Listen Up: Cochlear Implant Candidacy and Our 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 another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm joined by a returning guest, Dr. Sarah Sydlowski, Associate Chief Improvement Officer at Cleveland Clinic and Audiology Director of our Hearing Implant Program. As well as a new guest, Dr. Marc Bassim, Section Head of Otology and Neurotology and Medical Director of our Hearing Implant Program, and also an old friend that I was able to train with during my residency training. So Dr. Sydlowski and Dr. Bassim, welcome to Head and Neck Innovations.

Marc Bassim: Thank you Dr. Bryson.

Sarah Sydlowski: Thanks so much.

Paul Bryson: Well, before we get started, and I know we have some exciting things to talk about, I wanted to encourage everyone to go back and listen to Dr. Sydlowski’s previous Head and Neck Innovations episodes on hearing health perspectives and cochlear implant updates. For our new listeners, let's start by having each of you share some background on yourself, where you're from, where you trained, how you came to Cleveland Clinic, and what excites you about this really long standing center of excellence in hearing implants. Who wants to start?

Sarah Sydlowski: I'll go ahead and kick us off. So I'm really happy to be celebrating my almost 14th year here at the Cleveland Clinic. I'm originally from Michigan. I did my clinical training at the University of Louisville, and then I completed that training at the Mayo Clinic in Arizona. I loved working with patients, but I realized very quickly that I also really loved program administration, so I went back for my PhD at Gallaudet University in D.C., came up here to the clinic where I've been, as I said, for about 13 and a half years, I developed a huge interest in how do we run a really effective business in healthcare without compromising patient care quality, fantastic outcomes. I went back for my MBA and that led to me having this role in continuous improvement, which has been the most fantastic combination. I love both of my roles, both cochlear implant and continuous improvement and really just helping us do both better all the time.

Paul Bryson: Well, welcome back. Dr. Bassim?

Marc Bassim: Yes, my story is a bit longer and more circuitous to get to the Cleveland Clinic. I've been here since this past September, so coming on six months now. I'm originally from Lebanon. I did my medical school training at the American University in Beirut, and then I went to North Carolina where we did our residency training together. A few years back, I did my fellowship training in Otology and Neurotology at the House Clinic in Los Angeles. After that, I went back home. I was on staff at the American University in Beirut for almost 11 years. I joined the Cleveland Clinic in Abu Dhabi where I spent two and a half years, and in this past year, I was recruited as Section Head of Otology and Neurotology, and here I am in Cleveland, Ohio.

Sarah Sydlowski: And we're so excited to have him on the team.

Marc Bassim: I was just about to say, it's been fantastic. It's only been six months, but I really feel like I've been here much longer. The team is just phenomenal to work with. There's so much that has been done already and there's so much that we can do together as a team, and I'm really, really excited to be joining this team.

Paul Bryson: Yeah, I mean the tradition here and the heritage of hearing restoration and hearing health is really excellent. I know we're going to talk about this, but really since 1983, Cleveland Clinic has increased access to hearing through our Hearing Implant Program, and it's really one of the earliest cochlear implant centers established in the United States. We can celebrate this 40 year milestone here now, but I also understand that your program has now placed over 2,000 cochlear implants, so congratulations on these achievements.

Sarah Sydlowski: Thank you so much.

Paul Bryson: Can you both share some additional details about the program for our listeners? What can somebody expect when they walk through the door here?

Sarah Sydlowski: Well, maybe I'll start and I'll give a little bit of historical perspective, and then I think to hear the perspective of someone who's a little newer to the program and what your observations are would be great. One of the things that I think is just really exciting is that we've continued to grow at least 10% year over year for the last eight years, and that's been very intentional because we're really committed to making sure that every individual who needs a cochlear implant has access to one. We know that today only about 2% of people who can benefit have one, and so we've worked really hard as a program really over all of those 40 years, but especially in the most recent years to make sure that we're constantly innovating, that we're making choices that are going to make sure that patients have this option as early as possible and that they receive the best possible outcomes in order to make that happen.

We have certainly grown our team. We now have 11 audiologists. We have five surgeons. We have an auditory verbal therapist. We have many members on the support team who help to navigate our patients through the program, and we also are at many more sites now. It used to be that patients had to come only to main campus, which of course is a little bit trickier with traffic and parking and other factors, and we wanted to make sure that this was accessible care close to home, so we now also have a presence in many of the family health centers.

