Troubleshooting Cochlear Implant Processors via Tele-Audiology

Abstract

This case study examines the methods used to troubleshoot a cochlear implant processor via video visit with a nonagenarian (90+ years old) with a bimodal cochlear implant system. This article will discuss the evaluation and management as well as which specific issues could be addressed virtually and how they were resolved. Examples will be provided about how to virtually connect with the patient and how to best facilitate communication during a video visit. Additionally, this article will examine the captioning apps and other hearing assistive technology available for smartphones that can provide further assistance during a cell phone call along with their benefits and limitations.

When a patient has a cochlear hearing loss, there is an insufficient transduction of acoustic-mechanical energy into neural impulses at the auditory nerve. ¹ The purpose of a cochlear implant is to bypass the damaged structures within the cochlea and excite the neurons in the auditory nerve directly with electrical stimuli. ² A major benchmark of success for a cochlear implant patient is their ability to recognize speech. The patient's ability to reach this benchmark with their cochlear implant can be dependent on many factors. For example, in a 2013 study it was found that patients who were older than 80 years had lower speech perception scores compared with other adult cochlear implant recipients. ³ Schvartz-Leyzac et al ⁴ in 2019 performed a retrospective study that examined performance among patients with cochlear implants throughout the first year of having their device. When analyzing speech recognition among age groups, the study found that the individuals who were older than 80 years performed significantly worse on the AzBio Sentence Test compared with the other six age groups.

A patient's ability to recognize speech over the phone when using their implant can vary greatly. As a result, phone call use among patients with cochlear implants is reduced to a mean 128 minutes each week compared with 244 minutes each week among the general population. ⁵ Cell phone use is difficult for many patients with cochlear implants without the use of external aids. ⁶ There are three major factors that contribute to difficulty communicating over the phone for the population with hearing loss: the removal of visual cues which creates a complete reliance on the auditory system to understand the message, the reduced audibility of the telephone signal due to the hearing loss of the individual, and the limited frequency range of the telephone which reduces important high-frequency information that is critical to achieve speech intelligibility. ⁷ In a 2006 study, Anderson et al ⁶ found that 35% of cochlear implant users reported they could use their cell phone without problems, while more than 50% of the cochlear implant users stated that they only understood half or less of a particular conversation with an unfamiliar speaker.

Despite the obvious difficulties patients using cochlear implants have communicating via cell phone, many of them have not been afforded the opportunity to try an assistive listening device. A 2016 study by Rey et al ⁸ found that 71% of patients had never used any variety of phone listening aid. This study also found that 63% of the patients with cochlear implants had the technical ability to utilize a listening aid system, but only 30% had received the information that would give them this ability. Providing the patient with the opportunity to trial an assistive listening device could significantly improve their overall performance with their phone. Recent studies have demonstrated the benefits patients can receive from having access to hearing assistance technology for their cell phone. Wolfe et al ⁹ showed that there was significantly better performance on the phone using hearing assistance technology in both the quiet and noise conditions. A 2017 study by Marcrum et al ¹⁰ discovered that compared with using a basic acoustic setup for the phone there was an approximately 50% improvement in sentence recognition ability over the phone when using a clean wireless signal (direct streaming with microphones off).

It can be assumed that the difficulties that we observe with patients with cochlear implants on the phone can be a factor during a telemedicine visit. The patient's ability to communicate over the phone or over a video visit is what allows us as providers to be able to connect with them out of the office. Consequently, it must be our goal as audiologists to keep our patients connected via telecommunication.

Case Presentation

Background

The subject of this case study is a 92-year-old male who first visited our clinic in 2016 to be assessed for cochlear implant candidacy. Preoperative audiogram results revealed a moderate to profound downward sloping sensorineural hearing loss in the right ear and a moderately severe to profound downward sloping sensorineural hearing loss in the left ear ( Fig. 1 ). Following the cochlear implant pretesting procedure, it was determined that the patient was a candidate for bilateral cochlear implantation ( Table 1 ). After a detailed discussion of all three cochlear implant manufacturers, the patient decided to move forward with the Cochlear(TM) Americas N6 device. The surgeon ultimately implanted the patient's left ear with a cochlear implant 512 electrode array.

Figure 1.

Preoperative audiogram.

Table 1. Cochlear Implant Candidacy Testing Results.

