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Selecting a Cochlear Implant Surgeon

Advanced Bionics, Auditory Neuropathy Spectrum Disorder, Cochlear, Cochlear Implant, Jace Wolfe PhD, John Niparko, Kickbacks, Kickbacks, Med-El, Neurotology, Uncategorized 11 Jun 2015
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Hiring a cochlear implant surgeon for yourself or your child is just as important as selecting the right implant manufacturer, as the quality of the outcome is at stake. Unlike fitting hearing aids where the Best Practices are well documented and easily available to the consumer, the same cannot be said for CI surgery, as these practices are mostly scattered throughout hundreds of journal articles behind paywalls.
CI_Electrode_insertion

Video fluoroscopy courtesy of Med-El 10
Click to view full YouTube video

We at The Hearing Blog are addressing this issue, with our information having been vetted by several industry insiders for accuracy, with this article taking over six months to research, edit, and vet. However, when you cut to the proverbial chase, it comes down to the “touch” in the surgeon’s fingertips as s/he threads the inch-long flexible electrode resembling a wet noodle into the pea-sized hearing organ without making hash of the delicate structures inside, let alone folding over or kinking the electrode array. Almost everything else, such as bedside manner, number of papers published, or standing in the community, is no more than mere window dressing.

Update (6/23/2015): The 9th & 10th paragraphs on operating room electrical testing and radiographic imaging were edited to clarify terminology. Also, please see Brief Addenda to Selecting a Cochlear Implant Surgeon for additional discussion.

With CI’s, there is no 30 Day Return privilege, so choosing wisely at every step of the process is vitally important for the best outcome. Unfortunately, especially here in the United States, there are factors that conspire against making an informed choice, not the least of which is the CI manufacturers quietly keeping reams of information on each of the approximately 700 or so US CI surgeons’ outcomes. The problem is that the manufacturer’s patient reps and support personnel maintain omerta, lest they offend the delicate feelings of the audiologists or bruise the fragile egos of the surgeons, both of whom guide the brand selection.  Unfortunately, the CI manufacturers’ patient reps — as nice as they are to get you to select their brand — will give you zero guidance on selecting a surgeon, let alone a CI program, as you are .NOT. the customer: The CI center is their customer, and the manufacturers will do nothing to offend their customers.A  This even extends to when there is a problem during MAPping: The patient reps & tech support audiologists are not allowed to touch the MAPping computer, lest s/he offends the audiologist’s delicate ego, instead looking over her shoulder “suggesting” changes.

There is some effort to gather “tribal knowledge” amongst the various facilities by the Association for the Advancement of Medical Instrumentation (AAMI) into a sort of “standards” or “best practices” document.1 However, it’s still in draft form, it’s complex; and one of the experts who reviewed this document just made us aware of this as the draft was published only days ago.

Here are pertinent questions for which you need to get answers from the surgeons and audiologists, preferably in writing on the consent forms, and other things to watch out for:

First, just exactly who is threading the electrode into your or your loved ones’ cochleas, anyway? While it’s vitally important to train the next generation of CI surgeons, in fact at many programs in teaching hospitals it’s the resident, not the surgeon you believed you hired performing this delicate task. It’s one thing to have a resident performing the “grunt work” of grinding out the pocket for the implant package and cutting the mastoid opening without nicking any nerves; however drilling the cochleostomy and threading the electrode is what separates the top surgeons from the rest, especially when residual hearing preservation is required for hybrid (EAS) procedures (and more on this later). Our attitude on this is “go train your residents on someone elses’ ears.” Make sure you get this in writing on the consent form, as often in the fine print you really provide consent for the resident to perform the surgery’s actual delicate tasks, with the surgeon you think you hired “supervising;”

A cochlea with a MED-EL electrode array partially inserted. Photo courtesy of Adrien Eshraghi MD, University of Miami Miller School of Medicine, Miami FL

A cochlea with a MED-EL electrode array partially inserted with lateral placement in the scala tympani. Note how the outside edge of the laterally placed electrode scrapes the outside surface of the duct, which can cause trauma.
Photo courtesy of Adrien Eshraghi MD, University of Miami Miller School of Medicine, Miami FL 10

Second, as we alluded to above, you want to assure your surgeon will be using hearing preservation techniques to get the best performance, even if there is no residual hearing remaining, in order to keep the electrode in the scala tympani (bottom of the three chambers) to get the best outcome 2, 3 and to minimize the chance of triggering or exacerbating tinnitus. 12 [Worth noting is that on May 28th Advanced Bionics received the CE marque by TÜV for their Naída CI Q90 EAS combination hearing aid/CI speech processor, which unlike the Med-El and Cochlear systems uses a full length electrode insertion. We’ll have much more on this in an upcoming article, as we already know one person participating in the FDA clinical trials.]

October 5th 2015 Update: Two new articles on residual hearing preservation have just been published: The Impact of Perioperative Oral Steroid Use on Low-frequency Hearing Preservation After Cochlear Implantation 11 by David Haynes MD & his crew at Vanderbilt; and Effects of CI Electrode Insertion on Tinnitus 12 by Thomas J Balkany MD in The Institute for Cochlear Implant Training blog. Although Balkany talks about how tinnitus can be generated when the basilar membrane is pierced, in fact “when CI electrodes ruptured intrascalar partitions and traversed between the scala, tinnitus had a 16% chance of being generated or becoming worse; while when electrodes did not traverse scala, tinnitus was not made worse. We’re going to have a brief article breaking out these two articles;

Third, how many implant surgeries per year of each brand does this surgeon perform?cochlear_duct_cross-section_thumb You want a surgeon who performs at least 50 implants per year, and at least 25 implants of your particular brand choice in the last year: Experience pays;

Fourth, will the surgeon be advancing the electrode array off the stylet the proper way with the tip just inside the cochleostomy or round window opening, or will he be inserting the stylet down to near the basal bend 5-6mm in? [This paragraph was edited for clarity on June 12th, 2015.] If the stylet is inserted down into the cochlea to near the basal turn to avoid array kinking, it can act like a “spear” piercing the basilar membrane and protrude into the scala tympani (the topmost of the three chambers in the cochlear duct), instantly destroying residual hearing and, more importantly, causing a poorer quality stimulation, with resultant lower word recognition scores.2, 3 Although this is not an issue with AB’s Mid-Scala and Helix arrays as their stylet can be reloaded in the operating room in the event the surgeon accidentally kinks the electrode, this is not the case with the Nucleus Contour array; and what’s more, if the Contour electrode array becomes kinked on insertion because the surgeon does not have adequate “touch” in his fingertips to feel the interference, Cochlear Americas will not honor the warranty. This goes to explaining why, in one informal survey of CI surgeons, 85% use the potentially more traumatic method of inserting the stylet too deep when placing the 22 contact Contour electrode array. [6/12/2015] To clarify, it’s the combination of the inability of the Contour array to be reloaded onto the stylet .AND. Cochlear Americas’ not honoring their warranty if the surgeon kinks the electrode which conspire to cause 85% of surgeons to improperly insert the stylet too deep risking trauma.

Here is an example of an improperly placed Advanced Bionics HiFocus 1j electrode that was folded between the 3rd & 4th electrodes during placement. Because neither the implant was booted up and impedance checked during surgery, nor was there post-surgery radiography performed to detect the problem in a timely fashion, fibrous tissue started to grow by the time this x-ray image was taken a month post-op during switch-on, making revision surgery impossible. This patient was referred to a medical malpractice attorney.

Here is an example of an improperly placed Advanced Bionics HiFocus 1j electrode that was folded between the 3rd & 4th electrodes during placement. Because neither the implant was booted up and impedance checked during surgery, nor was there post-surgery radiography performed to detect the problem in a timely fashion, fibrous tissue started to grow by the time this x-ray image was taken a month post-op during switch-on, making revision surgery impossible. This patient was referred to a medical malpractice attorney.
Click to enlarge in a new window

Fifth, it’s mandatory that the implant be booted up in the OR by the audiologist with a cleaning cycle and an impedance check performed: This takes about 10 minutes but is necessary to detect electrical problems. Also, the inter-electrode impedance test (also known as Electric Field Imaging (EFI)  test; if the audiologist performs it and knows how to interpret the result matrix) will usually detect folded electrodes. For the example in the picture on the right, the impedance between electrodes 1 & 8, and 2 & 7 will be abnormally low, revealing the folded-over electrode. The problem is that OR time is booked in 15 minute increments with anesthesiologist fees the cost driver, with prices ranging as much as $1,000 per 15 minute block: The cost containment pressure is to skip this step; and when skipping boot-up is combined with delayed or even no post-op radiography, disaster can result. [Paragraph edited 6/23/2015.]

