Auditory brainstem implants: past, present and future prospects

Adam Politzer (1835-1920) and the cochlear nucleus

The year 2020 marks the centenary of the death of the great otologist Adam Politzer (1835-1920). From his descriptions of the cochlear nucleus between 1878 and 1908, we can gain insight into how contemporary otologists were beginning to embrace contributions from the neurosciences into their specialty. It is clear that this amalgamation was gaining momentum in the last part of the nineteenth century. The impressive clarity of Politzer's textbook (which went into several editions) secured Politzer's place in the history of otology as one of the founding fathers of his specialty.

Clinical Profile and Results Obtained in Patients Treated by Auditory Brainstem Implants

INTRODUCTION

Cochlear implants have been able to treat some types of hearing loss, but those related to cochlear nerve impairment made it necessary to find new ways to manage these deficits; leading to auditory brainstem implants (ABI).

AIM

Our objective is to present the clinical profile of patients treated through an ABI and the results obtained from 1997 to 2017.

MATERIAL AND METHODS

On the one hand, patients with statoacoustic nerve tumours (VIIIcranial nerve) were selected, and on the other hand, patients withoutVIII tumours with congenital malformations of the inner ear. Before and after the placement of the ABI, hearing was assessed through tonal audiometry, from which the PTA (Pure Tone Average) and the CAP (Categories of Auditory Performance) scale were obtained.

RESULTS

A total of 20 patients undergoing ABI surgery were included. Eight were of tumour cause (40%) and 12 non-tumour (60%). In 15 subjects (75%) a suboccipital approach was performed and in 5 (25%) translabyrinthine. The mean of active electrodes before the implantation of Cochlear® (Nucleus ABI24) was 13/21 (61.90%) versus 8.5/12 (70.83%) of the Med-el® (ABI Med-el). An improvement in the mean PTA of 118.49dB was found against 46.55dB at 2years. On the CAP scale, values of1 were obtained in the preimplantation and of 2.57 (1-5) in the 2-year revision.

CONCLUSION

The ABI is a safe option, and with good hearing results when the indication is made correctly.

The Therapeutic Dilemma of Cochlear Nerve Deficiency

Objective

To compare the outcomes between 2 age-matched cohorts of children with cochlear nerve deficiency: those receiving auditory brainstem implants (group A) or cochlear implants (group B).

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Subjects and Methods

Subjects were selected from a pool of 537 children fitted with cochlear implants (n = 443) or auditory brainstem implants (n = 94) over the past 14 years. Performance, examined with the Category of Auditory Performance scale, and complications were compared with a mean follow-up of 5 years.

Results

All children had bilateral profound sensorineural hearing loss and cochlear nerve deficiency. Magnetic resonance imaging documented an absent cochlear nerve (n = 12) and a small cochlear nerve (n = 8) in group A and an absent cochlear nerve (n = 11) and a small cochlear nerve (n = 9) in group B ( P = 1.000). Children with cochlear implants had Category of Auditory Performance scores spanning from 0 to 3 levels of performance, and all required manual communication mode and visual supplementation. Children with auditory brainstem implants had Category of Auditory Performance scores spanning from 2 to 7, and most patients demonstrated behavioral responses irrespective of inner ear malformations and an absent cochlear nerve or small cochlear nerve ( P < .001).

Conclusions

In children with cochlear nerve deficiency, patients fitted with cochlear implants did not develop speech understanding and production. Those fitted with auditory brainstem implants had the opportunity to develop open-set speech perception, acquiring verbal language competence using oral communication exclusively and participating in mainstream education. The overall complication rate of auditory brainstem implants was not greater than that of cochlear implants.

Electrical stimulation of the dorsal cochlear nucleus induces hearing in rats

Auditory brainstem implants (ABIs) restore hearing by electrical stimulation of the cochlear nucleus (CN). Depending on the physiological condition, duration of the pre-existing deafness, extent of damage to the CN, and the number of channels accessible to the tonotopic frequency gradients of the CN, ABIs improve speech understanding to varying degrees. Although the ventral cochlear nucleus, a mainstream auditory structure, has been considered a logic target for ABI stimulation, it is not yet clear how the dorsal cochlear nucleus (DCN) contributes to patients' hearing during ABI stimulation. To better understand the mechanisms underlying ABIs, we tested if electrical stimulation of the rat DCN induces hearing using a novel electrical prepulse inhibition (ePPI) of startle reflex behavior model. Our results showed that bipolar electrical stimulation of all channels in the DCN induced behavioral manifestation of hearing and that electrical stimulation of certain channels in the DCN induced robust neural activity in auditory cortex channels that responded to acoustic stimulation and demonstrated well-defined frequency tuning curves. This suggests that the DCN plays an important role in electrical hearing and should be further pursued in designing new ABIs. The novel ePPI behavioral paradigm may potentially be developed into an efficient method for testing hearing in animals with an implantable prosthesis.

[Present state of cochlear implant treatment in adults and children]

The technique of cochlear implantation was the first method which allowed replacement of a sense organ by a (partially) implantable electronic prosthesis. By this method the cells of the spiral ganglion of the cochlea are directly stimulated by the electrodes introduced into the cochlea, bypassing the functions of the outer and middle ear as well as the cochlea. Treatment with a cochlear implant (CI) has been established over the last 20-30 years as a reliable method for restoring hearing in adults and children with severe hearing disorders and is now a routine method in many centers. For optimal results in understanding speech and for children in the speech development phase, rehabilitation must be an integral part of the total treatment and follow soon after implantation. To achieve this early diagnosis of hearing difficulties or deafness is necessary, which is simplified by a consistent hearing screening of newborns, now a statutory procedure in Germany.