Implantable Hearing Devices: What Clinicians Need to Know. An Interview with George Cire, AuD

Brian Taylor
Hi, everybody, welcome to another edition of This Week in Hearing. I’m Brian Taylor. And this week we’re going to talk about implantable Hearing Solutions. And our special guest today is Dr. George Cire, who’s clinical technical product, product manager for Cochlear Americas. Welcome, George, good to have you on our broadcast.

George Cire
All right, thank you, Brian. It’s good to see you again. I’m really happy to be here.

Brian Taylor
Yeah, I know you’ve, you’ve maybe been in the industry longer than me, which is a long time. So maybe you could tell us a little bit about your background and what you do at Cochlear America’s?

George Cire
Yeah, yeah, excellent. I have the dubious distinction of being an audiologist for 43 years. So that’s both a blessing and a curse, I think. So I’ve seen a lot of things been full time in the industry. I’ve spent a little over half of the time in industry or in the field. in clinical practice, I was heavily involved in medical audiology and working in a audiology practice. It was embedded in an ENT office down in South Texas for a number of years. I’ve also worked in children’s hospital and then the rest of my career I spent in industry, I was with a major hearing aid manufacturer for a couple of years. And then I joined Cochlear and been with Cochlear for about 16 years. And somewhere in between there. dabble a bit in private practice, have a lot of varied interests, but have been really, really happy during my tenure with Cochlear and learned a ton and been able to travel and do quite a bit in the implantable world. So that’s kind of where I am at this point in time. But yeah, it has given me a good perspective to see a lot of really cool things developed in the field over the 43 years that I’ve been doing this.

Brian Taylor
Right. And I know what piqued my interest was an article you were the lead author on in Hearing Review a month or two ago that talked about different types of implantable devices. So I thought, kind of as a lead in if anybody wanted to find that article. And so the Hearing Review published, was it a month or so ago?

George Cire
That’s correct. Yep. It was. No, I was just gonna say the article really was a was a collaborative effort with some of my colleagues in Europe, where we were looking at implantable devices that are in our portfolio here at Cochlear, and we reference this thing called the IROS database, which stands for Implantable Recipient Outcome Study. We are like a lot of companies looking at Big Data and collecting data. And the real goal of the article was to try to broach the whole idea of the topic of what the implantable landscape looked at. And the that article in that particular publication was really good because it’s our goal was to try to educate the broader hearing healthcare community about implantables. And to continue to put that out front and center because I think there’s some confusion and just misunderstanding or lack of understanding of what that’s all about, and how people in the general hearing healthcare community fit into that. And we’ll probably talk some about that today.

Brian Taylor
Yeah, no doubt about it. I think that I’m speaking just for myself, as a clinician five years ago, there’s a lot of a lot to know or a lot to learn about implantable solutions, it seems like they’re always evolving. So maybe a good jumping off point would be to talk about the three different types of implantable devices that you review in the article?

George Cire
Yeah, that’s excellent. Well, certainly we talk about bone anchored devices and bone anchored solutions. And we also talk about cochlear implants. And then the third category that we talk about is AMEI, or active vidler implants. Interestingly enough, that’s still an active category in the implantable space. Cochlear sort of dabbled in that for a while, we’ve never had a product that was approved in the United States, or reviewed by the FDA. But we’re a global organization. And of course, the products that are out in the global space, were in fact introduced and used clinically. And at this point in time, we included that data because it was in the IROS database, we included that in terms of its selection, but very much aren’t doing much in that area now. But that doesn’t mean that there’s not other players in that marketplace. And so largely across the three the bone anchor devices are typically osseo-integrated devices that work in the bone conduction space, and a lot of clinicians are familiar with that from having worked with bone conductive hearing aids at some point in their career. Active middle ear implants are really more aimed at working with straight sensory neural hearing loss and have some direct drive capability. There is a surgical component to them. The sound gets transduced Then the driver is either attached to the ossicular chain or to the, to the tympanic membrane in such a way that it drives the signal in though increased amplitude directly into the cochlea. And again, it’s aimed mostly at sensory neural losses. And of course, cochlear implants, which I think most people in our field have some general knowledge of. But that’s basically leveraging electrical hearing, or using a prosthetic device that can actually transduce signals and directly stimulate the spiral ganglion, and by that point, the auditory pathway into the brain to leverage that, and that’s clearly being used in severe and profound hearing losses. And that landscape has changed in terms of candidacy. So those are kind of the three buckets that we talked about in the article and what we’re working with here at Cochlear

Brian Taylor
right, I think what would really be interesting to our viewers would be to talk about candidacy requirements for each one. I think that a lot of clinicians out there routinely see patients that might be candidates for these three different types of devices. If you can maybe talk a little bit about candidates and requirements, maybe how they’ve changed over time.