Sixth, it’s vitally important for radiologic imaging to be performed preferably in the OR before closing up. The reason for this is two-fold: First, you will not need to go through a needless second “revision” surgery if the surgeon makes an error; and second, that fibrous tissue starts growing around the electrode almost immediately, making revision surgery for a folded or kinked electrode more difficult, if not impossible after a few days — And this applies to a decade or two when the CI needs replacing, as well. At university hospitals there is tremendous pressure from the Ivory Tower to cut costs, and often this step is either postponed until the switch-on, or even skipped altogether, with the surgeon & audiologist crossing their fingers that all will turn out OK. The gold standard is to wheel a small CT scanner for the head into the OR, which is about the size of a breadbox, to verify the precise electrode placement; however an x-ray plate will suffice to spot gross problems such as a folded-over electrode. What’s more, by not using radiographic imaging the patient with the improperly placed electrode would need to be reimplanted, which involves additional trauma to the skin flap, an increased risk of infection, and also needless additional pain and lost time due to the second surgical procedure which could have been avoided. We are aware of a medical malpractice case at a major Michigan program where both the boot-up and imaging steps were skipped and the electrode was folded over between the 3rd & 4th contacts. This was not discovered until switch-on when there were major problems; but because this was four weeks after the surgery, fibrous tissue had already started to grow, making revision surgery impossible. [Paragraph revised 6/30/2015.]

Seventh, and this one should almost go without saying, but given cost-cutting measures you never know, so it’s better to specify that facial nerve monitoring be used. This is just about de rigeur but it’s better to be safe than sorry, so make sure you get this in writing;

Eighth, how will the implant electronics package be fastened down to the skull? It takes the surgeon time to carefully cut the pocket in the skull without going too deep and nicking the dura mater, and to drill the holes for the tie-downs. In the aforementioned Michigan MedMal case the surgeon used a “slip and go” method to reduce the OR time even further, which allows for movement of the implant package, and more harmfully puts unnecessary stress and strain on the delicate electrode array wires where they emerge from the package, which can result in premature device failure. As we understand it, a prominent Atlanta CI surgeon with over 1,000 procedures is also now using “slip and go,” needlessly compromising the device reliability;

Ninth, and often overlooked, is post-surgical infection control. Because of very limited blood circulation in the scalp, it’s easy for a “biofilm” infection to set in, which can spread into the cochlea causing ossification; and if the infection jumps the dura mater barrier, can cause life-threatening bacterial meningitis: Be sure to discuss post-surgical infection control with your surgeon and carefully follow his or her instructions;

Tenth, what is guiding the CI brand recommendation by the audiologist and surgeon? The best ones are comfortable implanting and MAPping all three major brands, so sometimes financial “considerations” are in play, such as exclusivity deals for better device pricing; or outright kickbacks, through Cochlear Americas’ unethical and unlawful Partners’ Program;4 and as we just discovered a few days ago but not publicized in the industry press, just two months ago by Med-El by providing them [the surgeons] free meals, overseas travel opportunities and honoraria requiring little to no actual work by the physicians.5, 6 What’s more, although for an American corporation it is highly illegal under the Foreign Corrupt Practices Act7 (FCPA) to pay any kind of bribe or kickback to any party anywhere in the world (under penalty of the CEO going to prison), this is not the case elsewhere, as in both the European Union and Australia these overseas bribes are considered a legitimate business expense that can be deducted from corporate taxes (though it is unlawful for EU corporations to pay bribes to entities inside the EU itself);

Finally, as you look at the list of surgeons we like, you’ll notice that there is only one pediatric program listed: If you have a deaf infant or child, you’ll quickly find out that the audiology & CI programs at many (but not all) “Children’s Hospital of [insert city name]” or “[insert big donor name] Children’s Hospital” are generally rather lousy (especially at diagnosing & managing ANSD), despite the “halo effect” from their name and “standing in the community;” so you’ll do much better by going to a CI center that also implants adults. As best we can tell, based on numerous off-the-record conversations, the problem with pediatric hospital audiology departments centers on very poor Medicaid reimbursement due to the indigent patient load;D and since adult hearing aid sales are a profit center, the audiologists at pediatric hospitals are generally at the bottom of the pay scale… And they get what they pay for.

CI surgeons & programs we like&c.

Just because the CI surgeon is not listed here doesn’t mean he or she is not good: This is merely a brief list of surgeons who have proven track records of good outcomes, in no particular order:

  • Tom RolandB, C at NYU Langone (we like “Roland’s Rules”);
  • Craig BuchmanC at UNC-Chapel Hill;
  • Daniel LeeC at Mass Eye & Ear in Boston;
  • Eric WilkinsonB, C & Bill Slattery at House Ear Clinic in LA;
  • Bob Labadie & David Haynes at Vanderbilt in Nashville;
  • Stanley Baker in Oklahoma City (and if you can convince Jace Wolfe across the street at Hearts for Hearing to MAP your CI, you’ll be in superb shape);
  • Dana Suskind (pediatric only) at Comer Children’s in Chicago (we also really ♥Love♥ her Thirty Million Words project she developed);
  • Rick Chole at WUSTL in St Louis;
  • Michael Novak at UI-Urbana Carle Foundation in Urbana Illinois;
  • Adrien Eshraghi at Univ. of Miami;
  • Colin Driscoll at the Mayo Clinic in Rochester, Minnesota;
  • Alejandro Rivas at the Rivas Clinic in Columbia;
  • Vittorio CollettiC in Milan;
  • Perhaps the best of them all is John Niparko at USC-Keck in LA though sadly he stopped performing CI surgery two years ago to concentrate on “administrative tasks.” We just found out he’s implanting again, confirmed by their PR rep, with 15 implant procedures in the last two weeks alone. Needless to say, we are quite pleased at this development; and we know he will give the excellent surgeons across town at House a run for their money.

On The Other Hand, certain cities such as Philadelphia, Atlanta, and (especially) Las Vegas have no decent CI programs; and candidates or parents of candidates would be wise to contact one of the facilities above. In fact, in Atlanta the pediatric CI centers and their associated audiology programs are so dodgy (especially with diagnosing and managing ANSD), your humble editor has literally established a “conveyor belt” to Vanderbilt’s world-class program just four hours away.

Choosing a CI brand:

On choosing a CI brand, The Hearing Blog recommends you focus on the implant electronics package itself, as that is what will be wired into your head for the next 20 or so years; and except for the Advanced Bionics HiRes 90k which is software upgradeable, is what you’ll be stuck with. (For more on this, see Prof. Mike Marzalek P.E.‘s tutorial here.) In addition, as we previously documented, Cochlear (and now Nurotron) have too many electrode contacts (for marketing purposes?) forcing them too close together, causing undesired channel crossover and poor performance, especially with music.9 Yes, some manufacturers’ have “sexy” externals; but the processors are replaced every 3-5 years; and also once one manufacturer has an “innovation” in their externals the others soon follow along, as with over 400,000 users worldwide and one million predicted by 2020, it’s a Big, Competitive Market out there.

We also recommend you go on a “CI Shopping Trip” to the Hearing Loss Association of America (HLAA) &/or Association of Late-Deafened Adults (ALDA) conventions and hang out in the noisy Expo hall (Expo hall-only passes are free at the HLAA convention). The CI manufacturers will all have their lavish parties and dog-and-pony shows with their “rock star” users flown in from all over; however what you should do is talk to the hundreds of actual CI users there, but when you do, shift to “anthropologist mode” to observe how well they are actually understanding what you are saying, preferably without them speechreading (lipreading). Good speech perception in the quiet of a sound booth is one thing, but you don’t live in a sound booth, either; and since the manufacturers will all fly in their “rock star performers” to man their booths, you’ll need to seek out others to get a better perspective of performance. Yes, they will all lay in front of you their “research studies” they paid good money for, each claiming how well their devices work — But of course, they’ll not show you the ones showing their wares don’t work well. However, most of these “studies” they will show you cannot withstand engineering level scrutiny — Especially for speech-in-noise claims — and they will not release the underlying raw test data;E so at the end of the day you need to trust what you hear and see with actual, random CI recipients in the busy expo halls; and then choose your brand accordingly, as you’ll be “married” to that CI company for the next 20 or so years.

