Interview with Derald Brackmann M.D., House Ear Clinic, Los Angeles, California

Topic: Perspectives on Cochlear Implants, Completely Implantable, Hybrids and More...

Beck: Good morning Dr. Brackmann. Thanks for meeting with me today.

Brackmann: Hi Doug. Nice to see you and welcome back to Los Angeles.

Beck: Thanks. Dr. Brackmann, I know you don't have much time this morning, and there are so many things to talk about it...so if you don't mind, I'll jump right in. As one of the premier neurotologists in the world with more than 20 years experience implanting patients, I wonder if you would please tell me your thoughts on bilateral cochlear implants?

Brackmann: Thanks Doug. The issue to me is that bilateral cochlear implants are useful, beneficial and fine...but I wonder if we don't have a responsibility to provide monaural cochlear implants to more people first? In other words, so many people need them, and I wonder if there isn't some way to make cochlear implants more available to those in need, rather than focusing on a second implant for those in more fortunate positions. So my thought is, yes, the second implant adds sound and improves the lives of those lucky enough to have two...but if it were my decision, I'd rather make sure everyone in need gets one first! I know that's sort of altruistic, but that's what I think. I'd like to see the best devices available at a lesser price so more people could have financial access to these amazing technologies. I have no idea how to lower the costs while maintaining the quality, but that would be my preference. I hope we can find a way to get that done.

Beck: What about hybrids? The combined cochlear implants/hearing aids which provide low frequency sounds through the hearing aid, while high frequencies are delivered through the cochlear implant?

Brackmann: Well, these are really interesting to me. There are probably a million people in the USA that are candidates for hybrids, and these devices appear to solve some of their unique problems. For example, imagine a patient with normal hearing through 1000 Hz, and then a precipitous loss at 1500 Hz and nothing after that, with 38 percent discrimination....that might be the ideal hybrid patient. We know people with these audiograms will do better with hearing aids than without, but the hearing aids cannot impact the frequency regions in which the person has no measurable acoustic hearing ... So for those individuals, the cochlear implant portion of the hybrid could deliver high frequency sounds, and that could make an enormous difference in their quality of life.

Beck: I agree. That would be the ideal situation, and I too, am excited about the potential that hybrids offer. What about the issue of short versus long electrodes for that same patient? In other words I think the hybrid devices advocate the short electrodes as they only need access to the basal end of the cochlea to deliver high frequency information...but if you were to implant a short electrode, and then if the patient loses all his hearing 7 years later, you'd have to re-implant a longer electrode at that time, and that could risk further damage to the cochlea, which might make the "traditional" cochlear implant less effective, or am I misunderstanding the argument?

Brackmann: No, you've got it, and that's the dilemma. There are good arguments on both sides and no resolution at this point. The determination of short versus long electrodes, and their use in hybrids and cochlear implants is a topic we need to focus on, but we haven't got enough data to really make the decision at this time. The shorter electrode is currently what is used in the hybrids, but again, this is under review and maybe it'll be resolved soon.

Beck: Very good. What are your thoughts on completely implantable cochlear implants?

Brackmann: There are still some issues related to completely implantable technology, but I think people will be standing in line to get them once they're commercially available. It's a funny thing...we all know that cochlear implants are tremendously successful, and the technology is unbelievably good, but cosmesis is an important issue too, and probably always will be. So yes, once they're available, I think people will really want them and I think the demand will be significant.

Beck: Dr. Brackmann, would you please tell me a little about the current status of the "Penetrating Auditory Brainstem Implant (PABI)"? For the readers not familiar with the concept, the ABI and the PABI are the electrodes placed on (ABI) or within (PABI) the cochlear nucleus of the brainstem, for people who have cochleas that cannot be implanted due to the cochlear anatomy, or perhaps the absence of the cochlear nerve....and typically these are patients who have neurofibromatosis II (NF-II), also known as Von Recklinghausen's Disease.

