Answering the Call
January 28, 2021
UH Otology Program expands services for patients with disabling hearing loss and related issues
Innovations in Ear, Nose & Throat | Winter 2021
Some 466 million people worldwide have disabling hearing loss, including 34 million children, according to the World Health Organization. That’s 5% of the world’s population. By 2050, the number will grow to more than 900 million people.
Because disabling hearing loss — a hearing loss greater than 40 decibels (dB) — can occur at any age, early detection and intervention are key to minimizing its functional, social, emotional and economic impacts.
“We need to expand and increase our efforts to provide hearing loss treatment options for patients with congenital or acquired hearing loss,” says Alejandro Rivas, MD, the new Division Chief of Otology/Neurotology and Director of the Cochlear Implant Program at University Hospitals Ear, Nose & Throat Institute. “Right now only 5-6% of cochlear implant candidates are getting an implant. That means we aren’t penetrating the market and we aren’t solving the problem.”
Slow insurance approvals for cochlear implants and reliable access to care are a few obstacles. Some patients and practitioners also lack awareness and understanding of different treatment options.
The UH ENT Institute is working to solve these problems, and more, through its fast-growing Otology division, which now includes five otologist/neurotologists and skull base surgeons. The recent hiring of Dr. Rivas, Maroun Semaan, MD, and Nauman Manzoor, MD, a returning UH ENT Institute resident who completed fellowship training at Vanderbilt University Medical Center, has greatly expanded the otology expertise and services offered through the division’s Audiology & Cochlear Implant Center and Skull Base Surgery Center. They join Dr. Sarah Mowry and Dr. Cliff Megerian as clinically active team members.
“We can now take care of the entire spectrum of pediatric and adult ear-related problems,” Dr. Manzoor says.
A LIFETIME COMMITMENT
The UH Cochlear Implant Program is one of the largest nationwide and top 10 in the nation for number of cochlear implant surgeries. In October, the program celebrated its 25th anniversary of performing cochlear implant surgery.
During this time, UH clinicians have been following many implant patients from their initial workup, through their surgery and programming of the speech processer to long-term monitoring.
“Each processor and map is uniquely designed for each patient,” explains Gail Murray, PhD, CCC-A, Clinical Director of the Cochlear Implant Program at UH Cleveland Medical Center, and recently appointed UH System Director of Audiology Services. “It’s a process that takes time and adjustments, as the ear and brain familiarize with the electrical signal.”
Eventually, the patient’s program will stabilize. Then once a year or more, they will need to see an audiologist who will monitor the condition of the device and their hearing performance. Dr. Murray is currently heading up an effort by UH ENT Institute to standardize audiology care throughout the entire UH system, so all audiology patients receive consistent care at whatever location they visit.
Cochlear implant patients receive individualized care from a multidisciplinary team of audiologists, speech therapists and psychologists who specialize in treating hearing loss. Local providers and audiologists also play an important role in providing ongoing care and monitoring for these patients, who will usually require regular audiology visits throughout their lifetime.
“We only have so many UH audiologists who can do cochlear implants, but the community has providers who can use training to manage those patients, especially for patients who are hours away,” Dr. Rivas says.
Setting up Clinical Practice Network (CPN) clinics is one way UH is making it easier for patients to access cochlear implant services from the audiologist they know and trust. “Even when patients are cochlear implant candidates, we find the referrals aren’t made because the managing audiologist doesn’t understand the candidacy criteria or wants the patient to continue their care locally,” Murray says.
UH partners with Cochlear Americas to establish the CPN clinics by identifying hearing aid dispensing practices in the region where audiologists have an interest in cochlear implantation and can benefit from training. Cochlear Americas facilitates training and support, so UH surgeons can send the patient back to the audiologist who has been treating them for pre-op and post-op programming, and follow-up.
A top reason many patients decide against getting a cochlear implant is that they are unable to travel for the surgery and regular follow-up appointments, Dr. Rivas says. So the Otology division is planning several clinical studies focused on telehealth — specifically, looking at how clinicians can improve remote care for cochlear implant patients using advanced technologies.
