Bilateral cochlear implantation in children: a systematic review and best-evidence synthesis

Simultaneous Bilateral Cochlear Implantation in Very Young Children Improves Adaptability and Social Skills: A Prospective Cohort Study

OBJECTIVES

To investigate the value of using the Gesell Development Diagnosis Scale (GDDS) to predict developmental outcomes in very young children who undergo simultaneous bilateral cochlear implantation.

DESIGN

In this prospective cohort study, a repeated-measures investigation was conducted in a tertiary referral hospital. A total of 62 children receiving simultaneous bilateral cochlear implantations were enrolled from April 2017 to August 2018. They were divided into 2 groups depending on the operative age: "Infants" group (6 to 12 months, N = 38) or "Children" group (12 to 36 months, N = 24). Data on the surgical outcomes, auditory development, speech production, and developmental indicators were collected until 2 years after the initial fitting. The primary outcome measure was the GDDS, a neuropsychological development examination. Secondary outcomes included the following: complication rate, aided pure-tone average, Infant-Toddler Meaningful Auditory Integration Scale, Categories of Auditory Performance-II, Meaningful Use of Speech Scale, Speech Intelligibility Rating, and the LittlEARS Auditory Questionnaire.

RESULTS

The mean ages at implantation in infants and children groups were 9.2 ± 1.17 and 16.6 ± 3.60 months, respectively. Significant differences were found in the social skills ( p = 0.001) and adaptability ( p = 0.031) domains of GDDS. The younger the age of bilateral cochlear implants surgery, the higher developmental quotient of language, social skills, and adaptability the child could achieve after 2 years. The complication rates in the infants and children groups were 0% versus 2.1% ( p = 0.57). There was no surgical complication in the infants group. In the children group, 1 case with enlarged vestibular aqueduct and Mondini malformation had a receiver-implant misplacement on the right side (2%, 1/48). In the two groups, auditory performance and speech production had improved similarly. In the infants group, social skills developmental quotient at baseline had a significant positive relationship with Meaningful Use of Speech Scale after 2 years.

CONCLUSIONS

Simultaneous bilateral cochlear implantation in younger children improves adaptability and social skills. GDDS is a sensitive tool of evaluating short-term effect of bilateral cochlear implants in neuropsychological development and constitutes a reliable predictor of speech production for the very younger pediatric cochlear implant users.

Listening effort and downstream effects due to hearing loss in children and young people: an online quantitative questionnaire-based observational study

INTRODUCTION

The clinical application of listening effort (LE) is challenging due to the lack of consensus regarding measuring the concept. Correlational analysis between different measuring instruments shows conditional and weak relationships, indicating they capture different dimensions of LE. Current research has suggested possible links between LE and downstream consequences such as fatigue, stress and confidence. One way to clinically measure LE would be to focus on its corollaries. Further research is needed to explore whether tools used to measure these downstream effects can be applied to capture LE. This study explores using existing questionnaire-based outcome instruments to evaluate LE and its associated consequences in children and young people (CYP), with and without hearing loss.

METHODS AND ANALYSIS

One hundred CYP aged 12-17 years with normal hearing and a range of hearing loss levels will be invited to complete a series of online questionnaires (Speech, Spatial and Qualities, Vanderbilt Fatigue Scale-Child, Perceived Stress Scale and Rosenberg Self-Esteem Scale) and a hearing test (Digits in Noise). They will complete the questionnaires at two time points (1) at the end of a rest day and (2) at the end of a workday. Standard demographic and hearing health information will be collected. The sample size was determined pragmatically due to a lack of comparable published data to power the study. Tests are exploratory and for generating hypotheses; therefore, the standard criterion of p<0.05 will be used.

ETHICS AND DISSEMINATION

This study has been reviewed within the funding organisation (Cochlear Research and Development Limited) by an independent and relevant peer reviewer/committee. This study has had a favourable ethics committee review by both NHS ethics and University of Manchester ethics. The study will be disseminated through newsletters, publication and presentations at conferences. The results will be made available to participants on request.

A Modified Pediatric Ranked Order Speech Perception Score to Assess Speech Recognition Development in Children With Cochlear Implants

PURPOSE

Characterizing and comparing speech recognition development in children with cochlear implants (CIs) is challenging because of variations in test type. This retrospective cohort study modified the Pediatric Ranked Order Speech Perception (PROSPER) scoring system to (a) longitudinally analyze the speech perception of children with CIs and (b) examine the role of age at CI activation, listening mode (i.e., unilateral or bilateral implantation), and interimplant interval.

METHOD

Postimplantation speech recognition scores from 31 children with prelingual, severe-to-profound hearing loss who received CIs were analyzed (12 with unilateral CI [UniCI], 13 with sequential bilateral CIs [SEQ BiCIs], and six with simultaneous BiCIs). Data were extracted from the Massachusetts Eye and Ear Audiology database. A version of the PROSPER score was modified to integrate the varying test types by mapping raw scores from different tests into a single score. The PROSPER scores were used to construct speech recognition growth curves of the implanted ears, which were characterized by the slope of the growth phase, the time from activation to the plateau onset, and the score at the plateau.

RESULTS

While speech recognition improved considerably for children following implantation, the growth rates and scores at the plateau were highly variable. In first implanted ears, later implantation was associated with poorer scores at the plateau (β = -0.15, p = .01), but not growth rate. The first implanted ears of children with BiCIs had better scores at the plateau than those with UniCI (β = 0.59, p = .02). Shorter interimplant intervals in children with SEQ BiCIs promoted faster speech recognition growth of the first implanted ears.

CONCLUSION

The modified PROSPER score could be used clinically to track speech recognition development in children with CIs, to assess influencing factors, and to assist in developing and evaluating patient-specific intervention strategies.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20113538.

Benefit of sequential bilateral cochlear implantation in children between 5 to 18 years old: A prospective cohort study

Objective

To determine the benefit of sequential cochlear implantation after a long inter-implantation interval in children with bilateral deafness receiving their second implant between 5 and 18 years of age.

Study design

Prospective cohort-study.

Setting

Tertiary multicenter.

Patients

85 children with bilateral deafness and unilateral implantation receiving a contralateral cochlear implant at the age of 5 to 18 years.

Method

The primary outcomes were speech recognition in quiet and noise (CVC) scores. The secondary outcomes were language outcomes and subjective hearing abilities, all measured before and 12 months after sequential bilateral cochlear implantation. Medians of the paired data were compared using the Wilcoxon signed-rank test. Univariable linear regression analyses was used to analyze associations between variables and performance outcomes.

Results

A significant benefit was found for speech recognition in quiet (96% [89–98] vs 91% [85–96]; p < 0.01) and noise (65% [57–75] vs 54% [47–71]; p = 0.01) in the bilateral CI condition compared to unilateral (n = 75, excluded 10 non-users). No benefit was seen for language outcomes. The subjective sound quality score was statistically significant higher in bilateral compared to the unilateral CI condition. Pre-operative residual hearing level in the ear of the second implant, the inter-implant interval and age at time of second implantation was not significantly associated with performance scores.

