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Cochlear Implants: Looking Ahead

May 14 | 12:30 PM

Dr. Milind Kirtane performed the first cochlear implant surgery in Mumbai & has been awarded the Dr. B.C. Roy award (2005), the Padmashri (2014) and the Qimpro Platinum Award for healthcare (2014). But his greatest reward to this date remains the smile on a child’s face when he / she says, “I Hear.” He has a vision: every child with hearing loss must get the opportunity to be part of the hearing world. Let's hear from Dr. Kirtane all about the future paths of the cochlear implant, an electronic device designed to enable sound perception and discrimination in profoundly deaf individuals who do not benefit from hearing aids. LIVE & Exclusively on Medflix!

[Music] welcome to netflix and on this special occasion i am dr prancho mehta an ent surgeon and with us we have dr milind sir is a consulting ent surgeon at pd hinduja national hospital and medical research center reach candy and safety hospital mumbai he is also the honorary surgeon at king edward memorial hospital and professor emeritus at state gs medical college mumbai dr kirtani has a particular interest in cochlear implants endoscopic sinus surgery and neuroautology the government of india has honored him in 2014 with the padmishri the fourth highest civilian award for his contributions to the field of medicine he was also awarded the prestigious dr bc roy award in 2005 by the president of india and the pro platinum standard award in healthcare in 2014 he is a member and ex-president of the association of auto rhino laryngologist of india that is aoi founder president of the sinus endoscopic society of india and founder member of indian society of autology and indian society of laryngology dr kiertane is an honorary ent surgeon to the governor of maharashtra he has served as an honorary neurotologist for the indian armed forces he is a member of the advisory committee at aliyawarjung institute of speech and hearing disabilities mumbai for the adept scheme adip scheme for the cochlear implants so uh we welcome you sir dr milan keith thank you and we feel we are blessed enough to be attending a session and to have for having this conversation on cochlear implants today so sir now handing over the screen and the mic to you thank you very much to all of you and netflix for this opportunity and we're going to see you know a cochlear implant is a well-established procedure now but what are we looking at what are the future changes that we expect in this so this is a statement which is very true as far as cochlear implants is concerned that the reasonable man adapts himself to the world the unreasonable one persists in trying to adapt the world to himself it is these kind of people who go against the grain of things who are responsible for progress i may not call them unreasonable but these are people who think outside the box and the second most important thing was a same by martin luther king which my professor from germany was a class and told me that if you want to do something new read a normal book because if you are thinking of something you probably somebody else has already thought about it before you and when we look at stimulation of the year by electric current it was alexandro old time the 1850s when he made the dry cell that he experimented by connecting a series of dry cells to each other to get sufficient current and then putting a metal rod in his ear and he heard a sound which he described as sound of boiling soup but he had already shown us almost 170 years ago that electric current applied to the earth could give the sensation of sound to a patient and this is what this gentleman on your screen professor graham clark worked on and gave us the multi-electrode cochlear implant as we use it today there were other people who worked on it before him but they had used a single electrode implant it was professor clark who gave us the multi-electric implant which made it possible for a deaf person not only to hear sound but also to understand spoken words also remember this saying by confucius that a journey of a thousand miles begins with a single step so whatever you do you have to start small and for those young ent surgeons who are aspiring to start a cochlear implant program i just want to share something with you when i started i this was the great moment for me meeting professor clark and being inspired by him to start a popular front program which i started in 1996 and today we stand at close to 3 500 operated cases but it wasn't always that smooth in the first few years we were doing barely a few cases every year but as more and more patients came in and the word of mouth spread then the rate at which we started going up was very high and as i said we are now close to 3 500 cases so if you are starting a program and you don't have too many cases in the beginning don't feel bad stick to it and you will build up a happy program hi my name is i was operated on when i was now i just want to show you what we can achieve with the cochlear implant this is now there this is not the future this is very much the present and this is the kind of result we get in children who are born totally deaf just hear her speech my name is uh i was operated on when i was one year old and i have a cochlear implant and i am now starting in ninth grade and school i can softly talk to her and she'll answer my questions i want to be a writer when i grow up writer for the movies or novels or books actually who's your favorite author my favorite author is jk rowling harry potter do you want to write children's novels yeah any other children's authors you've read my name is [Music] made a difference [Music] as to how they are going to bring up this child and this future so this is where we have reached already so what are we looking at if we can get this good result what more do we want so there are things which we are looking at about getting more candidates so changing the candidacy criteria early intervention processes i think we'll go through them one by one so let's start first with the candidacy issues now when i started doing this in 1995 96 we were very clearly told that mainly do adults because you'll get better results in adults and do not touch any patient who has the slightest amount of hearing left with whatever he can hear with the hearing it let him be only a patient who can hear nothing with a hearing aid you will take for surgery once we started getting good results that changed and they said well if the patient can hear something but he's not happy with his hearing aid when you give him the hearing aid he doesn't come into the speech banana the four thousand eight thousand are outside so he's getting no clarity of speech you can still take him up for a cochlear implant and now even when you have a normal or a near normal gear on one side if the other ear is not edible you can consider these patients for cochlear implants as a matter of fact in patients who have sudden sensory neural hearing loss which does not improve with treatment cochlear implants may be considered in that