On the Ear Ep 42
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[00:00:00] Dakota Sharp: You're listening to On The Ear, an audiology podcast sponsored by SpeechTherapyPD. com. I'm your host, Dr. Dakota Sharp, AuD, CCC-A, audiologist, clinical professor, and lifelong learner. While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general.

[00:00:35] Dakota Sharp: This podcast aims to explore the science of hearing, balance, and communication with a variety of experts in hopes of equipping you with the skills. To better serve your patients, colleagues, and students. So let's go. We are live and on the ear brought to you by speechtherapypd. com.

[00:01:02] Dakota Sharp: For children and adults with profound hearing loss, a cochlear implant is a proven and effective tool for restoring audibility. We know how to counsel patients and families, how to program the device, and can reasonably estimate what outcomes are to be expected. Of course, it works by way of bypassing any damage to the cochlea and stimulating the auditory nerve, but what if the problem exists at the level of the auditory nerve?

[00:01:25] Dakota Sharp: How does this change our approach with a cochlear implant? Well, today's guest is going to explain just that. Dr. Melissa Anderson, AuD CCC-A, is an audiologist and clinical assistant professor at the Children's Cochlear Implant Center at UNC. AKA one of my amazing coworkers. She received her doctor of audiology degree from the university of Florida,

[00:01:43] Dakota Sharp: go Gators. I think and her interests include patients with cochlear nerve deficiency and other complex anatomies, as well as advanced mapping techniques. She's also interested in ways to expand telehealth options and audiology to help reduce barriers to care. Just to note, I'm host of On the Ear and receive compensation from SpeechTherapyPD.com and Dr. Anderson received compensation from SpeechTherapyPD.Com for her contributions to today's presentation. So, Melissa. I've been nagging you to join me for an episode, probably within the first few months of me starting at the CCIC and we're finally here. Thank you so much for joining me. 

[00:02:16] Melissa Anderson: Well, thank you for having me.

[00:02:18] Dakota Sharp: So this is a topic that I think interests so many people, not just cochlear implant audiologists, but students especially, they always want to know more about the complex cases and they want to bring those up and I feel like CND when it comes to the cochlear implant world is a up there with about as complicated as you can get.

[00:02:37] Dakota Sharp: Is that fair to say? 

[00:02:38] Melissa Anderson: Yeah, I would think so. 

[00:02:40] Dakota Sharp: So tell me a little bit about how you came to work with cochlear implants in the first place, before we get into sort of your, we know cochlear implant audiology is niche, but being like a CND CI audiologist is the niche of the niche. So how did you even get into cochlear implants in the first place?

[00:02:55] Melissa Anderson: I got into cochlear implants. I've always wanted to do cochlear implants since I was 14 years old. And I heard about them actually through an audiologist at the Children's Cochlear Implant Center back before it was even called that and immediately just was amazed by what that technology could do for people with hearing loss or especially those more severe hearing losses.

[00:03:14] Melissa Anderson: So even just in high school started kind of looking into them and learning more about them. Carried that through all the way through grad school and then kind of fell into programming CND just by chance just have a lot of patients who had CND and then just kind of expanded that into research and ways to better help them and just kind of learn more about that malformation and how we can still help them with sometimes with the cochlear implant.

[00:03:39] Dakota Sharp: Yeah, so at the time that you were, and I mean, you're, we're like near the same age, so we, you've been doing this a little bit longer than I have, but at the time, I mean, was there a lot of information? What kind of background did you have on CND kind of in those first few cases as they were coming in?

[00:03:54] Melissa Anderson: Not a lot. There wasn't much research out at the time when I first started seeing cases with CND. There's definitely been more and more, you know, as we've learned more as a field, just about cochlear imprints in general, and more complex anatomy. I think more people are being more willing to implant patients with CND because historically that was considered to be a contraindication to the device.

[00:04:18] Melissa Anderson: And honestly, I just kind of started experimenting a little bit with mapping and doing things that made sense when you kind of think through it. But just kind of trying and seeing what, what helped and what worked and had some successes and just kind of kept moving forward with that. 

[00:04:34] Dakota Sharp: Awesome. I'm hoping tonight we'll have a chance to kind of dig into some of those like interesting mapping techniques and things that have, have been working for you.

[00:04:41] Dakota Sharp: Before we do though, just for, so we probably have, probably I would assume listeners have at least a background of how a cochlear implant is providing sound to someone, but what do we need to keep in mind when it, as it relates to stimulation for someone with CND, like what is happening physiologically that's different in that case that we might need to explain to a patient or family?

[00:05:01] Melissa Anderson: So I think the biggest thing is thinking about Where that stimulation goes once it leaves the cochlear implant. So we're sending that electrical current. Where is it going? And essentially it's going to the nerve. So if there isn't a nerve or that nerve is reduced or smaller you know, how is it going to get to the brain?

[00:05:20] Melissa Anderson: And I often talk to patients about it being a bridge. So the nerve is the bridge from the ear to the brain, or in this case, the cochlear implant to the brain. So if that bridge is damaged in any way, or not there. That's going to compromise the signals ability to get there. Or this, you know, speech is ability to get there.

[00:05:38] Melissa Anderson: And I think that's the biggest thing you have to think about with CND and cochlear implants is how damaged is that bridge. And that's really kind of the biggest piece in. CND is thinking about it that way. 

[00:05:52] Dakota Sharp: Gotcha. Yeah. I think that's a helpful like visual for, for people to hold on to, to help.

[00:05:57] Dakota Sharp: Cause again, that's probably one of the biggest things. And I guess this is a, this is a good thing to transition to actually before I get to that, but more just thinking about counseling aspect of it. With cochlear implants in general, there's a ton of counseling, but definitely with these more complex cases.

[00:06:09] Dakota Sharp: And I think, I think you're so right too, about where is the stimulation going? Because for, for patients with CND. I mean, they're more likely to have other malformations too. That might mean that their cochlear implant isn't exactly in the same place that it's supposed to be or that it might be for someone with normal anatomy, like, like charge, for example, they might have a cochlear malformation plus CND.

[00:06:27] Dakota Sharp: Have you seen much of that kind of combination? 

[00:06:30] Melissa Anderson: Yes, absolutely. I, if you have CND, you are more likely to also have something going on with your cochlea. I think, and I don't have the exact percentage off the top of my head, but the percentage of patients that only have CND is pretty low.

[00:06:42] Melissa Anderson: There's generally speaking, something else going on. So, you know, are you using a shorter array? Is there not full insertion? Is the position of the array not as maybe ideal? You know, are you kind of having to overcome some of those other things? And then you mentioned charge. There also is a much, for patients with CND, they are much more likely to have a syndrome than to be non syndromic.

[00:07:04] Melissa Anderson: So syndromes obviously come with not just other things with the ear, but other things with the whole body. So is there any kind of cognitive delay you know, other physical needs that they're having to overcome, which obviously can affect the potential for outcomes. 

[00:07:17] Dakota Sharp: Gotcha. Yeah, good thing to keep in mind.

[00:07:19] Dakota Sharp: And that actually kind of leads me into a little bit more of like the counseling discussion because I mean as audiologists who work with cochlear implants, I mean we see children super super young I mean, they're often referred to us well before they're even, you know insurance or FDA was allowed to get an implant.

