Speech processor Mapping for pediatrics & adults Amira EL Shennawy M.D Professor of Audio vestibular Medicine, Cairo University

What is programming ? • Measuring the response of spiral ganglion cells to electrical stimulation from each electrode along the array of the CI. • The recipient's threshold and comfort levels of electrical stimulation are set for each channel , creating a MAP that makes speech sounds audible.

First Session Switch on Tune – up Initial Activation 4-6 weeks postoperative. Breaking the ice , counseling , familiarizing with external parts.

1.Telemetry - Impedances changes after surgery. - Status of each electrode as basis for fitting.

- Compliance optimized. - ECAP measurements in assistance of first maps for very young or uncooperative patients.

2.Default parameters Speech strategy Pulse duration / width Volume and microphone sensitivity

Frequency band width Rate / maxima

3.Creating a MAP • CI is programmed for each individual based on their auditory perceptions in response to electrical stimuli.

• T levels: minimal amount of electrical stimulation required for the auditory system to perceive sound. • M or C levels: upper limit of electrical stimulation judged to be loud but comfortable. • Dynamic range

Setting T levels: • ADULTS : Behavioral • Pediatrics: According to the age & participation of the patient; . Objective : NRI , NRT . Behavioral: conditioned play audiometry. ( Locking T level to MCL ).

Setting C levels: • Adults: Psychophysical Live mode

(Interpolation)

Setting C levels: • Pediatrics: Observational / Live mode Loudness scaling Objective : ECAP, ESRT (Interpolation)

Amount of electrical stimulation Cochlear Nucleus : 0 – 240 clinical units T levels usually above 100 cus & C levels for adults usually below 210 cus. Advanced Bionics : M levels between 100 – 300 cus . Medel : MCL 10 – 25 (qu).

Etiology influences stimulation levels due to neural survival.

Meningitis : high stimulation levels Connexin 26 gene : low stimulation levels

4. Balancing Adults 5. Sweeping

6. Live stimulation

• 7. Loading programs

• 8.Instructions

Explaining how to use

1st Fitting • • • • • • • •

Telemetry Default parameters Setting T & C levels Balancing Sweeping Live stimulation Programs Instructions

Chronological procedures 4 weeks post op

Step

Action

Purpose

1st fitting

Detect hearing level MCL

1 week

2nd fitting

1-2 weeks

Follow up

Initial programming & activation of SP Adapt fitting to audiogram, feedback

2-3 months 6 months

Fine tuning Fine tuning

Check internal & external parts assess progress programming if needed

Regular system inspection

Whenever needed

6mo/ yearly

Check - up

Expectations/ progress First hearing sensation

Find comfortable hearing level Get used to Step by step until sound , learn to audiogram at 30 hear, interpret signals as sounds dB Specific fitting acc Improve hearing Speech dev , to needs & sensation improve speech feedback….. understanding Adjustment for better Specific fitting according to patient’s understanding in needs difficult listening conditions

Follow- up fitting • 1.Audiogram • 2. Check external parts • 3.Telemetry

• 4. Fitting: Current settings Adjust settings Adjust Map according to: audiogram , patient’s feedback and speech pathologist comments. Ling six sounds (a,u,i,m,sh,s).

• Fine tuning • Special programs : Music , noise Children start speech rehab after acquiring hearing at conversational level

Assessing progress • Audiogram • Language development • Feedback of: Patient , family , speech therapist , teachers . Quality of life , education.

Adult & Pediatric Stimulation Levels Stimulation levels change frequently on initial activation, a plateau is reached after 2 years. After continued use and practice , the brain adjusts (neural plasticity) & learns to effectively use the electrical input. Adult CI users do not have stimulation levels that increase overtime or they would reach the output limits. Pediatric users have higher stimulation levels.

Overstimulation • CI map settings with stimulation levels exceeding the amount needed to create the desired perception. • Why ?? 1. Lack of patient participation 2. Parents/ therapists pressure 3. Inaccurate objective measures

• Results in : Facial stimulation , discomfort. If thresholds too high → soft sounds perceived as loud , distorted consonants & poor speech production skills. Exaggerate background noise → poor listening ability in noise. (Associated more with children )

• Encourage patients to use their SP “ If you do not use it you lose it “

Electrical stimulation encourages neural survival. Poor MAP = Poor CI performance.

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