บทถอดความฉบับเต็มของ Cochlear Implants with Dr. Nathan Lindquist

concussions and having that sports background. I think a lot of a lot of doctors, especially surgeons have some sports backgrounds as well. And so, it's really interesting to hear that. And so going a little further. So you said in college, you majored in chemistry, is that right? That's correct. Yeah. And then you just had to come to medical school and you went to St. Louis University? And can you tell me a little bit about like, what kind of exposures did you get in medical school that made you think about like a neck surgery, the anatomy of that, what really captivated you in that moment? Dr. Lindquist: Yeah so I think that for a lot of medical students thinking about otolaryngology, the cases that you're involved with are a lot of the big surgical cases oncologic stuff, head neck surgery, but you get a pretty varied approach. So you know, you're scrubbing into the cases that are the big free flap reconstruction, where you're taking, you know, basically a distant piece of tissue and sewing it into the vessels of the neck to help reconstruct after and helping with quality life in that aspect, where, you're trying to restore the ability of people to swallow or to breathe or talk and so, a lot of those surgeries are really morbid. But then on that you also see the other parts, there's not just the communication side, that's the voice that otolaryngology offers, but the hearing, there's the smell and sensation, taste, all those things. So there's a lot of the senses that are involved, obviously. And then, we can talk about, kind of why the ear specifically, but I felt that cochlear implants, which is part of the discussion today, was one of the single coolest things that, you know, you could imagine in terms of probably the most successful neuroprosthesis of all time, that we actually can restore one of those senses. So the things that you're doing, for head, neck, people trying to get them to swallow safely or breathe safely, you're restoring the ability of someone to hear, which I think is really amazing. Aaron: I think that's one thing that is really cool about ENT, I've heard it described to me as it's a specialty really dedicated to the art of communication, because of senses that are involved in the ear, nose, and throat. And it's really cool to hear you talking about hearing in particular, because I think that's something that can be taken a little bit more for granted. It's not something like vision, where it's very, very obvious, like you can't see, but it's something that's very important as well. And so, you mentioned earlier that you didn't want to get into a little bit about why you wanted to be a nerd neurotology. But could you describe a little bit, the circumstances of what that decision was like for you as well? Like, why the ears in particular Dr. Lindquist: So again, kind of echoing what you're talking about, restoring quality of life, helping communication, I think that we are in a period of time, where, at least in terms of

the advances that are going on with a lot of the field that I'm in is, we're learning more and more about, cochlear implants have been around for decades, but we're starting to learn, and we're starting to expand kind of what they're used for. And so, seeing just the ability in, seeing the children that were implanted, many, many years ago, and having them come into the clinic and have basically, normal speech and intelligibility is incredible. And so, we’re finally at the point where, there's been decades enough for those children to be grown up and to be integrated into the speaking world. And so, there's very formative encounters that I had as part of my work, shadowing as a medical student, and then working as a resident, that that helped form that and I wanted to be part of the service of that, and also looking at how can we make things better? How can we expand access to people in terms of getting what they need? And there's a whole bunch of things that I could talk about, hearing aids are another thing. We're learning a lot about with some studies coming out in the past year, that there are a lot of consequences other than hearing loss for people with difficulty understanding and with damage or hearing loss in the inner ear. Things like depression, things like social isolation, we know the association with dementia, and now we're starting to see that maybe there's more of a causative effect to that. So, losing hearing or not treating hearing actually can exacerbate or accelerate the development of those kinds of things. And now we're looking at well, does treating that problem, help curtail some of those other issues? And that's something that I think is going to be hopefully very influential here in the coming decades as we move towards treating those conditions like a little bit more preventative like you would weight loss and preventing cardiovascular, metabolic disease. Can we help stave off some of those things by, maybe making hearing aids a little bit more accessible? Because those are really, really expensive. A lot of your insurance plans don't cover those. Aaron: Yeah, that's really interesting here, I think I've read a study that said that, it was like, within three years, having access to hearing aids or cochlear implants helped stave off like 50%, of dementia in older patients. And so, it's something that is becoming more of a conversation, especially as we see that hearing loss is connected to a lot of these other conditions, I think it's something that's going to come into view a lot more. And so yes, we're already kind of talking about the main focus of this episode, which is cochlear implants. And so, and then also for other like hearing aids and other kinds of like aural rehabilitation, so could you for a lesson for our listeners who might not be as familiar with cochlear implants, or the treatment options for hearing loss, can you just describe a little bit about what they are and who might benefit from that? Dr. Lindquist: Yeah, for sure, I will say, this, the treatment algorithm for someone who comes in with hearing loss, is part of what I really enjoy about otolaryngology, too, is that you're doing a lot of the medical care for them. And then, if the medical treatment doesn't help, the you're also the person that would, be able to do the surgery for him, which is nice, because another specialty, sometimes you have to refer to, neurology and neurosurgery or, cardiology