[00:07:35] Dakota Sharp: Oftentimes we'll get that referral before imaging has even happened, right? So we might not know family might already be on this kind of like, Oh, here's our expectations for an implant and then get imaging news that kind of changes. Well, how we have to counsel that. So would you mind sharing kind of what that process looks like?

[00:07:51] Dakota Sharp: Like how do families find out about their nerve status, right? Like how does, how does CND get communicated, I guess, to the family usually? Yeah. 

[00:08:00] Melissa Anderson: I think it's probably quite the spectrum of how they find out with, you know, kind of online medical records that people have access to. Sometimes patients find out the same time as us or even before us, because they'll go see, you know, a radiologist reads it, publishes this report and can be sent to the family immediately.

[00:08:19] Melissa Anderson: So I don't think it's uncommon in this day and age of, of that kind of electronic medical records that you get this phone call, Hey, my imaging says this, what does that mean? And so then you're kind of having to Play catch up because maybe you haven't read that imaging report. I've certainly have patients who have arrived in my office who did not know about their imaging until I'm the one who's having to kind of break that news and do that counseling, which especially kind of, like you mentioned, if I've already seen the patient for cochlear implant, like that initial eval, and we've done some counseling, we've talked about some things and then, you know, talked about potential outcomes.

[00:08:53] Melissa Anderson: Then they go get imaging. Then we have to have that discussion afterwards. You, you kind of find yourself backtracking, which can be difficult. I think in a perfect world, everyone would have imaging before they got to us, but I won't speak for other hospital systems, but, you know, getting in for an MRI is not an immediate thing, at least in ours or any that I've worked in.

[00:09:12] Melissa Anderson: So sometimes we do see them first and then have to kind of, you know, Okay, now we have to have this imaging discussion. Obviously sometimes it's the surgeon who is, you know, having that discussion with them, but I think the bulk of the counseling in terms of what outcomes to expect what language modality to choose, a lot of that is coming from the audiologist and when you think about language modality, the speech pathologist as well.

[00:09:36] Dakota Sharp: Yeah, absolutely. Yeah, that's actually one of the things I'm hoping we'll touch on tonight, too, is kind of the what the team looks like when in managing kids with kids. And I guess I should say kids and adults with CND. You and I both exclusively work with kids. It's so hard to not be in that mindset.

[00:09:49] Dakota Sharp: So we're just going to have this conversation be mostly pediatric focused. Okay, so then what? Like, I totally agree with you. My hope would be that they're managing physician would be the one to discuss, you know, their nerve status, right? But oftentimes, I shouldn't say oftentimes, but sometimes it falls to the audiologist.

[00:10:06] Dakota Sharp: What does that conversation look like for you? I mean, how, how differently are you having to counsel, you know, expectations in this situation? 

[00:10:14] Melissa Anderson: I think when I have a patient who's diagnosed with CND that I'm kind of the one breaking the news. I really like to spend a lot of time talking about ear anatomy, more so than I would for a patient who has normal ear anatomy.

[00:10:25] Melissa Anderson: I might just kind of like, Okay, outer middle, okay, now let's talk about your inner ear, and then talk about cochlear implants, and don't really spend a lot of time talking about ear anatomy. The actual like ear as much versus with CND. I'm like pulling out the picture of the ear. We're walking through all of it.

[00:10:41] Melissa Anderson: And we're talking a lot about the nerve and how important that nerve is. And then talking about the imaging results. Okay. So now that we know that we don't have this nerve, that bridge is not fully functional. Now we got to talk about what a cochlear implant can do and what it can't do. And you just spend more time talking about kind of what it can't do.

[00:11:04] Melissa Anderson: And I think the biggest thing when counseling that is knowing that that's a lot for a family to process. So there's definitely been times where I've just kind of had to just stop and just sit there and you know, sometimes parents cry or just need a moment to process, need a moment to talk with each other.

[00:11:19] Melissa Anderson: So. Sometimes I'll ask families like, do you just need a moment? I can just step out or just kind of, it depends on the case and, and how fresh that news is and what they've been told about cochlear implants. Cause the other thing, at least for a lot of our patients, they've already been in touch with early intervention or beginnings you know, two groups at North Carolina that kind of go in and chat with families. So they may have already heard about cochlear implants from A professional outside of kind of what you would think of as the Mormon. 

[00:11:47] Dakota Sharp: They're amazing. They're easy peasy. 

[00:11:49] Melissa Anderson: Oh, yeah. You know. They're going to get there. 

[00:11:52] Dakota Sharp: Which, by the way, is mostly true, right? Yes. We don't want to get a bad rap here, but I'm with you.

[00:11:57] Dakota Sharp: Yeah. Definitely. Yeah. Expectations can be swung hard in a direction that's not very realistic. Before we know. Yes. We kind of, what's, what's the phrase? Like you put the cart before the horse. Yes. A little bit on that one. Okay. 

[00:12:08] Melissa Anderson: Yep, exactly. So sometimes you're having to be like, well, that is true for most patients, but for your child, and that's always kind of a difficult conversation too, because no parent wants to hear. That their child is different in that way. You know, they, they want to hear that their child's going to be fine. It's going to talk like that kid that, you know, that person was telling you about, or that kid they saw in the store, that's what they're looking for. A lot of times when they come to our office, so breaking that news, that that's not really feasible can be really difficult. And so it's just kind of letting the family process that. And then I like to, I, I tried to do this with my patients in general, but definitely for ones with CND is kind of make sure we do have that second touch point or sometimes third or fourth touch point before surgery just so that way we're all on the same page.

[00:12:54] Melissa Anderson: They've gotten to ask all their questions you know, as they're processing everything. 

[00:12:59] Dakota Sharp: Yeah, and I think that's a good point, too. I think back, there's, there's an episode with a parent that kind of talked about the grief process and the acceptance of their child's hearing loss. So you have to imagine some of these families have kind of been on that journey. They've maybe may had some acceptance and are now hopeful, right? Like they've gone through the phase and now it's like, A whole new thing to deal with, right? A whole new blow to their expectations, right? So yeah, that, that definitely can be a difficult part of the conversation. I mean, these days, I mean, maybe it's evolved, but what, what do these days do those conversations about outcomes look like? Like, are we, It's so variable. I know that's probably going to be your answer too, right? And then we can, that's somewhat true. And it used to be more true for cochlear implants in general. Now we can like really swing way more on the positive outcomes. Where are we right now? How has that conversation evolved for you?

[00:13:48] Dakota Sharp: Maybe from the first few cases you had to today in terms of what you say about, okay, this is what you can expect for your child. 

[00:13:55] Melissa Anderson: I think when I first started with this, it was much more like, they're going to get nothing from it. We can do this if you really want to, but like, they're not going to hear. And I've kind of more evolved in that. There is a pretty decent chance for sound awareness. And you know, the research that I participated with it various other people at UNC that we're looking at about 60 percent that get at least something. So now that might just be sound awareness versus speech perception. Yeah, there is advantages to sound awareness from a safety perspective.

[00:14:26] Melissa Anderson: They're going to hear that fire alarm. They're going to hear that truck coming up behind them. They might be able to hear that someone's calling them. And then going all the way to, we do have some patients that have full open set and while there are some variables that are predictive for that, Certainly not predictive enough that I would counsel someone like, Oh, we saw this on your MRI.