George Cire
Sure. I think we’ll start with a bone conduction scenario, because when we’re dealing with either conductive or mixed conductive hearing losses where the air bone gap is greater than 30 dB. And there’s some contrary indication to the use of an acoustic type device like a standard hearing aid amplification system that uses an otoplastic or couples to the ear canal. The primary candidacy there is patients who can’t or won’t use those devices, because of the draining ears or lack of an ear canal, like in the case of a atresia or microtia. And by stimulating the bones in the skull and leveraging the bone conduction pathway, typically, a lot of those patients, particularly in that microtia atresia space have very normal functioning cochlea. And the idea is that if you can vibrate that pathway and move the signal beyond that, that you get a very efficient way to couple the acoustic amplification. In this case, it’s just enough to get through the bone and stimulate the the hair cells in their natural state. And that’s a big plus for that type of person. Now, we also work with mixed conductive losses where we can apply additional gain and overcome that and there’s some limitations, we actually our product portfolio will support up to 65 dB of sensorineural component or bone conduction reserve, if you will, across a variety of different sound processors and approaches. And so you need to consider that. And there’s some more detail that we can talk about in terms of that that’s available on our website, to look at the individual products that are there. And there’s also a subcategory in the bone anchored space where we can actually use bone conducted solutions to provide a contralateral routing of signal paradigm for single sided deafness where we actually have a non functional ear on one side and a perfectly normal cochlea on the other instead of routing the signal by wire or an RF signal, we can stimulate the skull and send a signal across the skull to the inner ear, that’s good on the opposite side. And that can be a real boon for people to lift that head shadow effect and allow them to be able to hear sounds in the head shadow and to get some general lateralization in hear better in noisy situations. So that’s, that’s the primary candidacy there. When we talk about cochlear implantation, I think a lot of audiologists who have been exposed to that. And if you’ve been around as long as I have, you remember that those products were typically only available for the deafest of the deaf individuals. I mean, we’re talking about people that had no measurable hearing or very corner audiorams. And I think that is evolved over time. And the criteria has loosened up a bit. But basically, cochlear implants are really good to consider when hearing aids just aren’t enough anymore. And we can talk more about some of the things that have been developed to kind of simplify that that matter. I think that for the average hearing healthcare practitioner who’s out there who’s not affiliated or embedded in a medical situation or formally tied to a surgical practice, it’s a little bit of a mystery to them, because they’re kind of outside that scope. And we’re trying to break those barriers down because we know that patients with that type of hearing loss do end up in that venue, especially our late-deafened adults and people who have been using acoustic amplification but because of diminishing their hearing or an advancement of their hearing loss over time, the hearing aids just aren’t doing the job anymore. And so to that end, cochlear implantation or leveraging that that electrical hearing can be a big boon and can actually provide some great greater outcomes. And then the active middle ear implant space is really again, not a space that we’re doing much with here in the United States. But those devices were really largely developed to kind of directly stimulate the ossicular chain, and therefore the cochlea. And use primarily in sensorineural hearing loss as kind of a hidden surrogate for a hearing aid, if you will. And there are that there were quite complicated there were some Cochlear’s interest in it was in a product we call it codax, which was really a micro motor that was used to really work with patients who’d had really advanced in stage your disease like otosclerosis where there had been quite a bit of erosion in stapedectomy had failed. And by placing the stimulator on the oval window, you could actually with a very wide dynamic range, stimulate the cochlea through vibration and get a really good hearing outcome. And so that was the primary focus on the commercial products that were out there in Europe were actually used a lot in that population. But again, we don’t talk much about that anymore. And it largely sort of suffered a lack of reimbursement, it was a complicated procedure, there are a lot of moving parts to it. So it’s still very much a work in progress. I can’t say that that won’t reemerge. But it’s certainly still out there.

Brian Taylor
Now, just to kind of talk on that a little bit, do you think that these middle ear implants will make a come back in the US so to speak, what’s your prognosis?

