Brief Addenda to Selecting a Cochlear Implant Surgeon

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.

Electric Field Imaging will show abnormally low impedances between electrodes 1& 8, and 2 & 7.

Electric Field Imaging will show abnormally low impedances between electrodes 1& 8, and 2 & 7.

► 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.

Bootnote:

1) Dr Stanley Baker implants at Integris Health, and the CI’s are MAPped across the street at Hearts for Hearing. Dr Baker also implants at Surgery Center of Oklahoma.

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About the author

Dan Schwartz

Electrical Engineer, via Georgia Tech

16 Comments

  1. Andrea Wilson
    June 23, 2015 at 5:30 pm

    appreciate forthright content of article. First implant 2013 in Miami. Now live in different area of Florida. What about Orlando area or Tampa? None on this list. Really do not want to go back to Miami. I use AB.


  2. Jeffrey Simmons
    June 25, 2015 at 10:23 am

    Perhaps you could inform readers about which clinical software platforms for the FDA-approved implants allow one to do EFI during surgery? Also, can you elaborate why you feel it is important to do a “cleaning cycle” or what CI audiologists typically refer to as electrode conditioning? In your view, what is on a newly inserted array that needs to be cleaned off–or that could be cleaned off by running an electrode conditioning cycle? I’ve never observed any appreciable difference in the electrode impedance values recorded both before and after conditioning during the surgical insertion process. I’m curious about why you feel it is so important that you made particular mention of it when you omitted some other pertinent details in your instructions. Also, the CI audiologists on my team and I can run ECAP interaction functions (aka spread of excitation) on at least a couple of electrodes in about 5 minutes or less, and this can be initiated right after electrode array insertion. The flow of activity in the OR isn’t interrupted by our testing, and I would guess that we’re no faster than what could be done by the average clinician. Do you really consider that (5 minutes) an excessive amount of time? I would agree with you that an x-ray is more accurate when viewed by someone with expertise, but it is going to take more than 5 minutes for radiology technician to get themself and the equipment into the OR, capture the image, etc. I’m not arguing about the intraop x-ray being an ideal way to check on electrode array insertion, however, as I mentioned in my previous comment that is still in moderation, if you spent as much time and vetting on this as you say, shouldn’t all your facts be dead on and your information clear?


  3. A Not-Evil Reader
    June 28, 2015 at 8:30 am

    It seems like you coulda used an extra month of research and maybe someone better to do your vetting.


  4. Sue Biery
    June 28, 2015 at 5:38 pm

    I’m considering Johns Hopkins. Is that the hospital you are referring to about The top surgeon who left 2 years ago?


  5. Jack Morton
    June 10, 2016 at 6:51 pm

    I am considering who should do my cochlear implant – leading contender so far is Dr. Antonelli at Shands/ UF Medical Center – I hope you will by now know more about him and his work. He is several hours distant from me. For the right surgeon, and best result, that is not an issue. As I look at followup, and the audiologist support to learn what I need to learn to get the best outcome, the distance and travel time begin to factor in. Is it reasonable to have the surgery done one place, and the followup care managed at another? I am much closer to the Orlando area than to Gainesville, where Shands and Dr. Antonelli are. Which leads to another question – on average, how many visits would be required for followup care, over what time span, before those could taper off to occasional maintenance or troubleshooting issues?
    Thanks,


  6. Kendra Bowman
    April 29, 2017 at 12:07 am

    Hi, thank you for providing this candid window into CI surgery and surgeons. I am a candidate for CIs and have arranged for an evaluation with Dr Stan Baker. As a surgeon myself, I agree that one cannot overstate how important the role of individual skill plays in outcomes. Bedside manner, academic fame, number of publications- not important. Some of the most famous surgeons I know are terrible in the OR! So my question is this: if I decide to seek a second opinion and eval, and I if could travel anywhere, who would you recommend? Thanks so much. Your website is invaluable.


