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Wu YL, Chen L, Zhu HY, Luo WY, Shi K, Hou XY, Sun JW, Sun JQ, Guo XT. Relationships between bilateral auditory brainstem activity and inter-implant interval in children with cochlear implants. Eur Arch Otorhinolaryngol 2024; 281:1735-1743. [PMID: 37924365 DOI: 10.1007/s00405-023-08285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/09/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE To investigate the effect of the interval between bilateral cochlear implantation on the development of bilateral peripheral auditory pathways as revealed by the electrically evoked auditory brainstem response (EABR). METHODS Fifty-eight children with profound bilateral sensorineural hearing loss were recruited. Among them, 33 children received sequential bilateral cochlear implants (CIs), and 25 children received simultaneous bilateral CIs. The bilateral EABRs evoked by electrical stimulation from the CI electrode were recorded on the day of second-side CI activation. RESULTS The latencies of wave III (eIII) and wave V (eV) were significantly shorter on the first CI side than on the second CI side in children with sequential bilateral CIs but were similar between the two sides in children with simultaneous bilateral CIs. Furthermore, the latencies were prolonged from apical to basal channels along the cochlea in the two groups. In children with sequential CIs, the inter-implant interval was negatively correlated with the eV latency on the first CI side and was positively correlated with bilateral differences in the eIII and eV latencies. CONCLUSIONS Unilateral CI use promotes the maturation of ipsilateral auditory conduction function. However, a longer inter-implant interval results in more unbalanced development of bilateral auditory brainstem pathways. Bilateral cochlear implantation with no or a short interval is recommended.
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Affiliation(s)
- Yan-Lin Wu
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Li Chen
- Department of Otolaryngology-Head and Neck Surgery, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, 519100, Guangdong, China
| | - Han-Yu Zhu
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Wen-Yun Luo
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Kai Shi
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Xiao-Yan Hou
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China
| | - Jing-Wu Sun
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China.
| | - Jia-Qiang Sun
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China.
| | - Xiao-Tao Guo
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China.
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Arjmandi MK, Herrmann BS, Caswell-Midwinter B, Doney EM, Arenberg JG. A Modified Pediatric Ranked Order Speech Perception Score to Assess Speech Recognition Development in Children With Cochlear Implants. Am J Audiol 2022; 31:613-632. [PMID: 35767328 PMCID: PMC9886162 DOI: 10.1044/2022_aja-21-00212] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Meisam K. Arjmandi
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston,Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston,Audiology Division, Massachusetts Eye and Ear, Boston
| | - Barbara S. Herrmann
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston,Audiology Division, Massachusetts Eye and Ear, Boston
| | - Benjamin Caswell-Midwinter
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston,Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston,Audiology Division, Massachusetts Eye and Ear, Boston
| | | | - Julie G. Arenberg
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston,Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston,Audiology Division, Massachusetts Eye and Ear, Boston
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Boo SH, Jeong SW. Cortical Auditory Evoked Potential in Adults With Cochlear Implants: A Comparison With Adults With Normal Hearing. J Audiol Otol 2021; 26:43-49. [PMID: 34719150 PMCID: PMC8755439 DOI: 10.7874/jao.2021.00339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives To examine the maturational status of the auditory cortex in adults with cochlear implants (CIs) using the latencies of the P1, N1, and P2 components of cortical auditory-evoked potentials (CAEPs). Subjects and Methods A total of 25 adults with CIs and 25 age-matched, normal-hearing control subjects participated in this study. Specifically, patients with CIs were divided into three groups depending on their age of deafness onset: Group A comprised patients with prelingual deafness who had received CI during early childhood (n=7), Group B comprised patients with early childhood-onset, progressive deafness who had received CI during childhood (n=6), and Group C comprised patients with adult-onset deafness (n=12). The P1, N1, and P2 latencies of their CAEPs were then compared between CI patients and normal-hearing subjects. Results All participants showed clear CAEP responses. P1 and N1 latencies in Group A and Group C patients were significantly longer than those in the control group. Meanwhile, Group B patients had significantly longer N1 and P2 latencies, as compared with those in the control group. Conclusions Patients with prelingual deafness and those with early-childhood onset, progressive deafness who received CI developed primary and higher-order auditory areas postoperatively when they became adults. However, their auditory cortex maturational statuses seemed to be worse than that of normal-hearing individuals. Furthermore, adult patients with late-onset deafness might experience degenerative auditory cortex changes during the auditory deprivation period between deafness onset and cochlear implantation.