Test	Left ear score	Right ear score
Hearing in noise test sentences in quiet	15%	30%
AzBio sentences in quiet	6%	15%
AzBio sentence in +5 signal-to-noise ratio	3%	5%
Consonant–nucleus–consonant (CNC) words in quiet	2%	8%
CNC phonemes in quiet	17%	29%

The postoperative unaided audiogram revealed a severe to profound downward sloping sensorineural hearing loss in the implanted (left) ear ( Fig. 2 ). During the initial stimulation appointment, neural response telemetry measures were completed on all 22 electrodes. Impedance measures were normal across all electrodes. After completing the cochlear implant mapping, the processor was activated, and the patient reported an immediate benefit. The rest of the appointment was spent discussing in detail how to properly care for the processor and accessories with the patient and his wife.

Figure 2.

Postoperative audiogram.

During the follow-up appointments over the next few months, many issues were identified. A main issue was that the strength-two magnet he was utilizing was too strong, causing irritation at his coil/magnet site. As a result, we replaced the strength-two magnet with a strength-one magnet and closely monitored the coil site. Another issue that proved persistent was the patient reporting that his batteries were not holding a charge. However, each time we checked his batteries and charger in the office, everything appeared to be working appropriately. The mystery surrounding the battery issue was finally resolved when the patient showed up at our walk-in clinic for said issue. It was at this time that we realized he had accidentally worked his disposable battery sleeve into his rechargeable battery rotation. Every time he used that sleeve, the battery was dead. The differences between the rechargeable and disposable battery sleeves were reviewed again with the patient and this issue was resolved for good.

Approximately 1 year later, the patient returned for a cochlear implant programming appointment. During this appointment, he was accompanied by his daughter who expressed concerns about his ability to communicate with his family members over the phone. Potential solutions to the problem were discussed and the patient settled on trying a new compatible GN ReSound hearing aid for his right ear in combination with the compatible Cochlear(TM) Phone Clip. Up until this point, the patient had been wearing an older Unitron Behind-The-Ear (BTE) hearing aid in his right ear that was not compatible with his Cochlear(TM) accessories. A few weeks later, the patient was fit with a GN ReSound Enzo BTE aid coupled to a custom earmold. Real-Ear-to-Coupler Difference (RECD) and Real-Ear Aided Response (REAR) measures were obtained to program the hearing aid to Desired Sensation Level (DSL) adult v5.0 targets using the Verifit 1 for verification. The Cochlear(TM) Wireless Mini Microphone that the patient was using with his cochlear implant processor was also paired to the hearing aid during this appointment so that he could hear through both devices.

The motivation behind pursuing the new hearing aid was to receive the benefits of bimodal hearing through his accessories, especially while using a cell phone. In 2016, Wolfe et al ⁹ reported that mean word recognition over the telephone improved by 25% in quiet and by 23% in noise with the use of the phone hearing assistance technology compared with performance when the cell phone was held next to the microphone of the sound processor. This improved performance is similar to that reported for hearing-aid wearers using wireless hearing assistance technology for the cell phone. ¹¹ During the hearing aid fitting appointment, a Cochlear(TM) for all subsequent appearances, if appropriate Phone Clip also was paired to his processor and hearing aid. In addition to the Cochlear Phone Clip, the patient uses the InnoCaption app on his iPhone 10. While practicing phone calls in the clinic, we discovered that receiving phone calls was now very complicated for this patient. Having to remember to have the Cochlear Phone Clip with him combined with pushing the button on the Cochlear Phone Clip and then needing to open his captioning app was not streamlined enough for his needs. The captioning app also appeared to be interfering with the reliability of the Cochlear Phone Clip receiving the phone calls. He felt comfortable with the action of pressing the green phone button on his iPhone to answer a phone call. Steps beyond this caused too much additional confusion and resulted in him not being able to successfully take the call.

Several phone calls were placed by the clinician during the appointment to determine if there was a way to make this process more streamlined for the patient. All our research came back with the same conclusion that this was the only way it was going to work. Our temporary solution was that the patient would continue to use his captioning app for his phone calls but would combine that with the speakerphone function so that he could benefit from hearing binaurally on the phone.

Frustrated by the inability to resolve this issue and determined to have successful conversations with her father on the phone, the patient's daughter decided they would pursue a new Cochlear Americas Nucleus(R) 7 (N7) processor. Since the patient was not eligible for an upgraded processor through his insurance, the N7 was going to be obtained through the family's own means. The benefit of the new N7 processor for this patient was going to be that he could directly stream his phone calls to both his processor and new hearing aid without the use of an additional accessory (e.g., Cochlear Phone Clip). Our hope was that this would simplify the process of placing and receiving phone calls for this patient so that he could comfortably communicate with his family. Aside from the phone benefits, the N7 processor was going to allow the patient to utilize the Cochlear Nucleus(R) Smart App. By utilizing the app, the patient would no longer need to worry about carrying around his remote. The much larger iPhone screen was significantly easier for him to see and control compared with the small screen on his Cochlear Remote Control.

