Early Cochlear Implant Activation

00:00:00: Hello and a warm welcome to our podcast about early cochlear implant activation.

00:00:05: My name is Claire Sheridan, I'm a speech language therapist And i've worked in the field of cochlear implants for about thirty five years.

00:00:12: I am with Dr Kelvin Hawker.

00:00:14: Do you want introduce yourself Kelvin?

00:00:17: Yes certainly Clare.

00:00:18: yes my names Kelvin Hawke and I have got background in audiology.

00:00:21: I work at the Field of Cochlear Implants over twenty years and current area interest as care pathway including activation.

00:00:30: Thanks, Kelvin.

00:00:31: We're excited to talk with you about something that's fundamentally changed how we think about cochlear implant care—that is early activation protocols.

00:00:40: If you've been practicing for a while You probably recall That we have routinely waited three-to six weeks after surgery before switching on the patient's device... ...That was just standard right?

00:00:51: We thought patients needed time to heal and go down for things to settle.

00:00:57: But what if we can create a scenario where patients are activated much sooner after surgery, so they get to hear much more quickly?

00:01:05: And clinics save on the time needed to programme patients in their first year.

00:01:10: Well it's not theory anymore that is reality and an increasing number of clinics around the globe!

00:01:17: We now have some remarkable insights from recent publications.

00:01:21: Kelvin Can you tell us about your seeing in some of the clinics.

00:01:26: Yes, and it's really worth paying attention to.

00:01:29: We're now seeing centres around the world successfully activating patients that vary next day after surgery And in some cases even the same day.

00:01:37: I know what you might be thinking because i had the same questions myself.

00:01:42: is It actually safe?

00:01:43: What about wound healing?

00:01:45: or do The patient sing?

00:01:47: and most importantly does this change clinical outcomes?

00:01:51: yes all very good Questions.

00:01:53: could you take us through some of the evidence?

00:01:56: Yeah, sure.

00:01:56: Let's walk through some of the evidence together.

00:01:59: We can look at systematic reviews real-world implementation to experiences from New Zealand patient satisfaction data From The United States and some fascinating electrode impedance research that may surprise you And with That You'll have a solid understanding Of how early activation May work in your clinical setting.

00:02:18: Thanks Kelvin, that sounds great.

00:02:21: So

00:02:21: let's look at the evidence space.

00:02:23: can you start with a big picture and then take us through some of the studies that you think are particularly interesting?

00:02:29: I certainly can Claire!

00:02:31: Let's think about the bigger picture.

00:02:33: so Parker & colleagues published a systematic review in twenty-twenty four.

00:02:37: they really nicely summarised what we know.

00:02:40: They looked to fifteen studies involving six hundred and twenty five patients who received early activation and compared those with two hundred forty-three control patients.

00:02:51: And when they say early activation, They're talking about within seven days postoperatively.

00:02:56: Here's what striking twelve of the studies reported activation Within twenty four hours after surgery.

00:03:03: The control group by contrast were activated anywhere between nine to forty six days postop.

00:03:09: Now When you look at the complication rates that is where things get really interesting Complication rates for low in both groups.

00:03:17: Studied by Brusco in twenty-twenty one, followed patients for twelve months and found no significant differences in pain or balance problems between early an standard activation groups.

00:03:28: There was a slightly higher incidence of minor issues like wound swelling and crusting at the first fitting in the earlier activation group.

00:03:37: but this is important that three month six month and twelve month follow up groups there were no differences at all.

00:03:44: Another systematic review by Alshalan in twenty-twenty three that same year looked at nineteen studies from eight hundred and fifty seven patients who underwent early activation.

00:03:56: What they found was reassuring impedance levels were actually comparable or even lower with early activation, And there are no major complications reported across any of these studies.

00:04:08: Some minor complications like pain, vertigo or swelling occurred but the authors emphasised these were negligible and didn't impact the feasibility or safety of this procedure.

