Cochlear implants and Cochlear implant surgery

Dr. K. R. Meghanadh

What is cochlea?

The cochlea is an organ in the inner ear that converts mechanical sound signals or energy into electrical signals for the nerves to carry to the brain.

Sound travels in the form of waves. Sound waves fall on the eardrum (the tympanic membrane) and then travel through the ossicular chain to the cochlea.

The ossicular chain consists of 3 bones malleus, incus and stapes. The first bone in the chain, the malleus, is connected to the tympanic membrane. The last bone in the chain is Stapes which ends in the fluid inside the cochlea. These three bones move like a piston to transmit the sound waves to the cochlea.

This piston-like movement by the ossicular chain creates ripples in the cochlear fluid. These waves drag till the end of the cochlea. There are hair cells on the bed of this fluid-filled tube, i.e., hairs attached to a cell on the bed of the cochlear tube. These cells convert soundwaves’ mechanical energy to electrical energy. This behavior is similar to turbines in a dam that move due to flowing water and generate energy. This electrical energy is transmittable to the brain through nerves. The hair cell base has a negatively charged protein, so when the hair moves, the base moves between two proteins. The base transmits this electron from one protein to another and travels to the brain. These electrons are carried by the eighth cranial nerve, i.e., the auditory or cochlear nerve. The auditory or cochlear nerve sends hearing inputs to the brain. The cochlea has a hair cell for every frequency in the human hearing range, i.e., 20 to 20,000 Hz. When a particular frequency sound falls on the tympanic membrane, the corresponding frequency hair cell will be stimulated by the fluid waves in the cochlea, helping the brain to detect the frequencies.

What causes a newborn to be deaf?

In some children or individuals, the negatively charged protein in the hair cell base in the cochlea responsible for converting sound waves to electrical signals could be missing. The deficiency of this protein could be due to missing or modified genes. So, in these scenarios, the transformation of mechanical sound waves into transmissible electric waves cannot happen, resulting in deafness in both ears. A cochlear implant has the mechanism to overcome this defect.

Why would a person who is not born deaf need a cochlear implant?

The degree of deafness varies. The typical hearing is 15 to 95 decibels. If the hearing loss is less than 75 decibels, we can try a hearing aid to correct it.

We do not have hearing aids for more than 75 decibels of hearing loss. In these scenarios, the cochlea cannot receive the signals even when the sound signals are amplified. In such scenarios, cochlear implants are suggested.

Immediate cochlear implant for labyrinthitis ossificans

In the case of an inner ear infection (otitis interna), labyrinthitis ossificans is a defense mechanism employed by the body to contain the infection and prevent it from spreading to nearby structures, such as the brain. This defense mechanism involves the formation of bone around the affected area in the inner ear.

Once this process of bone formation begins, it becomes crucial to act quickly and consider a cochlear implant. If the bone formation progresses too far, it can lead to permanent hearing loss in the affected ear. Even if the hearing loss is initially only 20%, it's essential to undergo a cochlear implant procedure promptly to prevent the bone formation from further affecting the ear. Delaying the surgery can make the ear ineligible for the procedure, resulting in irreversible hearing loss.

What is a cochlear implant?

How does a cochlear implant work?

A cochlear implant takes sound signals through a microphone and converts them into electromagnetic signals. These electromagnetic signals are transmitted to the cochlear implant fitted inside the skin via an electromagnetic coil. This cochlear implant’s internal device is called a receiver-stimulator. It receives the signals, codes them into electrical signals, and gives them directly to the cochlear nerve in the cochlea. So, the nerve gets the electric signals instantly. The conversion of mechanical soundwaves to electric signals step is being taken care of by the cochlear implant.

A cochlear implant has two components, one being external and the other component implanted surgically inside the head. These two together replicate the job of the cochlea, eardrum, and middle ear.

Cochlear implant parts

External components

The outer or external component consists of a receiver, microphone, sound processor, and transmitter.

The receiver and sound processor sit behind the ear pinna.

The transmitter attaches to the side of the head.

The external component of the Cochlear implant - microphone, sound processor, transmitter

The sound processor converts the sound waves into electrical signals. These electrical signals are sent to the internal device from the external transmitter coil to the internally implanted coil that sits just behind the skin. The signals are transmitted using radio-frequency transmission.

