Cochlear implant

A cochlear implant (CI) is a surgically implanted electronic device that provides a sense of sound to a person who is profoundly deaf or severely hard of hearing in both ears. Cochlear implants bypass the normal hearing process; they have a microphone and some electronics that reside outside the skin, generally behind the ear, which transmits a signal to an array of electrodes placed in the cochlea, which stimulate the cochlear nerve.

The procedure in which the device is implanted is usually done under general anesthesia. Risks of the procedures include mastoiditis, otitis media (acute or with effusion), shifting of the implanted device requiring a second procedure, damage to the facial nerve, damage to the chorda tympani, and wound infections. People may experience problems with dizziness and balance for up to a few months after the procedure; these problems generally resolve, but for people over 70, they tend not to.

Evidence is of low to moderate quality that when CIs are implanted in both ears at the same time, they improve hearing in noisy places for people with severe loss of hearing but other measures are mixed. Implanting the CIs sequentially instead of simultaneously makes things worse or causes no change. There is some evidence that implanting CIs to improve hearing, may also improve tinnitus but there is some risk that it may cause people who never had tinnitus to get it.

There is some controversy around the devices; much of the strongest objection to cochlear implants has come from the Deaf community, which consists largely of pre-lingually deaf people whose first language is a sign language. For some in the Deaf community, cochlear implants are an affront to their culture, which as they view it, is a minority threatened by the hearing majority.

Parts of the cochlear implant
Cochlear implants bypass most of the peripheral auditory system which receives sound and converts that sound into movements of hair cells in the cochlea; the inside-portion of these hair cells release potassium ions in response to the movement of the hairs, and the potassium in turn stimulates other cells to release the neurotransmitter, glutamate, which makes the cochlear nerve send signals to the brain, which creates the experience of sound. Instead, the devices pick up sound and digitize it, convert that digitized sound into electrical signals, and transmits those signals to electrodes embedded in the cochlea. The electrodes electrically stimulate the cochlear nerve, causing it to send signals to the brain.

There are several systems available, but generally they have the following components:
 * External


 * one or more microphones that pick up sound from the environment
 * a speech processor which selectively filters sound to prioritize audible speech
 * a transmitter that sends power and the processed sound signals across the skin to the internal device by electromagnetic induction,
 * Internal:


 * a receiver/stimulator, which receive signals from the speech processor and converts them into electric impulses.
 * an electrode array embedded in the cochlea

Surgical procedure
The surgical procedure most often used to implant the device is called mastoidectomy with facial recess approach (MFRA). In cases where the person who will receive the implants's anatomy doesn't allow MFRA, other approaches, such as through the suprameatal triangle are used. A systematic literature review published in 2016 found that studies comparing the two approaches were generally small, not randomized, and retrospective so were not useful for making generalizations; it is not known which approach is safer or more effective.

The procedure is usually done under general anesthesia. Risks of the procedures include mastoiditis, otitis media (acute or with effusion), shifting of the implanted device requiring a second procedure, damage to the facial nerve, damage to the chorda tympani, and wound infections.

The rate of complications is about 12% for minor complications and 3% for major complications; major complications include infections, facial paralysis, and device failure. To avoid the risk of bacterial meningitis, which while low is about thirty times as high compared to people who don't undergo CI procedures, the FDA recommends vaccination prior to the procedure. The rate of transient facial nerve palsy is estimated to be approximately 1%. Device failure requiring reimplantation is estimated to occur in 2.5-6% of the time. Up to one-third of people experience disequilibrium, vertigo, or vestibular weakness lasting more than 1 week after the procedure; in people under 70 these symptoms generally resolve over weeks to months, but in people over 70 the problems tend to persist.

Efficacy
A 2011 AHRQ review of the evidence of the effectiveness of CI in people with bilateral hearing loss - the device's primary use - found low to moderate quality data that showed: speech perception in noisy conditions was much better for people who had implants in both ears done at the same time, compared to people who had only one; that no conclusions could be drawn about changes in speech perception in quiet conditions and health-related quality-of-life. There was only one good study comparing implanting implants in both ears at the same time, to implanting them sequentially; this study found that in the sequential approach, the 2nd implantation made no change, or made things worse.

A 2015 review, examining whether CI implantation to treat people with bilateral hearing loss had any effect on tinnitus, found the quality of evidence to be poor, and the results variable: overall total tinnitus suppression rates varied from 8% to 45% of people who received CI; decrease of tinnitus was seen in 25% to 72%, of people; for 0% to 36% of the people there was no change; increase of tinnitus occurred in between 0% to 25% of patients; and in between 0 - 10% of cases, people who didn't have tinnitus before the procedure, got it.

