Audiologists' preferences in programming cochlear implants: A preliminary report

Experienced Adult Cochlear Implant Users Show Improved Speech Recognition When Target Fitting Parameters Are Applied

OBJECTIVES

The aim of the present study was to investigate whether prediction models built by de Graaff et al. (2020) can be used to improve speech recognition in experienced adult postlingual implanted Cochlear CI users. de Graaff et al. (2020) found relationships between elevated aided thresholds and a not optimal electrical dynamic range (<50 CL or >60 CL), and poorer speech recognition in quiet and in noise. The primary hypothesis of the present study was that speech recognition improves both in quiet and in noise when the sound processor is refitted to match targets derived from the prediction models from de Graaff et al. (2020). A second hypothesis was that subjectively, most of the CI users would find the new setting too loud because of an increase in C levels, and therefore, prefer the old settings.

DESIGN

A within-participant repeated measures design with 18 adult Cochlear CI users was used. T- and C-levels were changed to "optimized settings," as predicted by the model of de Graaff et al. (2020). Aided thresholds, speech recognition in quiet, and speech recognition in noise were measured with the old settings and after a 4-week acclimatization period with the optimized settings. Subjective benefit was measured using the Device Oriented Subjective Outcome Scale questionnaire.

RESULTS

The mean electrical dynamic range changed from 41.1 (SD = 6.6) CL to 48.6 (SD = 3.0) CL. No significant change in aided thresholds was measured. Speech recognition improved for 16 out of 18 participants and remained stable for 2 participants. Average speech recognition scores in quiet significantly improved by 4.9% (SD = 3.8%). No significant change for speech recognition in noise was found. A significant improvement in subjective benefit was found for one of the Device Oriented Subjective Outcome subscales (speech cues) between the old and optimized settings. All participants chose to keep the optimized settings at the end of the study.

CONCLUSIONS

We were able to improve speech recognition in quiet by optimizing the electrical dynamic range of experienced adult CI users, according to the prediction models built by de Graaff et al. (2020). There was no significant change in aided thresholds nor in speech recognition in noise. The findings of the present study suggest that improved performance for speech recognition in quiet in adult Cochlear CI users can be achieved by setting the dynamic range as close as possible to values between 50 and 60 CL when the volume level is at 10.

Development of Custom Sound® Pro software utilising big data and its clinical evaluation

OBJECTIVES

To inform and optimise a cochlear implant (CI) fitting software design through an analysis of big data to define array-specific comfort (C) level profiles, frequently-used MAP parameters, and the minimum number of Neural Response Telemetry thresholds (tNRT) needed to create an accurate profile. To evaluate the software's ease of use and completion time for AutoNRT®s.

DESIGN

MAPs analysis. Clinical study evaluating software use in creating MAPs, addressing sound-quality issues and setting patient goals.

STUDY SAMPLE

MAPs (N = 39,885); CI recipients (N = 47) and clinicians (N = 19).

RESULTS

Distinct C-level profiles were observed for lateral-wall, contour, and slim-modiolar electrode arrays. Default settings were used for most MAP parameters (13/16) except for Pulse Width, Rate, and Maxima. Nine tNRT measurements were required for an accurate C-level profile. Measurement-time of nine tNRTs via the new algorithm was comparable to five tNRTs using the previous algorithm. Nearly all (99%) clinical tasks were completed by clinicians with the first use of the software. Most CI recipients (79.5%) rated goal-setting as valuable.

CONCLUSION

Custom Sound Pro fitting software developed based on big data analysis incorporates a guided fitting workflow and expected fitting ranges. It helps to improve clinical efficiency, is easy to use and supports patient-centred care.

Effects of an evidence-based model for cochlear implant aftercare delivery on clinical efficiency and patient outcomes

OBJECTIVES

To assess an evidence-based model (EBM) approach to cochlear implant (CI) aftercare that includes a modified, reduced treatment schedule for newly-implanted adult CI recipients consisting of four appointments (initial activation, 1-, 3- and 6- months postactivation) in the first year post-surgery.

METHOD

This prospective multicenter proof-of-concept study was conducted across three clinics in the United States by five experienced CI clinicians. Seventeen newly-implanted adult patients with postlingual hearing loss enrolled in the study. Hearing outcomes were measured using objective speech testing and subjective self-report measures.