Internal Components

The internal device has a receiver stimulator placed just below the skin and on the side of the head. Receiver-stimulator receives the radio-frequency transmission from the external device and encodes these into electrical signals. These signals are given to the cochlear nerve directly through a cable called an electrode array. The thickness of the cable varies from 0.9 mm to 0.4 mm, and this cable contains around 24 fine wires, which are again insulated individually. So, these individually insulated 24 wires of the electrode array are very fragile and need to be handled with extra caution during the surgery. Wrong handling of the cable is one of the most common causes of the failure of cochlear implant surgery. The cable stimulates 24 electrodes responsible for stimulating the 12 points of the nerve in the cochlea. So, the nerve gets the electrons or electrical signals directly, bypassing the hair cells on the cochlear bed.

Internally implanted part of cochlear implant - receiver stimulator

Cochlear implant surgery

Cochlear implant surgery is a life-changing step, especially for deaf-born babies. The steps in the surgery need to be followed with great precision and care. Strict adherence to the Standard operating procedure of a Cochlear implant is important for the implant’s longevity and the surgery’s success.

Cochlear implant surgery makes a bed for the receiver-stimulator that fixes just below the skin. A circuit or chip and a coil are present in the receiver-stimulator. This is fixed onto the skull, diagonally on top of the ear.

The electrode array from the receiver-stimulator is placed through a groove in the bone that goes towards the cochlea. The terminal area of the electrode array will be placed in the cochlea to stay in close contact with the auditory nerve endings. This process needs to be implemented with great caution. As discussed earlier electrode array is super fragile.

The surgeon’s process determines the cochlear implant’s success or longevity. The more he sticks with the guidelines or SOP, the more longevity.

Are you still deaf if you have gotten cochlear implant surgery?

The answer is not a straight yes or no, for this question.

You are deaf if you switch off the cochlear implant or remove the external device.

You are not deaf if you switch on the cochlear implant and have the external device on you properly.

Nevertheless, technically, the hearing of a person who gets cochlear implant surgery is not the same as normal hearing.

Do cochlear implants restore normal hearing?

Although a patient with a cochlear implant can hear and the person might be able to differentiate the sounds like an average person, cochlear implant hearing is different. Usually, a person can listen to 20,000 sounds, but a cochlear implant patient can listen to only 12 to 24 sounds. Let us explain this clearly in the next paragraph.

The cochlear implant machine cannot individually stimulate the 20,000 nerves( part of the auditory nerve) that exist on the bed of the cochlea. Instead, the cochlear implant stimulates a bunch of nerves together. It divides the frequencies into 12 groups, so the sound differs from normal hearing. Thankfully, our brain can still understand these sounds perfectly, enabling the patient to talk like a normal-hearing person.

How often do cochlear implants need to be replaced?

How often are revision surgeries required?

Dr. K. R. Meghanadh says that the currently available components’ quality is very good, irrespective of the brand. Although he says he cannot give statistical proof that cochlear implants can work lifelong, he believes they can, and time will prove it. He has done 600 surgeries in the last 20 years, except for a single exception, presumably due to a small accident. The rest 599 are working fine.

Refer to the Cochlear Implant Lifespan article for more details.

Success Rate

To answer this question, we need to define what success is in cochlear implant surgeries.

There could be two ways of defining this success.

1. The patient can hear all sounds after surgery

2. A deaf or hard-of-hearing patient can hear and talk after surgery.

Regarding the first point, i.e., the hearing part success rate is nearly 100% for any experienced surgeon who follows SOPs strictly and does the procedure with patience and utmost care.

Regarding the second point, this depends not on the type of implant or variety or the surgeon but on the timing of surgery. A child below one year will be able to hear and talk normally. The ideal time to get surgery for a child would be nine months, as it would give wonderful results. As age increases, learning language and differentiating sounds can become tougher, and the quality of speech and hearing perception will decrease.

Implantation in both ears simultaneously is called simultaneous bilateral cochlear implants, which can give the best results.

What if there is a deviation from the standard operating procedure(SOP) or the process is not done with utmost care?

