Online Health Chat with Erika Woodson, MD and Sarah Sydlowski, AuD,PhD
February 19, 2015
Approximately 17 percent of American adults (36 million) report some degree of hearing loss – a condition in which a person is partially or totally unable to hear in one or both ears.
Experts in Cleveland Clinic’s Hearing Implant Program (HIP) know how much hearing loss can affect your life. The good news is that hearing device technology has improved tremendously over the past decade, making cochlear implantation a viable option for more people with more residual hearing. Improvements in surgical techniques and the development of new electrode arrays have made it possible to preserve low-pitch hearing while adding improved clarity through electrical stimulation provided by the cochlear implant.
Hearing loss ranges from mild to profound and can affect people of all ages. Based on the most recent figures available from the National Center for Health Statistics (NCHS), while most people with hearing loss are older – individuals who have lost hearing with age – approximately 12 out of every 1,000 persons with hearing impairment are under 18 years of age. There are different types and causes of hearing loss. Similarly, there are many types of devices that are used to partially restore hearing to people with hearing loss.
Cochlear implants are hearing implants that are appropriate for individuals with sensorineural hearing loss for whom hearing aids fail to provide adequate benefit. While hearing aids make sounds louder, the goal of cochlear implants is to make sounds clearer through direct stimulation of the hearing nerve. Cochlear implants have been used on patients from 8 months to more than 90 years old.
Osseointegrated auditory implants are appropriate for two different types of hearing loss: (1) conductive hearing loss in one or both ears, or (2) single-sided deafness, meaning complete hearing loss in one ear and normal hearing in the other ear. Osseointegrated auditory implants provide auditory input through bone conduction. Baha®, one type of osseointegrated auditory implant, is a brand name, not a type of implant in and of itself.
About the Speakers
Erika Woodson, MD, FACS, is the Medical Director of the Hearing Implant Program and is primary investigator for a number of active research trials at Cleveland Clinic related to hearing and cochlear implantation. She is a board-certified otologist/neurotologist/skull-base surgeon who earned her medical degree from Virginia Commonwealth University School of Medicine in Richmond, Va. She completed her otolaryngology residency and her fellowship in neurotology and skull-base surgery at the University of Iowa Hospitals and Clinics.
Dr. Woodson’s clinical interests include cochlear implants, acoustic neuromas, gamma knife radiosurgery and chronic ear surgery. She is available at Cleveland Clinic’s main campus and the Beachwood Family Health and Surgery Center.
Sarah Sydlowski, AuD, PhD, is Audiology Director of the Hearing Implant Program. She completed her clinical doctorate in audiology at the University of Louisville in Kentucky, and her PhD in audiology at Gallaudet University in Washington, D.C. Her dissertation focused on the auditory and vestibular impact of superficial siderosis of the central nervous system. She previously coordinated the cochlear implant program for the Department of Audiology at the Mayo Clinic in Scottsdale, Ariz.
Dr. Sydlowski is board certified in audiology with specialty certification in cochlear implants. She is also a fellow of the American Academy of Audiology and holds her Certificate of Clinical Competence in Audiology from the American Speech-Language-Hearing Association. Her clinical and research interests include auditory implants, electrophysiology and auditory-vestibular pathology. She sees patients at Cleveland Clinic’s main campus.
Let’s Chat About Hearing Implants
Moderator: Welcome to our chat, Hearing Implants, with Cleveland Clinic’s hearing experts, Dr. Erika Woodson and Dr. Sarah Sydlowski.
Dr. Woodson and Dr. Sydlowski, thank you both for taking the time to be with us to share your expertise and answer our questions about hearing loss and implants.
About Cochlear Implants
Jessica: I thought cochlear implants were for people who have very severe hearing loss and can’t benefit from hearing aids at all. Is that true?
Erika_Woodson,_MD: It’s true that cochlear implants used to be a last resort when patients could no longer benefit from hearing aids at all. The primary reason was that having a cochlear implant used to mean guaranteed loss of any and all residual hearing in the ear that was implanted. Since that time, two things have changed. First, the surgery has changed a lot. Surgeons have developed advanced, “soft” techniques that are less traumatic to the inner ear. Additionally, cochlear implants have gotten smaller and thinner, also, increasing our likelihood that we may conserve some or all low-pitched hearing after implantation. Second, we have learned that patients do better with their cochlear implant if we can minimize the time they spend without one if they aren’t getting enough benefit from their hearing aid. The longer you’ve had advanced hearing loss, the harder it is to “relearn” to hear with an implant.
