Cochlear implantation: Basic concepts. Everything you need to know about cochlear implants: features of installation and operation, manufacturers and prices Necessary examinations and surgery

What is cochlear implantation?

A cochlear implant is an electronic device that allows deaf people to hear surrounding sounds and speech. It consists of an inner and an outer part. The surgeon implants the inner part into the ear of a deaf patient. The outer part with the processor is located on the patient's ear and/or head. It picks up sounds, speech and transmits them through the scalp to the inside.

Cochlear implantation is a high-tech method of restoring hearing in deaf children and adults using a cochlear implant. It includes not only the surgical implantation of the implant in the inner ear, but also postoperative hearing and speech rehabilitation.

Cochlear implant surgery is surgery on the implantation of an electronic device (cochlear implant) in the inner ear of a deaf patient.

Hearing-speech rehabilitation after cochlear implantation is a set of measures after cochlear implant surgery aimed at developing the ability of a deaf patient to hear and recognize sounds and speech with the help of a cochlear implant. Includes adjustment of the cochlear implant processor, classes with a teacher of the deaf to develop auditory perception. In early deaf children, hearing and speech rehabilitation also includes the development of their native language, understanding the speech of others, oral speech, teaching parents to develop hearing and speech in a child at home.

Who gets a cochlear implant?

Cochlear implantation is done for people with bilateral deafness or 4 degrees of hearing loss (Fig. 1).

AT last years indications for cochlear implantation are expanding, and it may be recommended for a patient with residual hearing.

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At the same time, modern, correctly selected and adjusted hearing aids do not help the patient, because most of the hair cells in the cochlea are damaged. The decision on the appropriateness of the operation for the patient is made by a special commission at the cochlear implantation center based on the results of a comprehensive examination.

What is the difference between a cochlear implant and a hearing aid?

The hearing aid simply amplifies sounds and transmits them to the eardrum. A cochlear implant converts sounds into a series of electrical impulses that stimulate the auditory nerve using electrodes in the cochlea.

How is a cochlear implant made?

A cochlear implant (CI) consists of 2 parts - internal and external (Fig. 2).

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The inner part is implanted in the ear during surgery. After the operation, it is under the scalp and is not visible. The external part includes an audio processor with a microphone, a battery compartment and a transmitter that is held on the head over the implanted part of the cochlear implant with a magnet. In most models of cochlear implants, the outer part is similar to a behind-the-ear hearing aid that is worn over the ear and is not visible when covered by hair. There are models of cochlear implants in which all the components of the outer part are located in one housing (Fig. 3).

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The outer part is removed during sleep or bathing, like a normal hearing aid. There are models of cochlear implants, the outer part of which can be left on while swimming. The cochlear implant is powered by replaceable batteries, as in hearing aids, or rechargeable batteries. The cochlear implant processor is controlled using the knobs located on the outside of the processor or using the remote control.

How does a cochlear implant work?

The microphone on the outside of the cochlear implant picks up sounds and speech and transmits them to the audio processor (Figure 4). The cochlear implant's audio processor converts sounds and speech into a series of small electrical impulses and transmits them through a transmitter and receiver under the scalp to electrodes in the cochlea. These impulses stimulate the auditory nerve, which transmits these impulses to auditory centers brain. The auditory centers of the brain perceive these impulses as speech, music, sounds.

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What is the difference between different models of cochlear implants?

Currently, 4 major companies produce cochlear implantation systems: Cochlear (Australia), MED-EL (Austria), Advanced Bionics (USA), Neurelex (France). Models of cochlear implants from different manufacturers differ in the number of electrodes, the length of the electrode chain, speech processing strategies and many other technical characteristics (see the section "How to choose the right cochlear implant"). In modern multi-channel cochlear implant systems, audio signal processing strategies are the main characteristics of the cochlear implant that determine the intelligibility of speech perceived by the cochlear implant. All modern systems cochlear implants are multichannel and provide good speech intelligibility in silence. The latest cochlear implants provide better speech-in-noise and music perception.

How is the operation carried out?

The operation is carried out under general anesthesia and lasts from 40 min. up to 1.5 hours. This is an operation on the ear, not on the brain, so it is performed by an ENT surgeon in an ENT clinic. Most patients, including children, after the end of anesthesia on the same day can get up and communicate. The next day after the operation, the patient can move independently almost without restrictions. After 7-10 days, the bandage on the head is removed from the patient, the patient is discharged from the hospital and the patient can return to normal life, including work.

Which ear is operated on?

Due to the high cost of a cochlear implant, surgery is usually performed on one ear. Usually, surgery is performed on the hearing impaired ear so that the patient can continue to wear the hearing aid in the other ear. In some cases, the operation is performed on the better hearing ear. For example, if the patient has an anomaly or ossification (ossification) of the cochlea, or if the patient lost his hearing in childhood and wore a hearing aid in only one ear.

What are the possible negative consequences of the operation?

The risk of cochlear implant surgery is comparable to that of conventional middle ear surgery performed under general anesthesia. Among the most frequently encountered possible complications- dizziness, imbalance, pain, numbness around the implant, delayed wound healing, temporary change in taste. These feelings pass quickly.

Possible injuries during middle ear surgery facial nerve with cochlear implantation are extremely rare, due to the high qualification of surgeons performing these operations.

Cochlear implants are made from biocompatible materials, and cases of rejection of the implanted part of the cochlear implant are almost never encountered.

How long does a cochlear implant last?

The cochlear implant is intended for lifelong use. Manufacturers give a guarantee on the inside for 10 years, but this does not mean that after this period it will break. This is due to the fact that this technology appeared not so long ago and cochlear implantation systems are constantly being improved. There are patients who have been using a cochlear implant for over 25 years.

Elements of the external part (cables, microphone, audio processor) periodically fail and must be replaced. If the internal part breaks (rarely), a second operation is performed and the defective internal part is replaced. Currently, the government of the Russian Federation allocates funds for the planned replacement of the cochlear implant processor every 5 years for all patients.

Is it necessary to do a second operation if more modern models of cochlear implants are developed?

Developers are constantly improving cochlear implants, but the greatest changes occur in its external part. Therefore, some new models of external parts of cochlear implants can be used with the old model of the implanted part. Many patients have their old outer cochlear implant replaced with a more modern one. New models of the internal implantable part are also being developed. They are installed for new patients. If the patient wishes and the recommendations of specialists to the patient, the inner part can be replaced with a more modern model.