Brackmann: Sure Doug. Yes, we've been working with the ABI for a number of years, with many successes. The latest development there is the PABI. We initially we had approval for 5 trial patients, and we've implanted those first 5 patients. I would say, in general, the results have been mixed. Of course, these are difficult patients as most of them are NF-II patients, and if they are able to wear cochlear implants, we recommend that, but sometimes, their inner ear status prohibits the use of a cochlear implant, and so then they are potentially candidates for the PABI. Each patient had 8 penetrating electrodes and 14 surface electrodes, so there was redundancy within the design. The first patient had only one penetrating electrode from the PABI that was providing auditory percepts, the second patient had 6 PABI electrodes providing auditory percepts, and she does very well. The third patient has normal hearing in the contralateral ear, and he doesn't use the PABI very much, but he does get auditory percepts through the PABI. Neither the 4th or the 5th patient gets benefit from the penetrating microelectrode technology that is unique to the PABI. So although we've had some encouraging results, in general, we're hoping for better results for our patients with this technology in future. Importantly, none of the patients has had any medical problems with the implant, and each has surface electrodes that are working. The FDA has approved an additional 10 patients to be implanted with the PABI and we've developed a newer PABI design with 10 penetrating electrodes and 12 surface electrodes. We also have a new method for maximally placing the electrode. So we keep working towards the goal, and I believe we'll make this work.

Beck: I believe you will, too, Dr. Brackmann! I remember when we were working on cochlear implant hardware and software right here at House some 20 years ago, and I cannot believe any of us thought cochlear implants would ever achieve the remarkable results we commonly see in 2005 via cochlear implantation. What about the Auditory Brainstem Implants (ABI) implanted in Italy? I read some very interesting news on that.

Brackmann: Dr. Coletti is a very good friend of ours, and he has implanted non-NF-II patients with the ABI in Italy. In his small series of preliminary trials, his patients have done remarkably well, similar to cochlear implant patients.

Beck: Dr. Brackmann, I know that things have changed since I had the honor of working with you and Dr. Bill House in the operating room, and I suspect that you have probably removed more acoustic neuromas than any other neurotologist on the world...So I have two questions...How many acoustics have you operated on, and is the translabyrinthine craniotomy (TLC) still the preferred approach to removing acoustic neuromas?

Brackmann: I really don't know the exact number, but I guess I've operated on about 3000 acoustics. Regarding the TLC approach, it is still common, but the middle fossa craniotomy (MFC) is used about 45 percent of the time here at "House." We've really fine-tuned this approach, and it can be used for most tumors smaller than 2 centimeters, depending on where the tumor is and what structures are involved. But the MFC approach has served us very well particularly with respect to hearing preservation. 60 percent of the people have their pure tone hearing preserved within about10 dB at their post-op test.

Beck: That is phenomenal Dr. Brackmann...I want to thank you for your time, your expertise and your friendship for the last 22 years...It is an honor to know you, and I thank you for sharing your time with me today.

Brackmann: Thanks Doug. It's always nice to spend time with you, too.


For More Information about the House Ear Clinic, visit www.houseearclinic.com
or follow the links from www.hei.org

Derald E. Brackmann, M.D.
Otologist/Neurotologist

Dr. Brackmann's practice at the House Clinic is limited to Otology and Neurotology, specializing in diseases of the ear, facial nerve, dizziness and acoustic neuromas. He has served as president of the majority of the societies of his specialty, including the American Academy of Otolaryngology Head & Neck Surgery, the American Neurotology Society, the American Otologic Society, the North American Skull Base Society and the International Skull Base Society. He is Clinical Professor of Otolaryngology Head and Neck Surgery and Neurosurgery at the Los Angeles County USC Medical Center.

Dr. Brackmann has received many awards, including Medical Alumnus of the Year at the University of Illinois, University of Illinois Alumni Achievement Award and the Award of Merit of the American Otologic Society. He is a member of numerous societies of his specialty and is also an honorary member of the Otolaryngology Society of Australia and the Royal Society of Medicine of England. In addition to authoring nearly 300 scientific articles and book chapters, he is the editor or co-editor of four textbooks and is a co-editor of yearly series entitled Advances in Otolaryngology Head and Neck Surgery.

Dr. Brackmann was born in a small town in central Illinois in 1937. His primary education was completed there prior to his family moving to Champaign, Illinois, where he graduated from High School in 1955. He then attended the University of Illinois for undergraduate training and graduated from the University of Illinois College of Medicine in 1962. After one year of internship and residency in Chicago, he was inducted into the United States Air Force, where he served as a flight surgeon from 1964 - 1966. Following completion of his military duty, he had residency training in Otolaryngology Head and Neck Surgery at the University of Southern California, Los Angeles County Medical Center in Los Angeles, completing that training in 1970. Following a clinical fellowship in Otology and Neurology at the House Ear Clinic and Institute, Dr. Brackmann joined the House Clinic, where he has been in practice until the present time.

Dr. Brackmann resides with his wife of forty-six years in South Pasadena, California. They have four sons: David, Douglas, Mark and Steven; and two grandchildren: Lauren and Nick. Recreational interests include hunting and fishing with his family and good friends.