Will Implants Work?
spangler: What happens if I have a cochlear implant and I lose all the hearing in my ear. Will it still work?
Sarah_Sydlowski,_AuD,_PhD: Yes. Remember that cochlear implants were originally designed for individuals with no residual hearing whatsoever. So having residual hearing is like icing on the cake. It might mean that when you take your sound processor off at night, you can still hear alarms or other louder sounds. And you might like the sound quality with a combination of acoustic and electric hearing. But even if you do lose some or all of your residual hearing, the cochlear implant can be programmed to provide information for those pitches, and your speech understanding should still be improved over what you have with your hearing aid. In some cases, with the shorter hybrid array, it might be necessary to place a full-length cochlear implant instead, but outcomes are still very good.
SPORTSDR: Will the implants work when there has been nerve damage due to a previous bacterial infection?
Erika_Woodson,_MD: Yes, although there are many factors that can impact performance and suitability for a cochlear implant. If you feel your hearing is poor enough to consider a cochlear implant, a medical evaluation with an implant surgeon would be the next step. Good luck!
D1: My husband had sudden hearing loss in his left ear about seven years ago, resulting in a very major loss of hearing in that ear. Would an implant help?
Erika_Woodson,_MD: Yes, potentially. Cochlear implantation for single-sided deafness is not an FDA-approved indication; it's called “off label.” This means that it may be an acceptable option, but that it's not a widely recognized and accepted use of the device. Labeling may change in the future, but in the meantime, it's the next frontier and the biggest holdback on that may be insurer coverage of the device.
Living with an Implant
Vinny: What about talking on the phone or listening to music? Can I do that with a cochlear implant?
Sarah_Sydlowski,_AuD,_PhD: Cochlear implants’ first and primary goal is to improve speech understanding. That being said, many recipients can and do talk on the phone and listen to music. Doing so has also recently become much easier as cochlear implant manufacturers are developing ways to connect to devices and stream inputs through Bluetooth® directly to the cochlear implant sound processor. Some companies also have devices that can send phone or music signals to both a cochlear implant and a hearing aid for individuals who use one of each. These devices are great because they eliminate the need for headphones and help ensure that patients receive a good quality signal that can improve their hearing ability overall.
SPORTSDR: When you have cochlear implants can you perform normal functions and activities like something as simple as taking a shower to playing tennis to swimming in a pool or ocean, or do you have to be careful of getting the ear or surface wet?
Sarah_Sydlowski,_AuD,_PhD: Cochlear implants have two components – the part that is implanted under the skin and into the inner ear and also an external part that looks similar to a behind-the-ear hearing aid. Some recipients prefer to take their external equipment, the sound processor, off when showering or swimming. But there have been very exciting advancements in technology in the last few years as well, and sound processors now have special covers that make them waterproof and dustproof, meaning that recipients can wear them when swimming or showering or doing other activities while still hearing.
Making the Decision
jacqui: What does it mean to have limited benefit from a hearing aid? If I’m not understanding 100 percent of speech with my hearing aid, should I think about an implant?
Sarah_Sydlowski,_AuD,_PhD: Hearing aids are just that… aids. They cannot and do not restore normal hearing. Limited benefit means that even with appropriate, well-programmed hearing aids, patients aren’t able to adequately follow conversations even in a quiet room. We determine candidacy for cochlear implantation using a variety of guidelines, but the most important one is the results of speech perception testing in quiet, using appropriate hearing aids. This type of testing helps us to understand how much hearing aids can help; and if we think a cochlear implant could do more than hearing aids, then we may proceed with considering that device instead.
Lovetapas: What are some signs that I or my family member should consider a cochlear implant?
Sarah_Sydlowski,_AuD,_PhD: If you are having difficulty on the telephone or are withdrawing from social settings because it is too difficult to follow conversations, particularly in groups or in background noise, even with hearing aids on, it might be time to consider a cochlear implant evaluation. Even if the evaluation shows that you are not a candidate, the audiologist may be able to use the information to identify different hearing aids or accessories that may be able to address your particular needs and help you to hear better.
chickbull: I am 81 years old with hearing aids. Are there any options for me other than what I am already using such as implants, etc.?