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Affiliation(s)
- Seong-Hyun Boo
- Department of Otolaryngology-Head and Neck Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Sung Wook Jeong
- Department of Otolaryngology-Head and Neck Surgery, Dong-A University College of Medicine, Busan, Korea
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Bilateral Cochlear Implants or Bimodal Hearing for Children with Bilateral Sensorineural Hearing Loss. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021; 8:385-394. [PMID: 33815965 DOI: 10.1007/s40136-020-00314-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose of review This review describes speech perception and language outcomes for children using bimodal hearing (cochlear implant (CI) plus contralateral hearing aid) as compared to children with bilateral CIs and contrasts said findings with the adult literature. There is a lack of clinical evidence driving recommendations for bimodal versus bilateral CI candidacy and as such, clinicians are often unsure about when to recommend a second CI for children with residual acoustic hearing. Thus the goal of this review is to identify scientific information that may influence clinical decision making for pediatric CI candidates with residual acoustic hearing. Recent findings Bilateral CIs are considered standard of care for children with bilateral severe-to-profound sensorineural hearing loss. For children with aidable acoustic hearing-even in just the low frequencies-an early period of bimodal stimulation has been associated with significantly better speech perception, vocabulary, and language development. HA audibility, however, is generally poorer than that offered by a CI resulting in interaural asymmetry in speech perception, head shadow, as well as brainstem and cortical activity and development. Thus there is a need to optimize "two-eared" hearing while maximizing a child's potential with respect to hearing, speech, and language while ensuring that we limit asymmetrically driven auditory neuroplasticity. A recent large study of bimodal and bilateral CI users suggested that a period of bimodal stimulation was only beneficial for children with a better-ear pure tone average (PTA) ≤ 73 dB HL. This 73-dB-HL cutoff applied even to children who ultimately received bilateral CIs. Summary Though we do not yet have definitive guidelines for determining bimodal versus bilateral CI candidacy, there is increasing evidence that 1) bilateral CIs yield superior outcomes for children with bilateral severe-to-profound hearing loss and, 2) an early period of bimodal stimulation is beneficial for speech perception and language development, but only for children with better-ear PTA ≤ 73 dB HL. For children with residual acoustic hearing, even in just the low-frequency range, rapid sequential bilateral cochlear implantation following a trial period with bimodal stimulation will yield best outcomes for auditory, language, and academic development. Of course, there is also an increasing prevalence of cochlear implantation with acoustic hearing preservation allowing for combined electric and acoustic stimulation even following bilateral implantation.
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Lee Y, Sim H. Bilateral cochlear implantation versus unilateral cochlear implantation in deaf children: Effects of sentence context and listening conditions on recognition of spoken words in sentences. Int J Pediatr Otorhinolaryngol 2020; 137:110237. [PMID: 32658807 DOI: 10.1016/j.ijporl.2020.110237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/13/2020] [Accepted: 06/28/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Previous studies have investigated the efficacy of bilateral cochlear implants (CIs) in deaf children. The current study focused on the use of sentence-context information in different listening conditions to better explain the benefits of bilateral cochlear implantation. We compared the word recognition abilities of children with bilateral CIs and children with unilateral CIs in relation to sentence context and listening conditions. Additionally, we investigated whether sentence context- and listening condition-dependent word recognition scores can differentiate children with bilateral CIs from children with unilateral CIs. METHODS Twenty children with bilateral CIs and 20 children with unilateral CIs participated in this study. All children were presented with semantically controlled sentences (high vs. low predictability) in quiet and noisy conditions and were asked to repeat the final words of each sentence. RESULTS Children with bilateral CIs had significantly higher word recognition scores than children with unilateral CIs on words embedded in both high- and low-predictability sentences in noisy conditions. The two groups recognized more words in high-predictability sentences than in low-predictability sentences in noisy conditions. The scores on the high-predictability sentences in noisy conditions significantly differentiated children with bilateral CIs from children with unilateral CIs. CONCLUSION Bilateral cochlear implantation is more advantageous than unilateral cochlear implantation at the auditory-linguistic processing level in complex listening conditions.
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Affiliation(s)
- Youngmee Lee
- Department of Communication Disorders, Ewha Womans University, Seoul, Republic of Korea
| | - Hyunsub Sim
- Department of Communication Disorders, Ewha Womans University, Seoul, Republic of Korea.
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Zhang Z, Wei C, Zhang Y, Zeng Z, Cao K, Liu Y. Sequential Bilateral Cochlear Implantation With Prolonged Time Intervals. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2020; 63:3195-3207. [PMID: 32857631 DOI: 10.1044/2020_jslhr-20-00140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose The aim of the study was to assess whether sequential cochlear implantation (CI) with a prolonged interimplant interval (M = 15.2 years) between the first and second CIs benefited speech recognition and health-related quality of life. Method This prospective study included 14 prelingually deafened participants who received their second CI after a prolonged interimplant interval (M = 15.2 years). Additionally, speech recognition ability over a 12-month period of bilateral implant use was investigated. The results of the speech recognition test in both quiet and noisy conditions were statistically analyzed for each CI alone and both CIs together. Nijmegen Cochlear Implant Questionnaire scores were also collected at activation and at 12 months after activation. Results Improvements in speech recognition ability were observed following the use of the first implant alone and with the use of both implants together; however, progress was much slower with the use of the second implant alone, following its introduction. Furthermore, a significant difference in the trajectory of speech recognition ability was observed between the first and the second implanted ear. According to Nijmegen Cochlear Implant Questionnaire scores, all participants benefitted from bilateral CI after 12 months. Conclusions Prolonged interimplant intervals resulted in asymmetrical speech recognition abilities. A significant improvement in the speech recognition scores was observed with the first implanted ear, and much slower progress was observed with the second implanted ear. However, the "poorer" second implanted ear could provide a considerable beneficial effect on the improved speech recognition and health-related quality of life with the bilateral CI. Supplemental Material https://doi.org/10.23641/asha.12861152.
