Interview with Peter Roland, M.D., Professor and Chairman, Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center
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Topic: Cochlear Implants 2005 - A Surgeon's View
Beck: Good morning Dr. Roland. It's a pleasure to speak with you. I want to congratulate you on the tremendous success of the CI-2005 meeting in Dallas this past spring. It was a remarkable meeting, and I was honored to attend.
Roland: Thanks Dr. Beck. We were honored to have you there.
Beck: Before we get to the topic at hand...Would you please tell me a little about your professional education and training?
Roland: Sure thing. I went to medical school at the University of Texas at Galveston and graduated in 1976. From 1976 to 1980 I was a resident in the department of otolaryngology at Pennsylvania State University at Hershey, and then I was at Bethesda Naval Hospital from 1980 to 1984. After that, I was very fortunate -- my otology and neurotology fellowship was done under Dr. Michael Glasscock.
Beck: That is a very impressive resume. Thanks for sharing that. So you were getting involved with cochlear implants just as the FDA was approving them and making them available for adults (1984)...What do you remember telling patients about cochlear implants back in those early days?
Roland: I recall telling patients they might be able to hear some environmental sounds, and they might also be able to hear the phone or the doorbell ringing, and they might expect that over a long period of time, the cochlear implant might help them speech read.
Beck: I remember telling patients pretty much the same thing 21 years ago. Times have changed! What do you tell cochlear implant candidates at this time?
Roland: If the patient is a post-lingually deafened adult, and if they have normal intelligence, and they are implanted within a year or two of becoming deaf, they'll likely do very well. I am very comfortable telling them they have a better than even chance of understanding conversational speech through their cochlear implant and the chance they'll be able to use the telephone is quite good, probably better than 50-60 percent.
Beck: What can you tell me about the surgery...is it quicker, or perhaps more efficient now?
Roland: Absolutely. When we started working with cochlear implants, the average surgery probably took 3 to 4 hours. In 2005, the average time is somewhere between 45 and 90 minutes. Another major change in the surgery is the incision we make now is 1 to maybe 2 inches, whereas 20 years ago we used incisions that were 6 to 7 or more inches...so we expose much less tissue.
Beck: And the complication rate? Has that changed?
Roland: Well, there were never really very high complication rates to speak of. Even in the early days, probably better than 90 percent were totally fine right out of the box - so to speak! At this time, across the nation, probably about 1 to 2 percent of the folks receiving cochlear implants have local infections or wound complications or other issues that need medical attention, but 99 percent are "complication free." Interestingly, most complications can be predicted ahead of time...folks with very thin skin, people diagnosed with diabetes, and other medical conditions are more likely to experience medical problems, than would a normally healthy person.
Beck: That makes perfect sense. Can you tell me anything about new cochlear implant technologies and options you're excited about?
Roland: I really enjoy working with and exploring the new hybrid technologies. These are the devices that use electro-acoustic stimulation in tandem....the low frequency sound is delivered through a hearing aid-like device, and the high frequencies are delivered through the cochlear implant's electrode. To my way of thinking, this has tremendous applicability to our patients with high frequency hearing loss, and I think the potential is tremendous.
Beck: Would the hybrid have a shorter electrode than the standard?
Roland: That's an excellent question, and we're all trying to work through that at this time. As you know Doug, the highest frequency receptor fibers are at the basal end of the cochlea, and so in theory, we don't need a full insertion to activate the high frequency fibers. Then again, there are other issues...such as, what if the patient loses more hearing and then they need the standard cochlear implant? If we remove a short electrode and insert a longer one, we double the chance of inducing surgical trauma to the inner ear secondary to having two surgeries. Then again, if we start by inserting a long electrode, when we only need a shorter one, we also risk damaging the low frequency hearing receptors of the inner ear while inserting the longer electrode, in an ear previously serviceable with a hearing aid. So, it's a great question, and a double-sided sword. And I am sure it'll be debated for quite a while...but we need to gather data and evaluate it scientifically to derive the best answer. But I can say, of the patients I have worked with, those who are wearing hybrids, do very well in cocktail party and other background noise situations, so that's a great apparent benefit, as it addresses one of the major difficulties these patients have to deal with.
