhanced temporal resolution * Better speech understanding in noise * Improved music perception and appreciation * Recognition of vocal pitch * Potential for improved pitch perception

Answer 203

**Higher rates can result in a higher pitch perception** and increase loudness due to temporal summation.

Answer 204

**Higher rates** can result in a higher pitch percept and **increase loudness due to temporal summation.**

Answer 205

Closer spacing increases the risk of temporal channel interaction, which can degrade performance.

Answer 206

FALSE * It is important to select a magnet strength so the transmitting coil does not 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.**

Answer 207

Prolonged excessive magnet strength may cause **skin necrosis** under the coil, potentially leading to skin flap breakdown and requiring reimplantation.

Answer 208

Middle-aged males and obese recipients may require **stronger magnet strength due to thicker skin flaps.**

Answer 209

Young children and elderly women often need **weaker magnet strength due to thin skin flaps.**

Answer 210

Advanced Bionics: lowest amount of electrical stimulation a user can detect with 50% accuracy; T levels. Can be locked to 10% of the DR. * **Threshold → T Level**

Answer 211

Cochlear: the minimum amount of electrical stimulation the recipient can detect 100% of the time; T levels. * **little Above Threshold → T Level**

Answer 212

MED-EL: highest level at which a response is not obtained; THR. Can be locked to 10% of the DR. * **right below Threshold →THR**

Answer 213

Advanced Bionics: most comfortable; M levels

Answer 214

MED-EL: very loud but comfortable; MCL

Answer 215

Cochlear: loud, C levels

Answer 216

* Start with LF electrode; give them an audible sound and then ascend to find the threshold. * Used to prevent the t tail * Use larger steps early on, and smaller steps for fine tuning after a week.

Answer 217

* Traditional threshold measurement techniques (modified Hughson-Wastlake) * Count-the-beep method * Psychophysical loudness scaling * Threshold estimation

Answer 218

* Psychophysical loudness scaling * Global increase in upper stimulation levels while the user listens to speech

Answer 219

* Pt is asked to indicate the loudness percept of the stimulus by pointing to a loudness scale chart. * Clinicians gradually increase the level of the programming stimulus until the pt reports that it is comfortably loud. | Like MCL's on Audio

Answer 220

* Upper stimulation levels will be set where speech and environmental sounds are most comfortable.

Answer 221

* 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

Answer 222

* too low, the recipient will **not have adequate audibility** of low-level or soft sounds. * too high (i.e., above the real threshold), the recipient may experience **excessive ambient noise** and a reduced electrical dynamic range.

Answer 223

* 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

Answer 224

Loudness balancing 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.

Answer 225

* Measuring sound quality * Determining appropriate pitch transitions * Confirming equal loudness across all channels

Answer 226

* upper-stimulation level for two channels at a time. * begins with the most apical (lows/inside) channel and progresses toward the more basal (high) * PT attend to loudness and not the pitch * adjustment to stimu level **always** should be to the **second electrode**

Answer 227

For recipients who have a difficult time tolerating high-frequency stimuli, conduct from **high to low frequencies**. Basal → Apical

Answer 228

Sweeping involves the sequential presentation of the programming stimulus across **all** electrode contacts in the array, starting from **lows** to **highs**

Answer 229

* Sweeping- depends on your purpose * Loudness balancing, sound quality & speech understanding. To make sure the frequencies are balanced Pitch & comfort

Answer 230

**Otoplan** Goal: To **reduce spectral mismatch through imaging.** * Identify where each electrode contact is * Use that information to apply a place-specific map with individualized center frequencies for each contact that is a closer match to the natural frequency-place.

Answer 231

1. Try lowering the amplitude 2. Increase the pulse width 3. Turn off Electrode * Cochlear → monopolar to bipolar: more focused and reaches less neurons * MED-EL → triphasic stimulation: disperses the current between two reference electrodes instead of just one.

Answer 232

* Up to one month: Informal speech perception measures * One to three months: CNC words in the implanted ear and in the everyday listening condition.