deaf ear in spite of the fact that the other year is normal because you want to restore the patients to binaural hearing now going ahead you have an audiogram like this where the low frequencies are so good is hearing even without a hearing aid in the year but the high frequencies at two thousand four thousand eight thousand are not there now such a patient will be able to carry on a conversation but will keep on missing words even with a hearing aid he says that the speech is not always clear and therefore if he's a person interacting with other people in his profession he will be at a great disadvantage and that is because when you see the lower frequencies up to about 500 to 1000 they mainly give you the vowels the sounds i etc but when you want to come to the conservancy etc you need the high frequencies and if you don't have the high frequencies coming in just hearing sound with the hearing aid is not good enough and i'll tell you the importance of hearing consonants for example if a patient could only hear vowels okay and i give you this two lines all of you know these two lines but you can't make out what it is because you've only got wobbles no consonants it's jack and jill went up the hill to fetch a pail of water while if i give you the consonants without the vowels you don't need the vowels you can still make out exactly what the words are saying so when you have a situation like this where you have the low frequencies your speech discrimination is poor so in such patients if you were to do a speech audiometry and if they have a speech discrimination score with a hearing aid of less than 40 percent then although they have this good hearing in the lower frequencies you could still consider them for a cochlear implant so even if that is there they would be unhappy with their irrigation look at that man's face and today we are getting more and more elderly patients coming in otherwise healthy good mental health but they are so unhappy with the hearing aids they say i've tried every possible hearing aid and it is just not giving me the benefit so although we have in our series almost 92 percent children and only eight percent adults i think there is a huge portion of the population elderly adults who have progressively gone deaf with age who probably need a good hearing aid are not satisfied because of the peculiar configuration of the high frequency laws who could be candidates for cochlear implants all over the world especially in the uh developed world when i talked about this in europe or in america they're surprised to know that i've got 92 in children and eight percent errors because in most of their series they have as many adults or sometimes more adults than children because insurance or government schemes can sort of contribute to the a free cochlear implant even to the elderly while in india we have a lot of schemes that give donations to children a lot of government programs that help children but not adults and it's an expensive uh gadget to buy and that is why we have this poor ratio as far as adults to children is concerned but there is a huge population of adults who could be benefited with cochlear implants so i'm hoping that this graph that we have of almost 92 percent of pediatric patients in the future as time goes on we are able to change and we get almost an equal number of adults as children and we should work towards this the second thing is early intervention now we still talk about children in india and what we've realized and everybody all over the world has realized that you know you can operate at four years and you will get a result if you had operated the child at two years of age you would have got a better result and if you could operate on that child at one year of age it would be even better and it need not always be cochlear implant surgery it could be just a patient with a moderate deafness to whom a hearing aid is given but the sooner you intervene the better is the outcome and therefore for early intervention you need to make an early diagnosis as a matter of fact the child starts to learn and identify sounds even in utero it learns the mother's voice and you know you've heard mythological stories about uh chakra viewer how we could hear the part about entering the chakra view but not abhimanyu could not get the whole information but he already heard it in triutal intrauterine so a child that's more normal who hears everything doesn't understand the word of what is said and does not speak immediately takes some time for the child even a normal child to develop speech and language that is because you have in the brain that pinky area which is the auditory cortex and then auditory cortex keeps on receiving information in a child there is a memory area in which those sounds are stored meaning is given to those sounds and then synapses start opening up from the auditory cortex to the surrounding areas to the speech area so that the person the child learns for example that the word mummy mummy means this person and then if i want to call this person i will have to pronounce the word mummy so there is a connection between the auditory area and the speech area and these synapses are blank they are not open at birth as the child keeps on repeatedly getting the same sound it learns these words first to understand them and then to speak them and this is extremely important that the auditory cortex continuously receive this information because if the auditory cortex does not get this information because the child is there there is no electrical activity going on there that part remains blank and the visual cortex for example with normal eyes will come into play and take over that area now this development of synapse is opening up the process starts at birth or even before birth and occurs maximum between the age of zero to two years so you need to give input to the child in that age group for it to develop good language and speech it will still happen at four or six years but the density of the synapses that you get will be much poorer therefore the later you intervene either with hearing aids or with cochlear implants the results are not going to be good and it's really unfair to the child that there is a possibility of giving this child the benefit of early diagnosis but is the ignorance of the parents and sometimes the ignorance of the doctors that takes away this opportunity from this child so if you do not use that auditory cortex the message is very clear it's a silent area the auditory cortex is not being used because nobody knew the child was different didn't give a hearing aid and the visual cortex will see this silent area and just take over that path once that cortex is lost at the age of 10 or 12 you give this child a cochlear implant the sound will reach the brain but there'll be no area left there to make use of that so the message is very very clear either you use it or you lose it therefore it's necessary that we diagnose the deafness as early as you know every time the misguided started from the beginning even if we we shown to a pediatrician they say the pediatrician is saying that when