When does a person hear after surgery?

After the operation, the person does not hear. He can only hear when the cochlear implant speech processor on the outside is connected. It is connected 3-4 weeks after the operation, when the postoperative wound is completely healed.

How does a person hear with a cochlear implant?

After connecting the speech processor of a cochlear implant, a person hears even quiet sounds and speech, but does not recognize them. He does not understand speech, because the cochlear implant converts sounds differently, and not as it happens in a person with normal hearing. Late-deafened adults and children learn to understand speech in silence in 1-2 weeks if they see the face of the speaker, thanks to hearing-speech rehabilitation at the center. Rehabilitation includes fine tuning of the cochlear implant processor, classes with a teacher of the deaf, classes with relatives on the instructions of the teacher. In the future, the patient continues to learn to hear with a cochlear implant while communicating with other people, and speech perception with a cochlear implant improves within 1 year. Over time, many patients with a cochlear implant understand speech only by ear, communicate freely on the phone. The rate and degree of recovery of speech perception are different in different patients and depend on the duration of deafness, the age of the patient, the cause of hearing loss and the regularity of auditory speech training.

The patient with a cochlear implant also does not recognize surrounding sounds at first, but learns to recognize them faster - within a few days. The perception of music with a cochlear implant is the most different from how a person heard it before hearing loss. Rhythmic melodies are well known to a person with a cochlear implant, while classical music sounds unpleasant to patients using older models of cochlear implants. With the latest models of cochlear implants, patients perceive music well, play musical instruments.

Early-deafened adults learn to hear much more slowly with a cochlear implant. their auditory centers do not know how to process and memorize non-speech and speech sounds correctly, and there are no clear images of sounds and words in their memory. However, with regular classes on the development of auditory perception of surrounding sounds and speech according to the methodology developed at the St. Petersburg Research Institute of Ear, Throat, Nose and Speech, these patients learn to recognize not only surrounding sounds, which increases their safety and ability to navigate in the environment, but and partially understand the speech of other people. When conducting classes to correct pronunciation, their speech becomes more intelligible and natural-sounding.

How often do I need to visit the cochlear implant center?

Usually, the first time a patient comes to a cochlear implant center for cochlear implant surgery. After that, he comes for the second time in a month to undergo the first course of rehabilitation - connection of the cochlear implant processor, classes on the development of auditory perception with a cochlear implant. Then he is recommended to come for a correction of the cochlear implant speech processor setting every 6 months for 2 years. Subsequently, it is recommended that the processor and settings be checked annually or whenever there are any problems with cochlear implant use. Currently, some regional audiology centers are equipped with equipment for checking and adjusting cochlear implant processors.

Can a person with a cochlear implant use a phone?

Patients with a cochlear implant use a telephone, including mobile phones. Most late deaf patients can understand speech over the phone after 1-3 months. after using a cochlear implant. Sometimes they need repetition. Early-deafened patients learn to do this as their listening comprehension develops.

Can I play sports after cochlear implantation?

With a cochlear implant, you can ordinary life and play sports, including swimming, avoiding sports that involve hitting the head. The cochlear implant processor should be protected from shock, moisture, dust, just like a hearing aid. In the latest models of cochlear implants, you can swim without removing the outer part, usually using a special cover.

Can you fly with a cochlear implant?

Can medical procedures be performed with a cochlear implant?

With a cochlear implant, you can perform most medical procedures - x-rays, electrocardiography (ECG), electroencephalography (EEG), ultrasound diagnostics, etc. It is recommended to turn off and remove the outer part of the cochlear implant during procedures. There are limitations for magnetic resonance imaging (depending on the model of cochlear implants) and some types of magnetic and electrotherapy. Some modern models of cochlear implants allow the patient to perform magnetic resonance imaging without removing the magnet of the implanted part. Information about medical procedures with a specific cochlear implant model is provided by the specialists of the cochlear implantation center. Cochlear implant patients give birth like normal people.
1. To perform a cochlear implantation operation, the patient must apply to the regional (city, regional or regional) audiology center, where they must complete the documents necessary for the provision of high-tech medical care (HTMC). If the doctor confirms the diagnosis, in which cochlear implantation is recommended, the patient is issued documents to receive a coupon for the provision of VMP (quota). The center's audiologist can recommend cochlear implantation to the patient.
2. The patient must apply with documents for obtaining a coupon for the provision of HTMC to the regional health authority (department/committee/office/ministry of health). In some regions, the head of the audio center himself sends the documents to the health authority.
3. On the basis of these documents, the regional health authority draws up a coupon for the VMP, in which the institution for the operation will be determined. The patient can choose the center where the operation will be performed. To do this, he must write a statement. The desire of the patient is decisive.
4. The voucher for the provision of high-tech medical care is posted on the website for monitoring high-tech medical care, which is the same for the regional health authority and the cochlear implant center where the operation will be performed on the patient.
5. The patient is invited by the cochlear implantation center for the operation. At the same time, he must bring the results of standard tests necessary for the surgical operation (see the section "For Patients" - "Tests"). Usually, the patient needs to have several additional special examinations at the cochlear implant center before the operation (preoperative examinations carried out at the center are not funded from the budget and will be paid).
6. In the absence of an audiology center and an audiologist at the patient's place of residence, it is necessary to contact the ENT doctor of the polyclinic to obtain information on the procedure for providing high-tech medical care in the region.
7. The patient can independently come to the St. Petersburg Research Institute of ENT and undergo an examination to decide on the advisability of cochlear implantation. In this case, he himself pays the costs of the examination. Upon confirmation of the diagnosis, in which cochlear implantation is recommended, the patient is issued a conclusion (protocol) on the need for cochlear implantation. This protocol is also submitted to the regional health authority (department/committee), which draws up documents for issuing a voucher for VMP. In some cases, at the request of the department / committee of health, the patient must also provide additional documents from the medical institution at the place of residence.
CT of the temporal bones (the study should be performed on a tomograph with a slice width of not more than 0.6 mm).

In case of unsatisfactory quality of the above studies, consultations, they are carried out at the FSBI "SPb Research Institute of ENT" on a paid basis.

Where to go in St. Petersburg?

Routing of patients in need of cochlear implantation and subsequent rehabilitation in St. Petersburg: adults and children.