Answer 233

**Sweeping** * levels have been set sweep at the upper-stimulation level * detect any channel-specific undesirable effects such as loudness discomfort or a non-auditory response **Loudness balancing** * Loudness balancing should be completed whenever possible after setting upper-stimulation levels in live speech mode. * loudness balancing around 6 to 7 years - youngest

Answer 234

* map allows gives to access quiet spoken language while not exceeding levels of comfort. * wear consistently min of 10 hours per day. * hear ≤ 30 dB HL * hear to at least 30 feet away * able to tolerate loud sounds

Answer 235

Positive response pattern at activation

Answer 236

Patients enter the maintenance phase when ... * SF thresholds better than 30 dB. * 10 hours +/ day with data logs. * Post-operative CNC word score in the implanted ear is 56% or better; OR. the patient’s scores in the implanted ear have improved by at least 20% when compared to scores obtained in that ear prior to implantation If the patient has not yet met these milestones or if other concerns exist, they can remain in the optimization phase for further support.

Answer 237

* SF thresholds better than 30 dB. * 10 hours +/ day with data logs. * Post-operative CNC word score in the implanted ear is 56% or better; OR. the patient’s scores in the implanted ear have improved by at least 20% when compared to scores obtained in that ear prior to implantation

Answer 238

positive, neutral, or distressed

Answer 239

Neutral or non observable reaction response patterns at activation

Answer 240

Negative: Upset or distressed response pattern

Answer 241

* Early auditory input is a neurodevelopmental emergency — the **brain requires consistent sound exposure to develop speech and language pathways**. * Missing input during this critical period can **cause irreversible delays in auditory and spoken language development.**

Answer 242

Missing input during this critical period can cause **irreversible** delays in **auditory** and **spoken language** development

Answer 243

* Psychophysical loudness scaling * Global adjustment in live speech * Flat MAP * Flat MAP with fine tuning * Estimation from objective measures

Answer 244

* Using play behavior to guide upper-stimulation level settings * In live speech it may be helpful for children to play with noise makers. * **Child Plays with toys = Level too low** * **Child Stops Playing = uncomfortable level, too loud**

Answer 245

* begin with a flat MAP or global increase from T levels and then fine-tune based on the recipient’s feedback. * Upper-stimulation levels are refined to improve sound quality and comfort based on the user’s feedback. Advantages: has the advantage of possibly improving sound quality and recipient performance Limitations: Loudness may still be uneven across electrodes

Answer 246

* Start with flat stimulation levels (T + C), initially inaudible to the child. * live speech mode, gradually increase stimulation * Identify the level where the child first responds to sound—this is used to set T Levels. * Continue increasing upper-stimulation levels while observing the child’s responses to sounds until desired loudness is achieved. * Levels should reflect a typical electrical DR for the implant being used. * Advantages: Quick and easy to implement during live speech mapping and can serve as a starting point for programming in difficult cases or with limited time. * Limitations: Using the same intensity across all channels may result in uneven loudness perception.

Answer 247

“Building From the Floor” Approach * Programming begins by measuring minimal electrical detection levels. * Upper-stimulation levels are then globally increased from the T Level profile using live speech mode. * Clinicians observe the child’s behavior for signs of discomfort or overstimulation * If the child shows signs of distress, programming should be immediately stopped and levels adjusted to ensure comfort.

Answer 248

* Used primarily with older children (8–9 years and up) and adults * Present pulsed electrical signals to individual electrode(s), increasing loudness gradually until patient reports to sound is loud. * Procedure is repeated across multiple electrodes to determine frequency-specific levels. * Advantages: help identify if a child is struggling to access sounds in a specific frequency range or finds a certain channel aversive. * Limitation: Requires consistent reliable responses

Answer 249

* Routine increases can lead to stimulation levels that exceed those used by adults * Overstimulation could hinder long-term auditory performance

Answer 250

First year of device use: Initial activation: 1–4 weeks 1 week post initial activation 2 months post initial activation 3 months post initial activation 6 months post initial activation 9 months post initial activation 12 months post initial activation After the first year * every 3 mos if not reliable * Every 6 to 12 mos if reliable

Answer 251

* contraction of the stapedial muscle in response to intense electrical stimulation from the cochlear implant. * Objective and quick to administer * Preferable methods for setting upper-stimulation levels in children as precise loudness scaling and balancing are often unreliable before age 8.

