Cochlear implants are very advanced electronic devices used in the hearing rehabilitation of patients with hearing loss that cannot benefit from hearing aids. These devices convert sound energy into electrical energy and directly stimulate the auditory nerve in the inner ear, allowing the person to hear again. Cochlear implants consist of two main parts. It consists of an inner piece that is surgically placed inside the ear and an outer piece that is attached behind the ear, just like a hearing aid. The outer part and the inner part come into contact with a magnet system.
The cochlear implant takes over the function of the hearing organ in the inner ear. Therefore, in order for cochlear implant surgery to be performed, the patient must have an inner ear where the implant can be placed and a healthy auditory nerve.
Hearing is very important for language and language development. Normal hearing is necessary for a person to understand what is being said and to learn to speak. Therefore, rapid rehabilitation of hearing is very important in children with hearing loss.
WHO CAN A COCHLEAR IMPLANT BE INSTALLED?
Congenitally advanced hearing loss. Those with hearing loss: Early diagnosis of hearing loss in children with congenital hearing loss is very important. Because there is a critical period for children's language and language development. During this period, he is around 2 years old. Therefore, the ideal surgery time for babies with severe hearing loss is around 1 year of age. The probability of obtaining near-normal hearing and language development in children who have cochlear implant surgery at the age of 1 is over 95%. The results of surgeries performed between the ages of 1-2 are extremely satisfactory. After the age of 2, the success rate begins to decrease. Around the age of 4 is considered the critical age. Because it is not possible to achieve success when cochlear implants are applied after the age of 4 in children with congenital hearing loss and no language development. There is only one exception to this situation. If the child is over 4 years old but has some language development, then there may be a chance of benefiting from a cochlear implant.
Hearing losses that occur later: These occur in adults and children who have completed their language and language development. Cochlear implant surgeries are also performed in cases of severe hearing loss. In fact, this group is the group that benefits most from cochlear implants. If surgery is performed shortly after hearing loss occurs, these people will regain their hearing from the first use of the device and can generally understand what is being said. However, the passage of many years will reduce the success of the implant. If more than 10 years have passed since the hearing loss occurred, the chances of these people benefiting from the implant are greatly reduced. For this reason, surgeries should be performed as soon as possible.
WHAT IS THE COCHLEAR IMPLANTATION PROCESS IN A BABY WITH HEARING LOSS?
In our country, national newborn hearing screening is carried out by the Ministry of Health. All newborn babies undergo hearing screening within the first month. During this screening, babies with suspected hearing loss are sent to appropriate centers for further examination and to confirm the diagnosis of hearing loss. In these centers, the diagnosis of hearing loss is confirmed after detailed examinations. After this, the baby is immediately started on hearing aid use and training program. The baby is taken into the cochlear implantation program and monitored. If it is understood that the baby does not benefit sufficiently from the hearing aid around the age of 1, the baby undergoes surgery and a cochlear implant is placed. Approximately 1 month after the surgery, the device is activated and settings are made by attaching the external part. These children need to receive special education for language and language development.
WHO SHOULD NOT HAVE COCHLEAR IMPLANT SURGERY?
Even though they have hearing loss It is not performed on people who benefit sufficiently from hearing aids.
It is not performed on people whose inner ear structure is severely damaged and/or who do not have an auditory nerve (brainstem implant is applied to these patients).
Those with congenital hearing loss. It is not performed on children who are older than 5-6 and have no language development.
It is not performed on people who develop hearing loss in adulthood and whose hearing loss has passed more than 10-15 years.
ARE THERE RISKS OF COCHLEAR IMPLANT SURGERY?
All surgical procedures have certain risks. Of course, cochlear implant surgery has some risks. These are:
Risks related to anesthesia: These are very rare situations and are at the same rate as the risks of any surgery.
Risk of facial paralysis: Facial paralysis may very rarely develop due to the facial nerve passing through the surgical area. This rate is less than 1%
Cerebral fluid leakage: Since the inner ear is opened during surgery, rarely patients may experience postoperative brain fluid leakage. This problem occurs mostly in patients with defects in the inner ear structure.
Development of meningitis. There is a very rare risk of developing postoperative meningitis in these patients due to the opening of the inner ear. For this reason, all cochlear implant patients are vaccinated before surgery to protect against meningitis
Risk of device failure: since these devices are electronic devices, the device may break down over the years in some patients. This rate is around 1-3%. However, the damaged device can be replaced with a new one without any problems by surgery.