• Implant rejection

• Infection

• Soft failure The computerized scanning and check of the implant will be normal, but the patient’s hearing is unstable and keeps going on and off. This occurs when the electrode placement is not in the bone groove and the electrode was handled harshly.

• Hard failure The computerized scanning and check of the implant will be faulty. This could be a manufacturing defect or lack of adherence to the SOPs.

Are there any patients who regret cochlear implants? Non-users of cochlear implants

Almost 600 patients observed had normal hearing, except for one case. The patient chose not to hear and moved in with the conventional deaf community, who mastered sign language under the spouse’s influence. Such cochlear implant patients are called non-users. Some individuals who lived longer are habituated to the non-hearing world and do not want to come into the hearing world and be part of a deaf non-talking community. These people have accepted that they are deaf and proudly use sign language to communicate. Trying to enter or adjust to the hearing world might make them feel odd, different, or complex for us to understand. They might not be able to gel well with us and feel at home and better accepted in those communities. It is a matter of choice and an individual’s happiness that must be respected.

Is a cochlear implant wrong? Or can it go wrong? What can the complications be?

Cochlear implants are not harmful when SOPs are followed properly during the surgery. The cochlear implants have not caused neurological problems in the 600 patients author has operated on.

1 or 2 percent of implants worldwide had complications like infections or non-infectious rejections, which are a part of the procedure. “However, we have not seen such complications in 600 surgeries. These complications can occur mainly if the surgeon violates operating procedures, SOP, or protocols. It depends on how strictly a surgeon follows the given guidelines.

Refer to the “What if there is a deviation from the standard operating procedure(SOP) or the process is not done with utmost care?” section for more details.

Cochlear implants have some metals, so an MRI scan could be impossible. Nevertheless, now we have the latest cochlear implants with the advanced technology of MRI-compatible rotatable magnets.

So, look out for Cochlear implants with rotatable magnets.

Who can get Cochlear implant surgery?

Anyone with more than 75 decibels of hearing loss or not showing enough improvement with the best available hearing aid can go for Cochlear implants.

A person should not have hearing loss for more than six months due to neural plasticity. In neural plasticity, the brain can assign the jobless nerves after six months to different tasks, and it is difficult to change back the function of the nerves when the implants are fitted. Therapy could be required to get the nerves back on track, and the results are unpredictable.

How much does Cochlear Implants surgery cost?

As the author is from India, he has given details about the surgeries cost in India.

Cochlear implant surgery can cost from 9 Lakh rupees to 35 Lakh rupees. He has given all the details in the below article. The approximate costs are also mentioned in USD.

Article: How much do cochlear implants and surgery cost in India?

Dr. K. R. Meghanadh

FAQs

Are you still deaf if you have a cochlear implant?

The answer is not a straight yes or no.

Yes, you are deaf if the cochlear implant is off or if the external device is removed.

No, you are not deaf if you put on the external device and switch it on.

What is the success rate of a cochlear implant?

First, we must define what we mean by success to answer this question. Please refer to this section.

How long does a cochlear implant last?

Cochlear implants should ideally last for a lifetime unless and until there are errors in following SOPs during surgery or an accident that damaged the device.

You can read our article "Cochlear implant lifespan and warranties" to know more details.

To know what can happen if a surgeon deviates from SOP, you can read this section.

What are the side effects of cochlear implant surgery?

Our author has done over 600 surgeries and has not observed any complications or side effects in their patients. Cochlear implants will not have any side effects if the SOPs are followed correctly during the surgery. However, difficulties can occur if the surgeon violates or fails to follow the SOP or protocols.

Can all deaf people get cochlear?

Cochlear implants are recommended for individuals with hearing loss exceeding 75 decibels. When hearing loss surpasses this threshold, even with hearing aids, the cochlea cannot effectively receive the signals. Moreover, it's important to note that the duration of hearing loss is also a factor to consider. Suppose the hearing loss has persisted for more than six months. In that case, neural plasticity may impact the outcomes of cochlear implantation, making the results unpredictable.

What is the function of the cochlea?

The cochlea is a crucial component of the ear, and its primary function is to convert mechanical sound signals into electrical signals that can be transmitted to the brain through the auditory nerve.