he was a five-year-old this part is speaking she's okay she can speed do this everything no problem to her [Music] problem when we shown her in a good hospital in bahrain the doctor said she's having a wax they remove the wax they said everything is okay i said if everything is okay then when i speak why she is not able to tell me anything the classical example where the ignorance of the doctor led to the problem of the child being diagnosed late so sometimes the parents sometimes the caregiver sometimes the doctors they have all to learn that doing an early diagnosis is important because up to two years you get a fantastic result between two to six years you will still be suitable for the implant but if you get the diagnosis much later and you intervene late the outcome can be variable so in many places all over the world there is the universal newborn screening program started unfortunately not so in india there are certain centers which are doing it but the universal new one program that we hope will come into india is where every child born will not leave the hospital without having the hearing tested even in a one day old child the oae that's the auto acoustic emissions can tell you that the hearing is normal there is some problem which needs to be investigated further so the day the child leaves the hospital it's already determined that this child is going to need some help can be referred to the right center they can do the para they can do subjective testing and intervention by way of hearing aids or cochlear implants can be started at such an early age that the child has a very good chance of joining the mainstream of life very happy to say that one of our joint principal commissioner mr chori from mumbai has taken it upon himself to start a program he calls it dreams unlimited and he is pushing for at least introducing this into all municipal hospitals in nowhere hopefully all the births happening in mumbai it's a start and then we can spread this model to other parts there are certain states in india where this is already going on but it's only in isolated pockets this needs to be done in such a way that hearing aids or cochlear implants or who knows in future even cochlear implants in both ears can be given to these children as early as possible so as i said one of the futures that we are looking at is universal newborn screening and this sooner we get it the better it is we should be spreading awareness to parents that all children who look normal could still be having a hearing loss please have your child tested as early as possible even though the child is apparently looking now the next thing is the implant itself now you have these processes which sit on the patient's head now for those of you who may not be very familiar with cochlear implants we do cochlear implants when a child is so deaf that even the most powerful hearing aid does not work so the implant consists of two parts something that you wear outside like this like looks like a hearing aid but it's actually a computer and this computer receives the sound coming in does not send it to the ear it converts the sound into electrical signals exactly like the cochlear of the patient would have done if the cochlear is functioning unfortunately the patient's cochlea is not functioning so this is done outside the body by this processor but this electrical information now needs to go to the nerve so you put in an implant by surgery around the nerve into the cochlea and you send this electrical information to the nerve by this receiver which you are implanting inside the patient's ear using that little round thing that you see there that's a transmitting coil which sends the information using rf frequency is the carrier straight to the cochlear nerve and from there to the brain so you bypass the ear even if the cochlea is completely deaf the information coming in by sound goes to the computer computer to transmitting coil to the implanted receiver and to the nerve and the patient can hear again so this is the size of the processor which is invoked today most patients today going underway cochlear implant will have such a process processor which they wear behind the ear but it was not always so when professor clark did his first cochlear implant this was the size of the processor and that was the size of the computer the patient had to come into the hospital and be plugged into that computer to here this was not practical so they worked on it and they got a processor which looked like a transistor radio so the patient could wear it on his shoulder soon that gave way to something the size of a cigarette packet which we used in our earlier days that we were doing implants then came the year level processes like the skin is wearing and today we have processes that fit without any wires off the ear processors that look the size of a carom coin and with a magnet they just sit there but everybody is still trying to look for the next generation which is the totally implantable cochlear implant so the future is looking at getting the same quality of sound production as the outside processor gives with a totally implantable cochlear implant and these processes also have evolved over the time the electronics and the processes has improved if you see in the 1980s these processes were capable of sort of giving the patient about 12 speech discrimination score which means out of 100 words the patient would pick up 12. with subsequent technology improvements by the end of the century they had already gone to 85 and today with the kind of processing technologies and newer processes it's gone close to 100 in ideal cases so you can have a child listening almost as well as a normal child would understand spoken words so the processes have become smaller and smaller and they have become far more effective but as i said we are still looking at the possibility of a totally implantable no wires nothing seen outside and that is what people are looking at now the whole point here is there are already such systems in experimental use and i have met patients who had this thing done they were happy to carry on a conversation but the patient told me that if i have to really attend an extremely important meeting then i prefer to have the external processor now we are not doing this surgery for cosmetic reasons we want to give the best sound quality to the patient so till such time that the totally implantable implant does not give the same kind of speech discrimination as the current one does i think we should not be giving it to the patient because what we want to deliver is excellent voice quality not cosmetics but the totally implantable will be invisible will have greater reliability because there are no cables that the kid can pull out and it's on even during sleep but unless we have the performance same as better than ci there is no external hardware needed to be used there is no additional risk and it can be used for long term you don't have to keep on operating again and again only then should be totally implantable cochlear implant be used i really don't understand this people will use