Conclusion

After 12 months of use, sequential bilateral cochlear implantation showed improved speech perception in quiet and noise and improved subjective sound quality outcomes in children despite a great inter-implantation interval (median of 8 years [range 1–16 years]).

Cochlear Implantation in Young Mandarin-Speaking Children: One Year After First Fitting

INTRODUCTION

Bilateral cochlear implantation has been shown to be beneficial in terms of sound localization and speech recognition in children with congenital deafness. However, little is known about the benefits of bilateral cochlear implantationin children who communicate in a tonal language such as Mandarin. This study aims to investigate the auditory perception and speech intelligibility of Mandarin-speaking children 1 year after first fitting.

MATERIALS AND METHODS

Twenty-nine children aged between 11.5 and 17.9 months with severe-to-profound bilateral sensorineural hearing loss were recruited; 10 were unilaterally implanted and 19 were bilaterally implanted. A test battery was used to monitor improvements during the first year of cochlear implant use.

RESULTS

Bilaterally implanted children scored better in the spatial domain of the Speech, Spatial and Qualities of hearing scale for Parents (SSQ-P) in comparison to unilaterally implanted children. Significant improvements were observed in auditory performance and speech intelligibility at 6 and 12 months after first fitting for both groups of children.

DISCUSSION

Young children that speak a tonal language, such as Mandarin, can obtain significant improvements in hearing and speech abilities within the first year of cochlear implant use. Furthermore, bilateral implantation provides users with better spatial hearing in comparison to unilateral implantation.

French adaptation and validation of parents' evaluation of aural/oral performance of children (PEACH) scale in children

OBJECTIVE

Hearing loss can seriously impact children's quality of life. Disease-specific questionnaires are required to optimise medical care. This study aims to translate, adapt and validate the French version of the PEACH score for the auditory performance of children.

DESIGN

This is a controlled, prospective study, conducted between April and October 2020. The translation was conducted using a forward-backward technique, and statistical validation was conducted with a test and re-test, on a patient population and a control population.

STUDY SAMPLE

Patients were included if they were 1-11 years old, and had at least 30 dB hearing loss in one ear. The mean age was 6 years for the 39 patients and 3.9 years for the 34 controls.

RESULTS

Reproducibility, measured by Spearman's coefficient between global scores of the test and re-test was 0.78 (p < 0.001). The test was internally consistent (Cronbach's alpha was 0.89) and item per item construct validity was satisfactory. The ROC curve showed a moderate area under the curve (0.74 p < 0.001) with 67% sensitivity and 73% specificity.

CONCLUSIONS

The French PEACH had good statistical properties, although a brief 13-item questionnaire, and can be used for evaluation of the disease-specific quality of life for young children with hearing loss.

[Evaluation of hearing and speech rehabilitation after cochlear implantation in children with Waardenburg syndrome]

Objective:By comparing the hearing and speech rehabilitation effects of cochlear implantation （CI） in children with Waardenburg syndrome （WS） and children with common deafness genes （SLC26A4, GJB2） in the Chinese population, and the hearing and speech rehabilitation effects of bilateral CI and unilateral CI in children with WS, to provide a reference for clinical CIin children with WS. Methods:Follow up and return visit 72 pedestrian cochlear implant children with severe and above sensorineural hearing loss and clear gene mutation type diagnosed by Kunming Children's Hospital from 2017 to 2019, including 24 cases in the WS group, 24 cases in the control group （SLC26A4 deafness group and GJB2 deafness group）. All enrolled children were evaluated for auditory and speech ability 12 months after startup. Results:The hearing aid threshold, the correct recognition rate of speech recognition ability evaluation, IT-MAIS / MAIS score rate, CAP score, SIR score, there was no significant difference（P>0.05）. The correct recognition rates of IT-MAIS / MAIS score, SIR score, natural environment sound recognition, vowel recognition, tone recognition, monosyllabic word recognition, disyllabic word recognition and short sentence recognition in children with WS bilateral CI were significantly higher than those in children with WS unilateral CI （P<0.05）. There was no significant difference in CAP score, initial recognition and correct recognition rate of trisyllabic words between children with WS bilateral CI and children with WS unilateral CI （P>0.05）. Conclusion:Common deafness genes in children with WS and Chinese population （SLC26A4, GJB2） the effect of cochlear implantation on hearing and speech rehabilitation of sick children is equivalent. For children with severe and above sensorineural hearing loss associated with this syndrome, CI can be used clinically to improve their hearing and speech ability. WS bilateral CI has advantages in some hearing and speech abilities compared with unilateral CI, so those whomeet the conditions should be encouraged bilateral implantation.

Vocabulary Growth in Mandarin-Speaking Children With Bilateral Cochlear Implants, Bimodal Stimulation, or Unilateral Cochlear Implants During the First Year After Activation

PURPOSE

The purpose of this study was to evaluate vocabulary development in Mandarin-speaking children with bilateral cochlear implants (CIs), bimodal stimulation (CI plus hearing aids [HAs]), or unilateral CIs during the first year after CI activation.

METHOD

Participants included 23 children with simultaneous bilateral CIs, 23 children with bimodal stimulation, and 15 children with unilateral CIs. They all received CIs before 30 months of age. Parents were asked to endorse words that their child could understand only or understand and say using the Early Vocabulary Inventory for Mandarin Chinese at the day of CI activation and 1, 3, 6, 9, and 12 months after CI activation. Receptive and expressive vocabulary sizes were computed.

RESULTS

Growth curve analysis revealed that children with simultaneous bilateral CIs demonstrated faster growth of receptive vocabulary than those with bimodal stimulation, followed by those with unilateral CIs. Moreover, children with simultaneous bilateral CIs reached the 100-word mark for receptive vocabulary earlier than children with bimodal stimulation, followed by those with unilateral CIs. There were no significant differences among the three groups in expressive vocabulary.

CONCLUSIONS

Bilateral CIs have an advantage over bimodal stimulation in early receptive vocabulary development in Mandarin, a tone language. HA usage is still recommended for those who receive one CI.

Involving Children and Teenagers With Bilateral Cochlear Implants in the Design of the BEARS (Both EARS) Virtual Reality Training Suite Improves Personalization

Older children and teenagers with bilateral cochlear implants often have poor spatial hearing because they cannot fuse sounds from the two ears. This deficit jeopardizes speech and language development, education, and social well-being. The lack of protocols for fitting bilateral cochlear implants and resources for spatial-hearing training contribute to these difficulties. Spatial hearing develops with bilateral experience. A large body of research demonstrates that sound localisation can improve with training, underpinned by plasticity-driven changes in the auditory pathways. Generalizing training to non-trained auditory skills is best achieved by using a multi-modal (audio-visual) implementation and multi-domain training tasks (localisation, speech-in-noise, and spatial music). The goal of this work was to develop a package of virtual-reality games (BEARS, Both EARS) to train spatial hearing in young people (8–16 years) with bilateral cochlear implants using an action-research protocol. The action research protocol used formalized cycles for participants to trial aspects of the BEARS suite, reflect on their experiences, and in turn inform changes in the game implementations. This participatory design used the stakeholder participants as co-creators. The cycles for each of the three domains (localisation, spatial speech-in-noise, and spatial music) were customized to focus on the elements that the stakeholder participants considered important. The participants agreed that the final games were appropriate and ready to be used by patients. The main areas of modification were: the variety of immersive scenarios to cover age range and interests, the number of levels of complexity to ensure small improvements were measurable, feedback, and reward schemes to ensure positive reinforcement, and an additional implementation on an iPad for those who had difficulties with the headsets due to age or balance issues. The effectiveness of the BEARS training suite will be evaluated in a large-scale clinical trial to determine if using the games lead to improvements in speech-in-noise, quality of life, perceived benefit, and cost utility. Such interventions allow patients to take control of their own management reducing the reliance on outpatient-based rehabilitation. For young people, a virtual-reality implementation is more engaging than traditional rehabilitation methods, and the participatory design used here has ensured that the BEARS games are relevant.