According to statistics, for every thousand newborns there is one with total deafness, and in the first 2-3 years of life, three babies lose their hearing. Behind these dry figures lies a human tragedy - the dearest person in the world will never hear not only the sounds of music or birdsong, but also ordinary speech. It is impossible to convey the despair of parents in words. That was the case until recently. But today there is cochlear implantation.

What is a cochlear implant?

If most of the cochlear receptors are damaged, even the best hearing aids cannot help a deaf person, a person hears only low-frequency sounds of medium and high volume, but high-frequency or quiet ones are inaccessible to him, speech sounds illegible. A child in such a situation will not be able to learn to understand speech by ear and even more so to speak. Only cochlear implantation can help such a patient - a system of measures using high-tech tools, which is aimed at restoring hearing.

History of cochlear implantation

The problem of amplifying sound with the help of electrical stimulation began to be studied back in the 18th century, but it was not until the 60s of the last century that an apparatus was first made that could be worn by a deaf patient. In 1978, the patient received his first cochlear implant. However, such interventions were performed only in adults with profound hearing impairment, and only since 1990 the age of patients has been gradually decreasing. At the same time, the single-channel analog devices, which only allowed to determine the presence and volume of sound, but did not make it possible to perceive speech, were replaced by a multi-channel system.

In Russia, the technique appeared in 1991, when the first implantations were performed with the participation of Ernst and Monica Lenhardt. In 1996, the implantation system of the Austrian company Med-El was registered, the number of operations is gradually growing and in 2000 their number reached 10. If earlier financing was provided as expensive medical care, then since 2003 Federal targeted programs have been connected. The active work of the staff of audiology and hearing aids contributed to the fact that many institutions were able to join the work. In 2006, the 4th generation implantation system was registered and the first operation was performed on a 9-month-old child. Today, most patients are children with congenital deafness. Cochlear implantation is performed in several leading Russian clinics as part of various programs. Currently, more than 200 interventions are performed annually - both for children and adults.

When is an operation needed?

Of course, it is possible to achieve good results in the rehabilitation of deaf children with early prosthetics and with the help of conventional hearing aids, using various deaf pedagogical techniques. But cochlear implantation opens up new possibilities - to perceive such sound frequencies that cannot be heard using a conventional device. With sensorineural hearing loss, the cochlear receptors are most often affected, meanwhile, the fibers of the auditory nerve are preserved. But for the occurrence of an auditory sensation, damaged receptors (hair cells) are not capable of converting an acoustic signal into an electrical impulse. This role is taken over by a cochlear implant. But, unlike previous years, today, thanks to the improvement of techniques and cochlear devices, the criteria for selecting patients have changed: concomitant visual impairment, cerebral palsy, mental retardation are not an obstacle to the operation. Cochlear implants are reserved for patients with borderline hearing loss (75-90 dB) if conventional hearing aids fail.

The intervention can be carried out at any age, usually from 12 months, although earlier is not excluded. In patients with congenital pathology or who lost their hearing in the first year of life, results can be achieved up to three years. In older children, the issue is resolved, taking into account psychological and medical indicators. In adults, the decision to have surgery is made based on the state of health.

People with recent sensorineural hearing loss, as well as with disease progression, those who have successfully used a hearing aid, as well as socially adapted, speaking people - in such patients a cochlear implant is most effective.

Contraindications for the operation

In some cases, a cochlear implant may not be helpful.

If the pathology is caused by damage to the auditory nerve or the central parts of the auditory analyzer located in the temporal lobes of the cortex and the brain stem. This can be caused, for example, by neuritis, as a result of a cerebral hemorrhage.
With calcification or ossification of the cochlea, which makes it difficult to insert the electrode into it, thereby increasing the likelihood of unsuccessful treatment.
Hearing loss for a long time, while the patient refused to use a hearing aid, or when compensation from its use is insufficient. In such cases, atrophy of the branches of the auditory nerve occurs.

Implants - from simple to complex

The cochlear apparatus, encoding acoustic information into impulse signals, transmits it directly to nerve fibers bypassing the damaged link. The operation to implant it has been carried out for more than 30 years. In the distant 60s of the last century, a cochlear implant with a single electrode was created to help deaf patients. And only in 1978 a multichannel cochlear apparatus was developed and implanted. Until the end of the century, the dimensions of the outer part were gradually reduced, modernized and today's models differ significantly from their predecessors. Today, devices have been developed for patients with developmental anomalies or anatomical features buildings inner ear. Also, for the first time in Russia, an advanced method of introducing an electrode was introduced, which makes it possible to reduce trauma and preserve the remnants of natural hearing. A stem implant has been developed for those patients whose hearing loss is caused by a lesion at the level of the auditory nerves. In modern models, 8-24 electrodes are used, in addition, studies are underway to install two implants: to date, about 3000 bilateral operations have been performed in the world.

Rehabilitation is an integral part of treatment

Cochlear implantation consists of several stages:

Candidate Survey
Surgical intervention
Rehabilitation

Preparation for the operation consists of an in-depth audiological examination. In addition, the conclusion of an otolaryngologist is necessary. Sensorineural deafness must be confirmed by audiometry and studies that indicate damage to the sound-perceiving apparatus. It is also necessary to exclude the pathology of the auditory nerve, in which the operation will be ineffective. Integrity eardrum is a prerequisite. In addition, it is recommended to perform computed tomography and magnetic resonance imaging.

A standard operation lasts about 1.5 hours, during which a cochlear implant is placed behind the ear and electrodes are inserted into the cochlea. During the preoperative examination, pathologies that prevent general anesthesia should be excluded.

Rehabilitation is an integral part of cochlear implantation. After cochlear implantation, when connecting a speech processor and setting up, it is necessary to teach the patient to perceive, distinguish sounds and use this knowledge to develop speech. In fact, rehabilitation is the longest and most difficult period.

Long rehabilitation process

Rehabilitation is carried out by a team of specialists, which includes audiologists, deaf teachers, otosurgeons, and psychologists. You need to be ready for classes according to special methods, for long tuning sessions, and consultations of specialists. Throughout life, the supervision of specialists is necessary, as well as periodic reprogramming of the speech processor.