glasses we'll use dentures we'll use walking sticks but for some reason they don't want to be seen with a hearing device i have people of 85 or 87 years old coming doctor give me a hearing aid that can't be seen i don't want people to see me very hearing it i don't know why considering that people can do all sorts of things to their ears but not wear a hearing aid anyway it is for these people that maybe the totally implantable cochlear implant coming in the future will make us get more patients to be operated also in the implant you had the electrode the one that goes in it's got multiple points of stimulation why do you require that because the cochlea is like a rolled up piano the different areas of the cochlea are stimulated by different frequencies or sensitive to different frequencies so if you had only one electrode going stimulating only one point on the cochlea all sounds would sound the same so now you have multiple electrodes going in which can be individually stimulated the basal area of the cochlea this one here this part here this basal area is sensitive to high frequency sounds while the apical area is sensitive to low frequency sounds so when the computer outside its high frequency sound it will stimulate an electrode here when it gets a low frequency sound it will stimulate the electrode here so the information going with the nerve to the brain will make it possible for the recipient to understand what is the frequency of the sound so it can discrimination even the high frequencies will be perceived as high frequencies and as you know that is what is necessary for discrimination so these electrodes have become better and better the initial electrodes were quite stiff so that when you put those electrodes inside they tended to destroy a lot of the structures within the cochlea sort of taking away the capacity of the cochlea to function better the nerve to function better because you cause so much of destruction now you've got electrode areas which have become softer more flexible and you've got different introduction strategies because of which you can preserve hearing or if not the hearing you can at least preserve the intact structures in the top layer which are not completely gone in order to get better outcomes for example here is the way the introduction of the implant is done so that the implant instead of scraping the outside of the cochlea as it goes in the implant is in that little brown tube that goes into the cochlea so once it goes into the cochlea it does not go and touch any wall outside does not scrape against anything it just goes and stops there and now you push the implant which is capable of curling upon itself so as the implant is pushed inside the implant sort of curls around the nerve which is running through the center of the cochlea without damaging any structure around and it has been shown that even if you do not preserve the hearing preservation of structure gives much better output so you have arrays which have reached this stage the diameter of the array at the tip is something like 0.3 to 0.35 millimeters you can imagine almost like a hair and it's capable of going into the cochlea without producing any damage so these are some of the newer electrodes which have come in either the straight or the flexible ones extremely small not only that but the positioning is such that the blue one would be the older ones where you would have the array scraping along the outside and it is likely to damage the area of the scala media here and translocate into the scalar vestibuli while the newer areas will either go close to the module so this is what called the mid scaler from the advanced bionics which stays closer to the nerve without actually touching you and this leads to better focus of electrical information on the nerve and therefore better outputs not only that one of the biggest setbacks of cochlear implants was that because you had magnets in the cochlear implant for the outer part to fix onto the implanted portion you could not go in for an mri in the earlier times if a patient required an mri we would actually have to go take a small cut take out the magnet and after the mri was done put the magnet back which meant the child had to have another surgery so now you've got the next generation of implants where the magnet is made in such a way that it actually has the capacity to change its polarity these magnets actually can turn around and change their polarity in such a way that even without removing the magnet and using a three tesla machine you can now do an mri of these patients now i told you about the stimulation of the electrical information going in from the computer outside to the cochlea instead of using electrical information people are working like you have the fiber optic cables the future cochlear implant could be using not necessarily electrical but an optical fiber for cochlear implant or you could have the stimulation by a fiber-based optical stimulation so in short when you have normal hearing the vibration of the membrane leads to stimulation of the hair cells in a particular area so the frequency perception is perfect when you do a cochlear implant you have the implant giving the electrical signal so there is a spread of electrical energy so multiple spiral ganglion cells are likely to get stimulated so the understanding of that specific frequency may not be so good because the current is spreading well if you use an optical cochlear implant then you would have a much better focus of the information onto the spiral ganglion cells and therefore possibly the speech understanding and discrimination would be even better so today the technology is that of electrical stimulation but we hope that in future optical cochlear implants will improve the results even further not only that but it has been shown that if you introduce certain substances into the cochlea when you do the implant for example it's a foreign body going into the cochlea it's producing some kind of inflammatory reaction from the cochlea and if steroids are introduced in the cochlea at the time of being a cochlear implantation the amount of fibrous reaction the scarring that occurs in the cochlea this has been shown in animal experience is much less so now people are talking about making the electrode arrays with a drug delivery system so that you could actually have dexamethasone or a hydrocortisone in the silicon tubing over here so besides having the electrons on the array you could have a slow release in the initial period when the inflammatory reaction is taking place in the cochlea release of hydrocortisone over the next few weeks so that the inflammatory reaction is minimized scarring is less and therefore residual function or structure preservation is much better which we know leads to better speech discrimination now it's not only dexamethasone or hydrocortisone people have also thought of other substances that means to give not only hydrocortisone but you could think of putting something else along with the electric current that you're giving by loading the cochlear implant array with for example the brain