00:04:20: For me what really stands out in all research is that it doesn't happen.

00:04:24: There's no detrimental speech recognition.

00:04:27: there are no increasing major complication.

00:04:29: The rehabilitation process isn't compromised.

00:04:32: In fact we see the opposite.

00:04:35: Patients get earlier access to auditory rehabilitation and here's something we don't always think about enough.

00:04:41: Their

00:04:42: anxiety levels during that waiting period are significantly reduced.

00:04:46: That is really interesting, so no increase in major complications.

00:04:51: Do you

00:04:52: have any insights on patient perspectives?

00:04:55: Yes We do So.

00:04:56: thinking of patients let's talk about what they actually experience.

00:05:00: Beaver and colleagues published some fascinating patient satisfaction data in twenty-twenty five from a clinic in Colorado.

00:05:08: They surveyed thirty adult patients, three pediatric families who had early activation and the results were overwhelmingly positive.

00:05:17: Forty-three percent of respondents specifically commented on how early activation reduced their travel burden.

00:05:24: Think about your own patient population for moment.

00:05:27: How many of your patients travel considerable distances to get you a centre?

00:05:31: One patient in the Beaver study lived two hundred miles away and talked about how much easier it was to combine surgery trip with activation appointment rather than making separate journeys weeks later.

00:05:44: Another patient mentioned cost savings saying next day activation makes so much more affordable.

00:05:50: but this isn't just logistics.

00:05:53: Thirty percent of patients specifically mentioned they appreciated being able to hear sooner.

00:05:59: One patient said, it was great to hear the improvement immediately and another says I cannot think of any reason to wait for two weeks.

00:06:07: There's something psychologically powerful about that immediate feedback.

00:06:12: For patients who are living with profound hearing loss The wake between surgery and activation can feel endless.

00:06:19: They know their device is there They've been through the surgery and they're just waiting to hear.

00:06:24: The New Zealand experience gives us even more insight!

00:06:27: The hearing house in Auckland has been doing next-day activation standard practice since twenty seventeen, And they have served over a thousand patients across a geographic region of around six hundred square kilometres.

00:06:40: When Silveratnam and Tegel reviewed their outcome in twenty twenty four... ...they found something really interesting about patient safety.

00:06:48: They actually observed fewer complications in the first month, in early activation group.

00:06:54: Their hypothesis is that this might be because clinicians are seeing the wound sooner and catching any potential issues before they escalate.

00:07:03: Patients who wait three weeks may keep their bandages on longer creating an environment for infection or just not notice early warning signs as surgical sites still numb.

00:07:14: Thanks Kelvin.

00:07:16: It's really good to hear about these positive patient perspectives.

00:07:19: I'm sure people will be keen for you to share the technical details too!

00:07:24: Yes absolutely, i know you're wondering about electrode impedances and device stability.

00:07:29: so this is where Salji's twenty-twenty two research from the Mayo Clinic really becomes valuable.

00:07:35: So they looked at three groups patients activated the same day of surgery within five hours Patients activated the next day and patients activated at the standard ten to fourteen days.

00:07:47: To what they found, and this is quite counterintuitive, electrode impedances actually decrease within hours after surgery.

00:07:55: In same-day activation group, impedances dropped by one point three eight kilo ohms in first five hours And continued dropping another one point two one kilo ohm's.

00:08:06: The Next Day Group showed a similar Two Point One Nine Kilo Ohm Drop.

00:08:11: but in the standard activation group, impedances actually increased during that ten to fourteen day recovery period before electrical stimulation brought them back down again.

00:08:21: This observation was also supported by a more recent paper in late twenty-twenty five by Alma Howers and colleagues who demonstrated demonstrated significantly lower impedances compared to lateral wall electrodes with late activation.

00:08:43: So what this tells us is that electrical stimulation is really efficient at dispersing any protein buildup on the electrode surface, not a time sensitive effect.

00:08:53: you get the benefit whether you stimulate immediately or wait but there's no reason to wait.

