Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And our discussion today focuses on the Cochlear Implant Program at Northwestern Medicine. Joining me is Dr. Kevin Zhan. He's an Assistant Professor of Otolaryngology Head and Neck Surgery, and he's the Director of the Cochlear Implant Program at Northwestern Medicine.

Dr. Zhan, it's such a pleasure to have you join us today. As we're talking about cochlear implants and people have been hearing about these for years, what major changes have occurred in, say, the last five or 10 years when it comes to cochlear implants?

Dr. Kevin Zhan: Yeah. You know, there's been some massive changes that have occurred in the last five or 10 years, specifically when it comes to candidacy. And we are just learning more and more that there are so many more types of hearing losses that we can treat with cochlear implantation. And, you know, the criteria in the past used to be fairly restrictive. You had to be, you know, almost completely deaf in both ears for this to occur. In 2019, the FDA approved cochlear implantation for single-sided deafness. So if you lost hearing in just one ear, that now is an option for cochlear implants and patients are getting significant benefit from cochlear implants in that setting. And, you know, patients that have had sudden hearing loss in one ear or even have had vestibular schwannomas, which is a type of benign tumor that can cause you to lose some of your hearing, some of those patients are also potential candidates for cochlear implantation.

So really, the pool of candidates has dramatically increased in the past five to 10 years. And at the same time, really the surgery has now been just completely standardized. Really, everybody is doing it the same way. We're all using the same monitoring techniques and surgical techniques, those kinds of things. It's mostly the same incision as well. So, things have really been standardized across the country.

Melanie Cole, MS: Well, thank you for that. So when we think of cochlear implants, there's been misconceptions over the years. Do you want to clear some of those up for us?

Dr. Kevin Zhan: Yeah. So, you know, one of the biggest problems we still have in this country is that not a lot of people know what a cochlear implant is or have misconceptions about it. You know, something that I frequently hear from other providers actually is that, "Oh, I didn't realize those were not for just children," that we actually do them in adults as well. When in reality, actually, the vast majority of cochlear implants that we do in this country across the world actually are in adults. You don't have to be completely deaf anymore to get benefit from a cochlear implant. So, that's a big one. You don't need to have hearing loss in both ears to get a cochlear implant. That's another big one.

And there's also sort of a misconception about, and there's some degree of ageism as well that, you know, people think that, "Oh, I'm too old for that, too old to hear better and to reconnect with my social circles and my family, my friends." And really, we're finding that we're having a lot of success with patients even in their 80s and 90s even, as long as they're healthy and they can undergo a short medical procedure under general anesthesia, and they have a real vigor for life and wanting to hear better, then they could potentially be good cochlear implant candidates.

So, there's a lot of misconceptions still. You know, people think that this is an invasive surgery, when really this is a very short outpatient procedure. It takes about an hour, an hour and a half to do, with a very, very quick recovery. You know, I've even heard people say, "Oh, this is brain surgery," which is certainly not true. This is an outpatient ear surgery. Yes, we put the device behind the ear and, yes, that's close to the brain, but those are things that we don't typically have issues with during the surgical process. So, I think there's a lot of fear about cochlear implantation, about the surgery itself, and still some misconceptions going on out there.

Melanie Cole, MS: Well, thank you for that, and we're going to talk about patient selection in a little while. And as the selection is getting wider, and this is available for a broader audience, are there some barriers to cochlear implantation for specific populations or people?

Dr. Kevin Zhan: You know, it's estimated that there's probably about 30,000 candidates, adult candidates, just in the Chicagoland area alone, and we know probably less than 5% of them actually receive a cochlear implant. So really, it's a massive issue with awareness, patient awareness, as well as provider awareness too that patients don't know what a cochlear implant is or that it's even an option for them. And then, a lot of providers not being sure now, especially with our expanded candidacy pools of when is it appropriate to refer. And so, sometimes a lot of patients end up just getting, you know, hearing aid after hearing aid, unfortunately, and they don't really ever hear about the cochlear implant option.

So, I think that's probably the biggest barrier, is just lack of awareness. You know, there's not enough surgeons, I would say, relatively speaking to the size of Chicago, not enough cochlear implant surgeons. And so, that's certainly an access issue. You know, we're certainly trying to change that here in Northwestern Medicine by improving access to these kinds of procedures. And with the surgeons that are in place, there's not enough sort of professional networks, if you will, you know, connections to our communities, of hearing care providers, of audiologists, of hearing instrument specialists that are taking care of these patients, that if they do want to refer sometimes it's really hard getting in. And sometimes patients have challenges getting in. So, as we're doing more and more community outreach, as more patients, for example, more providers in my practice, for example, you know, they all have my email and my cell phone number, and I'm readily available if they have questions about patients, that they could refer and those kind of things that they know how to get ahold of me and get patients in much sooner. So, I think these are all important things that we're trying to improve upon at Northwestern.

Melanie Cole, MS: Well, based on that then, Dr. Zhan, when is it important that patients do get referred for cochlear implants to your practice?