RESULTS

Most recipients (14/17; 82%) were able to follow the four-appointment EBM schedule. The reduced number of visits translated into an average time savings of 3 hours per patient. Significant improvements in speech perception were observed at both 3- and 6-months postactivation, as measured by CNC words in quiet and AzBio sentences at +10 dB SNR, consistent with published results achieved by traditional practices. Recipients were significantly satisfied with telephone, music, small group conversation, and television listening at 6 months postactivation. Recipient satisfaction with overall service was rated as "excellent" by 14/14 (100%) respondents.

CONCLUSION

The four-appointment EBM approach delivered efficient and effective audiological aftercare to CI recipients in the first year following CI implantation.

Evaluation of a clinical method for selective electrode deactivation in cochlear implant programming

Background

Cochlear implants are a neural prosthesis used to restore the perception of hearing in individuals with severe-to-profound hearing loss by stimulating the auditory nerve with electrical current through a surgically implanted electrode array. The integrity of the interface between the implanted electrode array and the auditory nerve contributes to the variability in outcomes experienced by cochlear implant users. Strategies to identify and eliminate poorly encoding electrodes have been found to be effective in improving outcomes with the device, but application is limited in a clinical setting.

Objective

The purpose of this study was to evaluate a clinical method used to identify and selectively deactivate cochlear implants (CI) electrodes related to poor electrode-neural interface.

Methods

Thirteen adult CI users participated in a pitch ranking task to identify indiscriminate electrode pairs. Electrodes associated with indiscriminate pairs were selectively deactivated, creating an individualized experimental program. Speech perception was evaluated in the baseline condition and with the experimental program before and after an acclimation period. Participant preference responses were recorded at each visit.

Results

Statistically significant improvements using the experimental program were found in at least one measure of speech perception at the individual level in four out of 13 participants when tested before acclimation. Following an acclimation period, ten out of 13 participants demonstrated statistically significant improvements in at least one measure of speech perception. Statistically significant improvements were found with the experimental program at the group level for both monosyllabic words (p = 0.006) and sentences in noise (p = 0.020). Additionally, ten participants preferred the experimental program prior to the acclimation period and eleven preferred the experimental program following the acclimation period.

Conclusion

Results from this study suggest that electrode deactivation may yield improvement in speech perception following an acclimation period. A majority of CI users in our study reported a preference for the experimental program. This method proved to be a suitable clinical strategy for identifying and deactivating poorly encoding electrodes in adult CI users.

Effect of a CI Programming Fitting Tool with Artificial Intelligence in Experienced Cochlear Implant Patients

OBJECTIVE

Cochlear implants (CIs) are the treatment of choice for patients with severe to profound hearing loss. The hearing results, however, considerably vary across patients. This may partly be due to variability in the CI fitting. We investigated the effect of FOX, a software tool to program CIs using artificial intelligence (AI), on hearing outcomes.

METHODS

Forty-seven experienced CI patients who came to our tertiary CI center for their annual follow-up between 2017 and 2020 were recruited for this study. They received a new CI map created by the AI software tool. CI parameters and auditory outcomes obtained with this new map were compared with those of the initial manual map after 15 days of take-home experience. Within-patient differences were assessed. At the end of the study, the patients were offered a choice to continue using the AI map or to revert to their old manual map.

RESULTS

Several auditory outcomes improved with the AI map, namely, pure tone audiometric threshold at 6,000 Hz (median improvement 10 dB, range = -20 to 50 dB, Z = -2.608, p = 0.008), phonemic discrimination scores (median improvement 10%, range = 0% to 30%, Z = -4.061, p = 0.001), and soft-intensity (median improvement of 10%, range = -20% to 90%, Z = -4.412, p < 0.001) to normal-intensity (median improvement of 10%, range = -30% to 60%, Z = -3.35, p < 0.001) speech audiometric scores.

CONCLUSION

The AI-assisted CI mapping model as a potential assistive tool may improve audiological outcomes for experienced CI patients, including high-frequency pure tone audiometry and audiometric speech scores at low and normal presentation levels.Clinical trial registration: NCT03700268.

Prospective Comparison Between Manual and Computer-Assisted (FOX) Cochlear Implant Fitting in Newly Implanted Patients

OBJECTIVE

A prospective, longitudinal, randomized controlled trial with an original crossover design for 1 year was conducted to compare manual fitting to artificial intelligence-based fitting in newly implanted patients.