00:08:59: from an impedance standpoint in fact early stimulation might actually be advantageous By one month post activation, the differences between two groups were statistically significant but clinically meaningless.

00:09:13: Less than one kilo.

00:09:15: The devices perform well regardless of when you actually activate them and New Zealand data reinforces this.

00:09:23: They found that patients activated next day had lower impedance measures compared to three week group.

00:09:30: They also required fewer follow-up appointments and fewer programming adjustments in the subsequent nine months.

00:09:38: To think about what that means from clinical efficiency, The early activation group averaged about six hours less clinical time in their first year.

00:09:47: For patients in fulltime work That's all so significant.

00:09:51: One patient had decided not to get an implant five years earlier because he couldn't take his time off.

00:09:57: with early activation.

00:09:59: felt he could finally move forward.

00:10:03: And from a practical point of view, the New Zealand team developed some good strategies.

00:10:08: when they first implemented next day activation audiologists would photograph the wound and send it to the surgeon to confirm everything looked acceptable.

00:10:18: over time The audiologist became more comfortable assessing wounds status themselves had only consulted the surgeon When something looks concerning.

00:10:27: When the wound is particularly sensitive, they made more frequent use of things like head-worn adapters.

00:10:33: That's the device that couples the processor and coil into a single unit taking pressure off the pinner or longer coil cable so the processor can be fitted onto the contralateral ear.

00:10:44: It's simple accommodation which makes big difference for patient comfort.

00:10:49: Really great insights Kelvin.

00:10:51: So

00:10:51: how do you actually implement this in practice?

00:10:54: Well let talk about what centres that are doing the successfully have learned.

00:10:59: First, this works best with minimally invasive surgical techniques.

00:11:03: The evolution towards smaller internal devices and less invasive approaches is what makes early activation feasible.

00:11:11: So if your centre's still using older more invasive techniques you might need to consider looking at your surgical approach first.

00:11:19: Secondly patient selection matters!

00:11:21: The New Zealand team excluded six patients from their next day of activation during their five-year review period.

00:11:28: Three due to post surgical vertigo and three due to magnet retention issues related to skin flap thickness, those are your conjure indications.

00:11:38: for patient has significant vestibular symptoms or if you're concerned about device retention due to swelling of flapped thickness is perfectly appropriate delay the activation.

00:11:49: this isn't an all or nothing proposition.

00:11:52: third You need to think about magnetic strength.

00:11:55: Several studies mention that you often need to adjust magnet strength, or use off the ear wearing in early activation period.

00:12:03: The Parker Systematic Review I mentioned earlier knows this was a common recommendation.

00:12:09: It's about finding the right balance between good coil retention and not putting too much pressure on fresh surgical wound.

00:12:16: Your audiologist needs get comfortable making these real-time adjustments.

00:12:20: And fourth, room care protocols are essential.

00:12:24: The immediate inspection of the wound at activation is actually a benefit, not a drawback.

00:12:29: You're catching potential problems early or geologists need to know what to look for excessive swelling signs of infection or poor wound approximation.

00:12:39: they should have a clear pathway to consult with the surgeon when needed and from the surgeons perspective many report that they actually appreciate more immediate feedback about how.

00:12:53: Fifth, patient counselling is key.

00:12:56: Patients need to understand they might experience more awareness of the surgical site because it's so fresh.

00:13:02: They need to know about off-the-ear wearing options and they need clear instructions about wound care And red flags to watch for.

00:13:10: but here's what satisfaction data tells us.

00:13:13: when patients Understand these considerations.

00:13:15: They are still overwhelmingly prefer early activation Because other convenience and a reduced anxiety

00:13:22: Very good.

00:13:24: Can you tell

00:13:24: us about the evidence around clinical outcomes and benefits?

00:13:28: Yeah, let's talk about clinical outcomes because that is what really matters right.

00:13:32: The Good News is speech perception outcomes are equivalent between early in standard activation.