References:

  1. Public review draft of AAMI/CDV-2 CI86, Cochlear implant systems – Safety, performance and reliability: Association for the Advancement of Medical Instrumentation, May 21st, 2015
  2. Cochlear Implant Programming: A Global Survey on the State of the Art (31 authors). The Scientific World Journal Volume 2014 (2014), Article ID 501738, 12 pages
  3. Role of electrode placement as a contributor to variability in cochlear implant outcomes (Charles C. Finley and Margaret W. Skinner). Otol Neurotol. 2008 Oct; 29(7): 920–928.
  4. United States Settles False Claims Act Allegations with Cochlear Americas for $880,000: US Department of Justice, June 9th, 2010
  5. Medical Device Maker Agrees to Pay $495,000 to Settle Allegations it Improperly Rewarded Military Physicians for Choosing Company Devices: US Department of Justice, US Attorney’s Office, Western District of Washington, February 13th, 2015
  6. Med-El Pays $495,000 to Settle Allegations it Paid Kickbacks to Military CI Surgeons: The Hearing Blog, April 24th, 2015
  7. Foreign Corrupt Practices Act of 1977, as amended, 15 U.S.C. §§ 78dd-1, et seq: Overview.
  8. Wolfe, Jace, and Schafer, Erin C. 2014. Programming Cochlear Implants 2nd Edition. San Diego: Plural Publishing. ISBN-13: 978-1-59756-552-3 ISBN-10: 1597565520
  9. First Person Report: Cochlear Implant Channel Crossover. The Hearing Blog, June 1, 2011;
  10. A Photographic Tour of the Cochlea. By Melissa Waller, The Med-El Blog, October 31, 2013.
  11. Impact of Perioperative Oral Steroid Use on Low-frequency Hearing Preservation After Cochlear Implantation. Sweeney, Alex D.; Carlson, Matthew L.; Zuniga, M. Geraldine; Bennett, Marc L.; Wanna, George B.; Haynes, David S.; Rivas, Alejandro. Otology & Neurotology: October 2015 – Volume 36 – Issue 9 – p 1480–1485
  12. Effects of CI Electrode Insertion on Tinnitus, by Thomas J Balkany MD. Institute for Cochlear Implant Training, October 1, 2015

Bootnotes:

A. We give props to Envoy Medical, maker of the troubled Esteem implanted hearing aid, for tossing out one surgeon from their program, as this individual, who is also well known in his region as a butcher CI surgeon, was taking as long as nine hours to implant the hearing aid. What’s more, this particular surgeon took almost six hours on a friend’s routine CI surgery (normal time for a good surgeon is 70-90 minutes), yet still bungled it, rendering her ear completely destroyed and unimplantable in the process;

B. These gentlemen are also trained electrical engineers, which gives them a leg up over their peers when working with CI’s, as they have been trained to have an intuitive grasp of the underlying very complex signal processing involved with these magical devices;

C. These gentlemen also implant Auditory Brainstem Implants (ABI), which truly is “brain surgery;”

D. At the March Auditory Neuropathy Spectrum Disorder Conference 2012 held at All Children’s in St Pete, the CI program coordinator told the attendees that 100% of their CI patients in the last year were Medicaid;

E. We had this same problem as well with Siemens not releasing the underlying raw data for their dodgy Binax speech-in-noise claims.

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About the author

Dan Schwartz

Electrical Engineer, via Georgia Tech

85 Comments

  1. Mary Pat bibel
     June 11, 2015 at 7:55 pm

    I was implanted three days ago. I wish I had this to guide my questions prior to surgery. Now I just hope for best. Reading this article scared me.

    Reply
    • Dan Schwartz
       June 12, 2015 at 8:55 am

      Mary Pat: Since you are a nurse you should request a copy of your surgery report, as here in the United States it is you who owns your medical records. Also, you can print out this article to discuss the points discussed in this article with your surgeon, specifically on the measured impedance values after cleaning when the implant was booted up, and the post-surgical imaging to verify electrode placement.

      Also, now that your bandages are off, you should request a residual hearing test: You received an AB implant which uses a reloadable stylet, so there is no reason your surgeon should have improperly inserted the stylet down to the basal turn, risking spearing of the basilar membrane.

      Reply
      • Mary Pat Bibel
         June 15, 2015 at 7:22 pm

        I will be reviewing my records. I do have concerns with what you have shared or how it was shared. Indicating that you have access to access to industry related data/persons who vetted your post without sharing sources is rather disturbing and suggestive of covert conspiracy like arena.

        I don’t know how anyone can have knowledge of an each cochlear implant surgeon’s skill at threading a electrical array into a cochlea. I wish you would share that with us. You indicate that publications, standing in community etc. are not of merit to determine this. Please do share what is?

        Please do share if you evaluated each and every surgeon by this criteria.
        Is it possible that you might have missed one of value? Could that one been mine?

        I am disturbed by lists of “the best” when it comes to health care. There doesn’t have to be any “the best” just a great great number of really competent.

        I would have appreciated an article articulating the value of hearing preservation and in what circumstances it is indicated and how, engineering wise, it is accomplished.

        Reply
        • Dan Schwartz
           June 16, 2015 at 4:50 am

          Mary Pat: Unlike with hearing aids, CI manufacturers pay very close attention to outcomes, including residual hearing preservation, which is directly tied to how the skilled the surgeon is, and the “touch” in his or her fingertips, feeling for obstructions. Now, how does publishing an academic paper relate to the physical skills and judgment in the OR?

          As for our list of CI surgeons & programs we like&c., it involves more than just skills: It also involves their programs following Best Practices. Just like there are Best Practices for hearing aid dispensing including using Real Ear Measurement (REM), there are Best Practices for CI surgery, including imaging in the OR to verify electrode placement. These cost time — and hence money — and in today’s ruthless ObamaCare-driven cost-cutting environment, these Best Practices are often skipped, especially imaging to verify electrode placement in the OR

          What’s more, on occasion their scientists & engineers as well as tech reps scrub in and watch surgery, especially during FDA clinical trials, as knowledge exchange is a two-way street. Also, a manufacturer rep is present in the OR when there is an explant due to device failure to witness the procedure, due to chain-of-custody verification.

          In any case, we cannot reveal who our sources are.

          Reply
          • A Not-Evil Reader
             June 28, 2015 at 8:20 am

            Geez, Dan it’s not like he’s Deep Throat or something. I’ll bet he wouldn’t really mind if you told Mary Pat his name.

            Reply
    • Courtney
       June 13, 2015 at 8:40 pm

      Please don’t be scared. My daughter was implanted 12 years ago and has had no issues. It’s been a tremendous miracle :) I wouldn’t have changed a thing!!!

      Reply
  2. Pamela Tonello
     June 12, 2015 at 11:34 am

    I find your opinion, which is what it is, on pediatric hospital implant centers as totally off base. My son was implanted at 4 and we had the best surgeon (who isn’t even on your list – Thomas Balkany) and received beyond excellent mapping services at UM Children’s, all Children’s St. Pete and Nemours before moving to New England. The audiologists at the Children’s hospitals were well trained and versed in working with children and their language levels and working very closely with the parents/care givers.

    Reply
    • Dan Schwartz
       June 12, 2015 at 2:27 pm

      @Pamela: Dr Thomas Balkany would probably have made our list, except for one minor detail you overlooked:

      He’s Retired!

      Reply
      • Anita Michaels
         June 12, 2015 at 6:32 pm

        How unprofessional!(Actually are you a professional? Or just one of those Internet trolls that lives to create trouble?) I was not aware that Dr. Balkany had retired,either. So does that get me a laughing kitten response too? Clearly I am shocked that I was not personally informed of his retirement. He implanted my daughter over 19 years ago. I should have been the first on the list for his retirement party.
        Sarcasm aside, my daughter was a Medicaid patient. What did she miss out on? The fancy hospital room and the better dinner were all that were missed. She had her surgery at a world renowned hospital and was cared for by a team of professionals who were second to none. Audiologists,doctors,nurses, and support staff who all treated her as though she was their own. People who still love her and support her to this day. (Ok, Dr. Balkany does not call but her entire crew of audiologists share her with me and are considered family.)
        Not once has any of them ever mentioned Medicaid. In fact, we have been privately insured by an excellent company for more than 10 years now and I have never noticed any difference in care. True medical PROFESSIONALS care about people, not wallets. Yes, they have bills to pay and draw a salary, but you cannot compensate someone for their devotion to their patients.
        Children’s Hospitals in particular draw a special type of caregiver. Pediatric patients are the most vulnerable and are completely unable to make decisions for themselves. Their parents are frightened and lost. Staff at Children’s Hospitals embrace the entire family. They find ways to get things done. They offer solutions, compassion, and even love.
        Facilities that serve adults and children tend to be colder and less personal. ( Please note, I am not impugning their skills, just am painting a portrait of a much different dynamic). I dearly miss having my daughter cared for by pediatric specialists.
        Do not scare prospective patients away from Children’s Hospitals.You are creating additional stress and are obviously ignorant to the many additional perks to being surrounded by professionals dedicated to the care and nurturing of children AND their families. The quality of care received by these practioners is priceless; unable to be compensated by ANY means of Healthcare insurance or private pay.

