We are delighted to be able to offer you open access to the International Consensus Paper via JAMA Otolaryngology: Unilateral Cochlear Implants for Severe, Profound, or Moderate Sloping to Profound Bilateral Sensorineural Hearing Loss; A Systematic Review and Consensus: Delphi Consensus Paper
Raising awareness and understanding of cochlear implant use in adults
International guidelines on adult cochlear implant candidacy are limited, and country-specific guidelines are varied, leading to disparate levels of access and systemic underutilization across the world. Without standard clinical guidelines, individuals who can benefit from a cochlear implant may not receive one.
With the goal of addressing lack of awareness and improving literacy surrounding cochlear implant use in adults, an international group of clinical experts in the fields of otology, audiology, and hearing science were brought together to form a Delphi panel.
From the Delphi panel, consensus around cochlear implant candidacy was agreed and the International Consensus Paper created in response.
Adult Hearing aims to increase awareness via the latest clinical evidence to reach an agreed standard of care for adults with hearing loss.
Watch the video to discover more about Adult Hearing’s aim and purpose.
Please imagine a realistic utopia for those with hearing loss and marshal the best available science to recommend transformational actions to achieve that vision.
Richard Horton, Editor-in-Chief, The Lancet
The first global consensus on the use of cochlear implants
“The Delphi consensus panel is a group of professional otolaryngologists and audiologists from around the globe working in the area of cochlear implantation and care for patients with profound, or moderate to profound, sensorineural hearing loss.” – Professor Craig Buchman.
The first global consensus on the use of cochlear implants for the management of bilateral severe, profound, or moderate sloping to profound hearing loss in adults was published in the Journal of The American Medical Association on the 27th August 2020. According to Professor Craig Buchman, Chair of the Consensus Delphi Process Steering Committee and Head of Otolaryngology – Neck Surgery, Washington University School of Medicine, U.S., the consensus is a major landmark in the treatment of hearing loss.
The International Consensus Paper
“The International Consensus Paper is the culmination of a systematic review and a consensus process, put together to inform steps towards establishing clear and consistent guidelines, and best practices for the evaluation and management of patients with moderate to profound, or worse, sensorineural hearing loss, including cochlear implants and their aftercare, so they can reach their optimal hearing outcome and attain the best quality of life.” – Professor Gerard O’ Donoghue, Steering committee member of the Consensus Delphi Process and Professor of Otology and Neurotology, University of Nottingham, UK.
A representative process
The International Consensus Paper covers seven categories across the whole care path. Representatives from seven CI user and professional advocacy organisations provided comments throughout the process. One of the representatives, Dr. Harald Seidler, President of the German Hard of Hearing Association and CI user, described the consensus as a call to action for those involved in organising, delivering and receiving hearing health care.
“Globally, for up to 53 million hard of hearing people hearing aids might not be enough. The consensus empowers them to explore their opportunities with cochlear implant treatment” added Dr. Harald Seidler.
International Consensus Process and Publication
Based off of the literature that was reviewed for putting these statements together, there is an enormous gap in the education level for practitioners who are working with patients who have hearing loss and these statements will provide better awareness, increase access and certainly increase the education of anyone who comes in contact with someone with hearing loss.
Associate Professor Meredith Holcomb, Medical University of South Carolina, Charleston, SC, USA and University of Miami, FL, USA
Consumer & Professional Advocacy Committee
The Consumer and Professional Advocacy Committee was formed to ensure the cochlear implant user’s voice was considered during the Delphi consensus process. The committee members had a non-voting role but were asked to comment on the statements at each round of voting, to provide their views on the statements from the user and their professional organisation’s viewpoint.
Hearing loss impact
Hearing loss is one of the leading causes of disability worldwide, affecting 466 million people (6% of the total population). It is expected that there will be 630 million people living with disabling hearing loss by the year 2030, with that number rising to over 900 million by 20501, 2 if unaddressed.
Hearing loss has a substantial impact on people’s lives, including, but not limited to:
- communication difficulties 3
- social isolation4
- falls6 and
- increased healthcare utilisation7
In addition, it is the single largest modifiable risk factor for dementia.8
What causes sensorineural hearing loss?
Sensorineural hearing loss (SNHL) is caused by dysfunction of the cochlea, auditory nerve, or central auditory pathways. In many cases, SNHL in adults is attributed to presbycusis, which is a progressive and irreversible bilateral age-related SNHL, whose primary pathology involves the hair cells, stria vascularis and afferent spiral ganglion cells, in addition to the central auditory pathways.9-11
What are the treatment options for sensorineural hearing loss?