and cardiothoracic surgery. But in our case, we get a great longitudinal type of care for the patient. So someone who comes in to my clinic with hearing loss, they come in, they generally get an audiogram, we go through the history and physical, if there's a type of hearing loss that they have that is treatable with a hearing aid, then that's usually a really good option. There's other things like bone conduction devices, which is talking about the different types of hearing loss, there's really the nerve type of hearing loss, which is inner ear type of hearing loss, associated usually with getting older, or genetic, or hereditary factors, noise exposure, stuff like that. And that's kind of the run of the mill thing that people think about when they think about hearing loss, especially as people get older, that's usually the type of hearing loss that's improved with hearing aids. The other type is the conductive hearing loss, which is problems with the eardrum or earwax, or the bones in the ear, fluid in the ear. And that's usually more what you know, maybe kids have with ear infections and stuff like that. And those can also be helped with hearing aids, too, it's just a matter of whether those hearing aids are powerful enough to kind of overcome that degree of loss, and making sure that there's not a problem kind of lying deeper in the ear that might cause worsening issues or infections, things like that down the line. And so that's kind of my main assessment. And we usually start with hearing aids, as are something that, generally are accessible, yes, they're expensive. There's other things that you can do to different types of hearing aids, different powers, and then also bone conduction devices for people that they have the good inner ear type of hearing loss, but the signal is just not able to get through the ear canal, through the eardrum, all that kind of stuff in the ear, and there's surgical and medical options for that. But then when you start talking about cochlear implants, those are mainly for folks that have damage to the inner ear that hearing aids can't really rehabilitate. And a lot of that is kind of the clarity of speech. So with a hearing aid, you can turn it up. And if it's a volume problem, then that's going to help. If it's a clarity problem, you know, you're basically taking garbled noise or, a signal that's unclear and turning up louder, that's not going to be helpful, that actually may be hurtful or harmful. And so, the cochlear implant bypasses kind of those

damaged parts of the ears to directly stimulate the nerves that send the signal to the brain, the auditory nerve. And by doing that it's a different type of hearing, it's not the acoustic type of hearing that we're born with, or that we are using right now, it's more of an electronic or electric type of hearing, that really takes a while for the brain to kind of adjust to and there's a bunch of different electrodes on the, on the implant that are in the inner ear at different frequencies. And over time, the brain learns how to use those for something that's functional, for recognizing speech. And certainly, the implants that are around today are our best use for speech rehabilitation, rather than music or anything like that. But that's kind of the end stage of hearing loss, , people that we used to tell, hey, you got to learn how to read lips or sign language. Now we have an option for people that have developed speech and language, but have then lost it over time. Aaron: So, can you just tell us in more simple terms, what does the process look like of implanting a cochlear implant, and how does it work? Dr. Lindquist: Yeah, so the nuts and bolts of the day of surgery and then kind of the immediate care afterwards is that it's usually an outpatient procedure, takes a couple hours. And basically what we're doing is we're taking an internal device and placing it under the skin behind the ear, and then putting a tiny little electrode into the inner ear, the cochlea, through a tiny little window, and then, basically, having the patient recover, and then turning the device on with an external processor about two or three weeks later. And that's really when the first sound perception happens when that sound from the microphone is transmitted into an electrical signal and then transmitted through the skin, to the receiver stimulator, and then down to the cochlea and the auditory nerve. And so, that's the pathway there, that you have an external device and an internal device. But most of the time, like I said, it's a pretty, pretty safe procedure. And it's usually outpatient, unless there's other factors that would, you know, necessitate people staying in hospital for other reasons. But I think certainly you have to think about, you know, the comorbidities that come along with hearing are also some of those that are more serious medical conditions. But we do do this surgery routinely, for people in the 70s 80s 90s. Certainly, we have the right amount of trepidation as you get older and age, but, if someone looks like they're going to get benefit from it, and they're interested and motivated, then, that's the age where you want to give people all the tools that are available. Aaron: So it sounds like, so you see a patient, a patient is referred to you into your clinic. Your first assessment is, is there a difference between conductive versus sensorineural, which is conductive would be like the outer ear and transducing that sound? Dr. Lindquist: Exactly. Aaron: And then, sensorineural would be perceiving based off of that signal? And so, it sounds like what you're saying is, hearing aids would mostly be for conductive or sensory neural hearing that is a little more mild. And then cochlear implants would be more something more profound. Also, maybe like, integrating into the idea of perception of, are you able to process the information, not just perceive it? Dr. Lindquist: Exactly. Yep, and also the clarity of speech. And that's been changing. You say the mild is what we used to use for hearing aids. Now, we have a hearing aids that we can crank up and, you can get more than that, you can get moderate severe. The same thing is true for cochlear implants, where the first FDA approval of cochlear implants was for patients who had 0% speech recognition of sentences or words. And now, by expanding and liberalizing the criteria, now we're implanting people in the moderate range, that just aren't getting the same benefit, or the