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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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option for 1) children and 2) adults who are blind or have other disabilities with severe to profound deafness who do not receive adequate benefit from acoustic hearing aids. Sequential bilateral cochlear implantation is not recommended as an option for people with severe to profound deafness. (NICE, 2009) Cochlear implantation (CI) is associated with a variety of potential complications. The complication of greatest concern is the possible development of meningitis. In 2002, the FDA issued a notification regarding a possible link between CI and meningitis after receiving reports of 118 cases of meningitis in CI recipients, including 17 in whom meningitis resulted in death. Among CI users in the United States, 52 had contracted meningitis and 5 died from it. In the fatal cases, ages ranged from 13 months to 84 years but most were under 7 years of age. (Callanan and Poje, 2004) Meningitis in CI recipients has been caused by the bacteria S. pneumoniae in 62% of the cases and type b or nontypeable Haemophilus (H.) influenzae strains in 21% of the cases (Rose et al., 2004). It was determined that the incidence of meningitis caused by Streptococcus (S.) pneumoniae in pediatric CI recipients was over 30 times that in similarly aged children in the general population. (Callanan and Poje, 2004) Initially, it was believed that an electrode positioner used in some CI devices was at fault, since use of the positioner required a larger cochleostomy, caused more trauma and damage to the inner ear, and was associated with a higher incidence of meningitis than other CI devices. However, the positioner was voluntarily taken off the market and the meningitis cases in subsequent CI recipients still occurred, although at a substantially lower and declining rate. The development of bacterial meningitis also is related to middle and inner ear infections, inner ear malformations, and cerebrospinal fluid (CSF) leaks. (Callanan and Poje, 2004) Middle ear infections (otitis media) are prevalent in young children and can spread to the inner ear (Callanan and Poje, 2004), and inner ear malformations and CSF leaks often are present in patients receiving CI. (Bhatia et al., 2004; Arnoldner et al., 2005) These data emphasize the importance of ensuring that all pediatric CI users are appropriately vaccinated against S.

pneumoniae and are monitored and promptly treated for bacterial infections. (Callanan and Poje, 2004) See the following Web site for more information: http://www.fda.gov/cdrh/safety/101007-cochlear.html. Accessed July 2008.

Cochlear implants are contraindicated in patients with acoustic nerve or central auditory pathway lesions, active middle ear infection, or a large tympanic membrane perforation. The size, location and etiology of the tympanic membrane perforation influence the safety for proceeding with implant surgery. Children with recurrent otitis media and myringotomy tubes remain candidates for cochlear implant surgery. Success may be influenced by the degree of intracochlear fibrosis and/or ossification.

Professional Societies American Speech-Language-Hearing Association (ASHA): According to a 2004 technical report approved by the ASHA, bilateral implantation is currently being studied in a limited number of cochlear implant recipients with mixed results. In some cases, recipients experience enhanced speech understanding, especially in noise; in other users the improvement in speech understanding compared with unilateral performance is minimal or absent and the primary advantage of binaural implantation is sound localization. Bilateral implantation outcomes to date are encouraging but inconclusive due to the limited number of participants and the scope of the projects. There is a clear need for further exploration of the many variables that can affect the performance of people with binaural implants before widespread use is warranted. Many of these studies are currently underway and the results will help to define prognosis and optimization of binaural implant usage. Such studies will determine the ultimate benefit and cost effectiveness of bilateral cochlear implantation. (ASHA, 2004) American Academy of Otolaryngology (AAO): The AAO states that cochlear implantation is an appropriate treatment for adults and children with severe to profound hearing loss. The AAO also states that bilateral cochlear implantation is accepted medical practice based on extensive literature demonstrating that clinically selected adults and children can perform significantly better with two cochlear implants than one. (AAO, 2007) American Academy of Audiology (AAA): In a policy statement regarding Cochlear Implants in Children, the AAA states recognizes multichannel cochlear implants as sensory aid options for children with profound hearing impairments who Cochlear Implants - Commercial Medical Management Guideline demonstrate limited or no functional benefit from conventional hearing aid amplification. The audiological criteria for implantation are a congenital or acquired profound sensorineural hearing loss and limited or no functional benefit from electroacoustic hearing aid amplification. Generally, a pure tone average (500, 1000, 2000 Hz) of 90dB HL or greater in both ears is indicated. (AAA, 2008) American Academy of Pediatrics (AAP): In a 2007 position statement on the Principles and Guidelines for Early Hearing Detection and Intervention Programs, the AAP states that cochlear implantation should be given careful consideration for any child who seems to receive limited benefit from a trial with appropriately fitted hearing aids. The AAP also states that the presence of developmental conditions (e.g., developmental delay, autism) in addition to hearing loss should not, as a rule, preclude the consideration of cochlear implantation for an infant or child who is deaf. (AAP, 2007) National Institutes of Health (NIH): To provide clinicians and healthcare providers information on the benefits, limitations, and other relevant issues of cochlear implantation, the NIH sponsored a consensus development conference in 1995. This conference involved a 14-member consensus panel of experts and concluded that cochlear implantation improves communication ability, often leading to positive psychological and social benefits, in adults with severe to profound, postlingual hearing loss; provides more limited improvement in speech perception but allows important environmental sound awareness in adults with prelingual hearing loss; and results in more variable outcomes but may lead to gradual improvement in speech perception, speech production, and language in hearing-impaired children. (NIH, 1995) Additional Search Terms Cochlear prosthesis Definitions The spiral cavity within the ear which is the central organ of hearing.