Selection of candidates

Close attention is paid to the selection of candidates. With a deliberately ineffective intervention, not only the discredit of the method will follow, but also the collapse of hopes, which will lead to psychological trauma. Indications for implantation may be:

Bilateral sensorineural deafness
No improvement in sound perception with properly fitting hearing aids for 3-6 months
Absence of psychological and cognitive problems, as well as serious comorbidities

How much does a cochlear implant cost?

The cost of a cochlear implant includes diagnostic examination, operation and correction after surgery. However, it is possible to carry out the operation at the expense of financing within the framework of targeted programs from the federal budget. Referral of patients to federal medical facilities can be obtained from the regional health department.

The cost of cochlear implantation operation is about 1,200,000 - 1,300,000 rubles (price of cochlear implantation).But for citizens of the Russian Federation, it is paid by the state.

Problems of cochlear implantation in the Russian Federation

One of the main problems is the remoteness of the centers for patients, leading to a lack of adequate postoperative rehabilitation. However, in recent years, in order to bring high-tech assistance to the population, cochlear implantation by a mobile team has appeared. In this case, the selection of candidates, their full examination should be of paramount importance. There is also a question about the sufficiency of awareness of both specialists and parents of deaf children about implantation. For this, conferences are provided, there is a forum on the problem of cochlear implantation, media coverage. But despite the difficulties, cochlear implant specialists have hundreds of patients who have received a real chance to return to an active lifestyle, in which the world of sounds is a common thing.

The operation of cochlear implantation is a high-tech medical care and is financed by allocating quotas from the federal budget.

cochlear implantation Hearing restoration surgery, which involves the installation of an electronic system in the cochlea of the inner ear, which provides electrical stimulation of the intact structures of the auditory nerve. It is carried out with neurosensory hearing loss, accompanied by damage to a significant part of the cochlear receptors. The result of the intervention is the restoration of previously absent physical hearing. During the operation, a cochlear implant (a device that stimulates the auditory nerve with electrical impulses) is implanted behind the ear, and electrodes from it are inserted into the cochlea. Cochlear implantation is performed under endotracheal anesthesia.

Cochlear implants are designed to help restore missing physical hearing and improve social adaptation adults and children with sensorineural hearing loss and deafness. The operation is one of the modern high-tech techniques. In the process of diagnostic and therapeutic measures in preparation for this intervention, otolaryngologists, audiologists, otoneurologists, audiologists, deaf teachers, psychologists, speech therapists are involved. The installation of a cochlear implant is carried out with sufficient training of the patient and the motivation of the patient or (in the case of implantation of the device to a child) of his parents.

Implant device

In the course of psychological testing, learning ability, non-verbal development, and the state of the emotional-volitional sphere are assessed. An EEG of the brain and a consultation with a neurologist make it possible to identify contraindications from the side of the central nervous system. The otolaryngologist performs a number of special studies, on the basis of which he issues a conclusion on the morphological and functional state of the auditory analyzer. Otolaryngological examination prior to cochlear implantation includes audiometry, acoustic impedancemetry, promontory testing, otoacoustic emission testing, and auditory evoked potentials. To assess the condition of the scala tympani and its patency, an MRI or CT scan of the temporal bones is performed.

The decision to perform cochlear implantation is made on the basis of complex diagnostic data. Usually, an ear with severe hearing impairment is chosen for implant placement. In the case of identified violations in the temporal bone, preference is given to the unchanged or less modified side. Under equal conditions, as a rule, the right ear is operated on.

Methodology

Classical cochlear implantation is performed under general anesthesia and can last from 1.5 to 3 hours. An arcuate skin incision about 10 cm long is made in the behind the ear region. Skin and periosteal flaps are formed to close the implant body and provide access to the mastoid process of the temporal bone. After opening the mastoid process (mastoidectomy) through the posterior wall of the external ear canal creates access to tympanic cavity. The inner ear is opened - the scala tympani of the cochlea, into which an active electrode is inserted. A bone bed for the implant is formed in the temporal bone, and the device is immovably fixed. After inserting the electrode into the cochlea, the operation of the cochlear implant (its channels, acoustic reflexes of the stapedius muscle, etc.) is checked. After confirming the normal functioning of the device, the wound is sutured in layers.

In some cases, simultaneous bilateral cochlear implantation is performed. At the same time, independent cochleosystems are installed in both ears, which makes it possible to achieve a better threshold of hearing and distinguishing sounds. The cost of bilateral surgery is significantly higher than unilateral.

After implantation

The first testing - connecting and setting up the system is carried out a month after the operation. In the process of implant adjustment, the audiologist transmits sound signals of various volumes and tones to the speech processor through a computer. In this case, the patient subjectively determines the most comfortable auditory sensations. If a cochlear implant was performed little child, when setting up, they are guided by its reflex reactions. In the first month, the corrective adjustment of the implant is performed 1-2 times a week, in the future, one control adjustment is usually carried out per year.

A month after cochlear implantation, hearing and speech rehabilitation is started - audiological control, classes with a deaf teacher, phonopedist, speech therapist, psychologist. During surgery on patients childhood The active participation of parents in the rehabilitation process plays a significant role. The duration of hearing and speech rehabilitation increases with a large interval between hearing loss and cochlear implantation, as well as in prelingual patients. The most promising cochlear implantation in children. After surgery, lifelong follow-up is indicated. Periodically, patients undergo reprogramming of the speech processor or its replacement.

The cost of cochlear implantation in Moscow

This surgical operation is one of the modern high-tech interventions, performed by highly qualified doctors in specialized clinics and large multidisciplinary centers of the capital. Has a high cost. The price of cochlear implantation in Moscow depends on the type of operation (unilateral or bilateral), the type and manufacturer of the implant. Pricing may take into account experience and level vocational training the operating otolaryngologist, the form of ownership of the medical institution, the availability of additional services and other factors.

If the child wore hearing aids, then after the operation, he continues to wear the device on the non-implanted ear. After turning on the CI processor, the child should continue to wear the hearing aid with the CI. This provides binaural hearing, which improves the localization of sound in space, increases the noise immunity of speech perception in noise. In this case, it is necessary to reconfigure the hearing aid with the CI turned on according to the child's feelings (reducing the gain level, turning off high frequencies). It is also necessary to observe the mode of adaptation to the use of CI and a hearing aid. During the month, classes should be held only with CI. At the same time, the rest of the time the child should wear only CI (2/3) part of the time, and part of the time CI and a hearing aid. In some cases, this ratio may change. Later, the child constantly wears both devices, including in the classroom.

