Interview with John Niparko MD, Director of Otology and Neuro-otology, Johns Hopkins Medical Center

AO/Beck: Hi Dr. Niparko. Thanks for talking time out of your busy schedule to speak with me today.

Niparko: Hi Dr. Beck, my pleasure.

AO/Beck: Why don't we start with a little bit about your professional background?

Niparko: Sure. I was born and raised in Michigan and I attended the University of Michigan for all of my professional training, including medical school and specialty and sub-specialty training in otolaryngology. I now direct the Division of Otology and Neurotology at Johns Hopkins.

AO/Beck: How long have you been at Johns Hopkins?

Niparko: It's been12 years now.

AO/Beck: Very good. What can you tell me about the changes in cochlear implants from 12 years ago, as compared to cochlear implants available in 2003?

Niparko: First of all, the number of patients receiving cochlear implants has increased dramatically. Johns Hopkins is similar to many others programs in that we implanted a few people in the late 1980's and early 1990's. In essence, we went from doing one per year in the late 1980's to doing about 130 per year now.

AO/Beck: Wow, that's really impressive growth! I assume the growth will continue, and I think your office must've been bombarded with inquiries after you implanted Ms. America (1995), Heather Whitestone-McCallum?

Niparko: Yes, the attention she received has been quite impressive. But then again, she is an extraordinary person who has achieved some pretty remarkable things in her life.

AO/Beck: Can you tell me the subjective characteristics of the patients you look for? I know what the FDA guidelines are, but I wonder -- are there characteristics which are common across the most successful patients?

Niparko: That's a great question. The key, I believe, in using a cochlear implant to gain useful access to speech and environmental sounds is an internal motivation that drives the individual to begin participating or to rejoin the hearing world fully. By that I mean, they need to have the emotional bond to the hearing world that allows them to go out and use the device on a daily basis to take chances, and to go into social situations. You know, work place situations, listening to music and other sorts of listening activities that really allow them to fully exercise the restored sensitivity that they have. We know that cochlear implants restore tremendous sensitivity on an average of at least 65 dB at most frequencies and probably even more in the very highest frequencies. But, as you know, and as your readership probably knows, sensitivity and effective listening are two different constructs. They are two entirely different biologic processes.

AO/Beck: Absolutely. I often refer to the difference between simple sound awareness, which is not at all simple, but is the most basic level of the perception of sound, versus discrimination or understanding. They are very different and the difference between them is vast and powerful.

Niparko: Yes, I agree. To cross the bridge from restored sound sensitivity to improved listening ability, to really have effective listening and understanding, I think often requires an emotional incentive. We believe that children in particular, but adults as well, require a motivated system of support around them. While a cochlear implant restores high sensitivity when it is in use, it doesn't cure deafness. Not only does the individual need to understand that, but the family and the professional community around the child need to understand that too.

AO/Beck: So you emphasize to your patients that aural rehabilitation, or learning to hear takes time and work. Hearing clearly is usually not an instantaneous result, even in the best of circumstances and even with the best patients and the best equipment?

Niparko: That is correct. Patience and practice are significant factors. Patients who are emotionally bound to doing their best, will likely do very well.

AO/Beck: Let's talk about that a little. Suppose we are talking about a 45-year-old, post-lingually deafened adult patient. What do you tell him/her about reasonable expectations with a cochlear implant?

Niparko: There are some models for individuals with acquired deafness available, and those models predict single word scores for speech understanding. I think that provides a helpful guideline as to whether or not an individual will receive substantial, moderate, minimal, or no open set speech understanding. Much of that prediction is based on their residual hearing and their length of deafness. Greater residual hearing and shorter durations of hearing loss would combine to predict higher levels of speech recognition with an implant. The anticipated outcome for every implanted patient is different and there are many factors to consider. However, I'd offer that if we allow a patient to go from a severe or profound hearing loss to what we might consider as being totally deaf in both ears, there may be an opportunity lost in terms of open set speech understanding with a cochlear implant. The suggestion being that if you maintain a combination of peripheral and central auditory function, allowing the individual to continue to appreciate speech and avoiding a total loss of that ability, you may have a better substrate for using the cochlear implant.

AO/Beck: I think that's well established through the literature as well. I'd like to switch topics a little to telephone use among cochlear implant patients. What do you tell patient's regarding anticipated phone use? I've heard about 70 to 80% of patients implanted today can expect to be able to use a phone. Of course, we can't predict which particular patient that would be, but in general, do those numbers seem to be about right?