George Cire
I think it’s going to largely depend upon how we champion it in terms of reimbursement and how it fits into that right now, a lot of the third party payers view that is a very much an experimental procedure. It’s maybe somewhat overruled Rube Goldberg type of scenario, it’s a really complicated way, I like to say it’s sometimes killing a gnat with a nuclear warhead, you know, you’re going after things, but it’s using technology in a very unique way. And some of the players in the marketplace, including Cochlear, saw some really good results with that technology in terms of being directly being able to directly stimulate the cochlea. One of the things that runs in when you run into and you get in the moderate to severe hearing loss space is that the acoustic amplification that gets trapped between the medial end of the hearing aid and the tympanic membrane causes a lot of nonlinear vibration of the tympanic membrane. So some of the efficiency and high frequency resolution is lost. And by attaching something that vibrates the ossicular chain, for instance, and directly drives that acicular chain, you bypass those nonlinear things at a higher level of of amplitude improvement or amplification. And what the patient hears is a clear more crisp signal and gets better high frequency resolution, and therefore better quality hearing. And so I think given that we’ve seen some real promise there. I think that there could be a reemergence of that, but it’s going to have to there’s still some work to be done in that area. I believe.

Brian Taylor
It’s good to put it on clinicians radar.

George Cire
So yeah, absolutely. Yeah.

Brian Taylor
I wanted to circle back about a couple things. Actually, one, you mentioned using these devices, as a replacement for CROS hearing aids for single sided deafness. You know, every major hearing aid manufacturer has their own version of a CROS. I don’t know how many individuals out there use it. But if you could talk a little bit about why an implantable device could be a viable alternative to a CROS.

George Cire
Yeah, from my experience in working with that, and I’ve got a real strong interest in single sided deafness. I saw quite a few patients in my clinical career with that. One of the immediate cognitive disconnects when you start working with these patients is that they’ve got one good ear and they’ve got one ear that doesn’t function at all. And you’re talking to them about wearing a device behind both ears and you’re placing the transducer in the good ear and they’re looking at you’re going Why would you be… Can’t you just turn on my bad ear and I can go on with my life and, and so there is some expectation there. When we kind of moved into the single sided deafness arena with our Cochlear BAHA product portfolio, we were pretty successful, like convincing third party payers and Medicare that that was a viable option under prosthetic code. So we got reimbursement for that. And so there was a pretty good move, I think afoot that people were offering that because they knew that patients could get some relief or some third party reimbursement for that condition. But in a true sense, it’s it’s it’s an interesting process, because although patients want to be able to have really good localization and be able to have that normal binaural hearing system, you never get that with CROS and you never get that with a CROS hearing aid. And what I think is interesting is in the industry, a lot of manufacturers have really improved and upped their game with the technology and CROS and I think that’s really great. And that certainly offers a non surgical option for that. But at the end of the day, it’s still very much suffers from the fact that you know, you’re not going to get true localization you get some degree of lateralization in the real utility of a cross is to lift the head shadow effect and to try to help the patient in that regard. And when I see manufacturers of these devices, promote them and talk about them. And going, like AudiologyOnline for a continuing education courses where they talk about it. What surprises me is that they talk about single sided deafness. But when they show their case studies, what they’re really talking about are patients with asymmetrical hearing loss, meaning that they’ve got one year that’s not serviceable at all. And that’s where the microphone satellite lives. And then they use a hearing aid and the opposite ear, which routes the signal from the dead side, but also at the same time, amplifies. And in, when you look at that category, those devices and the manufacturers are really talking about asymmetrical unilateral hearing loss, or a combination of those two, and we don’t do that very well, in the bone anchored world, the bone anchored world is it works really well, as long as you’ve got a really pristine cochlea, on the opposite side, because you’re having to transmit that signal across the skull. So I’ve interviewed lots of patients, you’ve had life changing experiences by using this type of technology. And it makes sense to them, because it’s a device that’s fitted in implanted behind the ear, that doesn’t work for them. And they don’t wear anything at all. And they’re good here. And they like the cosmesis and the comfort and utility of that type of a situation and they get the benefit of the contralateral routing of signal paradigm to help them in that situation. So there’s a place for all of those things there. And I think clinicians are just challenged by the fact that they have to really talk to you and I think where we tend to fall into a hole sometimes is that we try to fit audiograms and not patients, you really have to talk to the patient and find out what the patient’s goals are, and what they’re really looking for, in terms of what their their hopes and aspirations are. And that helps guide the clinician to move them through this journey and show them what technologies are out there. So there’s a place for all of it there. I believe it’s quite exciting time.