Cochlea References and Resources Resources

American Academy of Audiology (AAA): Cochlear Implants in Children. 2008. Available at:

http://www.audiology.org/resources/documentlibrary/Pages/CochlearChildren.aspx. Accessed March 2009.

American Academy of Otoloaryngology (AAO). Cochlear Implants. 2007. Web site. Available at:

http://www.entnet.org/Practice/policyCochlearImplants.cfm. Accessed February 2009.

American Academy of Pediatrics (AAP), Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007 Oct;120(4):898-921.

American Speech-Language-Hearing Association [Web site]. Technical Report: Cochlear Implants. 2004. Available at:

http://www.cochlear.org/sys-tmpl/nss-folder/ashatechnicalpaper/ASHACI2004.pdf. Accessed February 2009.

Anderson I, Weichbold V, D'Haese PS, et al. Cochlear implantation in children under the age of two - what do the outcomes show us? Int J Pediatr Otorhinolaryngol. 2004;68(4):425-431.

Arnoldner C, Baumgartner WD, Gstoettner W, Hamzavi J. Surgical considerations in cochlear implantation in children and adults: a review of 342 cases in Vienna. Acta Otolaryngol. 2005;125(3):228-234.

Bassim MK, Buss E, Clark MS, Kolln KA, Pillsbury CH, Pillsbury HC 3rd, Buchman CA. MED-EL Combi40+ cochlear Cochlear Implants - Commercial Medical Management Guideline implantation in adults. Laryngoscope. 2005 Sep;115(9):1568-73.

Beadle EA, McKinley DJ, Nikolopoulos TP, Brough J, O'Donoghue GM, Archbold S. Long-term functional outcomes and academic-occupational status in implanted children after 10 to 14 years of cochlear implant use. Otol Neurotol. 2005 26(6):1152-60.

Beijen JW, Snik AF, Mylanus EA. Sound localization ability of young children with bilateral cochlear implants. Otol Neurotol. 2007 Jun;28(4):479-85.

Bhatia K, Gibbin KP, Nikolopoulos TP, ODonoghue GM. Surgical complications and their management in a series of 300 consecutive pediatric cochlear implantations. Otol Neurotol. 2004;25(5):730-739.

Bichey BG, Miyamoto RT. Outcomes in bilateral cochlear implantation. Otolaryngol Head Neck Surg. 2008 May;138(5):655-61.

Buss E, Pillsbury HC, Buchman CA, Pillsbury CH, et al. Multicenter U.S. bilateral MED-EL cochlear implantation study: speech perception over the first year of use. Ear Hear. 2008 Jan;29(1):20-32.

Callanan V, Poje C. Cochlear implantation and meningitis. Int J Pediatr Otorhinolaryngol. 2004;68(5):545-550.

Calmels MN, Saliba I, Wanna G, et al. Speech perception and speech intelligibility in children after cochlear implantation. Int J Pediatr Otorhinolaryngol. 2004;68(3):347-351.

Chee GH, Goldring JE, Shipp DB, et al. Benefits of cochlear implantation in early-deafened adults: the Toronto experience. J Otolaryngol. 2004;33(1):26-31.

Cheng AK, Rubin HR, Powe NR, Mellon NK, Francis HW, Niparko JK. Cost-utility analysis of the cochlear implant in children. JAMA. 2000 Aug 16;284(7):850-6.

Copeland BJ, Pillsbury HC 3rd. Cochlear implantation for the treatment of deafness. Annu Rev Med. 2004;55:157-67.

Dunn CC, Tyler RS, Oakley S, Gantz BJ, Noble W. Comparison of speech recognition and localization performance in bilateral and unilateral cochlear implant users matched on duration of deafness and age at implantation. Ear Hear. 2008 Jun;29(3):352-9.

ECRI. Hotline Response. Bilateral Cochlear Implantation. February 2008.

Francis HW, Koch ME, Wyatt JR, Niparko JK. Trends in educational placement and cost-benefit considerations in children with cochlear implants. Arch Otolaryngol Head Neck Surg. 1999;125(5):499-505.

