Dr. Loren Bartels - COCHLEAR IMPLANT BASICS
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Dr. Loren Bartels

I recently learned that Dr. Loren Bartels had performed a cochlear implant surgery on a five month old child.

He was also the surgeon who performed bilateral cochlear implant surgery on me in December 2015 just before my 65th birthday.

His career with cochlear implants predates the time of FDA approval for them in the United States.

In other words, he has seen and performed surgery and the restoration of hearing through these miracle devices from the start.  He talks about his background and the advancement of cochlear implants as well as his own criteria for determining a candidacy. His views on pediatric cochlear implant surgery are invaluable to parents seeking answers.

His unique perspective is invaluable to those starting their hearing journey research.  I am glad he agreed to take time on his busy schedule to sit down with me for this interview.

Transcript

Voiceover: Cochlear Implant Basics is a site for candidates, recipients and their families and friends. If you or a loved one is profoundly hard of hearing, newly deaf or have experienced sudden hearing loss, we are here to share our stories and tell how receiving a cochlear implant can be a life-changing event. This site is not medical advice, nor is it brand-specific.

Voiceover: Within these podcasts and videos, you will meet recipients who faced hearing loss situations and hearing aids could no longer provide comprehension of speech or music. They share the stories of how they lost their hearing, their struggles with growing isolation from their family and friends, their inability to compete in the world of business, their difficulties of navigating air travel without hearing, how the joy of music disappeared and the panic of not being able to use a telephone to contact 911 to get aid for a loved one.

Voiceover: They will talk about their fears and the reason they procrastinated to get a cochlear implant and the reasons they moved forward, how receiving a cochlear implant changed their lives and the lives of those who surround them. You will meet audiologists and surgeons and those who support the deaf and hard of hearing communities. Welcome to Cochlear Implant Basics. Reminder, Cochlear Implant Basics is not offering medical advice. Please consult your own healthcare provider.

Richard: In 2015 I met with a surgeon and was found qualified for a cochlear implant. I was scared to proceed. I went to seek a second opinion. I sent my records to Dr. Loren Bartels. He took one look at it and suggested, “Why not do both ears?” When I recovered from my shock and thought about it overnight, realized I had nothing to lose and I agreed. In the end, Dr. Bartels did bilateral surgery on me. I’ve been grateful and I’ve tried to play it forward ever since.

Richard: I recently reached out to him and asked him to share not only his career experiences but to talk about his recent pediatric cochlear implant surgery on a five month old child. He was gracious enough to sit down with me and to talk not only about that surgery, but about cochlear implants from the surgeon’s point of view. This is his story.

Richard: I’ve been absolutely enchanted with your work, enchanted with what you did for me, but people who are starting out are looking for basic information about what’s going on, what to expect from the surgery, so on and so forth. If you could give me a little bit about your background, your education, why you went into the field.

Dr.Loren Bartel: Well, I went into ear work because I was fascinated with ears as a medical student. Back then, we worked on the little hearing bones in the middle ear and that was of like micro-carpentry. So I’ve always enjoyed carpentry, and that just was fascinating. But deeper into ear work is very complex physiology, which I also find very fascinating. And then I was fortunate enough in my ear, nose and throat training to land a fellowship in Los Angeles with the House Ear Institute, and there, Dr. William House was working on cochlear implants on an experimental basis.

Richard: How long ago was that?

Dr.Loren Bartel: That was 1979, 1980. So literally, about six to seven years before cochlear implants became FDA-approved, I was helping Bill House doing cochlear implant work in Los Angeles. So again, very fascinating stuff. I did my first cochlear implant in 1986 after the House device became FDA approved. Soon after, the Nucleus first multichannel device became FDA approved and the House device went away and everyone moved to multichannel. So I’ve been doing multichannel cochlear implants now for 33 years.

Richard: You’ve obviously seen a lot of changes in the fields.