Brian Taylor
Yeah, no doubt it’s good to that’s that’s a good review of sort of where a boning product might fall into someone’s toolbox in the clinic, so to speak. The other thing I wanted to circle back on talking about cochlear implants, focusing on older adults, maybe that were an acoustic devices for a long time. And you mentioned that the guidelines or the candidacy requirements have changed, I know that there’s something out there called the 60/60. criteria, 60/60 guidelines, from Dr. Zwolan from the University of Michigan, if you can maybe talk about those new criteria, I think it’s really important for clinicians to know about that, if they haven’t already heard,

George Cire
right, yeah, there’s kind of different criteria. And I would encourage the viewers here that if they want to look, every manufacturer, because their implant sort of has a different set of criteria based on their regulatory filings with the US Food and Drug Administration, so you have to kind of reference those things. But there are some generic things to consider as well. And I can point people to really good website www.cochlear.com/us/en/professionals. And there is a wealth of information there. And it talks about it. But in general, when we look at the criteria for that, you know, with adults 18 years and older, moderate to profound hearing loss in the ear that you’re going to implant is sort of what we look for, and less than or equal to 50% sentence recognition in the ear to be implanted and less than or equal to 60% in the opposite ear. And these are all best aided conditions. So that’s just for the the subset of adults 18 and older kids from 2 to 12. It’s the severe to profound sensorineural hearing loss in the ear to be implanted. And it’s less than or equal to 30% using the multi syllabic lexical neighborhood test, which is a pediatric type of test. And then there’s a whole category there from 9 to 22 months, where these are children that are identified typically at birth, with newborn hearing screening where they need to have a profound hearing loss. What Dr. Zwolan and her colleagues at Michigan did was tried to kind of distill this down they had, I think, in excess of 5000 patient records that they could look at because they’re very active, very large and well ingrained cochlear Implant Center and looked at the big data from all of their their criteria and tried to come up with a way to make sense and I think what’s really good and I would encourage the viewers here to read the article because Terry did a really nice job of talking about how they reviewed this but they came up with this 60/60 criteria or 60/60 rule, if you will, and it was really designed primarily to simplify how politicians and people in the general hearing healthcare space could could view this and it’s largely that you know that you get a 60 appearance on average are greater than or equal to 60 dB HL in the better hearing ear and less than or equal to 60% speech intelligibility in the year that you want to implant and These are not strict criteria for implantation, but strict criteria for the consideration of referral to a Cochlear Implant Center because that’s really what the next step is. If you’re a general hearing healthcare practitioner and you’re working primarily in acoustic amplification in your practice, and you encounter somebody or you’ve got somebody who you’ve been following for years, and they’re approaching this 60/60 scenario, they may be this doesn’t guarantee that they’re going to get implanted or even meet the criteria. But across the board, all the manufacturers have contributed to this minimum speech test battery, which is used as a cochlear implant evaluation tool. And what we want to be able to do is educate the wider hearing healthcare community to keep that in mind and use that 60/60 criteria as a way to be their guideposts to say, “Hey, Mr. Jones, Miss Jones, you may want to consider going and I can connect you to a Cochlear Implant Center, or a group that does these these types of evaluations to make sure that you are in fact a candidate and learn more about this technology.” And this is hopefully going to move the needle because we know that there’s quite a few people out there, especially in that adult population that haven’t really done anything and from the time that they identify hearing loss to the time that gets so bad that they actually go for an implant, it can be 7 to 10 years, and our data is really showing the earlier you get implanted. If you meet that criteria, the better off you are in terms of being able to develop the rehabilitative strategies to use electrical hearing in a very good way and have a good outcome.

Brian Taylor
I mean, I’ve seen in my own. In my own travels, the success people have had that have struggled with hearing aids for years that were severely profoundly impaired. And with an implant, how it changed was a game changer for them. And how many clinicians still don’t know that their patient who’s been wearing hearing aids for decades, may be a really excellent cochlear implant candidate. By the way, I don’t know if you can see that people can see this on the screen. But I know Cochlear has made the rounds in the trade publications because here’s a little advertorial for the guidelines in print what you know, said George, was an Audiology Today and Hearing Review in the last month, it’s good to see that kind of remind people with that criteria. New criteria is. I guess the next question I have for you is, if I’m a clinician somewhere, and maybe the nearest Cochlear Implant Center is, you know, two or three hour or more car ride away? How does the referral process work in that kind of a situation? If I have somebody that I think might be a candidate?

