Now Hear This: Updates on Hearing Health Perceptions, Cochlear Implant Candidacy, and Cleveland Clinic's Hearing Implant Program

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology–head and neck surgery.

Thanks for joining us for our relaunch of Cleveland Clinic's Head & Neck Institute podcast, Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center in our Head & Neck Institute. You can follow me on Twitter, @paulcbryson, and you can get the latest updates from our Institute by following @CleClinicHNI. Our podcast will feature topics that span multiple specialties within head and neck surgery. These include cancer, facial plastic and reconstructive surgery; comprehensive and pediatric otolaryngology; laryngology; otology, neurotology, and lateral skull base surgery; rhinology and endoscopic sinus, and skull base surgery; surgical sleep management; dentistry and oral surgery; hearing, speech and balance disorders, and much more. So look for our podcast every other Wednesday on our website at clevelandclinic.org/podcasts, or you can subscribe to our podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts.

Today, I'm excited to introduce our first guest, Dr. Sarah Sydlowski, Associate Chief Improvement Officer and Audiology Director of Cleveland Clinic's Hearing Implant Program in our Head & Neck Institute. Dr. Sydlowski is also current President of the American Academy of Audiology. Dr. Sydlowski, welcome to Head and Neck Innovations.

Sarah Sydlowski: Thanks so much. It's fantastic to be here.

Paul Bryson: Well, we're delighted to have you. We know you wear many hats in our Institute, but let's start by sharing some background on yourself for our listeners, where you're from, where you trained, how you became interested in audiology and how you came to Cleveland Clinic.

Sarah Sydlowski: Sure. Well, it's a long and meandering path, quite honestly. I was raised in Michigan and I did have a grandfather who had very significant hearing loss who received a cochlear implant when I was in graduate school actually. I always knew that I wanted to work in the health professions and that I really wanted to be in an area where I could personally make a difference in the lives of as many people as I could, and that led me to audiology. And so I initially pursued my clinical doctor at the University of Louisville, and I finished my training at the Mayo Clinic in Scottsdale, Arizona. I stayed on there after I finished directing the cochlear implant program there.

I very quickly realized that I wanted to have a lot more impact than just the people who are sitting across the table from me. And so I decided to go back to pursue my PhD because I wanted to administrate a program in a big academic medical center, and I also really wanted to teach and to help encourage the next generation to be prepared to care for patients. That led me to the Cleveland Clinic. I came here right out of my PhD program. And what drew me to the clinic is really that this is a place where we can see the most complex patients and we have the opportunity to change the profession, change the industry, change how patients are cared for on a national landscape.

Paul Bryson: Well, congratulations on all of the achievements and contributions. Just walking around the Institute, you can see the impact in all of the different areas on a daily basis with the students that you teach, with the patients that you care for. So it's really awesome to see. I appreciate you sharing the story about your grandfather and sort of the impact that it can make on a person as choose your career path. Could you elaborate a little bit on just hearing loss in general across the country? What do people not appreciate for the magnitude of hearing loss in our population?

Sarah Sydlowski: Sure. So hearing loss is the third, most common chronic health condition in older adults. I would venture a guess that all of us know someone who has hearing loss, or we have hearing loss ourselves, and it impacts every aspect of the lives of people who are dealing with it. And so really being able to understand what hearing loss is, how to interact with people who have hearing loss, offering opportunities for how to manage it best is incredibly important, but it's also really, really misunderstood. And so that's one of my passions is trying to help close that gap between where we are today and where we need to go and think very critically about what are the steps that we need to take in order to close that gap.

Paul Bryson: Why do you think there's such a gap in both the public and the medical community on what might constitute normal hearing?

Sarah Sydlowski: Sure. So we recently conducted some research to understand the perspectives of both the public and primary care providers, because I think both of those groups are so important in terms of having a connection to hearing loss. And we were disappointed, although not surprised to see that people really don't understand hearing loss or the impact that it can have. In fact, among the general public, only 9% of individuals could recognize what constitutes normal hearing and a majority of primary care providers also were not able to define that. And in our research, we looked at the comparison to other more common health conditions and other screening measures, and the discrepancy is just enormous. So over 80% of providers screen regularly and understand the metrics for things like BMI and cholesterol and blood pressure. And consequently, the public also understands that those things are very important and they can talk intelligently about what the cutoffs are, what those important values are. But when it came to hearing loss, it was at the bottom of the list.