[00:14:46] Melissa Anderson: You shouldn't get one. And I mean, there are situations, especially when you think about cochlear malformations where you have CND in a super, super severe cochlear malformation where we might not even be able to get the cochlear implant in. Obviously, those patients aren't candidates, but it's For a lot of patients, it is worth the shot to do it.

[00:15:03] Melissa Anderson: It's just making sure that family is really fully informed about that. This is a gamble. We don't know. And that's something I think I find myself saying a lot in my CND counseling is that we don't know. We do not know how well they'll do. And even three or four years into the process, when you think about like a little baby, who's getting this, it might be. five or six years into the process before we really know what their potential may be because language development hasn't happened yet. So it's hard to know when you're going to hit that plateau. 

[00:15:37] Dakota Sharp: Yeah. That's, that's a great point. I think when we think back to the imaging conversation too, how that plays into expectations, because you might have somebody where they, where the radiologist, whoever, you know, describes the images like cochlear nerve, aplasia.

[00:15:51] Dakota Sharp: There's no nerve at all, right? Or we hear families will bring in the term and we use the term of a wispy nerve, right? Like there's a little something there, right? And I think those maybe don't affect outcomes as much as we predict. Is that fair to say? Like, just because it's read as cochlear nerve aplasia doesn't mean you might not still have, you know, detection or whatever we can expect from that ear, right?

[00:16:15] Melissa Anderson: And so that's, again, when we go back to some of the research that I've participated in If you have aplasia versus hypoplasia, you are more likely to be one of those non users or not have stem. That being said one of my patients who does pretty well with his implants he's one of those kids who does have open set, his, his imaging read aplasia.

[00:16:38] Melissa Anderson: So even though it is predictive in the sense that you're more likely to fall into that group, it doesn't mean you will. There are those kinds of weeks. We teasily call them unicorns. There are all those unicorns who do surprisingly well, despite what their imaging says. 

[00:16:55] Dakota Sharp: Yeah. And this is one of those tricky categories too. I'm curious how it plays into your counseling discussion with families. Like, do you find yourself wanting to mention the unicorns or do you find yourself not wanting to, like, how much do you want to, you know, impact expectations with these miraculous stories, right? Like we want to share these, but we also don't want to have, you know, false hope or, you know, poor expectations.

[00:17:17] Melissa Anderson: Yeah. And that's, I definitely, I struggle with that, especially when you see these families grieving. I just think, you know, I'll speak for myself. I got into audiology with the desire to help. And I think a lot of people did, right? That's what you want to help patients. You want to connect with these families and, and bring them that hope.

[00:17:35] Melissa Anderson: I mean, that's a lot of what cochlear implants is, right? It's like, get this technology. There's hope that your child will talk. And with CND, you have to kind of, you know, War with that inside yourself that you don't want to give too much hope because one of the big things that you recommend is also a visual language.

[00:17:51] Melissa Anderson: So if you're like, don't worry, your child will talk, but also you need to sign that's kind of mixed messaging. So I spent a lot of time talking to families, the, the. When we look at patients, one of the most likely outcomes is just sound detection. So I think I spend a lot of time talking about that and then talking about that even if they do get a little bit of speech, it's not going to be full open set.

[00:18:13] Melissa Anderson: It's going to be, you know, maybe they have some common phrases, maybe they can understand their name. You know, those types of things that that would be like best case scenario, they might get that. But most realistically, They're going to get some sound awareness. And that is where I do use the imaging piece too.

[00:18:31] Melissa Anderson: For the kids that are aplasia, I'm like, they may get sound awareness. They may get nothing. And I kind of focus more on that versus hypoplasia. You can kind of also talk about like maybe a little bit of open set. And it's just kind of counseling the families very realistically, because I would rather have somebody pleasantly surprised that their child can speak then upset that I had promised they're going to do something that they're just never going to be able to do.

[00:18:56] Dakota Sharp: Yeah, that's a great point. That's a great way to approach the counseling too. Where do you find most families are kind of on that spectrum? I guess maybe when they first see you. Hopefully by the time you're done talking to them, they're very much on the realistic expectations route. But where do you find just kind of families these days are at in that process when you first kind of describe what to expect?

[00:19:15] Melissa Anderson: I think when they first come to see me, a lot of them are, they just don't really understand what it is. So, you know, even if they've read that imaging report, they're like, we didn't really know what that meant. And then you have kind of the other end of the spectrum where you have the families who've Googled what that meant.

[00:19:28] Melissa Anderson: And they're like, well, what's the point of getting this? So, yeah. It's, it's really just educating about what it is, what it can do, what it can't do kind of really, really, really basic. And then as we go through the process, I feel like I started getting the questions of like, so will they ever be able to talk?

[00:19:45] Melissa Anderson: Will they ever be able to hear me? And you kind of have to say, well, we don't know yet. And that's kind of going back to the, like I said, I feel like that is. Probably the biggest thing that I say in those counseling appointments is, I don't know. Yeah. Which is always an uncomfortable place, I think, for healthcare professionals to be.

[00:20:00] Melissa Anderson: We want to know.

[00:20:01] Dakota Sharp: Absolutely, yeah. 

[00:20:02] Melissa Anderson: But we just don't. 

[00:20:05] Dakota Sharp: So kind of thinking back to that aplasia, hyperplasia, just like the imaging aspect of things, I feel like it's something that's pretty often overlooked in the audiology world. Like in my, you know, In my schooling, we didn't really get it. We didn't really talk about what you might see when you talk about MRI versus CT, like literally what are the differences there, but not like, what are the physicians looking for and how is that going to impact what you expect with this? You know, XYZ, you talk about syndromes and they might cause this thing, but you don't really get too much into like the imaging aspect of it. I'm just curious how that has played. I just feel like as people who work with cochlear implants, it's on my mind all the time. Like, okay, I know you have this malformation, so that's going to impact like that could impact, you know, what your programming looks like and what your outcomes could be and I'm curious how that's played out for you. Just in your role as an audiologist and implants, where does like imaging kind of fit into the picture for you? Cnd or not? 

[00:20:59] Melissa Anderson: I think it's something as I've gone through my career I've put so much more importance on just as I've learned more and then just my interactions with surgeons and things like that, that like, I would say just in general in my day to day when I go to like see a patient just any patient.

[00:21:17] Melissa Anderson: I like, you know, look through the past notes and see what we've done. And then I'm like, and what was your imaging? Cause whether it's something more simple, like EBA or something more complex, like CND, like I want to know that before I walk in. So I think. Even just some patients who, you know, I may have seen, but it's been a while.

[00:21:34] Melissa Anderson: It's like, I want that refresher on what your imaging is. And then I've also found myself like, cause we work with students. So I'll have grad students who are working with me and I'm giving them the history and the patient. One of the first things I tell them is the imaging. If it's normal, I don't usually specify if it's normal, but like, if we're like, we're going to see, go see this patient, they're IP one, and we're going to go see this patient, they're CND.

[00:21:54] Melissa Anderson: And I just find myself using those terms with students more and more and more as I've moved through my career. And then I think I'm also counseling it a lot more than I ever used to now with families. Cause I think when I started, It just wasn't something that was on my radar as much. And now before I see a family for the first time, I'm like, I want your imagery report.

[00:22:17] Melissa Anderson: And if I don't have it, cause they haven't had their scan yet. I spend a lot of time on my counseling daily, pending imaging, you know, with a little asterisk to everything. However so I think, I think it has become much more prominent in the field probably as a whole, but definitely for my own personal work is, is kind of the reliance on that piece.