Marc Bassim: Like I said, I haven't been here very long, but in the past six months since I joined this team, having worked with different centers around the world, I can tell you that the quality of care that this team provides is just outstanding. A lot of the credit goes to Sarah and the team she works with that she's built over the years. Having a cochlear implant is not an easy decision. It's a life-changing process. There are a lot of benefits to it, but the road is not very smooth and it's a long road for patients and it has a lot of anxiety in it, and I think just the way our team has been handling these patients in terms of the education, the testing, the follow through, as Sarah mentioned, where the team is very data-driven in terms of making sure that every patient who needs an implant should be able to get an implant but also should be able to get it at the minimal while reducing the inconvenience and the hassles along the way is significant, and I think that's what makes a big difference and what makes this program so good.

Paul Bryson: It sounds like there's really excellent collaboration between our audiology team and our surgeons. Can you share a little bit about maybe the patient experience, if they're getting referred to the program, who are they meeting with? What's that patient journey or roadmap look like?

Marc Bassim: So patients can either start with the surgeons or they can start with the audiologist. It depends, but essentially the evaluation process is the same. Whenever we feel that a patient has a hearing loss that's severe enough that they're not getting the optimal benefit from their hearing aid or their amplification device, we enroll them in the hearing implant evaluation, cochlear implant evaluation. That's where our audiology colleagues take over. They do an extensive evaluation that Sarah can discuss a little bit in more details. They do a lot of counseling. They do a lot of handholding and answering questions, and once we reach at this point where we feel comfortable that this patient is a good audiological candidate, we sit down together. Again, we have weekly meetings to discuss our program. We discuss the patients at least every other week, and more frequently if we need to. So it's always a shared team decision. Everybody has their input, even members of the team who have not seen the patient directly. We always get good feedback from everybody about how to best serve this specific patient, and once that decision is made, then they are scheduled for surgery and then we can talk about the surgical process a little bit later.

Sarah Sydlowski: Yeah. Marc, I'm so glad that you mentioned about our team meetings where we really staff the patients, talk about them, because when I began my career, most cochlear implant patients had similar backgrounds. They had similar outcomes, and so there weren't as many choices that went into that process. But today, every patient is so unique. We implant people now who have a lot of residual hearing patients who only have hearing loss in one ear, lots of different causes of that hearing loss. And so I believe that it's absolutely critical to get the perspective of every team member. It's not just about choosing a device, it's not just about the number that audiology gets on a test that we administer. It's about that big picture, and so we really want to make sure that we manage all of that for our patients. As far as the evaluation itself, I think that is a really critical part of this process, and at the Cleveland Clinic, we are committed to making it about any patient with hearing loss, not just patients who could potentially be candidates for a cochlear implant.

So one of the most important components of our test battery is to evaluate how someone is able to hear with a hearing aid. Many times we measure how someone's hearing and we learn that their hearing aid wasn't appropriate for their hearing loss or it wasn't programmed as effectively as it could have been, or maybe the patient's hearing had changed and therefore their needs had also changed. And so we've sort of stopped calling that testing just for determination of a cochlear implant candidate, but really a hearing benefit assessment. How much is this hearing aid helping you in your daily life? Could you be doing better? We used to wait until cochlear implant was a last resort when we thought the hearing aids couldn't help at all. And we know today that the sooner we implant someone, the better someone will do, and so we really want to see how much benefit are you getting and could you get more with a cochlear implant? And many times, even if people are getting 50% word understanding, they might benefit more from a cochlear implant, which surprises a lot of audiologists and ENTs. And so we'd love to see patients get in our doors much, much sooner. Even if they're not a cochlear implant candidate, we can provide recommendations about adjustments to their hearing aids or new technology or assistive devices that could really help them excel and change the way that they're experiencing their day-to-day life.

Marc Bassim: Yeah, that's true. Actually, I want to stress on two points that Sarah just mentioned. One is the fact that patients, even if they don't get an implant at the end of the process, they always benefit from going through this process and evaluation and fine tuning of their hearing aids or figuring out something that we can do better to help with their hearing. And the other thing is also Sarah mentioned it's not about just the numbers. It's easy to just get the numbers and the surgery and be very mechanical about it. A lot of times what comes up in our discussions when we talk about patients is that specific patient, what are their expectations? What is their family support? What is their ability to come and get their programming or surgery or training? A lot of these factors are what makes a difference in terms of not just a good patient experience, but also good outcomes In the long term.