A few months later, the patient was seen for his N7 upgrade programming appointment. The processor and the hearing aid were linked in the Cochlear software and then both were paired to the patient's iPhone 10. Several demonstrations of the InnoCaption app with the new streaming setup were completed and the patient called several family members to make sure he was comfortable. He stated that he was able to hear everyone on the phone and was both happy and excited about his new ability to keep in touch with his family.

One month after his upgrade appointment, the patient returned to our office due to issues answering phone calls through his captioning app. After some investigation, it was discovered that when the patient's phone rings while unlocked, he can answer the phone call through his InnoCaption app with one button tap. However, if his phone is locked when it rings, he must first answer the phone call and then press the InnoCaption button that appears. This added second step created additional confusion and was causing the family to have trouble reliably contacting him. A one-page sheet of instructions with a picture of his iPhone screen was created to help him remember the process of how to answer his phone with captioning at home ( Fig. 3 ). The family also instructed the patient to just call them back directly through the InnoCaption app if he was unable to successfully receive their call. During the appointment, we attempted to contact InnoCaption to see if there was a way to have a phone call open directly in their app from the lock screen. We were unable to reach the company at any point. Our next phone call was to Apple tech support who indicated that such a function must be written into the software of the app. The Apple support tech referred to it as a “swipe to open” feature. The goal would be that even if the phone was locked, the patient could simply tap/swipe their green phone button and the call would automatically default to opening in the captioning app. Thinking that perhaps it was just the InnoCaption app that had this limitation, we also downloaded the CaptionCall app and encountered the exact same issue. We were able to speak with a CaptionCall representative and they stated that they would take the concern into consideration and try to find a solution.

Figure 3.

Handout describing how to answer the iPhone.

Method

Our next appointment needed to be rescheduled due to restrictions on in-person appointments during the coronavirus 2019 (COVID-19) pandemic. The scheduled appointment was to help the patient with issues he was experiencing with battery life again as well as pairing his iPhone 10 to his hearing aid and cochlear implant processor. A virtual appointment was offered to the patient and he was interested in moving forward. Due to the appointment being scheduled in early April 2020 shortly after the restrictions were put into place, our department did not yet have the capability to complete video visits that were integrated into the electronic health record. Instead, we created a password-protected Zoom meeting with the patient, his at-home caregiver, and his daughter who lives in another state. One immediate benefit of the video visit was that his daughter, who is very involved in his care, was able to be present for the appointment when normally she is unable to attend due to her location. The patient's caregiver was able to open the Zoom meeting on the patient's tablet so that he could use the Otter app on his iPhone to live caption the Zoom meeting with his phone picking up the audio from the tablet speakers. Live captioning is now available for Zoom meetings, but at the time of this meeting it was not. If the patient had an Android phone, he could have used the Google Live Translate app.

The main issue that needed to be addressed during the appointment was the issue of battery life. The Cochlear software estimated that this patient should be receiving approximately 15 hours of battery life. The patient reported he felt as though he was only receiving approximately 5 hours of battery life but was not sure if the issue was with one or all of the batteries. The caregiver was able to bring the battery charger and batteries in front of the camera to demonstrate what was happening. One of the patient's three rechargeable batteries was flashing orange instead of green. Cochlear was contacted to mail the patient a new rechargeable battery under his warranty. While on the video call with the patient, we also took the opportunity to check his coil site which looked normal and warranted continuing with the same magnet strength. The final issue that needed to be addressed during the call was the pairing issue with the iPhone. As we needed the phone for this part of the appointment, we could not utilize the captions, so we instructed the caregiver on the necessary steps to “forget” the devices from the iPhone and pair them back together again. The caregiver was able to successfully complete this task. To ensure that the pairing was in fact successful, we called the patient's cell phone from our clinic. This step allowed us to verify that both the hearing aid and processor were paired, and the phone call was streaming to both devices. Demonstrating the phone call allowed us to review the “two-step” answering process while using his InnoCaption app if his phone happened to be locked. The video stream allowed us to watch what he was doing on the phone screen so we could ensure that the proper steps were being taken to answer the call. Both the patient and his daughter were very happy that we were able to offer this service via a video call. Without the ability to have the video call, this patient would have likely had to wait months before he was able/comfortable to come into the office to resolve these issues.

