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As the life expectancy of the general population continues to increase, so has the number of people experiencing varying types of perceptual loss. One area of perceptual loss that is gaining more and more recognition is auditory functioning. The number of individuals experiencing a post-lingual hearing loss, or hearing loss after the acquisition of language, is increasing among the older adults in our society. This increase has facilitated a need for a means of managing such a loss of functioning. The group of people affected by hearing loss is by no means strictly limited to older adults. Pre-lingually deaf children and adults, as well as, postlingually deafened individuals can benefit from the technology that is currently being developed and refined for the management of hearing loss. The conventional hearing aid is probably the most common device pictured when thinking in terms of managing hearing loss. However, another option that may not be as well known is the cochlear implant.
The cochlear implant is a relatively new option in the management of hearing loss. Cochlear implants amplify sound, code sound into an electrical signal, and send those signals into the auditory nerve. The signal then travels to the auditory brainstem and onward to the temporal lobe of the brain for interpretation. The cochlear implant system consists of internal and external components. The internal components include a receiver, an internal magnet, and an electrode array. During a surgical procedure, a space is made in the mastoid bone behind the ear. This space holds the internal magnet and receiver. The electrode array is then placed in contact with the nerve endings in the cochlea. After implantation surgery, the skin and hair around the incision are allowed to heal for about five weeks.
Then the patient is fitted with the external components of the implant. These components include a microphone, an external transmitter coil, cords, and a speech processor. The microphone is attached to the ear by means of an earhook. The microphone picks up sound waves and sends them to the transmitter for convertion into an electrical signal. The transmitter coil is held in place against the patient's head by means of an external magnet that is attracted to the internal magnet. A cord connects the microphone to the transmitter coil. Another cord then connects the microphone to the speech processor. The speech processor contains a software program that determines how sound waves will be coded and transformed into electrical impulses.
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Individuals with cochlear implants have been the subjects of numerous tests and experiments focusing on the functioning of the auditory system. These studies include experiments dealing with how the pitch of sounds and voices is processed and with the recognition of words at normal speaking rates. Because the technique bypasses the cochlea and stimulates the auditory nerve directly, implant users can be studied for the loudness coding mechanisms of the human auditory system.
The electric stimulation and resulting loudness perceived by the subjects in one study was shown to depend on stimulus frequency and intensity. Zeng and Shannon (1994) propose a two stage model which suggests that high-frequency stimuli are processed by the mechanical mechanisms of the cochlea, and low-frequency stimuli are processed by neural mechanisms.
Other studies have focused on the abilities of adults with implants to discriminate pitch rank and scale as well as recognizing speech at soft and loud levels. Collins, Zwolan, & Wakefield ( 1997) focused on the ability of cochlear implant users to discriminate pitch in relation to the area of stimulation of each electrode in the array. The orderly progression of frequency bands along the electrodes was found to aid in pitch perception. In another study examining speech recognition (Skinner, Holden, Holden, Demorest, & Fourakis, 1997), ten post-lingually deaf adults were presented with vowels, consonants, words, and sentences under two circumstances; simulated, soft conversation and raised-to-loud vocal efforts. These subjects were found to communicate successfully in a variety of listening situations ranging from 50 to 70 dB. Situations of the conversational speaking level of 60 dB was shown to successfully simulate the speech perception of everyday life.
The recognition of simple, familiar open-set words in short statements has also been evaluated. The understanding of everyday words, improvement in lip-reading, and recognizing words and sentences are essential benefits to implant users. Factors found to influence word recognition include the sex of the speaker, rate of speaking, frequency of the vowel-consonant format of words, and duration of vowel sounds (Tyler, 1988). Other factors which influence the communication and perception of speech for implant users are acoustic cues and features. The acoustic cues in speech recognition include amplitude/time domain and the frequency domain. The reception features or articulation of words includes sounds with differing acoustical characteristics such as the stop consonants; b, d, g, p, t, k and the semi-vowels; w, r, l, y (Tyler, 1993).
Many of the studies conducted in relation to cochlear implants tend to focus on the effects of the implant on the existing auditory system, brain pathways, and structures. Although these areas of research are crucial for the continued development of technologically more advanced devices, many times the thoughts and expectations of the patient can be overlooked. The expectations of the recipients and their families are every bit as important as the electrical conductivity of the implant. Unrealistic expectations can be very damaging to the recipient. Realistic expectations of cochlear implant recipients include an enhanced ability to speechread or recognize speech using both auditory and visual signals. Some recipients can detect and recognize environmental sounds. Speech will sound mechanical in the beginning, and it takes time before speech will sound natural (Tyler, 1993). The cochlear implant, at this time, is by no means a Òbionic earÓ. People with cochlear implants should not expect a dramatic, overnight improvement in the auditory ability. Months of tuning sessions, practice recognizing and interpreting sounds, and aural rehabilitation may be necessary for even limited success with the cochlear implant.
Recipients and family members can also go through various stages in reaction to a diagnosis of deafness. These stages begin with shock and disbelief, then recognition of the deafness, followed by denial, and finally ending with acknowledgment and constructive action. The shock stage is often described as feeling of numbness in reaction to the diagnosis. The recognition stage is a time of recognizing the severity and repercussions associated with hearing loss. Denial is often characterized by visits to many different doctors in search of a differing opinion. The acknowledgment stage is very important because it is at this time that reasonable action and intervention can be considered. It is at this time that the cochlear implant may be introduced as an option for the management of hearing loss. This is also the time in which the expectations of the recipient should be addressed. The unrealistic expectations for implant users can be handled in various ways. Approaches to dealing with unrealistic expectations range from education and guidance to professional counseling (Kampfe, Harrison, Ottinger, Ludington, McDonald-Bell, & Pillsbury, 1993).
Another area where more research needs to be done is in the psychological assessment of prospective recipients. Prospective patients and recipients must examine a number of items during assessment. Individual testing and evaluations are necessary requirements to assess the suitability of the recipient. A test of reading is important in order to gain an idea of the patient's ability to read and comprehend words in written form. Measures of intellectual ability are important to insure understanding of the responsibilities involved in maintaining and caring for the implant. Personality questionnaires and self-concept measures are valuable in determining the mental state and capabilities of the patient for handling the problems, slow progress, and unrealized goals that are part of the adjustments to implantation. Major justifications for the psychological assessment of a prospective patient help in determining the patientÕs ability to cope with the involved procedure. The evaluation of the results of surgery and the collection of data for use in future studies are additional reasons for assessment. Recipients need follow-up assessment in order to ensure no psychological damage has been done. The recipientÕs psychological state should be monitored for improvement or decline. Individual benefits or disadvantages can be addressed with a professional other than an audiologist during this time. Emphasis is placed on recall, information processing, and the ability to attend to detail during these sessions. The personality, self-concept, and level of depression of the subject before and after implantation are all factors considered within the psychological assessment (Aplin, 1993).
With increasing technology, the face of the recipient of a cochlear implant is constantly changing. Pre- and postlingually deafened children and adults have all been shown to benefit in varying ways from the implant. In the future, cochlear implants may be paired with hearing aids for improved speech and environmental sound perception. The technology behind the cochlear implant has already led to the development of an auditory brainstem implant that bypasses the cochlea altogether and stimulates the auditory nerve directly. Genetic studies utilizing tissue cloning and regeneration may eventually make devices for the management of hearing problem obsolete. Until that time, however, the cochlear implant will remain in the forefront for the management of hearing loss.
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