Answer 252

* Place an acoustic immittance probe (reader) into contralateral ear to the CI * Record acoustic admittance while presenting stimulus to the implant in an ascending manner. * Decrease Stimulation levels to avoid loudness discomfort before activating the sound processor in live speech mode. * Gradually increase the upper-stimulation levels while monitoring. Adjust levels until optimal loudness and sound quality are achieved.

Answer 253

* ESRT for predicting upper-stimulation levels * ESRT is within an average of 9 clinical units of upper-stimulation levels

Answer 254

ESRT is lower than levels set by behavioral measures, making it a safer starting point.

Answer 255

* **middle ear anomalie**s may interfere w/obtaining a measurable response. * If a contralateral ESRT is not measurable, testing may be attempted in the ipsilateral ear. * ESRT measurements may be more **problematic** to measure in **bilaterally implanted** recipients because both ears have undergone surgery.

Answer 256

Electrical Stimulation Threshold needs to be **at or below your ESRT but you are never above** * If they are way above red line = over stimulation * Below Red line = lots Under stimulation

Answer 257

EABR is a neurophysiological test measuring auditory brainstem activity in response to electrical stimulation from a CI. * EABR is recorded from scalp electrodes in response to electrical stimulation from the cochlear implant. * Reflects synchronous firing of neurons in the auditory brainstem. * Waves III and V are typically present, with wave V being most prominent. * **No latency shift** * Waves are generated in the pons and midbrain regions.

Answer 258

We do not need EABR when **telemetry** is present in CI’s because the function and responsiveness is already determined though impedance or ESRT’s * Telemetry: communication between the implant and the hardware; radiofrequency

Answer 259

* confirm implant function or auditory responsiveness in recipients without telemetry systems. * With the development of telemetry and ECAP, the routine clinical use of EABR has declined.

Answer 260

synchronous response from electrically stimulated auditory nerve fibers. (ECochg) * neural response from the distal cochlear nerve fibers and/or spiral ganglion cell bodies of the cochlear nerve. * ECAP give you upper and low levels

Answer 261

* ART (MED-EL), * NRI (AB), * **NRT (Cochlear)**

Answer 262

* Spiral Ganglion Neurons are the most likely generator of the ECAP. * A neural response from the distal cochlear nerve fibers and/or spiral ganglion cell bodies of the cochlear nerve. * (ECochg)

Answer 263

ECAP is recorded as a negative peak (N1) at about 0.2 - 0.4 ms following stimulus onset, followed by a much smaller positive peak (P2) or plateau occurring at about 0.6 - 0.8 ms.

Answer 264

ECAP is essentially the electrical version of Wave I of the ABR with Greater amplitude Shorter latency No myogenic artifact Unaffected by sleep and anesthesia. No need for sedation when measured in children.

Answer 265

* **Current source saturation**: greater distance results in lower voltage. * **Poor reference contact**: Poor contacts = high impedance = recording more difficult andartifacts bigger. * **Stimulation artifact**

Answer 266

Off-set method:

Answer 267

Live Speech method

Answer 268

**Amplitude to growth function**: measuring with ECAP threshold **Refractory function** **Spread of excitation**: Overlap between two electrode * Further = less excitation * Closer = more excitation

Answer 269

Surgically implanted device that directly stimulates the cochlear nucleus of the brainstem.

Answer 270

Difference in speech understanding between CI and ABI is caused by the * **ABI bypassing or distorting activation of specialized neural circuitry** occurring in the CN. * ABI does not make selective contact with the tonotopic dimension of the CN which limits the number of independent channels of spectral information.

Answer 271

Inclusions (must meet both): 1. At least 12 years of age or older who have neurofibromatosis Type II 2. Who are rendered deaf due to bilateral resection of neurofibromas of the auditory nerve

Answer 272

* Children without NF2 * Anatomy Factors * Physiological factors

Answer 273

* Standard surgical risk * Meningitis (risk with all neurosurgery) * CSF leak * Unsuccessful hearing enhancement * Unknown long-term effects of electrical stimulation

Answer 274

Translabyrinthine & Retrosigmoid approach:

Answer 275

Translabyrinthine approach:

Answer 276

Translabyrinthine approach:

Answer 277

Translabyrinthine approach

Answer 278

Retrosigmoid approach

Answer 279

Retrosigmoid approach

Answer 280

Retrosigmoid approach

Answer 281

On the cochlear nucleus

Answer 282

* Confirms stimulation from the electrode array activates the auditory brainstem pathway, as reflected in the eABR waveforms * Assists in optimizing electrode placement by confirming effective stimulation of the CN