George Cire
Yeah, that’s been a big question, a good question. And one, that it’s always an issue, especially depending upon where you live in this, this wide, vast country of ours, because there is a higher density of centers on the east and west coast. And when you get kind of in the middle of the country, things kind of spread out a bit. We’ve been working really closely with private practice audiologist and other general healthcare, hearing healthcare practitioners to develop what we call the Cochlear Provider Network, which is kind of a localized group of folks to try to extend the reach of these larger centers. And we have a pretty comprehensive list right now that shows up on our find a clinic web page that is part of that professional link that I talked about earlier, where clinicians can go and plug in and find people as close as they they are to where your referral is to get evaluated. And we’re tying and trying to tie these centers to surgeons in that situation. So yeah, it does create that telemedicine and telehealth has helped to some degree. And what we’re trying to do, especially in the Cochlear Provider Network is where there’s interest, we’re actually training these hearing healthcare practitioners to actually be able to program and support programming. So maybe the patient does have to travel two to three or four hours to the center to have the implant done, but they may be able to get their follow up care once they’ve been activated, right there in a local area within an hour or so of themselves. So we’re working hard on that couple years really kind of taking the lead in that regard. And we we continue to try to build out and flesh out that type of a scenario for that very reason to try to give better access to the technology into the to the cochlear implants.

Brian Taylor
I mean, it’s an excellent program, I think because it shows that the local audiologist can still be involved in the process and absolutely rewarding for them. As well as a another revenue stream potentially for the practice that’s concerned about those things. But I wanted to circle back a little bit just maybe talk at a high level about outcomes associated with we’ll just keep it the adults with cochlear implants. What are some of the what’s what’s the data say around outcomes with an implant versus somebody that’s been wearing a hearing aid for a long time?

George Cire
Yeah, well, I think one of the things that happens is, is that when these patients get into this into this fence or get above the fence, that 60/60 guideline that Theresa talks about in her in her article and promotion of this consideration for referral and evaluation, these folks, at least from my experience, have been consumers of elect of hearing aids and can keep coming back. Remember, we used to see quite a few of those folks would come back every two or three years looking for the latest and greatest superpower hearing aid that might be able to help them and they struggled. And it wasn’t that they were not getting any benefit whatsoever. But they kept looking for more and more benefit what we’re seeing today, and I think what will surprise clinicians who haven’t been exposed to patients who’ve been post implanted, is that with with, with careful selection, these individuals are, you know, providing open set speech discrimination, they’re able to use the telephone where in the past, they just couldn’t even think about using the telephone. And we’re seeing, you know, good sentence recognition scores, are we curing deafness? By no stretch of the imagination is that the case I mean, even though we like to think of these things as bionic ears, they’re still prosthetic devices. And we’re still dealing with a damaged sensory organism there that that we’re not going to be able to completely correct for. But by leveraging electrical hearing, and being able to use it and doing things like the combination of acoustic and electric, or what we call EAS, in the ski slope type hearing losses. In that particular we see that happening with that general rule of thumb is is that when you start having deterioration of your hair cell function in your outer hair, and in the inner hair cells go south, the tuning curves and the ability to just brute force amplify that signal and get anything that’s meaningful into the copely and stimulate the nerve endings gets bypassed and a cochlear implant by directly stimulating the viable spiral ganglion cells in the modalias of the cochlea. And using really improved speech coding techniques and other kinds of things that have advanced over, you know, my tenure as an audiologist, patients are actually able to leverage and get that better hearing. And they’re actually able to do things. And then when you add a layer on top of that connectivity, with wireless, Bluetooth 2.4 GHz remote microphone technologies, these individuals are just amazed and it’s always so fulfilling to have them come back to you after you’ve made that referral. And find them just being profusely thankful for the referral and for the information because it becomes life changing for them because they tend to withdraw. And then with all the other stuff that we’re tying now into the potential for these hearing losses to just completely complicate and aggravate cognitive decline. cochlear implantation is in this population is something that I hope people will really take seriously, it’s not for everybody, it’s certainly not something we forced on anybody. But at the same time, we want to educate our group, and we want all hearing healthcare practitioners to use whatever we can put in their toolboxes. And even if they can’t be part of that implant process, they can be ancillary to it. And where we see really good cooperative work is when we’re dealing with patients who we’ve identified who get an implant in one ear, and then the local clinician in the provider network provides the bimodal acoustic amplification in the better hearing opposite here. And then you get a real win-win because the patient, they don’t lose the revenue stream or the care of the patient. And the patient is way better off for those types of scenarios.

Brian Taylor
Right. And I know with bi modal, since there’s data out there and show that people do well, with the Bimodal. I wanted to go back. And you mentioned one thing that I think was warrant, warrants a little bit further discussion that’s around this ski slope hearing loss, you referred to a hybrid, hybrid device, right? If you could talk just a little bit about that. Maybe what the criteria is how that differs from a conventional CI, that’d be great.