Sarah_Sydlowski,_AuD,_PhD: It is hard to say for sure whether there would be other options for you, as there are many factors that contribute to candidacy for cochlear implants. However, if you are using appropriate hearing aids that have been programmed well, and you still feel that you are not hearing well (particularly if you are even struggling in one-on-one conversations or on the phone), then having a cochlear implant evaluation may be appropriate. During that appointment, your audiologist can also assess whether your hearing aids are adequate. Even if you are not a candidate for cochlear implantation, you can gather valuable information about whether there are other options available for you. These options may consist of newer hearing aids or other accessory devices that work with your hearing aids.
Ted: Wouldn’t it be better to wait until I have no hearing in both ears before I think about a cochlear implant?
Sarah_Sydlowski,_AuD,_PhD: No. We used to think so, but we have learned so much about cochlear implants over the last 10 to 20 years. We have learned that individuals who have shorter durations of hearing loss and who have worn hearing aids consistently typically have better speech understanding with a cochlear implant. The reason is that the nerve has been receiving and processing information all along so it is better able to adjust to the new information a cochlear implant provides.
aiden: If so much is changing with cochlear implants, maybe I should just wait. I want the best technology.
Erika_Woodson,_MD: One of the most important factors for determining our expectations for how someone may perform with a cochlear implant is how long they’ve had severe-profound hearing loss. If someone has had that amount of hearing loss for decades, they will not do as well as someone who recently dropped to that level of hearing. Therefore, you will lose benefit if you hold out for the next best thing. There will always be newer technology coming out. All the current implant manufacturers are committed to making today’s implants compatible with any new processor technology that will come in the future. That means that you can still take advantage of new features and science in the future, because the external piece can be upgraded over time.
Hearing Disorder and Devices
bobcat72737: Are hearing aids still needed with a cochlear implant? How is the implant different/better than hearing aids for hearing loss due to nerve damage? Thanks!
Sarah_Sydlowski,_AuD,_PhD: Great question. The need for hearing aids depends on your hearing loss. Many cochlear implant recipients today still have residual hearing in one or both ears. If you are one of those individuals, then we would recommend making use of that residual hearing. If you have residual/useable hearing in the ear that does not have an implant, then we would recommend using a hearing aid in that ear in addition to the cochlear implant in the other ear (this is called Bimodal stimulation). Due to advances in cochlear implant design, some cochlear implant recipients will have residual hearing left in the ear with the cochlear implant. In that case, we can use a hearing aid or a special addition to the cochlear implant called an acoustic component in the implanted ear. In both cases, we know that having the ability to use acoustic hearing in addition to the electric hearing a cochlear implant provides helps improve speech understanding in background noise, music appreciation and overall quality of sound.
Tigercat: Hello. I am a 62-year-old female mostly deaf since birth. I’ve worn two hearing aids since I was 10 years old. In 2008, I had a first vertigo attack and was diagnosed with Meniere's disease/tinnitus. Since 2013, I can no longer wear my hearing aids without getting a vertigo attack with severe tinnitus. Any noise is super sensitive and makes my head spin. Is there any hope for me without getting cochlear implants? I really do not believe it would help me. I would still get vertigo and tinnitus. Any feedback is highly appreciated. Thank you.
Erika_Woodson,_MD: I would assume you've had a medical evaluation to look closely at the reasons for your vertigo. There are some conditions that can make people vertiginous when exposed to loud noises, even if they have very advanced hearing loss. This does not preclude someone getting a cochlear implant, but the underlying reason for why you're sensitive to sound must be explored. I have seen this before, sometimes for identifiable reasons, but sometimes not. A cochlear implant does not amplify sounds, so it doesn't rely on making things LOUD to get good speech understanding. It therefore may be an option worth considering. Good luck!
loveitaly: I have had Meniere's disease since my teens. It disappeared for more than 30 years and came back in 2008. I had many injections of cortisone the following years, oral prednisone, diazepam, betahistine (I'm still taking it). In the past two years, the doctor injected the antibiotic gentamicin a few times. In October 2014 (exactly four months ago), I had major surgery of the inner ear to repair a perforated eardrum and to drain the endolymphatic sac. My hearing in the left ear deteriorated over the years. In the audiology tests, I can hear now (after the surgery) tones and beeps, but words I hear fragmented and distorted. They recommend to use a hearing device but not as a hearing aid. It will be used as a channel to reroute sounds and words from the left ear to the right one (the good one).What can you tell me about this device and what is the percentage of it working correctly? I will have a trial period before. Thanks so much for your input and expertise.