Answer 283

* The full surface of the CN is not visible during surgery * No clear anatomical landmarks * Anatomical variations between patients * Removal of large tumor can distort surrounding anatomy

Answer 284

If minor, the following adjustments should be considered: * Reduce current level * Increase the Pulse Width of the electrical pulse * Change the electrode coupling mode to avoid the non auditory side effect. * Reduce pulse rate * If current level reduction does not help, the affected electrodes should be disabled. Non-auditory sensations often decrease over time

Answer 285

* Auditory perception * Tinnitus or ringing sensation * Other sensations (e.g., paresthesias, vertigo, dizziness) * Any combination of auditory and non-auditory effects

Answer 286

**Placement of the device & anatomy** * Motivation to hear - Commitment to rehabilitation * Psychological readiness * Acceptance of device limitations * Anatomical status * Family and support system

Answer 287

* **Development of fibrosis and calcification** * Immediate inflammation is normal but if persists the inflammatory response will become subacute and pass into a chronic phase. Development of fibrosis and calcification and even new bone formation.

Answer 288

ALL OF THE ABOVE * Electrode Impedance will be variable across electrodes and determined by the impedance at each electrode * Voltage: Once stimulation reaches the voltage compliance limit, additional current cannot be delivered. As a result, increasing the current level in the programming software will not result in loudness growth. * Distance from target neural elements: Not in notes but i would say yes because current would need to flow though fluid and tissues and greater distance would = reduced stimulation.

Answer 289

CIS * The CIS strategy uses high-rate pulsatile stimuli to capture the fine temporal details of speech.

Answer 290

Common Ground * Common Ground: Electrical current is delivered to an active intracochlear electrode, and all of the remaining intracochlear electrodes serve as the collective return .

Answer 291

Annoyance w/ HF Stimulation * becuase annoyance with HF stim is common and not just a sign of soft failure - Dr.G

Answer 292

Operates at higher stimulation rates * **ACE (Advanced Combination Encoder) uses higher stimulation rates compared to SPEAK.** * ACE is an N-of-M strategy used in Cochlear Ltd. implants and is currently the default coding strategy for most users. – selects highest envelope signals for each cycle of stimulation * ...Similar to SPEAK but it uses much higher stimulation rates. * Most recipients perform better with ACE than with SPEAK.

Answer 293

Kinked Electrode Array * Kinked electrode array = Short circuit -- Short circut = low impedance (lower than 1) * Broken electrode contact = Open Circuit * Air bubble or ossification = Open Circuit * Prolonged electrode deactivation = Impedance can increase for electrodes that are not stimulated for a period of time

Answer 294

TRUE * Telemetry is the bi-directional communication of data between the programming hardware and the implant, using radio-frequency code. * Telemetry simply means data transmission via radio frequency from a source to a receiving station * Telemetry means receiving data from the implant to ensure that it works within the specification

Answer 295

Electrodes with the highest signal amplitudes

Answer 296

Scala Tympani * The electrode array is typically inserted into the scala tympani, which provides the safest route and closest proximity to the neural elements of the cochlea.

Answer 297

Development of fibrosis and calcification * Immediate inflammation is normal but if persists the inflammatory response will become subacute and pass into a chronic phase. **Development of fibrosis and calcification and even new bone formation.**

Answer 298

HiResP * HiResolution sound processing is available in two commercial forms, HiResS (sequential stimulation) and HiResP (partial stimulation).

Answer 299

Charge-balanced biphasic current pulses * Each pulse is made up of equal-sized negative and positive phases, designed to deliver no net charge through the electrode at the end of the pulse. * Localized electrochemical reactions are reversed during the second phase of the biphasic pulse, ensuring that no net electrochemical products are formed. * **This charge balancing avoids the accumulation of charge that could produce toxic tissue reactions.**

Answer 300

True * “Adaptive directional microphone technology & Speech Tracking” * “Intelligent Sound Adapter 2.0 Noise Reduction”

Answer 301

MED-EL * The longer electrode array of MED-EL arrays may further support FSP by targeting low-frequency nerve fibers in the apical cochlea.