Niparko: I think you're probably right. We certainly can't predict which patients will or won't use the phone. Although, I think there is a sense that the patient who is at a high level of probability for open set speech understanding will enjoy use of a telephone. First, Doug, let me just back up a little bit and say this is a very important question. We have found in our quality of life surveys of adults with cochlear implants, that having the ability to use the telephone, truly represents a watershed of sorts. If you're able to use the telephone, there is a level of overall quality of life benefit that is provided that is much higher by virtue of that link. Telephone use remains a very important part of modern society.

AO/Beck: I agree, despite instant messaging and the multitude of electronic text information exchange available, electronic communication is often devoid of emotion, and the telephone overcomes that obstacle. When you hear my voice and I hear your voice -- that makes a world of difference.

Niparko: Well, in general, I think most people have experienced the frustration of trying to negotiate a concern through email for example. That involves a level of subtle communication that just isn't as effectively conveyed through the written word, as an example.

AO/Beck: Absolutely! I'd like to get your thoughts on binaural cochlear implantation. Where are we and what is your reflection on that, and where ought we be heading?

Niparko: I believe we simply don't know the level of benefit provided by binaural intervention - beyond that of effective unilateral implantation. Early studies indicate that some patients clearly benefit, most patients get some limited benefit, and few show no benefit over unilateral implantation. Given this background, an aggressive approach is not appropriate, particularly given associated risks and costs. Until we can better characterize the anticipated benefit, whether there is substantial incremental benefit, I believe it should be withheld from mainstream clinical application. I would not consider moving forward on a large scale without better outcomes data based on well controlled, smaller cohorts. More research is needed.

AO/Beck: What are the primary pluses and minuses of cochlear implants, from the pateint's perspective? In other words, what do your patient's come back and tell you about? Imagine a patient follow-up office visit one year post-op, what are the primary things you anticipate they might tell you?

Niparko: Generally they tell me they wish they had been implanted earlier, and they report on many benefits in their quality of life experiences. I think it's safe to say that access to mid- and high-frequency phonemes is sort of a common denominator of benefit that patients report. So much of spoken English has been problematic for them because of their lack of access to closing consonant sounds that occur in that portion of the spectrum. Access to that information can be a real blessing for them.

AO/Beck: And that goes directly to word recognition or discrimination versus sound awareness, which we mentioned earlier?

Niparko: It does. And that introduces a whole host of opportunities for effective communication whether it's by open set mechanisms or whether it involves enhanced speech reading. It's also likely to involve better environmental access. By that, I mean the individual is feeling much more confident in their setting because they hear environmental sounds that have mid- and high-frequency representation. They now hear those sounds and they have a better idea of what is going on around them. For example on a simple level, it's almost routine that on the day of activation, and after leaving the clinic and driving home, most patients discover the blinker on the turn signal makes a sound -- and that's something they typically hadn't appreciated at all. It's a simple sort of thing but it suggests to you they now have a level of awareness of their location and environment and it can give a heightened sense of security.

AO/Beck: What is the single most common negative when patient's come back one year post-op? What do they wish could be different?

Niparko: Speech understanding in noise.

AO/Beck: Okay. Have you had any experience with FM systems in cochlear implants?

Niparko: Yes, I have.

AO/Beck: Can you describe that a little bit?

Niparko: Doug, I don't want to sound like I know much about hearing aid technology, because I really don't. But what I learned from going to AAA meetings and talking to people who work with hearing aids on a daily basis is that, while digital processing technology has now produced tangible benefits, for many, real leaps forward occurred due to more highly directional microphones and improved linkages with the sound source through FM transmission.

AO/Beck: That's correct.

Niparko: That technology is already showing a lot of promise with regard to improving speech in noise with cochlear implants as well.

AO/Beck: I'm excited about that too because I believe that handheld FM microphones and directional mics in cochlear implants are going to make a world of difference. It's going to be so much easier for the patients to understand spoken language because these technologies can actually reduce or eliminate reverberation and significantly reduce or eliminate environmental noise. In fact, I believe all the benefits of FM technology in hearing aids will probably be applicable to cochlear implants.

Niparko: I agree completely.

AO/Beck: I know you're pressed for time so I will let you run. But I really want to thank you for being so generous with your time and sharing your thoughts on cochlear implants. How can patients get in touch with you if they have questions?

Niparko: Our website is www.thelisteningcenter.com

For more information on cochlear implants, click here