Cochlear implants (CIs) are currently the most successful neuro-prosthesis used across healthcare.16 Although hearing aids are effective for many adults with hearing loss, CIs can provide further benefit to individuals affected by bilateral severe, profound, or moderate sloping to profound SNHL who receive little or no benefit from hearing aids.17
A CI is a surgically implanted device that electrically stimulates the peripheral auditory nerve and associated spiral ganglion cells directly, restoring the individual’s perception of sound.18 A key advantage of a CI over a hearing aid is that, while a hearing aid simply amplifies sound, a CI will directly stimulate the auditory nerve, bypassing injured hair cells of the cochlea and providing salient coded information for better speech perception.19
The Action Required
International guidelines on adult CI candidacy are limited, and country-specific guidelines are varied, leading to disparate levels of access and systemic underutilisation across the world.9,20-22 For example, in the UK, the audiometric criteria for CI candidacy include severe to profound hearing loss at two or more frequencies, with no adequate benefit from conventional hearing aids;9 however, in the USA, the criteria include moderate to profound SNHL, or greater, with little or no benefit from hearing aids.19
Cochlear implantation is still not a routine intervention in adults with significant hearing loss in many regions. Without standard clinical guidelines, individuals who can benefit from a CI may not receive one. Barriers to access include a lack of awareness and understanding of CIs in individuals with SNHL, low awareness and understanding of the candidacy criteria for cochlear implantation among healthcare professionals, and a lack of defined care pathways to provide this important intervention.23,24
A world in which hearing loss is no longer a barrier to human communication and fulfilment.
Advanced Bionics (Valencia, CA, USA), Cochlear Ltd (Sydney, NSW, Australia), MED-EL (Innsbruck, Austria), and Oticon Medical (Smorum, Denmark) provided funding for assistance with the preparation of the manuscript and were informed of the decision to submit the manuscript for publication; they had no input to the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. There was no remuneration of the Delphi participants including the Chair and Committee members.
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4. Jiam NT, Li C, Agrawal Y. Hearing loss and falls: a systematic review and meta-analysis. Laryngoscope. 2016;126(11):2587-2596.
5. Hsu AK, McKee M, Williams S, et al. Associations among hearing loss, hospitalization, readmission and mortality in older adults: A systematic review. Geriatr Nurs. 2019;40(4):367-379.
6. National Institute for Health and Care Excellence. Cochlear implants for children and adults with severe to profound deafness (TA566). 2019. https://www.nice.org.uk/guidance/ta566/resources/cochlear-implants-for-children-and-adults-with-severe-to-profound-deafness-pdf-82607085698245. Accessed June, 2019.
7. Keithley EM. Pathology and mechanisms of cochlear aging [published online May 7, 2019] J Neurosci Res.doi:10.1002/jnr.24439.
8. Roehm CEM, J.; Parnham, K. Presbycusis. Encyclopedia of Otolaryngology, Head and Neck Surgery: Springer, Berlin, Heidelberg; 2013.
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11. Rosenhall U, Hederstierna C, Idrizbegovic E. Otological diagnoses and probable age-related auditory neuropathy in “younger” and “older” elderly persons. Int J Audiol. 2011;50(9):578-581.
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13. Sato M, Baumhoff P, Kral A. Cochlear implant stimulation of a hearing ear generates separate electrophonic and electroneural responses. J Neurosci. 2016;36(1):54-64.
14. Korver AM, Smith RJ, Van Camp G, et al. Congenital hearing loss. Nat Rev Dis Primers. 2017;3:16094.
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18. Liang Q, Mason B. Enter the dragon – China’s journey to the hearing world. Cochlear Implants Int. 2013;14 (suppl 1):S26-31.
19. Raine C. Cochlear implants in the United Kingdom: awareness and utilization. Cochlear Implants Int. 2013;14 (suppl 1):S32-37.
20. Sorkin DL. Cochlear implantation in the world’s largest medical device market: utilization and awareness of cochlear implants in the United States. Cochlear Implants Int. 2013;14 (suppl 1):S4-12.
21. Nct. Efficacy and Safety Study of Botulinum Toxin Type A for Moderate to Severe Crow’s Feet Lines. https://clinicaltrialsgov/show/nct01776606. 2013.
22. Eubank BH, Mohtadi NG, Lafave MR, et al. Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology. BMC Med Res Methodol. 2016;16:56.
23. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85(1):1-3.
24. Appelbaum EN, Yoo SS, Perera RA, Coelho DH. Duration of eligibility prior to cochlear implantation: have we made any progress? Otol Neurotol. 2017;38(9):1273-1277.