Objective vestibular function changes in children following cochlear implantation

BACKGROUND:

To date, systematically objective evaluations of vestibular function in children with cochlear implantation (CI) have been conducted sparsely, especially in children with large vestibular aqueduct syndrome (LVAS).

OBJECTIVE:

Our goal was to investigate the function of all five vestibular end-organs pre- and post-cochlear implantation in children with LVAS and normal CT.

METHODS:

In this retrospective cohort study, 34 children (age 4–17 years) with bilateral profound sensorineural hearing loss (SNHL) undergoing unilateral CI were included. Participants included 18 (52.9%) children with LVAS. Objective modalities to evaluate vestibular function included the caloric test, cervical vestibular-evoked myogenic potentials (cVEMP), ocular vestibular-evoked myogenic potentials (oVEMP), and video head impulse test (vHIT). All measurements were performed before surgery and 9 months after surgery.

RESULTS:

Mean age at CI was 8.1±3.7 years. Caloric testing showed hypofunction in 38.2% of cases before implantation and in 50% after (p > 0.05). We found a significant increase of overall abnormality rate in cVEMP and oVEMP from pre- to post-CI (p < 0.05). In all three semicircular canals tested by vHIT, there were no statistically significant mean gain changes (p > 0.05). Higher deterioration rates in cVEMP (53.3%) and oVEMP (52.0%) after surgery were observed (p < 0.05). In children with LVAS, cVEMP revealed a higher deterioration rate than superior semicircular canal (SSC) and posterior semicircular canal (PSC) (p < 0.05). In children with normal CT, the deterioration rates in VEMPs were both higher than those in vHIT (p < 0.05).

CONCLUSIONS:

In general, the otolith organs were the most affected peripheral vestibular sensors in children after cochlear implantation. The variations in otolith function influenced by CI were different between children with LVAS and normal CT. We recommend the use of this vestibular function test battery for children with cochlear implantation.

Bilateral Cochlear Implantation in Children: Long-Term Outcome in the Adult Population With Special Emphasis on the Bilateral Benefit

OBJECTIVE

To investigate the benefit of bilateral cochlear implantation in adults, who had been implanted being a child under the age of 10 years.

STUDY DESIGN

Retrospective data analysis.

SETTING

Tertiary referral center with a large cochlear implant program.

MAIN OUTCOME MEASURES

Speech understanding in the Freiburg monosyllabic words in quiet and the HSM sentence test in quiet and in background noise.

PATIENTS

Seventy-seven bilaterally cochlear implantation implanted adults.

RESULTS

Bilateral cochlear implantation in children under the age of 10 years results in a significant benefit in speech comprehension in adulthood. In addition, a dependency regarding the time between the implantations and speech intelligibility was found.

CONCLUSION

The results emphasize the benefit of bilateral cochlear implantation with a short interval between the operations in young children not only during formative years but also in adulthood.

Long-Term Language Development in Children With Early Simultaneous Bilateral Cochlear Implants

Objectives:

This longitudinal study followed the language development of children who received the combination of early (5 to 18 months) and simultaneous bilateral cochlear implants (CIs) throughout the first 6 years after implantation. It examined the trajectories of their language development and identified factors associated with language outcomes.

Design:

Participants were 21 Norwegian children who received bilateral CIs between the ages of 5 and 18 mo and 21 children with normal hearing (NH) who were matched to the children with CIs on age, sex, and maternal education. The language skills of these two groups were compared at 10 time points (3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months after implantation) using parent reports and standardized measures of general language skills, vocabulary, and grammar. In addition, assessments were made of the effects of age at CI activation, speech recognition abilities, and mothers’ education on language outcomes 6 years after implantation.

Results:

During the first 4 years after implantation, the gap in general expressive and receptive language abilities between children with CIs and children with NH gradually closed. While at the initial five to six assessments (3 to 36 months after implantation), significant differences between children with CIs and children with NH were observed; at 4 years after implantation, there were no longer any significant group differences in general language skills and most children with CIs achieved scores within 1 SD of the tests’ normative means. From 2 to 3 years after implantation onward, expressive vocabulary and receptive grammar skills of children with CIs were similar to those of the reference group. However, from 4 years after implantation until the end of the observation period, 6 years after implantation, expressive grammar skills of children with CIs were lower than those of children with NH. In addition, a gap in receptive vocabulary appeared and grew increasingly larger from 4 to 6 years postimplantation. At the final assessment, the children with CIs had an average receptive vocabulary score around 1 SD below the normative mean. Regression analysis indicated that the children’s language outcomes at 6 years after implantation were related to their speech recognition skills, age at CI activation, and maternal education.

Conclusions:

In the first 4 years after implantation, the language performance of children with CIs became increasingly similar to that of their NH peers. However, between 4 and 6 years after implantation, there were indications of challenges with certain aspects of language, specifically receptive vocabulary and expressive grammar. Because these challenges first appeared after the 4-year assessment, the findings underline the importance of long-term language intervention to increase the chances of a continued language development comparable to that of NH peers. They also indicate that there is a need for comprehensive longitudinal studies of the language development of children with CIs beyond 4 years after implantation.

Language and Audiological Outcomes Among Infants Implanted Before 9 and 12 Months of Age Versus Older Children: A Continuum of Benefit Associated With Cochlear Implantation at Successively Younger Ages

OBJECTIVE

To compare language and audiological outcomes among infants (<9 and <12 mo) and older children receiving cochlear implantation (CI).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic referral center.

PATIENTS

Pediatric patients receiving CI between October 1995 and October 2019.

INTERVENTION

Cochlear implantation.

MAIN OUTCOME MEASURES

Most recent language and audiological assessment scores were evaluated by age group.

RESULTS

A total of 118 children were studied, including 19 who were implanted <9 months of age, 19 implanted 9 to <12 months of age, and 80 implanted 12 to <36 months of age. The mean duration of follow-up was 7.4 ± 5.0 years. Most recent REEL-3 receptive (88 ± 12 vs. 73 ± 15; p = 0.020) and expressive (95 ± 13 vs. 79 ± 12; p = 0.013) communication scores were significantly higher in the <9 months group compared to the 9 to <12 months group. PLS and OWLS auditory comprehension and oral expression scores were significantly higher in the <12 months group compared to the 12 to <36 months group. The difference in NU-CHIPS scores between <12 and 12 to <36 months was statistically significant (89% ± 6 vs. 83% ± 12; p = 0.009). LNT scores differed significantly between <9 and 9 to <12 months (94% ± 4 vs. 86% ± 10; p = 0.028).