George Cire
Yeah, yeah, basically, what you’re doing in a hybrid cochlear implant is you’re dealing with a segment of this sound processor, which basically takes the microphone input and transducers the signal in an acoustic acoustic way just like a normal hearing aid would. And that’s typically bandpass in that low frequency range from maybe 125 Hz out to maybe as high as 1000 Hz. And then the remainder of the crossover is done in the very high frequencies. And what we see is that when you get these really steep high frequency, ski slope type losses, and you’re trying to amplify in the 4000, 6000 Hz range, and you’ve got 70, 80, 90 dB thresholds, you can drive acoustic signals all day long and it just seems to add distortion. And now we’ve had some success with frequency lowering. And I know that that’s been a popular, you know, adjunct to what acoustic hearing has been able to do. But we’re finding that the combination of combining in matching that acoustic signal in the low frequencies, and allowing for good perception of the, you know, the fine details of low frequency where you can actually appreciate music better and everything and then using the electrical part of the stimulation in that high bandpass to to be able to help with the speech and understanding that these patients do do quite well. And they get the they get the double effect, they not only hear community speech communication well, but they remark that they’re able to enjoy music, like they remember that they were able to do before and, and those kinds of things. And so, you know, typically you’ll see patients with that criteria, you know, with a credit expansion, and they’ll have sometimes as much as close to normal hearing and that low frequency domain with a really steeply sloping loss, kind of in the middle of that bandpass, around 60, 70, 80dB, 1000 – 1500 Hz and above. And those people are definitely candidates for that. And with newer surgical techniques, and better designed electrode arrays, the surgeons can place those electrode arrays in the cochlea and do it a traumatically in a way that won’t damage the fine structures in the cochlea, so that they can still get low frequency use of the acoustic part of that array, our acoustic coupler, and the electric part. So it’s an evolving science and technology that, that we’ve sort of, pioneered here and had early in my career coupler had some good opportunity to work with, with some of the original prototype devices. And given my experience in hearing aids, it was really, really interesting to work with that. So that’s still another option out there for individuals. So there’s all of that comes into play as you consider these options for folks.

Brian Taylor
And at the end of the day, it’s all about trying to optimize somebody’s residual hearing and one of these devices is appropriate. It’s great that to know that it’s available. Absolutely. Now that we’re kind of taking up a lot of your time, so I kind of wanted to wrap things up. You mentioned the website where people can find more information, maybe if you can mention that, again,

George Cire
I’d happy to it’s www.cochlear.com/us/en/professionals, and a simple pathway that I found when I was looking this stuff up is just a Google Cochlear Find a Clinic. And good search engine optimization puts that your number one or number two hit. And I think that anybody who wants to learn more about this can go there. There’s a professional sub page there that you can link to multiple articles, photographs, pictures, all kinds of things. And then obviously, a way to contact if you need further information, we do have a very active field force that can work. And we’re trying to do that we’re trying to do not only to look for people in the add to the provider network, but also provide some just general education to folks in hearing healthcare. So they know about these as options and can speak intelligently about them to their patients, as they encounter them, because these folks enter from all different venues and avenues. And we just want to heighten the awareness of what’s available there.

Brian Taylor
Right now, that’s good, good, good to know. And clinicians don’t have to be intimidated anymore by implantable devices, you made it much more accessible. I think by having that information by having that Cochlear Provider Network up and running. That’s all a really great information for people to know about. Okay, well, any any final words before we conclude?

George Cire
Now, I just wanted to thank you for for your interest. And, and I hope that folks got some benefit from the article that my colleagues and I put in the in the journal, just so that we could give further that knowledge base along in certainly happy to communicate and answer questions. I spend a fair amount of my world or my time in the bone anchored world, but across all of the products, we can certainly provide people with more information. And I would just encourage people to to consider these options for their patients and find who you’re comfortable working with and do it because there’s there’s a lot of good tools out there to access these days. It’s an exciting time.

Brian Taylor
Yep, no doubt. And that’s the for those of you we mentioned the article earlier was in August 2021 hearing review, you and your colleagues wrote that article about the three different types of implantable devices. So Dr. George Cire from Cochlear, audiologist thank you very much for spending some time with us. We really appreciate

George Cire
it. Thank you. I appreciate your time, Brian. Yep.

Brian Taylor
So long. Take care of George. Thank you