Dr.Loren Bartel: We have. Initially, they weren’t as reliable or anywhere near as reliable as they are now, but reliability now for all of the major manufacturers of cochlear implants now is very high. And what can be done with software with cochlear implants is quite remarkable. There are some ancillary things that are still changing, like Bluetooth connectivity, connectivity to things like Roger systems. So there are some things that are happening now that are pretty exciting that help integrate people into groups more effectively.

Richard: Well, the Bluetooth aspect, both for the cochlear implants and hearing aids, is growing drastically. I’ve seen that happen, and in fact, I had an interview recently with Dr. Victoria Moore and she said the future she saw again was Bluetooth, as great advancements for hearing impaired and for cochlear implants.

Dr.Loren Bartel: Yeah, Bluetooth is making a significant difference. Combining Bluetooth with Roger systems improves ability to understand and moderate noise. So if you go to a restaurant that’s fairly noisy on a weekend, with a typical cochlear implant or a typical hearing aid, you can get lost pretty easily. But if you have a Roger system, you’re more likely to stay connected or at least better connected than you can do without them.

Richard: The same with the Mini Mic from Cochlear, whichever, some of the devices-

Dr.Loren Bartel: The Mini Mic is a lapel microphone and Phonak makes them, Resound makes them, Oticon makes them, Siemens makes them, a few other companies make them, so depending on the brand of hearing aid you have, you can get a lapel microphone that you can pass around and some of them, it can be a table microphone, and it helps. And it will help up to about 60, 65 decibels. Above that level, it gets overwhelmed, and then the Roger system will work up to about 85 decibels.

Richard: Okay. When you interview a cochlear implant candidate, are they referred to you by an audiologist or how do they come to you?

Dr.Loren Bartel: Most come either from another audiologist or from primary care or from other patients.

Richard: And what’s the procedure when you interview a candidate?

Dr.Loren Bartel: Well, first is I can go through what I call the Bartels kitchen table test. So the game I play is I have my face turned toward the computer and I speak in a modest voice and see if they can understand me. I don’t tell them I’m doing that, but the game I play is, do I perceive them to be severely enough hearing impaired to consider a cochlear implant. And then we go through the usual history and physical exam and review their audiometric studies. If it looks like they might be a cochlear implant candidate, then we put them through a series of testing that we call cochlear implant determination.

Richard: And they go through that test. Now, one of the things that new candidates are overwhelmed with the choice of which company to go with. Do you help them decide or is there a certain criteria that you use to help them or let them decide on their own?

Dr.Loren Bartel: Well, let me first say that we have recently done our own internal study on how well people do with each of the three major companies, and there isn’t a significant difference in how well people do with one device or the other. There are some circumstances where I will specifically recommend one particular device. So for example, I had a lady come in who had never in her life heard in the high frequencies. In that particular scenario, we made a choice to have an implant that went out way far into the inner ear so that we can stimulate predominantly the low frequency areas. Cochlear implants in general stimulate the mid to high frequencies of the inner ear and don’t reach the real low frequency areas. So if the high frequencies are not going to be used because the inner ear doesn’t have nerve fibers there, then we want an implant that goes deeper in.

Dr.Loren Bartel: So there are a few scenarios where we will make a specific choice. Most of the time though, we want the patient to go through the device selection process and make their own decision. There are some other things that come into play. There are people who need MRI scans on a recurring basis. All three of the major companies are nominally MRI compatible, but the most compatible with MRI right now is the new advanced Bionics device that’s been out about a year. With that particular device, you can have your head in any position in an MRI machine and not have a problem. With the other two devices, you have to be careful to go into the MRI machine nose up. Now, almost all MRIs are done nose up, so it’s not very common with any of the devices to have a problem with MRI machine with the current devices. But there are a few scenarios where advanced Bionics would be better.

Richard: What about the array that goes into the cochlea? Does that make a difference and when you make a choice?