COCHLEAR IMPLANTATION IN CHILDREN WITH ADDITIONAL PROBLEMS
Today, the audiological criteria for the selection of cochlear implantation candidates have been determined in a way that everyone agrees on. However, in some candidates, various organic or psychological disorders accompany hearing loss and can sometimes constitute a contraindication for cochlear implantation. We call such situations additional handicap. Gallaudet University defines the term additional handicap as "any physical, mental, emotional, or behavioral impairment that makes the education of a child with hearing loss more complex." The World Health Organization mentioned three categories in this field in 1980: 1- impairment—any loss or abnormality in the psychological or anatomical structure, 2- disability—limitation or limitation in performing activities that are considered normal for humans. inability to do, 3- handicap—disadvantage resulting from the inability to perform something that should be normal for that person due to deficiency or disability (1).
Approximately 30-40% of children with hearing loss have various hearing impairments as well as hearing impairment. has handicaps. The most common additional handicaps are: Mental retardation, learning disorders, attention deficit and hyperactivity disorders, visual disorders, cerebral palsy, orthopedic impairment. handicaps and other physical disabilities (2). While the presence of additional handicaps was considered a contraindication for cochlear implantation in the early years, as a result of developments in implant technology and increasing surgical and educational experience, cochlear implantation is now performed in many centers in children with additional handicaps (2-4). However, there is still no consensus in the literature regarding cochlear implantation of children with additional handicaps. In individuals where hearing loss is the only obstacle, the decision to implant should be based on the benefit to be obtained. However, the benefit to be provided for those with additional handicaps is controversial. Should the benefit be considered only as success in language and language development, or should the increase in psychosocial development and quality of life be taken into consideration? In fact, children with additional handicaps have lower scores in language and language development than children who do not have additional problems other than hearing loss, and only a limited number of them can show language and language development (2). Hamzawi et al. (3) published the results of the EARS test battery in 10 children with cochlear implants who had additional handicaps and stated that most of the children were regular implant users. As a result of the study, they stated that cochlear implants provide certain benefits for both the child and the family in multi-handicapped children. Recently, Berretini et al. (5) published the results of 23 children with additional handicaps to whom they underwent cochlear implantation and stated that all of the patients benefited from the implant to a certain extent.
The presence of additional handicaps causes special problems regarding pre-surgical evaluation, post-surgical rehabilitation and follow-up. It brings with it. A multidisciplinary approach should be applied, especially neurological and neuropsychiatric evaluation should be carried out carefully. However, diseases such as learning disorders, mental retardation, and autism may be difficult to diagnose in very young children or may not yet show symptoms. Considering that the implant age is gradually decreasing, the importance of pre-surgical evaluation and informing the family about this issue will be better understood. The family is informed that approximately one-third of children with hearing loss have additional handicaps and that this may not show symptoms until the child reaches a certain age. It should be stated that it will happen. In addition, it should be noted that the presence of additional handicaps may affect the success of cochlear implants (5).
Additional handicaps related to cognitive retardation and learning difficulty:
The general consensus in the literature is that patients with mild and moderate mental retardation It is believed that children will benefit from cochlear implants. In a study conducted by Daneshi and Hassanzadeh (2), the auditory perception scores of the patients before and after the implant were compared, and in 8 patients with mild mental retardation, the auditory perception score, which was 2.75 before the implant, increased to 45 after the implant, and in 5 patients with moderate mental retardation, the auditory perception score increased to 45 after the implant. The auditory perception score, which was 2.8 before, increased to 37.2 after the implant.
Recently, Holt and Kirk (6) published their study on 69 children with prelingual hearing loss and children with cochlear implants. 19 of the children in this study had cognitive delay and the others had no additional handicap. During the entire follow-up period, significant progress was detected in language and language development in children in both groups. However, a significant difference was observed between the group with cognitive delay and other healthy children in terms of both receptive language development and expressive language development. The scores of the group with cognitive delay were lower. As a result of this study, the researchers stated that children with mild cognitive delay benefited from cochlear implants, but this benefit was lower than in healthy children, and they concluded that it would be appropriate to implant these children. Similarly, Berrettini et al. (5) reported that the results were satisfactory in the evaluation of 10 children with mental retardation and cochlear implants. They stated that all children used the implant continuously and half of the patients developed open-ended perception ability. Although only 2 patients managed to communicate by speaking, they found that all patients' communication skills improved.
Motor Developmental Retardation:
Edward et al. (7) reported that children's general development and cognitive development levels improved after the implant. They reported that it is the most important determinant of the level of language and language development. Significant improvement back
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