Answer 302

Magnet * Magnet to locate and maintain connectivity between internal and external components.

Answer 303

Receiver-stimulator package * The receiver/stimulator decodes the digital signal and delivers electrical stimulation pulses to the electrode array implanted inside the cochlea.

Answer 304

Spectral formants * **Use feature extraction algorithms to extract type of spectral information, such as formants, to use this information to generate the stimulus to the electrodes** * F0/F1/F2 strategy: available in 1985 with the Nucleus wearable speech processor (WSP). * Average scores on word recognition increased from 30% correct with the F0/F2 processor to 63% correct with the F0/F1/F2 processor.

Answer 305

Filtering * **Filtering: used to divide the pre-emphasized signal into multiple frequency bands** using a filter bank, designed to mimic the natural tonotopic organization of the human cochlea. This separation also allows each band to be processed independently for targeted stimulation

Answer 306

Electrode array * The “electrode array” refers to the distal part of the device that carries the electrode contacts and is inserted into the cochlea. * Electrode contact: describes a physical contact in the internal device electrode array where stimulation is delivered to the auditory nerve fibers. * **Electrode array: Stimulate the auditory nerve fibers in the cochlea**

Answer 307

True * Shape and design of each electrode contact can affect the shape of the resulting current fields.

Answer 308

Match the acoustic signal to electrical dynamic range * Compression: used to compress the incoming signal into the narrow electrical DR to make it suitable for stimulation because of the large difference between the acoustic and electric dynamic ranges.

Answer 309

Electrodes selected for stimulation

Answer 310

**A tear in the silicone insulation** * are bundled separately from each side of the internal receiver-stimulator. Depending on where **silicone fractures** occur,

Answer 311

Mechanism: * Piezoelectric materials oscillate when subjected to electrical stimulation and generate electrical voltage when physically displaced (by vibration or pressure). HA * When coupled to the middle ear, piezoelectric transducers deliver mechanical energy to the ossicles. They convert electrical signals into mechanical vibrations to stimulate hearing OR (depending on configuration) can convert mechanical vibrations into electrical signals for analysis or feedback.

Answer 312

Advantages: ✅ **No external power source** required when used in sensor mode (to detect vibrations). ✅ **Highly stable and durable** due to solid-state design and lack of moving parts in the traditional sense. Limitations: ❌ **Limited output and narrow bandwidth**, which may not provide sufficient amplification for individuals with moderate to severe hearing loss.

Answer 313

TRUE * active middle ear implants, piezoelectric transducers typically convert electrical signals into mechanical vibrations, not the other way around (unless used as a sensor). * hearing amplification, external power is usually required to drive the signal through the system, even if the piezoelectric element itself doesn't need much power or a magnetic field to function.

Answer 314

Mechanism: * Electromagnetic MEIs use electromagnetic induction by placing a biocompatible magnet on the ossicular chain or other middle ear structure, near a stationary wired coil. Function: * When electrical current flows through the coil, it creates a changing magnetic field. This field causes the magnet (attached to the ossicles) to oscillate, which directly stimulates the ossicular chain, converting electrical signals into mechanical energy that the ear perceives as sound. Coil is fixed in position & magnet moves The coil is fixed in the middle ear cavity (usually attached to nearby bone or tissue). → The magnet moves, transferring vibratory energy to the ossicles.

Answer 315

* ✅ Higer output than pizeoelctric * ❌ Output depends on the magnet-coil distance (proximity is critical for consistent performance). * ❌ Head and jaw movements may momentarily alter this distance, potentially affecting sound output or signal transmission.

Answer 316

Magnet and coil are housed together. * ++ They deliver higher output levels and wider frequency responses compared to electromagnetic transducers. * ++ They are not affected by changes in magnet-coil distance. * -- More complex design and more prone to mechanical failure.

Answer 317

* Calculate the average BC thresholds and the average air-bone gap * Average BC threshold at .5, 1, 2 and 3 kHz; patient is a candidate if 65 dB HL or better * Additional considerations: Average air-to-bone gap at .5, 1, 2 and 4 kHz; patient is a candidate if > 30 dB -- **need to have bone gap better results if ABG is 30+** Age: * Surgical solution: 5 years and older * Non-surgical solutions: any age

Answer 318

* Poor ear: Profound sensorineural hearing loss 80 dB HL or worse * Good ear: Air conduction PTA (0.5,1,2,3 kHz) 20 dB or better Age: * Surgical solution: 5 years and older (Osia, Baha, Bonebridge). * Non-surgical solutions: any age * This is essentially a cross device, you have to make sure one cochlea is good so they can hear with bone conduction.