Dr.Loren Bartel: Well, it turns out that all of the company’s dominant arrays now are about 23 to 24 millimeters long. Advanced Bionics has 16 electrodes in that distance. Cochlear Corporation has 22 electrodes, and then MED-EL for their 24 millimeter electrode has 12 pairs of electrodes. So in terms of depth of insertion, they’re going to be pretty close. There is a longer device with MED-EL that’s 28 millimeters long and another one that’s 31 millimeters long, but the vast majority of people are going to get the same depth of insertion regardless of which device they pick.

Richard: But you just mentioned before that you’ve done studies recently here that there was not much difference between the results of all three brands.

Dr.Loren Bartel: That’s correct. There is a study that was done a number of years ago in Hanover, Germany that compared the three brands and Advanced Bionics and MED-EL were statistically equal with Cochlear Corporation, them not being as good, but Cochlear Corporation has done a lot of software work in the interim, and in our study of the last number of years, we think the hearing benefit is the same among the three devices.

Richard: Now, my next question to you is, are there times to advise a candidate not to proceed with the cochlear implant? What would those be?

Dr.Loren Bartel: Well, there are a variety of scenarios. So the first thing to mention is that the insurance rule and the Medicare rule is we have to prove with a best possible hearing aid set up that they won’t do better than certain criteria with hearing aids than with a cochlear implant. And those criteria are based on the fact that you have to meet those criteria in order for you to perceive a cochlear implant to be better than a hearing aid. So they first have to meet those criteria.

Dr.Loren Bartel: Now, those criteria are a little fuzzy. So there are some scenarios where one ear has hearing aid usable hearing and you can put a cochlear implant in the other ear. So there is some fuzziness in those criteria that we can work with. For example, I saw a lady yesterday from Miami who had been tested and said she was a cochlear implant candidate down there. But when we put her through testing here with our hearing aids, she was not a cochlear implant candidate. And the problem was, she was tested with hearing aids that were not best possible. So one of the challenges we have, make sure that we test them with the best possible hearing aid fitting. You don’t want to subject somebody to surgery that you can really reach with hearing aids well enough.

Dr.Loren Bartel: There are a few others scenarios that are unique. For example, I had a man a number of months ago who had Meniere’s disease. It was real bad in one hear, so he was having recurring bad vertigo spells in an ear with very poor hearing. He had a moderate hearing loss in the other ear. So we had done all the conservative things. The next step was to drill out his balance organ in surgery. And if we do that, then we may lose the ability to put a cochlear implant in later. So we sought permission from his insurance company to put a cochlear implant in that ear at the same time we drilled out the balance organ. So we drilled out to balance organ, but we kept the hearing organ and put a cochlear implant in and he’s doing very well. And that’s called a cochlear implant with single-sided deafness, and there is now a growing body of research that a cochlear implant often helps in single-sided deafness.

Dr.Loren Bartel: So there are a variety of scenarios. There are some scenarios that we can’t help. An example would be a gentleman I saw who had a skull fracture and both of his inner ears were broken, cracked, and had turned to solid bone. Well, I can’t get cochlear implants into ears like that that are likely to work. So there are some scenarios where you can’t get it in. I saw a gentleman last week who had had surgery 40 years ago in his left ear. That ear went deaf. He’s had some surgery in his right ear for [inaudible 00:13:30]. He’s got moderate to severe hearing loss in the right ear. He wanted to know if a cochlear implant would work in his left ear. Well, as a complication of the surgery he had 40 some years ago, that left inner ear has turned a bone. So there’s no fluid space, no nerve fibers I can put a cochlear implant in.

Dr.Loren Bartel: So there are some scenarios where I can’t get in. So part of being a candidate is I have to make sure the anatomy will accept the cochlear implant, and then part of it is you have to be bad enough and we have to do that with appropriately fitted hearing aids. So we have to test you with the best possible hearing aids.

Richard: That’s a question I hear all the time from new inquirers about it, so that’s very helpful information. Vestibular issues, balance issues, do you see those all the time?