        Reply
  3. Genny A
     June 12, 2015 at 11:53 am

    As a CI recipient at a children’s hospital, I’m curious to understand how does Medicaid = substandard service as you had implied in your reference to a statement collected in your boot notes. On the contrary, the only two other adults I know that are CI recipients at my job have gotten the procedure done at adult hospitals, and both have had issues. One actually had it done from a doctor at the University of Miami (you recommended that hospital) who completely botched the operation and intensified her dizzy spells to the point where she couldn’t do her job, and the CI never functioned correctly altogether. Prior to that, my family at the time had actually considered going there, but opted to go with a children’s hospital instead since they felt it was the best decision for us. Since I was in my older teens when I got the CI, I’m confident in saying that the service I received from the entire CI staff was beyond exceptional and has propelled me in my career further than I’d ever imagined. My parents agree as well.

    I took a look at your background, and as someone that is an audiologist and not a CI expert, I think you’d do better to refrain from equating facts such as insurance used to service. You are potentially hindering families with children from going the CI route when they see you stating that children’s hospitals are a bad option and cannot afford to go to a profit center.

    While I feel that this article was intended to help deaf and hard-of-hearing folks in making a decision about cochlear implants, I am a bit disappointed when I saw that you made worldly assumptions about children’s hospitals from “numerous off-the-record conversations” with only a single statement regarding Medicaid as a reference to back up your opinion that you state as fact. Really? Is this middle school? Please, add more sources, with contact information so your readers can be well-informed and not mislead.

    For readers. How does:

    Dan: “As best we can tell, based on numerous off-the-record conversations, the problem with pediatric hospital audiology departments centers on very poor Medicaid reimbursement due to the indigent patient load”

    equal:

    Bootnote: “At the March Auditory Neuropathy Spectrum Disorder Conference 2012 held at All Children’s in St Pete, the CI program coordinator told the attendees that 100% of their CI patients in the last year were Medicaid”

    Give me a break! I highly recommend looking at other places for better information on CI.

    Reply
    • Dan Schwartz
       June 12, 2015 at 12:53 pm

      It’s ironic how University of Miami figures prominently in the anecdotal reports of Genevieve’s friend’s bad experience and Pamela’s son’s good experience. However, if you actually read the article, you will clearly see two salient points:

      1) We didn’t pull the surgeon list out of thin air: This list of top surgeons was compiled with the significant help of experts inside the CI manufacturers who quietly keep tabs on each surgeons’ results. If your favorite surgeon was not on the list, there may be a very good reason why his or her name is missing;

      2) The subhead reads CI surgeons & programs we like&c. Just because you went to a given program doesn’t mean you used a surgeon on the list… Or even that the surgeon & not a resident drilled the cochleostomy and placed the electrode.

      @Genevieve: Your friend who had problems — most likely related to electrode insertion trauma — should request a copy of the surgery report to find out exactly who did what during the procedure. Here in the United States, by Federal law, the patient owns their medical records.

      Also, you are conflating full-service hospitals with for-profit facilities when you write

      children’s hospitals are a bad option and cannot afford to go to a profit center.

      What you don’t know is that I also created and moderate the largest Auditory Neuropathy Spectrum Disorder (ANSD) group in the world with almost 1000 members, including CI and ABI surgeons, audiologists, and (mostly) parents of ANSD kiddies, along with a sprinkling of adult-onset ANSD patients; and not only do I get to see the complaints from parents, I also get to read the 20+ page audiologic workup reports people send to me for evaluation; and quite frankly, many of the ones from “Children’s Hospitals” stink, with improper test protocols used, missed diagnoses bordering on medical malpractice; and also poor management once the ANSD diagnosis is made. What’s more, it’s almost always the same “Children’s Hospitals” that are repeatedly appearing in the group. Fortunately for parents in Atlanta and here in Philadelphia, world class surgeons and programs are just four and two hours’ drive away.

      Finally, it’s rather obvious you are not familiar with abysmal Medicaid reimbursements, which are just pennies on the dollar of Medicare and insurance company reimbursements: This is why many doctors in general do not accept money-losing Medicaid patients to begin with; and the problem was exacerbated by ObamaCare’s perverse incentives for small employers to simply discontinue employee insurance & push employees onto the exchanges & into Medicaid, and on the push to get States to expand Medicaid rolls.

      The upshot of all this is that many audiologists at the various “Children’s Hospitals” are at the bottom of the audiologist pay scale, with higher salaries to be had by just hanging hearing aids at Costco.

      Reply
      • Jeffrey Simmons
         June 12, 2015 at 6:17 pm

        I’m sure it took a lot of expertise to create a group on Facebook and then send out lots of invitations to people to join it, but I can’t for the life of me see how that possibly makes you an authority on anything. Where are your peer-reviewed publications? Where are your presentations at professional conferences? Where are your professional medical or audiological credentials?

        Reply
        • Dan Schwartz
           June 13, 2015 at 12:28 pm

          Actually, the now-950+ member Auditory Neuropathy Spectrum Disorder group was created by your humble Editor on Friday, March 16th, 2012 at the big ANSD 2012 Conference, moderated by Chuck Berlin & Linda Hood. In fact, Dr Berlin suggested I create the group; and when he announced it at the Conference to the 100+ professionals in attendance, about half signed up right there. Although it was created for professional discussions, in fact all are welcome.

          What’s more, my interest in ANSD was an outgrowth of the older Reverse Slope Hearing Loss group, where after learning about ANSD for the first time in a Chuck Berlin workshop in March 2010, I went back over the many audiograms posted and uncovered a veritable rats’ nest of undiagnosed congenital and adult-onset ANSD, with the upshot that a number of members went back, received a proper diagnosis, and about 15 adults (so far) having received their CI’s.

          Reply
  4. Kashmir Roy
     June 12, 2015 at 12:27 pm

    When it comes to make a informed decisions regarding choosing cochlear implants and surgeons. I cannot ask for a better staff and teams at all children’s! Dr. Peter Orebello is the best surgeon, whom you didnt list, I have ever known. I felt very informed about the complete process. I never felt I was cheated out of recieving the best care I can get. I as a patient felt confident and had complete trust in my team of specialists. If the patient is not feeling comfortable,they should consider other options or seek different specialist.

    Reply
    • Dan Schwartz
       June 12, 2015 at 2:38 pm

      Top surgeons don’t make bone-headed mistakes:
      ‘Wrong-site’ surgical mistakes are rare, preventable
      By: Letitia Stein, Times Staff Writer, June 20, 2010:

      A surgical procedure to relieve pressure was performed on the wrong ear of a 10-year-old boy at All Children’s Hospital in St. Petersburg in 2007…
      :
      …These medical mistakes belong to a rare and completely preventable category of errors known as wrong-site surgeries. Experts and doctors agree they should never happen, but struggle with the realities of human error.

      Timeouts before the first cut, body parts marked with permanent ink, surgical checklists — step after step has been put in place in recent years to better safeguard patients. And yet, wrong-site errors still happen.

      In the 10-month period ending in April, the Florida Board of Medicine disciplined 34 doctors for wrong-site surgeries, roughly on par with the 41 actions taken in the previous year. Just this month [June 2010 Ed.], it fined the physician who made the wrong ear incision at All Children’s…

      Further down in the June 2010 article Stein lays out the details:

      Before the first incision, surgeons in Florida are required to take a timeout. They must confirm they have the right patient, the right procedure, the right surgical site. The pause rule, as it’s known, was adopted by the Board of Medicine in 2004 and reflects nationally followed safety standards.

      But it wasn’t enough to prevent the error involving the 10-year-old boy at All Children’s Hospital.

      The boy’s right ear was correctly marked for a procedure to relieve fluid buildup, state records indicate. However, Dr. Peter Orobello, a pediatric ear, nose and throat specialist, cut the left ear, inserting a small tube before realizing his mistake.

      Orobello corrected his error immediately, records show, and informed the patient’s family.

      “In the 22 years of the otolaryngology program at All Children’s Hospital we have had one case in 2007,” Orobello said in an e-mail sent through his lawyer. “With the excellent systems in place, this was identified in surgery, corrected, no harm came to the patient and no claim was filed.”

      He did not say how the error happened. As discipline, he agreed to pay a $7,500 fine.

      All Children’s Hospital officials say they have for many years followed national patient safety standards, including a timeout established by the Joint Commission, the hospital accrediting group. They use a safety checklist tied to the electronic medical record in the operating room.

