.png){kind=small}
.png){kind=small}
BackTable / ENT / Article
Aural Rehabilitation Goals for Children with Cochlear Implants
Iman Iqbal • Updated Nov 28, 2024 • 34 hits
Cochlear implants can offer significant benefits, but long-term success with an implant often depends on ongoing aural rehabilitation care. While aural rehabilitation in younger patients focuses on sound access and speech development, older individuals move toward more advanced speech recognition.
Audiologist Dr. Sarah Cordingley examines the key factors that contribute to the success of cochlear implants and the role of long-term aural rehabilitation care in achieving and maintaining optimal outcomes. This article features excerpts from the BackTable ENT Podcast. You can listen to the full podcast below.
The BackTable ENT Brief
• Cochlear implant success is measured by the physical use of the device–how often it is worn and activated–and the development of speech, with a focus on age-appropriate milestones.
• For young children, the primary concern is ensuring good access to sound, which is evaluated through visual reinforcement audiometry (VRA) or conditioned play audiometry (CPA), assessing thresholds across key frequencies like 500, 1,000, 2,000, and 4,000 Hertz.
• Speech development is tracked over time, with more advanced testing for older children and adults, including word and sentence repetition to assess progress.
• The timeline for aural rehabilitation varies depending on factors like hearing history, device wear time, and commitment to therapy, with improvements typically visible within a few months.
• Success is subjective, varying from patients who achieve near-perfect speech recognition to those who are simply happy with gaining access to sound, especially in cases of long-term deafness.
• Many patients continue to rely on tools such as lip-reading, closed captioning, and streaming devices, especially for older adults and children undergoing aural rehabilitation.
• Initial follow-up visits occur every six months, transitioning to annual check-ups as children stabilize, with some patients needing reprogramming due to hormonal changes, medications, or injuries.
• Long-term complications are rare, though re-implantation may be necessary in cases of poor outcomes or physical damage, with adjustments generally happening quicker than the initial implantation.
Table of Contents
(1) Aural Rehabilitation Goals for Children with Cochlear Implants
(2) Long-term Objectives of Aural Rehabilitation in Cochlear Implant Patients
Aural Rehabilitation Goals for Children with Cochlear Implants
The process of measuring success in cochlear implantation involves various metrics, starting with the physical use of the device. One key factor is how long children wear the cochlear implant with it activated, as well as how well they are developing speech. For infants, the primary concern is ensuring good access to sound, which is assessed through behavioral responses like visual reinforcement audiometry (VRA) or conditioned play audiometry (CPA), focusing on thresholds across specific frequencies. While speech outcomes vary by age, early intervention teams play a significant role in tracking progress and addressing any issues that arise, such as difficulties distinguishing certain sounds.
For older children and adults, more advanced speech testing is conducted, and the focus expands to word and sentence repetition. In younger children, audiologists aim to establish good thresholds across frequencies like 500, 1,000, 2,000, and 4,000 Hertz, though sometimes it takes several appointments to achieve full audio testing. Aural rehabilitation timelines vary widely depending on individual factors like hearing history, wear time, and commitment to therapy. Most patients see improvement in a few months, with adults often experiencing better results compared to their hearing aid use. However, success is subjective, and expectations differ among patients, ranging from achieving near-perfect speech recognition to simply gaining access to sound, especially for long-term deafened individuals.
Additionally, while cochlear implants provide significant benefits, many patients still rely on other tools, such as lip-reading, closed captioning, or streaming devices, to improve communication. Audiologists continue to advise the use of these resources, especially for patients who are undergoing rehabilitation or in specific situations like school. The need for such aids can persist across ages, though younger patients who received implants early tend to require less external assistance as they grow older.
[Dr. Sarah Cordingley]
The ideal would be that they can repeat words at near 100%, 90 plus or sentences. That's not the realistic expectation for everybody. Given all the things we talked about before, the metrics do change based on age for sure. Obviously, like I said, when they're infants, they're not going to repeat words for you. If you can get into a point to their nose, you're doing really well.
Again, we're just in really good contact with the early intervention team and how are they doing? Are they making progress? Are we missing something? They'll sometimes pick up on stuff that's like, they aren't telling the difference between these two words and it's an F versus an S. Can you look at that frequency and see if there's something we can change there? Really specific stuff like that, or this kid's not hearing anything at all. Something's wrong. Everything in between.
