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With pleasure and enthusiasm we’re sharing the interview with dr. Domenico Rosario Cuda:
often in the web you can find opinions and concepts about deafness and it’s possible solutions, we’re convinced that the correct information must be this, in other words a meeting between the questions and the answers given by real professionals(and researchers). On my personal behalf (Pablo Pisano) I thank the person who allowed me to change my (and my brother’s) life, and to be able to hear… Thank you one more time “fairy’s hands” (affectionately called like that because he saved my residues despite the operation).
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WHO IS DR, DOMENICO ROSARIO CUDA?
Domenico Cuda, primary at Piacenza’s hospital has been elected president of italian otolaryngologists hospital workers (AOOI) in 2014.
The biennial assignment, has ben given to the expert, Piacent of adoption, during the 101st National congress held in Catania.
The scientific society collects 1600 professionals active in the italian hospitals and is very active on the upgrading front of specialist and scientific publications.
Calabrian by origins, has led the otoringolaryngology ofGuglielmo from Saliceto since 2003, the department is a point of National excellence especially in the field of bionic auditory (insertion of cochlearimpiants to fight deafness).
Graduation in Medicine and Surgery, Catholic University, Rome (July 1982, top marks and honors);
Specialization in Otorhinolaryngology, Catholic University, Rome (July 1985, top marks and honors);
Specialization in Audiology, University of Ferrara (July 1988, top marks and honors);
Internship at: House Ear Institute (Los Angeles), Mount Sinai Hospital (New York), Institute of Otologie Pratique (Paris), Ospedali Riuniti (Bergamo);
From 1-3-2003 to current date: Director of Otolaryngology Unit "Guglielmo da Saliceto" Hospital, Piacenza
From 1-7-1993 to 28-2-2003 Medical Director of Otorhinolaryngology Operating Unit, "S. Maria Nuova" Hospital of Reggio Emilia.
From 1-10-1987 to 30-6-1993 Assistant Unit of Otorhinolaryngology Hospital "Santa Caterina Novella" of Galatina, Lecce
Member of the Board of the Italian Society of Audiology and Phoniatrics
President of the Otorhinolaryngology Group of Upper Italy
Founding member of the Emiliano Romagnolo Group of Otorhinolaryngology (GERO)
Founding member of the Italian Academy of Otolaryngology
Founding Member of the Italian Society of Otology and Science of Hearing
1) Dr.Cuda You have done a lot of research and many studies. We are in 2017 which of these has produced results that it considers most comforting and why? Which, if there were, have had results below its expectations?
The precociousness of treatment in children. Linguistic and communicative development are significantly better when the implant is performed in the first year of life. A difference of a few months leaves stable traces for years. Our data indicate that until the school age the gap is not filled.
Another significant result is that of bimodal stimulation. When adequate residues are present in the unimplanted ear, bimodal stimulation produces significant results because the hearing aid provides spectral information on the low frequencies otherwise inaccessible to the implanted patient. To benefit fom it are the perception of music and speech in terms of prosodic quality.
The perception of speech in the noise and the consequent fatigue in listening continue to be the Achille’s heel of the patient with implant, especially in old age. Technology, waste preservation, directional microphones etc. they resulted in modest benefits compared to expectations.
2) IC, bone induction and hearing aids ... in which cases do you recommend them?
When there is a discrepancy between the expected benefit and the benefit obtained with hearing aids, then there is an indication to the cochlear implant. Hearing aids are indicated in most cases of hearing loss, at least up to 75 dB of hearing loss.
Although it is incorrect to refer only to the audiometric thresholds, it can be stated with certainty that above the 90 dB of hearing loss the cochlear implant is the treatment of choice. Between 75 and 90 dB it is necessary to perform very accurate valuations of the benefit obtained with hearing aids; many of these cases are in fact to be started at the plant. Stimulation by bone is limited to cases of transmissive or mixed hearing loss of complex prosthesis (auricular malformations, outcomes of otological interventions, active inflammatory processes of the middle ear).
Stimulation by bone is very effective with semi-implantable devices in the bone as the amount of vibrating energy transmitted to the cochlea is greater.
3) Many IC patient candidates are afraid of the intervention. Is it a founded fear? What are the real risks?
Face a surgery intervention always creates apprehension; it is a normal defense of every living being. However, it must be known that cochlear implant surgery is a minimally invasive procedure that, in specialized centers, is burdened by very few complications.
There are no specific risks; these are the risks of every intervention in the middle ear. Sometimes there is a brief period of vertigo, other times a tinnitus appears or intensifies, there may be a modest pain in the first days after the operation. These are unfavorable, modest and easily managed effects in a hospital setting. Infections, haematomas are more rare. Paralysis of the facial nerve is a possible but truly rare event thanks to the adoption of intraoperative monitoring techniques.
4) Premising that in Italy there are still no statistical studies in this regard and that, only at the very few region, it is beginning to do them in relation to the pediatric population alone, it is a fact that in other countries, such as Germany, the number of IC interventions is considerably higher (even four times). You surely have an idea of why. Can you share it with us?