It's really easy to get numbers and say, schedule you for surgery and get the implant, and that's not even half the game. Most of the work gets done afterwards, and we want to make sure that these patients are able to get all the benefit that they should be getting from an implant. And I think occasionally we have slowed down or delayed surgeries for patients whom we felt were not ready overall to get their implant, just not because we want to rush and do an implant on everybody just because we want to make sure that every single patient who gets an implant actually gets benefit from their implant.

Paul Bryson: Yeah. I appreciate you kind of explaining the process. It sounds like a very thoughtful approach. You mentioned being driven by data as well, but it sounds like you also kind of take into account some of the other sort of soft patient factors, social support, insight. Maybe their hearing aids aren't operating as efficiently or as effectively as they could. So it sounds like people get a pretty high level consultation and approach that accounts for many factors

Sarah Sydlowski: Without a doubt. And the one other thing we didn't mention is that they hear a lot about the importance of auditory training or practice. We emphasize that to a huge degree, and we're very fortunate to have several audiologists and speech pathologists who specialize in that approach. That allows us to really optimize the benefit that patients are able to receive because cochlear implants, as Marc said, are much more than just a surgery and a device. It's really retraining your brain to hear in a new and more successful way.

Paul Bryson: I understand there is some other sort of exciting evolution in terms of assessment and implant candidacy. Sarah, can you talk a little bit about some of the new recommendations regarding cochlear implant candidacy as well as some refinements in one of the test batteries?

Sarah Sydlowski: Yes, absolutely. So I was really fortunate and really very proud to be a part of both of the task forces that worked on those materials. So the first was with the American Cochlear Implant Alliance. We released some new guidelines on identifying cochlear implant candidates who are adults. This was really groundbreaking and something that our field really needed because the patients that we actually implant have much more residual hearing, have hearing loss in only one ear. We know that we need to address these patients earlier, but most people's approaches was still pretty outdated. We were identifying candidates the way that we used to 5, 10, 15 years ago. Now, here at the Cleveland Clinic, we've always pushed the envelope and we've always made sure that we're identifying candidates as soon as we can, but we needed to have a guideline that was familiar to all centers across the country so that we're functioning more consistently.

And so this new guideline is actually almost identical to what we've been doing here at the Cleveland Clinic, and that wasn't just because I was a part of the team. That was something that we all talked about and really felt was best practice. And so now that we have that guideline in writing that it should not be something that we wait for, it's not a last resort. We also recommend that if someone is understanding less than 50% of words in the ear that we want to implant, they should receive a cochlear implant. There's also guidance there about when to refer someone for a cochlear implant evaluation, and that recommendation is that if they are understanding less than 60% in either ear and have a pure tone average of worse than 60, that it's time to come for a cochlear plan evaluation. But even more importantly, we pointed out that if they don't meet that guideline and they're having a hard time and you think they could be doing better, they need to be sent to us and we will absolutely work to find them the best option.

The last thing I'd share that I think is important from that document is there's very clear differentiation between candidacy and coverage for an implant, and those two terms were often interchanged in the past. If someone, for example, didn't meet their insurer's guidelines, even though they could benefit clinically, they would often be told you're not a cochlear implant candidate, which is hugely misinforming them of their reality. So we feel like it's really important that patients understand when they can benefit, and then what's getting in the way of them receiving that benefit if it's their payer, we need to document that so that we can continue to move the needle and increase access for many more individuals. So that document provides guidance on that point. The other new document is the minimum speech test battery. This is the third edition. It's really revising recommendations for when we should measure the benefit that someone's getting from a cochlear implant and whether we include their hearing aid, which test measures we use, words, sentences, sentences and noise.

But what's most exciting about this revision is that it really refines the recommendations. It streamlines the process. It also has implications for doing this testing beyond cochlear implant evaluations for any hearing aid patient, and I think it will create a lot more consistency so that if a patient comes to the Cleveland Clinic, they're going to receive the same testing when they go to another center. We had concerns in the past that patients would get different recommendations depending on their provider, so hopefully this will be a step towards standardizing so that patients who need an implant aren't turned away.

Paul Bryson: Well, thank you for sharing those updates. Sounds very impactful. It'll be interesting to see how, if it does make things a bit more uniform for patient's experience in counseling and assessment, really.

Sarah Sydlowski: Yes, absolutely. That's a goal.

Paul Bryson: And I wanted to ask Dr. Bassim a similar question on the surgical side. Are there are some new techniques or treatment strategies that have changed in the, from maybe when you and I trained in residency to now, I'm not a neurotologist, but what's changed now when you look at doing implant surgery with the electrodes or with hearing preservation or even the approach to the insertion of that? Can you share a little insight into how things have changed, and…

Marc Bassim: We've pretty much touched on the important points.