Dr. Kevin Zhan: Yeah. So, I think, you know, without getting into the specifics of it, I think if you have a patient, if you're taking care of a patient and they have been using their hearing aids for a while and they have a significant hearing loss, but they're still struggling with their hearing aids for whatever reason, let's say, especially, they say that, you know, "There's just not enough clarity. I can hear that there are some sounds, but I just don't understand." Really, it's a lack of clarity that's when a cochlear implant comes into play. And so, that might be a time to push that patient and say, "Oh, maybe reach out to the cochlear implant program and see if you're a candidate or not."

And you know, at the time of the evaluation, it doesn't mean that you're going to necessarily get surgery, it's just to see if you're a good candidate. So, I would say, you know, patients that have properly fit hearing aids, but they're still struggling with clarity, that's a good group of individuals.

To get a little bit more specific, you know, when patients undergo a hearing test, a diagnostic audiogram, they should always have speech information, speech testing. And the primary way in which we determine how good their clarity is with the sound is we ask them to repeat words back. And so, this should be a part of every single diagnostic hearing test offered across the, you know, the Chicagoland area. And really, when those scores drop below 50% or 60% per se, that's when we really start thinking about cochlear implantation.

You know, the biggest difference between cochlear implants and hearing aids, and a lot of people don't know the difference, is that hearing aids really only increase the volume of the sound that's coming in. But patients that need a cochlear implant, those are patients that it's not just a volume issue, that they have poor clarity of the sound. And so, even though they can hear that something is going on, they just can't understand what's going on. And so, that's what a cochlear implant is really designed to help with, is to help with the sound clarity of what's coming through.

Melanie Cole, MS: That's so interesting, and how quickly these advancements have been made and what an exciting time in your field. Dr. Zhan, speak a little bit about patient selection now. How are you picking these patients? Speak about that specific criteria because I think that's the crux of the message here today.

Dr. Kevin Zhan: Yeah. Yeah. So when a patient comes in for an evaluation, they're really meeting with two individuals to start off with, really, they're meeting with a surgeon like myself who does the surgery. But they're also meeting with an audiologist who's a hearing care professional who does a lot of the testing that we need to determine if they're a candidate.

You know, the majority of the programming and the workup and those kind of things are all done by our Audiology team, our amazing audiologists. And so, one of the primary ways we determine if someone is a candidate is how well or poorly they score on their speech testing. So for example, if they come in for an evaluation and we do a specific set of speech testing on these patients, and they're scoring maybe, you know, 10% correct or 5% correct, that means they're missing 90% or 95% of the words when we're asking them. Those are probably good patients for cochlear implantation, because we know that the average user, you know, the average adult user, gets somewhere between 60% correct with a cochlear implant. So if you're starting out very, very low, then even getting just an average result, you might get a significant improvement to your quality of life and your ability to hear. So, those are the sort of the audiometric criteria when we think about what makes a good candidate.

Now, the set of speech tests that we do is very different from the hearing tests that are typically done in the community. And so, that's one important thing that we do a very different set of tests for cochlear implant evaluation. And then, of course, on my end, my job is to make sure that they're medically and surgically safe to undergo a brief outpatient procedure, right? That they're in good health, that they can undergo anesthesia for a brief period, that they don't have any sort of anatomical limitations. But those are very rare, right?

You know, it's important that we assess how motivated that patient is to hear better, right? The best cochlear implant users are the ones that come in motivated, they want to hear better, they want to put in the work and the training, right? Because in many ways, when you have a cochlear implant, you're learning how to hear in a different way. And the more time you use it, the more you wear it, and the more you, you know, stream directly to it and really rely on that one ear that you're listening with to hear better, the better you're going to do, right? And so, if someone, for example, lives alone, you know, doesn't interact with the the world very much, they don't work, they don't listen to music, they don't watch TV, they don't talk with anybody, you know, those are patients that are not good cochlear implant candidates because they're not really participating in the auditory world. But most patients, of course, are not like that.

And so, these are all sort of motivating factors that we consider. You know, what's their motivation to hear better? How motivated are they? How bad or good are their speech scores? Obviously, if they have pretty darn good speech scores and maybe they're sort of a borderline candidate, that warrants further discussion. So, these are all sorts of, you know, things that we think about. And then, we discuss it as a team, right? We discuss it, our audiologist, me, you know, we all discuss it as a team just so that we make sure that we're making the right recommendation for that patient.

Melanie Cole, MS: Well, Dr. Zhan, how do the patients react? Because hearing loss is such a socially isolating disorder condition, really, people don't think of it as such, and I've even seen families where they get mad at the person for their hearing loss and yell at their relatives. I've seen that time and time again. So, it can be quite socially isolating. What do your patients think of the cochlear implants and how has it changed their quality of life?

Dr. Kevin Zhan: Yeah. You know, a cochlear implant can be such a life-changing procedure. And you're right, because you know, I always tell my patients, hearing is not just about yourself, it's also about the people that are trying to communicate with you, just like you said, right? And it's frustrating for both you as a patient who can't hear and you're having to ask people to repeat themselves, but it's also frustrating for the other person trying to communicate with you. So, it's a two-way street for sure.