[00:22:39] Melissa Anderson: And just even my communications with the surgeons are very imaging aware, I guess. It's like, okay, we need to talk about this before we do XYZ. Let's look at the imaging before we do XYZ. 

[00:22:51] Dakota Sharp: Yeah. So on that note, who is primarily making up the team? If you're thinking of like a child with CND, you mentioned they're more likely to be syndromic.

[00:23:01] Dakota Sharp: So we'll probably have other professionals involved. Like if you have a case that comes to mind, like what kind of professionals are you having to keep communication with to, you know, provide really good care. 

[00:23:10] Melissa Anderson: Yeah. So, I mean, you have kind of what you think about as your kind of core team, audiologist, surgeon, and speech language pathologist.

[00:23:16] Melissa Anderson: You know, if we're looking at a child under three, we're incorporating early interventionist, a child at school age, you know, school audiologist, school speech pathologist, teacher of the deaf. But then you also kind of have to think outside of that, because that group that I just mentioned, Those are people who probably have a better understanding of what CND means.

[00:23:34] Melissa Anderson: So they know, okay, they have a cochlear implant, but they have CND. That's going to mean this for outcomes. But a lot of these kids also are working with PT, OT behavioral therapists. They might be seeing ABA therapy you know, lots of other medical professionals. It could even be, you know, neurology or nephrology or any of those.

[00:23:54] Melissa Anderson: And. But especially thinking about the therapists who are working more like day to day with those patients. So like a PT who might be seeing them once a week, they might see a cochlear implant and have enough knowledge to know like, Oh, they have a cochlear implant. They're going to learn to talk. They can understand me.

[00:24:08] Melissa Anderson: And like, Whoa, Whoa, Whoa. No, they can't like they have CND. And so you might find yourself just kind of similar to how you had to cancel counsel the families. You have to also counsel these other therapists who are working with them about. Again, what it can do and what it can't do. And these be kids who can't understand they're not going to talk.

[00:24:31] Melissa Anderson: So just giving them that information. Cause I think as cochlear implants have maybe become more mainstream, people kind of, especially therapists and things like that might be like, okay, this is what that means. It's like, no, no, no, not for this kid. 

[00:24:43] Dakota Sharp: That's I think that's a great point. How about that relationship with the otologist or the, you know, the managing cochlear implant surgeon?

[00:24:52] Dakota Sharp: How early are these conversations happening? And like, are they different than what it would be for a child who with typical anatomy who's getting a cochlear implant? Like, how is there more communication? Is there more to the device selection aspect of things? Like, how does that differ? 

[00:25:08] Melissa Anderson: I definitely think there's more communication when it's normal anatomy. I feel like the surgeon is just like normal anatomy and we're like, okay, good. And then we move on, you know, there's not really a much more discussion than that. 

[00:25:18] Dakota Sharp: Yeah. Yeah. 

[00:25:19] Melissa Anderson: The thing about anything more complex, there is slightly more discussion, but with CND for sure. Cause now we're looking at, okay, what array might fit in the cochlea cochlea that's also malformed or, you know, what device might help this child you know, keep it on their head.

[00:25:34] Melissa Anderson: So there's some syndromes That havCND kind of as part of the syndrome that also can affect head size and things like that. So you have to think about 

[00:25:43] Dakota Sharp: like in a size, right? Do we have something sit on, right? 

[00:25:47] Melissa Anderson: You know, but head size, you know, do we need to make those, those coils a little bit farther forward so they don't interact because when they're farther back, they could interact.

[00:25:55] Melissa Anderson: You know, that's something that you have to think about when you're programming too, is watching your power settings, because when they're both on, they might. You know, you get those little warnings here. Yep. So, those are conversations that you have to have with the surgeon is like, Hey, this kid's head's pretty small.

[00:26:10] Melissa Anderson: Maybe let's scooch those forward or, you know, some of those kids again with, with syndromes and other things, if they're in a wheelchair, you have to think about that in terms of device placement. And then as well as what arrays might fit in their cochlea. 

[00:26:24] Dakota Sharp: Sure, that's that's a great point. I wonder too.

[00:26:27] Dakota Sharp: How does that did those similar kinds of conversations happen with the family like You're talking to them a lot about expectations, right? That seems to be a big Yes. Frame that we have to get through with families when we're talking about CND. But what about when it comes to not so much like outcomes, expectations, just more like here's things you're going to need to consider with your device that other families might not be dealing with.

[00:26:49] Dakota Sharp: One thing that I think of is like these kids we might have, and we're going to get to mapping in a minute here, cause I don't want to forget that. But you know, you might have a very, very, very wide pulse width and you might be pulling a lot more, you know, battery than, you know, other people. A typical cochlear anatomy case.

[00:27:05] Dakota Sharp: So, do you have to talk about, like, you might need this other kind of battery, or an extra battery source, or, you know, how does that kind of play into those conversations? 

[00:27:13] Melissa Anderson: So I think it also depends on the family because there are some families that by the time you get to device selection, they are so overwhelmed.

[00:27:20] Melissa Anderson: They just really want you to, to kind of make some of those choices for them. Which, you know, not that you want to pick for the family, but you can kind of help them along that a little bit more, kind of a little more handholding. In terms of battery life with any of my patients with CND, you know, I, know the companies love to talk about smaller batteries and things like that, but that is not for this population.

[00:27:41] Melissa Anderson: You need the biggest battery you can get. That's going to have the most juice because these are going to take more power, generally speaking. So I think for me, When I'm counseling, I'm like, okay, and we're going to get you this battery. It's a little bit bigger, but it's going to get the job done. The other one's not for you.

[00:27:56] Melissa Anderson: Like, and just kind of take that off the table as a choice, because I know that's not going to work for that family. So sometimes that's a more of a conversation. Sometimes that's less of a conversation that depends on the family. You know, when you get that you know, I'm going to throw it an audiology stereotype, the engineer dad.

[00:28:13] Melissa Anderson: You know, you're gonna have more of a conversation about that than you will, you know, a parent who's maybe just very overwhelmed, deep in that grief process. They're just like, whatever, bigger battery sounds good. Great. And then so I think I kind of leave that up to the family, how in depth they want to get about why they have to get the bigger battery, but the bigger battery is what they're going to get.

[00:28:31] Dakota Sharp: Yeah, that's a, that's a great point. I didn't even think about that. How much, how much every company is going to promote their teeny tiny little battery. In this case, it's like, just forget that. Just ignore that. We need to make sure you can stay on for, you know, hopefully as, as much of your day as possible.

[00:28:46] Dakota Sharp: Okay. So let's just imagine we, you know, we've had the referral, we've got an implant candidate, they've got CND, we've got our imaging, that's confirmed it. We've built up our team. They go through surgery, all goes well. Okay, it's activation day, you got your backpack out, you got your little stuffy, you're ready to roll.

[00:29:05] Dakota Sharp: How does what you're doing in the mapping software differ on activation day for a child with CND versus a child with typical anatomy? Are there differences? 

[00:29:15] Melissa Anderson: Yes. So again, kind of going back to the counseling piece, I kind of counsel everybody on activation day, like any response is normal. You know, they may cry, they may laugh, they may not react at all.