So we asked about a lot of common health conditions. You know, how important are these if you had to rank them, and hearing loss was dead last. We also asked about how likely are you as a consumer, as a member of the public to pursue a lot of the common screenings that you need to have done. Things like having a physical or having your eyes checked or having your blood pressure measured. And all of them were quite likely, maybe around 60% or 70%, even how likely are you to take your pet to the vet was about that high. But when we asked about how likely are you to go have your hearing tested, only about a quarter of the population said that, that would be a priority for them.

Now, I think this is not surprising because we pursue the things that our providers tell us are important. So if our physician tells us, “It's important that you check your blood pressure regularly. It's important that you're focused on diet and exercise. It's important that, you know, you come see me annually.” It's more likely we're going to do it. But when we talk to primary care providers about what they understand about hearing loss and how important it is, about half of them think that there's nothing that you can do about it and only about 15% think that it's preventable. So it's not surprising that, that's not something that they talk about or that they push their patients to follow up on. So subsequently, patients don't.

Paul Bryson: What are the implications of that in real life scenarios? What does the research tell you about the downstream implications of putting hearing loss perhaps at a lower level of priority? What are some of the things that you see in your practice or that patients and families share with you?

Sarah Sydlowski: Gosh, there's a lot of things. Somebody asked me recently, what health conditions does hearing impact? The answer is really, it impacts all of them because hearing is what connects us to people. And so if you're not hearing well, you're not able to hear your healthcare provider well, it's much less likely that you're going to be able to follow up on their recommendations, that you're going to be able to be compliant. So hearing loss has the potential to impact every single aspect of our health.

Sarah Sydlowski: We have seen data that suggests that hospital readmissions are higher in patients who have untreated or undermanaged hearing loss. We know that hearing loss has some association or connection to depression, cognitive decline. It's actually the number one most modifiable risk factor for Alzheimer's disease in middle age. And here, we're all talking on a regular basis about, what do we do about Alzheimer's? What do we do about dementia? And recognizing that hearing loss is important and connected early and doing something about it could be a very easy way to start to mitigate what is a huge healthcare problem in the U.S.

Sarah Sydlowski: We also know that hearing loss is connected to social isolation. I think coming out of COVID, we all had the opportunity to experience what social isolation can really feel like. None of us liked it. And as doors continue to open, I think everybody's really happy and excited to be able to reconnect with people and the things that we love to do. But if you are someone with hearing loss, that social isolation continues because when it's not managed, you're still not able to connect fully to the people you care about, to participate fully in a job that you love, maybe even to stay in the workforce, to feel connected to the activities that keep you vital and engaged as you move into older adulthood. And so the implications are just enormous, and it's amazing actually that there's such a gap between the knowledge and the actions that people take, knowing how important hearing loss is for every other aspect of our life.

Paul Bryson: I appreciate that. It's pretty clear. You've talked pretty eloquently about how important hearing is and how it needs to be recognized as an important part of healthcare and healthcare conversations, even outside of your office. The public and even healthcare professionals are probably hearing a little bit, no pun intended, but at least hearing or reading a little bit about over-the-counter hearing aids and hearing assist devices. When you see patients in the office, do they ask about these things? So that would be one question. And then how do we move hearing loss up the priority list? What do you think it will take? What are small steps that the medical community can do?

Sarah Sydlowski: That's a very loaded question that you've asked. Lots of components there, and a lot of really important things to think about. First of all, with over-the-counter hearing aids, we're on the brink of a whole new delivery model. In the past, patients had to come to an audiologist or a hearing instrument specialist. It's required medical clearance in order to pursue a hearing device. And so there's been a lot of hoops to jump through, which can make it a little bit more difficult to pursue something. It can be confusing and overwhelming. What has been fantastic about over-the-counter hearing aids is that I have never heard hearing loss talked about as much as it has been in the media, by legislators, by regulators, by payers. It's becoming part of the common conversation, which is the first step to really seeing change.