“Soon we could do programming from home using telemedicine,” he says. “We can check the implant remotely, and if it’s a simple cable that needs to be reordered, they might avoid a visit.”
Improving understanding of hearing loss treatments and technologies will play an important role, specifically in helping expand cochlear implants — and insurance approvals – as a solution for patients with less severe or moderate hearing loss.
“Historically, cochlear implant patients had to have severe to complete loss to be a candidate,” Murray says. “In the last several years, manufacturers have been working to design implants to benefit a population that has more residual hearing.”
UH is currently involved in two clinical trials to examine different types of electrodes of cochlear implants, and whether they allow surgeons to preserve hearing appropriately for patients without profound hearing loss. A third is exploring the use of implants on patients with partial hearing loss.
“When the remaining hearing is not lost, patients do well with a combination of acoustic and electrical stimulation or a hybrid device,” Murray says.
An upcoming UH trial will assess one such device, the CI-624 by Cochlear Americas, by following its use in patients for one year. The CI-624 synchronizes to the most current cochlear implant speech processors to bring in sound for patients who have trouble hearing over the phone or television, or in a large auditorium.
“This is exciting research that could potentially expand the indication of candidates for cochlear implant to a broader population of hearing-impaired people,” Murray says.
In 2020, UH also introduced a new FDA-approved technology for patients ages 12 and older that have normal hearing in at least one inner ear but significant hearing loss in the other ear or both ears. The bone conduction implant, called Osia, is a partially implanted device that allows doctors to send an auditory signal through an abnormally formed outer and middle ear, making it a promising treatment for patients with partial hearing loss. UH is planning studies to research the performance and outcomes in children under 12.
“What has always excited me about the field of otology is the technical advances that we’re able to make for the benefit of patients, and we’re doing that,” she says. “We’re on the forefront.”
Having more fellowship-trained otologist/neurotologists is also helping improve patient outcomes by bringing greater expertise to the division’s Skull Base Surgery Center. The team treats tumors in the brain involving the critical neurostructures that affect a patient’s balance and hearing.
“With different tumors, we’re trying to individualize care for patients to find the right solutions for them,” Dr. Rivas says. “That includes having a robust multidisciplinary team where multiple opinions count, so we can give patients a customized solution to their need.”
"In August 2020, the Otology division expanded therapy options with a multidisciplinary dedicated program utilizing stereotactic radiosurgery. This is an alternative therapy for the treatment of complex lateral skull base tumors, such as acoustic neuromas, that uses precision focused beams of radiation to treat lesions. This treatment is highly successful in local control of the tumor with minimal morbidity", Dr. Manzoor says. The addition of this treatment option expands our portfolio of treatment capabilities within ENT which is patient focused and outcome driven.
“You take away the risks that stem from traditional surgery with this modality, which has excellent control for small- to medium-sized tumors,” he says. “These patients go home after the procedure with minimal pain or discomfort.”
The radiosurgery team includes a radiation oncologist, neurosurgeon, a radiation physicist and now an otologist/neurotologist, who collaborate to develop treatment plans together with patients. With the addition of a hearing and balance specialist to the team, patients can have critical input to minimize hearing loss and imbalance when treating a lesion using radiation modalities. Dr Manzoor’s central role in the team will allow for critical input to minimize hearing loss and imbalance in patients when treating a lesion using radiation modalities.
“Too much radiation to the cochlea can cause dizziness or hearing to decline over time, for example,” Dr. Rivas says. “So it’s important that the otologist/neurotologist are involved and monitor these outcomes. We want to create a culture that focuses on preserving hearing.”
The Ear, Nose & Throat Institute now has one of the most talented otology/neurotology and audiology centers in the country. Our focus on new therapies, clinical trials, applied advanced technology, and leveraging the combined experience of this team, ensures focused individualized, expert care for each patient every time. In this manner, we fulfill the UH mission: To heal. To teach. To discover.