Dr.Loren Bartel: We do see people with things like bad Meniere’s disease in both ears. So they have episodes of bad vertigo in both ears and then get progressively worse hearing. And some of those people become cochlear implant candidates. In fact, some of them get cochlear implants in both years, so there are vestibular issues at times. There are times when a vestibular issue will guide us to do one ear instead of the other. One of the possible side effects of cochlear implant surgery is dizziness. So if a person has a real bad balance organ in one ear and both ears are candidates for a cochlear implant, we might choose to put the implant in the ear that has poor balance so that we don’t risk injuring the balance and the better balance organ ear.

Richard: Do you have some kind of idea of percentage of people that might come into that category?

Dr.Loren Bartel: Well, let me just in general say a rough number. About 10% of cochlear implant candidates have major balance issues that we have to deal with as part of the decision process.

Richard: What about tinnitus? Does that get alleviated with a cochlear implant? Do you see that?

Dr.Loren Bartel: About 60 to 70% of people who have tinnitus and meet cochlear implant criteria have less tinnitus when the cochlear implant is turned on. So tinnitus by itself is not a reason to do a cochlear implant except on very rare occasions. But in general, a person with troublesome tinnitus does a better with a cochlear implant turned on.

Richard: And after the candidate decides on surgery, about how long is the average period until they get it?

Dr.Loren Bartel: Usually just two to four weeks.

Richard: And when you do surgery … They ask me this all the time. I say it’s an out- patient procedure but I was put under when they didn’t mind mine, so I have no clue how long it takes. What’s your-

Dr.Loren Bartel: Well, the surgery itself takes about 45 to 55 minutes under general anesthesia. So the total anesthesia time is about an hour, and it is done as an outpatient with rare exceptions.

Richard: And the follow up visit’s with you?

Dr.Loren Bartel: We see them back at two weeks and that’s when we also start doing the cochlear implant tune up.

Richard: Okay. Now my next question is about your relationship with audiologists. What is your relationship with them?

Dr.Loren Bartel: Well, we have an integrated practice here, so we have seven audiologists in three ear doctors, and we just work closely together. And when we have challenges for making decisions on cochlear implant patients, we talk to each other to see where we ought to go.

Richard: Okay. I know that my next question to you was about your greatest success stories and your most difficult cases, and I also understand you recently did a five month old child, which is astounding to most people when I say that. Could you talk a little bit about that?

Dr.Loren Bartel: Well, one of the questions that’s critically important is at what age for a baby does it become less likely that they will have normal speech and language. The statistics show that if you don’t get the cochlear implant in before six months, there will be some permanent language deficit. In Poland, which is a place that does the most pediatric implants in the world, they do them now down to four months of age. How young am I willing to go is a good question.

Dr.Loren Bartel: So this five month old baby is a baby who has a genetic abnormality called Connexin 26. With a Connexin 26, we know this baby is never going to hear without a cochlear implant. And then the question is, when is the baby big enough and mature enough to tolerate anesthesia? So lung maturity in children reaches suitable age somewhere in the four to eight months of age. A premature baby or a sickly baby will take longer to become healthy from a lung perspective. So this particular baby is relatively large, so at four and a half months, that baby weighed already 17 pounds and the baby’s head was plenty large enough for a cochlear implant, so we were willing to go ahead early on this baby.

Dr.Loren Bartel: So that’s one of those things where we saw this child when the baby was about six weeks old. The child failed infant hearing screening. All babies implored and born in birth facilities, hospitals or birth centers are required by law to have their hearing checked. That’s called infant hearing screening. The baby failed. That was repeated. Something called auditory brainstem responses testing was completed. Otoacoustic emissions testing was completed, and the baby turned out to be deaf. And then on an urgent basis, I asked the geneticist to see the baby and the genetics testing was done. The testing proved that the baby was never going to hear.

Dr.Loren Bartel: And so then the question was, how soon can we get the implants in? Well, since six months of age is when you start losing something on a permanent side for speech and language, we want to do the baby as soon as we can after the baby’s healthy enough. So we just made plans to see the baby regularly until I felt the baby was large enough and made sure the baby looked healthy, breathing well, functioning well. This baby was a relatively large baby, so we were happy to go ahead at five months. I probably would’ve done this baby at four and a half, maybe four months because it’s just a big baby. There are other babies where I wouldn’t make that choice.