      Reply
  5. Mindi Thibodeau
     June 12, 2015 at 1:07 pm

    My son is a patient at All Children’s in St. Pete also he is a Medicaid recipient. He was implanted at 15 months of age. He receives the best care we could have ever imagined. Our audiologist and our surgeon are amazing!!!! The fact that their pay my not be that of other facilities just means they are that much more dedicated to helping our children from the goodness of their hearts. I believe it takes a very special person to sacrifice what they deserve, to work in a field that they truly believe in. Never for a moment did we feel pressured. They gave us every bit of information before we decided. Our sons surgery went flawless and his aftercare had been the same. Our audiologist takes time to understand and get to know our children. They take the time to console us and care about us! They are extremely experienced and knowledgable. You can not group them all together that is wrong!! Until you have spoke to all of the parents and the recipients at these facilities ( the opinions that really matter) you don’t have a right to scare future CI recipients away from a life changing opportunity. I would not bring my son anywhere else other then All Children’s. That is where he receives the very best care!!!!

    Reply
    • Dan Schwartz
       June 12, 2015 at 1:49 pm

      Actually, All Kids in St. Pete was an unexpected beneficiary of Hurricane Katrina: When the Kresge Hearing Research Center in New Orleans blew apart in 2005, the team that discovered Auditory Neuropathy Spectrum Disorder scattered to the four winds, with Linda Hood landing at Vanderbilt, Thierry Morlet landing at Nemours in Wilmington Delaware, and Ben Russell & team leader Chuck Berlin landing at USF… And one of the achievements of (the now semi-retired) Prof. Berlin was to whip the ANSD portion of All Kids’ audiology program into shape.

      That Being Said, Dr Loren Bartels‘ CI program across the bay at Tampa General is better; and in fact he just about made our cut for surgeons we like.

      Reply
  6. Kris Robinson
     June 12, 2015 at 1:27 pm

    Dan,

    I absolutely do not agree with you regarding the audiology team at our local Chidren’s hospital in St Petersburg, we have an amazing group of audiologist. I have two daughters that receive their mapping their, and I chose to do that. I am privately insured, so I am pretty sure the comment you made regarding 100% Medicaid was incorrect. That being said I adore Shelly and Sybil and the rest of the audiology team and I chose them because they can spend the time and they do to ensure the mapping is just where it needs to be. My surgeon Dr Bartels did not seem to make your list either and he was exceptional.

    Reply
    • Dan Schwartz
       June 12, 2015 at 2:15 pm

      @Kris: In fact, our comments crossed, as I discussed All Kids’ ANSD program and also Dr Bartels. In fact, several years ago I referred our mutual friend Regina from Sarasota to him for Gianna’s implants.

      I’ll also reply to you privately on Facebook messenger.

      Reply
  7. Constance L.
     June 12, 2015 at 6:46 pm

    My daughter had her right side cochlear implant at 26 months of age, her left side done when she was 7 years old. She is now 16 years old. Thus, we have been around cochlear implants for many years. We have lived in 4 different states since she was diagnosed. The first thing I would recommend to a family with a child that is HI is to join the cicircle group on Yahoo. There is also a group for parents that have children with Auditory Dysnchrony. Parents have always been my best resource. Talking to families that live and breathe this 24/7 is priceless. If there are any local groups, go and talk to recipients and parents of recipients in person. AG Bell, Minutman Implant, Hands and Voices, etc. etc.

    Second, I would definitely talk to the different cochlear companies (about anything and everything). I had a very lengthy discussion with Jim Patrick, one of the first engineers at Cochlear regarding various current surgical procedures. It was very enlightening and furthered my research for what was best for kid for her second implant.
    When our daughter was first implanted, AB had a serious issue with cases of meningitis. I believe all of the implants slightly increase the risk of meningitis. Therefore, it is important for parents to make sure their pediatricians are familiar with what the CDC (Center for Disease Control) is recommending for these kiddos vaccinations. I know there were some scared families when AB went through its buyout. I also considered financial history of the company. Having the best equipment at the time of implant, but the company goes under, is not a situation I would want my child to be in as an adult. Also look at the history of updating older devices.

    When a child is deaf there can be other issues to consider (things that caused the deafness, etc). This is why we felt so much more comfortable going with a Children’s Hospital. Once the child is implanted, the hard work starts. I believe it is crucial to the success of the child and their implant to have the best pediatric audiologist possible. The speech and listening therapy is also crucial and parents must do their part in carrying over the therapy.

    Children are not little adults and should not be treated as such. Our family has always been fortunate to have an excellent job with really good insurance and yet, we have chosen Children’s Hospitals.

    One last word about doctors, if you don’t feel comfortable with the surgeon, you do not owe them anything, CHANGE doctors. This is your child and you want what’s best for him/her. For us personally, it’s a Children’s Hospital.

    Reply
    • Dan Schwartz
       June 13, 2015 at 1:04 pm

      @Constance: I notice you didn’t name the “Children’s Hospital” which serviced your daughter: If it was so praiseworthy and her outcome so fantastic, you should have identified both the facility and the team.

      Auditory dys-synchrony (AD) was folded together with auditory neuropathy (AN) and then rolled into auditory neuropathy spectrum disorder (ANSD) at the 2008 Lake Como Conference, moderated by Prof. Charles Berlin. For more, please see the proceedings: Management of Individuals with Auditory Neuropathy Spectrum Disorder, by Charles Berlin PhD (2008; Lake Como Conference proceedings).

      [Separately we at The Hearing Blog argue that AN and AD should be separated again as diagnosis, management, and prognosis varies greatly between the underlying pathologies (the “bottom-up” view); while others, including Prof. Nina Krause argue that central auditory processing disorder should also be included into an even-bigger spectrum. You can follow the discussion here.]

      The issue with the connection between CI’s and higher incidence of meningitis is somewhat tenuous, as in fact the incidence of it occurring in deaf people is higher than normal, with one possible vector being enlarged vestibular aqueduct syndrome (EVAS). That being said, AB’s use of the “positioner” in 1999-2000 appears to also be a culprit, somewhat depending on the method the surgeon used to seal the cochleostomy.

      All that being said, the issue of maintaining meningitis vaccinations for CI recipients was settled over a decade ago. [Latest CDC recommendations are here] and in fact Advanced Bionics has a vaccination reimbursement program for their recipients who do not have insurance coverage.

      As for the CI manufacturers’ financial stability, in fact this is a big factor for FDA approval of any implanted device manufacturer — And has been for decades, such as back in 1985 when 3M exited the CI business, the FDA brokered an agreement still in effect today in which Cochlear took over all support for the many hundreds of 3M/House single-channel devices, a few of which are still in operation.

      Reply
    • Constance L.
       June 13, 2015 at 8:53 pm

      Boston Children’s Hospital. The surgeon was Dr. Margaret Kenna and the audiologist was Dr. Mariylyn Neault. These two women and the hospital were not only amazing in their skills and knowledge, but also emphatic and caring. The fact that they taught/teach at Harvard, I believe, is a blessing for all the parents that will need their students services for their children. Our daughter being born at 26 weeks and suffering from necrotizing entercolitis in Cincinnati, was transferred to the Cincinnati Children’s Hospital Medical Center when the level III NICU couldn’t help her. The surgeon who worked on her as a 1 lb 6 oz baby was Dr. Frederick Ryckman.

      We will forever be grateful for all of the Children Hospitals that we have used and continue to use across the U.S. The Doctors, Audiologists, Nurses, Surgical staff, administrative staff are amazing people following their passions to save the lives of children and/or enhance to the children’s lives to the fullest extent humanly possible.

      It was Dr. Neault who first told us that our daughter had ANSD. Dr. Neault also told me about Dr. Berlin, whom I contacted. I actually sent him all of our daughters paperwork tests, etc. as I am quite fond of second opinions. It was Dr. Berlin who told me that Auditory Dy-synchrony was a better word than Auditory Neuropathy since it wasn’t the nerve that was the problem. I was also fortunate enough to hear him speak and to meet him at a conference in Rhode Island. That was about 12 or so years ago.

      Since things change, AN to ANSD, one small example, I truly believe that parents should continue to educate themselves regarding issues of meningitis. What is tenuous to you might not be tenuous to the families that have been affected. Parents of children that are deaf soon learn that “rarely happens” actually can happen.

      There have been companies approved by the FDA that have gone under. Just because a company has been approved doesn’t ensure they will be financially viable for the life of your child. It certainly doesn’t hurt to look at a companies financial history. Know what you are buying into.

      All that being said, I still believe one of the most important factors for parents to consider is to connect with other families. Internet groups, local groups, etc. I would strongly urge families not to rely on one source for all of their information and education.

