Cochlear Implants from Consultation to Activation: Navigating the CI Surgeon-Hearing Care Provider Relationship

Hello and welcome to another episode of This Week in Hearing. I’m your host, Brian Taylor. And this week our topic is cochlear implants and the hearing healthcare professional’s relationship with the cochlear implant surgeon and the broader otolaryngology community. And joining us today is Dr. Kevin Zhan, who’s the assistant professor of otolaryngology and director of the Northwestern Medicine Cochlear Implant Program, which is based in Chicago. So welcome to this week in hearing. Dr. Zhan, it’s great to have you. Thank you so much for having me. It’s a real privilege to be here and talk to you. Well, we’re lucky to have you on our show this week. I think my first question before we talk about cochlear implants in general is if you could give us an idea about your training, your experience, how you got involved in cochlear implants. Yeah, sure. So I went to medical school at the University of Virginia and then I did a research fellowship at the medical University of South Carolina. I did my residency training at Ohio State University the Ohio State University in Columbus. And really it was there where I started to really start to feel connection towards otology neurotology and just kind of how rewarding taking care of patients with hearing losses can be. And then I did a fellowship in otology neurotology at Washu and St. Louis for two years. And then now I’m here at Northwestern and I also practice at Lurie Children’s Hospital too. Excellent. And tell us about your experience with cochlear implants. Yeah, so it, it’s something I’m really passionate about cochlear implantation. You know, I remember early on when I was a, When I was an intern in residency you know, I remember meeting a young girl in, in the peds clinic. And I had no idea why she was there. I was just sort of interviewing her and I walked out of there asking the nurses, like, why. Why is she seeing us today? And she was just so lively. She was very, you know she talked about her school and she was just. She wasn’t a fun person to talk to. And the nurses told me she was there for, to fill out her disability paperwork. And I remember thinking, what on earth? Like, what disability does she have? And she said and then, you know, come to find out later on that she had been implanted with cochlear implants while she was pretty young. So she had developed normal, normal speech and language. And And it was wonderful. And I saw. I became really intrigued early on and I was very grateful to have mentors in residency and fellowship that are also very passionate about cochlear implantation. And so it’s something that I’ve just sort of throughout my career my, you know, early on that I’ve been really, really interest. But also just the whole gamut of otology, neurotology and everything else in taking care of your problems essentially. Well, let’s talk a little bit about the relationship process between cochlear implant surgeons like yourself and the larger hearing healthcare community. I guess one question I have is what sorts of activities do you do in the community to try to build relationships with hearing care professionals? Yeah, I think it starts at all levels. You know, I, I’m just upon about getting. Getting to about you know, a year and a half to almost two years into practice. And And so I’ve. I’ve really tried to connect with. With people on multiple different levels even as. As early on as really trying to get our Northwestern University audiology students engaged and And giving them like some lectures as well as having them in my clinic and in the operating room to get them excited about, you know, what it is that we do to also just you know, go to local society meetings for audiology and hearing care providers networking there. Ive done plenty of sort of direct outreach messaging people and using industry connections as well. Really? How? You know, working with industry to build connections as well you know, with. For cochlear implants but also really just for hearing care of all kinds. Right. I mean while cochlear implants are certainly a big part of what I do, but really trying to take care of patients of all kinds that have hearing problems is. Is. Is the. The main reason why I do this. And then you know, even you know, networking through industry I talked about. And then also you know, sometimes even on social media and LinkedIn people have connected with people as well. And so I just. I think just sort of the Just trying to outreach on numerous different levels. Excellent. One question I’m kind of curious about is I’d like to kind of. Let’s focus on cochlear implants in the adult population. Whats your experience been as far as the Process of referrals from audiologists and hearing instrument specialists to your clinic for a couple possible cochlear implant candidates. Yeah, it’s something that I rely entirely upon. Right. And so I think when we look at a lot of reasons why not enough cochlear implants are being performed in this country. You know, in the Chicagoland area alone, there are estimated about 30,000 candidates. Right. So that’s an enormous number and that’s a pretty conservative measure as well. And so it’s really incumbent upon clinics to create these connections with hearing care providers in the community. Right. Because they’re the ones taking care of all these hearing loss patients. And so it’s important for us to network and to work with each other and sort of get to know each other so that we can deliver the best care possible. I mean, you know, I would say at least half right now of all of my cochlear implant referrals are coming from the community. So audiologists, hearing care specialists, or hearing disorder specialists. And it just takes finding the right people and people that are motivated to help their patients and they’ll make those referrals. So it’s been a wonderful