derived neurotropic factors or neurotrophic three which will promote better health of the neural elements in the cochlea for example you could use delivery systems of different type whether it's osmotic pumps or smart polymers nanotechnology to push those uh substances the bdnf and neurotropin into the cochlea along with the cochlear implant array and this is from an article that i came across experimental work the a and c are from an animal where you see higher density of the spiral ganglion cells very clearly seen here the higher density fibers here in the resistant pulse canal because in these the bdnf was put into the cochlea along with the electrode array while on this side the control side on the opposite side you see a much poorer spiral ganglion population because no uh brain derived neuropathic factor was put in so if you can put in the bdnf or neurotrophins into the cochlea along with the cochlear implant and i have a slow release over a period of time you might probably have better results because the dual population could be more protective the next advance could be in imaging see today we have a fantastic imaging technology with the ct scans and the mris we can see a lot of detail in the cochlea find out malformations forces of nerves we can see each individual nerve the cochlear the vestibule of the facial nerve you can even have a reconstruction of the cochlea like this to see the shape of the cochlea see if there's any ossification we can have these kind of protocols to see the cochlea in three dimension so all these already exist as a matter of it you can even do an endoscopy of the top layer virtual endoscope of the cochlea especially when you are suspecting obstruction because of an autosclerotic focus that's the basal turn that's the middle turn that's seen to see if there is any ossification so you already are this far ahead then what more are you looking for well we could look at functional mri to see the auditory cortex and the amount of stimulation that is available and it could be a prognosis indicator depending upon the amount of activity you find there in the auditory cortex telling us what would be the chances of what would be the result or outcome in a particular case so functional mri is one thing that we're looking at to see whether we can predict the type of outcome and once we start doing this maybe more applications will come in the other thing that came out of this pandemic you know it says that the necessity is the mother of invention because there were patients who were operated who could not come for a teletherapy for therapy and for mapping and they could not be left alone a lot of audiologists and therapists turn to looking at doing the mapping and the auditory verbal therapy which is required with cochlear implants without which cochlear implants are not going to function mapping is the tuning of the implant that you have to do for each electrode as the current levels changes because of the healing of the wound and the avt is teaching the child to make use of this gadget now so that slowly over a period of the next say two to three years the child learns language and learns to speak without this auditory verbal therapy a cochlear implant is not going to work in the child and now the child could not come to the clinic because of the lockdown so a lot of people then turn to this and today it's become almost a way of life where people are finding it quite convenient the child is far away they work out a program they have the hardware given to the parents so that they can continue their therapy and even mapping on long distance to make sure that just because it's too difficult for a child to travel to a particular center the child does not miss out and this came to be because they were forced to do it by dependent so something good ultimately did come out of the pandemic lastly the surgical technique i think today the surgical technique which is fairly standard all over the world a postericular incision mastoid posterior tympanotomy and if possible an insertion through the round window or by a small cochlea be done very very atraumatically just next to the ground window to ensure that you put the implant into the scalar tympani this is a completely standard technology a postural incision posterior impeller to me and as i said you would want to do the insertion through the round window but look at one thing as the insertion is being shown you look at the direction of insertion you try to follow it towards the outer wall of the cochlea so that the insulation is done very slowly very gently over a certain period of time and it is always directed towards the scalar tympani so you don't actually translocate going into the scala media so if that's the round window then you want to go along that way and not just try to push now there is a technique called vivaria technique where through the middle ear the implant is pushed in unfortunately because of the area of approach you cannot follow the blue arrow path and you have to push in the implant to the wrong window translocation chances would be much higher so better to follow the posterior tympanotomy and follow the technique of pushing the implant in the correct direction because if today you are operating on let's say adults who have some amount of hearing like i showed you in the audiograms you want to preserve that hearing they can have a hearing of low frequencies by auditory means by their normal hearing or with hearing aids and they can have the high frequency hearing which has gone down badly with a cochlear implant so they can have both this hybrid kind of a hearing in the same year giving very good results but for that you need to do the insertion very dramatically and in the correct direction if you can't preserve hearing at least try to preserve structures as much as possible because if you preserve the structure don't damage the cochlea the outcome will be better and in this uh the advanced bionics has come out with this aim tablet where you can do the uh copy potentials can be checked as you are doing the introduction so as the implant is going in you're looking at the cochlear microphonics you can look in the electrical activity and if you have a patient who has fair amount of hearing in the lower frequencies as you go in you keep on monitoring as you advance electrode by electrode and at the point where you feel that the cochlear activity is starting to drop dramatically as you see in this graph over here that's where you will stop your insertion not try to go further so the chances of you preserving the hearing become that much more so this technology is helping us go towards preservation of hearing and therefore giving the patient the optimum result even hybrid technology where part of the hearing is with auditory and part of it is electrical so as you're going along you're monitoring the endocrine potentials and the moment you see something happening and those potentials dropping you will stop the insertion i wonder whether you could do this by imaging i mean it's a thought process and again what the future holds is that you could actually do