Now, the reason that over-the-counter hearing aids have been introduced or will be here just shortly, is to address the two barriers that were identified, which are accessibility and affordability. Now, I think that those are probably very important factors that we need to consider, but I actually think the root cause of the entire issue that we have with hearing loss and its importance is that people don't think it is important. So we have to start there. Just because there's a technology, a device, a delivery model that's available, does not mean that people are going to take advantage of it. And so the very first step is that we have to elevate the importance. And as you said, that's probably very likely to start with physician, APP, nurse providers, people who are really the gateway that patients are going to see first.

We know that there is quite a bit of evidence in the literature that people trust their healthcare providers. And if their provider says, “This is something you need to do,” they're much more likely to do it. By the time somebody makes it to my office, they've already decided that they should learn more about this or do something about it. Those are not the people that I need to actively reach. The people that I need to reach are the people who haven't decided yet. And sadly, we know that's about 80% of people who have hearing loss. So number one for physicians I think is make it simple, something that's easily integrated into their practice.

So I have a study going on right now with some of our colleagues in family practice and in geriatric medicine, where we have tablets embedded in their offices as part of the rooming process to quickly, in two minutes, screen the hearing of all of their patients over the age of 50. And we're hopeful that we're going to see that having a quick and easy tool like that is going to facilitate the conversation about hearing that it's important. It might prompt patients to actually ask, “Hey, I saw I failed that hearing screening, what should I do about it?” Even if you don't have access to that technology, I think as a healthcare provider, just asking a quick question, “Do you want to hear better?” It's interesting because I don't think you can necessarily ask the question, “Are you having difficulty hearing?” Because about 30% of patients mischaracterize their own hearing. You don't know what you're not hearing. So it's really common that patients don't report it, even if they're already suffering the consequences.

But a lot of people will say, “Yes, I think I could be hearing better.” So that's really the first question. And it's an easy thing to be able to integrate. It's also really important that we work to a place where we have adult hearing screening for ages 50 and up mandated. This was reviewed by the U.S. Preventive Services Task Force a couple of years ago. Unfortunately, the results came back as insufficient evidence. That's not because we don't know the benefits, it's because they haven't been documented well in the literature. So we have a lot of work to do as far as generating that research so that the next time this comes up for review, the level of importance of hearing screening aligns with the evidence that there is to support having that incorporated in every primary care visit.

Paul Bryson: As you talk about the research and initiatives you're doing with family practice and our successful aging program here, do you think colleagues and other centers, you know, are we starting to build that story so that when the task force meets again to consider the evidence, do you think that the data and the evidence is becoming higher quality, building a more compelling story toward telling decision makers that hearing, we should be looking at this?

Sarah Sydlowski: It's a good question. I think, yes, there's definitely some work that's beginning. Unfortunately we're quite a few years later than I wish we were, but we're starting to get some traction behind that. I'm currently co-chair of the Hearing Health Collaborative along with Matt Carlson, who is a neurologist in the Mayo Clinic. We have a team of several dozen at this point, audiologists, otologist, geriatrician, family medicine, physicians, association leaders from across the country. And we are focused on using a process of A3 thinking, which is a very methodological approach to identifying the root cause of a problem, and then choosing the counter measures that will actually drive change to work toward identifying exactly what steps we need to take in order to move the needle on hearing loss. I would say it's the most encouraged I've ever been in my career that we are going to make it happen because we have a unified cohesive effort where everyone is committed to the same result, the same outcome. We have a lot of people who know how important this is and are really committed to making it happen for our patients.

Paul Bryson: I commend you on those efforts and all the work that you're doing here in Cleveland in bringing, expanding the tent, if you will, with family medicine and successful aging. It's great to see it sort of expand locally and then also the national level too.