DESIGN

Twenty-four patients who received their first cochlear implant (CI) were randomly assigned to the manual or Fitting to Outcome eXpert (FOX) arm; they followed the corresponding fitting procedures for 1 year. After 1 year, each patient was switched to another arm. The number of fittings, auditory outcomes (pure-tone thresholds, loudness scaling curves, spectral discrimination scores, bisyllabic word recognition in quiet and noise, and speech tracking), fitting session questionnaire, and CI parameters (T level, C level, Threshold Sound Pressure Level (T-SPL), Comfortable Sound Pressure Level (C-SPL), and loudness growth value) were compared between the two groups. Differences between the two groups were analyzed using the Mann-Whitney test, and Holm corrections were applied for multiple statistical tests. At the end of the crossover session, patients were offered the choice to continue with their old or new map.

RESULTS

As early as 3 mo postactivation, the FOX group showed less variability and significantly better speech intelligibility in quiet conditions at 40 and 55 dB SPL and noise ( p < 0.05) with median phoneme scores of 50%, 70%, and 50% at 55, 70, and 85 dB SPL compared with 45%, 50%, and 40%, respectively. This group showed better results at 12 mo postactivation ( p < 0.05). In the manual group, 100% of the patients decided to keep the new FOX map, and 82% performed better with the FOX map. In the FOX group, 63% of the patients decided to keep the manual map, although the measurable outcome had not improved. In this group, participants reported to prefer the manual map because it felt more comfortable, even if the FOX map gave better measured outcome.

CONCLUSION

Although the study size remains relatively small, the AI-FOX approach was equivalent to or even outperformed the manual approach in hearing performance, comfort, and resources. Furthermore, FOX is a tool capable of continuous improvement by comparing its predictions with observed results and is continuously learning from clinicians' practice, which is why this technology promises major advances in the future.

Cortical auditory evoked potential in cochlear implant users: An objective method to improve speech perception

OBJECTIVE

To investigate if cortical auditory evoked potential (CAEP) measures can be used to verify the cochlear implant (CI) map and consequently improve CI outcomes in adults with bilateral hearing loss.

DESIGN

CAEPs were measured in CI recipients using the speech tokens /m/, /g/, /t/ and /s/. If CAEP responses were present for all speech tokens, the participant's map was considered "satisfactory". If CAEP responses were absent, the CI map was considered "unsatisfactory" and therefore adjusted and CAEP measures repeated. This was repeated until auditory potentials were seen in response to all four speech tokens. Speech testing was conducted pre-CI, as well as before and after CAEP-guided map adjustments.

RESULTS

108 adult unilateral CI users participated, whose sound processors were previously programmed using subjective methods. 42 CI users elicited a CAEP response to all four speech tokens and therefore no further mapping adjustments were made. 66 subjected lacked a CAEP response to at least one speech token and had their CI map adjusted accordingly. Of those, 31 showed a CAEP response to all four speech tokens, and the average speech score significantly improved after CI map adjustments based on CAEP responses.

CONCLUSION

CAEP's are an objective tool that can be used to guide and verify CI mapping in adults CI users. Significant improvement in speech scores was observed in participants who had their CI map adjusted based on CAEP responses.

Intraoperative Use of Electrical Stapedius Reflex Testing for Cochlear Nerve Monitoring During Simultaneous Translabyrinthine Resection of Vestibular Schwannoma and Cochlear Implantation

OBJECTIVE

To report the novel use of intraoperative electrically evoked stapedial reflex (eSR) for cochlear nerve monitoring during simultaneous translabyrinthine resection of vestibular schwannoma (VS) and cochlear implantation.

STUDY DESIGN

Clinical capsule report with video demonstration.

SETTING

Tertiary academic referral center.

PATIENT

A 58-year-old female presented with a small right intracanalicular VS with associated asymmetrical right moderate to severe sensorineural hearing loss, poor word recognition, tinnitus, and disequilibrium. Based on patient symptomatology and goals, simultaneous CI with translabyrinthine resection of the VS was performed.

INTERVENTION

Cochlear implantation before the tumor was resected facilitated intraoperative eSRs by delivering repeated single-electrode stimulations through the cochlear implant (CI) electrode during tumor resection. A pulse duration of 50-us and a current amplitude of 200-CL or 648-us was used to elicit eSRs visible through the facial recess. Intraoperative eSR was monitored in conjunction with electrically evoked compound action potentials via neural response telemetry and electrical auditory brainstem response.

RESULTS

Despite the transient evoked compound action potentials amplitude and electrical auditory brainstem response latency changes, the visually observed eSR was preserved and remained robust throughout tumor dissection, indicating an intact cochlear nerve. Four weeks postoperatively, the patient exhibited open-set speech capacity (14% CNC and 36% AzBio in quiet).