[00:29:28] Melissa Anderson: For my patient with CND, I kind of stressed the not react at all part a little bit more. And what I kind of, and I talked to families about this beforehand, but then I emphasize it on, on activation day. It's like, give me at least three months to try and see if I can get them hearing something. If at the end of three months we're still not hearing something, we'll have a conversation about that and just kind of see where we're at and just kind of try to get families to at least commit because it's really common with these patients for the families just kind of get discouraged and then they're not wearing it.

[00:29:56] Melissa Anderson: And wear time is an issue across pediatrics in general, but especially for this population because they aren't seeing those benefits. It's like, no, no, but if you don't put it on, we can never know if there would be a benefit. And then again, you're dealing with a lot of kids who are syndromic, so keeping it on is even harder.

[00:30:12] Melissa Anderson: So that's one of the things I really, I talk about that a lot at Activation. In terms of the mapping slowing it down is never a bad idea. Just kind of bringing the rate down a little bit. But the biggest thing is just being prepared to go louder than you normally would. You know, when you think about activation maps, you're, it's like, I don't want to over stem and you can, you know, especially if you kind of can not get much from the patient, but they have normal anatomy.

[00:30:35] Melissa Anderson: I tend to be like, okay, I think this is kind of a good place to start. This is kind of an average starting level with CND. It's like, okay, let's turn it up. Let's, you know, give it a shot. Cause they might need that much higher stem. And then for some companies, you know, if you go higher stem, you might have a little bit widening the ports with So just being prepared to do that more.

[00:30:52] Melissa Anderson: And I always tell students, when you think about mapping CND it's like, you take the rule book of like what you do with cochlear implants and you kind of toss it out. CND has its own rule book and one of those is higher stim levels. So, I'm less concerned about overstim necessarily at activation because there's not much to overstim

[00:31:12] Dakota Sharp: yeah. And I mean, I guess the basis for that is just, you've got kids who have these functional maps, right. And they are older and they're maybe even old enough and have the language, whether ASL or spoken to give you feedback, like, Oh, that's too. We, we see enough of those and they're at. Higher levels.

[00:31:30] Dakota Sharp: Much higher levels.

[00:31:31] Melissa Anderson: Yeah. Yeah. 

[00:31:31] Dakota Sharp: So you can have a little more confidence on activation day to work things up. I like that you also mentioned on activation day. I mean, I'm guessing you're having to devote a little more time to establishing retention. So what does that look like on activation day? What are you finding that's, you know, effective for these, I guess, you know, it depends on everybody and what they look like, but, and, and their age, right.

[00:31:50] Dakota Sharp: Is it going to sit on their ear or not? But let's say we've got like, you know, 10 month old. You know, CND. We've turned things up. We've slowed down the rate. How are we keeping it on their head? 

[00:32:01] Melissa Anderson: Yeah. So, I mean, I think for kids who don't have anatomical difference elsewhere on their head, it looks fairly similar to those without CND.

[00:32:11] Melissa Anderson: It's just finding a way to hold it on. It's just some of these also do have anatomical difference. You know, smaller heads, you know, maybe malformed pin as they're in the wheelchairs. I feel like this population I'm using, like clipping the process to their shirt or to their hair or like I have, you know, some kids we clip it to the back of their wheelchair, like on their, their wheelchair headrest, you like can clip it back there as weird as that sounds.

[00:32:32] Melissa Anderson: Obviously when that kid leans forward, it's going to come off, but it's for that patient. That is the best way to hold it on. So I just feel like you have to be more willing to take it off the ear for this group of patients. But that has less to do with CND, more to do with what might be comorbid with CND.

[00:32:50] Dakota Sharp: Sure. Any other things that come to mind when you think like initial mapping things? Like, would you still want to use progressive maps? How do objective measures play in with this population? Is that any different for you usually? 

[00:33:05] Melissa Anderson: In terms of objective measures, I don't do a ton of activation just because I want to just kind of send some signal into that nerve and just kind of like, or whatever might be there from that nerve.

[00:33:16] Dakota Sharp: Yeah. What we hope is a nerve. Yeah. 

[00:33:19] Melissa Anderson: And just kind of try to get that, just kind of use that simulation. And then I like to, we see patients back at two weeks, I like to kind of take a stab at some of those then. Terms of progressive maps. I think it kind of depends on where we're at. I'm more likely.

[00:33:34] Melissa Anderson: I mean, there are a lot of patients that I, you know, you get that response. It's like, Hey, let's do some progressives. This is the first hearing. Let's do some progressives and see if we can work our way up. There are some patients that because of compliance and some different things you might end up setting.

[00:33:47] Melissa Anderson: Okay. Maps that are different in parameter versus different and just STEM levels. And so you kind of have the family work through it. So it's kind of a different conversation when it's that, that's like, give these a try, you know, see which one you think they respond to best, leave it on each program for three days, and then see what you feel like we've got the most responses on and come back and tell me, and then we can kind of use that to build a map.

[00:34:13] Melissa Anderson: When looking at kind of the later appointments with objective measures like that next appointment is usually when I like to pull those out. When thinking about. Ecap, you would actually be surprised how many have something. Are they pretty? No, they're not. They're certainly not the, the classic response that you are used to seeing, but sometimes you can kind of get something.

[00:34:33] Melissa Anderson: And I can definitely use that to kind of guide my program, especially if you kind of run it with some different parameters and some different things like that, it can definitely guide, okay, this is where I got the prettiest response. This seems to be the setting that that nerve kind of locked into let's build based on that.

[00:34:48] Melissa Anderson: And then. I was, I would say you would also be surprised how many actually might have some ESRT. I think still learning how to use that. Is it, you know, do you use that the same way for a CND patient as you do for a patient with normal anatomy? I'll be honest. I don't have the answer to that yet. 

[00:35:04] Dakota Sharp: Yeah.

[00:35:04] Melissa Anderson: But I have found it. on some of my patients. Now, those are the patients who I've been successful with getting it on. Thus far, which this is completely subjective, happen to be the ones who are stronger performers. You know, so that obviously that makes sense, right? Like there's obviously some amount of nerve that's responding to allow you to get that measure.

[00:35:25] Melissa Anderson: You know, it's just, you know, what, how, how can you program using that? Is it the same? I don't think we know as a field. 

[00:35:31] Dakota Sharp: That's a good point. And so, thinking through if ECAP's going to be present had me thinking about different array types, basically, right? Like, if we're going more perimedial or lateral wall.

[00:35:41] Dakota Sharp: And when we were talking earlier about, you know, communication with the surgeon prior to, I forgot to mention that too. Do you find that either the surgeons have thoughts there or that you have thoughts there in terms of what you're seeing? And maybe it's. Easier to get whether it's ECAP present or just responses, lower levels, or you, you know, I mean, do you have to, are you less likely to widen the pulse with, with one over the other?

[00:36:05] Dakota Sharp: Or how much does that role play as a factor? 

[00:36:08] Melissa Anderson: In terms of that, I haven't noticed a strong, I guess, like outcomes are better with one versus the other, or I'm more likely to get a response. It's really about what the surgeon can get in. So I think a lot of that I really do leave to the surgeon. You know, when you think about lateral wall, lateral wall arrays they tend to be, and this is, This is from surgeons.