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Affiliation(s)
- Zhikai Zhang
- Department of Otolaryngology, Head and Neck Surgery, Peking University First Hospital, Beijing, China
| | - Chaogang Wei
- Department of Otolaryngology, Head and Neck Surgery, Peking University First Hospital, Beijing, China
| | - Yanmei Zhang
- Department of Otolaryngology, Head and Neck Surgery, Peking University First Hospital, Beijing, China
| | - Zhengang Zeng
- Department of Otolaryngology, Head and Neck Surgery, Peking University First Hospital, Beijing, China
| | - Keli Cao
- Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Peking Union Medical College, Beijing, China
| | - Yuhe Liu
- Department of Otolaryngology, Head and Neck Surgery, Peking University First Hospital, Beijing, China
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The Effect of Cochlear Implant Interval on Spoken Language Skills of Pediatric Bilateral Cochlear Implant Users. Otol Neurotol 2020; 40:e600-e605. [PMID: 31135675 DOI: 10.1097/mao.0000000000002245] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the effects of cochlear implant (CI) interval (time between CI surgeries) on receptive vocabulary and receptive language skills for children with bilateral CIs. STUDY DESIGN A prospective cross-sectional study design. SETTING Participants were recruited from, and tested at, oral schools for the deaf and pediatric audiology clinics across the United States. PATIENTS Eighty-eight children, 4 to 9 years of age, with bilateral CIs and known hearing histories. Twenty-three participants received CIs simultaneously and 65 received CIs sequentially. Of those implanted sequentially, 86% wore a hearing aid (HA) on the non-implanted ear during the CI interval. INTERVENTION Bilateral cochlear implantation. MAIN OUTCOME MEASURES Receptive vocabulary was measured via the Peabody Picture Vocabulary Test (PPVT). Receptive language skills were measured via the Clinical Evaluation of Language Fundamentals (CELF). RESULTS Multiple linear regression models indicate better receptive vocabulary and receptive language skills are associated with earlier ages at first CI (CI 1), but not with shorter CI intervals. CONCLUSIONS Early cochlear implantation (i.e., age at CI 1) is critical for better receptive vocabulary and receptive language skills. Shorter CI intervals are not associated with better receptive vocabulary and receptive language skills for these 88 children, who nearly all used bimodal hearing during the interval. Use of a HA at the non-implanted ear, before receipt of a second CI (CI 2), may mitigate the effects of early bilateral auditory deprivation.
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Jang J, Roh JM, Choo O, Kim YJ, Kim H, Park H, Choung YH. Critical Factors for Binaural Hearing in Children with Bilateral Sequential Cochlear Implantation: First Implant Performance and Inter-Implant Interval. Audiol Neurootol 2019; 24:174-182. [DOI: 10.1159/000500700] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/30/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives: This study evaluated the influence of the performance of the first cochlear implant (CI-1) on the second implant (CI-2) and the significance of inter-implant intervals in children with sequential cochlear implantation. Method: Thirty-four patients were included for speech perception outcome and 38 patients were included for subjective hearing satisfaction in daily life in this study. The patients were classified into 3 groups according to inter-implant interval: group I, <4 years; group II, 4–7 years; group III, >7 years. Open-set speech perception scores before and at 3, 6, 12, and 24 months after the second implantation was compared among the CI-1, CI-2, and bilateral CI conditions. Subjective hearing benefits in daily life were measured using a questionnaire of Speech, Spatial, and Qualities of Hearing Scale (SSQ) for parents of children with impaired hearing, and device use and preference were evaluated (by phone interview.) Results: The speech perception of children using the CI-2 only improved quickly within 3 months postoperatively and were similar to those using the CI-1 only. The results of monosyllabic and disyllabic word tests using CI-2 at 3 months after second implantation were not significantly different from those in patients using the CI-1 only. In the sentence test, the scores using the CI-2 only were not significantly different from those using the first implant only at 6 months after second implantation. SSQ scores were similar among groups and the worst score in each section was shown from the questions about performance under noisy conditions in each section. Device usage habits showed that 17 (44.7%) and 16 (42.1%) patients preferred bilateral and the CI-1, respectively. Only 5 (13.2%) patients wanted the CI-2 rather than the CI-1. While group I and II showed a prominent positive attitude to bilateral use, group III, for which the inter-implant interval was 7 years or more, showed a definite preference for the CI-1 (p < 0.01). Conclusions: Functional binaural benefits were achieved in patients who were good performers with the CI-1 after the second implantation irrespective of the inter-implant interval. Sequential CI should be strongly recommended for patients with unilateral CI showing a good performance.