CONCLUSIONS

The recent FDA expansion of pediatric CI eligibility criteria to include infants as young as 9 months of age should not serve as a strict clinical cutoff. Rather, CI can be pursued in appropriately selected younger infants to optimize language and audiological outcomes.

Alteration of Vestibular Function in Pediatric Cochlear Implant Recipients

Background: Vestibular dysfunction is a complication of cochlear implantation (CI). Reports on the evaluation of vestibular function before and after CI are limited, especially in children. We investigated the effect of CI on vestibular function in pediatric patients.

Patients and Methods: We routinely evaluated vestibular function before but not immediately after CI. Therefore, patients who underwent sequential bilateral CI were enrolled in this study. Seventy-three children who underwent sequential CI from 2003 to 2020 at our hospital were included. Since the vestibular function of the first implanted ear was evaluated before the second surgery for the contralateral ear, post-CI evaluation timing differed among the cases. The evaluation included a caloric test, a cervical vestibular-evoked myogenic potential (cVEMP) test, and a damped rotation test. The objective variables included the results of these tests, and the explanatory variables included the age at surgery, cause of hearing loss, electrode type, and surgical approach used. The associations of these tests were analyzed.

Results: cVEMP was the most affected after CI (36.1%), followed by the caloric test (23.6%), and damped rotation test (7.8%). Cochleostomy was significantly more harmful than a round window (RW) approach or an extended RW approach based on the results of the caloric test (p = 0.035) and damped rotation test (p = 0.029). Perimodiolar electrodes affected the caloric test results greater than straight electrodes (p = 0.041). There were no significant associations among these tests' results.

Conclusions: Minimally invasive surgery in children using a round window approach or an extended round window approach with straight electrodes is desirable to preserve vestibular function after CI.

Bimodal Stimulation in Children With Bilateral Profound Sensorineural Hearing Loss: A Suitable Intervention Model for Children at the Early Developmental Stage

OBJECTIVE

To evaluate the auditory and speech benefit of bimodal stimulation for prelingual deafened cochlear implantation recipients.

STUDY DESIGN

Retrospective and comparative study.

SETTING

Tertiary referral center.

PATIENTS

Fifty-six children with bilateral prelingual profound sensorineural hearing loss were enrolled, including 28 consecutive children with unilateral cochlear implantation (CI group), and 28 consecutive children with bimodal stimulation (BI group) who used an additional hearing aid (HA) in the contralateral ear.

MAIN OUTCOME MEASURES

Hearing assessments included the Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) and Categories of Auditory Performance (CAP). Speech evaluations included the Meaningful Use of Speech Scale (MUSS), and Speech Intelligibility Rating (SIR). These measurements were evaluated at the first mapping of cochlear implants and 0.5, 1, 3, 6, 12, 18, 24 months after. Data were analyzed by repeated measures analysis.

RESULTS

The mean ages of BI and CI groups were similar (17.6 ± 6.87 vs 19.0 ± 8.10 months, p = 0.497). The initial scores for hearing and speech assessments showed no differences between the two groups, apart from IT-MAIS (2.46 ± 0.631 in BI group vs 0.50 ± 0.279 in CI group, p = 0.004). The auditory and speech development over time were different in the two groups as seen in IT-MAIS (p < 0.001), CAP (p = 0.029), MUSS (p < 0.001), and SIR (p < 0.001). A continuing but stable difference was observed in CAP, MUSS, and SIR at 3, 18, and 12 months after the first mapping, respectively. In addition, the BI group had better IT-MAIS scores at 3 and 6 months compared with the CI group; however, the difference was not significant after 12 months.

CONCLUSION

Bimodal stimulation is beneficial for prelingually deafened CI recipients who have minimal contralateral residual hearing when bilateral CIs are not available. Hearing aid use in the contralateral ear might be recommended for children after unilateral cochlear implantation to facilitate the development of auditory and speech skills.

Comparison of Speech Performance in Bimodal versus Bilateral Cochlear Implant Users

OBJECTIVE

To assess whether listening with two cochlear implants (bilateral) offers significant benefits in terms of speech perception over listening with one cochlear implant and one hearing aid (bimodal).

METHODS

Retrospective review of bilateral cochlear implant recipients (24 pediatric and 26 adult). Bimodal listening was compared to bilateral listening in terms of speech perception performance at 1-year post second implant under three listening conditions: 50 dBHL, 35 dBHL, and 50 dBHL+5 SNR. Changes in speech performance from bimodal (before second implant) to bilateral (after second implant) listening were determined within subjects and compared to a separate control group of bimodal users matched for age of first implantation who never received a second implant (10 pediatric and 20 adult).

RESULTS

In the pediatric group, compared to bimodal listening prior to a second implant, speech perception scores with bilateral implants increased significantly when measured at 50 dBHL, 35 dBHL, and 50 dBHL+5 SNR. By contrast, pediatric bimodal controls who never received a second implant failed to demonstrate similar improvement over 1 year's time. In the adult group, compared to bimodal listening prior to a second implant, speech perception scores with bilateral implants increased when measured at 50 dBHL, but were not significantly different at 35 dBHL and 50 dBHL + 5 SNR. Adult bimodal controls who never received a second implant failed to demonstrate significant improvement in all conditions over 1 year's time.

CONCLUSION

Bilateral listening with two cochlear implants improved speech perception performance relative to bimodal listening in the pediatric population. Improvement in the adult population was not as significant.

LEVEL OF EVIDENCE

4, Retrospective Chart Review. Laryngoscope, 131:E1322-E1327, 2021.

Speech perception with simultaneous bilateral cochlear implants: Is there a unilateral predominance?

OBJECTIVES

To assess the audiological outcomes and speech performance among children with simultaneous bilateral cochlear implants (CIs).

METHODS

This was a retrospective case review of 41 patients with prelingual deafness who failed a hearing aid trial and received simultaneous bilateral CIs. Ear-specific responses in terms of pure tone average (PTA), speech reception thresholds (SRTs), and speech discrimination score (SDS) were recorded for both ears of all patients.

RESULTS

The PTA and SRT for the right and left CIs were comparable (P-value = 0.861 and P-value = 0.524, respectively). The SDS was slightly higher for the right ear, although it was not significantly different from that for the left ear (P-value = 0.375), yielding only a 2.42% difference.

CONCLUSION

We found no significant side preference in all assessment scores for children with simultaneous bilateral CIs. Therefore, we cautiously advise implanting the CI in the right ear in case of symmetrical hearing loss when other prognostic factors do not favor the left ear.