live imaging as you're doing the insertion and whether it's possible i don't know but you can always dream about it and as you dream about it sometimes the impossible becomes possible so imagine that you are putting the implant in the cochlea and the imaging is telling you as you go inside whether you are going correctly or are you going towards the scale scala vestibule so this is something which hopefully future technology might bring in for us and of course we're also looking at what the human hand cannot do is robotic in session because it has been shown that if you do your insertion very slowly and smoothly without jerks then the chances of hearing preservation and structure preservation are good if you can do it over three to five minutes maybe over seven to ten minutes now imagine a surgeon sitting there trying to introduce that uh 18 millimeter or 20 millimeter implant over 10 minutes there is no way the surgeon is going to be able to do it that beautifully and smoothly and slowly but a robot can do it so people are working on robotic insertions at the moment and of course there are some people who dream that the robot might be able to do the whole operation by getting the trajectory straight to the round and putting an implant inside for that apart people are working on the insertion roma being reduced by robotic insertion so that hearing preservation becomes a reality lastly we come to the research that's going on on stem cells and gene therapy and i must admit that this is one area where my knowledge is extremely limited or almost not existing because i have never had the opportunity to work except reading up some stuff and what we know that the research that's going on is mainly in animal experiments you know it has been shown lizards can regrow their tails it's amazing that a starfish if you cut off a limb it will grow the limb immediately it has been shown in birds that if you deafen a bird by giving it let's say gentamycin within two to three months you destroy the hair cells of the pigeon by gentamicin the pigeon becomes completely deaf but within two to three months automatically there is a regeneration of the hair cells and the bird can start to hear again now this is also been done in animals in mammals for example guinea pigs using for example what they call the math one gene or the atonal homogelogy it's called the a21 gene and i'll show you one experiment that was done in guinea pigs where this is quite old but it says here that by inserting the corrective gene with the viral vector the team induced formation of new cochlear hair cells in the sense what they did was they defined the guinea pig by injecting gentamicin by hearing tests showed that the guinea pig had become deaf the hair cells were destroyed then they used the 801 gene using a viral vector into the animal on the fourth they used the gene therapy using a viral vector to insert the 801 gene within two months new hair cells had appeared in the treated years but not in the untreated years so genetic engineering introducing the gene using a viral vector could in an animal that would otherwise not normally generate damaged hair cells they could induce this it's not been done in humans as yet people talk about injecting stem cells and regenerating and cochlear hair cells but one thing that could be used by this technology is not necessarily stimulating hair cell growth but long-term administration of the brain derived neurotrophic factor could be achieved by using genetically modified mesenchymal stem cells so you use these so that they will keep on liberating or introducing bdnf but not necessarily develop new air cells but they could at least give you a supply of vdnf inside this cells would need to be protected by a viscous alginate to prevent the recipient's immune system from destroying them and from uncontrolled migration again a step into the future of introducing bdnf into the earth but if you try to grow hair cells by introducing stem cells as somebody pointed out how would you control where this regeneration would stop and maybe you would land up with too many hair cells being formed and nobody really knows whether there would be a malignant transformation in this newly formed cells this is from the literature no personal experience so in no human trials have been done with this kind of stem cells i am sorry to say that there are some centers in india newspaper advertisement we are talking about platelet-rich plasma being injected into the year acupressure giving rise to uh regeneration of hair cells i don't think there is any scientific basis from this and i don't think you should let your patients fall into this trap now there is one trial which came to our notice and it's called the regain trial it started off in london in uk and now there are other countries like germany and greece and the concept is that if this can happen in let's say birds that the hair cells form so what is obviously happening is that the hair cells which were damaged were supported by the supporting cells so in development certain cells from the embryo became the aortic cells aortic capsule developed then you've got the development of the cochlea the vestibular system in the cochlea the cells became supporting cells and some cells went on developing beyond the supporting cells and became hair cells while the other supporting cells were stopped from becoming hair cells when the hair cells are damaged if you can allow the supporting cells to start their journey again and become hair cells then you can restore the damaged asses this is the concept that's been followed so there has to be some mechanism in the ear which is blocking the supporting cells from becoming hair cells and that's called the notch pathway so they have found this notch inhibitor this is the ly3056480 substance which can be injected into the ear hopefully it will trans sort of press the round window membrane and enter the cochlea so that the hair cells that ones that you see in in blue over here if they are damaged these cells that you see are in in the in the red here and the gradient which are the supporting cells with the help of the injection of this substance that was told to you which is actually what is called a gamma securities inhibitor you could stop this notch pathway from preventing the supporting cells from becoming a cells allow them to proceed and maybe the hair cells would form again now this is the trial which is underway for mild deafness patients in the uk since 2015 but we still haven't got its outcome yet so if that happens and if you can successfully generate new hair cells where the hair cells are damaged or not existing then you can restore hearing by medical means and cochlear implants will no longer be required that's a look into the future and till such time that this happens we still have to resort to cochlear implants in children who are born deaf and in adults who have lost their hearing because of trauma infections or drug toxicities thank you very much for the patient listening and if there are any questions i would be happy to answer thank you so much sir well uh this actually