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Speech Perception Growth Patterns in Prelingual Deaf Children With Bilateral Sequential Cochlear Implantation. Otol Neurotol 2019; 40:e761-e768. [PMID: 31318784 DOI: 10.1097/mao.0000000000002303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate speech perception following the first (CI-1) and second (CI-2) cochlear implantation (CI) in children with sequential bilateral CI. STUDY DESIGN Retrospective. PATIENTS Seventy children with follow-up for 60 months post CI-1 and 36 months post CI-2. MAIN OUTCOME MEASURES Word recognition score (WRS) was the main outcome. WRSs were compared by age at CI operation (group A ≤ 3.5 yr, B 3.6-8.6, for CI-1; group I ≤ 3.5 yr, II 3.6-7.0, III 7.1-13, IV > 13, for CI-2). RESULTS For CI-1, the WRS of group A exceeded 80% at 24 months post procedure, earlier than group B (54 mo). Group A also had a shorter period of CI-1 use up to the WRS plateau than group B. CI-2 showed an initial burst of WRS growth much earlier than CI-1. This initial burst was most robust within 3 months in group II, but modest in group IV. The periods of CI-2 use (11-17 mo) up to the WRS plateau were much shorter than CI-1 (40-64 mo). Group I did not show the best WRS at 1 month post CI but later exceeded the other groups. CONCLUSION Children received an immediate benefit by a burst of WRS growth from CI-2 earlier than CI-1, even within 3 months, suggesting that CI-1 gets the auditory cortex ready to foster speech processing from CI-2. The CI-2 performance depends on age at CI-2 implantation and on CI-1 performance. Our current findings will be relevant for clinicians who are counselling parents on CI-2 surgery.
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Hess CL, Misurelli SM, Litovsky RY. Spatial Release From Masking in 2-Year-Olds With Normal Hearing and With Bilateral Cochlear Implants. Trends Hear 2019; 22:2331216518775567. [PMID: 29761735 PMCID: PMC5956632 DOI: 10.1177/2331216518775567] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This study evaluated spatial release from masking (SRM) in 2- to 3-year-old children who are deaf and were implanted with bilateral cochlear implants (BiCIs), and in age-matched normal-hearing (NH) toddlers. Here, we examined whether early activation of bilateral hearing has the potential to promote SRM that is similar to age-matched NH children. Listeners were 13 NH toddlers and 13 toddlers with BiCIs, ages 27 to 36 months. Speech reception thresholds (SRTs) were measured for target speech in front (0°) and for competitors that were either Colocated in front (0°) or Separated toward the right (+90°). SRM was computed as the difference between SRTs in the front versus in the asymmetrical condition. Results show that SRTs were higher in the BiCI than NH group in all conditions. Both groups had higher SRTs in the Colocated and Separated conditions compared with Quiet, indicating masking. SRM was significant only in the NH group. In the BiCI group, the group effect of SRM was not significant, likely limited by the small sample size; however, all but two children had SRM values within the NH range. This work shows that to some extent, the ability to use spatial cues for source segregation develops by age 2 to 3 in NH children and is attainable in most of the children in the BiCI group. There is potential for the paradigm used here to be used in clinical settings to evaluate outcomes of bilateral hearing in very young children.
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Lee Y, Sim HS. The Effects of Listening Conditions on Sentence Judgement and Listening Effort in School-Aged Children with Bilateral Cochlear Implants in a Dual-Task Paradigm. ACTA ACUST UNITED AC 2018. [DOI: 10.12963/csd.18534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Polonenko MJ, Papsin BC, Gordon KA. Limiting asymmetric hearing improves benefits of bilateral hearing in children using cochlear implants. Sci Rep 2018; 8:13201. [PMID: 30181590 PMCID: PMC6123397 DOI: 10.1038/s41598-018-31546-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/17/2018] [Indexed: 11/08/2022] Open
Abstract
Neurodevelopmental changes occur with asymmetric hearing loss, limiting binaural/spatial hearing and putting children at risk for social and educational challenges. These deficits may be mitigated by providing bilateral hearing in children through auditory prostheses. Effects on speech perception and spatial hearing were measured in a large cohort of >450 children who were deaf and used bilateral cochlear implants or bimodal devices (one cochlear implant and a contralateral hearing aid). Results revealed an advantage of bilateral over unilateral device use but this advantage decreased as hearing in the two ears became increasingly asymmetric. Delayed implantation of an ear with severe to profound deafness allowed asymmetric hearing, creating aural preference for the better hearing ear. These findings indicate that bilateral input with the most appropriate device for each ear should be provided early and without delay during development.