Systematic Review of Outcomes After Cochlear Implantation in Children With X-Linked Deafness-2

OBJECTIVE

Outcomes following cochlear implantation in children with X-linked deafness-2 are variable, resulting in challenges in appropriate preoperative counseling. To address this uncertainty, we performed a systematic review and synthesis of the literature on audiologic and speech outcomes after cochlear implantation in these patients to inform prognostic counseling.

DATA SOURCES

PubMed, Embase, and Cochrane Library were queried for articles published between January 2000 and July 2019.

REVIEW METHODS

We performed a systematic review of all studies published between 2000 and 2019 that reported on (1) children with confirmed X-linked deafness-2 undergoing cochlear implantation and (2) formal assessment of hearing and/or speech capabilities postimplantation.

RESULTS

Our initial database search yielded 313 articles. Fourteen articles met inclusion criteria. These studies reported on 61 children with X-linked deafness-2 who underwent implantation at a wide age range (1-29 years) for severe-profound sensorineural hearing loss of prelingual onset. The mean follow-up duration after implant activation was 32 months (range, 12-61). Outcome domains assessed at follow-up were heterogeneous, though each study employed at least 1 assessment of hearing (eg, pure tone audiometry), speech perception (eg, Early Speech Perception Test), or auditory perception (eg, Categories of Auditory Perception scores). In 10 of 14 studies, cochlear implantation afforded significant improvement in hearing and speech capabilities relative to preoperative performance or as compared with age-matched, normal-hearing controls.

CONCLUSION

The majority of studies demonstrate that cochlear implantation provides improvements in hearing and speech performance in patients with X-linked deafness-2. This information is valuable for decision making regarding cochlear implantation in these patients.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Reading and Theory of Mind in Adolescents with Cochlear Implant

Previous research has shown a possible link between reading comprehension and theory of mind (ToM), but these findings are unclear in adolescents with cochlear implants (CI). In the present study, reading comprehension and ToM were assessed in adolescents with CI and the relation between both skills was also studied. Two sessions were performed on two groups of adolescents aged between 12 and 16 years of age (36 adolescents with CI and 54 participants with typical hearing, TH). They were evaluated by means of a standardized reading battery, a false belief task, and Faux Pas stories. The results indicated that reading and cognitive ToM were more developed in the TH group than in adolescents with CI. However, early-CI and binaural group performance were close to the TH group in narrative and expository comprehension and cognitive ToM. The results also indicated that cognitive ToM and reading comprehension appear to be related in deaf adolescents.

Is CT necessary for imaging paediatric congenital sensorineural hearing loss?

Objectives: To determine if MRI alone is adequate for pre-operative assessment of paediatric congenital sensorineural hearing loss (SNHL). While aberrant intratemporal facial nerve anatomy is usually occult on MRI, we postulate that the majority of cases have no adverse bearing on surgical outcomes.Methods: MRI and CT of the temporal bones were analysed in 240 children who underwent both on the same day for SNHL. Only children under the age of 5 years with no reported clinical syndrome or dysmorphic external ear anatomy were included.Results and discussion: 169 patients satisfied the inclusion criteria. MRI detected 32/54 cases of cochleovestibular dysplasia, with the majority of the additional CT findings comprising subtle incomplete partition type 2 (IP2) anomalies. Of the 22 cases not evident on MRI, 13 patients also had large vestibular aqueduct syndromoe (LVAS), which would have prompted evaluation with CT due to the near universal co-existence of these entities. Only one patient exhibited aberrant intratemporal facial nerve anatomy that may have conferred surgical risk and was occult on MRI.Conclusion: In a defined paediatric SNHL cohort, the addition of routine temporal bone CT to MRI offers limited additional yield but confers a significant radiation burden on a young population.

[Sequential bilateral cochlear implantation with long interval between surgeries in deaf-blind patient]

The efficacy of sequential bilateral cochlear implantation with long interval between surgeries (18 years) was investigated in deaf-blind patient (22 years old man, lost hearing and vision after meningitis at the age 2.5 years). At the age 4 years he got cochlear implant at right ear. His speech skills completely disappeared before the implantation. Auditory-speech rehabilitation with cochlear implant was successful - patient has good auditory, language, speech, cognitive skills. At the age 22 years patient made decision to get cochlear implant at the left ear after breakdown of internal part of cochlear implant at right ear in spite of successful reoperation. After activation of new processor (all electrodes were activated) the patient got daily auditory training with cochlear implant at left ear (Concerto/Opus 2, Medel) on the base of 'auditory' method, in daily life patient uses 2 devices. After 1 month of using cochlear implant at left ear the patient recognized environmental sounds and music instruments, words and sentences in close set tests EARS battery, the score for OLSA test in quiet was 90%, but the perception in noise was complicated. The balance of parameters of fitting for 1-st and 2-nd processors and special auditory training with two cochlear implants provided the development of initial binaural interaction. Perilinqually deaf patients can achieve high effect after sequential bilateral cochlear implantation with long interval between surgeries. The necessary conditions are - preservation of electrical activity of auditory nerve, intensive structured auditory training with new 'ear', patient's motivation of using of cochlear implant at 'new' ear.

Cost-effectiveness analysis of bilateral cochlear implants for children with severe-to-profound sensorineural hearing loss in both ears in Singapore

A cochlear implant is a small electronic device that provides a sense of sound for the user, which can be used unilaterally or bilaterally. Although there is advocacy for the benefits of binaural hearing, the high cost of cochlear implant raises the question of whether its additional benefits over the use of an acoustic hearing aid in the contralateral ear outweigh its costs. This cost-effectiveness analysis aimed to separately assess the cost-effectiveness of simultaneous and sequential bilateral cochlear implantations compared to bimodal hearing (use of unilateral cochlear implant combined with an acoustic hearing aid in the contralateral ear) in children with severe-to-profound sensorineural hearing loss in both ears from the Singapore healthcare payer perspective. Incremental quality-adjusted life year (QALYs) gained and costs associated with bilateral cochlear implants over the lifetime horizon were estimated based on a four-state Markov model. The analysis results showed that, at the 2017 mean cost, compared to bimodal hearing, patients receiving bilateral cochlear implants experienced more QALYs but incurred higher costs, resulting in an incremental cost-effectiveness ratio (ICER) of USD$60,607 per QALY gained for simultaneous bilateral cochlear implantation, and USD$81,782 per QALY gained for sequential bilateral cochlear implantation. The cost-effectiveness of bilateral cochlear implants is most sensitive to utility gain associated with second cochlear implant, and cost of bilateral cochlear implants. ICERs increased when the utility gain from bilateral cochlear implants decreased; ICERs exceeded USD$120,000 per QALY gained when the utility gain was halved from 0.03 to 0.015 in both simultaneous and sequential bilateral cochlear implantations. The choice of incremental utility gain associated with the second cochlear implant is an area of considerable uncertainty.

Subjective and objective vestibular changes that occur following paediatric cochlear implantation: systematic review and meta-analysis

Objective

Cochlear implantation can result in post-operative vestibular dysfunction of unknown clinical significance. The objective of this study was to characterize the presence, magnitude, and clinical significance of vestibular dysfunction that occurs after pediatric cochlear implantation.