However, experience shows that many children soon refuse to wear a hearing aid. There are several factors that determine this. One of the main ones is the feeling of discomfort from a poorly made or inappropriate size due to the growth of the child's liner. The second factor is the small remnants of hearing on the non-implanted ear - in their complete absence, the use of a hearing aid is impractical. The third factor is the type of hearing aid used by the child - the sound from an analog hearing aid, especially a low-quality one, is very different from the signal transmitted by the CI. The sound transmitted by a high-quality digital apparatus is close to the signals transmitted by CI and is better integrated by the brain. Professionals and parents should make every effort to ensure that the child continues to wear a hearing aid with a CI.

CI models have now been developed that combine the use of CI and a hearing aid in one ear. These models are designed for people with good low-frequency hearing remnants, providing them with the best perceived speech quality.

3.3. Hearing-speech rehabilitation of children with a cochlear implant who lost their hearing after mastering speech Restoration of hearing-speech perception

Since the language system and own speech are already formed in postlingual or late-deafened children, postoperative rehabilitation, in addition to setting up the CI processor, mainly includes the restoration of auditory perception of surrounding sounds and speech with CI.

The speech signals transmitted by CIs are significantly distorted and differ from those stored in the memory of a late deaf child. This determines the main objectives of the auditory training program:

To teach the child to find a correspondence between the sound images of speech sounds and words transmitted by CI with those stored in his memory;

To teach the child to distinguish in new images of speech sounds the acoustic correlates of the differential features of phonemes - “voicedness-deafness”, the place and method of articulation, etc.

Accumulate in the child's memory new sound images of speech sounds, words, phrases, environmental sounds,

Classes on the development of auditory-speech perception begin immediately after the first setting of CI. On the first day there are 2 lessons lasting 30 minutes. with a break of 2-4 hours to adapt and correct the settings of the speech processor. As our practice has shown, the optimal duration of the course of hearing and speech rehabilitation for PLP is 3-4 weeks. In the first two weeks, it is desirable to conduct 2 classes (45-60 minutes per day with different teachers, then 1-2 classes per day. During this period, it is possible to sufficiently restore auditory perception and achieve stable values of the CI processor settings necessary for good intelligibility of perceived speech and its perception in various communicative situations, to correct existing speech disorders. with tinnitus, in which the ability to perceive speech is restored more slowly.

Training for the development of auditory perception with CI in PLP includes:

1. Training for the detection, discrimination and recognition of non-speech (everyday) sounds of the environment (tasks 1-6 are carried out from the 1st lesson).

2. Training to recognize words with different syllabic structures (one-, two-, three-syllable words, numbers) in a closed (limited) choice.

3. Training to distinguish between different signs of non-speech and speech sounds (number of sounds, long-short, loud-quiet).

4. Training to distinguish and recognize the sounds of musical instruments, sounding toys.

5. Training to distinguish and recognize isolated low- and high-frequency speech sounds (isolated phonemes [a], [i], [y], [s], [w], etc.).

6. Training in recognition of words with the same syllabic structure (three-, two-, or monosyllabic) and with different/same position of the stressed syllable (polysyllabic words) in closed choice.

7. Training for the perception of suprasegmental characteristics of speech signals (number of syllables, position of the stressed syllable, position of the highlighted word in the phrase, intonation of the sentence) (tasks 7-10 are carried out from the 2nd lesson).

8. Training to distinguish and recognize isolated vowels, as well as vowels in syllables of the SG type in the context of various consonants.

9. Training for word recognition in continuous speech with a closed choice.

10. Training for recognition of words with the same syllabic structure (three-, two- or monosyllabic), differing in vowels / consonants in a closed choice (from the 3rd lesson).

11. Training for distinguishing and recognizing isolated consonants, as well as consonants in syllables such as consonant-vowel, vowel-consonant-vowel (from the 3rd lesson).

12. Training for the recognition of words with different syllabic structures with an open choice (tasks 13-18 are carried out from the 4th lesson).

13. Training for the recognition of monosyllabic words with an open choice.

14. Training for distinguishing phonetic characteristics (vowel-consonant, sonority-deafness, place of formation, sonority, softness-hardness) in syllables and words.

15. Training to distinguish words in sentences with a well-predictable last word in an open choice.

16. Training for the perception of prosodic information in speech (interrogative / narrative / exclamatory intonation, position of semantic stress, emotional state of the speaker, identification of male and female voices)

17. Training in understanding familiar issues.

18. Training to distinguish words in sentences with a poorly predictable last word in an open choice (from the 7th lesson).

19. Training for the perception of continuous speech in a situation of open choice (from the 8th lesson).

20. Training in recognition of words with different syllabic structures (one-, two-, three-syllable) in a closed choice under conditions of external noise (20-25 tasks from the 10th to 40th lesson).

21. Training for recognition of words with the same syllabic structure (three-syllable, two-syllable, one-syllable) in closed choice in noise.

22. Training for word recognition in continuous speech (sentences) in closed choice in noise.

23. Training in understanding familiar questions in noises.

24. Training of perception of speech on the phone.

25. Training of sound source localization in space.

Restoration of auditory perception with the help of CI starts with simple tasks, moving successively to more complex ones.

The easiest task- is to detect if there is sound or not. In this task, the child is presented with different non-speech and speech sounds, of different loudness, frequency and from different distances. The child must say whether he hears this sound or not. He does not need to recognize this sound.

The second task in terms of difficulty- is the ability to distinguish between two sounds. To do this, the child is presented with two words (or two non-speech sounds, or two phonemes). The child must say what word he heard. The child can perform this task even if he learns only one word. For example, when the words “house” and “car” are presented, the child recognizes the word “car” well. When the word “house” is presented to him, he does not hear it clearly, but he definitely hears that it is not a “car” and answers correctly.

The third task in terms of difficulty- this is the ability to recognize sounds (non-speech and speech) in a situation of closed (limited) choice. In this situation, the child knows exactly which signals (words, syllables, sentences, phonemes, non-speech sounds) will be presented to him. At the same time, a list of these signals (or a set of pictures) lies on the table in front of the child. Answering, the child shows the heard word (sound, sentence, etc.) in the list in front of him or repeats it. In such tasks, the child can recognize the word, even if he does not hear it clearly, excluding those for which what he hears is unlike. At the same time, he should try to guess which word, from those lying in front of him in the list, the heard word looks like. The minimum number of signals that can be presented in this task is 3. An increase in the number of signals complicates the task.