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Affiliation(s)
- Melissa Jane Polonenko
- Institute of Medical Science, The University of Toronto, Toronto, ON, M5S 1A8, Canada.
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada.
| | - Blake Croll Papsin
- Institute of Medical Science, The University of Toronto, Toronto, ON, M5S 1A8, Canada
- Department of Otolaryngology - Head & Neck Surgery, The University of Toronto, Toronto, ON, M5G 2N2, Canada
- Otolaryngology - Head & Neck Surgery, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Karen Ann Gordon
- Institute of Medical Science, The University of Toronto, Toronto, ON, M5S 1A8, Canada
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
- Department of Otolaryngology - Head & Neck Surgery, The University of Toronto, Toronto, ON, M5G 2N2, Canada
- Otolaryngology - Head & Neck Surgery, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
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Jeong SW, Chung SH, Kim LS. P1 cortical auditory evoked potential in children with unilateral or bilateral cochlear implants; implication for the timing of second cochlear implantation. Eur Arch Otorhinolaryngol 2018; 275:1759-1765. [PMID: 29855691 DOI: 10.1007/s00405-018-5021-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/26/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine maturation of the central auditory pathway, using P1 cortical auditory evoked potential (CAEP), in children who had received unilateral or bilateral cochlear implantation (CI). STUDY DESIGN Prospective study. SETTING Tertiary referral hospital. METHODS Twenty children who had received CI due to congenital, or prelingual, deafness participated in the study. Participants had received the 1st implant at a mean age of 3.4 ± 0.7 years; 16 had also received a 2nd CI for the contralateral ear, at a mean age of 11.1 ± 2.1 years. P1 CAEP was recorded while using the 1st implant and, for those who received contralateral CI, within 2 weeks of switching on the 2nd implant. Relations between P1 latency and duration with the 1st implant, and between age at 1st CI and P1 latency, were investigated. Relations between P1 latency with the 1st and 2nd implants, and between the interstage interval and difference between P1 latencies with the 1st and 2nd implants, were also examined. RESULTS P1 CAEP with the 1st implant was present in 16 of the 20 children. Mean P1 latency was shorter in the early CI group compared with the late CI group, but this difference was not statistically significant (p = 0.154). There was a significant negative correlation between the duration with the 1st implant and P1 latency (r = - 0.783, p < 0.001). Among the 16 children with sequential bilateral CI, P1 CAEP with the 2nd implant was present in 10. There was a significant negative correlation between the duration with the 1st implant before receiving the 2nd implant and P1 latency with the 2nd implant (r = - 0.710, p = 0.021); there was also a significant positive correlation between P1 latency with the 1st and 2nd implants (r = 0.722, p = 0.018). There was not a significant correlation between interstage interval and the difference between the two P1 latencies (r = - 0.430, p = 0.248). CONCLUSION Longer cochlear implant use is associated with shorter P1 latency. Unilateral hearing with the 1st implant may positively affect P1 latency with the 2nd CI ear. These findings imply that increased auditory experience may influence central auditory pathway maturation and that the degree of central auditory pathway maturation before the 2nd CI, rather than the timing when the surgery is received, may influence 2nd CI outcome in children with sequential bilateral cochlear implants.
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Affiliation(s)
- Sung Wook Jeong
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Dong-A University, 3-1 Dongdaeshin-dong, Seo-gu, Busan, 602-715, South Korea
| | - Seung Hyun Chung
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Dong-A University, 3-1 Dongdaeshin-dong, Seo-gu, Busan, 602-715, South Korea
| | - Lee-Suk Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Dong-A University, 3-1 Dongdaeshin-dong, Seo-gu, Busan, 602-715, South Korea.
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Audiological Outcomes and Map Characteristics in Children With Perimodiolar and Slim Straight Array Cochlear Implants in Opposite Ears. Otol Neurotol 2017; 38:e320-e326. [DOI: 10.1097/mao.0000000000001539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Reeder RM, Firszt JB, Cadieux JH, Strube MJ. A Longitudinal Study in Children With Sequential Bilateral Cochlear Implants: Time Course for the Second Implanted Ear and Bilateral Performance. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2017; 60:276-287. [PMID: 28060992 PMCID: PMC5533558 DOI: 10.1044/2016_jslhr-h-16-0175] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/21/2016] [Accepted: 08/04/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE Whether, and if so when, a second-ear cochlear implant should be provided to older, unilaterally implanted children is an ongoing clinical question. This study evaluated rate of speech recognition progress for the second implanted ear and with bilateral cochlear implants in older sequentially implanted children and evaluated localization abilities. METHOD A prospective longitudinal study included 24 bilaterally implanted children (mean ear surgeries at 5.11 and 14.25 years). Test intervals were every 3-6 months through 24 months postbilateral. Test conditions were each ear and bilaterally for speech recognition and localization. RESULTS Overall, the rate of progress for the second implanted ear was gradual. Improvements in quiet continued through the second year of bilateral use. Improvements in noise were more modest and leveled off during the second year. On all measures, results from the second ear were poorer than the first. Bilateral scores were better than either ear alone for all measures except sentences in quiet and localization. CONCLUSIONS Older sequentially implanted children with several years between surgeries may obtain speech understanding in the second implanted ear; however, performance may be limited and rate of progress gradual. Continued contralateral ear hearing aid use and reduced time between surgeries may enhance outcomes.
