Brain Stem Implants, Cochlear Implants, and Dr. House: Interview with Laurie S. Eisenberg, PhD
Douglas L. Beck, AuD, speaks with Dr. Eisenberg about her new book Clinical Management of Children with Cochlear Implants, published by Plural Publishing .
Academy: Hi, Laurie. It’s a pleasure to work with you again.
Eisenberg: Hi, Doug. Thanks, good to work with you, too.
Academy: I should mention you and I met and worked together in the basement of the House Ear Institute in Los Angeles, back in 1984 or so—some 25 years ago—amid some of the most brilliant minds and exciting times in audiology and neurotology.
Eisenberg: Yes, it really was an exciting time and it was an honor to be part of that exciting team.
Academy: Absolutely, it was an honor! Laurie, you started at House in 1976 and later earned your PhD in Speech and Hearing Sciences at the City University of New York (CUNY). Then in 1990 went on to do a post-doc fellowship at the University of California at Los Angeles (UCLA) and then since 1996, you’ve been back at the House Ear Institute as an audiologist and scientist in the Division of Communication and Auditory Neuroscience.
Eisenberg: Yes, that sounds about right!
Academy: I thoroughly enjoyed your new book. You pretty much nailed down everything associated with cochlear implants from the history of cochlear implants (CIs), infants, management, AR, surgical considerations, programming, assessing post-implant ability, CI team members, auditory brainstem implants an more, and it’s all wonderfully current! Okay, so let’s time travel a bit, when was the first cochlear implant?
Eisenberg: Well, the first “incident” of electrical stimulation of the ear is attributed to Allesandro Volta in 1790. He was an Italian physicist and apparently he did stimulate his own ear electrically—but that’s not really who we think about when we refer to the history of cochlear implants. In 1957, work by Djourno and Eyries from France was mentioned in a newspaper article regarding their use of direct stimulation of the auditory nerve. Fortunately, Dr. William House heard about the article from a patient and he obviously became very interested! Dr. House first implanted two American patients in 1961 for short-term trials and after that moment, rapid developments in cochlear implants occurred. Prior to Dr. House’s surgical innovations, the primary area for otological intervention was the middle ear.
Academy: I’m glad you mentioned that, and frankly, I’m glad to spend a few moments on Dr. House and his amazing contributions to otology and neurotology. Dr. House is nothing less than a true pioneer and a visionary in neurotology. His development of the translabyrinthine approach to acoustic neuromas, his work on the middle fossa approach, his development (with Jack Urban) of major engineering accomplishments like being the first surgeon in the United States to use an operating microscope, developing the hand-held suction-irrigation system used daily in ORs across the world, developing the “side arm” for the microscope, as well as his pioneering surgeries for Meniere’s Disease, such as endolymphatic sac surgery and vestibular neurectomy, all changed otology forever.
Eisenberg: Exactly, those contributions and many more are why Dr. William F. House has come to be called the “Father of Neurotology.” His insight and fortitude in developing and promoting the cochlear implant and the auditory brainstem implant have forever changed the course of more than 100 hundred thousand implant recipients around the globe.
Academy: Laurie, in your book you noted that in 1980, Dr. House announced he was going to implant a congenitally deaf child—and it was like a bomb had been dropped! In fact, there are so many wonderful stories about Drs. House and Hitselberger, that I’ll add links to interviews I did with each of them years ago at the end of this interview.
Eisenberg: Okay, great. As you recall, many of his accomplishments were quite controversial in their day—and only really appreciated years later. Thankfully, Dr. House had the grit (or “chutzpah” as my mother would have said) to push all this forward. But you’re right…when Dr. House announced in 1980 he was going to implant a child, it was like a bomb went off and the scientific community in the United States involved with cochlear implants was stunned and appalled! Dr. House had been through these things many times previously—and fortunately, he prevailed.
Academy: And so the first child in the United States was implanted in 1980?
Eisenberg: That’s right. The first child implanted by Dr. House was a 10-year-old who was congenitally deaf. The following year, a 3-year-old child, deafened by meningitis, was implanted. I believe she was the first preschool-age child in the world to receive a cochlear implant. Cochlear implants were FDA approved for adults in 1984 and in 1990 the FDA approved cochlear implants for children.
Academy: What are the current implant criteria for children?
Eisenberg: As mentioned in the chapter by Margaret Winter and Brooke Nicholson Phillips, the implant criteria for children are as follows: (1) minimum age of 12 months per FDA guidelines, or younger under extenuating circumstances; (2) bilateral sensorineural hearing loss to the extent that detection levels with the implant are expected to be better than those obtained from well-fitted hearing aids; (3) performance with hearing aids does not support auditory/oral skill development; (4) no medical contraindications; (5) availability of appropriate therapeutic and educational services; (6) realistic expectations by parents with strong commitment to the habilitative process.
Academy: Excellent, and of course the physicians can go “off label” and they can implant children below 12 months of age, if the family and the physician so choose?
Eisenberg: Yes, and many have done that, and do that regularly across the globe.
