The University of Southampton

Author: Georgia Bannister

Should Adults Qualify for Bilateral Cochlear Implants?

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NICE guidelines state that ‘simultaneous bilateral cochlear implantation is recommended as an option for […]: children; adults who are blind or who have other disabilities’. Unilateral cochlear implantation is recommended for those with severe to profound deafness but bilateral cochlear implantation is not recommended on a cost-effectiveness basis. With the improvements shown below for adults after receiving a second implant, why does the NHS only cover unilateral implantation?

For Bilateral Cochlear ImplantsAgainst Bilateral Cochlear Implants
Improved speech perception in noisy situationsPossible worsening of tinnitus as a side effect
Improved directional perception of soundNot considered cost-effective
Easier, less exhausting conversation
Table demonstrating reasons from the NICE guidelines for and against bilateral cochlear implantation for adults. The data came from a small sample of studies.

When making decisions for the guidance ‘the committee did not consider […] different cochlear implant systems were associated with different cost-effectiveness profiles’. The main focus of the guidelines was to find the cheapest option to restore hearing, and this is repeated throughout the document. The guidelines were made in 2009. A 2018 update included a 15% reduction in costs that were not adjusted for in cost-effectiveness profiles, and a lack of update as to current models on the market.

It was found that for a simultaneous bilateral implant in an adult to be cost-effective, the NHS would require a 75% discount on the second implant. Although simultaneous bilateral implantation has better results than sequential bilateral implantation, adult patients who wish to have bilateral implants are forced into sequential implantation as they must fund the second implant themselves.

It is time these guidelines are reassessed using a larger sample size and a greater focus on patient wellbeing and quality of life. If data still shows that bilateral implantation is not cost-effective, could the NHS look to cover some of the second implant cost?

Deaf adults should receive the same level of care as deaf children. The data used is identical for children and adults, but the NICE committee came to the conclusion that children are more cost-effective and will have a greater improvement in quality of life after receiving bilateral implants. Expecting deaf adults to pay upwards of £20,000 for their healthcare when other, more expensive surgeries are covered does not sit right with me. This leaves deaf adults unnecessarily struggling day to day which is unfortunate given people with hearing loss are twice as likely to experience mental health difficulties.

Making the only route to restoring hearing to the level science can an expensive one is unfair to put on someone who is likely to be struggling to work. This is particularly prominent for those with sudden deafness (i.e. from illness or injury) or those whose hearing has declined rapidly, preventing them from having time to save money. Many people end up fundraising for their second implant, but restoring hearing should not be a luxury few can afford – particularly given that the individual cost of an expensive implant is not far below that of a pair of cheaper implants.

Comparing Behind-the-ear and Off-the-ear Cochlear Implants of UK Brands

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Cochlear implants have been an approved method of treatment for the profoundly, and more recently severely, deaf since the late 20th century. Their continued technological improvements since have provided those patients with the ability to hear through a processor (Hainarosie, 2014). The audio is not a perfect replication of natural hearing, but allows for interpretation of speech and sound in a way the brain can understand. Modern technology around cochlear implants provides patients with the option to have the external processor of their implant either behind their ear or off of their ear. Both designs allow for bluetooth connection between phone and processor, and each option has its own positives and negatives for users to consider.

Behind-the-ear (BTE) Cochlear Implants

BTE cochlear implants are the originals – this design for the external processor has been used since implantation in the cochlear began. The processor (containing the microphone) sits on the ear of the user and a short cable connects this to the magnet that transfers the audio information to the electrodes implanted in the cochlear. The location of the microphone on these processors differs between companies. For example, Advanced Bionics’ Naida Cl M sound processor has the microphone dipping down into the outer ear region whereas Cochlear’s Nucleus 8 sound processor has dual microphones. Each company has taken a slightly different approach to the goal of reducing background noise and making the sound as close to natural hearing as possible.

BTE – Naida Cl M sound processor – Advanced Bionics

OTE – Kanso 2 sound processor – Cochlear

Off-the-ear (OTE) Cochlear Implants

OTE cochlear implants are a more recent development in cochlear implant technology with Cochlear’s Kanso 1 sound processor being released in 2016. These processors contain only one piece that sits on the side of the head connecting directly to the magnet inside the head. There is no part that rests on the ear. Because of this, some users find it more comfortable because their ear can have a break from holding the processor. However, it is often found that the magnet needs to be stronger to ensure that the processor does not fall off because it is a less secure connection. This is a problem for some people as they feel more comfortable with a processor on their ear when they are playing sport or in other situations where the processor could get dislodged. The single piece design of the OTE processor means that the microphone is placed on the side of the head. This can have some impact on the audio that the user receives as it is not being collected from the natural location – the outer ear.

Conclusion

Some cochlear implant users opt to obtain both a BTE and OTE sound processor after surgery so that they can use each to their strengths. Throughout reading for this blog I found that my preferred design is the Naida Cl M sound processor by Advanced Bionics because of its microphone location and BTE design. A BTE design allows for better microphone placement and a more secure feeling whilst an OTE design allows for a more discrete processor with fewer pieces attached to the head – perhaps making glasses or hat wearing slightly easier. To improve comfort around OTE sound processors, there are clips and headbands available. I think that it is important for each user to be able to weigh up the pros and cons of each processor type to make an informed decision about which would work best with their lifestyle. Perhaps the difference in age between two patients would be enough to result in different choices. Access to both processor types appears to be a great solution for those who find that OTE and BTE processors are each useful in different parts of their life.

Further reading suggestions:

A Reddit thread discussing personal experiences with OTE and BTE processors:

https://www.reddit.com/r/Cochlearimplants/comments/wtdkvd/ote_kanso_2_vs_traditional_bte_processors/?rdt=42393

A list of current cochlear implant processors available in the UK:

https://www.bcig.org.uk/ci_manufacturers.aspx

Cochlear’s comparison of their current sound processors:

https://www.cochlear.com/us/en/home/products-and-accessories/cochlear-nucleus-system/nucleus-sound-processors/compare-nucleus-sound-processors

References:

Hainarosie, M., Zainea , V. and Hainarosie , R. (2014) ‘The evolution of cochlear implant technology and its clinical relevance’. Journal of Medicine and Life. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4391344/ (Accessed: 8 March 2024).

Sheep

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My favourite breed of sheep are Herdwick sheep. They are found in the Lake District and have distinctive white faces and grey wool. They have evolved over many centuries with the assistance of selective breeding to be hardy to survive out on the fells all year round. Modern farming uses Herdwick sheep for meat.

Domestication of sheep has been traced back about 10,000 years with Herdwick sheep being introduced to Britain around 5,500 years ago descending from the Northern Pin Tail group of sheep. Genetic analysis shows that Herdwick sheep are closely related to the Soay and North Ronaldsay sheep.