Pisa, Italy, is celebrating a milestone in the treatment of hearing loss: the completion of 1,000 cochlear implants. The University Hospital of Pisa (AOUP) has become a leading center for this life-changing technology, offering a comprehensive approach that extends far beyond the surgery itself. This achievement represents decades of dedication to restoring the sense of sound to individuals of all ages, from infants to adults and underscores the evolving landscape of auditory care. The success of the program hinges on a multidisciplinary team and a commitment to lifelong patient support, a philosophy championed by Professor Stefano Berrettini, head of the Otorhinolaryngology, Audiology and Phoniatrics Unit at AOUP.
The journey began in 1985 with the first single-channel cochlear implant performed at the hospital. While these early devices allowed patients to perceive sound, they struggled with speech comprehension. Professor Berrettini recalls, “Patients could hear sounds, but they couldn’t understand words; verbal discrimination was missing.” The arrival of multi-channel technology in 1998 marked a turning point, enabling a far richer and more nuanced auditory experience. This advancement, which utilizes multiple electrodes positioned along the cochlea to stimulate different frequencies, allowed patients to discern speech with significantly greater accuracy. Today, the AOUP performs approximately 65-70 cochlear implant surgeries annually, serving both pediatric and adult patients.
From Monochannel to Multichannel: Four Decades of Technological Advancement
The evolution of cochlear implant technology has been remarkable. Early single-channel implants stimulated the cochlea through the round window, providing basic sound perception. The multi-channel implants, however, leverage the tonotopic organization of the cochlea – the principle that different frequencies are processed at different locations along the spiral-shaped structure. By placing electrodes within the scala tympani, surgeons were able to achieve more precise stimulation, leading to improved speech understanding. “For children, this has been an enormous benefit,” explains Professor Berrettini. “Today, thanks to multi-channel cochlear implants, they can develop language skills comparable to their hearing peers.”
Pioneering Neonatal Screening in Tuscany
A key factor in the success of the Pisa program is its proactive approach to early detection and intervention. Since 2007, Tuscany, thanks to the efforts of AOUP, has been at the forefront of neonatal hearing screening, becoming the second Italian region after Campania to adopt the practice. This screening became nationally mandated in 2017 with its inclusion in the Essential Levels of Assistance (LEA). In 2010, bilateral simultaneous cochlear implantation became reimbursable by the Tuscan National Health Service (SSN), and the hospital performed its first bilateral simultaneous implant in a 12-month-old child with profound bilateral congenital deafness. “Previously, diagnosis often occurred around 24-30 months,” notes Professor Berrettini. “Today, it’s done practically at birth: a hearing aid can be fitted at three months, and cochlear implantation in profoundly deaf infants can be performed at 10-12 months.”
Addressing Complex Cases and Rare Diseases
The AOUP has developed particular expertise in managing complex cases, including those involving congenital malformations of the ear, cochlear ossification, advanced otosclerosis, and chronic otitis media. Approximately 20% of the children undergoing implantation also have multiple disabilities, requiring close collaboration with the Stella Maris Institute. The center is actively involved in identifying and addressing hearing loss associated with rare genetic syndromes, such as Pendred syndrome and mutations in the otoferlin gene, as well as conditions like distal renal tubular acidosis. A significant focus is also placed on congenital cytomegalovirus (CMV) infection, a leading acquired cause of congenital deafness. Pisa has been a pioneer in integrating CMV testing into its neonatal screening program for infants who fail their initial hearing test, a practice Professor Berrettini believes is crucial for early intervention with antiviral therapies and ongoing monitoring.
Collaboration and Future Directions
The AOUP’s commitment extends beyond clinical care to encompass research, education, and the development of national guidelines. In 2011, Professor Berrettini coordinated the development of the first Italian HTA guidelines on cochlear implantation, promoted by the Ministry of Health, Agenas, and the Tuscany Region. More recently, Professor Francesca Forli, along with Sara Ghiselli from the University of Parma, coordinated latest Italian guidelines published on the website of the Istituto Superiore di Sanità. The center also participates in a project with the Istituto Superiore di Sanità (ISS) to establish a national registry of cochlear implants and maintains a long-standing collaboration with the Cochlear Implant Center at the Karolinska Institutet in Stockholm. OtoLab, the temporal bone dissection laboratory, further supports innovation through research in tissue engineering and surgical training.
The success of the AOUP’s cochlear implant program is built on a holistic approach, with a dedicated team – including Professor Forli and Dr. Ramona Nicastro, coordinator of the speech therapists – providing comprehensive care throughout the patient’s journey. As Professor Berrettini emphasizes, the center’s philosophy remains consistent: a truly multidisciplinary examination of each patient, ensuring the best possible outcome. While rehabilitation requirements have decreased with advancements in implant technology – from several sessions per week for years to now typically two weekly sessions for the first few years, followed by periodic check-ups – the commitment to lifelong support remains unwavering.
The AOUP’s dedication to cochlear implantation exemplifies a commitment to improving the quality of life for individuals with hearing loss. The center continues to refine its techniques, explore new technologies, and collaborate with international partners to advance the field. The next step involves ongoing participation in the national registry project with the ISS, which will provide valuable data for further optimizing patient care and outcomes.
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