I wanted to change gears a little bit. I wanted to move into that group of patients that are interested in having better hearing, but maybe have a pretty severe hearing loss. You know, people will hear about implants and things like that. So one effective way to treat hearing loss is through cochlear implantation. Pretty big technological jump from hearing aids and hearing assist devices and hearables or wearables, and it's a large role that you've filled here in the Institute and continue to do so. Can you give your perspective on who makes a good cochlear implant candidate? What are some lessons learned and perspectives as you've seen this technology hopefully reach more people?

Sarah Sydlowski: So this is the other soap box that I really like to stand on because we also have a lot of work to do when it comes to cochlear implants. The person who makes a good cochlear implant candidate is not the person everyone thinks of. Everybody thinks of a good cochlear implant candidate as somebody who's scraping the bottom of the barrel in terms of the benefit they can get from hearing aids, that this is a last resort and let's try everything else we can do before we have to jump to a cochlear implant for those severe hearing losses. But in reality, that was what cochlear implants look like 30 or 40 years ago. But over time, what we've learned is that the sooner we identify that a patient could benefit from the technology, the shorter the duration of severe to profound hearing loss, the more residual hearing they have, the better they do.

We also used to think that you had to wait until you had really significant hearing loss in both ears, and that is 100% not the case. Unfortunately, we know that utilization of cochlear implants is even worse than hearing aids. So hearing aids is probably around 20% to 30% at best. For cochlear implants, those traditional candidates, the ones who should be the slam dunk severe to profound hearing loss, it's about 12%. For the patients who meet that more expanded criteria, it's only 3%. I can't think of many health conditions where 97% of people who could benefit from the technology don't have it. So it's a huge, huge problem. Part of the issue is that most providers and many in the public don't recognize that evolved criteria for who should be referred for a cochlear implant evaluation.

We did a project here about six years ago or so, where we were noticing that although candidacy criteria were expanding, our volumes had completely plateaued and we pride ourselves on pushing the envelope on connecting patients to the care that they need as soon as they need it. And so we were really frustrated and confused and worried about why we weren't seeing our numbers increase. And so what we learned is that providers, people who would be recommending a referral for a cochlear implant evaluation thought they were recommending the implant and they weren't comfortable with appropriate candidacy and so they weren't sharing anything.

And so using actually a program that we have here called Solutions for Value Enhancement through our Continuous Improvement Program, we again went through a very methodological process to understand what are the barriers. And then we were intent on moving them. And since then, we've tripled the number of people that we're able to connect to this care. And primarily that's because we've made it simple and easy for our internal providers to know who is likely to benefit. And the people that we're seeing more and more of are those who still have residual hearing. Not those who have no benefit from hearing aids, but those who could be doing better, because that's really who should hear about cochlear implants.

We just did a study recently where we looked in particular at those patients who have a better ear, one that is not appropriate for a cochlear implant. So in one year they might have an ear that's appropriate and the other ear has some hearing loss or could even be completely normal. We had about 63 patients that we looked at, and what we found is that the outcomes are outstanding, but these are the people who are hardest to get to us and who are even harder to get through insurance. But that being said, as a program, we're absolutely committed to doing everything that we can to make sure that those individuals who we know can get really great outcomes have access. In many other centers and many other programs, they would be told no, but here they will be told yes, because we believe very, very firmly that as soon as you could potentially benefit, we want to make sure you know it's an option. If there are hoops we have to jump through to try to deal with insurance, we will.

But historically, in cochlear implant world, there has been a confusion of you're a candidate for this technology and your insurance will cover it. And a lot of times people look at what insurance will cover and if it doesn't meet those criteria will tell a patient, “Well, then you're not a candidate.” We believe very firmly here that patients hear about what is in their clinical best interest. And then they understand the barriers. And if it's insurance, then that's something we have to try to work through, but we don't want that to be a reason that they can't potentially proceed.

Paul Bryson: When you went through the methodological process, how did you make it more simple? What were some things that are either caregiver or patient facing out of that process that's made it perhaps more accessible or easier, if you will, for patients here at Cleveland Clinic?