perceived necessary benefit from hearing aids because of the pattern of the speech or the clarity problem, like you talked about. Aaron: So can you talk a little bit about the criteria for the differentiation between you see a patient who comes in with a hearing loss, what would make them a good candidate for a cochlear implant, rather than that traditional hearing aid? Dr. Lindquist: Yeah, so a lot of that is building relationship over time, assessing the etiology, or the cause of the hearing loss. So a lot of times, we'll do that with an audiogram with a physical exam, a history, genetic factors, and then imaging typically, and I think that a lot of times, we'll do imaging, as part of the cochlear implant evaluation process, but it's really also to help work up the cause of the hearing loss and make sure there's not another inner ear reason for it, or inflammatory infectious etiology. And then from there, most people come in with some trial of hearing aids where they say, Hey, my, whatever ear is diminishing in quality here, my hearing aids aren't as helpful, they told me, either Hey, can you help me with this with a different hearing aid? Or is there another option for me, and so a lot of times, I'm kind of the one who's helping explain what that next step would be and figuring out, if they need that further evaluation. There's a process that they go through, and this is a lot of, it's actually counseling. So there's a cochlear implant evaluation where people go through a battery of tests, but it's also kind of learning about, alright, what would be the expectations for getting this device, because there's a lot of pros to them, but there's certainly some cons and if people aren't prepared, or at least you haven't prepared them, for what to expect with the surgery, but also, in the months that they're doing a lot of the hard work afterwards, it's not me, I see them for a postop visit. And then, it's kind of like, alright, you just got to use this thing,

there's certain things we can do to program it. But a lot of the time ,you're going to be putting in, I'm not living that, you're the one living that, I'm just here to kind of help facilitate it and come up with solutions along the way, if you have problems. But, especially with the expanding criteria, people that used to be really clear cut, and we say, okay, this is definitely going to help you. Now we're going to point of well, it's a nuanced decision. It's an audiologist, who is the hearing doctor, and also an otolaryngologist who's deciding, well, is it worth doing a little bit longer with the hearing aids, and we will tweak some things, there's some things I can do with the programming or a different fit, is that going to help you more? Or is it, hey, we're talking about this next step. Like if we're saying we're out options, what do we go to? And there's some evidence now that, the earlier that we implant people, the better that they do, and that's because of residual ear and function and all that kind of stuff. But preparing them for that the sound will not be the same quality and that the brain and neuroplasticity has to have its the ability to help modulate that signal and help it mesh with kind of what they're used to in terms of hearing. That's the important part, and a lot of that is finding people that could benefit from it, but also making sure that the people that are getting it are actually the right people for it and making sure they're not becoming non users or things like that. Gianni: I think that's something that a lot of people don't recognize, like myself included, just the amount of rehabilitation in the process of getting used to the implant. What does that process generally look like? And what are some of the challenges that a lot of those patients have? And about how long would you say it typically takes somebody to kind of get used to using it and feeling comfortable with it? Dr. Lindquist: Yeah, it's a great question. That’s part of what's being actively looked at, in the field in terms of what we want to learn more about. There's a recent study that came out that about 30% of people that get cochlear implants have decisional regret, meaning there's something that they didn't know that they wish they had known. And that's a third of people. So that's pretty impressive. And if you could change that, that would certainly make me feel better about it and also make my patients do better with it. But there's a whole lot of things, when people had bilateral, so both sides profoundly deaf that was, well, let's just pick one ear and go with it. People that have different degrees of hearing loss, people that may even have normal hearing on one side, and then no hearing on the other side, single sided deafness. That's an indication that was approved in 2019. And, we did a study where 15% of those patients are non users, when we look back and figure it, we want to figure out why. Sometimes it's situations, so are people in a

busy area where maybe having both ears can help with a lot of the diminishing the noise, the background noise, or helping with localization? Or do they work in an office where they really just need one ear, and that's good enough. And if they have an ear that the, the quality is not good, they're just not going to use it. And we know that those people tend to use their devices less. But there's a whole bunch of things. So there's the pre-surgical part of it, where you're talking about the age, the duration of deafness, how long they've been without usable hearing on that side. A lot of the cognitive things, the top down processing, where, you do need the central auditory processing in the brain to help really with this rehabilitation, neural health, things like that. You have the surgery, where, I’m picking what electrodes going in, there's different types, maybe surgical planning, placement, trying to preserve any residual hearing. And then there's the part afterwards, which is the programming part, which is making sure, hey, all these electrodes are fitting with the different frequencies there that but also data logging, which is a focus of mine, which is how long do we have to use this device, in order for it to work. So it's the analogy I would make is that it's somebody who's going out to the soccer pitch and has all the right equipment and has been fit well with their shoes and all that stuff. But they need to go out there and just kick the ball around. And that's the amount of time that it takes to become