Erika_Woodson,_MD: There are several options for single-sided deafness if we feel that the ear is too far gone for a hearing aid. We have a single-sided deafness program here that is very comprehensive. It includes a review of your options and a device demo in a more challenging listening environment than a typical hearing test. This helps you determine which option may be best for you. Some devices are covered by insurance, some are not. A trial period is possible with hearing aid devices (like a CROS hearing aid or a BiCROS), but is not an option for a surgically implanted device (obviously). Some patients perform better with some devices than others. They will all “work” but by varying degrees for the individual. That's why an in-depth evaluation, we feel, is the best way to feel comfortable pursuing an option. Durability of the devices varies depending on what you're talking about and your lifestyle. Hope that helps!
loveitaly: I relate myself to the lady who mentioned before that since she was diagnosed with Meniere's in 2008, she can't hardly wear the hearing aids without having vertigo. In my case, I had the surgery hopefully to eliminate the vertigo, and now they recommend the CROSS hearing devices. Does this situation tend to happen often? I mean having vertigo because of the use of hearing devices?
Sarah_Sydlowski,_AuD,_PhD: Typically no. The hearing and balance centers are connected within the inner ear, so there can certainly be causes of both hearing loss and vertigo that affect both systems. And there are some situations where the individual may experience dizziness in response to loud sounds, but it is not the most common situation. If you have concerns that your hearing aids are causing dizziness, you should talk with your hearing health care provider.
Tigercat: I wore Phonak hearing aids for years and loved them. I then got my first vertigo attack in 2008 as I mentioned earlier. Doctors have said that they cannot guarantee that the cochlear implant would help me. I wanted an honest answer. I still do not know what to do. I miss wearing my hearing aids. I am just hoping for a new kind of hearing aid that could help me that is not a loud hearing aid in hope I can hear without getting vertigo or dizzy. Any feedback is welcome. Thank you.
Erika_Woodson,_MD: If you would like a medical evaluation/second opinion, we'd love to weigh in on your particular situation. Please contact the appointment line for further assistance/appointment scheduling with either myself or my partner, Dr. Tom Haberkamp.
ccligal: What is the name and or model number of the newer devices you referenced?
Sarah_Sydlowski,_AuD,_PhD: There are two companies that currently offer devices for an abutment-type bone-anchored implant. Cochlear Americas most current device is the Baha 4, and Oticon Medical's current device is the Ponto Plus.
Something About Surgery
LisaAnn: My daughter is 43 years old and has a profound hearing loss. She has had all the appointments and meetings necessary to have a cochlear implant, but is afraid to have the surgery. Should I keep encouraging her to have the surgery? Since she has a profound hearing loss, do you feel she would benefit from the implant?
Erika_Woodson,_MD: Although I cannot make predictions about your daughter's situation and potential performance with a cochlear implant, I can tell you that fear of making that leap to a cochlear implant is very common, especially among people with long-standing hearing loss. There are online communities, local support groups and patient advocates who can all lend emotional support to candidates. Good luck!
Graceland: I thought about a cochlear implant a few years ago, but was afraid of surgery. Is the surgery the same as it was?
Erika_Woodson,_MD: For the most part, yes, the patient experience is very similar. It’s typically an outpatient surgery, lasting a couple of hours. Some hair is shaved. People may have dizziness after surgery; however, we suspect that people are having less dizziness than in previous years (in fact, we’re doing a research trial about this currently). The healing time until the device can be activated is at least two weeks. We aim to activate about two weeks after surgery. Many patients experience little pain with this surgery, although some patients may need pain medicine for the first week. In general, implant surgery is safe, even if we have to take extra precautions for patients who are elderly or who have other medical conditions such as a pacemaker.
SPORTSDR: I am currently using a hearing aid that gives me only 30 percent hearing, and I am considering the hearing implants. What is the failure rate of the implants?