Results

The following week the patient contacted the office to inform us that he received the new battery from Cochlear and that the issue with the battery drain had resolved. Regarding his cell phone use, the patient is now familiar with the process required to answer and make phone calls through his iPhone 10 while utilizing the InnoCaption app. The patient and his family expressed gratitude for his improved ability to communicate over the phone, especially during a pandemic when getting on a plane to visit has become much more complicated. Sadly, this patient's wife recently passed away and he is now living alone. According to his daughter, he likely would not have been able to continue living alone safely without his cochlear implant providing him the ability to better communicate both in person and over the phone. Before his wife's passing, we made sure that his home was equipped with the necessary alerting devices to allow him to safely continue living independently.

At our most recent in-person appointment, we completed aided sound booth testing to assess the left cochlear implant as well as bimodal performance. Potts et al ¹² found that performance in the bimodal condition was significantly better for speech recognition and localization compared with the cochlear implant- and hearing aid-only conditions. As seen in Tables 2 and 3 , this patient performs slightly better when in the bimodal condition. Without wearing his cochlear implant processor, the patient is not able to communicate successfully. Given that his nonimplanted ear is also a candidate for cochlear implantation, it is understandable why he becomes frustrated with his hearing aid and inquires as to why he needs to even bother wearing the device. According to Potts et al, ¹² all cochlear implant recipients with residual hearing should use a hearing aid in the nonimplanted ear. Extensive counseling was provided to the patient about the benefits of hearing bimodally. We wanted him to understand that even though it may seem as if the hearing aid provides him nothing of value on its own, it is in fact enhancing his overall ability to communicate in combination with his cochlear implant processor.

Table 2. Aided Soundfield Testing Results (Cochlear Implant Only).

Test	Left cochlear implant only
HINT sentences	57%
AzBio sentences	31%
CNC words	36%
CNC phonemes	64%

Abbreviations: CNC, consonant–nucleus–consonant; HINT, hearing in noise test.

Table 3. Aided Soundfield Testing Results (Bimodal Condition; Cochlear Implant + Hearing Aid).

Test	Left CI + ReSound Enzo BTE (bimodal)
HINT sentences	79%
AzBio sentences	32%
CNC words	42%
CNC phonemes	67%

Abbreviations: BTE, behind the ear; CI, cochlear implant; CNC, consonant–nucleus–consonant; HINT , hearing in noise test.

Discussion

Currently, nothing is commercially available to program cochlear implants remotely via a smart phone. However, it is possible to set up a system to program a cochlear implant remotely. In general, the system involves the clinic mailing the patient the necessary equipment to physically connect their processor to a computer. The audiologist would then connect to the computer remotely and take over control. Once the audiologist is in control of the remote computer, they can open the software and program the processor just like they would in the office. Once programming is completed, the patient would box up the equipment and mail it back to the office. Some obvious issues with this method are the risks and costs involved with mailing clinic equipment out to various patients' homes as well as making sure equipment is received back in a timely manner. Cochlear Americas has developed a remote check feature for their patients. This gives the patient the ability to perform a variety of function checks through their cell phone that can provide some important information back to their audiologist. The activities include but are not limited to taking a photo of their magnet site, completing questionnaires, aided testing completed through direct streaming, data logging, and impedance information. The audiologist can then check the results of these activities through Cochlear Pro. Using a feature like remote check is just another way to provide the audiologist with as much additional information as they can ascertain without having the patient physically in the office.

Conclusion

The patient's newfound ability to communicate via the phone has allowed him to continue living independently while remaining in close contact with his family. He continues his daily exercise regime and his routine of keeping in close contact with all his beloved grandchildren. Personally, I have always been inspired by the love of this family. All the extended family lives far enough away that it requires a flight to visit. However, over the last couple of years, I have managed to meet his wife, daughter, son, granddaughters, and even some of his children's significant others because of remote access. He never has to attend an appointment on his own. This patient and his family are truly special, and I am convinced the success he has had is directly correlated to how involved his entire family is with his care. Remote access has supported this type of family involvement. Having family support when going through any major medical procedure is paramount to yielding positive outcomes and receiving a cochlear implant is no different. While it is not a requirement for cochlear implant candidacy, family support is certainly something that can help promote overall success and satisfaction with the device.