opened a new window for future of cochlear implants because till now what we are reading or what we deal with is the present scenario it was wonderful to know what future might hold or what things are going around in the world so anyone if anyone has any question uh you can come up with a question and you can go ahead ask till then sir uh till we get the questions uh i would like to play a very small rapid fire with you so that we and our audiences uh get to know you uh as a teacher come human friend for everyone so sir what what's your favorite memory from your post graduation days post graduation days okay i i was i got interested in neurotology in vertigo i just want to tell you the kind of teachers we have i mean my memory of my teachers whom i i respect just the way i respect my parents or god they were wonderful people and i'll just give you one example i was a young as a sort of uh lecturer and i was working on meniere's disease at that time trans labyrinthine cochlear vestibular neurectomy was the operation that everyone was talking about and i was doing a lot of work on diagnosis and doing temporal bone dissections and finally i had a case where i felt that the patient was refractory treatment and would benefit with a trans labyrinth and popular vestibular neural i was a at a level of a tutor that's just junior to a lecturer and i told my chief doctor that you know sir we can say you show you want to go and open somebody i said sir this patient is not improving and so you should do this it says okay have you done so i said no sir i'm not done i'm only done on the category so he said okay put it on the list tomorrow so before he came i got the patient scrub prepared everything and when he came in i told him sir start and i went to the head and you know we used to put water with that little balloon where the master was yes and he says no he came and sat at the end and it said you start and i started and it took me quite some time because after doing a master victim you had to expose the tree behind this dr kamishwin showed us some beautiful videos today and uh this was the first time i was doing it never done it before never seen it being done before only and those were days when there were no videos available on youtube there was no youtube at that time and he my chief sat there and he put water for me for almost three hours till i demonstrated the nerves and i cut them they got up patted me on the back and mentor saying well done and this is unheard of when your chief sits with you like an assistant during this so this was the kind of encouragement that we got and i can say i told you how i respect my teachers even today what was beautiful in that relationship was we had a lot of respect but no fear no fear at all we could talk to them we could discuss we could tell them if we disagreed i could tell him sir i have read something like this can we not put it and that was the most beautiful part of that relationship respect without fear i completely agree sir the best thing about our profession which i feel is which i somehow feel these days the youngsters they are going away from that but the amount of bond or the amount of respect a student and a teacher in specifically surgical fields can have and the amount of learning that takes place between that the relationship that's wonderful and that's something which we should relish during our pg days so this kind of encouragement is amazing when i did my first epidemic he brought his own set from home to say my registrar will operate with the best instruments yes because in the general hospitals the quality of instruments are always pretty good so that was a feeling that we were nurtured we were nurtured we were looked after and hopefully i i don't know whether my students will agree with me or not but that's the kind of trend that we have tried our best to carry on you said definitely sir i've heard a lot of stories from my uh aged people my colleagues who have worked and learned under you so i have heard similar sort of stories sir uh what's your favorite book one as per our subject and the one or not related to our subject well the bible for uh every eight surgeon is his fault so when i appeared for ms there were two volumes today i think there are six or seven volumes the knowledge has multiplied i can tell you that i'm glad i became a doctor and a surgeon at a time that i did in today's world i don't think i would have managed the amount of information load that is available and for our talk then we had different books for every kind of like for autology we would read uh shambal then for you know for cancer we would need something else so but the the main stay in post graduates was of course uh okay answer a book which is not related to medicine just your go to book when i i used to read a lot of nonsense but there was one author that i was fond of reading and that was uh aj cronin you know books like the citadel or the keys of the kingdom those were fascinating books i somehow there fell into that groove and read most of his book so i can't hear you am i audible sir no yeah now you're ready so when first time you heard that um the news about the padmishiri was announced what was your feeling what was your reaction where were you like uh you know where i was i will tell you yes i'm saying this in the lighter when i was gone my pants down because i was changing clothes in the changing room of bharatiya vidya pete and poona i had gone there to mentor dr gabriel for a cochlear implant i was slipping into the scrub suit when the phone call came i picked it up and i said i'm so and so from from delhi the president wants to give you this we wanted to know whether you are willing to accept it or that's the time i got to meet so it was a fantastic feeling but i'll tell you what was even greater even greater was the feeling when some of my operated patients those kids phoned me up and talked to me on the phone my cochlear implant is congratulating me so i don't know which of the two was greater pleasure getting the award or having those kids phone me up and and talk to me on the phone to congratulate that that the smile on the face of that kid and the parents uh it's it's really something that is beyond words there is nothing in the world that can replace that field i agree sir must have been a proud moment answer to all those who are attending this session maybe some of you yet are to enter your post graduation days you won't be able to understand that a kid who is not able to hear can never develop speech until unless he is able to undergo the process of learning because he cannot listen you cannot first you have to tell him that it's a tree then only he can tell that it's a tree so even if he has normal voice box he cannot speak until he has learned so when these kids speak or talk the way sir showed in the videos that sound quality the voice quality of that kid the ones who were talking once you see or meet those patients in reality you'll understand how good those cases were or what is the importance of that amazing uh speech of clarity of speech i would say two things i would like