a proficient user. And so, that's, we're learning that those people that use them all day, 12-14 hours, they are doing the best at it. And so, there's a lot of things that kind of come into play. That being said, to answer your question a little bit more with timing, it's interesting. There's a, one of the earlier ecologists, their neuro otologist, down in Arkansas actually had one of these devices placed, common knowledge, he wrote some papers about it. And I remember hearing him speak at a meeting where two to three months in, he was not liking it very much. But then he came back with a paper around the four to six month mark, and was like, hey, look, a lot of things changed here. This has really changed my outlook. And just those few extra months of practice and some of the neuroplasticity, the brain adjusting to it. He's like, this is changed my life. So I do think it's a buy in. We usually measure people, you know, at activation at one month afterwards, at three months afterwards, six then 12. And you usually start people, there's some people that do great off the bat, and they love it, but a lot of people, it takes them kind of three, six month mark, and then, there's a question about do people plateau? When do they plateau? And that's something that we're still kind of figuring out where there's the worry that they plateau early, and then after 12 months, they don't get a whole lot more benefit. We may be doing some research to help kind of clarify that. But, I think early use and kind of early investment is really key as with anything, right? If you're most excited to use it, right when you get it, then more power to you. Let's just do it. Aaron: That’s really interesting. Good question, Gianni. And one thing I was thinking about is that it is a long process and there is an interest with like the data logging, what is the kind of like an interdisciplinary nature of that care? You talked about audiologists, speech language pathologists, what kind of like other people are part of this team to make sure that patients that do receive cochlear implants are actually utilizing them in the way that they are able to benefit from the most, and then also, making sure that they are able to kind of stave off some of those regrets that you were quoting earlier? Dr. Lindquist: Yeah so, on the adult side, we have the cochlear implant audiologist, the cochlear implant surgeon, and then a lot of patients end up doing aural rehabilitation so a lot of kind of learning how to use the implant afterwards with, there's some folks at University of Houston, in different places, different programs for it. The Veterans Affairs has a program that they help people get. On the pediatric side, which I also do ear surgery for the pediatric population of Texas Children's one day a week, we have a big team with a social worker, we have audio verbal therapists who are a particular type of speech language pathologist, and we do evaluations and we do a big team discussion, multidisciplinary care for all these kids to make sure that they are going to be set up for success, they're going to become users, and, they're invested as much as we are. And I think that helps get everybody kind of maximize in terms of their benefit, but it is a big process and a big team. And a lot of it, the work that I do, I'm doing my hard work for a couple hours, and then seeing them in post op. It's the patient and a lot of the therapy that goes on afterwards, that's where the major strides are made. So it's a big effort kind of all around, and the more people you get involved, you know, it can make it a little bit more difficult, difficult for scheduling and stuff like that. But with telemedicine, things like that, certainly, things have been improving. And for kids, we know, it's a very pivotal time to help with their language development, if they're already behind because of their hearing loss. Gianni: Do you generally find that like kids have better outcomes, given the increased neuroplasticity that kids have? Dr. Lindquist: Yeah so, it's a great question. There's different types of language development, there's pre lingual, and then postlingual. So hearing loss that happens in the pre lingual stage, that's somebody who's maybe more congenital, right. And we know that implanting them earlier helps. The FDA has approved up to nine months or nine months and above, I should say, and we will implant people even below

that, if there's a good reason to. And that tends to give people a really, really good outcome, those kids get really good speech intelligibility, they get really good at understanding, they're able to often, if there's not other comorbidities, they're often able to live a life where they walk into my office 15 years later, and I can't tell that they're an implant user, except for then I read the chart, which is pretty incredible. The patients that, maybe we identify a little bit later, have had a delay where they're three, four or five years old, where a lot of that language development should have already happened, they do not do as well, we know that. Adults that didn't really develop language, that's a tough pill to swallow in terms of implant for them may give them some sound awareness, but it's not going to necessarily give them speech recognition. And then the adults who are post lingual and that they have speech and then over time they lose their hearing, for whatever reason, those patients generally do very well as well. So it's a whole spectrum. And, in terms of the sound quality, it's a great question. I feel like the older folks, because they've had hearing so long of the acoustic variety that they'll say the hearing is different. But for the kids that you implant early on, they don't know anything else. So it's, that's normal for them, which is cool in itself. Aaron: Yeah, so I think one thing that you're talking about here is like the difference between pediatric patients and adult patients and their process and their ability to access. So I was wondering, what is the screening process like for a pediatric patient who might be a better candidate or might benefit from a cochlear implant versus like an adult, or an older adult who is newly experiencing hearing loss. Dr. Lindquist: So, you know, the pediatric side of things where, there's a lot of hospitals screening, which is great. And there's a rule, which is the 1 3 6 rule where you want to identify people, you want to screen them, then you want to identify them, and they want to treat the hearing by six months is the goal. With adults, people often get dragged in by their family members and stuff like that, so they're not always as eager. The people that have a sudden hearing loss and then come in, those people are motivated, but those are the people that I still say, if you have hearing on the other side, there's not a rush to do it because we can do the implant at any point. Some people adjust, it's not something you want to make a rash decision about getting into. But it certainly does affect things in terms of the timing of it. And it's a very interesting question. It's one that we get together, and talk about in our boards about, “hey, is this duration deafness been too long? Yeah, maybe? Well, is still a candidate, I think he was, just got to talk to him about expectations. He's pretty motivated, I think, let's do it.” Things like that. I mean, there's different criteria