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Cullington HE, Bele D, Brinton JC, Cooper S, Daft M, Harding J, Hatton N, Humphries J, Lutman ME, Maddocks J, Maggs J, Millward K, O'Donoghue G, Patel S, Rajput K, Salmon V, Sear T, Speers A, Wheeler A, Wilson K. United Kingdom national paediatric bilateral project: Demographics and results of localization and speech perception testing. Cochlear Implants Int 2016; 18:2-22. [PMID: 28010679 DOI: 10.1080/14670100.2016.1265055] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To assess longitudinal outcomes in a large and varied population of children receiving bilateral cochlear implants both simultaneously and sequentially. METHODS This observational non-randomized service evaluation collected localization and speech recognition in noise data from simultaneously and sequentially implanted children at four time points: before bilateral cochlear implants or before the sequential implant, 1 year, 2 years, and 3 years after bilateral implants. No inclusion criteria were applied, so children with additional difficulties, cochleovestibular anomalies, varying educational placements, 23 different home languages, a full range of outcomes and varying device use were included. RESULTS 1001 children were included: 465 implanted simultaneously and 536 sequentially, representing just over 50% of children receiving bilateral implants in the UK in this period. In simultaneously implanted children the median age at implant was 2.1 years; 7% were implanted at less than 1 year of age. In sequentially implanted children the interval between implants ranged from 0.1 to 14.5 years. Children with simultaneous bilateral implants localized better than those with one implant. On average children receiving a second (sequential) cochlear implant showed improvement in localization and listening in background noise after 1 year of bilateral listening. The interval between sequential implants had no effect on localization improvement although a smaller interval gave more improvement in speech recognition in noise. Children with sequential implants on average were able to use their second device to obtain spatial release from masking after 2 years of bilateral listening. Although ranges were large, bilateral cochlear implants on average offered an improvement in localization and speech perception in noise over unilateral implants. CONCLUSION These data represent the diverse population of children with bilateral cochlear implants in the UK from 2010 to 2012. Predictions of outcomes for individual patients are not possible from these data. However, there are no indications to preclude children with long inter-implant interval having the chance of a second cochlear implant.
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Affiliation(s)
- H E Cullington
- a University of Southampton Auditory Implant Service , Highfield , Southampton SO17 1BJ , UK
| | - D Bele
- a University of Southampton Auditory Implant Service , Highfield , Southampton SO17 1BJ , UK
| | - J C Brinton
- a University of Southampton Auditory Implant Service , Highfield , Southampton SO17 1BJ , UK
| | - S Cooper
- b St. Thomas' Hospital Hearing Implant Centre , London , UK
| | - M Daft
- c Nottingham Auditory Implant Programme , Nottingham , UK
| | - J Harding
- d Cardiff Paediatric Cochlear Implant Programme , London , UK
| | - N Hatton
- e Emmeline Centre , Cambridge , UK
| | - J Humphries
- f The Oxford Cochlear Implant Programme , London , UK
| | - M E Lutman
- g Hearing and Balance Centre , University of Southampton , Southampton , UK
| | - J Maddocks
- h West of England Paediatric Hearing Implant Programme , Bristol , UK
| | - J Maggs
- i The Midlands Children's Hearing Implant Programme , Birmingham , UK
| | - K Millward
- j The Richard Ramsden Centre for Hearing Implants , Manchester , UK
| | - G O'Donoghue
- c Nottingham Auditory Implant Programme , Nottingham , UK
| | - S Patel
- k St George's Hospital Auditory Implant Service , London , UK
| | - K Rajput
- l Great Ormond Street Cochlear Implant Programme , London , UK
| | - V Salmon
- m North East Cochlear Implant Programme , Middlesbrough , UK
| | - T Sear
- n Royal National Throat Nose and Ear Cochlear Implant Programme , London , UK
| | - A Speers
- o Belfast Regional Cochlear Implant Centre , Belfast , UK
| | - A Wheeler
- n Royal National Throat Nose and Ear Cochlear Implant Programme , London , UK
| | - K Wilson
- b St. Thomas' Hospital Hearing Implant Centre , London , UK
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Cysneiros HRS, Leal MDC, Lucena JA, Muniz LF. Relationship between auditory perception and vocal production in cochlear implantees: a systematic review. Codas 2016; 28:634-639. [PMID: 27849241 DOI: 10.1590/2317-1782/20162015165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/06/2015] [Indexed: 11/22/2022] Open
Abstract
Purpose To conduct a systematic review of the scientific literature studying the relationship between vocal production and auditory perception in cochlear implant users. Research strategies This is an integrative systematic review. The plattforms/databases Bireme, SciELO, Cochrane, Scopus and Web of Science were consulted and the descriptors used were voice, cochlear implant and auditory perception. Selection criteria Original papers published in English, French, Spanish or Portuguese involving the study of vocal production and auditory perception in cochlear implant users were selected and there was no restriction about year of publication of the articles. Data analysis The studies selected were analyzed according to the author, location, year and publication of the article, as well as for their sample size, type of vocal production and auditory perception assessment and for its major findings and recommendation grade/level of scientific evidence. Results The results suggest the existence of positive relationship between vocal production and auditory perception in cochlear implant users, and indicate that the deployment time has a positive influence in this relationship. Conclusion None of the selected studies were rated at level 1 of scientific evidence or grade A of recommendation, which is related to the methodological approach that can go with this subject matter. There is great lack of publications relating auditory perception and speech production in cochlear implant users. This gap is even greater when it comes to the adult population.