    • Dan Schwartz
      April 29, 2017 at 3:31 pm

      Kendra, congratulations on your deciding on getting `planted! Auscultation is always an issue, and to that end I recommend the AB HiRes 90k implant with the HiFocus V semi-curved array: It’s almost as tightly curved as the Helix array, but there is much less risk of piercing the basilar membrane, which will destroy residual hearing. Unlike the Med-El & Cochlear Nucleus arrays, the HiRes 90k with it’s independent current sources can be configured for 124 or even 128 channels, firing off the ends of the array.

      Med-El is decent, but many surgeons have difficulty threading their ultra-flexible array.

      As for insertion depth, due to the width of the scala tympani, it takes several more mm array length for a lateral placement than a perimodional placement; and also the tighter placement provides for a better stim, as it’s closer to the spiral ganglion dendrites.

      Since apparently you are in the OKC area, you’re lucky: Jace Wolfe at Hearts for Hearing is one of the very best CI audies in the country. He’s not seeing as many patients as before to focus on research, but he still practices some. He & Erin Schafer at UNT co-wrote Programming Cochlear Implants — The second edition (available here on Amazon) is much newer and better, and I owe Jace & Erin a review on it as well as the first edition, found here.

      As for surgeons for a second opinion, I recommend Tom Balkany at University of Miami: Although he handed off the scalpel to Adrien Eshraghi at the University of Miami, he publishes the CI Surgery Blog, which you should peruse. Also, the Institute offers online (as well as hands-on) CI surgeon training, which you may want to take.

      I also highly recommend you hop a plane to the Burbank airport and take a scheduled tour of the Advanced Bionics factory. Let them know you’re a surgeon, and they’ll tailor it to your knowledge base.

      As for selecting the surgeon, I personally would use any on our list.


  7. Donna Kim
    August 6, 2017 at 10:33 pm

    My mother had a consult with Dr. Michael Novak at Carle Clinic and was recommended to have bilateral CI during the same surgery.
    I see that your addendum states that a few Drs have been deleted from the original list
    (from where I found Dr. Novak’s name). Is he still on the list of recommended surgeons?
    Also what are surgeons’ and patients’ opinion of bilateral implants during the same surgery?


  8. Ramachandran
    October 15, 2017 at 12:35 pm

    I am male age 61 want to implant for my right ear,I live in India and my question is who is the best cochlear implant surgeon in the world and pls kindly provide his contact address.


    • Dan Schwartz
      October 15, 2017 at 2:21 pm

      Any of the surgeons on this list is very good; and I would use any of them myself.


  9. LAM
    June 15, 2018 at 11:33 pm

    Help please! I’m scheduled for CI surgery at Johns Hopkins in a month! Should I go somewhere else in Maryland/Va/DC?


    • Dan Schwartz
      June 16, 2018 at 12:23 pm

      Johns Hopkins was once one of the top 3 CI programs in the country when Dr John Niparko headed it, as he recognized as since he was “captain of the ship” he made sure all of the elements of the program worked together for great results. However, about five years ago, he decamped for USC-Keck (and he unexpectedly died two years ago); and since then, the Hopkins CI program has gone markedly downhill.

      We are in the process of revising our CI program article, which takes months. However, we will be removing one program in Illinois as the surgeon retired and the replacement is not capable of preserving residual hearing; and we are adding Dr Daniel Coelho at Virginia Commonwealth (among others) to the list. I would recommend that program to you.


  10. Melanie Korndorffer
    July 31, 2018 at 1:33 pm

    My mother who is in her early 80s was tested at UAB and a was found to be a cochlear implant candidate. We have no family there to help her with the many visits back to the audiologist, and she is particularly terrible with technology. My sister lives in Atlanta, so we thought this would be a good option for her. She does have some residual hearing and no symptoms of tinnitus. Is there anyone in Atlanta, now in 2018, that you would recommend and what device do they use?


    • Dan Schwartz
      July 31, 2018 at 6:55 pm

      Melanie, we do not recommend any of the CI programs in Atlanta: Instead, we highly recommend the outstanding CI program at Vanderbilt’s Bill Wilkerson Center in Nashville. As I wrote in Selecting A Cochlear Implant Surgeon:

      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.


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