Richard: It’s interesting because I seen this on social media time after time from parents with very young children concerned about the bulging of the implant, the appearance of the child, how the child’s going to do in society with the cochlear implant, because obviously it’s a very traumatic experience for a parent. Your experience with the appearance is?

Dr.Loren Bartel: Well, what we do is partially recess the implant in bone. The child skulls are not as thick as adult skulls, so we can’t get it in as far. But by and large, when people realize what a huge difference a cochlear implant in a baby makes, the fact that you’ve got something relatively large appearing for a baby on the side of the head isn’t really an emotional obstacle. If you consider what happens to people who grow up deaf in terms of language development, cognitive development and emotional issues versus those who get implants, it’s a no brainer.

Richard: Now, you’ve been with cochlear implants from the beginning. What do you see the future, robotics, or something changing you can see in the future?

Dr.Loren Bartel: At present, we think cochlear implants are going to be come better in terms of reliability of electronics and I think ability to use microphones to optimize hearing and noise will improve. Something we hope happens eventually is that some of these disorders where the inner ear gets progressively worse, we will learn how to fix with genetics. So there may come a day when we can send new genetic material into the inner ear and make the inner ear rebuilt. That’s not anytime soon, but that’s really the long term hope.

Richard: What about the preservation of residual hearing? Again, that’s a topic I hear time after time.

Dr.Loren Bartel: There are candidates, and about 80% of the time, we can save at least some hearing and the operated ear enough to use a hybrid cochlear implant system. For example, a man over age 80 with a severe hearing loss is less likely to have hearing salvaged, but by and large, we can save hearing in a good number of ears. Now, it turns out the better the hearing before surgery, the more likely it is we can save some.

Richard: The hybrids. That’s become a hot topic. I’ve seen it again time after time. You mentioned the single-sided deafness, and cochlear implants, again, is a growing field. What do you see about the hybrids?

Dr.Loren Bartel: Well, the hybrid, let me put it this way. The interest in hybrid now has all three companies onboard with FDA approval to do that. There are a little different criteria among the three companies, but in functional terms, if you meet criteria for a hybrid, most places are willing to do that now. There are some animal data that suggests that if you start steroids two days before surgery and continue for two to three weeks after surgery, you’re more likely to have hearing preserved. So that’s our protocol now is we start steroids two days before and continue them for three weeks after, and it looks like we’ve got about 80% chance of saving at least some hearing.

Richard: That’s a fascinating number. And may I ask about what you would like to see the cochlear implant manufacturers do in the future that will make your job easier?

Dr.Loren Bartel: Well, what they’re working on is making it more possible for patients to interface directly over the internet. Part of the challenge for that is that the current insurance and billing pathways don’t pay for that. So it would be nice to get that all figured out so that people don’t have to drive so far for relatively minor things.

Richard: That’s true. Again, one of the topics I see all the time, if somebody lives in a place far away from the audiologist, they’ll suffer with a poor mapping than drive two or three hours to get there.

Dr.Loren Bartel: Right.

Richard: That would help. Can I ask you, what would you like to add toward candidates considering a cochlear implant?

Dr.Loren Bartel: Well, I mentioned the Bartels kitchen table test earlier. So let me tell you what that is. Fairly simply, you sit across the table from a person with a hearing aid set to whatever is their perception of a best setting. Don’t turn any household noise off, and then someone speaks to you with their face covered. If a person talks to you across the kitchen table with their face covered and you struggle to understand, you’re probably bad enough for a cochlear implant.

Richard: Or a better hearing aid.

Dr.Loren Bartel: Well, that may be. That sometimes is the challenge is you just need a better hearing aid.

Richard: Thank you so much for your time, Dr. Bartels.

Dr.Loren Bartel: All right, take care.