[00:36:30] Melissa Anderson: I'm, you know, they tend to be a little floppier versus, you know, when you think more periodontally, they might be able to get those in a little bit better, just depending on what kind of anatomy they're up against. But really it's just, if the surgeon can get it in there effectively and in the right place and, you know, that's going to be, give you the best chance of success versus one array versus the other.

[00:36:51] Melissa Anderson: Obviously when you think about like a Cougar branded device You know, when you go more lateral while you're already having to increase the pulse width. So now a CND might have to be increasing it more you know, when you just think about what the defaults are in the system. So that is something I do kind of think about.

[00:37:07] Melissa Anderson: But in terms of my cover. The surgeons, it's really just, you know, Hey, this is the situation we have CND, they're leaning towards this brand. And then it's whatever they, they feel most confident in being able to get in, especially when you're thinking about a cochlear malformation, which often accompanies CND.

[00:37:23] Dakota Sharp: Yeah. Cause like at the end of the day, it's not going to be very effective if it's not actually in their cochlea. 

[00:37:27] Melissa Anderson: Right. Right. 

[00:37:29] Dakota Sharp: And that is my favorite segue of the night, because I'm going to segue that right into maybe the weirdest Place a cochlear implant could be when it's not in the cochlea, a paper that you published and a case that you led on. I guess when did this happen? Like two years ago or even longer maybe at this point? 

[00:37:47] Melissa Anderson: Oh no, it was a little longer than that. 

[00:37:49] Dakota Sharp: Could you, could you break down kind of what happened there for us? 

[00:37:52] Melissa Anderson: Yeah, I had a patient who transferred into our clinic. Excuse me, the family's military. So they've been seen by audiologists kind of throughout the country.

[00:38:02] Melissa Anderson: And he received his implant when he was four and he ended up getting in both years. The first one when he was four and then the next one, a few months later. And he when he came to see me, he had had them for about. About three years, seven, and when I was testing him, he could do all this stuff with his right ear, but couldn't with his left ear.

[00:38:26] Melissa Anderson: And he is such a sweet little boy, such a people pleaser, and you could just see him in there trying to do things, and he just couldn't. He didn't really know what you're asking him to do, and I'm not talking speech perception, I'm talking like, Condition play audiometry. So I called up the surgeon who had kind of taken on this case and asked him for imaging and he got it for me.

[00:38:46] Melissa Anderson: And it revealed that this child had a cochlear malformation. He had IP3, but then also that his left implant was in his IAC instead of in his cochlea. So it was sitting on his nerve. And he had a pre curved device and we were not sure if it was both cochlear nerve and facial nerve. So, at the time it was not recommended to pull it out and re implant because of the potential for it to be cold around the nerve.

[00:39:15] Melissa Anderson: And you don't want to pull out the facial nerve. So we, he had four contacts left in his cochlea. So we tried to just stem on those four and he basically couldn't hear anything from it. And so I partnered with our wonderful research team and we kind of came up with a, a, we basically programmed him as if he had an A, BI.

[00:39:37] Melissa Anderson: And so we did a pitch ranking task with him using a xylophone. So we would play on two channels back to back, and then he would like ding on the xylophone, whether it was. Low, high or high low. And we use that to set up a map that only has, it has six, he's cochlear device. He has six channels active, which is obviously not ideal.

[00:39:57] Melissa Anderson: And we, we assigned the pitches to them based on kind of what he presented and what wasn't overlapping. That's how we ended up with those six channels. And over the course of several months, he started being able to do, you know, just like, yes, I hear that beep all the way to getting open set speech perception.

[00:40:14] Melissa Anderson: So he went from having no speech perception, very little or confused, maybe sound perception to getting 56 percent on a CNC. 

[00:40:22] Dakota Sharp: Crazy.

[00:40:23] Melissa Anderson: So we published, we published the paper. We always tease we published it too soon because he had made so much progress. And we published this paper, but then the next time I saw him, he actually made so much progress that he no longer had a dominant ear of his left and right ear were doing the same.

[00:40:37] Melissa Anderson: So it was, it was really cool. His, his case, but. Yeah. 

[00:40:40] Dakota Sharp: Yeah. That's amazing. And it makes me think about, like, how these complex cases, there can be so much more to it. Like, it goes beyond, you know, hopefully they're able to get the cochlear implant in. Now we also have to think, hopefully they don't overshoot it and go into the IUC or the facial nerves.

[00:40:57] Dakota Sharp: Yeah. And so that kind of leads me to another aspect of this, which is kind of like, what, what are you seeing, you know, years in for some of these kids? It's like, how often are you running into other complications of things? Facial nerve stim, equipment challenges, like what are some of the big picture things you see that you would want other audiologists out there who are maybe new to working with CND and implants to know or to have in mind?

[00:41:21] Melissa Anderson: Yeah, in terms of equipment problems, I think it's very comparable to other kids. In general, the kids who are more syndromic might have a little bit more of a challenge just because of other things going on in there. You know, with their medical care the Facial stim is a big, big, big thing with mapping.

[00:41:38] Melissa Anderson: You sometimes might think you're stimulating the auditory nerve or whatever fibers may be there, but you're really stimulating the facial nerve. I think the other big thing you have to think about is if you have a really compromised nerve is, are you stimulating something auditory or are you stimulating something vestibular?

[00:41:56] Melissa Anderson: So you have to kind of think about like, You know, is that patient spinning and that can be a really hard thing to assess in the moment. 

[00:42:04] Dakota Sharp: Especially one who's not mobile yet. Maybe 

[00:42:07] Melissa Anderson: right. Yeah. Yeah. So we're talking about, you know, kids are sitting in a stroller. Are they dizzy? Who knows? And so that can be really tough. You know, when the kids get older and can report things to you, they might be able to say like, Whoa, that, you know, feels weird. Or, Oh, I'm, you know, I'm feeling that here or something like that. But the little babies, it can be really hard to determine that facial stim is a little easier because you can, you know, see that, that face twitch or the eye twitch or whatever it is.

[00:42:34] Melissa Anderson: But you're definitely running up against that way more than you are just the general population. I mean it definitely can limit what you can and can't do and so sometimes it's that conversation with the family like this is pretty much all we can do without you know this facial stimulation and it's not working which means there is no auditory nerve fibers responding everything we're seeing is a facial nerve and so that can also be a hard conversation to have and I think that's again you know I've talked a lot about counseling it's just you The counseling process is, for any cochlear implant patient, is not isolated to that initial evaluation appointment.

[00:43:11] Melissa Anderson: That is especially true with CND. The counseling for this is ongoing and you know, the family's acceptance of the CND is also ongoing, especially for the kids who might make a little bit of progress at the beginning and they're doing it. They're starting to go and families are like, great, it worked.

[00:43:28] Melissa Anderson: We don't have to assign. It's like, no, no, no, no, no. Like still use that visual language. And then you, you see it where they kind of hit that plateau and then the family's like, okay, well now what? It's like, well, you know, we've done what we could. This is what their anatomy could do. And there's, there's lots of things you can try.

[00:43:45] Melissa Anderson: So it might take a while to kind of get to that point. And that's, I think the biggest thing I would encourage anyone seeing any patient with CND to do is be willing to try those different things. So change the rate, change the pulse width, you know, put the stim levels higher, try ECAP, try ESRT, just try it.