Beck: Another controversial issue is the bilateral cochlear implant. Can you tell me your thoughts on that?
Roland: Well, that's another unresolved issue under ongoing exploration. I believe there are clear-cut advantages to binaural cochlear implantation, and I certainly would like to be able to offer those to children and their parents.
Beck: But the issue is multi-faceted....you have the cost issue, which is tough for individuals and their insurance companies, but you also have the issue of using both ears in a child, leaving no "untapped" ear for what might be available in 20 years.
Roland: Exactly right. That is the key point, and it's a difficult one because we know children will develop better speech and language with bilateral cochlear implants, and that is tremendously important...But, as you said, if we implant the second ear, what happens if there is a major development in 5 or 10 or 20 years, and the child is excluded from that new development because both ears have today's technology? That's an important consideration. And the other side of that coin is...what if we withhold the second implant, and the child goes through their formal education hearing monaurally, and not doing as well as we'd like, and then...what if there is no major change in 10 or 20 years? Then we've withheld treatment for what will in restrospect appear to be a very weak rationale.
Beck: I think that underlines the importance of leaving these decisions to the parents and the surgeons, not the insurance companies! I absolutely agree...the bilateral implants should be available for those that choose them, as long as the parents and patients are well informed, and they make the best decision for their unique situation.
Roland: I think so. That makes the most sense at this time.
Beck: Dr. Roland, it's been a pleasure. Thanks for your time today.
Roland: Dr. Beck, it's been fun. Let's do it again one of these days!
For more information on Advanced Bionics, www.bionicear.com
For more information on Cochlear Americas, www.cochlearamericas.com
For more information on the Department of Otolaryngology - Head and Neck Surgery, at the University of Texas Southwestern Medical Center, Dallas, Texas, www.utsouthwestern.edu/utsw/cda/dept28166/files/45897.html and
www.dcip.org
Roland: Thanks Dr. Beck. We were honored to have you there.
Beck: Before we get to the topic at hand...Would you please tell me a little about your professional education and training?
Roland: Sure thing. I went to medical school at the University of Texas at Galveston and graduated in 1976. From 1976 to 1980 I was a resident in the department of otolaryngology at Pennsylvania State University at Hershey, and then I was at Bethesda Naval Hospital from 1980 to 1984. After that, I was very fortunate -- my otology and neurotology fellowship was done under Dr. Michael Glasscock.
Beck: That is a very impressive resume. Thanks for sharing that. So you were getting involved with cochlear implants just as the FDA was approving them and making them available for adults (1984)...What do you remember telling patients about cochlear implants back in those early days?
Roland: I recall telling patients they might be able to hear some environmental sounds, and they might also be able to hear the phone or the doorbell ringing, and they might expect that over a long period of time, the cochlear implant might help them speech read.
Beck: I remember telling patients pretty much the same thing 21 years ago. Times have changed! What do you tell cochlear implant candidates at this time?
Roland: If the patient is a post-lingually deafened adult, and if they have normal intelligence, and they are implanted within a year or two of becoming deaf, they'll likely do very well. I am very comfortable telling them they have a better than even chance of understanding conversational speech through their cochlear implant and the chance they'll be able to use the telephone is quite good, probably better than 50-60 percent.
Beck: What can you tell me about the surgery...is it quicker, or perhaps more efficient now?
Roland: Absolutely. When we started working with cochlear implants, the average surgery probably took 3 to 4 hours. In 2005, the average time is somewhere between 45 and 90 minutes. Another major change in the surgery is the incision we make now is 1 to maybe 2 inches, whereas 20 years ago we used incisions that were 6 to 7 or more inches...so we expose much less tissue.