Data sources

The databases Embase, Medline (OvidSP), and PubMed were used. Only articles published in English were included. Grey literature and unpublished sources were also reviewed.

Study selection

Articles published from 1980 until the present which documented pre-operative and post-operative vestibular testing on children under the age of 18 were used.

Data extraction

Parameters that were assessed included number of patients, pre- and post-operative vestibular-evoked myogenic potentials (VEMPs), head impulse testing (HIT), calorics, and posturography, timing of pre- and post-operative testing, symptomatology, and other demographic data such as etiology of the hearing loss.

Data synthesis

Ten articles were included. Relative risk values evaluating the effect of cochlear implantation on vestibular function were calculated for VEMPs and caloric testing due to the availability of published data. I² values were calculated and 95% confidence intervals were reported. Separate analyses were conducted for each individual study and a pooled analysis was conducted to yield an overall relative risk. Assessment on risk of bias in individual studies and overall was performed.

Conclusion

Pediatric cochlear implantation is associated with a statistically significant decrease in VEMP responses post-operatively (RR 1.8, p < 0.001, I² 91.86, 95%CI 1.57–2.02). Similar results are not seen in caloric testing. Insufficient data is available for analysis of HIT and posturography. Further studies are necessary to determine the effect of cochlear implantation on objective vestibular measures post-operatively and whether any changes seen are clinically relevant in this population.

Auditory comprehension outcomes in children who receive a cochlear implant before 12 months of age

OBJECTIVE

The U.S. Food and Drug Administration guidelines for cochlear implantation (CI) include age greater than 12 months. Studies have suggested that implantation in children younger than 12 months with congenital deafness may be associated with better spoken language outcomes. Compare auditory comprehension (AC) outcomes for children with congenital deafness who received CI less than 12 months of age to those implanted at 12 to 24 months of age.

METHODS

Retrospective review of prospectively collected data in consecutively implanted patients under 2 years of age who received CI and had post-CI Preschool Language Scale (PLS)-AC scores. Receptive language was assessed with the AC subtest of the PLS. Patients without pre-CI PLS-AC scores were excluded. The association between age at implantation and post-CI PLS-AC scores up to 2 years after CI surgery was modeled using a linear mixed-effects model. Time from CI surgery, number of implants, risk factors for language delay, pre-CI PLS-AC score, and sex were included in the model. Patients implanted less than 12 months of age were compared to those implanted between 12 and 24 months.

RESULTS

Twenty-nine patients who had CI surgery by 12 months and 82 who had CI surgery between 12 and 24 months were included in the analysis. Younger age at implantation and better pre-CI PLS-AC scores were significantly associated with better post-CI PLS-AC scores.

CONCLUSION

Cochlear implantation in children with congenital deafness less than 12 months of age was associated with better PLS-AC than in children implanted over 12 months of age up to 2 years after implantation.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:776-781, 2020.

Bilateral cochlear implantation is regarded as very beneficial: results from a worldwide survey by online questionnaire

PURPOSE

Bilateral cochlear implant (CI) provision is now widely regarded as the most beneficial hearing intervention for acceptable candidates. This study sought to determine if a number of well-regarded hearing professionals at highly reputable clinics shared similar practices and beliefs regarding bilateral CI provision, use, and rehabilitation in children and adults.

METHODS

An 11-question online questionnaire was created and distributed to all 27 clinics in the HEARRING group. Questions 1-5 asked for facts; questions 6-11 asked for opinions.

RESULTS

20 completed questionnaires were returned. All 20 respondents reported that their clinics perform bilateral cochlear implantation in children; 18 do so in adults. Regarding the fact-based questions, bilateral CI provision is more commonly performed and more likely to be reimbursed in children than in adults. Children are also much more likely to be implanted simultaneously than are adults. Regarding the opinion-based questions, respondents gave broadly similar answers. Communication between the CIs and speech coding strategies specifically developed for bilateral CI users were regarded as the two future technologies that would most enhance the benefit of bilateral CI use.

CONCLUSIONS

Most clinics in the HEARRING group are very familiar with bilateral CI provision and hold similar opinions on its results and benefits. Hopefully the results described herein will lead to a greater acceptance and regular reimbursement of bilateral CI provision, especially in adults.

Audio-visual speech perception in prelingually deafened Japanese children following sequential bilateral cochlear implantation

OBJECTIVES

An effect of audio-visual (AV) integration is observed when the auditory and visual stimuli are incongruent (the McGurk effect). In general, AV integration is helpful especially in subjects wearing hearing aids or cochlear implants (CIs). However, the influence of AV integration on spoken word recognition in individuals with bilateral CIs (Bi-CIs) has not been fully investigated so far. In this study, we investigated AV integration in children with Bi-CIs.

METHODS

The study sample included thirty one prelingually deafened children who underwent sequential bilateral cochlear implantation. We assessed their responses to congruent and incongruent AV stimuli with three CI-listening modes: only the 1st CI, only the 2nd CI, and Bi-CIs. The responses were assessed in the whole group as well as in two sub-groups: a proficient group (syllable intelligibility ≥80% with the 1st CI) and a non-proficient group (syllable intelligibility < 80% with the 1st CI).

RESULTS

We found evidence of the McGurk effect in each of the three CI-listening modes. AV integration responses were observed in a subset of incongruent AV stimuli, and the patterns observed with the 1st CI and with Bi-CIs were similar. In the proficient group, the responses with the 2nd CI were not significantly different from those with the 1st CI whereas in the non-proficient group the responses with the 2nd CI were driven by visual stimuli more than those with the 1st CI.

CONCLUSION

Our results suggested that prelingually deafened Japanese children who underwent sequential bilateral cochlear implantation exhibit AV integration abilities, both in monaural listening as well as in binaural listening. We also observed a higher influence of visual stimuli on speech perception with the 2nd CI in the non-proficient group, suggesting that Bi-CIs listeners with poorer speech recognition rely on visual information more compared to the proficient subjects to compensate for poorer auditory input. Nevertheless, poorer quality auditory input with the 2nd CI did not interfere with AV integration with binaural listening (with Bi-CIs). Overall, the findings of this study might be used to inform future research to identify the best strategies for speech training using AV integration effectively in prelingually deafened children.

Objective and Subjective Measures of Simultaneous vs Sequential Bilateral Cochlear Implants in Adults: A Randomized Clinical Trial

Importance

To date, no randomized clinical trial on the comparison between simultaneous and sequential bilateral cochlear implants (BiCIs) has been performed.

Objective

To investigate the hearing capabilities and the self-reported benefits of simultaneous BiCIs compared with those of sequential BiCIs.

Design, Setting, and Participants

A multicenter randomized clinical trial was conducted between January 12, 2010, and September 2, 2012, at 5 tertiary referral centers among 40 participants eligible for BiCIs. Main inclusion criteria were postlingual severe to profound hearing loss, age 18 to 70 years, and a maximum duration of 10 years without hearing aid use in both ears. Data analysis was conducted from May 24 to June 12, 2016.

Interventions

The simultaneous BiCI group received 2 cochlear implants during 1 surgical procedure. The sequential BiCI group received 2 cochlear implants with an interval of 2 years between implants.