Francis HW, Pulsifer MB, Chinnici J, Nutt R, Venick HS, Yeagle JD, Niparko JK. Effects of central nervous system residua on cochlear implant results in children deafened by meningitis. Arch Otolaryngol Head Neck Surg. 2004;


Francis HW, Yeagle JD, Brightwell T, Venick H. Central effects of residual hearing: implications for choice of ear for cochlear implantation. Laryngoscope. 2004;114(10 I):1747-1752.

Galvin KL, Mok M, Dowell RC. Perceptual benefit and functional outcomes for children using sequential bilateral cochlear implants. Ear Hear. 2007;28(4):470-482.

Cochlear Implants - Commercial Medical Management Guideline Grantham DW, Ashmead DH, Ricketts TA, Labadie RF, Haynes DS. Horizontal-plane localization of noise and speech signals by postlingually deafened adults fitted with bilateral cochlear implants. Ear Hear. 2007 Aug;28(4):524-41.

Gantz BJ, Tyler RS, Rubinstein JT, et al. Binaural cochlear implants placed during the same operation. Otol Neurotol.


Gantz BJ, Tyler RS, Woodworth GG, et al. Results of multichannel cochlear implants in congenital and acquired prelingual deafness in children: five-year follow-up. Am J Otolaryngol. 1994;15(Suppl 2):1-7. Cited in: Makhdoum MJ, Snik AF, Vanden Broek P. Cochlear implantation: a review of the literature and the Nijmegen results. J Laryngol Otol.


Green KM, Bhatt YM, Saeed SR, Ramsden RT. Complications following adult cochlear implantation: experience in Manchester. J Laryngol Otol. 2004;118(6):417-420.

Grieco-Calub TM, Litovsky RY, Werner LA. Using the observer-based psychophysical procedure to assess localization acuity in toddlers who use bilateral cochlear implants. Otol Neurotol. 2008 Feb;29(2):235-9.

Hayes, Inc. Directory. Cochlear Implantation. December 2007. Update Search December 2008.

Hocevar-Boltezar I, Vatovec J, Gros A, Zargi M. The influence of cochlear implantation on some voice parameters. Int J Pediatr Otorhinolaryngol. 2005 Dec;69(12):1635-40. Epub 2005 Jun 6.

Illg A, von der Haar-Heise S, Goldring JE, et al. Speech perception results for children implanted with the CLARION cochlear implant at the Medical University of Hannover. Ann Otol Rhinol Laryngol Suppl. 1999;177(4 pt 2):93-98.

Jeong SW, Kim LS, Kim BY, Bae WY, Kim JR. Cochlear implantation in children with auditory neuropathy: outcomes and rationale. Acta Otolaryngol Suppl. 2007 Oct;(558):36-43.

Kaplan DM, Shipp DB, Chen JM, Ng AH, Nedzelski JM. Early-deafened adult cochlear implant users: assessment of outcomes. J Otolaryngol. 2003 Aug;32(4):245-9.

Klop WM, Briaire JJ, Stiggelbout AM, Frijns JH. Cochlear implant outcomes and quality of life in adults with prelingual deafness. Laryngoscope. 2007 Nov;117(11):1982-7.

Kuhn-Inacker H, Shehata-Dieler W, MJ, Helms J. Bilateral cochlear implants: a way to optimize auditory perception abilities in deaf children? Int J Pediatr Otorhinolaryngol. 2004 Oct;68(10):1257-66.

Labadie RF, Carrasco VN, Gilmer CH, Pillsbury HC III. Cochlear implant performance in senior citizens. Otolaryngol Head Neck Surg. 2000;123(4):419-424.

Laszig R, Aschendorff A, Stecker M, et al. Benefits of bilateral electrical stimulation with the nucleus cochlear implant in adults: 6-month postoperative results. Otol Neurotol. 2004 Nov;25(6):958-68.

Litovsky R, Parkinson A, Arcaroli J, Sammeth C. Simultaneous bilateral cochlear implantation in adults: a multicenter clinical study. Ear Hear. 2006a;27(6):714-731.

Litovsky RY, Johnstone PM, Godar S, Agrawal S, Parkinson A, Peters R, Lake J. Bilateral cochlear implants in children:

localization acuity measured with minimum audible angle. Ear Hear. 2006c Feb;27(1):43-59.

Cochlear Implants - Commercial Medical Management Guideline Litovsky RY, Johnstone PM, Godar SP. Benefits of bilateral cochlear implants and/or hearing aids in children. Int J Audiol. 2006b;45(suppl 1):S78-S91.

Litovsky RY, Parkinson A, Arcaroli J, et al. Bilateral cochlear implants in adults and children. Arch Otolaryngol Head Neck Surg. 2004;130(5):648-655.

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