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Simultaneous bilateral cochlear implantation in a five-month-old child with Usher syndrome. The Journal of Laryngology & Otology 2015; 129:919-22. [PMID: 26177750 DOI: 10.1017/s0022215115001760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To report a rare case of simultaneous bilateral cochlear implantation in a five-month-old child with Usher syndrome. METHOD Case report. RESULTS A five-month-old boy with Usher syndrome and congenital profound bilateral deafness underwent simultaneous bilateral cochlear implantation. The decision to perform implantation in such a young child was based on his having a supportive family and the desire to foster his audiological development before his vision deteriorated. The subject experienced easily resolvable intra- and post-operative adverse events, and was first fitted with an externally worn audio processor four weeks after implantation. At 14 months of age, his audiological development was age-appropriate. CONCLUSION Simultaneous bilateral cochlear implantation is possible, and even advisable, in children as young as five months old when performed by an experienced implantation team.
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Friedmann DR, Green J, Fang Y, Ensor K, Roland JT, Waltzman SB. Sequential bilateral cochlear implantation in the adolescent population. Laryngoscope 2015; 125:1952-8. [PMID: 25946482 DOI: 10.1002/lary.25293] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To examine the variables affecting outcomes for sequential bilateral cochlear implantation patients in the adolescent population. STUDY DESIGN Retrospective chart review at tertiary care center. METHODS Main outcome measures were open set speech recognition tests at the word (Consonant-Nucleus-Consonant/Phonetically Balanced Kindergarten List Test [CNC/PBK]) and sentence levels in noise (Hearing in Noise Test-Noise [HINT-N]) in different test conditions with respect to the age at first and sequential implantation, as well as the interval between implants. RESULTS Despite a mean age at sequential implantation of 13.5 years, sequential bilateral implanted adolescents revealed significant improvement in the sequential cochlear implant (CI2) ear. The mean time interval between implants was 8.2 years. A wide range of performance was noted, and age at implantation and interval between first cochlear implant (CI1) and CI2 did not predict outcome. Mean CNC/PBK score with CI1 alone was 83.0%, with the CI2 alone was 56.5%, and with bilateral implants was 86.8%. Sentence scores (HINT-N) were 89.5% for CI1, 74.2% for CI2, and 94.4% for bilateral CI condition. The clinical relevance of these enhanced perception abilities requires attention to individual device use, performance with the first implant, and subjective benefits reported by patients. CONCLUSIONS Bilateral sequential cochlear implantation leads to improved speech perception in the adolescent population and should be considered in this population, even after a long period of deafness and despite a prolonged interval between implants. Numerous factors affect the ability to predict performance, but age at implantation and interimplant interval were not correlated with performance measures. Extensive preoperative counseling and individualized evaluation are critical to ensure that patients and families understand the range of possible outcomes. LEVEL OF EVIDENCE 4
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Affiliation(s)
- David R Friedmann
- Department of Otolaryngology-Head & Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Janet Green
- Department of Otolaryngology-Head & Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Yixin Fang
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, New York, U.S.A
| | - Kelsey Ensor
- Department of Otolaryngology-Head & Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - J Thomas Roland
- Department of Otolaryngology-Head & Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Susan B Waltzman
- Department of Otolaryngology-Head & Neck Surgery, New York University School of Medicine, New York, New York, U.S.A
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Killan CF, Killan EC, Raine CH. Changes in children's speech discrimination and spatial release from masking between 2 and 4 years after sequential cochlear implantation. Cochlear Implants Int 2015; 16:270-6. [PMID: 25655134 DOI: 10.1179/1754762815y.0000000001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To document changes in speech reception thresholds (SRTs) and spatial release from masking (SRM) for sequentially implanted children at 2 and 4 years after they received their second cochlear implant (CI2). METHODS Participants were 17 children who consistently used two sequentially implanted and optimally programmed CIs. SRTs were measured monaurally in quiet and binaurally in noise using the adaptive McCormick toy discrimination test. Speech signals were presented from 0° azimuth and noise from 0°, +90° or -90° azimuth. SRM was calculated from SRTs in noise. Measurements were made at 2 and 4 year post-CI2. RESULTS There were significant improvements over time in SRTs in quiet, SRTs in noise and SRM. SRTs in quiet improved more for CI2 than for the first implant (CI1). SRTs in noise and SRM improved more when noise was presented closest to CI1 than when closest to CI2. Performance became more symmetrical over time. DISCUSSION Despite prolonged periods of unilateral auditory deprivation sequentially implanted children exhibited continued improvement in SRT and SRM. These results are valuable in setting expectations for and counselling families of children considering sequential CIs.