Suggestions can be used as signals in this task. Compared to isolated words, this is a more difficult task, because at the initial stage, patients with CI analyze speech very slowly and do not have time to recognize words in continuous speech.

All these tasks begin with the presentation of auditory-visual signals - the child sees the face of the teacher, who indicates which word from the list he pronounces or sees objects that make sounds. After that, the signals (sounds, words, sentences) are presented only by ear.

In contrast, in open-choice tasks, the child does not know what kind of signals will be presented to him and cannot predict them. Therefore, he can rely only on his ability to hear. These tasks are carried out when the child performs the speech recognition tasks well enough in a closed choice of 10-12 words.

The first lesson begins with the restoration of the ability to detect various non-speech and speech sounds, identify the difference in their sound and identify them. For this purpose, the child is offered to listen to various everyday sounds, including non-speech sounds made by a person (steps, door creaking, strumming of a spoon in a glass, phone ringing, paper rustling, whistling, drumming, sound of a stream of water, coughing, blowing nose, etc. .), sounds of musical instruments (drum, pipe, whistle, rattle, xylophone, etc.). At the same time, real situations and objects are used with a preliminary attraction of the child's attention to the sound source.

In the same lesson, non-speech sounds, as well as speech sounds, are used to restore the ability to distinguish certain characteristics of sound signals: "loud-quiet", "one-many", "long-short", "high-low".

Speech perception training begins with distinguishing and recognizing isolated words and speech sounds in a closed choice situation. First, 3 words are presented. Previously, the child is presented with these signals auditory-visually - the child sees the face of the teacher, who indicates which word from the list he pronounces. If the child cannot recognize the word, you should ask him to try to guess which word of the words in front of him looks like the word he heard. Some children answer only when they are sure of the answer. And for the development of perception, it is important that they learn to make a decision about a signal (for example, a word) even in the presence of partial information. This is one of the basic principles of information processing in the brain. If the child learns all 3 words, the number of words is increased to 6, 9.12. The first words should also include the name of the child, the words "mother", "dad", "grandmother", the names of family members. Children, as a rule, are already able to cope with this task, and the realization that they already understand the words is very inspiring for them and their parents.

For the first 1-2 days, children may report that they hear speech with some delay. At the same time, they get the impression that the sound of the voice lags behind the articulation. Within 2-3 days, the child ceases to notice this discrepancy.

At the first lesson, it is also proposed to distinguish (when comparing in pairs) and recognize (when choosing from 3 or more) acoustically very different long speech sounds, for example, [a], [y], [w], [s]). They start with 2 signals, as the task is completed for different pairs of sounds, the number of signals is gradually increased.

In tasks with a closed choice in the first lessons, the speech material is first presented several times with visual reinforcement. Then the same task is performed without visual reinforcement only by ear. If the child makes mistakes, then it is necessary to return to the audio-visual method of presenting the material, and then continue without visual reinforcement. As the auditory-speech perception with CI is restored, the speech material can be presented immediately only by ear. First, the teacher pronounces the speech material at a slower pace and with clear articulation. Upon reaching a stable correct recognition of material spoken at a slow pace, the material is presented at a fast pace of pronunciation.

Each lesson should end with a task that the child is already doing well. This keeps him positive. This algorithm is used when working with different speech material. The teacher must first select speech material and have printed lists with a different number of signals of different types (isolated phonemes; groups of phonemes with common phonemic distinguishing features; syllables; words with different and the same syllabic structure; pairs of words that differ in one phoneme; monosyllabic words; sentences with good predictable and poorly predictable composition of words; questions; texts - Appendix 1).

When working with teenagers and children, it is very important to choose speech material that matches the age of the child and his interests. This material should also be diverse in terms of topics, linguistic composition, etc.

For homework, listening to songs that the child knew before hearing loss can also be recommended. Although CI distorts the melody of songs to a certain extent, their rhythmic pattern is accurately conveyed, and many children enjoy listening to their favorite songs and recognizing their lyrics.

In tasks with an open choice in the first lessons, an audio-visual method of presenting the material is also first used. Then the signals are presented only by ear. If the child does not understand the spoken word (or phrase), it is repeated. If he did not understand in this case, then he should explain to the child what was said by writing this word or showing the appropriate picture. After that, it is necessary to repeat this word again several times, so that the child perceives it only by ear. If the child named some other word instead of the one presented, then it is necessary to pronounce these two words in turn, giving the child the opportunity to compare the sound of these two words, to feel the difference in their sound.

When training the understanding of continuous speech, reading short entertaining texts (100-200 words) is used, while the student must repeat the sentences read by the teacher. If the student did not understand any word, then the teacher repeats the sentence or part of it, gives words - synonyms, etc., achieving recognition of this word by the child. If it is difficult to recognize a word, you can write it down and show it to your child. In this case, another approach can also be used: the child first reads the text on his own, and then the teacher presents sentences only by ear.

The most important role in restoring the perception of speech with the help of CI is played by classes to develop the ability to recognize individual speech sounds, because. this determines speech intelligibility. Due to the peculiarities of coding acoustic information of CI, individual speech sounds undergo significant changes. In order for the child to learn to recognize individual phonemes well, several types of exercises are used:

Distinguishing phonemes in paired comparison (with isolated presentation, as part of syllables surrounded by different sounds of speech, words). Start with vowels. (Attachment 1);

Recognition of phonemes when choosing from 3, 4, 5 or more (with isolated presentation, as part of syllables surrounded by different speech sounds);

Distinguishing and highlighting differential signs (voicing-deafness, softness-hardness, place of formation, vowel-consonant, nasal-non-nasal, etc.); This exercise is especially effective, because. contributes to the rapid development of the ability to distinguish individual phonemes. The greatest difficulty is the distinction between explosive consonants that differ in the place of formation /b-d-g/, /p-t-k/.

The ability to detect the presence or absence of a sound in a word and determine its position in the word;

Determining the correct and incorrect pronunciation of a phoneme in a word, etc. As a result, most children using CI with a fast coding strategy manage to achieve 90-95% of phonemic intelligibility in syllables.