Sarah Sydlowski: Sure. I think honestly, it's a very similar approach to what I was talking about as far as identifying hearing loss at all. It's all just to make it very simple, very easy, not to ask busy providers who have a thousand things on their plate to have to understand all of the ramifications and implications and details of cochlear implant candidacy. How can we make it most simple? So what we did is we just made a tool where you could essentially combine it with the results of the hearing test and it immediately told you, yes, we want to see them for a cochlear implant candidate appointment or not. So the provider didn't really have to think about it, or remember any specific facts or protocols. They were disabled to say, “Ah, the implant program wants to see them, okay.” And send them on over. And I think that that's really what's going to be key for most of the change that we want to drive, is it has to be easy, it has to be comfortable, and it can't take a lot of time.

Paul Bryson: Yeah. I love that. That's great. As a clinician myself, to be able to have that sort of decision support is very much appreciated, particularly if perhaps the clinician, surgeon doesn't live in that space with the same level of sophistication as you and the team do. So that's really nice. Particularly if it's in the primary care setting, like you alluded to earlier, it makes it an even easier pathway for clinician and for patient.

Sarah Sydlowski: I'm really glad you've mentioned, and I think it's really important that this collaboration is key. I think for far too long as a profession, we've held on to ownership of hearing. And yes, we do as audiologists have that expert knowledge and we are the right people to see when you need somebody to come have a hearing test, to pursue hearing management. But we all, as a health industry really, as a hearing healthcare system need to own the importance of hearing loss at every level, whether it's identifying it early, helping encourage patients to manage it, or pushing them to the next step when it's time to think about an implant. That prioritization has to be something that we share across primary care, geriatric medicine, otology, audiology. And without that collaboration, we will not move the needle.

Paul Bryson: Well, obviously at Cleveland Clinic, we're very fortunate to have our Hearing Implant Program. It helps a lot of patients. You can see that we're trying to make the tent bigger, improve access. I mean, you've kind of talked about the program already, but would you be able to summarize or just expand upon the program as you see it right now and the services that you and the team provide? Obviously, inclusive of cochlear implantation, but other things that patients and referring people might expect when they come to the center.

Sarah Sydlowski: Sure. I think the most important thing for people to realize is that we aren't just cochlear implants. We really are addressing care across the spectrum. We have different tools at our disposal to do that, from over-the-counter devices, to hearing aids that require the fitting expertise of an audiologist, to implants, to bone conduction implants, which we haven't even talked about yet today. But we have the expertise and the resources here to cover that entire gamut. And we consider it our responsibility to be able to care for the whole patient. And so in the implant program, we're not just looking at the one ear that might benefit from a cochlear implant. We're trying to understand the patient's entire communication needs, the environments that they're in. We want to make sure that they can have one provider who can best support all of that so they're not bouncing from one person to the next for a hearing aid and a cochlear implant and the diagnostics. They're going to get that comprehensive care.

I think also what's really important to us is that we do our very best to not only stay on the cutting edge of what's coming out into the literature, but to be producing that information. I think that benefits our team because it pushes us to be our best all the time. It also benefits our patients because they know that they're always hearing about the latest and greatest and that they have all the information that they need to make an informed decision. And then also, I think it's really important for people to know that when someone does come for a cochlear implant evaluation, so to speak, it isn't just cochlear implant or no, it's really a functional communication assessment. You know, how much are your hearing aids benefiting you? How could you do better? What are you perceiving? And so it can be a much, much broader conversation.

I think people worry that if they send someone for an evaluation and they're not an implant candidate, it was a failure. I think it's a big win because the patient comes away with a lot more information than they started with. And that's something that we pride ourselves on here.

Paul Bryson: Yeah, no, that's a great point. When people come, maybe they're coming, an example would be, you know, “I need my shoulder replaced.” Well, maybe you don't, maybe there's another problem. Maybe there's some other innovative therapies or assist devices for hearing, or other things that they didn't know they were a candidate for. And maybe it's relief they don't need a cochlear implant and there's something that can be modified or enhanced with what they have.

Sarah Sydlowski: Yeah, that's such a great point.

Paul Bryson: Great point.