      Reply
      • Dan Schwartz
         June 13, 2015 at 9:44 pm

        Brian Fligor PhD actually did a nice job running the audiology program at Boston Children’s, as we had few issues with them in the ANSD group. However, he departed about a year & a half ago to become Chief Audiology Officer at Lantos Technology.

        On The Other Hand, Daniel Lee at Mass Eye & Ear made our list as he is a truly outstanding CI and ABI surgeon who trained under Dr John Niparko at Johns Hopkins.

        Cincinnati Children’s is, overall, a very good hospital; and Lisa Hunter PhD does a decent job running their audiology department.

        Reply
      • Dan Schwartz
         June 15, 2015 at 11:42 am

        Just to clarify, the FDA is extremely strict with the implanted medical device industry; and when one is sold it typically takes at least six months for the FDA to perform it’s own due diligence: It took that long for Boston Scientific to buy Advanced Bionics in 2006; and more recently, it took an unusually short 3 months for FDA to investigate when Sonova (Phonak) purchased AB in late 2009 for $480 million, probably because they were established in 1966 & their market capitalization (VTX: SOON) at the time was over $6 billion (and today is over $9 billion), traded on the Zurich stock exchange.

        Cochlear Pty. is also a publicly traded company on the Sydney Exchange (ASX: COH) with a market cap of US$3.6 billion; plus since it’s a “star” in the Aussie tech sector it gets extensive support from the NSW government.

        Oticon has been around since 1904, and is owned by William Demant Holdings (CPH: WDH), and has a market cap of US$4.5 billion. They purchased French CI manufacturer Neurelec two years ago; and they will have a Major Product Announcement in Toulouse this week — Stay tuned!

        Med-El is privately held by the Hochmaier family; and they have repeatedly turned down offers to be acquired by almost every one of the Big Six hearing aid manufacturers.

        Reply
  8. Going Deaf Girl
     June 14, 2015 at 2:40 pm

    Thank you for the article. Any insight on a surgeon in Texas? Been referred to Brian Peters, James Kemper, or Joe Kutz.

    Reply
    • Dan Schwartz
       June 15, 2015 at 11:18 am

      Although there are some decent CI surgeons in Texas, none are outstanding; and none are any good in Austin. My suggestion is to drive or fly to Dr Stanley Baker in OKC: Although we didn’t rank the surgeons in our list, if we did, he’d be about 2nd or 3rd.

      Reply
    • Melissa Benton
       June 15, 2015 at 12:03 pm

      Going Deaf Girl: Dr. Brian Peters at Dallas Ear Institute is EXCELLENT! He did my CI surgery in 1998 and I had AMAZING results! He has being doing CI’s since 1992, he’s a very skilled surgeon and he sincerely cares about his patients as much as any physician can possibly care. He has an excellent team of audiologists and auditory-verbal therapists. I HIGHLY recommend him! I would suggest that you research reviews by actual patients of Dr. Peters. You will find that his pristine reputation precedes him! This person who writes these blogs has his own opinion, and as you can see from reading the comments, a lot of people who have experienced cochlear implants themselves do NOT agree with him. Please let me know if I can answer any questions for you!

      Reply
      • Dan Schwartz
         June 15, 2015 at 12:20 pm

        Melissa, unfortunately neither of us are qualified to rate CI surgeons, which is why we received inside information from the CI manufacturers who are qualified to rate them. Let me remind you, from the second paragraph of the article:

        With CI’s, there is no 30 Day Return privilege, so choosing wisely at every step of the process is vitally important for the best outcome. Unfortunately, especially here in the United States, there are factors that conspire against making an informed choice, not the least of which is the CI manufacturers quietly keeping reams of information on each of the approximately 700 or so US CI surgeons’ outcomes. The problem is that the manufacturer’s patient reps and support personnel maintain omerta, lest they offend the delicate feelings of the audiologists or bruise the fragile egos of the surgeons, both of whom guide the brand selection. Unfortunately, the CI manufacturers’ patient reps — as nice as they are to get you to select their brand — will give you zero guidance on selecting a surgeon, let alone a CI program, as you are .NOT. the customer: The CI center is their customer, and the manufacturers will do nothing to offend their customers.

        That Being Said, UT-D’s Callier Center is a very good, but very busy audiology clinic. Also, the UNT clinic in Denton is quite good; and is on the rise with new Program Director Erin Schafer PhD.

        Separately, a prominent member of the Dallas CI community had all sorts of problems with her two CI’s; and she had to go to the above-mentioned Dr Baker in OKC to get reimplanted to get good results.

        Reply
        • Melissa Benton
           June 15, 2015 at 1:00 pm

          Yes, I am very familiar with the Dallas CI Community. My cochlear implant was so successful that it transformed my life. My experience was 12% with a hearing aid to 92% with the CI. Prior to my CI, I could count on one hand the number of people I could understand on the phone. Within a month, I was hearing well enough on the phone to become a volunteer and eventually the Administrator for the Dallas Hearing Foundation, which Dr Peters founded to help people who cannot afford hearing aids and cochlear implants. I worked with Dr Peters and his CI team for many years prior to relocating to my hometown in Indiana. I was the organizer and leader of the CI support group meetings in Dallas and I literally met hundreds of Dr Peters’ CI patients. They are extremely happy with their results and with him personally. It is rare for a CI surgeon to never have a patient who ends up having a problem. Dr Peters is a very prominent neuro-otologist who has done extensive published research on bilateral cochlear implantation. He is an excellent, very experienced surgeon. And he has a heart of gold. I would trust him with my life and I know his patients feel the same way.

          Reply
          • Dan Schwartz
             June 15, 2015 at 1:11 pm

            Melissa, let me be blunt: Although you did a good job with the Dallas Hearing Foundation, you are Not Qualified to rate CI surgeons, which is why we relied on inside information from the CI manufacturers who do keep the records and who are qualified to rate them.

            Reply
            • Melissa Benton
               June 15, 2015 at 1:25 pm

              I didn’t claim to be qualified to rate CI surgeons… It is ridiculous to tell a candidate to travel to another state when she could receive excellent care locally.

      • Mom of HOH child
         June 17, 2015 at 7:11 pm

        Going Deaf Girl: I can’t speak much on the side of CI but I can give you some input on Dr. Brian Peters (just my experience). Dr. Peters in Dallas was just one of the doctors that I took my child to. After a lengthy but wonderful day at UNT it seemed like we were on the right track for a diagnosis of Meniere’s. UNT was wonderful but we still needed the doctors “stamp of approval” for the next steps in our journey. So, we ended up seeing Dr. Peters in Dallas. I had heard great things about him. What we encountered with him was very disappointing as parents trying to do anything and everything for our child. He was nice but really didn’t answer any of our questions. He gave vague answers that really just seemed like a response to try to please me. He took a tuning fork and touched the side of my child’s head with it and came up with some answer from that. He nixed the test from UNT with a response of “kids don’t have Meniere’s Disease, they just don’t get it.” After that he signed a form for a hearing aid and sent us out the door. Needless to say it was all I could do to fight back the tears of disappointment and of feeling lost on what to do to help my child. I was not impressed at all. We are still looking into other options as where we need to go next.

        I hope you find the answers that you are looking for. Just a little input from a mother who wouldn’t take my child back to Dr. Peters.

        Reply
  9. Mike Levad
     June 15, 2015 at 9:08 pm

    I have been scheduled with Sam Levine at the University of MN in Minneapolis. Sam has been doing implants since they were invented. Should I be excited or nervous to have him as my surgeon?

    Reply
    • Dan Schwartz
       June 16, 2015 at 5:38 am

      Congratulations Mike on taking the step to hear well again — We wish you well in your journey!

      Our suggestion is to print out this article outlining Best Practices and discuss this with Dr Levine.

      Reply
  10. Miss Kat's Mom
     June 16, 2015 at 12:16 pm

    Interesting article. We had the opportunity to have our daughter implanted by Dr. Clough Shelton in Utah. He is an excellent surgeon and does all the things mentioned in this article.

    While the surgeon is a critical piece to the puzzle, I believe that the audiologist is FAR more important and unfortunately, there are a HUGE number of pathetic doctors masquerading as pediatric audiologists today.

    Reply
  11. Shannon Davis
     June 17, 2015 at 6:18 pm

    Just saw your info on Dr. Niparko who just performed bilateral implants on my son. We could not be more thrilled. I called his office and learned that he has been elected President of USC Care, but has kept his surgical practice going full speed. You are correct about one thing, however, he is probably the best of all of them. Given his schedule, he must be the busiest surgeons in Los Angeles!”

    Reply
    • Dan Schwartz
       June 17, 2015 at 8:13 pm

      Dr Niparko is implanting again?! That’s the best news we’ve heard all week! He implanted my former girlfriend in 2003, as well as implanting a number of friends here in the Delaware Valley who drove the 90 miles down to Baltimore. In addition, he saved a dear friend from facial paralysis after another surgeon badly bungled a procedure.