A 2016 systematic review of CI for people with unilateral hearing loss found that of the studies conducted and published, none were randomized, only one evaluated a control group, and no study was blinded; after eliminated multiple uses of the same subjects, the authors found that 137 people with UHL had received a CI. While acknowledging the weakness of the data, the authors found that CI in people with UHL improves sound localization compared with other treatments in people who lost hearing after they learned to speak; in the one study that examined this, CI did improve sound localization in people with UHL who lost hearing before learning to speak. It appeared to improve speech perception and to reduce tinnitus.

A 2015 literature review on the use of CI for people with auditory neuropathy spectrum disorder found that description and diagnosis of the condition was too heterogeneous as of that date, to make clear claims about whether CI is a safe and effective way to manage it.

Usage
As of December 2012, approximately 324,000 people worldwide had cochlear implants surgically implanted; in the U.S., roughly 58,000 adults and 38,000 children had been recipients.

Cost
In the United States, medical costs run from US$45,000 to US$125,000; this includes evaluation, the surgery itself, hardware (device), hospitalization and rehabilitation. Some or all of this may be covered by health insurance. In the United Kingdom, the NHS covers cochlear implants in full, as does Medicare in Australia, and the Department of Health in Ireland, Seguridad Social in Spain and Israel, and the Ministry of Health or ACC (depending on the cause of deafness) in New Zealand. According to the US National Institute on Deafness and Other Communication Disorders, the estimated total cost is $60,000 per person implanted.

A study by Johns Hopkins University determined that for a three-year-old child who receives them, cochlear implants can save $30,000 to $50,000 in special-education costs for elementary and secondary schools as the child is more likely to be mainstreamed in school and thus use fewer support services than similarly deaf children.

Manufacturers
As of 2013, the three cochlear implant devices approved for use in the U.S. were manufactured by Cochlear Limited (Australia), Advanced Bionics (USA, a division of Sonova) and MED-EL (Austria). In Europe, Africa, Asia, South America, and Canada, an additional device manufactured by Neurelec (France, a division of William Demant) was available. A device made by Nurotron (China) was also available in some parts of the world. Each manufacturer has adapted some of the successful innovations of the other companies to its own devices. There is no consensus that any one of these implants is superior to the others. Users of all devices report a wide range of performance after implantation.

Criticism and controversy
Much of the strongest objection to cochlear implants has come from the Deaf community, which consists largely of pre-lingually deaf people whose first language is a sign language. For some in the Deaf community, cochlear implants are an affront to their culture, which as they view it, is a minority threatened by the hearing majority. This is an old problem for the deaf community, going back as far as the 18th century with the argument of manualism vs. oralism. This is consistent with medicalisation and the standardisation of the 'normal' body in the 19th century, when differences between normal and abnormal began to be debated. Despite the cochlear implant being justified from a medical perspective, it is also important to consider the sociocultural context, particularly in regards to the Deaf community, which considers itself to possess its own unique language and culture. This accounts for the cochlear implant being seen as an affront to their culture, as many do not believe that deafness is something that needs to be cured. However, it has also been argued that this does not necessarily have to be the case; the cochlear implant can act as a tool Deaf people can use to access the 'hearing world' without losing their Deaf identity.

Cochlear implants for congenitally deaf children are considered to be most effective when implanted at a young age, during the critical period in which the brain is still learning to interpret sound. Hence they are implanted before the recipients can decide for themselves, on the assumption that deafness is a disability. Deaf culture critics argue that the cochlear implant and the subsequent therapy often become the focus of the child's identity at the expense of a possible future deaf identity and ease of communication in sign language, and claim that measuring the child's success only by their mastery of hearing and speech will lead to a poor self-image as "disabled" (because the implants do not produce normal hearing) rather than having the healthy self-concept of a proudly deaf person.

Children with cochlear implants are more likely to be educated orally, in the standard fashion, and without access to sign language (Spencer et al. 2003). They are often isolated from other deaf children and from sign language (Spencer 2003). Children do not always receive support in the educational system to fulfill their needs as they may require special education environments and Educational Assistants. According to Johnston (2004), cochlear implants have been one of the technological and social factors implicated in the decline of sign languages in the developed world. Some of the more extreme responses from Deaf activists have labeled the widespread implantation of children as "cultural genocide". Andrew Solomon of the New York Times states that "Much National Association of the Deaf propaganda about the danger of implants is alarmist; some of it is positively inaccurate."

As the trend for cochlear implants in children grows, deaf-community advocates have tried to counter the "either or" formulation of oralism vs manualism with a "both and" approach; some schools now are successfully integrating cochlear implants with sign language in their educational programs.