to say here number one is that just two weeks ago one of my implants came and gave me a box of sweets saying sir i have joined the medical college medical college that's that's right that's secondly since you talked about they have a normal voice box and they can't hear they can't so a common term used for these kids is they are deaf and dumb but heaven's sake heaven's sake never use that terminology they may have some hearing loss but they are by no stretch of imagination give them their hearing back and they can even outshine their that is the reason i choose to say that they are normal voice box because i prefer that uh one of the kid i recently met specifically their parents made him underwent an iq assessment and it came out to be 110 better than most of the people so it's not about the brain it's like they cannot hear until i tell them this is a tree he'll never know that this is a tree so he needs to deal with this kid did not receive an implant or a hearing aid he could go to a normal school with the parents not knowing that he's deaf would get labeled as a duffer and a poor learner because he possibly couldn't hear what is going on and he doesn't know what the other kids are hearing so he thinks what he's hearing is normal that's where the problem comes and as a matter of fact one of the audiologists told me this story that this kid was hearing with one year the other year was very poor and he was under the impression that everybody hears with one he didn't know that people here with two years so she said of course i'm giving you a hearing aid because you're supposed to hear with two years don't you know why did god give you two years and your answer was to wear glasses sir i agree so that is why because i feel some of the people who are attending this session might be young and not get into the specialities and might not be having the idea about the video which sir showed those two kids post operated uh the clarity of the speech which they had is something once you hear it you feel proud and sir it's an honor that we are seeing this and doing this session today so sir before we leave the session there are a few questions from the audience uh they want to know familial hearing loss by old age is it an indication for cochlear implant so first of all the question that's a very good question because what we are seeing now is that there is there is definitely a heredity involved in this unfortunately if the father became deaf at the age of 65 70 the next generation might get it a little earlier this is what we are noticing and like baldness for example you're noticing a lot of younger people now with bonus than what you saw in the previous generation so if it's a hereditary hearing loss yes and if it progresses to a level where a hearing aid no longer gives them good speech discrimination so you should in these people do a hearing a trial and do a speech discrimination score and if it's below 40 in the worst year then i think they are definite candidates for cochlear implants we are not nobody in india has a high series because of the cost and it's it's not something that a middle class family would jump at you know spending seven eight lakhs because there are a lot of programs giving it to children we have such a high population but yes if if even if it's a 85 year old man if he's in physical and mental good health there is no reason why this press bar accuses cannot be treated with the cochlear implant if it can be shown that a hearing aid is not giving good response certainly true that said i totally agree sir one thing one a small story i'd like to share from my side i met a patient sir that patient the difference you showed initially that in the western countries more of the adult population wants to go for a cochlear implant i met a patient patient had cs1 a patient came to me and directly told me she wants to undergo in surgery and the surgery i asked like what surgery do you want to undergo i had not seen the patient before a cochlear implant and i was when i examined the patient the patient had uh proper csm but inactive has been dry for years she told me that some of her friend in the western countries underwent cochlear implant for the similar thing she did not know the exact details but when i heard it for the first time i thought she was bluffing or probably she did not understand what her friend had told then i went on and i researched that in western countries many of the adult people for press bike uses even for the cases who have been operated proper tympanoplasties have been done they are undergoing cochlear implants just for the sake of tackling hearing issues because their main issue is not the presence of a perforation even if it's dry their issue is the hard of hearing and they are willing to undergo cochlear implants for that they are not uh stepping back the exact cause you mentioned sir is because they're covered by the insurance but you just give me half a second just barely so till now this has been a wonderful session and i hope everybody has enjoyed this till now sir so i was telling probably the same reason uh i think the medical insurance that is covering them and in india the issue is the common one they are not ready to spend that much for gaining back their hearing specifically above the age of 50 or 55 they just feel that it's okay to be that way also the concept of joint family they're looking after maybe the children or even the grandchildren's education and this whole amount of weight likes could come in useful somewhere else so yes any other questions no sir there are no further questions and but we are getting some amazing comments people are telling it was a wonderful session uh they've learned and majority of them are telling that what they have learned today something they had never heard of like there are a few things which probably because at the undergraduation level we are not exposed to the subject assets so thank you so much i i thought we were mainly talking to ent because otherwise i would have gone a little more into explaining what the cover cochlear implant is different from a hearing aid you know but hearing it is i hope it was otherwise quite clear yes it was amazing sir and i feel good uh because me being an ent surgeon i got to learn a lot so off the recorder after this presentation ends i would personally like to talk to you because i have personally been working on something which is medical correction just like you showed in the end a few researchers which might in a few cases uh alleviate the need for popularity plan so i'll definitely uh take your guidance and your opinion on that after this i have my phone number so give me a call thank you so much thank you for the session it was wonderful sir it was wonderful joining and talking once again thank you netflix i was happy to be associated with you and carry on the good work that's all i can say it is wonderful sir i learned a lot it was amazing i was glued to the screen wonderful to hear you on this topic thanks a lot for joining us and thank you dr branch thank you


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