There are two factors, one economic and the other cultural. The first concerns the limitation of the budget dedicated to the plant. This means that, for example, bilateral implantation in children is not widespread nationwide or that different reimbursement policies exist for individual hospitals. The second concerns the lack of knowledge of the medical profession and of hearing care professionals on new indications of the implant such as unilateral deafness, the so-called 'ski-slope' hypoacusis, ie those with accentuated audiometric slope and finally asymmetric hypoacusis.
5) A goal that all IC carriers pose: the ability to discriminate in noise. Is it related to the residue of the ciliated cells or the acoustic nerve? Or what else? Could you explain it with an example?
This is perhaps the most difficult argument. Both auditory and cognitive factors must be considered. Auditory factors involve the perfect audibility of acoustic signals. This involves the bilateral restoration of hearing by exploiting the maximum possible acoustic information that can also be obtained by preserving the hearing residues and stimulating them in electroacoustic mode (prosthesis and implant in the same ear). Furthermore it is necessary to use directional microphones and signal preprocessing strategies; processors usually have different algorithms for noise limitation or for emphasizing speech. Another help can come from using wireless devices with remote microphones. Cognitive factors are more difficult to understand and include - among others - work memory and attentional skills. Even the normoudente may have difficulty in perceiving noise when cognitive performance expires as occurs in old age,
6) What do you think of optical fiber instead of traditional electrodes?
We are experimenting with devices that perform an optical stimulation of acoustic terminations. The goal is to increase the endocochlear excitation sites with devices with very low energy consumption (think of the consumption of LED lights) and of reduced dimensions (mini-invasive). Technological research in this area is promising, however, clinical relapses are not expected in a short time.
7) How influential is the proximity of the electrode array to the modulus?
Certainly a stimulus closer to the modulus is more selective and requires less energy expenditure. However the perimodiolar positioning is also more traumatic and is burdened by a lower potential for preservation of auditory residues and in more general terms of the anatomical integrity of the cochlea. For these reasons it can not be said with certainty that the perimodiolate is better than the 'lateral wall' or linear electrodes.
8) What role does it give to the different components, technology, surgery, rehabilitation and psychological support, in the success of the hearing recovery with IC?
High technology and surgical standards are the essential prerequisite for a successful implant. Rehabilitation and psychological support are crucial in the management of deviant or complex cases (late implanted preverbal forms, adolescents, the elderly, hearing neuropathies, etc.).
9) In view of the fact that, even at the last SIO congress held in Sorrento this year, there was an admission by some specialists with a recognized reputation on the fundamental role that, even for adults, has the logopedic rehabilitation However, a large disparity between rehabilitation therapy applied to children and that reserved for adults persists in Italy. With many difficulties on the part of the latter in finding appropriate accompaniment in the path of adaptation to this hearing system completely different from the natural one. Why?
This is a problem of definitions and quality standards. Let's just talk about adults because the child's situation seems well codified. In a high-volume center the whole team is oriented to the daily management of these patients. For this reason, patients undergo counseling at all stages of the journey. The counseling is sometimes also conducted by the psychologist on specific topics. A speech therapist monitors the evolution of perceptive and communicative abilities. Most adult patients follow a regular monitoring path without the need for a specific 'rehabilitation'. On the other hand, it must be considered that many patients with activation already have amazing perception performance! The situation is different in particular cases such as adults with preverbal deafness or in patients with advanced age or simply in some patients with evolution under expectations. In these cases there is a rapid identification by the team of the problem and the patient is initiated into a real structured rehabilitative path. For reasons of 'sustainability' I do not think it is necessary to provide rehabilitation to adult patients, but only to specific categories or to cases that do not show the expected benefit.
10) since that there are rechargeable batteries with electromagnetic induction, what do you think it depends on the absence in the current market of a subcutaneous cochlear implantation ?
From the high energy consumption of current systems
11) What do you think about the use of the robot recently used in Bern to insert the electrode array with extreme precision?
There are many experiences in the world on robotic surgery. I am very supportive of this line of research as it will be possible in the future to insert with extreme precision and accuracy as well as a minimally invasive way a personalized electrode to the morphological characteristics of the patient's cochlea.
12) The profile of the patients suitable for the implant has been changing in line with the evidence of the results achieved. Until including patients with monolateral profound deafness. What are the perspectives?
The 'extended' indications include cases with less severe asymmetric and ski-slope deafness. In perspective I foresee the insertion of short electrodes to treat forms of selective hearing loss on high frequencies as in the case of the elderly.
13) Are there longitudinal studies on patients who have been implanted as children and are now adults who highlight whether ICs can be risk factors or facilitators in the development of some pathology affecting the ear or the acoustic pathways?
There is no certain evidence of increased otological or otoneurological morbidity caused by cochlear implantation except for a slight and known increase in meningitic risk in the event of a simultaneous malformation of the inner ear.