that are laid out by the FDA. And one thing that if we can get approval for these implants, a lot of times, the doctor knows, what's what with that relationship, as long as they discuss, “hey, it's off label.” Those people are still candidates, and they still do really well, and they still derive benefits. So that's what we do. Aaron: That’s really interesting. I kind of like that implant board is kind of like a cancer board or like transplant board. It sounds really very interesting. And so, I think the one thing that might be a concern, so it's one thing to know that somebody is a candidate, but like how about somebody who may not have insurance or might be concerned about maybe the cost? And so one concern I can imagine for potential recipients would be that they, they may be a little concerned about the cost or the upkeep and then also potentially having to get a subsequent cochlear implant later, how would you say that cochlear implant accessibility kind of has changed over time? And what kind of barriers continue to exist with that? Dr. Lindquist: Yeah so, it's great question, certainly there's been some recent opening of the candidacy criteria from both the Centers for Medicare and Medicaid, as well as private insurance. And so the big upfront cost is the is the surgery in the device itself. That, hopefully, is a one time cost. And I will say, the internal part is the part that you put in during surgery, and that's the receiver stimulator, which is the part you hopefully never have to remove from the patient's body. Obviously, there's the failure and failure rate of those devices, which is small over time, or medical problems with it, whatnot. But the outside part, which is the processor, is the part that you can switch out, and that's the part of that has all the upgrades and the fancy features and maybe waterproof and may have different sound cancellation stuff, different programming things, different streaming to your phone, or whatever. And so that's the part that is the upgradeable part. With insurance generally, that's covered because, at a certain point, obviously, if you lose it or break it over over and over, there's probably going to be some cost to that. For people that use it, and then five years, maybe the device isn't supported as much by the company, that is a medical necessity. So I write letters for insurance companies and the cochlear implant companies to help replace those all the time. So hopefully, those costs are actually less over time. And I would say it's probably more of the upfront cost. But you know, it's having not had one myself, I don't see those numbers. And that's part of where, as a doctor, you have to think about that stuff for the patient. It's a great thing to be aware of that, yes, these things are expensive. They're, they're 10s of 1000s of dollars. Aaron: So if I'm a patient, I have a cochlear implant, how long do you expect me to have that cochlear implant for is something that you know? Dr. Lindquist: Yeah, no, it's the implants that we're putting in now, again, I would say that we want them to last the rest of the patient's life. We have devices now that are MRI compatible, we have devices in the past that were not. And so sometimes we end up having to switch them out because of MRI compatibility issues, if they need imaging for any other reason. But as long as there's not a failure, or anything like that, or an adverse medical issue, like an infection, or exposed electrode or extrusion through the skin or anything like that, as long as it's working, and then if it needs to be changed out, there are ways to do that, where generally people get back to where they were, with the prior device, in terms of speech recognition, within three months of doing a revision surgery, if there's no complications or other complicating factors. Aaron: I think one thing is, what I heard from you're saying is also that cochlear implants, especially when it gets to the point where you are indicating you've been evaluated seems like it is going to be covered by insurance. Can you tell us a little bit about the discrepancy between like insurance covering that kind of surgery versus covering something like a traditional hearing aid, because I know a number of plans don't cover traditional hearing aids or Medicare doesn't cover it often, especially when you have mild to moderate hearing loss. And so, where do you see that kind of discrepancy between covering that kind of surgery versus covering something that's a little bit more tame, but still is pretty expensive and inaccessible for patients with hearing loss? Dr. Lindquist: That is a question I've asked myself before, why are these expensive devices covered, and sometimes, the cheaper devices aren't? It's a good question. So I think a lot of it has to do with, there's a, we have a very strong American cochlear implant Alliance, who I would say, has done a great job in terms of awareness and working in terms of helping make sure that those things get covered. We have a lot of interest. I think that it's a good question, because the hospitals truthfully don't make a ton of money on cochlear implant surgery. But I think that they realize that these people are having a really hard time and it's the only answer. I wish that it would extend to covering more of the hearing aids. And so, I would say that that would be something that I would take it as a preventative treatment, and I do think should be covered as well. But that's a question that I wish I could solve that problem and it's a valid question. Aaron: Okay, and then, I guess maybe a little change of pace as well. So Dr. Lindquist is a newer faculty here at Baylor, he did his residency here. And then he did his fellowship at Vanderbilt, and then he's come back, this is first year as an attending. And so just looking forward into your career, into the future, what is something that really excites you about being a new faculty? And what kind of things