[00:44:00] Melissa Anderson: And just kind of see, you know, see what sticks, especially in pediatrics with adults, they can give you some, they'll give 

[00:44:06] Melissa Anderson: you 

[00:44:08] Melissa Anderson: for these, you know, these kids that can't give you the feedback, just kind of try and see what happens and be willing to do that. You know, over the course of, 

[00:44:16] Dakota Sharp: I was going to say, be patient, right?

[00:44:19] Dakota Sharp: Like that's another one of those things that you got to be patient with these things to even more so you would say than maybe the patients with typical anatomy. 

[00:44:26] Melissa Anderson: Yes. Cause with, with typical anatomy, there's a general trajectory that you would expect. So, you know, especially when. I mean, device uses is good when the families are using the device and wearing it all the time, there's kind of a general trajectory with CND.

[00:44:42] Melissa Anderson: That trajectory is not there. You know, so, I mean, I have a case I'm working on right now. He's been making all this great progress and, you know, now we're kind of having this conversation about, we're kind of hitting this plateau. There's still lots I can, haven't done with his map. So it's like, okay, let's try the next thing and see if we can continue progress or not.

[00:44:59] Melissa Anderson: And we might try a few things and discover like, nope, this is the level, this is what his anatomy could do. I could also try it. We kind of keep making progress. So the only way to find out is to try. 

[00:45:08] Dakota Sharp: Yeah, I was, that was actually sort of one of my, one of the last couple of questions I had was just kind of if there are cases.

[00:45:14] Dakota Sharp: So you mentioned your unicorn with cochlear nerve aplasia who has open set speech perception. I'm wondering if any other cases come to mind, whether it's, you know, how they're doing now for better or for worse, or how kind of the family struck you, or something that really challenged the way that you were approaching their mapping or any, any cases that come to mind that you'd be willing to share about.

[00:45:36] Melissa Anderson: So, I definitely have a few cases that kind of jumped to mind where I've used a lot, and this is going back to talking about the importance of the team, is I've used a lot of either what a speech language pathologist told me or an early interventionist has told me, or, oh, we were seeing this at school to kind of guide what I'm, what I'm doing.

[00:45:52] Melissa Anderson: You know, so it's like, you know, they start to make progress and it's like, then when you stall out, it's like, okay, let's do this. And then you know, they're responding. I mean, this, this is one that jumps to mind a patient of mine from a long time ago who was hearing, they were doing Ling sound checks that are.

[00:46:07] Melissa Anderson: Ventral was trying to see if they could hearing Ling sounds and he was able to detect some of those lower pitch Ling sounds, the ooh and the but wasn't hearing this or the shh, which are, you know, for higher pitch. And you know, I actually managed to get some booth testing. And he was very little, I got some booth testing out using a little VRA.

[00:46:22] Melissa Anderson: And it was, that's what I found is like a very loud level. So you could hear some of those low pitch, but couldn't hear the high pitches. Over the course of about six. six, seven months, gradually turned off some channels, shifted frequencies onto channels that we were getting responses and I was able to get him to be able to detect all of them.

[00:46:38] Melissa Anderson: He never got discrimination, but he was able to detect over, you know, the entire frequency range that we were looking for. So yeah, You know, through a lot of patience and a lot of work with different team members was able to you know, get kind of max out what this kid is doing, or at least what we think was, you know, maxing that out for him.

[00:46:56] Dakota Sharp: Yeah. I want to ask you about another case, but that actually reminded me of something we didn't talk about when it came to, you know, mapping outside of the box with these kids is not being afraid to disable channels, which I feel like oftentimes with cochlear implants, we want to like last resort that because it's like, you could hear something there.

[00:47:11] Dakota Sharp: I want to use it. But no, in these cases, it's like, If you're not hearing it and I'm up at these crazy high stim levels, like you're better off reallocating that somewhere else. And being willing to kind of play around with that frequency allocation table, I think is also a big part of working with this population. Right. 

[00:47:26] Melissa Anderson: Absolutely. And it's, again, if you think about just what nerve fibers may be there, that may affect what channels are actually working. So, you know, and there's a, there's a lot of amazing research out there. Now about like face based methanes and things like that, and that's great. That does not, in my mind, apply to this population.

[00:47:42] Melissa Anderson: This population, it's what nerve fibers might work with some channels. And if you have, you know, eight channels that somehow have made connections to whatever nerve fibers are there, let's maximize those eight channels and give you the most that we can. Is that ideal for discrimination? No. But is discrimination possible for those patients?

[00:47:59] Melissa Anderson: Also no. So are we giving them the best sound awareness that we can? Yes. 

[00:48:04] Dakota Sharp: That's a great point. Wow. So many tidbits in here. I'm hoping that people who are unfamiliar with this are gonna be able to like take in and use. Any other cases that come to mind that maybe like from the counseling angle that you felt like are just kind of memorable families or experiences that you've had?

[00:48:20] Melissa Anderson: I have had So actually, the unicorn case him and there was another family, they were kind of going through everything at the same time. They came to me within a few weeks of each other and got in touch. I don't know if it was through our Facebook or somehow these mothers touch with each other and they were kind of going through this experience.

[00:48:41] Melissa Anderson: Which, you know, was great. The little unicorn boy obviously did very well with his. The other little girl, and she's now a non user, right? Just, she had less success. We tried all the same things. So just kind of watching the child who didn't do as well kind of compare like, well, he, you know, this little boy has seen you too, and he's doing all these things.

[00:49:02] Melissa Anderson: That was a very difficult counseling situation for me. And I hadn't really experienced that before that. It's just how to counsel that mom that like, yeah, but. Everyone's anatomy is different and hers just didn't work. And this little girl I will just throw out is doing amazing with sign language and doing very well with that.

[00:49:21] Melissa Anderson: But a cochlear implant ended up not being for her. That was definitely just the way that mom grieved and kind of walking her through that process and that eventual acceptance that it wasn't going to work was just a little bit more challenging just because she has seen other kids with CND who do well.

[00:49:36] Melissa Anderson: I also, another case that jumps my mind is we have a sibling set at the clinic where one of they have a syndrome one of them is more advanced but the, so it's an older child and younger, they're both little boys and older boy when they're not so little anymore, now they're much older than I was like, Oh my gosh, you've grown so much, but the older child, his anatomy wasn't as bad and he had some cochlear malformations, but his nerve was intact, the younger child.

[00:50:01] Melissa Anderson: Also cochlear malformations, but nerve wasn't and I think that was something for that mom that is just seeing the difference between that you know, and kind of counseling that it's like, you know, yes, this child did this, but, you know, this child may not it was just a difference because she had an expectation having been through this process before that you kind of had to like walk back and be like, yes, this is different.

[00:50:23] Dakota Sharp: Yeah. That's a great point. And it's, it points out one of the things I feel like I find myself from recommending to families all the time on their, you know, cochlear implant journey early on is, you know, one of the best things you can do is connect with other families who are, who are on this journey with you.

[00:50:37] Dakota Sharp: Right. And then this is one of those times where it's like, wow, the outcomes are so variable that this could really go a whole different way than we expect. 

[00:50:46] Melissa Anderson: Yeah. Yeah. And I think CND is probably the hardest thing to recommend Like talking to other families because do you connect them with a family that had great success and is doing really well and build expectations beyond?