CONCLUSION

The current study demonstrates the feasibility of using intraoperative eSR via a CI electrode to monitor cochlear nerve integrity during VS resection, which may indicate successful CI outcomes. These preliminary findings require further substantiation in a larger study.

Decoding Billing Practices in Cochlear Implant Programs

OBJECTIVES

The purpose of this study was to examine current cochlear implant (CI) billing practices across CI audiologists in the United States, to determine if CI audiologists are following the National Correct Coding Initiative (NCCI) edits, and to assess the CI audiologist's exposure to billing education.

DESIGN

A 48-question survey was electronically distributed to and completed by audiologists who bill for CI services. Demographic data including work setting, population served, years of experience, number of CI patients managed per week, and exposure to billing education were collected. Data were analyzed to identify codes and modifiers used to bill for commonly performed CI procedures such as unilateral and bilateral CI programming, preoperative and postoperative testing, and objective measures.

RESULTS

Data were obtained from 96 audiologists. The majority (86.3%, n = 82) of respondents agreed or strongly agreed they understand billing and coding practices for cochlear implants and 94.7% (n = 89) rated themselves as somewhat to highly efficient when performing these practices. Only 16.8% (n = 16) of respondents reported receiving formal training for practice management, and half of the respondents (51.1%, n = 48) reported unfamiliarity with national billing guidelines. Those who received formal training reported higher billing efficiency. Wide variability was seen for various billing scenarios. Billing questions were presented, and answers were coded as correct or incorrect based on the NCCI edits. Respondents who reported higher agreement with understanding billing and who received formal training scored better on common billing questions related to the NCCI edits.

CONCLUSIONS

Most CI audiologists rated themselves as efficient in billing; however, wide variance in billing practices was observed. Incorporating practice management and current billing education into daily practice and into audiology training programs is essential to clinic efficiency, practice management, and CI program viability. CI audiologists should be knowledgeable about appropriate billing practices to ensure long-term sustainability of programs.

Investigation of an Outcomes-Driven, Computer-Assisted Approach to CI Fitting in Newly Implanted Patients

OBJECTIVE

To evaluate the efficacy of outcomes received by newly implanted cochlear implant recipients when an outcomes-driven, computer-assisted approach to cochlear implantation fitting was used. This approach, referred to as "Fitting to Outcome eXpert," or FOX, was developed by Otoconsult in Antwerp, Belgium.

DESIGN

Thirty-one newly implanted subjects participated in a nonrandomized, single-subject, repeated measures design that involved a within-subject comparison of preoperative and postoperative speech recognition scores. Sound processors for all subjects were programmed using the FOX software that utilized the evidence-based results of various psychoacoustic tests to adjust MAP parameters and improve performance. Additionally, mean word and sentence recognition scores obtained by the subjects programmed with FOX were compared to results obtained by newly implanted patients enrolled in the Nucleus CI532 clinical trial whose devices were programmed using traditional methods.

RESULTS

Subjects whose sound processors were programmed using FOX obtained a mean 6-month postactivation Consonant Nucleus Consonant word score of 60.2% correct. This represented an improvement of 46% age points when mean preactivation and postactivation scores were compared and represented a statistically significant change in score (p < 0.001). This mean score is similar to the mean 6-month Consonant Nucleus Consonant Word score of 61% obtained by 96 subjects enrolled in the Nucleus CI532 trial. Additionally, subjects in this study obtained a mean 6-month postactivation AzBio Sentence score of 42.7% correct when stimuli were presented at 65 dBA using a +10 signal-to-noise ratio. This score is also similar to the mean score of 43% obtained by 96 subjects enrolled in the Nucleus CI532 trial using the same test material and signal-to-noise ratio. Patients enrolled in this study attended 43% fewer programming appointments than the number reported by cochlear implantation centers in recent surveys of clinical care.

CONCLUSION

The results of this study support the use of an outcomes-driven, computer-assisted approach to supplement the management of newly implanted cochlear implant recipients. Subjects whose devices were programmed using such an approach demonstrated mean postoperative word in quiet and sentence in noise scores comparable to those obtained by subjects in the Nucleus CI532 clinical trial whose devices were programmed using traditional programming techniques. Use of this approach positively impacted patient care by reducing the number of postoperative visits needed to optimize sound processor programs, simplified patient testing via the use of direct streaming, and ensured that patients received consistent programming of their sound processor, regardless of the location where the programming was performed.