do you want to evaluate in your career in the future? Dr. Lindquist: Yeah, so I think that, obviously, the teaching part of things is really important. For me, I love working with residents and working with the fellow that we have, as part of training future neuro otologists. I think that the environment is awesome. I love my colleagues and coworkers. And that was a big part of it is kind of the mentorship that I that I received in fellowship from where I went, and at Vanderbilt, I saw some of the same traits and the folks here at Baylor. And so that’s been not only as friends, but also as people that have been through before and can kind of help make the direction that I want to take my career, something that's achievable. Obviously, the diverse patient populations here, I have time at the Children's Hospital, at the Veterans Affairs, and then also at the main Baylor group practice. And so treating the whole gamut of different pathologies, also ages is one thing that I really enjoyed. And the fact that I can go to Texas Children's one day a week and see, children there is just like, it's great, being able to do the medical and surgical and all ages, which is really cool. And so that's the other thing that I really enjoyed. My wife's family's from East Texas, and so this is a very nice spot to land, in terms of being close to family, and it's just a place where there's all sorts of people to reach out to and collaborate with, there's Rice, there's University of Houston, there's different hearing and speech schools in the area. It's just a great center for it. So I think we'll be able to do as much as I want to, and won't have time for everything. But I really am interested in looking at a lot of the outcomes for cochlear implants. So one of my things that I'm most proud about is kind of deciding or helping to give an answer for how much people should use their devices afterwards by looking at kind of a more scientific approach to scores and things like that. But I also want to figure out, is there a way to improve accessibility? There's a, obviously, Houston's a very diverse city, you know, there's a lot of people out there that don't have access, for whatever reason. And I think trying to expand, that would be awesome. In the past, they looked in and of all the people in a private practice environment, I think I read that the average primary care doctor has about eight patients in their practice that could benefit from a cochlear implant. The penetrance is about 10% of all people with hearing loss. And then once the indications have expanded as they have in the past few years, we're now reaching about 2% of people that could actually benefit from it. And so it's a very small number, and there's a lot of gains. If I could do cochlear implants all day, I would be very happy. There's a lot of obviously else to neurotology. But, it's a very rewarding thing to help patients with. So I do think there's some studies going out, there's going to be future improvements, there's going to be, fully implantable devices that are being worked on, which is a pretty cool thing. Some people don't like the fact that they have the external part. Obviously, a fully implantable, you'd have to talk about what do we need to do for the battery there, and the battery there is actually down in the chest. So it creates a little bit of a different surgery, but it's a very cool idea. Obviously, Baylor has the genetics department here, which is world class, a lot of funding. I think that gene therapy is going to be a really interesting thing and it's actually going to create a little bit of a question for us. If we start having treatment for some of these genetic hearing losses, should we be implanting people in both ears? Do we need to save one of the years for future developments down the line? It's something we do talked about. If we put an implant in this year, you're not going to be able to potentially get hearing altering treatment in the future depending on what the etiology is for your hearing loss, especially for genetic causes. So that's, I mean, that's a whole other can of worms. That's a very interesting question to think about. And we'll certainly be something that we learn about more about in my lifetime. Yeah, there's a lot of reasons, but that would be kind of the start. Aaron: There's a lot of really cool stuff happening, especially here in Texas Medical Center. So it's really great to hear that Baylor is on that road of being able to lead some of those advances and to benefit and help patients with those kinds of advances as well. And so I think it's really interesting to hear this relationship between these advancements in technology, but then also, you're saying that only 2% of people who would qualify for a cochlear implant are able to actually get the cochlear implant, especially with these new widening criteria. And so I think that one thing I'm really interested in is how do we increase access for these patients? How can we make sure that not only are patients who are coming in with hearing loss being screened for hearing loss, but then also, if they are a candidate, how can we make sure that they get the technology that they need in order to support that? And I know that you've done some work in using AI in order to make sure that people who should be referred to formal evaluations get it. What kind of role do you think your research and your work in the future will play in that? Dr. Lindquist: Yeah, so that's the most important thing, it's really sexy to talk about all the different ways to get five percentage points better on speech testing in a year, but how do we just get these devices for more people that need them. There's a rule that is really well known and very accurate and called the 60/60 rule, where it's basically a screening tool to help decide if an audiologist or an ENT doctor should send them for cochlear implant evaluation. And that's 60% pure tone average and less

