Clinical Guidelines for Paediatric Cochlear Implantation
Department of Health, Western Australia. (2011).
Perth (Australia): Health Networks Branch, Department of Health, Western Australia, 1-24.
This guideline provides an example service pathway from the point of identification of hearing loss through postoperative rehabilitation for children who receive a cochlear implant. This template is based on an existing cochlear implant pathway followed by the Western Australian Children’s Cochlear Implant Clinic (based at Princess Margaret Hospital). The guideline is intended for health professionals involved in cochlear implant services. Aspects of the template that specifically pertain to audiologists and speech-language pathologists are detailed below.
Department of Health, Western Australia
"Extensive audiological/speech and language, ENT investigations are required as part of the cochlear implant suitability [for children with auditory neuropathy/dys-synchrony]. Additional investigation such as electrocochleography and electrically elicited auditory brainstem response is also performed" (p. 5).
<p>Appropriate functional assessments for pre-lingual and very young children include:</p>
<ul>
<li>threshold detection of the Ling sounds both through the sound field and live voice at various distances (conversational levels);</li>
<li>the Meaningful Auditory Integration Scale (MAIS)/the Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS);</li>
<li>Early Speech Perception (ESP) low verbal/standard; and</li>
<li>Report from the Teacher of the Deaf.</li>
</ul>
The speech language pathologist should provide the cochlear implant team with information regarding the child's "current communication skills and ability to develop and maintain verbal communication with optimally-fitted hearing aids" (p. 7), which should help to determine the child's potential for developing verbal language skills following cochlear implantation.
<p>Appropriate speech assessments for older children or children with good speech and language include:</p>
<ul>
<li>Bamford-Kowal-Bench (BKB) or City University of New York (CUNY) sentences;</li>
<li>Northwestern University - Children’s Perception of Speech (Nu-Chips) (open set);</li>
<li>Arthur Boothroyd (AB) word lists; and</li>
<li>Central Institute for Deaf (CID) everyday sentences for very young children.</li>
</ul>
Princess Margaret Hospital considers candidacy for clients with unaided thresholds sloping from moderate to severe in the low frequencies to profound in the high frequencies and aided thresholds outside the speech spectrum.
<p>The key principles of habilitation are to:</p>
<ul>
<li>"provide family-centered services to enable parents/caregivers to become the primary facilitators of their child's listening and communication development;</li>
<li>provide an optimal environment to stimulate development of listening as a learning tool for the child;</li>
<li>provide a combination of auditory oral and auditory verbal approaches, as appropriate for each child (clients are supported in a total communication approach if appropriate);</li>
<li>facilitate acquisition of listening skills, speech and language skills in normal developmental order through use of the implant; [and]</li>
<li>present learning to listen skills in a hierarchy" (p. 10).</li>
</ul>
<p>After implantation, a battery of tests (depending on the age and nature of hearing loss) should include:</p>
<ul>
<li>Aided and unaided audiogram;</li>
<li>Bamford-Kowal-Bench (BKB) or City University of New York (CUNY) sentences;</li>
<li>Northwestern University - Children's Perception of Speech Test (Nu-Chips; open set);</li>
<li>Arthur Boothroyd (AB) word lists;</li>
<li>Central Institute for the Deaf (CID) everyday sentences for very young children;</li>
<li>Early Speech Perception (ESP); and</li>
<li>Phoneme detection.</li>
</ul>
Candidacy will be considered for clients with normal low frequency hearing sloping to moderate to profound hearing loss in the high frequencies and poor results from speech testing (worse than 70% in the best ear and 40% in the poorer ear).
Children identified as candidates for cochlear implantation should be referred to the speech-language pathologist at the cochlear implant center for candidacy evaluation and cochlear implant work-up. Pre-implant services should include a baseline assessment of communication and listening skills and interagency service planning with a deaf educator and outside speech-language pathologist.
Prior to implantation, the educational audiologist should coordinate with interagency services, monitor the child's audiological status, and collect information about the child's pre-implant history including: first language, type of educational support, use of amplification, use of hearing for speech and language acquisition, communicative competence, linguistic performance, general development, and audiological history.
"It is critical that intensive cochlear implant habilitation is provided post implant to develop the client's speech, language and listening skills through the use of the implant. Intensive habilitation is offered to clients for a period of approximately 3 to 6 months post cochlear implant surgery (often weekly or fortnightly depending on parental preference and client progress) with habilitation services offered up to 12-months post-implant" (p. 9).
<p>The audiologist should:</p>
<ul>
<li>provide parents/caregivers with "an overview of the device, speech processor, rehabilitation and outcomes" (p. 5);</li>
<li>ensure that "all possible measures and devices are trialled to maximise the hearing potential—especially for those borderline candidates" (p. 5);</li>
<li>administer continual functional assessments;</li>
<li>consult with the team on recommendations; and</li>
<li>participate in a joint meeting with the parents, surgeon, and others.</li>
</ul>
<p>"Progressive losses and meningitis should be referred sooner" (p. 5).</p>
<p>"Patients with meningitis should be considered for bilateral implantation due to the significant risk of cochlear ossification" (p. 5).</p>
"Repeated testing and assessments are required as response to amplification and possible improvement of hearing thresholds with neuronal maturation must be monitored" (p. 4).
Borderline candidates require additional investigation; for example, aided speech perception testing to determine if speech perception drops significantly in noise, in which case cochlear implantation may be considered.