Paul Bryson: Alright, all good.

Marc Bassim: There has been quite a bit of change in the way we do the surgery. This has been driven in part by our understanding of what gives us better outcomes for the patients and also by the evolving candidacy. So now we're not just dealing with patients who are profoundly deaf, we're dealing with patients who have residual hearing, and sometimes we need to preserve that residual hearing to be able to use it in case of combined stimulation. So the surgical field has evolved, of course, in terms of making it as an easier surgery. It is a same day surgery. It takes about two, two and a half hours all included, and then the patients go home the same day. There's minimal pain after that and the complication rate has gone down dramatically. But also in terms of the special technique you mentioned, the electrodes, the electrodes have evolved over time.

We have different kinds of electrodes, so choosing the kind of electrode is one of the decision points we have to make along the selection of the decision criteria for the patient, how we approach the cochlear, it used to be that as long as you get to the cochlear, you just open the cochlear somehow and insert the electrode. 20 years ago, that's all that mattered. Now we know that it's not just where you do that opening, how you approach, how you insert the electrode, how fast you insert the electrode, which techniques you use in that. All that matters big time in terms of getting better outcomes. So the electrodes have gotten slimmer, they've gotten less traumatic. We have new advances in terms of robotics potentially to allow us to insert the electrode very slowly and minimize the trauma. We have intra cochlear measurements. There are quite a few changes that are happening in the field that allow us to refine the surgery and the outcome for these patients.

Paul Bryson: It's very exciting. It seems like the perfect sort of integration of technology and tissue handling and just refinement sort of in an ongoing fashion.

Marc Bassim: It is. It's a surgery that's very rewarding at many different levels. It's very rewarding for the surgeon because it's a very technical surgery. It's also very rewarding for the outcomes because the difference that we make in people's lives is just, it cannot be described just from seeing somebody who's struggling, who has been starting to get socially isolated, who has difficulty in their work or in their relationship with their family, and with time as their hearing improves. All that starts to change is just rewarding me onwards.

Paul Bryson: Well, it's great to have both of you here today. I congratulate you on the Center and the work that you're doing and just how it's growing and refining and really making this difference for our patients. As we wrap up, any final take home messages for our listener?

Marc Bassim: Well, I think we've mentioned this a few times during the episode, but teamwork is really, really, really important. I cannot stress it enough. It's not just about communicating. It's not just about the audiologist, an otologist talking to each other whenever there's a problem. It's establishing this as a routine, almost daily communication, just even because there are simple things that could be missed in the process and this input from all the team members, be it the surgeon, the audiologist, the scheduler, the coordinator, somebody who may not be directly involved in the care of these patients. We have this on a very regular basis, and I think that's one of the secret of the success of these program. And Sarah also mentioned some of the collaboration with different centers, the centers that do a lot of implants as we work together, and I think that's driven the field big time over the past, probably decade or so, is the fact that a lot of the large centers across the world really, not just across the us, have started talking to each other more frequently. We've shared our experiences more frequently, and that's also helped us move things forward in a safer, better way for the patients.

Sarah Sydlowski: Yeah, I couldn't agree more, Marc. I think that really what it boils down to is that we have a lot of trust. We have trust with each other so that on our team, we feel comfortable saying, Hey, I have a question. Hey, I'm not sure. It allows us to continue to grow and develop, and I think that we have worked really hard to build great trusting relationships with our colleagues and other centers as well so that we're able to share our best practices and we can incorporate some of theirs in our program. I'd also just like to reflect on what you shared about how great it is to be a part of such life changing work. The thing that I hear more often than anything else, as I wish I'd done this sooner, and so I think my last message I'd like to share with any listeners is don't wait. If you're a patient who thinks that you aren't hearing as well as you'd like to be, have a cochlear implant evaluation. If you're an audiologist or an ENT who has a patient that isn't achieving the milestones or the benefit that you hope they might have a cochlear implant evaluation, we will only be able to help provide more information and make the best decision for that individual.

Paul Bryson: Well, for more information on our Hearing Implant Program and Otology-Neurotology services at Cleveland Clinic, please visit ClevelandClinic.org/audiology. That's ClevelandClinic.org/audiology. And to connect directly with a specialist or to submit a referral, call 216.444.8500. That's 216.444.8500.

Dr. Bassim and Dr. Sydlowski, thanks for joining Head and Neck Innovations.

Marc Bassim: Thank you.

Sarah Sydlowski: Thanks for having us.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.