Interview with Sujana Chandrasekhar MD, Director of Otology and Neurotology, Mt. Sinai Medical Center in New York
AO/Beck: Good morning Dr. Chandrasekhar. Thanks for sharing a little of your time with me today. Please tell me where you went to medical school and where you did your residency and fellowship?
Chandrasekhar: Good Morning Dr. Beck. Nice to be with you too. I went to Mt. Sinai Medical School in New York and I did my residency in Otolaryngology, or Ear, Nose, and Throat Surgery at New York University School of Medicine and then I did a fellowship at the House Ear Clinic in Los Angeles and finished in January 1993. And then I was an assistant, and then subsequently associate professor at New Jersey Medical School, and I was director of their cochlear implant program there. I was there from '94 until the end of August of 2001. I am now the Director of Otology and Neurotology at Mt. Sinai Medical Center in New York, and I run our cochlear implant program and implantable hearing aid program.
AO/Beck: Thank you. What I'd like to focus on today is the Baha System, the implanted hearing system, and your perspectives on that. Can you explain the system for me?
Chandrasekhar: Sure. The implanted component of the Baha is a titanium device that's implanted into the skull about two inches behind, and slightly above the level of the ear canal. It's been used for many years in Europe and it was FDA cleared for use in the United States to treat mixed and conductive hearing losses in 1996. So we've had a lot of experience in the USA, using it initially for unilateral conductive hearing loss, like inoperable atresia, or bad otosclerosis in an only hearing ear when you don't want to subject the patient to stapedectomy. Many of us have experience with the Baha System for conductive hearing impairments. In 1999, the FDA expanded the criteria to include children, and that has made a world of difference in children with inoperable conductive hearing impairments. And in 2002, the FDA cleared the Baha for Single Sided Deafness, like we see with post-op acoustic neuroma patients or sudden sensorineural deafness that doesn't recover or even idiopathic unilateral hearing loss.
AO/Beck: So the device has been cleared by the FDA, not only for conductive losses, but for unilateral sensorineural deafness, or Single Sided Deafness.
Chandrasekhar: Exactly. I think the FDA has seen that it is a safe and effective treatment. When they go ahead and clear something for children, they really put it through a rigorous assessment.
AO/Beck: Would you please spend a few minutes discussing osseo-integration?
Chandrasekhar: Yes. The portion that is implanted is titanium because titanium is a metal that osseo-integrates, which means the bone of the skull grows actively around the implant fusing completely with it. For bone-conducted signals, osseo-integration is the key to excellent sound transfer through the bones of the skull.
AO/Beck: How long does it take for osseo-integration to actually occur, and how long is the period of time between the surgery and the fitting of the external component?
Chandrasekhar: It's about three months. For the patients, that seems like a long time, but once they get the sound processor unit it is very simple, and very easy. There is an on/off volume control, it's a small device, and it comes with a multi-directional microphone which patient's love.
AO/Beck: So there is no computer interfaced with it?
Chandrasekhar: No, none. It's very simple and very efficient. Really just an on/off switch and a volume control.
AO/Beck: And the patient has the ability to make it louder and softer?
Chandrasekhar: Right. It goes from a setting of 1 to 4. Most patients wear it at a volume setting of about 2 or 2 ½.
AO/Beck: How is the system powered?
Chandrasekhar: It uses small hearing aid batteries. Apparently they last between 7 and 14 days, depending on the usage.
AO/Beck: Dr. Chandrasekhar, please tell me about the abutment.
Chandrasekhar: I really am very frank with my patients and so I will tell you what I tell them. I tell them the unit is implanted into the skull and there is a percutaneous abutment. Many of them think that's a little too weird at first, but then I tell them, You're going to have a bolt sticking out of your head and it's not going to be like Frankenstein. It's going to be hidden in their hair and I've even implanted bald people who really don't care. They want to hear and they don't mind that there's a thing sticking out! The size of the abutment is the size of the metal band that connects a pencil to an eraser. That's about it, not a big deal really when you compare that to hearing!
AO/Beck: Please tell me how the Baha System works.
Chandrasekhar: It stimulates the inner ear on the good side, although it's placed on the bad hearing side. You're essentially avoiding the entire normal sound path (via air conduction) and the air conducting mechanisms, such as the outer and the middle ear, completely. You're going right to the good inner ear using bone conduction.
AO/Beck: What do the implanted patients tell you?
Chandrasekhar: They say it feels and sounds very natural. They have this sort of a wholeness restored to them, where they were essentially ignoring the hearing impaired side previously. They don't have that occlusion effect which is common with hearing aids, and they never fiddle with it. They put it on, they turn it one, and they go. They'll report things like, I was hesitant and awkward in boardroom, or cocktail party situations. I couldn't use the telephone at work because I felt nervous that I would miss things because I couldn't hear the ambient sound on my bad ear. And they tell me that after they get their Baha, they are able to function as they were before their hearing loss.
AO/Beck: How many patients have you implanted, if I may ask?
Chandrasekhar: I am in a busy metropolitan area, in New York, and I probably implant 15-20 a year I think.
AO/Beck: Is the Baha System hardware and surgical procedure covered by insurance?
Chandrasekhar: The implantable part and the surgery are almost always covered by insurance. The external sound processor seems to be about 50/50.
I'll write letters of medical necessity for the patient, but essentially, they need to be prepared to purchase the sound processor in case the insurance provider won't cover it.
AO/Beck: Can you tell us any first-hand observations that you've made about your patients wearing the Baha System?
Chandrasekhar: I had dinner with a lady someone else had implanted. She had bilateral Bahas and we were eating in a noisy Italian restaurant. It was dark and there was lots of background noise. So much so that I was having trouble hearing, and I have normal hearing! I was on one side of her and this man with a very heavy European accent was on the other side of her, and it was dinner conversation so it was virtually any subject. She did not miss a beat. I finally said to her, "Are you faking this? How are you managing?" She said, "I'm hearing you." It was very impressive because it was not only a difficult listening situation, not only dim lighting but we were next to each other at a restaurant eating, so every possible bad thing you can do for a hearing impaired person was present. The conversation was anything from Aardvarks to Zebras. She did amazingly well.
AO/Beck: Have any of your patients asked to have the device removed? Or have they said it wasn't what they had hoped for?
Chandrasekhar: I have not yet had a single person come and ask me to take it out! I've been implanting them for some seven years now. I've had patients come in to be upgraded from the early abutment design that needed an O ring to the much easier snap coupling now available. The snap coupling is so nice, even the kids can put it on now. And speaking of kids, the company makes the Baha in black, gray, and brown I think, and bright yellow and bright blue! The kids love that. I should also mention that they cannot get the sound processor wet. It must be removed when swimming or showering. But the abutment can get wet. They can go through an airport metal detector and they can have an MRI scan. They can do everything they want with the abutment, no problem at all.
AO/Beck: And lastly, how does this system compare to the contralateral routing of signal (CROS) hearing aids, from your perspective?
Chandrasekhar: I think the Baha has revolutionized the way we deal with Single Sided Deafness because I think none of us have been very happy, patients or professionals, with CROS aids.
AO/Beck: Dr. Chandrasekhar, it has been a pleasure speaking with you. I appreciate your time and knowledge.
Chandrasekhar: Thanks Dr. Beck, it's really been fun for me too, and I hope the information is useful for the readers!
For more information about the BAHA system, click here.