Pediatric Cochlear Implants: Candidacy, Diagnosis, & Mapping

[Dr. Prashant Malhotra]
Our goal is to see them right upon identification of hearing loss. We're not just a pediatric implant center. We actually manage kids with hearing losses of all types.

[Dr. Gopi Shah]
For the pediatric cochlear implant population, what percentage is your failed newborn hearing screen? And then what percentage is your delayed onset kids who are over the age of two? I guess your two categories would be prelingual and postlingual?

[Dr. Prashant Malhotra]
I think that earlier on, about eight years ago, we were capturing a lot of the older kids because there was a backlog of their cases. It was probably 80% postlingual, late ID patients. Now, I would say that we are seeing more young babies and kids, so the split is about 50%.

We still see with etiologies like congenital CMV and other progressive losses as we've implemented targeted and then universal screening for CMV in our NICUs and trying to extend them to the surrounding areas. We're capturing those kids and monitoring them very carefully, and then following them when they become implantable later on. But I would still say, we're probably 50% of the babies at this point.

[Dr. Ashley Agan]
What does the appointment look like? First, we can talk about the patients who were diagnosed at birth. So they've failed their newborn hearing screen and they're referred to you to have additional testing. What can parents expect as they go through that process, up to the point when they're actually being recommended for a cochlear implant?

[Dr. Prashant Malhotra]
After diagnosis, which may be done at an outside facility, they'll come to us. Actually, we have a pretty wide catchment area, so we might capture them at first. A very consistent message from the very beginning is incredibly valuable. We've got good relationships with audiologists, and they are pretty well aware of when patients are coming to cochlear implant category level. After that first diagnostic ABR is complete, audiologists may say, "Hey, look, we need to set up an ENT appointment and a follow-up audiology appointment." They'll kind of lay that groundwork.

At that first ENT appointment with me, I view these counseling appointments as super essential. I take the appropriate amount of time to do it, and I tell this to the residents and the fellows as well. I honestly believe that if we don't take the time to do it, nobody else does. I don't think that a lot of general ENTs feel very comfortable with the pediatric cochlear implant counseling pathway. They might not want to put words in the mouth of the program that they refer to.

For some families I'm going to do a quicker play. But sometimes, I’ll do a slow play and say, "Hey, look, you know what? Let's just make sure we go to the hearing aid evaluation, or we'll get our second ABR, and then we'll meet again to take the next steps." Typically at that first appointment, we'll try to do two things: Set up the diagnostic pathway, and then set up the treatment pathway.

My first appointment (and actually all every follow-up appointment) is: Where are we at on those pathways? My diagnostic part, do we know the reason why? And then, what are we doing about it? And are we where we need to be on our timeline for that?

[Dr. Prashant Malhotra]
I really appreciate you guys having me on. I guess a couple of other things that I was thinking about is, any child with an implant who's not doing well. If you see them, capture them in your office and send them out to the CI center to evaluate what's going on. They should make sure their mapping is up to date. If need be, get a CT scan to make sure there are no issues with the implants.

If I haven't seen them in a couple of years, because now they're in school, my goal is to make sure they're making the progress we anticipated them to make. It always pains me when I see somebody comes back and they haven't seen anybody in like six years, and their speech is not very well managed and they're struggling in school. I just wish that they had seen somebody.

The families don't always know that long-term mapping and programming needs to be done. I think that you come across someone and they're not really performing very well, send them back to the CI center. If they haven't had a mapping in a year, they need to be seeing somebody.

We do try to help families with those transitions on educational milestones. In kindergarten, as they go to middle school and high school, there is still a ceiling on some of the things that an implant can provide kids. They still have issues with reading, spelling, and literacy kinds of things.

If I think about all the things a family will ask me when they find out their kid is deaf. They always think about things like sports and academics and all these things, and the kids can usually do these very well. But, they still need to be ushered even after that critical period of when they started to get into school. And I think it's not in our realm to typically think about this as otolaryngologists. We’re not teachers, but I've definitely seen that as time has gone on, I've really taken on just making sure that we really plugged them in with the resources appropriately so they can succeed. It does take work even after they've left our halls. When I see the older kids, I'm really worried about the long-term outcomes a lot.

If you send them back to the CI center, then they should at least be visiting a speech therapist when they're older, doing literacy evaluations, and making sure their IPEs are written. All of these things can still help them from an educational standpoint, even if they don't specifically need speech therapy.

[Dr. Gopi Shah]
What's the followup? Should they be coming every year? Do they see you during that one month when you put the processor on? What does the post-op short-term and long-term look like?

[Dr. Prashant Malhotra]
After surgery, I'll see them at a post-op visit, which typically is a telemedicine visit, just for an incision check. Then, they will be seeing the audiologist in-person, who will be able to monitor. If anybody has any concerns, they'll notify me and I can always get them in for an in-person appointment.

I'll usually see them at six months afterwards, to make sure that they've been plugged in and making their appointments. I'd rather find out in several months, as opposed to like a year later, that they'd never made their activation appointment, or they're not seeing speech therapy. So I'll see them at the post-op, at six months, and every six months for the first year or so. For the younger kids, I'll see them every six months until they get into kindergarten. For the older kids, I'll see them every six months for at least a year and then annually. I do want to see them every year. There is a Medicaid expansion, in our state, in which hearing loss is an eligible qualifying diagnosis. In order to continue with these services, they have to see me once a year. So that's a nice thing to help some people keep coming back. The older kids don't often see me every year. That's just not going to necessarily happen, especially if they're doing really well. But, they should still be seeing audiology at least yearly from their mapping.