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Cochlear re-implant rates in children: 20 years experience in a quaternary paediatric cochlear implant centre. Eur Arch Otorhinolaryngol 2014; 272:2667-72. [PMID: 25106546 DOI: 10.1007/s00405-014-3206-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/18/2014] [Indexed: 10/24/2022]
Abstract
The aim of this study is to determine the incidence and causes for cochlear explantation/re-implantation in children as a retrospective case review in a Quaternary paediatric Cochlear Implant (CI) Centre. The subjects included in the study were Paediatric CI patients requiring cochlear explantation/re-implantation. Outcome measurements were incidence and aetiology of device explantation/re-implantation. Patient age at implantation, aetiology of deafness, CI manufacturer, and timing of explantation/re P implantation were the independent variables. 778 paediatric cochlear implants were performed in 653 children between 1992 and January 2013. There were a total of 40 (5.1%) failed implants in 38 patients. The most common reason for explantation was device failure in 22 (2.8%). Risk factors for device failure were known manufacturing defect/device recall. Medical/surgical issues accounted for 18 (2.3%) implant failures. The mean time to explantation was 3 years 10 months. The incidence of explantation/re-implantation in our paediatric cochlear implant population is comparable to other published studies. The most common reason for explantation was device failure, however, the aetiology of deafness, in particular meningitis, does not appear to increase the risk of explantation as described in previous series.
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Acquisition of early auditory milestones with a cochlear implant. Int J Pediatr Otorhinolaryngol 2013; 77:1852-5. [PMID: 24063769 DOI: 10.1016/j.ijporl.2013.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Speech acquisition after cochlear implant is a long process. Various studies have followed the auditory milestones in the early period after implantation. The aim of the present study was to track the development of hearing skills in the early period after cochlear implantation and evaluate which factors influence the process. METHODS 195 records of children implanted in the Hadassah Medical Center were examined retrospectively. Data on etiology, age at implantation and type of implant were collected. In addition, information on the rate of progress was measured: the first time that there was detection and identification of Ling sounds, the first time it was possible to obtain SDT (speech detection threshold), SRT (speech reception threshold) and an audiogram, and the first accurate repetition of VCV (vowel consonant vowel) sounds. RESULTS Results show a consistent pattern of auditory milestone acquisition similar to that of normal development, from milestones that do not require decoding beginning with SDT, detection of Ling sounds followed by an audiogram which requires cooperation, to tasks that involve decoding starting with SRT and repetition of Ling sounds and finally VCV repetition. The children implanted before 24 months of age achieved the auditory milestones later than children implanted between 2 and 6 years, apparently since these tasks involve cognitive abilities which are not yet developed in the youngest children. Previous hearing experience improved the rate of acquisition of the auditory milestones and progress was faster in the second implanted ear compared to the first implanted ear. CONCLUSION More research is needed to address the relationship between acquisition of early auditory milestones and performance with the cochlear implant later on in life.
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Lammers MJW, Venekamp RP, Grolman W, van der Heijden GJMG. Bilateral cochlear implantation in children and the impact of the inter-implant interval. Laryngoscope 2013; 124:993-9. [DOI: 10.1002/lary.24395] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/18/2013] [Accepted: 08/19/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Marc J. W. Lammers
- Department of Otorhinolaryngology-Head and Neck Surgery; University Medical Center Utrecht; The Netherlands
- Brain Center Rudolf Magnus; University Medical Center Utrecht; The Netherlands
| | - Roderick P. Venekamp
- Department of Otorhinolaryngology-Head and Neck Surgery; University Medical Center Utrecht; The Netherlands
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; The Netherlands
| | - Wilko Grolman
- Department of Otorhinolaryngology-Head and Neck Surgery; University Medical Center Utrecht; The Netherlands
- Brain Center Rudolf Magnus; University Medical Center Utrecht; The Netherlands
| | - Geert J. M. G. van der Heijden
- Department of Otorhinolaryngology-Head and Neck Surgery; University Medical Center Utrecht; The Netherlands
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; The Netherlands
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