      Reply
  12. C, J.
     June 24, 2015 at 9:35 pm

    I know for a fact that at least one of the surgeons on your list allow residents (not fellows but residents–and not senior residents either) do parts of the surgery including placing the electrode array into the cochlea on both adults and children. As one neurotologic surgeon told me, it is one of the easiest surgeries he does because the is working with a healthy cochlear and many of the other surgeries he does that is not true.

    Reply
    • Dan Schwartz
       June 24, 2015 at 11:21 pm

      @CJ: What you write about CI surgeons allowing a resident to perform the electrode insertion is precisely why we put this in the article, as oftentimes in general the surgeon is watching the resident perform a given procedure — And often this is buried in the consent forms, which is why we are alerting our readers to this issue

      However, the surgeon is pulling your chain (or maybe something else) when s/he tells you “it is one of the easiest surgeries he does” as in fact it is quite difficult, especially when placing the Med-El Flexsoft array, which is like pushing a wet noodle, or when placing a curved AB, Oticon or Cochlear electrode, which is prone to kinking.

      Reply
      • Mary Pat bibel
         June 24, 2015 at 11:29 pm

        I don’t think it is for anyone but another surgeon to comment on how challenging any particular procedure is compared to another.

        Reply
      • C, J.
         June 24, 2015 at 11:48 pm

        I think you missed my point. These surgeons you mention as best track record doesn’t mean that they are actually doing the surgery so in those cases their track record is irrelevant.

        I know my surger was done by a fellow because I read the hospital report but others might not realize that these surgeons you mention as best track record might not even be doing the insertion so it is a moot point.

        As for the surgeon pulling my leg about the cochlear implant surgery. I can tell you that this surgeon is highly regarded in the otolaryngology field, has a very prestegious position, and does very complicated cases so I believe he knows of what he speaks.

        Reply
  13. Chad Denning
     June 26, 2015 at 12:49 pm

    Dr Niparko did my CI surgery on February 5,2015. He has to be the most humble Dr I have ever met. As my hearing has worsened, he said to me, “Please, let me implant you and resolve your issues.” I believed him and let me tell you, it was the best decision of my life. By old implant standard’s, I had to much residual hearing at 40%. But I was missing more then half of everything said. Dr Niparko told me the sooner we implant, the faster the results. Not only did I preserve most of my residual hearing, the placement of my electrode by medical standpoint is optimally perfect. In 3 months I was at 99% on sentences in quiet, 86% in noise and 93% on word recognition. Now coming up on my 5th month activated, my hearing in my implanted ear is so great, I am considering going bilateral. For the record, I did not choose AB but Cochlear. It really doesn’t matter which brand you choose, if your surgeon does a bad placement, you will struggle. I feel extremely blessed to have Dr Niparko for a surgeon and his vast knowledge of implantable device’s. USC was very smart in hiring him, he has raised the bar for surgeon’s at House and UCLA. He has also secured millions of dollars in funding to further advance the research coming out of USC.

    Reply
    • Dan Schwartz
       June 26, 2015 at 1:08 pm

      Chad, we are very pleased you are achieving such good results so soon! Since you opted for the Nucleus, you’ll want to take advantage of the “sexy” externals’ features, especially the Unite wireless accessories. To that end, we recommend the ReSound Enzo 7 or 9 hearing aid for your opposite ear, possibly programmed to linear for speech envelope preservation.

      We published a comprehensive list of accessories for the ReSound & Cochlear systems last year at this link. Whether you choose to use an Enzo or not for your non-implanted ear, we recommend purchasing accessories which are compatible with it, as the forthcoming Nucleus 7 processor will require them, so it’s better to maintain forward compatibility.

      Reply
      • Chad Denning
         June 26, 2015 at 2:04 pm

        Dan, I have an ReSound Alera in my left ear which is effected by Meniere’s. So some days I can hear great with that ear and others… well it sounds like a broken speaker with Tinnitus that sounds like a freight train in my head.

        By the way, I didn’t choose Cochlear because of it’s “Sexy” features, but for reliability, longevity and promise to leave no one behind. The fact that the FDA just aproved the N22 for upgrade to the N6 processor tells me that I made the right decision for me. As for perks, such as the wireless capabilities of the N6, I believe that they are one of the major reasons for my success. Besides have beautful impedence numbers (thanks Dr Niparko), my Dynamic range is huge (between 38 and 72) and stimulation of 900hz X 8 for 7,200. Back to the wireless capabilities… I can now talk on the Phone again… been 2 years, the Mini Mic… I use it to stream my computer at school while editing shows (Studio Production Student) and listening to tutorials for my Didgital Multimedia stuff, I also plug it in to the intercom system/party line in the studio and they talk wirelessly to my head… NO MORE HEADPHONE that I so struggled to hear with and I also use it at my men’s group, setting it at the end of the long table so I can hear the guys at the other end with ease, while everyone else struggle, I enjoy loud clear voices. Last but not least… The TV streamer… AHHHHH I can blast my TV away in head and my Family doesn’t have to hear it! My Dad asked me if I could get that for my Mother… She is getting hard of hearing in her old age and kidney disease. So I actively am listening to something in my CI ear pretty much 10-12 hours a day and using my HA ear for my local surroundings. I will be remapped on Tuesday and look forward to even hearing better.

        I am not posting to get into brand wars… But to tell you the honest truth, regardless of monopolar or bipolar… if you don’t put the hours of rehab in, you spiral ganglion are severely damaged or have a bad placement, you will struggle. It breaks my heart to see those that strugle after surgery, have componet failure, bad placement, infection or whatever the matter. The whole goal is to hear better! Regardless of if you Choose AB, MedEl or Cochlear… it’s all rubish if you get implanted for any other reason then to be able to continue to communicate with the world. Some will hear Music, Some will struggle with Music, if you got implanted with the thought that you will hear music again like you did with your regular ear, you are being set up for failure. I am fortunate in the fact that I am an early implatee. My recovery and my learning to hear again has been incredibly easy and a lot of workalong with a great relationship with my Audiologist. Placement, Mapping and Hard Work/Therapy are the 3 major factors in the outcome of you CI journey. The lack of one of those can make a huge difference how fast you return to hearing.

        So like I said earlier, “I feel blessed to have Dr Niparko as my surgeon.” I trust him 100% and we have an amazing relationship. He also takes time out of his busy schedule to go to many awarness meeting here in So Cal, both for Patients and Physicians to spread awarness. How many Presidents of University medicine do this.. How many Internationaly Renowned Scientist and Researchers do this??? Dr Niparko does… So if you are in So Cal and reading this, look up Dr Niparko at Keck School of Medicine, USC. It may just be the best decision you will ever make, it sure is for me!

        Reply
  14. D.D.
     July 27, 2015 at 3:12 pm

    I am considering a cochlear implant. What information do you have about Dr. Rick Friedman at USC-Keck?

    Reply
    • Dan Schwartz
       July 28, 2015 at 6:41 pm

      I don’t have any info on him; however we highly recommend Dr John Niparko

      Reply
  15. Hadron
     September 3, 2015 at 2:52 pm

    Dan,

    What do you think of the reputation of Dr. Patrick Antonelli and his body of work at the Universiiy of Florida at Gainesville?

    Thanks.

    Reply
  16. Jim Flesch
     September 22, 2015 at 6:29 pm

    Mr. Schwartz,

    Our 29 year old daughter has profound hearing loss and the ENT recommended that she receive a cochlear implant.

    Do you have a recommendation for someone to see in the Phoenix area?

    We are being referred to Dr. John Macias.

    Thank you.

    Jim Flesch

    Reply
    • Dan Schwartz
       September 23, 2015 at 12:45 pm

      No, I do not recommend any of the CI surgeons in the area. Hop a shuttle to LA to USC-Keck or House Ear Clinic, for Dr’s Niparko, Wilkinson, or Slattery.

      Reply
  17. Di
     September 25, 2015 at 2:25 am

    Hi Dan,

    I have some personal questions seeking your advice. If you don’t mind, can we chat over emails?

    Thanks

    Reply
    • Dan Schwartz
       September 25, 2015 at 7:44 am

      Sure! Message me on Facebook.

      Reply
      • Di
         September 25, 2015 at 11:43 pm

        Hi Dan,

        I sent you two messages on facebook, but it’s said the message sent to your “other folder”. Please check your other folder.

        Thanks

        Reply
        • Dan Schwartz
           September 26, 2015 at 2:41 pm

          Di, it is my pleasure to point you to the right neurotologic surgeons to straighten out your SSDS (SCDS) as well as hybrid CI!