relationship so far. That reminds me can you remind our viewers what’s the criteria for somebody, an adult what’s the criteria for them to maybe to have to be a consider to go through the process of cochlear implant evaluation? Yeah, so there’s a couple of different referral criteria, sort of mnemonics out there. You know, I think to, to, to speak very broadly, it’s, it’s important for everybody to remember that really cochlear implant referral candidacy has changed dramatically in the last five years. I think one of the big ones is the fact that the FDA now approves a single sided deafness as, as an indication for cochlear implantation. So patients, you know, with that had a sudden hearing loss or even patients that have in the past have non growing vestibular schwannomas, we would never consider or it would be difficult to get them to be approved for cochlear implantation. But now we’re having those conversations. We’re finding that we’re finding a lot of success with implanting these patients. So that’s one sort of expanded criteria on that. But specifically for your question, I think what you’re asking is audiometric criteria in that ear itself. And I would say you know, a very common one is, is the 60, 60 criteria which is if, if the ear that you know, if the ear in question, if the pure tone average is greater than 60 decibels and the word recognition scores are below 60% in that year, then that’s somebody that might be a cochlear implant candidate. Some other clinics use even simpler criteria, just simply less than 50% word recognition score you know, on an audiogram as possible referral criteria. These aren’t perfect. You know, they’re not 100% sensitive nor a hundred percent specific but they’re a good starting point. But I would say if you have a patient, if you’re a hearing care provider, if you have a patient who you know you fit appropriately with a hearing aid and they’re still not getting a lot of good clarity and they’re still struggling with their hearing aids, then that, that’s, that’s you know, that’s the demographic right there of who we should be thinking about for a cochlear implant. You know, when it comes to single sided deafness you know, somebody who’s already tried a cross hearing aid and they’re still looking for another option potentially. Those are also very easy referrals to consider for, for referring to see if they’re a candidate for a cochlear implant. That’s good to know. So let’s take it to the next step then. Lets say that a hearing care provider is working with a patient that you just described that meets this criteria for referral. Talk to us about that process of how they should interact with you or one of your colleagues. Yeah, I think this is going to be well for I can certainly answer for me specifically and our colleagues you know a lot of these a lot of the providers in the community have my cell phone number, they have my email they know especially once they’ve gotten permission from their patients, they know they can reach out to me with their contact information and I can have our schedule them so that it’s a little bit easier on that patient. They don’t have to worry about calling in and you know, being told that it might be six to seven months from now or something like that, something crazy like that, that they can be seen. Which is, was simply not true. So I think I think it depends on which clinic you’re trying to reach. But I know that there are certain having trying to Navigate. I think a lot of large health systems, you know, you might be told it might be a really, really long time from now before you can be seen. And sometimes you can even be scheduled inappropriately. So that’s why I think the, the, the, the personal connection, those professional connections are so important because it’s not hard for me to add on a clinic, add on a patient to my clinic especially when they’ve come in with an audiogram, for example, from, from a hearing care provider. It’s very, very easy actually to do that. And so so I think that’s one of the biggest frustrations for referring providers you know, audiologists, hearing care professionals because they’re like, all right, we’ll go see an ENT and then their patient’s told it’s going to be, you know, half a year before they can be seen. Free, you know, even if it’s a sudden hearing loss or something like that, God forbid. Right. So, so I think it’s important for, for, for the people I work with, they all know they have my direct contact information so that if they need somebody to be seen, you know, urgently, like a sudden hearing loss or a vestibular schwannoma or something like that, or, you know, they can, they can get in touch with me fairly quickly. So are you talking about audiologists that are within the Northwestern system, or are you talking about audiologists just in the general Chicagoland area that would know you? In the Chicagoland area. I mean, all the audiologists here, regardless of what system they’re in, I try to make it, you know, I try to be as accessible as possible. Thats from. That’s what I want to talk to you about is what have you done to make yourself more accessible, I guess, is the question. I mean, I think it’s, it’s those things, right? I think, you know it’s first of all, yeah, just, just being available, you know, having, having sharing my email information and, and you know, cell phone information, I think I feel very comfortable doing that. I think patient, you know, our, the, the, the providers I work with really appreciate that they can get in touch with me and, and if they have questions whether this person you know, needs to be seen or not, you know, they can always ask and you know, you know and so, so that I can just be, you know, a resource for them. Right? That, you know, this is, of course, you know, some of what I do is with cochlear implantation, but obviously there’s a whole bunch of other things that can affect their patients severely. Impacted