[00:50:59] Melissa Anderson: Or do you connect them with a family that ended up being an on user and then they don't want to go through the surgery? So it's, it's hard and obviously there's a middle ground, but it's really hard to, for me to like pick families to go get in touch with this person versus, you know, for my kids with neurotypical anatomy, I feel like I have all these people I can get them in touch with.

[00:51:21] Dakota Sharp: What do you, so if you had a, I know we're kind of coming up on the end of our time here in just a little bit, so if you had the ear of, you know, all three cochlear implant manufacturers, which I know you do, because you're a powerful lady in the implant world, but let's say they were sitting down for a meeting just with you and they said, we know it's not We know programming kids with CND is not ideal right now, or, you know, what aspect of our device or programming, like if you could just tell them, Hey, please add the feature that can do X, Y, Z, or that can account for this.

[00:51:52] Dakota Sharp: Like, honestly, my bigger question here is like, what do you hope for the future of working with kids with CND and implants? But I guess also like from like a device management side, if you want to include that too. 

[00:52:03] Melissa Anderson: So I think in terms of like mapping softwares I would love to see. ECAP being able to be run with lots of different parameters to be a little bit easier and maybe a little more time efficient, especially when thinking about working with kids.

[00:52:17] Melissa Anderson: Because if I'm having to run it in multiple different parameters in one session with a child, that, I mean, and even ECAP, they can move around and do all the things, but you know, sometimes that's really challenging just to kind of keep them like, Seeded to, to do that. You know, and then I definitely think, you know, being able to modify the frequency table is something that it's easier in some manufacturers than others, but I think having that be something that's a little bit more easier to, to really manipulate that would be something I would be looking for and then just kind of different ways to, to manage kind of how that current is going through just to make that sometimes a little bit more accessible.

[00:52:54] Melissa Anderson: Because sometimes it is and sometimes it isn't depending on what you're trying to do and depending on what manufacturer so I think when you think about these more complex cases, it's just sometimes you really have to dig in the software really find what you are looking for and I think that makes it more challenging for you know, audiologists as they're, you know, looking to work with these kids more.

[00:53:16] Melissa Anderson: So it's just having that more accessible for those cases. 

[00:53:19] Dakota Sharp: Yeah. Could we look at a different type of array maybe for more complicated anatomy? I mean, I don't know. 

[00:53:27] Melissa Anderson: There's so many arrays out there and, and so many different things you can do with the arrays. You know, especially depending on which company you choose.

[00:53:34] Melissa Anderson: I mean, some of the companies really do have a pretty diverse portfolio. You know, that I, and again, I'm not the surgeon having to get this in. So maybe this is very easy for me to say, but I really feel like there is. quite a diverse array potential you know, that most cochleas are able to, you know, be successful in getting that array and having that more, more full insertion.

[00:53:59] Melissa Anderson: I mean, we have a case where they raise in backwards. They can still hear you know, we're able to do it. You can flip the, you know, how you have the channels allocated and everything. So, you know, you know, obviously I feel fortunate to work with very talented surgeons who are able to do that, but I feel like it's not often that we truly can't get it in, except for in, in situations where, you know, there is no cochlear, in which case that is what it is.

[00:54:25] Dakota Sharp: Yeah, I feel like this. I'm very grateful. We work together. We deal with the same surgeons. I'm very grateful. I don't have to say I'm very grateful. I don't have to say what I'm about to say ever, but something you could always say, like, if they're like, Oh, there's like, I can map around it. Right? Like that's the beauty of an audiologist.

[00:54:43] Dakota Sharp: Like we can probably map around it. We'll figure out something for that. Right. Cool. So just before we wrap things up, I'm curious if you have any other kind of upcoming projects, any other kids with Arrays in their IAC that you need to tell us about and the amazing things you've done for them to hear I know you were a part of a paper that was just put out that was kind of talking about when implants aren't Where they're supposed to be.

[00:55:05] Dakota Sharp: Is that a fair way to summarize that paper? 

[00:55:07] Melissa Anderson: So, are you talking, which paper are you talking about? The one with 

[00:55:12] Dakota Sharp: It was about like misplacement of the array. Oh, yeah. Oh, yes, yes, yes. It was specifically reviewing misplacement into the IAC, right? Not just your single case, but maybe a review. Okay. 

[00:55:23] Melissa Anderson: Yeah. And so what that was looking at was really just four cases where maybe the implant isn't where you would think it would be.

[00:55:29] Melissa Anderson: It's just kind of how to handle them. And based on that literature review, which one of the papers reviewed was the original paper that I published about the kid in the IAC and what are the kids whose devices in the IAC was to, you know, if it's caught in the moment in surgery. To just try to revise it, you know, pull it out, put a new one in, obviously kind of pending what happened, but that was kind of the recommendation.

[00:55:52] Melissa Anderson: And then if it's caught afterwards, rather than immediately revising to try this alternative mapping technique, you know, try to see if you can map around it. Like you were saying, it's, you know, as audiologists like, Oh, let's map around it. Like maybe try that before you go to the surgical option. And then if that didn't resolve the problem, you could look at revising.

[00:56:12] Melissa Anderson: So that's basically what the findings of that were, and it looked at several papers. A lot of those were based on revision but the ones that weren't revised the papers that were published that weren't about revisions that didn't use an alternative technique. pretty much across the board, the patients were not able to achieve open set speech perception or eventually became non users and a lot of them did.

[00:56:34] Melissa Anderson: So that was kind of where this, this new technique you know, we did achieve that open set. So that's where that recommendation came from. 

[00:56:41] Dakota Sharp: Cool. Cool. So I'm looking forward to all of your upcoming work that tells us all the novel ways to map when things go awry and are in the place that they're not supposed to be.

[00:56:52] Dakota Sharp: And I'm super grateful for you joining me for this. This has just been an awesome conversation. I'm very grateful that I get to chat with you about these things in a day to day context, but it's also fun to do it here too. And I know a lot of people are going to benefit from, from hearing what you have to say here.

[00:57:04] Dakota Sharp: For those people who listen and have. questions or they've got that, you know, that case that they just can't quite pin down or, you know, they, they want to hear, you know, how are you setting up ESRT in the situation? Like, what does that look like? Is it okay for them to reach out? And if so, how could they best reach you?

[00:57:19] Melissa Anderson: Absolutely. The best way to reach out to me is through email. And so my email is melissa. anderson at unchealth. unc. edu. 

[00:57:28] Dakota Sharp: Perfect. Perfect. Well, it's been great talking to you. I look forward to seeing you tomorrow at work. And thanks so much for talking with me. And hope you have a great rest of your day.

[00:57:39] Melissa Anderson: Yes. Well, thank you for having me.

[00:57:40] Dakota Sharp: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Uh, start today! SpeechTherapyPD. com has over 175 hours of audio courses on demand, with an average of 19 new audio courses released each month. And here's the best part, each episode earns you ASHA Continuing Ed credits! Oh, no wait, this is the best part.

[00:58:01] Dakota Sharp: As a listener of On The Ear, you can receive 20 off an annual subscription when you use code ear21. Just head to SpeechTherapyPD. com to sign up. And use code EAR21, E A R 2 1, for 20 off your annual subscription. 

[00:58:15] 

[00:58:17] Dakota Sharp: And that's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education through Speech Therapy PD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes.

[00:58:35] Dakota Sharp: Just head to speechtherapypd. com slash ear. That's speechtherapypd. com slash e a r.