Sarah Sydlowski: Great point. We published some data on this recently too, where we saw that about a third of people that we evaluated had hearing aids that were not optimally appropriate for their hearing. So we had people coming in feeling like, I'm struggling enough, I think I might need to pursue a surgical intervention. And we were able to program and verify appropriate devices and tell them, “Actually, no, you can do 70% better. It's just that you don't have the right device or it hasn't been fit appropriately for you.” And I think that information is empowering for patients to recognize that they have options.

Paul Bryson: Yeah. And I think so important, as we see things come out over the counter, perhaps that segment of the population is another group that can be reached in that way. It would be interesting to see how that goes over time.

Sarah Sydlowski: Yeah. I think that's such a great point. I'm really glad you mentioned it because over-the-counter hearing aids will absolutely be appropriate, just like over-the-counter readers are appropriate for people who aren't ready to pursue prescription glasses, for example. However, I believe it is absolutely imperative to first see an audiologist and have a hearing test. You need to know what your hearing status is and then your audiologist can talk with you about what options are most appropriate, which could very well include going down to one of the local pharmacies and purchasing an over-the-counter device. But as I mentioned, patients are not always able to perceive accurately their own level of hearing or how much it's impacting their daily life. So getting that baseline information first is absolutely essential.

Paul Bryson: You've mentioned a couple really pragmatic research studies, very clinical, very sort of real life in nature in terms of the conclusions and the implications. What's on the horizon as far as ongoing, or additional research rather that patients are referring providers might want to consider or at least know about as they come to the center?

Sarah Sydlowski:

One thing that's really important is just the kinds of services that audiologists are providing. We have the capability and the expertise to do a lot of measures that are not always available in every location. For example, what we call aided speech recognition testing, which is where we're able to measure how well someone is benefiting from their hearing aids using individual words, speech and quiet, sentences and noise. It can give us far more information than what we think of as a standard hearing test. And so that's something that we pride ourselves on here, but I think that there is not enough evidence in the literature so that that's a widespread utilization of a really fantastic tool that benefits patients. So I'm hopeful that we're going to see more work in that space.

I think also any work that we can do that will help us to achieve the mandate for adult hearing screening. So that's something that we're very active in here, and that really, we need involvement across the nation in order to have enough evidence in order to be able to push that forward. So that's something I think is really important.

And then finally, I think we still have a lot to learn about cochlear implants and how can we give the most optimal outcomes. We're doing some of that work here in terms of understanding hearing preservation, the most appropriate electrode arrays that should be selected, but there's still far more that we can understand that will result in much better outcomes for patients in the future. Just as we've seen the rapid trajectory of improvement over the last 20 years, I think we still have long ways to go.

Paul Bryson: Well, I'm confident we'll be on the forefront of that. I know we really appreciate your leadership, both here locally and at the national level with these initiatives and care delivery. Any final take home messages for our listeners? It's a broad audience of clinicians and possibly even patients. Any final thoughts to the audience?

Sarah Sydlowski: I would say we have one set of ears for our lifetime and we absolutely have to take the best possible care of them. For providers, my message would be, this is our responsibility. We need to raise hearing loss to the level of importance that it deserves. And it's absolutely imperative that we convey that importance to our patients and show them the path to take the appropriate action as early as possible. For patients, I would say, don't wait, get a hearing test, see your audiologist, even if you aren't having any concerns as of yet, it's great to have a baseline and learn how to protect your hearing for a lifetime.

Paul Bryson: Well, really appreciate you. It's been great to sit down and talk and catch up and hear about all of the great things that we're working towards here.

To learn more about the Cleveland Clinic Hearing Implant Program, please visit clevelandclinic.org/hearingimplant. That's clevelandclinic.org/hearingimplant. And to speak with a specialist or submit a referral to our Head & Neck Institute, please call 216.444.8500. That's 216.444.8500. Dr. Sydlowski, thanks for joining Head and Neck Innovations.

Sarah Sydlowski: Thanks for having me.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org/podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real time updates from Cleveland Clinic Head & Neck Institute experts on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.