wax, you know, asymmetrical hearing loss, needing, you know you know, medical clearance. Those are all things that if they can get their patients seen quicker, right. Then they can go back to those providers for their hearing amplification if indicated. So that those patients can be taken care of better and quicker. Right. So I think there’s all these enormous barriers when it comes to large health systems and sometimes even smaller clinics too. But but there are ways around it and to navigate you know, those patients in much quicker than. Than you know if they were to do it themselves. It sounds like you made your. Made it a, a point of emphasis that you’re reaching out to the hearing care community, the audiology community. Like have you spoken at meetings or is this mainly through social media? I’m just kind of curious to know how you’ve raised awareness about your own practice. You know, in my. So in the Chicagoland area you know especially being a new provider in a very saturated market. 1 of the I found out very quickly that a lot of hearing care providers in their clinics did not have a great sort of, you know direct connection with a particular surgeon. Right. And so you know, they. Many times I would receive an email back or something. It’s like you’re the first surgeon that’s ever reached out to me in my 10 years of practice as an audiologist or something like that. And so I, I noticed that pretty early on. And so I made a point to, to really be available and to. To meet these providers where they are. And you know, we have a local Chicago, Illinois Academy of Audiology. Their, their meeting is, is in Naperville every year. So I’ve given talks there. You know later this year I’m giving a talk to the. At the IHS meeting in September to a lot of hearing instrument specialists. So you know, these kind of things I think. And again, you know, we talked about visiting with audiology students in the Northwestern University Audiology School sort of at various different levels. There’s ways in which we can, we can communicate and network. Great. So you mentioned barriers a few minutes ago kind of within the health system. I think we’re all sort of familiar with that. But are there any other barriers that are common that get in the way or impede the relationship between hearing care providers and surgeons? Yeah, I think, you know, I think one of the biggest barriers is, you know, the possibility that you know, if they refer somebody for medical or surgical care, that they’re going to somehow lose that patient. Right. And so that is something that I’m very, very explicit about and very upfront about that. You know, after I see this patient, if simply just need continued amplification of any kind, then we. We send them back, right? We’re. This is at least, you know, this is how we care ourselves, and this is how we value our professional relationships with our referring providers. So I think being really upfront with that, you know, is. Is very helpful because I think that is one considerable barrier. Right. People don’t want to lose their patients to some other clinic and then never hear from them again. Right. And so. You know, I always tell my referring providers that I’ll send you. A note with my clinic visit, I’ll. Fax you a note and you know with what I think, and certainly. If there’s more discussion to be had, I’ll call you or I’ll text you. Or something like that to let you know, keep you in the loop. And I think people certainly appreciate that. I certainly appreciate that when I refer to somebody else and they, and they do the same for me, you know, about patients that I send away. So I think that is one barrier, but I think that can also be easily addressed. Lets talk about on the flip side. What are the benefits of a really close or effective relationship between the CI surgeon and same epidemiologist? Benefit from? Yeah, I mean it’s such a wonderful, I mean listen, we’re all in this to help patients with ear and hearing problems, right? And I think in rapid communication. And good communication is the key to. You know getting patients seen by both providers. Right. And this is such a multidisciplinary field. It’s incumbent upon us to really work together and work together well, you know from a medical insertable side, obviously, you know, I can get patients in that need to be seen urgently, you know, very quickly into my clinic. But also, you know, at the same time you know these are, you know, I work with some outstanding. Providers that also provide for example tinnitus. Retraining therapy and you know. Hyperacusis therapy and misophonia care. And, and, and I rely on them to help take care of the patients that I, I don’t know how to manage very well. And so you know, some providers also, you know, at Northwestern we don’t accept third party insurance for hearing aids. And so we need patients, you know, it’s, it’s amazing to have really good connections so that we can send those patients to providers that I know I can trust that accept those insurance benefits to take care of those patients. So it’s, it’s a definitely a two way relationship and and there are, you know, and so I mean it’s. But like in the realm of cochlear implants, for example, you know, that’s a patient that keeps coming back to you as a hearing care professional and you know, they’re still unhappy with their hearing aids and you know, you’ve done the best you possibly can do and it can be frustrating for both the patient and the, and the provider. Right. So, you know, if we get them their cochlear implant, they’re hearing better. You know, that’s a, that’s a that’s just another person that’s. That’S helped and somebody else new that. Can see that provider as well instead of having to sort of deal with the same frustrations over and over again because you’re sort of at your limit of what you can do. So. Exactly what advice would you give to a hearing care professional who’s looking to build a