In the clinic, when they're really young, we're mostly just confirming good thresholds, aided thresholds. Put them in the booth with the cochlear implant on and do our diagnostic testing with VRA or CPA, how quiet can we make the sound? They still react to it. As long as they've got good access to sound, our job at that point is sort of done, right? We got to get as good of a program as we can on that kid. If they've got good thresholds, we've done that. Then we send it to early intervention and those people to take that good program and get that kid to learn language from it.
…
As that kid gets older, we can do more in the clinic. Repeat words, repeat sentences, all sorts of different speech testing to see if they're making progress.
[Dr. Gopi Shah]
When you test the kids or the infants using VRA or CPA, is it the same four frequencies that we normally test for? Are you also including high frequency or is it just 500, 1,000, or are we going higher?
[Dr. Sarah Cordingley]
Our goal for a little, little, like 12 to 18 months, if we can get 500, 1,000, 2,000, and 4,000 on each side, we're doing good. That's a good day. We're happy for that. Sometimes all we get is like a speech threshold and 2,000 Hertz. Then we come back on another day and--
…
For older kids and adults, we do include 250 and 6,000 Hertz. Cochlear implants aren't very good up at 8,000 Hertz, so we don't usually test that one, but we will try and get six.
[Dr. Gopi Shah]
The timeline, we mentioned like one month, three months, six months, a year. What is the expectation for like aural rehabilitation? Does it take a full year? Is this something like, nah, you're going to start using it well if you do this for in three months? Is it just, what's the range? I guess maybe a better question.
[Dr. Sarah Cordingley]
Yes, we get that question all the time from patients, right? When am I going to get a 100% correct? I don't know, dude, that's a good question. Like I said, there's that theme again of like everybody's different and they're hearing history and their buy-in and their wear time and their dedication to any aural rehab plays a huge part. I would say that as long as you're wearing it really well, 10-plus hours a day, you're going to make some good progress.
I would say, we can safely tell patients, at least that typical adult patient. Within a few months, you're going to be doing much better than you did with your hearing aid. I'm not going to tell you you're going to get a 100% correct on my word test, but you'll be doing better. It's still a funny relationship that the patient sometimes has with their cochlear implant.
Sometimes you can get that patient that comes in and they get 96, a 100% percent, something like that, and they hate it. It's awful. It's the worst thing they've ever done and they regret it, or you get that like long-term deafened patient who knows they're not going to get speech out of it, but they are thrilled that they have some thresholds. It's the best decision they ever made in their life. It's really variety of what does success mean to you? What does success mean to me for you? It varies widely and we do our best to counsel, but it's going to sound different.
It's not going to sound like your hearing aid. It's not going to sound like it did when you were 20. It's going to sound different, but sometimes it's just still weird.
[Dr. Gopi Shah]
How often do patients who have their implants on still, get benefit from closed caption or lip reading? How often do you advise or recommend some of those things to help or ASL or visual language to help communicate?
[Dr. Sarah Cordingley]
Yes, a lot, a lot. I would say the patients who got their implant when they were really young and now they're 20 or 30, they do pretty well and they don't use a lot of closed captioning or speech to text on their phone or anything like that. I would say for the vast majority of adult patients, those things are still true. Those things still help a lot.
The other thing that really helps is streaming. Most manufacturers have a way to connect the TV to your implants with streams directly or phones or whatever device you're trying to use. As the audiologist, you can even turn off the environmental mics so that they're not hearing outside noise. They're only getting that streaming. For the, 75 year old guy that really likes to sit and watch the news all day, that's life changing for him. Connectivity to that TV is really important. For our littles, it depends on the situation. Are you working on aural rehab at the time or are you trying to function, right? If you're in school, I want you to use every resource at your disposal. You need a sign language interpreter? Do it. You need a note taker? Do it. You need a remote microphone? Do it. Whatever, and I'm not a school audiologist, so I don't do all of that. If you need those supports, then grea, but if you're in speech therapy and you're working on that, like you got to make it hard. You got to do that or you're never going to improve. Hopefully the improving that in those therapy sessions can generalize over to other things. We still use a lot of additional help and resources.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Long-term Objectives of Aural Rehabilitation in Cochlear Implant Patients
After a child has had a cochlear implant for roughly one to two years, follow-up typically becomes less frequent. Initial follow-ups every six months transition to annual check-ups as the child stabilizes. Some patients may not need a visit for up to two to three years if they’re doing well. However, changes in hormone levels due to puberty, pregnancy, or menopause can sometimes necessitate a visit for reprogramming. Medications and physical trauma, such as an injury to the internal component of the implant, are rare but possible causes of complications.
