Tuesday, 2 October 2018

Adult Cochlear Implant Program: Boon to silent ears

Adult Cochlear Implantation: A boon to ears unable to listen with hearing aids
Cochlear implants (CI) are designed for individuals with hearing impairment to compensate for moderately-severe to profound sensorineural or mixed hearing losses, if there is limited or no benefit from hearing aids.
CIs bypass the non-functioning part of the auditory system in order to deliver electrical signals directly to the auditory nerve.

A cochlear implant consists of two parts, an external and an internal component. Internally, the implant consists of a receiver-stimulator, which contains the electronics, the receiving antenna and a magnet that holds the coil in place behind the ear, and the electrode array. Externally, the device consists of a sound processor that is generally worn behind the ear and consists of a microphone, which picks up sound, a processing unit which processes and converts sound into a radio frequency signal, and a transmitting coil through which the information is transmitted through the skin to the internal components of the implant. The sound processor also includes manual controls and batteries.
Cochlear Implantation only works well in those who have developed language before their deafness or in those who receive their implant at a very young age.

Implantation requires an operation and comes at a high cost. Also there is a requirement of post implantation auditory and language therapy for 3-4 years in children born with profound deafness. 

There are about 25000 CI done in India and this has increased exponentially in the last 5 years. About 10 state governments are sponsoring CI in children below 5 years and there are about 300 independent clinics in India running a multidisciplinary CI program. All these programs are mainly concentrating on children and the adult deaf population is not aware of CI option available to them.
However we have a large young and elderly deaf population who could benefit from this technology. 

As per Census 2011, in India, out of the 121 Cr population, about 2.68 Cr persons are ‘disabled’ which is 2.21% of the total population. The Census 2011 revealed that of this disabled population, 19 % are with disability in hearing. If we refer to the age group statistics, out of the total disabled in the age group 0-59 years, 18 % are having disability in hearing. The impact of hearing loss in the elderly effecting their quality of life and cognition is already well known.

Hearing loss in adulthood is linked to a greater likelihood of unemployment, as well as an increased risk of poor health, depression and other conditions, including dementia. Despite this, there is little recognition of the impact of hearing loss or of the latest hearing technologies which could improve hearing in the adult age group in India. This failure to address the consequences of hearing loss is exemplified, above all, by the low level of awareness and provision of cochlear implantation for adults.

Age of onset of hearing loss has a big influence on selection criteria for Cochlear implantation. People who are born with profound sensorineural hearing loss are prelingual deaf. This group should get a cochlear implant within 3-5 years of birth. The second group is the post lingual deaf population who were born with normal hearing and lost hearing later in life due to following causes
·         Ear infections and surgeries
·         Tumour and lesions of nerve of hearing
·         Meneires Disease damaging hearing
·         Trauma and ototoxic medications
·         Progressive hearing loss of any etiology

People who are born with normal or mild to moderate hearing loss and later progress to profound deafness are called progressive hearing loss group. This group should be fitted with appropriate hearing aids and regularly monitored for hearing and speech. The absolute contraindication for CI is complete absence of inner ear or absent nerve. Also as it involves general anesthesia-sometimes a high risk medical condition can become a risk for CI.
In our program we have have strict selection criteria for adult CI. The factors commonly influencing decisions are age of onset of hearing loss, use of hearing aids, duration between hearing loss and CI and also cause of hearing loss. The etiology in adult can be so varied, it needs careful planning and different surgical technique tailored to each of them.

Hearing with CI is not automatic. After the implant is switched on, the recipient is likely to hear sounds right away. But, it can take months or years of hard work to interpret these sounds and give meaning to them. Rehabilitation, regular mapping, family support and setting appropriate expectation is the key to success of a CI program.
Adult population form 50% of the CI we have performed in our program and that is due to the awareness we have created and also the rehabilitation support. Our deafness rehabilitation team patiently works with age groups of 6 months to 65 years who are using hearing aids or cochlear implants.
We recently offered CI to a 63 year old Mrs Savitri and her husband had some genuine feedbacks.