          Reply
  18. John David Stegeman
     October 5, 2015 at 9:56 am

    Dan,

    Very interesting information, and certainly it’s not something that you see discussed much on the Internet.

    Are you able to name the Michigan program and surgeon that had the malpractice issue with the kinked electrode array? I’m being implanted next week in Michigan, and it would be good to know…

    My surgeon is Dr. Eleanor Chan at the Michigan Ear Institute – do you have any information on her or the program there? I’m not on Facebook…

    Reply
  19. Lettie
     October 19, 2015 at 2:51 pm

    Hi I am interested in your comments as we are currently researching CI for our daughter who has been approved as a candidate. It’s interesting that you have such bad things to say about CHOP. Our daughter currently has medicaid, and maybe we will look into the possibility of going to NYU. Do you know the doctors at NYEE? I’ve heard good things about them as well.

    Our current plan was to implant with Brian Dunham at CHOP and programming by Melissa Ferrello.

    My husband and I are professional musicians and am curious if you have input on the best implant or programming for musical access, specifically pitch perception.

    Reply
    • Dan Schwartz
       October 19, 2015 at 4:52 pm

      NY Eye & Ear is good; but we recommend Dr Tom Roland at NYU Langone, as that center has the best outcomes; and as we discussed, he tries for residual hearing preservation

      As for brand, we recommend the Advanced Bionics implants, as there’s a new 1024-channel stim for music being developed which will run on the HiRes 90k implant. Also, although the externals are not as important as the implant circuit, we really like the Phonak processors; and as we recently discussed here, their radio technology is already very good, and will be getting much better mid-to-late next year.

      The Med-El i100 is a decent implant, but although twice as fast as the Nucleus CI522 and with the electrodes spaced far enough apart, it’s OK. However, it’s a smaller company and they aren’t also in the hearing aid business, so their processors lack the advanced noise reduction processing that Phonak brings to the table.

      Reply
      • Lettie
         November 29, 2015 at 9:30 pm

        Hi Dan,

        I apologize if this is a double post, but I’m not seeing my last comment. We live in Philadelphia, and unfortunately, I can’t get Keystone first medicaid to pay for us to go to New York to get CI for our daughter. That leaves CHOP, Dupont Nemours, or St. Christopher’s I guess. I know you said you weren’t a big fan of any Philly CI programs, but since these are our options, do you have any input whatsoever on surgeons or programming audiologists?

        We are looking at either AB or Med-el at this point, and unfortunately CHOP does 75% Cochlear, so I’m not sure we’re going to find a surgeon who does a ton of the other brands.

        Thanks!

        Lettie

        Reply
        • Dan Schwartz
           November 29, 2015 at 11:14 pm

          Try Willcox at Jefferson

          Reply
          • Lettie
             November 30, 2015 at 6:57 pm

            It looks like Jefferson only implants adults currently.

            Reply
            • Dan Schwartz
               December 1, 2015 at 6:56 pm

              Since you’re getting Advanced Bionics for your daughter, talk to the patient coordinator (I think it’s still Katie Peter Skipper) for guidance. Also, Hershey has a good program.

  20. Rene Moerman
     October 25, 2015 at 2:38 pm

    Would you have any knowledge about the the Audiology center at Emory in Atlanta.
    Thanks

    Reply
    • Dan Schwartz
       October 25, 2015 at 2:51 pm

      We recommend Auditory-Verbal Center of Atlanta in Century City (404-633-8911), and the Atlanta Speech School on Northside Drive: Both places have full pediatric & adult audiology clinics including MAPping CI’s, and both places do a very good job.

      If you or your child needs CI’s, you’ll be driving up to Nashville, as the surgeons up there are much better than any in Atlanta. One of my longtime patients who still had significant high frequency hearing was just implanted a few weeks ago (I’ll not name the surgeon), and even though the electrode was an AB mid-scala for atraumatic insertion, she woke up with her residual hearing destroyed, with resultant poorer outcome (see Effects of CI Electrode Insertion on Tinnitus by Balkany for the research) — Nice going, schmuck.

      Reply
  21. Rob Cunningham
     November 17, 2015 at 1:05 pm

    My 89 year old mother just had a consult with an audiologist in Cincinnati about the possibility of a cochlear implant…she’s been totally deaf in one ear for decades, and is progressively losing her hearing in the other ear. Many years ago, she consulted with Dr House in Los Angeles, but there have been advancements since then…

    The news from the audiologist was not good regarding her candidacy…however, we’d like a second opinion. Please advise: who are the very top Otolaryngology docs in Cincinnati?

    Would it be worth traveling to Los Angeles to consult with Dr Niparko?

    Thank you in advance for your reply…
    kindly, Rob

    Reply
    • Dan Schwartz
       November 17, 2015 at 2:32 pm

      Rob, the age record for CI’s is 99 in the US, and 100 in UK. The biggest issues are motivation and ability to tolerate the surgery, which takes about 90 minutes.

      Dr Ravi Sami is an excellent CI surgeon in Cincinnati — Talk to him first. Any of the surgeons on the list are outstanding.

      I asked Dr Niparko at the 2010 HLAA convention if a CI can be done under a local (it was for a friend who is a dwarf, and dwarves don’t tolerate general anesthesia well): He said he’s implanted under a local for a couple patients in their 90’s, so it’s do-able.

      Reply
      • Rob Cunningham
         November 19, 2015 at 11:04 pm

        Many thanks, Dan…

        As it turns out, mom’s audiologist also recommended Dr.Ravi Samy…so that’s who she’ll go to if/when she decides to pursue this course. It was also recommended that she attend an upcoming conference/meeting of CI patients, to gather info and ask questions, which she’ll do.

        The service that you’re providing here is invaluable, Dan…Just having Dr. Samy’s expertise confirmed is a great comfort. Again, many thanks.

        kindly, Rob

        Reply
        • Dan Schwartz
           November 20, 2015 at 1:00 pm

          Rob, thank you for your kind words, as it makes what I do worthwhile!

          Reply
  22. Jane Richman
     November 18, 2015 at 8:25 pm

    Can you recommend a CI surgeon in Chicago?
    Thank you!

    Reply
    • Dan Schwartz
       November 20, 2015 at 1:03 pm

      For pediatric CI’s I recommend Dr Dana Suskind and her excellent program at UC/Comer Children’s. None of the Chicagoland adult CI surgeons made the list; but the adult program at UC is rather good.

      Reply
      • Jane Richman
         November 20, 2015 at 5:26 pm

        thanks, Dan. I also appreciate the work you do to share information and optimize outcomes! Is there someone special at U of C you would recommend? I’m looking for a CI surgeon for an adult (myself). Also, if I go out of state, can my local audiologist do the fine tuning post op, or do I need to return to the site where the implant was done?

        Reply
        • Dan Schwartz
           November 29, 2015 at 11:17 pm

          Unfortunately, Dr Dana Suskind at UC/Comer Children’s only implants pediatric patients. If you get implanted in another city, then Yes, you can be MAPped locally; however switch-on (1st stim) and the first couple of MAPpings would be where you were implanted, especially if there are any “issues.”

          Reply
  23. Kimberly
     December 1, 2015 at 11:25 pm

    I live in southwest Colorado and have been referred to Dr. Stephen Cass of University of Colorado Hospital in Denver for a CI (adult). I am also investigating surgeons/clinics in Albuquerque, NM. Do you have any recommendations?

    Reply
    • Dan Schwartz
       December 2, 2015 at 1:48 pm

      Hop a plane to LAX for Dr’s Niparko, Wilkinson, or Slattery.

      Reply
  24. Ruth Katz
     December 2, 2015 at 9:19 pm

    This is incredibly helpful! Thank you! Do you have any experience with Colorado implant surgeons? We have been referred to Dr. Kelsall and Dr. Feehs in Englewood. I would love an outsiders opinion on either surgeon. Thanks!

    Reply
    • Dan Schwartz
       December 3, 2015 at 9:24 am

      Hop a plane to LAX for Dr’s Niparko, Wilkinson, or Slattery.

      Reply
      • Ruth Katz
         December 3, 2015 at 9:35 am

        Unfortunately that is impossible. We must use a surgeon in Colorado for insurance purposes.

        Reply
  25. Ralph Roesler
     December 6, 2015 at 10:34 am

    Dan, thank you for your excellent blog post on selecting a cochlear implant surgeon. I am 53 years old, have worn hearing aids bilaterally for most of my life, and am considering a CI. There is a bewildering array of (conflicting) information out there, so I find your blog very helpful. I live in Houston, do you have any information on surgeons in the area you would recommend or not recommend? Thank you in advance for your help.

    Reply

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