Cochlear implants are usually performed in one ear. With such a monaural perception, the localization of sound in space is not an easy task for the PLP. To develop this ability, special classes are needed to localize the sources of non-speech signals and speech, which improves the child's orientation in space and adaptation in a changing acoustic environment. However, it should be borne in mind that even after training, the child's ability to determine the position of sound in space with one CI is limited, especially in the front-to-back direction and in noisy environments (outdoors, in a noisy room). As a rule, the child first detects the sound, begins to look for its source, turning his head in different directions, simultaneously identifies the sound image (for example, speech or car horn) and, first of all, determines from the situation where the sound signal comes from.

Since the speech signals transmitted by CIs are distorted, children take longer to process them. Therefore, children with CI, especially in the first year of using CI, are much slower to understand what was said, they need to repeat it several times before they understand what they hear. In this regard, in the process of auditory-speech work with a child, it is necessary to present speech material (words, phrases) for identification, pronouncing it at different speeds - first a little slower, with clear articulation, and then, after the child has exactly repeated what he heard - in a faster pace.

It is also necessary to conduct exercises to develop the ability to distinguish people's voices. At first, the voices of different people sound the same to the child, but gradually this skill develops, although he will do it worse than a normal hearing child. It is better to start with the fact that, when presenting speech material to a child, it is sometimes necessary to pronounce words in a higher or lower voice. The child should at the same time note a change in the pitch of the voice. Parents can also be involved in this exercise. Together with the teacher, they pronounce words or sentences (already worked out) in turn in a random order, and the child must find out who said it. Audio recordings with male, female, children's voices are also used. Parents conduct such exercises at home. In the process of these classes, the child recovers the ability to distinguish male-female-children's voices, the ability to distinguish between familiar voices. This ability is also important for the perception of the speech of one speaker against the background of several speaking people.

To train speech perception against the background of noise, you can use audio recordings with noisy speech material, speech perception against the background of music or the radio on, as well as talking on the phone. At the same time, one should also start with perception in a situation of a closed (limited) list, i.e. when the child knows exactly what signals will be presented to him (when talking on the phone, you need to write the text of the dialogue in advance). Training in speech perception in noise is an important stage of work, since PPLs have difficulty understanding in noisy environments even after wearing a CI for a long time. This is due to less information redundancy and, accordingly, the noise immunity of speech signals transmitted by CI, as well as a violation of the central auditory processes in a part of the PLP. In the course of such classes, the problems of speech perception in noisy conditions are discussed with the child and parents, methods of successful implementation of communication using alternative strategies that contribute to the psychological stabilization of the child in difficult situations.

It should be remembered that the process of listening and perceiving speech with CI requires a lot of tension and energy from the child. In addition, many children who have lost their hearing after neuroinfections have various neurological disorders (asthenia of the nervous system), central hearing disorders (impaired auditory memory, attention). Therefore, at first, children in the classroom quickly get tired. In this regard, in the course of the lesson, it is important to intersperse auditory-speech work with other types of correctional work, which rely more on other analyzers.

As a rule, after 3-4 weeks of intensive training in the development of speech perception with CI at the center of cochlear implantation, late-deafened children understand speech in most communicative situations. However, their speech processing speed with CI is still insufficient, and the child needs to continue classes with a deaf teacher at the place of residence 1-2 times a week for several months. The child also needs additional Russian language classes. At the same time, throughout the entire process of auditory-speech rehabilitation, the child's parents are actively involved in the process of auditory-speech rehabilitation - they daily work with the child on the instructions of the deaf teacher.

on our website there is the most popular one, where you can read a lot of useful information about CI from specialists and those who live with CI themselves

1. What is a cochlear implant and how is it different from hearing aids?

Hearing aids and assistive devices simply amplify sounds by making them louder, so even the most sophisticated hearing aids cannot help people with severe hearing loss.

In cochlear sensorineural hearing loss, the cochlear hair cells, which are responsible for converting the mechanical energy of sound into electrical impulses for the auditory nerve, die. But the nerve endings themselves function normally. The cochlear implant system is an electronic device that induces auditory sensations in the deaf by direct electrical stimulation of the nerve endings of the auditory nerve, thus simulating the work of dead cochlear hair cells.

Many years of research in the field of cochlear implantation have made it possible to work out and develop this technology. The first operations were carried out in the 1970s, and in the 80s the first multichannel devices appeared. At the same time, the first commercial operations were carried out.

Of course, the signals transmitted from the cochlear implant to the brain are different from the standard ones. In order to understand the speech addressed to him, a person will have to practice (rehabilitate) for several months according to a special program that will help give obscure sounds a specific shape and help the brain get used to the new way of sound delivery. To date, such operations are the only way out for people with severe and profound hearing loss who are not helped by conventional hearing aids.

2. Which is better for the deaf: a hearing aid or a cochlear implant?

It depends on many factors: the type of hearing loss, the degree of hearing impairment in the patient, his intelligence, degree of motivation, age, time and duration of hearing loss, as well as a number of other factors. The hearing aid helps the hard of hearing with hearing loss up to 80-90 dB. In turn, cochlear implants are more effective in cases of severe hearing loss and deafness in both ears, i.e. with a hearing loss of more than 90 dB.

3. What companies produce CI?

Currently, several firms specialize in the creation of CIs. It:

Cohlear (Australia)
Med'El (Austria)
Advanced Bionics (USA)
MHM (Neurelec) (France)
Nurotron (China)
iEnjoy Sound (South Korea)

In Russia, implants from Cochlear, Med`El, Advanced Bionics and MXM (Neurelec) are certified and are being installed.

In Ukraine, implants from Cochlear, Med`El, Advanced Bionics are certified and placed.

4. Which company is better to choose?

In principle, all firms are on an equal footing in the process of their technological development. Cochlear is considered the leader - also due to its prevalence in the world (about 70 percent of those implanted in the world). In second place is Med'El. However, in the US, for example, Advanced Bionics is the leader. According to the reviews of those who have been rehabilitated for a long time, the difference in the sound quality of implants from different companies is approximately the same. In any case, when choosing a manufacturer, you should proceed from your financial capabilities, the price of the system as a whole (as well as spare parts for it), and the presence of a tuner of this company in the area of \u200b\u200bthe place of residence.