00:13:39: The New Zealand study found no differences in speech perception between their next day and three week groups.

00:13:45: Multiple other studies have confirmed this finding at six months nine months, and twelve months post-surgery.

00:13:53: You're not compromising outcomes by activating early.

00:13:56: you just getting to those outcomes much faster.

00:13:59: And there are some genuine benefits beyond just convenience.

00:14:03: First earlier access to auditory input means patients start their rehabilitation journey much sooner And for pediatric patients especially, though we haven't focused on them today there's a theoretical benefit related to brain plasticity and auditory development.

00:14:19: For adult patients it is about quality of life and reintegration into their auditory world.

00:14:26: Secondly patience and family anxiety are significantly reduced.

00:14:31: Think about the patient who has just had that surgery.

00:14:34: They're worried whether they'll be able to hear.

00:14:39: Every day of waiting amplifies that anxiety and the Parker Systematic Review specifically mentions this as a key benefit, reducing anxiety linked to delay in activation.

00:14:51: And third there are real logistical and financial benefits for patients traveling long distances.

00:14:57: combining surgery and activation into a single trip is hugely beneficial.

00:15:02: The New Zealand data showed patients travelling on average for about a hundred and ninety kilometres per visit, with some coming as far as six-hundred and ninety kilometers away.

00:15:12: When you reduce the number of visits – you're reducing their travel time….

00:15:16: …the accommodation costs... ...and the time away from work or school.

00:15:20: One study calculated that nonmedical financial burden had found early activation could significantly alleviate costs especially for patients in remote areas.

00:15:31: And fourth, there are clinical efficiency gains.

00:15:34: The New Zealand experience showed fewer total appointments and fewer hours of follow-up care needed in the first nine months.

00:15:42: That additional clinical capacity could enable more patients to receive implants.

00:15:48: At a time when demand for cochlear implant services is increasing that's not a trivial consideration.

00:15:54: Thank you Kelvin.

00:15:56: So where does this leave us?

00:16:00: Yes indeed, the evidence is very persuasive.

00:16:03: The new evidence in literature reviews are being published all of time from across the globe.

00:16:08: Recent papers supporting same day or early activation have been published for Middle East, Europe and Asia in recent years.

00:16:17: Early activation defined as within seven days an often implemented a same-day or next-day activation has proven to be both safe and effective.

00:16:28: Complication rates are low Electro performance is excellent, speech perception outcomes are equivalent to standard timelines and patient satisfaction is high.

00:16:38: As one reviewer put it all the factors mentioned previously favor early activation.

00:16:44: so based on that the question should be why not consider early activation?

00:16:49: The limitations we should acknowledge are primarily about long-term data.

00:16:54: Most studies follow patients for six to twelve months.

00:16:57: We could probably benefit from some longer term outcome studies, and we also need more standardization of protocols.

00:17:03: different centers define early activation differently And there aren't clear universal guidelines yet.

00:17:10: But here's my take.

00:17:11: if you're working in a center with minimally invasive surgical techniques experienced audiologists and good communication between your surgical and audiology teams Early activation is absolutely worth considering.

00:17:26: Start with the appropriate patient selection, make sure your wound care protocols are solid ensure you're audiologists are comfortable with device adjustments and troubleshooting And get feedback from early adopters and refine your approach.

00:17:41: The cochlear implant field has always been about innovation.

00:17:46: Early activation represents the next evolution in how we deliver these services.

00:17:51: More efficiently, more conveniently and with better patient experience or while maintaining excellent clinical

00:17:58: outcomes.".

00:17:59: Thank you Kelvin.

00:18:00: this has been great!

00:18:02: And thanks to you for listening.

00:18:04: if you want to dig into any of these studies in more detail We particularly recommend The Parker twenty-four systematic review as a great starting point and the Selveratnum and Tegel, twenty-four paper for a more practical implementation perspective.

00:18:21: So until next time keep questioning Keep learning And keep putting your patients first.