stronger relationship with a CI surgeon? Yeah, I think, you know, one of the things that So first of all the advice is. That there are these sort of barriers that exist, especially with major health systems. But it doesn’t have to be that way. And so, you know, it can, you know, it goes both directions. Right. You know, I, I can certainly reach out to hearing care professionals and vice versa as well. Because ultimately it leads to faster and more efficient and better patient care. Right. And so, so that’s, that’s one thing that, that is there, there. Are barriers in place when it comes to scheduling. And we’ve all sort of experienced this. As patients ourselves when we’re trying to schedule a visit. And it can be kind of challenging. Unless, you know, somebody, you know, in that health system or something like that that can get you in quicker. And so it doesn’t have to be that way. Right. So that’s, that’s sort of issue number one. But I always, you know, like when we talk to young surgeons. As well, who are just starting to. Build their practice, like, like me, for example while I am very, very motivated and passionate about cochlear implant care, you don’t, I mean, these kind of relationships, these kind of professional relationships are beneficial even if you aren’t as passionate as I am about cochlear implant care. Right. Because these are ultimately patients with hearing loss problems. And you know, I, I have had multiple patients come in from audiologists and hearing care providers that had the CIB schwannomas and otosclerosis and you know, bad draining ears and, or severely impacted wax. And you know, all sorts of stuff. That help to, you know, those are patients that need medical and surgical care in addition to, you know cochlear implants, for example. So this is really sort of the fundamentals of building a practice for both parties. And I think it really, it just, at least it just it’s just so helpful to have these relationships going forward. Another question I have kind of along the same lines I’m curious to know how does early inter. And how does early involvement of the audiologist in the treatment plan? How does that impact surgical outcomes? Yeah, so it’s extremely, extremely important. Right. So, I mean you know I mean, pretty much if you want to be seen in my clinic, almost. Everybody needs to have a hearing test. For for, for what I provide, for the kind of care I provide. And so if you, you know, you already come in with a hearing test that just gets you in quicker. Right? Because sometimes we’re limited with how many hearing tests we can do in a day. Or, you know, our audiologists are also doing other things. And if I need an add on audio or something like that at. The last second, it may not be possible. So, so for, for someone who’s already had that done and you know My referring providers, they, they know when to refer patients and what’s appropriate, you. Know, and, and so their involvement early, they, they’ve already done all the hard work, you know, and, and now it’s my job to, to sort of take, you know you know, to. Take the baton and then, and to. Move on to the next step of, of medical or surgical care. So they’re already, you know their early involvement is the first step of. Of all of this care. And, and a lot of times it can, it can get patients in a lot quicker testing information they need, or at least a key and critical piece of it. Which you know, the limitation might be on our end in terms of our, you know, Booth space availability and a number of diagnostic audiograms we can. Perform in a day. So again, it’s really helpful when all of this is already in place and, you know, a lot. I have also other audiologists I’ve worked with that, you know, they have been, you know, they have been working on their patients for months or years trying to talk them into getting a cochlear implant because they know how much it would help them. And so it’s all of that effort, it’s all of that work that they’ve done with their own patients and their relationship with their patients. That’s really made my job so much. Easier when they come to me. Right. And so I really value them and cherish that. I have two questions, two follow up questions that stem from what you just said. The first is what specifically now we can get a little weeds in audiology here. When somebody comes in with with an audiogram. What specific tests are you looking for? Like I’m, I’m, I. Obviously pure tones. But like what speed test do you look for? What do you say? Oh, I don’t have it here. I gotta get this done while they’re in the office and try to work them in. Yeah, So I would say basics Of stuff that I need. And I think any, any, any ent provider, otologist, neurotologist would, would, would probably need or basic pure tonometry, you know, pure tone audiometry, speech speech audiometry, speech information, speech testing and then tympanometry and and then also for me personally I only need reflex, acoustic reflexes only when someone has a conductive hearing loss and they have a normal tympanogram. That’s pretty much the only time I ever need acoustic reflexes. And really what I’m looking for. Right. Is otosclerosis versus superior canal dehiscence. I don’t really use acoustic reflexes in the setting of asymmetrical hearing loss or those kind of things. That’s my personal practice preference. You know, a lot of these patients are within a significant asymmetry, are getting an MRI anyway and that’s a lot more effective than acoustics reflexes. Exactly. Makes sense. That makes sense. And my second question is what in what advice would you give an audiologist who’s trying to persuade a patient to come in to get a CI evaluation? What should they say to the person to motivate them into action? Yeah, I mean, I think. Well, so that’s a really great question. I think where this comes from is how comfortable that audiologist already feels about the counseling. Right. And so I think if