Till we start thinking of benefit beyond hearing and speech, we will not be able to convince families or governments for an adult CI program. We need to take into account the broad cognitive, social, and physical functioning outcomes that are likely detrimentally impacted by hearing loss. This can be overcome by cochlear implantation in the right patient group followed by dedicated rehabilitation.

Dr Sheelu Srinivas
Consultant ENT Surgeon and Cochlear Implant Surgeon

Saturday, 9 June 2018

Preauricular Sinus

Preauricular Sinus is a common congenital malformation characterised usually by a dimple near the external auditory canal. Most of them are asymptomatic and not treated unless they get repeated infections.

Preauricular Sinus can have some clear or whitish discharge even when it is not infected. In this case , just keep the area clean by washing with soapy warm water.
If there are signs of infection: pain, fever, pus discharge: meet a doctor and antibiotics are needed.
If abscess, then incision and drainage is required.
If a preauricular Sinus is getting infected repeatedly or abscess is drained, then a definitive decision of Sinus is planned in 8–12 weeks.

Monday, 4 June 2018

Does technology distances Doctors from Patients?

Clinicians, inundated with information in the form of over-stuffed electronic medical records, lab and imaging results, medical websites, decision trees, algorithms, screening guidelines, and best practice pathways have a responsibility to carefully evaluate that information and ask whether it is good, and what can be done with it, and — most importantly — whether it is applicable to our singular patient now.
—Dr. Faith Fitzgerald, “Medicine: The Greatest of Humanities”
To start this discussion, let me say that I believe I am a blessed generation of doctor who was trained in an era when technology was just entering in medicine. We saw an exponential increase in availability of technology and dare I say “dependence on technology” in the last 3 decades.

Healthcare has changed dramatically because of technological developments, from anesthetics and antibiotics to magnetic resonance imaging scanners and radiotherapy to new drugs and treatments, new device, new social media support for healthcare...the list goes on and on.

So being a clinical bedside physician, we went on to adapt the various investigations and interventions. However while these changes occurred one thing remained constant “The Patient” as caretaker and “The doctor” as primary caregiver.

I used to see outpatients something like this...
 then it was something like this with telescopes and endoscopes as opd gadgets...

and reached to 
I still examine patients in opd and interact with them as well...Above pictures depict the change in settings over a period of time.

It will be naive of me to say technology is not required but it is the clinician’s responsibility to use it sensibly and appropriately case –specific. The best example everyone has been quoting is radiology scans. We need to correlate with clinical history and examinations. Without proper examination, ordering scans is futile. We will pick up coincidental findings and then what do we do with them? 
To use and apply new interventions, the clinicians have to regularly upgrade their skills. Also comes a time to store and save this information. Many clinicians in our country are still finding it difficult to come in terms with Electronic Medical Records. There are various issues with this form of data storage but at the same time we can lists its benefits as well. If it makes things efficient and eligible and reproducible, it also takes way the “Doctor-Patient” interaction time.
I feel that there is no substitute to be at the patient’s bedside and to get to know the patients and their families. The priority is to understand the subltleties of their illness and not just their altered path of physiology. Once we understand and form a clinical impression, we need to carefully chose a test or an intervention.
The discussion of overuse of technology will exist but we also know the fact that technologies in the coming decades will multiply, we are already talking about role of artificial intelligence in medicine.
What better quotes shall I leave this debate with expressing both the parties involved:

The trouble with many doctors is not that they do not know enough but that they do not see enough.”

—Sir Dominic Corrigan (emphasis added)  suggesting the role and responsibility of doctor

“I have a non-negotiable final position in this debate. When I fall ill, I want a disciplined intellect at my bedside, and I care less for how gentle she or he may lay on hands. I have less need for anointment than I have for the disciplined use of knowledge and for well-honed judgment. Empathy gives me little comfort in the face of the devious puzzles nature can throw at the physician.”

—J. Michael Bishop indicating the need of trust 
I would love to hear from both patients and doctors – about what is the way forward to improve patient care and doctor-patient relationship.

Adult Cochlear Implant Program: Boon to silent ears

Adult Cochlear Implantation: A boon to ears unable to listen with hearing aids Cochlear implants (CI) are designed for individuals with...