Giving children the gift of hearing

  • Eimear Vize

Profoundly deaf children in Ireland will have the opportunity to receive hearing implants in both ears from next year, giving them the best chance to develop spoken language.

Ireland is one of the few countries in Europe that limits children to one cochlear implant (unilateral), which still offers significant gains in hearing and speech development but cochlear implants in both ears (bilateral) are recognised as international best standard - a fact acknowledged by the HSE in its National Audiology Review of 2009.

Approximately 350 children have already had one of these tiny complex electronic devices implanted at the National Cochlear Implant Centre (NCIC) in Beaumont Hospital. And at least 200 of them may be suitable for a second implant.

Health Minister James Reilly recently confirmed the Government's plans to introduce a new bilateral cochlear implant service from 2014, which would involve funding for children awaiting a second implant and simultaneous implantation for those who are born from here on.

Welcoming the news, Dr Laura Viani, director of the national cochlear implant programme, said she has been seeking funding from the Department of Health to get a bilateral programme in place at Beaumont since 2009.

Although the centre's 2013 business plan was turned down again last year because of budgetary restrains, Dr Viani and members of her implant team have been working behind the scenes meeting with health officials on a regular basis to progress their plans for 2014.

"They are certainly listening to us and we are all working together to progress this for next year so we can achieve the goal of offering bilateral cochlear implants to severely or profoundly deaf patients who fulfil the suitability criteria," she told

Responding to a call from Deputy Billy Kelleher in the Dail recently for this bilateral implant programme to commence as quickly as possible, Health Minister James Reilly said: "It has not been possible to implement the recommendations made in 2009 because of budgetary considerations but we are providing as many children as we can with single implantations in order that we can begin sequential bilateral implantations in 2014.

"High priority is being given to this matter and, without being a hostage to fortune, we will have provision to undertake the bilateral implantations next year in order to give children the best chance. I do not want any child to miss out on the opportunity to have bilateral hearing and the same chances as other children. The Estimates for this year do not allow us to immediately engage in bilateral implantations, although some have been carried out. It is a priority for me to start providing them next year and we will enter into negotiations with Beaumont Hospital in this regard."

HSE representatives also recently met members of the Happy New Ear Campaign - launched in January by parents of children who need second cochlear implants - to outline plans for the national roll out of bilateral implantation in 2014.

Dr Viani, a consultant ENT surgeon, founded the national cochlear implant service in Beaumont in 1995. That year, two adults and one child received implants. In 2012, approximately 90 children, adolescents and adults in Ireland had some level of hearing restored with cochlear implants.

To date, more than 700 patients have received cochlear implants in Ireland; primarily at the national centre in Beaumont but some children have also had their surgery in Temple Street Children's Hospital, where Dr Viani and her NCIC colleague Peter Walshe, ENT surgeon, run a consultant-delivered service.

"We've come a long way since the 90s," Dr Viani remarks. "Peter Walshe joined me in Beaumont in 2009. Over the years we've built up a team of audiological scientists, speech and language therapists, teachers of the deaf, clinical psychologists and administrators. We're very much multidisciplinary and we are probably the only service in this country that is totally public; we don't do any private work at all, which means you can be a king or a pauper, it doesn't matter to us."

A cochlear implant is a highly sophisticated electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of- hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin.

Cochlear implants bypass damaged portions of the inner ear (cochlea) and directly stimulate the auditory (hearing) nerve. Signals generated by the implant are sent by way of the auditory nerve to the brain, which recognises the signals as sound.

The target groups that could benefit from cochlear implantation include severely or profoundly deaf children, aged one - five years if spoken language has not been acquired or aged 6 - 17 years if spoken language has been acquired, and post-lingually deafened adults.

However, hearing through a cochlear implant is different from normal hearing and takes time to learn or relearn.

"I've asked a few adults, who have had normal hearing, what it sounds like to them and they said that, in the beginning, it sounds robotic but then over time it sounds normal; so the brain adapts," explained Dr Viani.

"We don't really know what pre-lingually deaf children are hearing but it can't be that robotic because if children are getting Cork or Limerick or Donegal accents, this means they must be hearing to quite a good level with their implant. It must be finer tuned than we actually realise.

"The level of hearing that is achieved can vary between patients. Some people might just get environmental sounds and then some children will hear speech and learn to speak very well. These are children who may not have learned to speak otherwise."

"The important issue for children is that they should be implanted within the first four years of life, if spoken language has not been acquired. A growing body of research has demonstrated that children who receive cochlear implants when they are very young make greater gains in acquiring age-appropriate language skills than children implanted when they are older. We would aim to implant as close to the age of one year as possible.

"With older children the outcome is less good. If, for example, a seven-year-old came to us having spent all her life signing and had never used hearing aids, it would be too late to use a cochlear implant because the auditory pathways diminish if they're not used."

Dr Walshe also highlighted the importance of early implantation, which provides exposure to sounds that can be helpful during the critical period when children learn speech and language skills.

"Much the same way that your brain gets feedback from touching, you get feedback from hearing. The brain has this neural plasticity up to about age five, so if the brain is not stimulated in terms of the hearing, if there is no sound travelling in through the different hearing pathways of the brain, those areas get taken over for other purposes. Basically, there's a 'use it or a lose it' time period, so the earlier you can tap into that neural plasticity the quicker and more effectively the brain adapts," he said.

Among international studies comparing the benefits of one versus two cochlear implants, the majority found patients had better hearing, significantly improve quality of life, and were better at communicating and localising sound when they had a cochlear implant in each ear.

"As a single national unit, we are affiliated with the British Cochlear Implant Group and abide by the NICE guidelines, as such the gold standard of treatment is bilateral simultaneous implants from close to one year of age for congenital deaf children, and then sequential implants for other children who are born congenitally deaf as well," said Dr Walshe.

This international best standard was acknowledged in the HSE national Audiology Reviews of 2009 and 2011. The latter report recommended that continued ring-fenced financial support be provided for the cochlear implant programme, but at levels that allow for simultaneous bilateral implantation for children.

"I understand that representatives from Beaumont Hospital, HSE management and the HSE's audiology clinical care programme have met recently to discuss a joint process to identify the options for developing and resourcing a programme of simultaneous and sequential cochlear implantation," Minister Reilly told the Dail recently.

"An important element of this process will be the development of clear clinical criteria to prioritise clients for assessment and follow-on implantation. Each child must be assessed to determine if he or she is suitable for a bilateral implant. The provision of information about the advantages and potential disadvantages of bilateral implantation is required to facilitate an informed decision on whether to proceed.

"Not all suitable patients proceed with the second implant when appraised of all the issues involved."

The Minister said the development of the service would require additional resources for Beaumont Hospitaland these resources would be progressed through the HSE 2014 Estimates process," The Minister said


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