than 60% word recognition score. So, the machine learning where we look at all like the different parts of their hearing tests, and their demographics and their speech performance, and things like that helps decide, are they going to be a candidate? Ultimately, it's about just getting as many people as possible in for those evaluations, getting their hearing loss treated, whether it's a hearing aid or an implant, but a lot of it's going around and kind of improving knowledge. So, hopefully getting word out to more people that, “oh, yeah, there are those devices out there.” I think getting, like so many drug companies and stuff like that, maybe we should see more commercials for these devices. You know, I may put my foot in my mouth on saying that, but, talking to audiologists and to be like, “hey, you know, here's what we're doing, here's the current criteria.” Talking to ENT doctors in the future, we're making it easier for people to get in. I came into Vanderbilt when my mentor, Dr. Haynes had been working on a one day CI program. Tennessee is actually a pretty long state. And there's people that drive five hours from East Tennessee, down to Nashville, and they were working on a way where they actually ended up getting 10 patients who could get their imaging done outside and then send it in, and then they do an over the phone, kind of introduction, and then they come down, and they do their evaluation and surgery all on the same day, which is a huge time saver, obviously, there's the conflicting interests of making sure that people are fully aware of what's going on here, and trying to streamline their care. But telemedicine has helped that a lot and I think that just improving access, and making it easier for people rather than harder is the other way to do that. Obviously, got to be careful not to jump in too quickly and be rash about things, but it's just also about training people to help be able to do the surgery safely and reach more people that way as well. Aaron: It's really interesting to hear about that, spreading awareness, making sure that people know that these options exist. So, for example, if I were, I were a concerned family member, and I noticed that one of my family members, maybe my dad, maybe my mom, and my grandma, they're experiencing some hearing loss, what is the point where you think that you should, how do I one get them to see a doctor and to get an evaluation? And then if I were a doctor, and I noticed that a patient is experiencing some hearing loss, what does the process look like to referring them to somebody who might be able to get an evaluation, and then talking about the next steps of getting maybe surgery or getting a hearing aid? Dr. Lindquist: I think getting into an audiologist and ENT, and I believe in trying to strike while the iron is hot because people lose momentum over time if they have to wait three months to get into a doctor. But I've also , as part of my first year here and part of my practice building, you want to go meet people and just do handshakes and let them know what you do, let them know who you are and give them your cell phone number and I try to get those people in as quickly as I can because I do know that, while people have been dealing with that prompt for a long time, you do lose a little bit momentum if you have to go through that. And it's already a process with enough hoops in it to begin with. But yeah, it's about seeing an ENT, an audiologist and then being like, “alright, if a hearing aid trial doesn't work, then who are who you sending to me to see,” and they should have people that they know and that they trust to help take care of their patients. Aaron: I think one great thing is, we're talking about trying to increase accessibility to cochlear implants and hearing aids, let's say there's a world where everybody's finally able to get cochlear implants, and you're doing surgeries all day, what are some of the considerations that you think as more people receive this technology? What kind of support do you think that they need? And what kind of what kind of dangers or opportunities exist with that kind of utopia? Dr. Lindquist: Yeah no, it's a question to, interesting to think about. The other stuff we're looking at is yes, exactly, as you said, we're putting implants in people, they have magnets in them, what about if they need an MRI, down the future, down the road of their brain? So the magnet, we're working on different kinds of imaging studies to help limit the artifact from that. We know that a lot of the devices are safe to go through an MRI machine now, but it's not necessarily going to give you a clear picture of what you want. There's the electrical Bovie, which is the monopole or electrocautery, we did some work on that to show like, you know, a lot of the companies won't really support that when you have a cochlear device in place or cochlear implant in place, because they're worried about potential arcing or sending that electrical signal to the cochlea or into the device, either, damaging the nerves or to the device itself. And we know that that is safer and safer. But as more people have other electric surgery, having something that's metallic and, magnetic in your body obviously has its own challenges. And, I think part of that is also educating other doctors to be like, “oh, this person has a cochlear implant, let me just make sure that like, I can do the surgery for him.: Because, if it's a spine surgery, you have to use the Bovie electrocautery. For those, there's certain surgeries that you just can't get around it very easily or it’d be impractical or take too long, or it'd be unsafe. Aaron: So, talking about like having metal, is the concern like a fire? Or is it the actual device? Dr. Lindquist: It’s the actual device, so sending the voltage to the device, or since the contacts are made in the inner ear next to the nerves, that the inner ear would somehow have damage. And so

