Our 3,000 word article on Selecting a CI Surgeon where Best Practices are discussed has generated 1900 hits so far; and also quite a strong reaction in both the comments and on social media, prompting this addenda to clarify a few items.
► Some CI users and parents of CI kiddies wrote in wondering why their particular surgeon and/or program was not in the CI surgeons & programs we like&c. section. There are other surgeons who are also rather good; but they were not included because they either
- Didn’t follow Best Practices;
- Didn’t quite have that “touch” in their fingertips to thread the inch-long flexible electrode into the pea-sized hearing organ without wrecking the delicate structures inside;
- Did not provide outstanding pre- and/or post-op audiologic services.
Making the list entails adherence to Best Practices, excellent surgical skills including residual hearing preservation, and also management of the CI audiology program, as when all three are present, such as what you find at Vanderbilt, House, NYU, or UNC-Chapel Hill, or in OKC,1 you or your child will have the highest probability of an excellent outcome.
► Several people wrote about experiences at University of Miami almost simultaneously: Two were screaming because Dr Thomas Balkany was not on the list — He retired! — and one was complaining that a friend of hers was implanted by another surgeon at this facility with a bad outcome including debilitating vertigo. We need to remind our readers that success involves all three ingredients listed in the previous paragraph. [We also remind readers that Dr Balkany’s colleague Adrien Eshraghi is on our list. ~Edited 6/27/2016]
► 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 by David Haynes MD & his crew at Vanderbilt; and Effects of CI Electrode Insertion on Tinnitus 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;
► Several parents commented that their kids were on medical assistance and received good CI services. Although we are happy that the professionals did not discriminate against their children because of the poor Medicaid reimbursements, this is still a problem for the busy, underpaid, understaffed pediatric audiology departments at the typical “Children’s Hospital of [insert city name]” as it puts budgetary pressure on everyone.
► We admit we made somewhat of a mistake in terminology (since corrected) in the fifth item, namely booting up the implant, running a cleaning cycle, and impedance check: In fact, the interelectrode impedance test, also known as Electric Field Imaging (EFI) will detect folded electrodes. For the example we cited in the picture on the right, the impedance between electrodes 1 & 8, and 2 & 7 will be abnormally low. In addition, electrical faults (“short circuits”) of a certain pattern could also produce a similar EFI pattern to tip fold over: Such a collection of faults, although rarer than a fold over, would be another reason to explant and replace the device. Only the EFI will tell you, not the ECAP growth, nor pure impedance measures which can be volatile in surgery due to air bubbles and other anomalies. However, ECAP interaction functions maybe could see a folded electrode; but it involves excess time to perform these tests, more time than an X-ray; and in any event is still less accurate than radiographic imaging.
► During the six month editing and vetting process of our Selecting a Cochlear Implant Surgeon article, we added & removed several entries in the CI surgeons & programs we like&c. section:
- One otherwise-excellent pediatric surgeon at [Big Donor Name] Children’s Hospital was de-listed because she does not provide adequate supervision of the audiologists, resulting in spoilage of outcomes. This one particular audiology and CI program has numerous problems across the board, including improperly fit hearing aids, inability to manage ANSD, and poor quality CI MAPpings (and this last problem extends to this university’s adult CI program). The CI Surgeon is the “captain of the ship,” and hence held accountable for the outcomes; and at the centers described in these first two paragraphs, these otherwise-good surgeons have fallen down on the job;
- One excellent surgeon was de-listed because he forces pediatric patients to be managed and implanted at [Big City Name] Children’s Hospital, which has an abysmal history of diagnosing and managing ANSD bordering on malpractice (and we have the audiologic reports to document this). What’s more, this surgeon is not fully up to speed on ANSD, only implanting one ear, when the body of clinical evidence overwhelmingly supports bilateral implantation. Down the road we may put this surgeon on the list for adults only;
- Another program that was once one of the very best has markedly slipped since their top surgeon left two years ago [and sadly, unexpectedly passed away on April 26th ~Edited 6/26/2016]: None of their other surgeons are truly outstanding (but one sure talks a good line [and has since decamped for UCSF ~Edited 6/27/2016]); and more tellingly, their audiology services have rapidly fallen in quality, such as improperly using live speech testing for CI qualification evaluations; and also refusing to apply changes in ComPilot/Mic balance settings on a Naida Q70 speech processor to the patient’s Naida Q90 hearing aid. [When you work on an AB/Phonak or Cochlear/ReSound bimodal hearing system, if you’re in a CI center you need to be prepared to apply changes to both devices in the hearing system: Finish what you start and don’t leave the patient hanging!] What’s more, one young lady who was just implanted there is also a Masters of Public Health student at this same university, and has reported that the administration of the CI program is a tangled mess;
- One surgeon at a prominent clinic was de-listed because he “cherry-picks” only the easy patients who will have good outcomes (which they do) to pad his statistics; but when you’re at a world class clinic you take all comers, including difficult cases such as Mondini’s and common cavity; and we know of at least three instances where he turned down difficult pediatric cases. In addition, several years ago this surgeon needed to have a CSF shunt moved for a little girl to make room for the implant; but he failed to convey adequate information to the neurosurgeon: This girl was in agony for over five days after the shunt revision surgery, only to find out that there still was not enough room for the implant package. [Eventually, when a new, smaller implant was released & her head grew a bit, a CI surgeon was able to squeeze in a CI];
- One surgeon with 25+ years experience who was on our original list — And to whom we have referred quite a few people, including one personal friend from ALDA implanted just a couple of weeks ago — was pulled in the final edit as although he’s still rather good, his surgical skills have slipped a notch due to age. This gentleman is still the best one in the extended metro area encompassing two major cities an hour apart, but a surgeon who made the list is about four hours’ drive away. To his credit, this gentleman has recognized that it’s time to pass the torch and is training two neurotology fellows to continue in his footsteps. What’s more, he’s outstanding at diagnosing and managing Ménière’s Syndrome, and we hope he continues on for many years in this role. [6/27/2016: OK, for all who ask, it’s Dr Loren Bartels; and for people in the Tampa Bay – Orlando – Sarasota region who are tied by insurance from using Dr Adrien Eshraghi at UMiami, Dr Bartels and his CI program is still a very good substitute; and we reiterate he’s our “go-to guy” to send Meniere’s patients in Florida, south Georgia, and LA. ~Edited]
Our original article was primarily assembled to provide talking points when you meet with your surgeon so you can make informed choices for you or your child; and our CI surgeons & programs we like&c. section is merely a guide, and in fact over time we will probably add several names as we gather more information.