Answer 319

Comprehensive Audiological Evaluation * Otoscopy * Acoustic Immittance * Air conduction * 125 - 8,000hz w/inserts Hearing Aid Verification * Choose and fit HA's to optimize WRS performance * Listening check and or electroacoustic test for internal noise or distortion * REM to verify output matches targets * Verify output with a calibrated speech signal at 60/65 dbSPL Aided Speech Recognition Testing * Speech discrimination score are key for candidacy * Calibrate - very important * Aided Speech recohnition is evaluted w/ the minimum speech test battery (MSTB) * CNC & AzBio (RE only,LE only & bilateral if needed) Outcome measures * Patient reported outcome measures. * Questionnaires.

Answer 320

Least amount of stimulation a recipient can detect when electrical signal (biphasic pulses) are delivered to individual electrode contacts.

Answer 321

Upper limit of electrical stimulation.

Answer 322

Duration or length of one single phase (typically in microseconds)

Answer 323

Current amplitude per phase of a biphasic electrical pulse

Answer 324

Refers to the number of biphasic pulses that are delivered to an individual electrode contact within 1 second (PPS).

Answer 325

Adjustment to channel gain controls the amplification provided to the signal in a channel specific and therefore frequency specific manner. The effect of gain occurs prior to the processing of the signal.

Answer 326

range of acoustic inputs that are mapped to the user's electrical DR

Answer 327

Difference between the CI user’s perceptual threshold and most comfortable level for electrical stimulation.

Answer 328

Frequency allocation table controls how frequencies are delivered across the active channels. * They can also choose from four frequency allocation tables based on different psychoacoustic models. * Current methods include anatomy-based assignment. * If an electrode is turned off, its frequencies are reallocated to remaining active electrodes.

Answer 329

Inaccurate T-level programming * If set too low, the recipient will not have adequate audibility of low-level or soft sounds. * If set too high (i.e., above the real threshold), the recipient may experience excessive ambient noise and a reduced electrical dynamic range Inaccurate upper stimulation levels * 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

Answer 330

* Holding his or her breath * Exhibiting facial expressions of mild concern * Looking to a caregiver for reassurance * Tensing or stiffening of the body or shoulders * Playing more actively or aggressively * Wringing hands, clothes, or toys * Producing blinks in response to the stimulus

Answer 331

ESRT: * ESRT for predicting upper-stimulation levels * ESRT is within an average of 9 clinical units of upper-stimulation levels * Preferable methods for setting upper-stimulation levels in children as precise loudness scaling and balancing are often unreliable before age 8 * ESRT is lower than levels set by behavioral measures, making it a safer starting point ECAP: ART (MED-EL), NRI (AB), and NRT (Cochlear) * The ECAP represents a synchronous response from electrically stimulated auditory nerve fibers. (ECochg) * A neural response from the distal cochlear nerve fibers and/or spiral ganglion cell bodies of the cochlear nerve. * Typically recorded by stimulation of pulses applied to a single electrode at a relatively slow rate * ECAP give you upper and low levels

Answer 332

Threshold needs to be at or below your **ESRT** but you are never above

Answer 333

Facial nerve stimulation is common non-auditory stimulation point * 1st, Try l**owering the amplitude** - the current leak will become less. Drop it until you do not see the facial nerve stimulation anymore. * 2nd, **Increase the pulse width** if the amplitude is not loud enough, this gives the stimulation of more loudness. * 3rd, If they still cannot hear it, and the problem cannot be fixed by the other two ways, you can **turn off the electrode.**

Answer 334

SF thresholds better than 30 dB. 10 hours+/ day with datalogs. Post-operative CNC word score in the implanted ear is 56% or better; OR. the patient’s scores in the implanted ear have improved by at least 20% when compared to scores obtained in that ear prior to implantation

Answer 335

Default IDR 40 to 60 dB.

Implantables Flashcards

(365 cards)