even then, if you replace the device, you fried the nerves that are needs to help send the signal. So theoretical stuff, but no one really wants to test that. Yeah, exactly. So that's kind of where we are right now with that. And it's a great question for people that we had a big conference with the radiology folks about that a couple of months ago, for a patient who had something. Aaron: That is certainly something to consider, especially when more people are getting cochlear implants, having that on your radar, because I don't know, I would not like to fry somebody’s ear. Dr. Lindquist: The other thing is trying to make it like a little bit cooler to have them too, because they are pretty big devices, they have some now that are off the ear, so they just kind of sit on the scalp. They don't have the hearing aid thing, or that kind of shape over their ear, which a lot of people, once they're kind of ready to put down the hearing aids, they don't want anything on the ear anymore. And I'd be like kind of a mind thing where they say I don't want that. But the fully implantable one might be the other thing that would be a game changer, in my opinion. And that's going through with it's been, you know, placed into patients. And I know it's in trials and stuff like that. So stay tuned. And there might be some cool stuff out with that. Aaron: Yeah, changing our perception, seeing cochlear implants as cool. Some of the technology is really cool. Like, they can connect to your phone now, you can do you like Bluetooth things. And so, I think if somebody experienced some hearing loss, and then they hear some of the cool things that can happen. Dr. Lindquist: Yeah, you always hear about the people that are celebrities or on notorious TV shows, or anything like that. The Great British Bake Off had somebody on. I heard the most recent season of The Bachelor has a lady with it, but I haven't watched that one. I'm relying on word of mouth. Aaron: That's cool because it bleeds between medicine and the real world. And when you have an implant, you're going to be interacting the world as well. And so, it's not just in your doctor's office, it's in your community, it's in your family, it's with other people as well. Dr. Lindquist: It’s a lot about identity too. So that's the other thing where you could talk about the deaf community, and then the hearing community too. And that's a whole big conversation. But I think just improving the visualization or people that have those devices and you see them and they become more commonplace, then that's just improving everybody's information about or knowledge about what's out there and talking then to their neighbor or their grandfather or whoever it is, :maybe we should look into that.” Aaron: And so you also, so you've already kind of touched on this, but one of the questions would be what kind of future research or work do you want to complete in your career? And then, yeah, anything that excites you about being in this community and something that you want to invest in, it seems like you're interested in maybe increasing accessibility and improving these outcomes, and then also this cultural progress and making sure that people who have implants don't feel othered in any way. Is there anything in particular that you want to continue with your work? Dr. Lindquist: I think one of the things, we talk about outcomes a lot, because there's a lot of data that you can talk about with that, in meetings and publications, and things like that. I think that one thing that would be really rewarding is to say, take someone who's maybe not performing as well as they could be, and then, even a few years after their surgery, and then rehabilitate them to get to a point where then they started using the device more consistently, and figuring out, are there ways that we can change that? Are there tricks to programming it or to using it or things like that? Or just putting in the work for people that, maybe live alone, or they don't have family that they can talk to, or other ways to kind of rehabilitate it. That would be something that I'd be really excited in. Because there's only so much you can do after the implant’s actually in. Again, it's about kind of using it, and then making sure that all the pieces are there and working. And then obviously, there's just very diverse populations that we have here. So I think that we started looking at different languages and things like that, in terms of how people do with it. And that goes with increasing accessibility, but also just figuring out, does it work the same for different, in Spanish, or Mandarin, or what have you so. Aaron: That’s interesting. Have you seen patients who do speak other languages? And, anecdotally, how does it go? Dr. Lindquist: I think it's a little tougher with the tonal languages. I know people with English and Spanish tend to do really well. But I think it's obviously an area that's evolving. And I think that we will learn more as we go. Aaron: That’s really interesting. Okay, so maybe some last things. If somebody is interested in cochlear implants or other hearing devices, or even like neurotology, where are some places where you think that they can go to learn about it, other than this podcast, of course? Dr. Lindquist: Yeah, I think American Cochlear Implant Alliance has a great website, with different pages for providers, for surgeons, for audiologists, as well as patients, speech language pathologist, all that, encompasses kind of the full breadth of who would be interested in learning more about it. That's a great place to start, I think they do a really good job about creating awareness, and also improving accessibility, and advocating as well as supporting research. So that'd be kind of my first place. Obviously, there's a lot of information out there, with varying degrees of, anecdotal stuff is always kind of tough, but certainly, there's a lot about support groups and stuff like that. But I'd say that'd be probably where I would point people first and then go from there. Aaron: Okay, cool. So the official stuff, and then also Great British Bake Off and The Bachelor. Dr. Lindquist: Exactly. Aaron: And then, where can people find some more information about your work if they were interested in continuing this conversation? Dr. Lindquist: Yeah so, just through my faculty page. Obviously, I don't think I have any, PubMed would be the only other place. You find me in the halls at Jamail, and I'll talk your ear off probably about it. But yeah, that'd be about it. Aaron: Yeah, our listeners will be on the lookout. They'll be trying to shake your hand and learn a little more about it in the future. So are there any other things, anything else you want to share anything? Other questions that you want to talk about at all? Dr. Lindquist: No, I think we covered a wide range of topics on this. And I'm very happy to share any information I have. And I just appreciate you having me on the podcast. Aaron: Thank you for coming. I think our listeners have learned a lot, and we definitely did cover a lot of really great information. So, it's been a pleasure to have you. Dr. Lindquist: Thank you.