Interview with Jed Kwartler MD, Neurotologist and Cochlear Implant Surgeon
Jed Kwartler, MD
AO/Beck:Good morning Dr. Kwartler
KWARTLER: Good morning Dr. Beck.
AO/Beck: If you don't mind, I'd like to start by learning a little about your professional background.
KWARTLER: Sure, that's fine. I went to medical school at New Jersey Medical School in Newark, graduated in 1983. I did my residency in Newark too, in otolaryngology, finishing in 1988. I was a clinical fellow at the House Clinic in Los Angeles and then came back to New Jersey in 1990. When I returned to New Jersey, I went to a hospital that no longer exists, the old Newark Eye and Ear Infirmary. It was about 125 years old at the time, but due to the economics of Newark, it closed. By mid-1991, I opened my private office in Springfield, New Jersey, it's called The Ear Specialty Group.
AO/Beck: How many audiologists and otologists do you have there?
KWARTLER: Well, when we first started out, it was just my office manager and me. Today, we have 3.5 FTE audiologists and I have one other physician associate, Dr. Avrim Eden. Dr. Eden was formerly an endowed professor and Chief of Otology at Mt. Sinai for about 15 years. So we're fortunate to have him.
AO/Beck: Very good. I'd like to focus on cochlear implants and your recollections and observations over the last decade or so.
KWARTLER: When I was a resident, I think most people in New Jersey went to New York City to get implanted. There was a fledgling cochlear implant program within the Division of Otolaryngology at UMDNJ and several adult patients were implanted. The challenge in building up an implant program is that the surgery is actually the easy part -- it took a really long time to get the audiologists and ancillary services organized, and those elements of the program are critical to the success. Because of this it was not until 1993 when we actually implanted our first patient who was also the first child to receive an implant in a New Jersey hospital. We felt this was a big step for patients who now would not have to travel into NYC for their implant surgery and rehabilitation.
AO/Beck: How old is that child now?
KWARTLER: He must be about 14 now. He's doing great.
AO/Beck: What has changed in the last few years with
respect to cochlear implants?
KWARTLER: Cochlear implants have changed and continue to change dramatically. As we've learned what works best, the manufacturers have all responded. The electrode design seems to have more or less coalesced around a common thought and the amount of information deliverable to the cochlea has increased. Computer and processor speed has increased, batteries have improved - allowing more robust processing of the sound signals.. But probably the most significant change arethe results. The patients consistently do very well. Another big issue is that the implant criteria have changed. We're pushing more and more into that gray zone that overlaps with hearing aid use. In other words, as cochlear implants have become better in all aspects, we are implanting people with more hearing than ever before. When I was at House, we only implanted people with profound hearing loss, and still at that time, they had to get essentially no benefit from hearing aids. Today, we sometimes implant people with severe hearing loss, and even if they do get benefit from hearing aids, the expectation may be they'd actually do better with a cochlear implant. That's a reasonably new expectation and a new situation. Of course the cochlear implant evaluation is very important in making these decisions to see if the patient is more likely to perform better with their hearing aid, or with a cochlear implant.
AO/Beck: What's going to impact cochlear implants in the next, let's say, the next 36 months?
KWARTLER: I think there are several things. One, is the idea of Soft Surgery. We're going back to much smaller openings into the cochlea, with low-speed drills so you're really not disturbing the neural structures. Then we're sliding in soft electrode arrays with softer tips to better preserve residual hearing. So that's one area I expect to see changes in over the next 36 months. The second area of interest would be bilateral cochlear implants. There are two trials, one an adult trial where patients are being implanted simultaneously and a pediatric trial where they are implanted sequentially. Of course, the basic question is, should people have one or two cochlear implants? Beyond that, is it better to do both surgeries at the same time, or is there a difference when they're implanted sequentially.
AO/Beck: I think it's better to have bilateral implants. I cannot imagine any reason to presume that hearing from one side would be as good or better than hearing from both sides! Seems to me like the real issue is not binaural hearing, but indeed, financial issues.
KWARTLER: I tend to agree with you. Patients who've been implanted binaurally state they like it better. Whether they're able to demonstrate a binaural improvement may just be an inherent limitation of the tests being used.
AO/Beck: We found that was true with hearing aids. When you try to objectively describe differences in monaural versus binaural it's very difficult. But of course, there are very real differences.
KWARTLER: My sense of it is that it makes intuitive sense. I think that probably people will get implanted binaurally. But again, whether they want to take the risk of getting bilaterally implanted simultaneously or sequentially is a big question.
AO/Beck: I can imagine the risk of simultaneous bilateral cochlear implantation is significant. Can you discuss that please?
KWARTLER: The problem with simultaneous bilateral surgery isn't so dramatic with respect to hearing -- but -- suppose the surgery causes a vestibular loss, and then even worse, a bilateral vestibular loss. Is the benefit from simultaneous implantation worth the risk of a potentially significant vestibular problem?
AO/Beck: Let's talk about that. Generally speaking we do not recommend doing anything on both sides of the head during one surgical event.
AO/Beck: And it's really just because we want to make sure everything's okay before we go to the next side. Is that correct?
KWARTLER: Right. That's a general ear surgical principle, do one side at a time. I think perhaps softer surgery may create less vestibular problems and I think that's an issue being looked at in the trials and it needs to be weighed against the benefit that you're getting. It's one thing to hear better, but if you accidentally make someone a vestibular cripple, the expense is too high. I think that's one major issue regarding simultaneous bilateral cochlear implantation at this time.
AO/Beck: I think you're correct. But I'd like to underline and further separate the idea of simultaneous implantation from bilateral implantation. In other words, I think the issue you're addressing is the safety of having two operations at one time. It sounds to me like you are endorsing bilateral implantation, while questioning whether or not to do both sides at the same time?
Kwartler: Yes, that's essentially correct. I think of some of the older patients we've implanted, they basically just say they've been give their life back. They can communicate freely and fully, and it's a tremendous thing for them. It'd be great if every single patient in all groups ended up like that.
HH/Beck: Tell me, is there a particular characteristic you look for in a patient that makes you say to yourself this guy is just going to do great?
KWARTLER: The ideal patient would be an adult who gradually lost hearing and only had true deafness for a short period of time. Of course it would be nice if they're educated and motivated and were surrounded by family support too! Another really important thing is speaking with another patient that has been through it. After a cochlear implant candidate speaks with a patient wearing a cochlear implant, they really understand what it's all about.
AO/Beck: Yes, I think that's always a recommendation for all cochlear implant candidates. I want to thank you for your time Dr. Kwartler. It's a pleasure to speak with you.
KWARTLER: Thanks for the opportunity Dr. Beck. It's been fun for me too.
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Jed Kwartler, MD
Neurotologist and Cochlear Implant Surgeon