Main Outcomes and Measures

First, the results 1 year after receiving simultaneous BiCIs were compared with the results 1 year after receiving sequential BiCIs. Second, the results of 3 years of follow-up for both groups were compared separately. The primary outcome measure was speech intelligibility in noise from straight ahead. Secondary outcome measures were speech intelligibility in noise from spatially separated sources, speech intelligibility in silence, localization capabilities, and self-reported benefits assessed with various hearing and quality of life questionnaires.

Results

Nineteen participants were randomized to receive simultaneous BiCIs (11 women and 8 men; median age, 52 years [interquartile range, 36-63 years]), and another 19 participants were randomized to undergo sequential BiCIs (8 women and 11 men; median age, 54 years [interquartile range, 43-64 years]). Three patients did not receive a second cochlear implant and were unavailable for follow-up. Comparable results were found 1 year after simultaneous or sequential BiCIs for speech intelligibility in noise from straight ahead (difference, 0.9 dB [95% CI, -3.1 to 4.4 dB]) and all secondary outcome measures except for localization with a 30° angle between loudspeakers (difference, -10% [95% CI, -20.1% to 0.0%]). In the sequential BiCI group, all participants performed significantly better after the BiCIs on speech intelligibility in noise from spatially separated sources and on all localization tests, which was consistent with most of the participants' self-reported hearing capabilities. Speech intelligibility-in-noise results improved in the simultaneous BiCI group up to 3 years following the BiCIs.

Conclusions and Relevance

This study shows comparable objective and subjective hearing results 1 year after receiving simultaneous BiCIs and sequential BiCIs with an interval of 2 years between implants. It also shows a significant benefit of sequential BiCIs over a unilateral cochlear implant. Until 3 years after receiving simultaneous BiCIs, speech intelligibility in noise significantly improved compared with previous years.

Trial Registration

trialregister.nl Identifier: NTR1722.

Cost-Utility Analysis of Cochlear Implantation in Australian Adults

OBJECTIVES

Sequential and simultaneous bilateral cochlear implants are emerging as appropriate treatment options for Australian adults with sensory deficits in both cochleae. Current funding of Australian public hospitals does not provide for simultaneous bilateral cochlear implantation (CI) as a separate surgical procedure. Previous cost-effectiveness studies of sequential and simultaneous bilateral CI assumed 100% of unilaterally treated patients' transition to a sequential bilateral CI. This assumption does not place cochlear implantation in the context of the generally treated population. When mutually exclusive treatment options exist, such as unilateral CI, sequential bilateral CI, and simultaneous bilateral CI, the mean costs of the treated populations are weighted in the calculation of incremental cost-utility ratios. The objective was to evaluate the cost-utility of bilateral hearing aids (HAs) compared with unilateral, sequential, and simultaneous bilateral CI in Australian adults with bilateral severe to profound sensorineural hearing loss.

RESEARCH DESIGN

Cost-utility analysis of secondary sources input to a Markov model.

SETTING

Australian health care perspective, lifetime horizon with costs and outcomes discounted 5% annually.

INTERVENTION

Bilateral HAs as treatment for bilateral severe to profound sensorineural hearing loss compared with unilateral, sequential, and simultaneous bilateral CI.

MAIN OUTCOME MEASURES

Incremental costs per quality adjusted life year (AUD/QALY).

RESULTS

When compared with bilateral hearing aids the incremental cost-utility ratio for the CI treatment population was AUD11,160/QALY. The incremental cost-utility ratio was weighted according to the number of patients treated unilaterally, sequentially, and simultaneously, as these were mutually exclusive treatment options.

CONCLUSION

No peer-reviewed articles have reported the incremental analysis of cochlear implantation in a continuum of care for surgically treated populations with bilateral severe to profound sensorineural hearing loss. Unilateral, sequential, and simultaneous bilateral CI were cost-effective when compared with bilateral hearing aids. Technologies that reduce the total number of visits for a patient could introduce additional cost efficiencies into clinical practice.

Economic Evaluation of Treatments for Pediatric Bilateral Severe to Profound Sensorineural Hearing Loss: An Australian Perspective

OBJECTIVES

In Australia, surgical treatment options for children with bilateral severe to profound sensorineural hearing loss exist in a continuum ranging from unilateral cochlear implantation (CI), sequential bilateral CI through to simultaneous bilateral CI, depending on the condition. When treatment options are mutually exclusive, the mean costs and benefits of each treatment group are summed together to obtain the total mean costs and benefits. This enables an incremental analysis of treatment options in the context of the treated populations.The objective was to evaluate the cost-utility of current Australian CI treatment practices in children using domestic costs and consequences when compared with bilateral hearing aids (HAs).

RESEARCH DESIGN

Economic evaluation including a Markov model based on secondary sources.

SETTING

The base case modeled a government health payer perspective over a child's lifetime. Primary and secondary school education costs were also assessed.

INTERVENTION

Bilateral HAs compared with CI, including unilateral, sequential bilateral, or simultaneous bilateral CI weighted according to treatment.

MAIN OUTCOME MEASURES

Incremental costs per quality adjusted life year.

RESULTS

Approximately 42% of children in Australia with unilateral CI did not transition to sequential bilateral nor undergo simultaneous bilateral implantation. This differs from previous economic evaluations that assumed 100% of children transitioned to sequential bilateral CI treatment or were treated with simultaneous bilateral CI.The incremental cost utility of unilateral cochlear implantation compared with HAs was AUD 21,947/QALY. The weighted average incremental cost utility of the combined cochlear implantation treatment groups was AUD 31,238/QALY when compared with HAs.

CONCLUSION

Previous economic evaluations of cochlear implantation assumed 100% of unilaterally treated patients would transition to sequential bilateral or be treated with simultaneous bilateral implantation. This approach does not take into account the total treated population, where a proportion of patients are treated with unilateral CI.CI was cost effective when compared with HAs, and included children treated with unilateral, sequential bilateral, and simultaneous bilateral CI.The model was sensitive to the number of assessment and habilitation visits. Alternative health service models with cost efficiencies are needed to reduce after care costs.

Cost-effectiveness of pediatric bilateral cochlear implantation in Spain

OBJECTIVES/HYPOTHESIS

To determine the incremental cost-effectiveness of bilateral versus unilateral cochlear implantation for 1-year-old children suffering from bilateral sensorineural severe to profound hearing loss from the perspective of the Spanish public health system.

STUDY DESIGN

Cost-utility analysis.

METHODS

We conducted a general-population survey to estimate the quality-of-life increase contributed by the second implant. We built a Markov influence diagram and evaluated it for a life-long time horizon with a 3% discount rate in the base case.

RESULTS

The incremental cost-effectiveness ratio of simultaneous bilateral implantation with respect to unilateral implantation for 1-year-old children with severe to profound deafness is €10,323 per quality-adjusted life year (QALY). For sequential bilateral implantation, it rises to €11,733/QALY. Both options are cost-effective for the Spanish health system, whose willingness to pay is estimated at around €30,000/QALY. The probabilistic sensitivity analysis shows that the probability of bilateral implantation being cost-effective reaches 100% for that cost-effectiveness threshold.