Sarah_Sydlowski,_AuD,_PhD: Cochlear implants are relatively reliable medical devices. Most companies have a failure rate for the device itself of less than 2 percent. There are other medical reasons that can contribute to the failure of the device, but those are also typically less than 5 percent to 10 percent. Your surgeon will talk with you about specific risks and potential for failures. It is also important to note that in many cases of failure, the original device can be explanted and a new device implanted, and most patients do very well after revision.
Erika_Woodson,_MD: Agreed. Failures can happen due to device issues, infections (very rare), medical complications or for reasons unknown related to performance. In general, revision surgery is possible and patients tend to do well.
cheriwilczek: Can you outline what is entailed with cochlear implant surgery and if someone, in good health at 90 years old would be considered?
Erika_Woodson,_MD: There is no age limit to cochlear implantation. The biggest determining factor is duration of deafness. Healthy octogenarians or nonagenarians are still candidates for surgery. The surgery takes two to three hours and is outpatient. There is little blood loss and typically little pain. Some balance loss can happen after surgery, so our expectations for the individual would be discussed as part of the medical evaluation. We do know that even in our golden years, quality of life is important and communication with our family and friends is an important part of that.
Finchly: I would like to know if this procedure is considered experimental by insurance companies or if most insurance companies, including Medicare, will help cover the expenses.
Sarah_Sydlowski,_AuD,_PhD: There are certain criteria that must be met in order to be a candidate for a cochlear implant. The primary guidelines are those approved by the Food and Drug Administration (FDA), and most commercial/private insurers cover those individuals who meet FDA guidelines. Medicare has their own, stricter guidelines, but if an individual meets those criteria, then cochlear implantation is typically a covered benefit. Cochlear implantation is not an experimental procedure, and candidacy is determined by a number of factors, but is primarily based on whether a cochlear implant could provide more benefit than hearing aids can.
cheriwilczek: Is outcome of surgery age dependent?
Erika_Woodson,_MD: Most important is duration of deafness. Age-related factors such as dementia/memory problems or other medical problems may weigh in on our decision-making about the fitness for surgery and our long-term expectations.
ccligal: I have an older model Baha. My doctor says he does not recommend new implant surgery to get the magnetic version. Do you agree?
Erika_Woodson,_MD: If you have an ABUTMENT (sticking though the skin), then getting the Attract would require removal of the abutment, healing of the skin and replacement with a newer abutment and skin healing for that. We are currently recommending the Attract only for patients who have CONDUCTIVE hearing loss (problem with hearing bones or ear drum, but inner ear is fine) and not single-sided deafness. Compared to the abutment, you would lose about 10 dB of volume (at least) if it's going through the skin, so it would not work quite as well as your current configuration.
Incidentally, the new Baha processors are very good compared with older models. A lot of advances make this a much better device than previous versions. Newer technology may be your best bet.
How About Hybrids
JCN215: What’s the difference between a cochlear implant and a Hybrid implant?
Sarah_Sydlowski,_AuD,_PhD: Cochlear implants and the Hybrid implant are nearly identical. Both are implanted by a surgeon into the cochlea (the inner ear) and both directly stimulate the hearing nerve in order to provide improved sound quality to the nerve and brain. But the electrode array (the part that is implanted) is shorter in the Hybrid than in a cochlear implant. This is very important because the cochlea is coded for different pitches along its length. So a standard cochlear implant covers much of the cochlea and can provide all the different pitches that are important for speech. The Hybrid is designed to only stimulate the mid to high pitches (which are the regions where most people have hearing loss). Some people have pretty good hearing in the low pitches, but severe hearing loss in the high pitches. The Hybrid allows for electrical stimulation through an implant in the high pitches and acoustic (or natural) hearing through the ear itself or an amplification device (called an acoustic component) in the same ear for the low pitches. Research has shown that the combination of electric and acoustic hearing can be very beneficial for hearing in noise and enjoying music, and for overall sound quality.
paulrei218: I don’t know if I would be a candidate for the Hybrid or the regular cochlear implant. What do I do?