Academy: Well, I think it makes good intuitive sense to say “as soon as possible” there was the 2008 article (see Beck, DL, 2008) by Holt and Svirsky who studied six children implanted prior to age 12 months and compared them to almost 100 other implanted children. The advantages of very early implantation (prior to age 12 months) appeared rather small. But they certainly advocated implantation between 12 and 24 months.
Eisenberg: Yes, and other investigators (e.g., Dettman, Pinder, Briggs, Dowell, and Leigh, 2007) present compelling evidence to support implantation under 12 months. This is an area that still requires study and time to really evaluate the pros and cons, and a repeat of the Holt and Svirsky protocol with a larger sample size would surely be beneficial.
Academy: What are your thoughts on bimodal stimulation?
Eisenberg: Doug, I’m sure you can recall some of the same patients I can from 25 years ago. We used to have lots of single-channel patients who wore a cochlear implant on one side and a hearing aid on the other side. So, I think this fitting strategy is coming around again, as many ideas do. Acoustic amplification of low-frequency residual hearing in the non-implant ear appears to supplement the speech cues processed from the cochlear implant. Bimodal is an excellent approach for patients able to benefit from it.
Academy: Yes. Mark Ross recently told me when he wears his cochlear implant (which he has had for almost three years) and his hearing aid together, bimodal helps smooth out the sound quality and I suspect it also offers some spatial advantages and gives the sound more depth. I would argue that we’ve recently entered the age of true “binaural” hearing aids, i.e., hearing aids that work together to process and manage sound, and indeed, binaurals offer distinct advantages over previous bilateral hearing aid fittings….what can you tell me about binaural versus bilateral cochlear implants?
Eisenberg: Yes, well we know there are binaural advantages that occur when the two ears work together to deliver to the brain a coordinated and synchronous signal. For instance binaural summation, binaural squelch, binaural unmasking and of course spatial perception that is so dependent on interaural timing differences (ITDs) and interaural loudness differences (ILDs). So of course, binaural hearing aids seem like a really good idea! But in cochlear implants, we don’t really have true binaural cochlear implants—we have bilateral cochlear implants. That is the two implants, on a bilaterally implanted person work independently of each other.
Academy: Sure. Well that brings us to your thoughts regarding bilateral cochlear implants?
Eisenberg: Well, that’s a fairly broad topic. Ruth Litovsky and Jane Madell have written an excellent chapter on this topic in the book. In general, the literature has shown favorable and promising results for adults with regard to localization and speech comprehension in noise. With newborns and babies, many people are concerned that placing a second CI early may destroy some residual hearing, and of course, that’s an issue to be considered. However, there is a definite trend to provide bilateral implants to young children. When a child is identified at birth with severe-to-profound hearing loss and they’re fitted with hearing aids soon thereafter, one has the opportunity to observe the child’s behaviors to see if they appear to be benefitting from hearing aid amplification. If the child is fitted with hearing aids early, by age two to four months, then when the child is one year of age, that child will have had six to eight months of experience with hearing aids, and we can get a lot of information at that time. The thing to keep in mind is there is a lot of difference within the broad category of severe-to-profound hearing loss.
Academy: Of course, some of those children will have a 71 dB HL loss, and others may have 110 dB HL plus!
Eisenberg: That’s right, and the child with the 71 dB HL loss has many more opportunities to do quite well with hearing aids, whereas the child with 110 dB HL loss has less opportunities and options. However, it is so important to always start with a hearing aid trial using well-fitted, high quality instruments.
Academy: Great point. I personally break out in a sweat when clinicians pull out the 18-year-old linear boomer BTE and fit that to a child for a hearing aid trial! The newer power aids are so much better across so many parameters including everything from fitting rationales to directionality, noise reduction, feedback management, the physical size, compression strategies and so much more.
Eisenberg: Exactly. The take-home point is that when conducting a hearing aid trial, use the very best equipment available and be able to fit the instruments using a reasonable prescriptive approach.
Academy: Nice to have someone else say that—I totally agree! Laurie, the new book is very exciting and comprehensive and I cannot imagine the patience it must have taken to assemble some 21 chapters across almost 700 pages!
Eisenberg: Well, the authors of all those chapters did an extraordinary job, and I am so grateful for their work and dedication to the task.
Academy: Can you give me a quick name by name listing, and the chapters they wrote?
Eisenberg: Sure, click here to review the chapter titles and authors (PDF).
Academy: Okay, Laurie. It has been a total pleasure catching up with you. I absolutely endorse the book, Clinical Management Of Children with Cochlear Implants, for anything and everything anyone could possibly want to know about children with cochlear implants.
Eisenberg: Thanks, Doug. I appreciate that!
Academy: My pleasure Laurie.
Laurie Eisenberg, PhD, is the author of Clinical Management of Children with Cochlear Implants, published by Plural Publishing.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.
For More Information, Recommendations, and References:
Interview with Dr. Hitselberger
Interview with Dr. William F. House
Beck DL. (2008) Cochlear Implantation Prior to Age One
Deafness Research Foundation’s Cochlear Implant Timeline