5. What is the principle of operation of CI?

The cochlear implant system consists of an implant, an external speech processor, and external components such as a transmitter, cables, etc. The speech processor encodes the signal received from the microphone. The microphone converts acoustic signals into electrical signals.

Electrical signals are converted into a sequence of electrical pulses in accordance with a special coding strategy. The encoded signal is sent to the transmitter, which sends this sequence via radio signals through the skin to the implant.

The transmitter is worn under the hair behind the ear and is held in place with a magnet and earhook.

The implantable part consists of a ceramic or titanium body, a reference electrode (sometimes missing) and a chain of active electrodes. The implant contains electronics hermetically sealed in the housing. The impulses are fed to the electrode carrier for electrical stimulation of the auditory nerve.

The speech processor uses batteries that provide power to both external components and the electronics of the implanted part of the system through the radio frequency path. The implantable part does not contain batteries.

Functional Diagram of the Cochlear Implant System

1) sound waves received by the microphone.

2) The speech processor converts the acoustic signal into a rapid sequence of short electrical impulses in accordance with a special audio signal processing strategy.

3) The encoded signal is transmitted via cable to the transmitter.

4) The transmitter sends the signal and the necessary power through the RF path to the implant.

5) Electrical impulses stimulate various parts of the auditory nerve. The auditory nerve, performing its natural functions, transmits nerve impulses to the brain.

6) The brain receives nerve impulses and interprets them as sound, forming a sound image.

6. What is the cost of a CI operation?

The cost of CI depends on the manufacturer and model of CI. In general, you can focus on the range from 14 to 35 thousand euros for the device, operation and setup.

7. Do they put CI in Russia or Ukraine? Where exactly can CI be placed in Russia or Ukraine?

Yes, in Russia CIs are engaged in operations. Since CI is an extremely expensive device, the vast majority of these operations are paid for by the state as part of the provision of highly specialized medical care.

Operations are carried out:

Federal State Institution "Russian Scientific and Practical Center for Audiology and Hearing Prosthetics" (RSPCAiS)
Federal State Institution "Scientific and Clinical Center of Otolaryngology"
Moscow Scientific and Practical Center of Otorhinolaryngology
Research Institute of Neurosurgery named after N.N. Burdenko (on a paid basis)

Moscow region

Moscow Regional Research Clinical Institute. M.F.Vladimirsky (MONIKI)

St. Petersburg

St. Petersburg Research Institute of Ear, Throat, Nose and Speech
FBGUZ "Clinical Hospital No. 122 named. L.G. Sokolov FMBA of Russia "(MSCH 122)

There are also operations based on local hospitals by surgeons from Moscow and St. Petersburg, in particular, in Yekaterinburg, Ufa, Krasnodar, Voronezh and other cities.

In Ukraine, the situation is somewhat more complicated, there is a queue for operations, and mostly children are operated on.

Kyiv Research Institute of Otorhinolaryngology. A.I. Kolomiichenko

8. Is it possible to put CI for free?

Because CI is an extremely expensive device, the vast majority of these surgeries are paid for by the government through a tertiary care program.

However, in essence, the operation is not completely free, since funds are needed for:

Preliminary examinations to determine indications for CT;
hospital admission;
Setting up the device in the future, after the first session of settings;

For non-residents additional funds are needed for:

Tickets to the city (2 round-trip tickets - at least), if there is a disability, trips can be issued free of charge, since the state pays for the trip of a disabled person to the place of treatment;
Living in the city for 1-3 months in total;

9. How to get to the operation? What is needed for this? What is the procedure for referring a patient for examination for CT?

The direction of patients for cochlear implantation in federal medical institutions is carried out by the heads of the health authorities of the subjects Russian Federation, Ministry of Health of the Russian Federation and its structural divisions. The procedure for referring citizens to cochlear implantation (a type of high-tech medical care - VMP) is established by order of the Ministry of Health and social development Russian Federation No. 786n dated December 29, 2008 (Appendix 7) "The procedure for the formation of the state task for the provision of high-tech medical care to citizens of the Russian Federation in 2009 at the expense of the federal budget." (Note: The order is updated every year.)

The procedure for the patient or the child's parents is as follows:

Contact the attending physician (audiologist) at the place of residence.
To the committee (department, department, ministry) of health of the subject of the Federation from medical institution sent: a referral from the head of a medical organization (or an authorized official) at the place of observation and (or) treatment of the patient; extract from medical records the patient, containing information about the state of health and the examination and treatment carried out, recommendations on the need to refer to a medical institution for the provision of VMP, the results of clinical diagnostic examinations carried out according to the profile of the disease; a copy of the identity document of a citizen of the Russian Federation with data on the place of his residence or stay; certificate of compulsory pension insurance of one of the parents or legal representative (for children). The procedure for issuing a quota for high-tech medical care (HMP). The commission of the subject of the Russian Federation decides on the presence (absence) of indications for the planned referral of a patient for the provision of HTMC to a federal medical institution. The commission is held with the involvement of the chief full-time or freelance specialist of the executive authority of the constituent entity of the Russian Federation in the field of healthcare according to the profile of the patient's disease.
The protocol of the decision of the Commission of the subject of the Russian Federation is sent to medical organization, who sent the patient's documents, and to the federal medical institution.
The medical institution determines the date of the patient's call.
As a rule, all patients need an additional examination, after which the Commission of the federal medical institution makes a decision on the advisability of cochlear implantation.
After the examination, the patient's data is entered into the waiting list (queue), according to which the patient is called for surgery.

A citizen of the Russian Federation has the right to appeal against decisions made during the procedure for referral to a medical institution for the provision of HTMC at any stage. A citizen can apply directly to the health management body of the constituent entity of the Russian Federation, the department high-tech assistance Ministry of Health and Social Development.

Options for decisions of the Commission of the medical institution are given above, if necessary, for example, preliminary hearing aid, a decision can be made to conduct a re-examination after a certain period.

In addition, the patient can go directly to a federal cochlear implant facility for faster referral, or the patient can be self-supported by the center. In any case, the decision of the commission will be sent to the health authorities of the constituent entity of the Russian Federation, that is, the patient will be able to receive further referral for surgery at the expense of the Federal budget.

If the patient does not want to wait or is not a citizen of the Russian Federation, the operation can be performed on a self-supporting basis.

MED-EL Implants

MED-EL implants

The implant consists of a small body, a chain of electrodes and a reference electrode.