Erika_Woodson,_MD: The evaluation process is the same for both devices. If you believe you may be a candidate for a Hybrid (you have good low-pitch hearing but poor high-pitch hearing), you will want to contact a cochlear implant center that works with both devices. You can find a Hybrid center at www.cochlear.com then click “find a hearing specialist.” You can search by ZIP code for all providers of cochlear implants and Hybrid implants. If you believe you are not a Hybrid candidate but may be a standard cochlear implant candidate, then you can visit any center that works with cochlear implants. FDA-approved companies in the US include Cochlear Americas, Advanced Bionics and Med-El. You can find a provider by talking with your audiologist or ENT, or by searching company websites for providers in your area. Whether you are undergoing an evaluation for a cochlear implant or a Hybrid implant, you can expect to complete a hearing test as well as special tests in both quiet and noise while wearing hearing aids. You will also see the surgeon to discuss whether you are a medical/surgical candidate for cochlear implantation.
devonshire: Are there any research trials going on at Cleveland Clinic?
Erika_Woodson,_MD: Yes. We currently have two trials for cochlear implant candidates. The first is the Cochlear 422 study. Its aim is to expand implant criteria to include patients with more residual hearing. This is based on our collective experience that these patients may struggle more with real world listening than their hearing test may suggest. We are seeking candidates who have up to moderate/moderately severe hearing loss in the mid ranges. The study is a national one, involving multiple centers. If you are wondering if you would be a candidate for this trial, you should contact us or another 422 trial site as soon as possible to assess your candidacy. The study will close after the maximum number of patients has been implanted.
Tigercat: Dr. Woodson, does Meniere's disease ever burn out permanently?
Erika_Woodson,_MD: The stat I quote to my patients is that 70 percent go into remission within seven years.
Moderator: That is all the time we have today for questions. Thank you everyone for participating today; and thank you, Dr. Woodson and Dr. Sydlowski, for your insightful answers to our questions about hearing loss and hearing implants.
To make an appointment with Erika Woodson, MD, or Sarah Sydlowski, AuD, PhD, in the Head & Neck Institute at Cleveland Clinic, please call 216.444.0354 or call toll-free at 800.223.2273, ext. 40354. You can also email the Hearing Implant Team at firstname.lastname@example.org.
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For More Information
On Cleveland Clinic
Cleveland Clinic’s Head & Neck Institute has one of the largest audiology programs in the country today, with more than 20 clinical and research audiologists located at either Cleveland Clinic's main campus (including our Hearing Implant Program) or one of the Family Health Centers throughout Northeast Ohio (Beachwood, Independence, Strongsville, Twinsburg and Westlake). Each audiologist is part of the hearing health care team at Cleveland Clinic, working closely with our physician partners in otolaryngology in the Head & Neck Institute and other professional colleagues in a variety of specialty areas including pediatrics, geriatrics, neurology, psychology, dentistry, speech language pathology, plastic/reconstructive surgery and oncology to treat hearing disorders.
Cleveland Clinic's Hearing Implant Program (HIP) is committed to providing high quality, team-centered, patient-focused hearing care for adults and children with hearing loss. The Hearing Implant Program Team consists of specialists from a variety of disciplines, including audiology, neurotology, otolaryngology and speech language pathology, who specialize in the assessment, treatment and (re)habilitation of cochlear implant and bone-anchored hearing implant recipients. The HIP team is dedicated to the long-term support of our implant recipients: from candidacy evaluation through surgery, initial device fitting and programming, (re)habilitation and long-term management. Cleveland Clinic HIP Team members offer comprehensive clinical services and are also involved in various areas of implant research.
Other specialties within the Head & Neck Institute related to audiology and the Hearing Implant Program include speech-language pathology, vestibular and balance disorders and Cleveland Clinic’s Voice Center. In 2012, Cleveland Clinic’s Ear, Nose and Throat program ranked second in the nation by U.S. News & World Report.
Cleveland Clinic Health Information
Learn more about symptoms, causes, diagnostic tests and treatments for Hearing Loss and Implants
Please use this guide as a resource to learn about the causes of hearing loss and your treatment options. As a patient, you have the right to ask questions and seek a second opinion.
Currently Cleveland Clinic is involved in two clinical studies (see response above). For additional information about clinical trials: clinicaltrials.gov (must use Chrome or Firefox as browser to link).
For additional information about specific Cleveland Clinic studies, contact the Hearing Implant Program (HIP) Assistant, JP Podriznik, at 216.444.0354 or email email@example.com.
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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
If you need more information, click here to Live Chat with a health educator (click on Questions and then Live Chat) or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272, ext. 43771, to speak with a Health Educator.