Beck: And the complication rate? Has that changed?
Roland: Well, there were never really very high complication rates to speak of. Even in the early days, probably better than 90 percent were totally fine right out of the box - so to speak! At this time, across the nation, probably about 1 to 2 percent of the folks receiving cochlear implants have local infections or wound complications or other issues that need medical attention, but 99 percent are "complication free." Interestingly, most complications can be predicted ahead of time...folks with very thin skin, people diagnosed with diabetes, and other medical conditions are more likely to experience medical problems, than would a normally healthy person.
Beck: That makes perfect sense. Can you tell me anything about new cochlear implant technologies and options you're excited about?
Roland: I really enjoy working with and exploring the new hybrid technologies. These are the devices that use electro-acoustic stimulation in tandem....the low frequency sound is delivered through a hearing aid-like device, and the high frequencies are delivered through the cochlear implant's electrode. To my way of thinking, this has tremendous applicability to our patients with high frequency hearing loss, and I think the potential is tremendous.
Beck: Would the hybrid have a shorter electrode than the standard?
Roland: That's an excellent question, and we're all trying to work through that at this time. As you know Doug, the highest frequency receptor fibers are at the basal end of the cochlea, and so in theory, we don't need a full insertion to activate the high frequency fibers. Then again, there are other issues...such as, what if the patient loses more hearing and then they need the standard cochlear implant? If we remove a short electrode and insert a longer one, we double the chance of inducing surgical trauma to the inner ear secondary to having two surgeries. Then again, if we start by inserting a long electrode, when we only need a shorter one, we also risk damaging the low frequency hearing receptors of the inner ear while inserting the longer electrode, in an ear previously serviceable with a hearing aid. So, it's a great question, and a double-sided sword. And I am sure it'll be debated for quite a while...but we need to gather data and evaluate it scientifically to derive the best answer. But I can say, of the patients I have worked with, those who are wearing hybrids, do very well in cocktail party and other background noise situations, so that's a great apparent benefit, as it addresses one of the major difficulties these patients have to deal with.
Beck: Another controversial issue is the bilateral cochlear implant. Can you tell me your thoughts on that?
Roland: Well, that's another unresolved issue under ongoing exploration. I believe there are clear-cut advantages to binaural cochlear implantation, and I certainly would like to be able to offer those to children and their parents.
Beck: But the issue is multi-faceted....you have the cost issue, which is tough for individuals and their insurance companies, but you also have the issue of using both ears in a child, leaving no "untapped" ear for what might be available in 20 years.
Roland: Exactly right. That is the key point, and it's a difficult one because we know children will develop better speech and language with bilateral cochlear implants, and that is tremendously important...But, as you said, if we implant the second ear, what happens if there is a major development in 5 or 10 or 20 years, and the child is excluded from that new development because both ears have today's technology? That's an important consideration. And the other side of that coin is...what if we withhold the second implant, and the child goes through their formal education hearing monaurally, and not doing as well as we'd like, and then...what if there is no major change in 10 or 20 years? Then we've withheld treatment for what will in restrospect appear to be a very weak rationale.
Beck: I think that underlines the importance of leaving these decisions to the parents and the surgeons, not the insurance companies! I absolutely agree...the bilateral implants should be available for those that choose them, as long as the parents and patients are well informed, and they make the best decision for their unique situation.
Roland: I think so. That makes the most sense at this time.
Beck: Dr. Roland, it's been a pleasure. Thanks for your time today.
Roland: Dr. Beck, it's been fun. Let's do it again one of these days!
For more information on Advanced Bionics, www.bionicear.com
For more information on Cochlear Americas, www.cochlearamericas.com
For more information on the Department of Otolaryngology - Head and Neck Surgery, at the University of Texas Southwestern Medical Center, Dallas, Texas, www.utsouthwestern.edu/utsw/cda/dept28166/files/45897.html and
www.dcip.org