Long-term complications are uncommon. A small percent of cochlear implant patients may require re-implantation due to poor speech outcomes or damage from physical impact. Although re-implantation is rare, it usually leads to a quicker adjustment for the patient compared to initial implantation, with only a few days to weeks needed to adapt.
The lifespan of cochlear implants is estimated at around 80 years, though the technology hasn’t been around long enough to confirm this. Older implants, some over 20-30 years old, still function, but certain early models may not be compatible with modern external devices, necessitating re-implantation for upgrades.
[Dr. Gopi Shah]
Let's say now we've been a year and a half to two years out and the child is wearing the cochlear implant. We're seeing progress and speech and engagement and communication. How often do them after? What does long-term follow-up look like DCM? Every two years? Every year? How often do you have to make adjustments to like, do you have to make adjustments again to programming?
[Dr. Sarah Cordingley]
The longer they have it, the more stable it is as a general rule. We follow them every six months for a few years at least, and then try and go to annual. Some patients will go like two or three years before we see them again and they're doing great. They're doing fine. They get an upgrade and they need us to program it or show them how to use it or whatever. It's definitely getting less and less.
I think it used to be you'd see them every three months for years. We're finding we don't need to do that much and that they're doing pretty well and things are pretty stable. We do see changes anytime there are hormone changes-
…
-puberty, pregnancy, menopause, those kinds of things. Yes. Medications, certain medications can do really weird things. Sometimes like we had one kid that bonked just right and hurt that internal. Things like that happen. For the most part, it's been sailing after a couple of years.
[Dr. Gopi Shah]
What major complications do you guys see five to 10 years out?
[Dr. Sarah Cordingley]
Very few.
[Dr. Gopi Shah]
I know on our side, every once in a while, you might get such a significant infection where every once in a while it has to be removed and re-implanted and things like that. That's not common, thankfully.
[Dr. Sarah Cordingley]
It's not. I've been doing this for almost 10 years now and I can think of like a small handful of patients that we've had to re-implant for one reason or another. Advanced Bionics did have their recall in the last couple of years or so. We had a good chunk in our clinic that had to get re-implanted for that. That's an out-of-the-norm thing.
Outside of that, I can think of maybe three or four that our clinic has had to re-implant and anything from there was one patient just sort of not doing well. She just wasn't getting good thresholds. She wasn't getting good speech. She just, no matter what we did, we brought in the rep, we reprogrammed and no matter what, it just wasn't good. We re-implanted her and she's doing great. Like I said, I had that one kid that bonked just right on the corner of a table, and hurt the antenna on the inside. Had to get re-implanted. Once in a blue moon, but for the most part, there's nothing.
[Dr. Gopi Shah]
When you have to get re-implanted, like for those kids, was there another initial period until they got used to the new implant of aural rehab? They slide right back in pretty easy?
[Dr. Sarah Cordingley]
They slide much faster. Yes. It's like maybe like days to weeks instead of weeks to months. It depends on their age too, and like how long they were off the air, how long they had a poor program, or there's a lot of things that can make it so it's easier or harder for the re-implant.
[Dr. Gopi Shah]
Then do we know what the life span is on a cochlear implant? Because now we have babies with implants or infants, adults who've gotten implants 20 years ago. Do we know the life expectancy or the technology so dated now, or does that stuff happen?
[Dr. Sarah Cordingley]
Not much. I've been told that cochlear implants were designed for an 80-year lifespan, but like cochlear implants haven't been around for 80 years. We don't know that that's the lifespan. There have been a few cases, like the really, really old implants. Really early on, Cochlear America's implants are still in heads and still being used. They're 20, 30 years old now, and still functional.
Podcast Contributors
Dr. Sarah Cordingley
Dr. Sarah Cordingley, Aud, CCC-A is an audiology specialist practicing in Provo, Utah.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2024, July 9). Ep. 180 – Aural Rehabilitation After Pediatric Cochlear Implantation: Expert Insight from Audiology [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Navigating the Cochlear Implant Process: A Guide for Parents & Practitioners