And I'll tell you, it's one of my favorite things to kind of pop my head in during an activation visit when a patient gets their cochlear implant turned on, because it's always so emotional. You know, it never gets old. It's one of the most rewarding things that we do and one of the biggest reasons why I got into the field that I am in. And a lot of patients just, on day one, can start to understand speech better, can hear better. Sometimes it's a very, very emotional day for that patient, for their family members, for all of us really. And it's really a big reason why we do what we do, because it can be so life-changing for them.

So when we properly select patients, which we always aim to do, of course, and and appropriately select patients, the vast, vast majority of them do significantly better than what they were doing preoperatively, so before surgery.

Melanie Cole, MS: How wonderful for their quality of life and your passion for what you do. Dr. Zhan is just absolutely great to behold. So, tell us about the technology and the surgical advancements that have really advanced your field and postoperative protocols for the program at Northwestern Medicine.

Dr. Kevin Zhan: Yeah. You know, in our program, we always try to stay as current as we possibly can. And fortunately, the surgery itself has been fairly standardized for the majority of the procedure. But, you know, there's all sorts of new techniques now. We're offering robotic surgery techniques to advance the electrode as slowly as possible. And that's one way we can try to preserve the inner ear structures as much as we can when we're inserting the electrode. There's also image-guided mapping that we're doing to look at, you know, after the electrode has been placed and we're trying to custom fit certain types of electrodes to that person's cochlea. So, it's not sort of just one-size-fits-all. You know, we're always engaging in research and going to conferences. We have one come up in a few months here to stay current. And the vast majority of the care is actually done after surgery, right? Like I said earlier, the majority of the work is done by our amazing cochlear implant audiologists. And we've certainly changed a lot of our protocols and try to be as up-to-date as possible. So, we're offering the most latest programming techniques and making sure that our patients are optimized the best way they can be.

So, it's an exciting field. You know, the devices definitely work very well for patients when they're appropriately selected. But the field is always changing a bit and it's exciting. There's all sorts of new technologies on the frontier. You know, we're trying to personalize the medicine as much as we can, right? Giving that particular patient the most personalized care possible at Northwestern, and trying to select the right electrode for that patient, the right care for that patient, the right rehab for that patient. All these things matter a lot, and we care a lot about what we do for them.

Melanie Cole, MS: Well, I can certainly see that. And while you're talking about that care, that interdisciplinary and multidisciplinary approach is so important for these patients, because you've mentioned the audiologists, but then there's also Speech and Language Pathology because as you spoke about that before, they're relearning the way that they understand language and bring it to them for them to be able to really speak differently. They're relearning so many of these things. So, speak about all the people involved in your team that make this such a comprehensive approach.

Dr. Kevin Zhan: Yeah. It's a huge team, right? And I'm really, really grateful to be a part of it. And so, speech pathologists are really important in the rehab process and tailoring how a patient really uses their device afterwards. Our audiologists also get involved in that quite a bit as well. You know, we also collaborate with a lot of researchers at Northwestern University on the rehab process. So, that's been really, really important.

You know, we have a lot of basic scientists in our team trying to understand cochlear implants in more depth and hearing loss, really just hearing loss in depth as well. We have members in our team looking at other ways cochlear implants can be designed, using infrared technologies and optical stimulation instead of electrical stimulation. All sorts of cool stuff going on, you know. And so, it's a big team and we all care passionately about our patients. And honestly, it just makes it more fun when you're working with individuals of all different disciplines and you're sort of learning in a cross-disciplinary fashion. And I do think our patients appreciate that from the care they receive.

Melanie Cole, MS: Dr. Zhan, this has really been such a fascinating discussion. And I love what you do for a living and how much you're really helping people to improve that quality of life. What's your vision for the program, the Cochlear Implant Program at Northwestern Medicine? As you were to look five to 10 years, give us a little blueprint for future research, evolving technologies, patient demographic selection. Just give us a blueprint and wrap this up with your best advice for us.

Dr. Kevin Zhan: Yeah. Yeah. You know, it's not just my vision it's just our vision for sure, you know, and from our department. We're really trying to create the best hearing care center in the city. And so, whether it's hearing aids or cochlear implants and everything in between, we're very motivated to create that kind of institute. And so, we're trying to attract more and more researchers to our field, more surgeons. You know, we'd like to be one of the biggest cochlear implant centers in the country for that fact. And, next year, one of the major cochlear implant meeting in the country is occurring here right in Chicago. So, we're really excited about that, to host that here right in Chicago. And we'll certainly put something on for that.

But, you know, our vision for the future is to be one of the premier hearing centers in the country. You know, we want to have courses in the future for surgeons and for audiologists. We want to run clinical trials and to be on the cutting edge of research. Really, it's all for the patient and the best patient care that we can offer. And so, first step is certainly in trying to increase our access and talking about that problem we talked about first, where we're trying to increase our clinical numbers as well. But there's a lot of exciting stuff going on.

Melanie Cole, MS: Thank you so much, Dr. Zhan. What a great guest you are. This was so informative. Thank you for really giving us such an enlightening discussion today. And to refer your patient or for more information, you can visit breakthroughsforphysicians.nm.org/ent to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.

Dr. Kevin Zhan: Thank you so much.