CONCLUSIONS

Bilateral implantation is clearly cost-effective for the population considered. If possible, it should be done simultaneously (i.e., in one surgical operation), because it is as safe and effective as sequential implantation, and saves costs for the system and for users and their families. Sequential implantation is also cost-effective for children who have received the first implant recently, but it is difficult to determine when it ceases to be so because of the lack of detailed data. These results are specific for Spain, but the model can easily be adapted to other countries.

LEVEL OF EVIDENCE

2C. Laryngoscope, 127:2866-2872, 2017.

Bimodal Stimulation in Prelingually Deaf Children: Lessons from a Cross-sectional Survey

OBJECTIVE

(1) To survey the use of bimodal stimulation by prelingually deaf children receiving unilateral cochlear implantation and (2) to investigate demographic and audiologic factors explaining the use of bimodal stimulation.

STUDY DESIGN

Cross-sectional survey.

SETTING

Tertiary care institution.

SUBJECTS AND METHODS

The study included 44 unilaterally implanted prelingually deaf children from a single institution, with a minimum follow-up of 1 year. During routine follow-up visits, an examiner interviewed parents on their children's use of bimodal stimulation. At the same time, residual hearing and hearing aid gain in the contralateral ear were assessed.

RESULTS

Approximately half of patients (52%) used bimodal stimulation. On average, bimodal users showed better mean unaided and aided thresholds than nonbimodal users (P < .001). A mean 250- to 500-Hz unaided threshold ≤90 dB HL in the contralateral, nonimplanted ear was associated with a higher probability of bimodal use (P = .008). Parental satisfaction with the contralateral hearing aid was inversely correlated with mean 125- to 500-Hz and 1000- to 4000-Hz unaided thresholds (P < .001) and mean 250- to 500-Hz and 1000- to 4000-Hz aided thresholds (P < .001).

CONCLUSIONS

A mean 250- to 500-Hz unaided threshold ≤90 dB HL is associated with a higher probability of bimodal use by prelingually deaf children. Better residual hearing is associated with a higher degree of parental satisfaction with the contralateral hearing aid. This information could be useful to counsel parents of prelingually deaf children, when deciding between bimodal stimulation and simultaneous bilateral cochlear implantation.

Current trends in outcome studies for children with hearing loss and the need to establish a comprehensive framework of measuring outcomes in children with hearing loss in China

Since the 1970s, outcome studies for children with hearing loss expanded from focusing on assessing auditory awareness and speech perception skills to evaluating language and speech development. Since the early 2000s, the multi-center large scale research systematically studied outcomes in the areas of auditory awareness, speech-perception, language development, speech development, educational achievements, cognitive development, and psychosocial development. These studies advocated the establishment of baseline and regular follow-up evaluations with a comprehensive framework centered on language development. Recent research interests also include understanding the vast differences in outcomes for children with hearing loss, understanding the relationships between neurocognitive development and language acquisition in children with hearing loss, and using outcome studies to guide evidence-based clinical practice. After the establishment of standardized Mandarin language assessments, outcomes research in Mainland China has the potential to expand beyond auditory awareness and speech perception studies.

Cochlear implant and congenital cholesteatoma

BACKGROUND

The occurence of cholesteatoma and cochlear implant is rare. Secondary cholesteatomas may develop as a result of cochlear implant surgery. Primarily acquired cholesteatoma is not typically associated with congenital sensorineural hearing loss or cochlear implant in children. The occurrence of congenital cholesteatoma during cochlear implant surgery has never been reported before, partly because all patients are preoperatively submitted to imaging studies which can theoretically exclude the disease.

CASE PRESENTATION

We have reported a rare case of congenital cholesteatoma, found during sequential second side cochlear implantation in a 3-year-old child. The child underwent a computed tomography (CT) scan and magnetic resonance imaging (MRI) at 12 months of age, before the first cochlear implant surgery, which excluded middle ear pathology. The mass was removed as an intact pearl, without visible or microscopic violation of the cholesteatoma capsule. All the areas where middle ear structures were touching the cholesteatoma were vaporized with a laser and the cochlear implant was inserted uneventfully. Further follow-up excluded residual disease.

CONCLUSION

We believe that primary, single stage placement of a cochlear implant (CI) with simultaneous removal of the congenital cholesteatoma can be performed safely. However, to prevent recurrence, the capsule of the cholesteatoma must not be damaged and complete laser ablation of the surface, where suspicious epithelial cells could remain, is recommended. In our opinion, cholesteatoma removal and cochlear implantation should be staged if these conditions are not met, and/or the disease is at a more advanced stage. It is suspected, that the incidence of congenital cholesteatoma in pediatric CI candidates is much higher that in average pediatric population.

Positive Outcomes and Surgical Strategies for Bilateral Cochlear Implantation in a Child With X-Linked Deafness

OBJECTIVES

To recognize that bilateral cochlear implantation (CI) in X-linked deafness is safe, describe techniques to maximize successful electrode placement and minimize surgical risks, and recognize that normalization of hearing as well as language acquisition is achievable.

METHODS

A 6-month-old male patient presented with bilateral profound sensorineural hearing loss and was confirmed to have X-linked deafness secondary to POU3F4 gene mutation. Due to lack of benefit from amplification, he underwent bilateral CI in a staged fashion at 12 (right) and 15 months (left) of age. A transmastoid-facial recess approach was used bilaterally utilizing perimodiolar electrodes. High-flow gushers were controlled with muscle plugs. C-arm fluoroscopy was used during insertion of electrodes.

RESULTS

Follow-up data are available for 12 months. No complications were encountered, including no postoperative cerebrospinal fluid (CSF) leakage or facial stimulation. Postoperative audiograms in aided conditions showed hearing thresholds <40 dB. At 11 months following activation of his second CI, he scored in the normal range for his chronological age on standardized language measures.

CONCLUSION

With careful preparation and the assistance of intraoperative fluoroscopy, CI in patients with congenital X-linked deafness can be done safely. Performing bilateral CI followed by dedicated auditory-verbal rehabilitation may allow patients to achieve normal language development.

What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills?

As a result of neonatal hearing screening and subsequent early cochlear implantation (CI) profoundly deaf children have access to important information to process auditory signals and master spoken language skills at a young age. Nevertheless, auditory, linguistic and cognitive outcome measures still reveal great variability in individual achievements: some children with CI(s) perform within normal limits, while others lag behind. Understanding the causes of this variation would allow clinicians to offer better prognoses to CI candidates and efficient follow-up and rehabilitation. This paper summarizes what we can expect of normally developing children with CI(s) with regard to spoken language, bilateral and binaural auditory perception, speech perception and cognitive skills. Predictive factors of performance and factors influencing variability are presented, as well as some novel data on cognitive functioning and speech perception in quiet and in noise. Subsequently, we discuss technical and non-technical issues which should be considered in the future in order to optimally guide the child with profound hearing difficulties. This article is part of a Special Issue entitled <Lasker Award>.