you are an audiologist and you’ve been in practice for many, many, many years and. You’Re not sort of up to date. On the counseling, then it’s going to be tough. Right. Like this is they don’t perform surgery like they don’t perform these, you know, procedures. And it might be kind of, you know, it might be tough to talk about, oh, the procedure is this from that or it’s, you know, but. The truth is cochlear implant surgery is. Now so standardized and it’s so consistent across surgeons I believe, you know, especially high volume surgeons that you can pretty much say there are there at least when I work with referring providers, I Tell them, please feel free to say these things. Right? Things like this is generally, this is outpatient surgery takes about, you know, an hour, an hour and a half to do under general anesthesia. Typically you know, it’s a small incision behind the ear. You know, because the majority of patients, I think, or a lot of patients are just terrified of the procedure itself. Right? Like this is a big surgery. I think if you use phrases like the surgeon’s gonna drill a hole in your skull, right. Like that’s not gonna, that nobody wants to hear that, nobody wants to do that. Right. And so. Or if they’re told that brain surgery, it’s near the brain. Right. Those are in my opinion, misinformation. Right. Because this has nothing to do with the brain. And so I think it just. Comes down to how the counseling might be if the surgery itself is the primary reason why they’re afraid of going in for evaluation. Right. If we’re talking about audiometric criteria and those kind of things, I think again, some of the counseling too. And how much they already are aware. You know, nowadays we are implanting patients with almost normal, sometimes normal low frequency hearing and just precipitously dropping high frequency hearing or middle and high frequency hearing with poor speech discrimination. But those are candidates, those are actually excellent candidates. Right. You don’t have to be no response on everything anymore to be a candidate for a cochlear implant. You don’t have to be so completely deaf. Obviously knowing that you can be one sided deaf and, and, or you know, with significant hearing loss and be a candidate for cochlear implant. It’s just, it, it’s just a lot of, I think education. And and, and the ones that have, are pretty up to date with everything and feel comfortable saying some of these things that I’ve talked about. I I think it’s probably easier for them to, to, to get their patients to come in. You know, again, just, you know. And then also now we’re, we’re finding. That, you know, there are, there’s really. No age limit too really as far as the upper, upper end is concerned. I mean we’ve had great success with people in their 80s, 90s even, you know, people that are, just have a vigor for life and are, and are healthy and just want to hear better and communicate better with their, with their loved ones and family and, and friends. They’re, if they’re, you know, healthy enough. For a brief general anesthesia, they’re Going to be fine. Right. So but these are sort of new, newer, depending on, you know, how out of the game you are or something. You know, newer concepts. And it just. It’s just, you know, it’s important for us in the cochlear implant community to. To spread the word and educate on how we’re doing things now. Well, I see our time is winding down. Any final thoughts? Any other advice that you’d want to share with possible CI candidates? With audiologists, with hearing care providers? Yeah, I think, you know I mean. I mean, obviously bias. Right. I think cochlear implants are amazing that we can, you know, restore hearing to patients that have lost it. But remember, just going in for an evaluation doesn’t mean you’re getting surgery. Right? This is ultimately the boss is the patient, and it’s their decision. I think having the evaluation is really helpful just to sort of quantify. How good or bad you’re currently hearing. And while we don’t have a. Magic wand or to be able to. Or crystal ball, to be able to. Predict how well you’re going to do with a cochlear implant. Right. We can at least provide some averages. And if you are way, way, way. Below average already starting out, then you. Might be a really good candidate for a cochlear implant. Because even if you get just average scores, you’re doing a lot better than you currently are. I think when it comes to sort of what we’ve talked about in the first half of this is relationship building and professional networks, I think this, you know, working together in this way and being, you know, having good communication and reaching out can. Be so, so rewarding for you as an individual and provider, but also certainly for your patients. And I know that’s certainly been the case for me in my practice. And how it’s grown. And so you know, the worst thing that can happen is they, you know, someone says no. Right. So So So I think it’s just been rewarding to. To reach out and do this outreach and get to know the, you know, the community providers. So. Great. Do you have a website or some other place that you would direct people to if they wanted more information about your practice or Northwestern’s implant program in general? Yeah. So our cochlear implant, or our Northwestern Medicine cochlear implant website is is. Is nm.org backslash cochlear implants with an S so that’s a nice link for, for them, you know, and obviously, you know, if you Google my name, you can find me in, you know, with Northwestern especially. Then you can find me if you’re in the Chicagoland area. Excellent. And we’ll post that on the, on the bottom of the screen, too. So thank you very much, Dr. Kevin Zahn, assistant professor of otolaryngology and the director of the Northwestern Medicine Cochlear Implant Program. Thanks for your time and expertise. We really appreciate it. Really great to be here. Thank you so much. Br.