Sensitivity to Interaural Level and Envelope Time Differences of Two Bilateral Cochlear Implant Listeners Using Clinical Sound Processors

Rate dependent neural responses of interaural-time-difference cues in fine-structure and envelope

Advancements in cochlear implants (CIs) have led to a significant increase in bilateral CI users, especially among children. Yet, most bilateral CI users do not fully achieve the intended binaural benefit due to potential limitations in signal processing and/or surgical implant positioning. One crucial auditory cue that normal hearing (NH) listeners can benefit from is the interaural time difference (ITD), i.e., the time difference between the arrival of a sound at two ears. The ITD sensitivity is thought to be heavily relying on the effective utilization of temporal fine structure (very rapid oscillations in sound). Unfortunately, most current CIs do not transmit such true fine structure. Nevertheless, bilateral CI users have demonstrated sensitivity to ITD cues delivered through envelope or interaural pulse time differences, i.e., the time gap between the pulses delivered to the two implants. However, their ITD sensitivity is significantly poorer compared to NH individuals, and it further degrades at higher CI stimulation rates, especially when the rate exceeds 300 pulse per second. The overall purpose of this research thread is to improve spatial hearing abilities in bilateral CI users. This study aims to develop electroencephalography (EEG) paradigms that can be used with clinical settings to assess and optimize the delivery of ITD cues, which are crucial for spatial hearing in everyday life. The research objective of this article was to determine the effect of CI stimulation pulse rate on the ITD sensitivity, and to characterize the rate-dependent degradation in ITD perception using EEG measures. To develop protocols for bilateral CI studies, EEG responses were obtained from NH listeners using sinusoidal-amplitude-modulated (SAM) tones and filtered clicks with changes in either fine structure ITD (ITDFS) or envelope ITD (ITDENV). Multiple EEG responses were analyzed, which included the subcortical auditory steady-state responses (ASSRs) and cortical auditory evoked potentials (CAEPs) elicited by stimuli onset, offset, and changes. Results indicated that acoustic change complex (ACC) responses elicited by ITDENV changes were significantly smaller or absent compared to those elicited by ITDFS changes. The ACC morphologies evoked by ITDFS changes were similar to onset and offset CAEPs, although the peak latencies were longest for ACC responses and shortest for offset CAEPs. The high-frequency stimuli clearly elicited subcortical ASSRs, but smaller than those evoked by lower carrier frequency SAM tones. The 40-Hz ASSRs decreased with increasing carrier frequencies. Filtered clicks elicited larger ASSRs compared to high-frequency SAM tones, with the order being 40 > 160 > 80> 320 Hz ASSR for both stimulus types. Wavelet analysis revealed a clear interaction between detectable transient CAEPs and 40-Hz ASSRs in the time-frequency domain for SAM tones with a low carrier frequency.

Preliminary Study on Speech in Noise Training in Children with Sensory Processing Disorder and Hyperacusis

Hyperacusis is the perception of certain everyday sounds as too loud or painful. Past research suggests that some individuals with Sensory Processing Disorder (SPD) may also have a comorbid hyperacusis. The aim of this preliminary study was to explore if hyperacusis symptoms in children with SPD change following Speech in noise training (SPINT). This was a retrospective cross-sectional study. Data were included for 28 children with SPD and sound intolerance (12/28 were female, mean age was 8.7 ± 1.9 years old). Patients were assessed using the Persian Buffalo Model Questionnaire-Revised version (P-BMQ-R) that measures various behavioural aspects of auditory processing disorder and word in noise test (WINT) before and after SPINT. After SPINT the subscales of DEC, TFM with its Noi, and Mem, subcategories, APD, ΣCAP, and Gen of P-BMQ-R questionnaire significantly improved (P < 0.05), however, the changes in subscales of Var, INT and ORG were not statistically significant (P > 0.05). In addition, SPINT led to better performance in WINT in both ears (P < 0.05). This preliminary study showed promising result for the effect of SPINT on improving behavioural indicators of APD (as measured via P-BMQ-R and WINT) and decreasing hyperacusis symptoms (as measured via Noi).

Pitch discrimination in electric hearing with inconsistent and consistent amplitude-modulation and inter-pulse rate cues

Users of cochlear implants (CIs) struggle in situations that require selective hearing to focus on a target source while ignoring other sources. One major reason for that is the limited access to timing cues such as temporal pitch or interaural time differences (ITDs). Various approaches to improve timing-cue sensitivity while maintaining speech understanding have been proposed, among them inserting extra pulses with short inter-pulse intervals (SIPIs) into amplitude-modulated (AM) high-rate pulse trains. Indeed, SIPI rates matching the naturally occurring AM rates improve pitch discrimination. For ITD, however, low SIPI rates are required, potentially mismatching the naturally occurring AM rates and thus creating unknown pitch effects. In this study, we investigated the perceptual contribution of AM and SIPI rate to pitch discrimination in five CI listeners and with two AM depths (0.1 and 0.5). Our results show that the SIPI-rate cue generally dominated the percept for both consistent and inconsistent cues. When tested with inconsistent cues, also the AM rate contributed, however, at the large AM depth only. These findings have implications when aiming at jointly improving temporal-pitch and ITD sensitivity in a future mixed-rate stimulation approach.

Lateralization of binaural envelope cues measured with a mobile cochlear-implant research processora)

Bilateral cochlear implant (BICI) listeners do not have full access to the binaural cues that normal hearing (NH) listeners use for spatial hearing tasks such as localization. When using their unsynchronized everyday processors, BICI listeners demonstrate sensitivity to interaural level differences (ILDs) in the envelopes of sounds, but interaural time differences (ITDs) are less reliably available. It is unclear how BICI listeners use combinations of ILDs and envelope ITDs, and how much each cue contributes to perceived sound location. The CCi-MOBILE is a bilaterally synchronized research processor with the untested potential to provide spatial cues to BICI listeners. In the present study, the CCi-MOBILE was used to measure the ability of BICI listeners to perceive lateralized sound sources when single pairs of electrodes were presented amplitude-modulated stimuli with combinations of ILDs and envelope ITDs. Young NH listeners were also tested using amplitude-modulated high-frequency tones. A cue weighting analysis with six BICI and ten NH listeners revealed that ILDs contributed more than envelope ITDs to lateralization for both groups. Moreover, envelope ITDs contributed to lateralization for NH listeners but had negligible contribution for BICI listeners. These results suggest that the CCi-MOBILE is suitable for binaural testing and developing bilateral processing strategies.

Interaural time difference sensitivity under binaural cochlear implant stimulation persists at high pulse rates up to 900 pps

Spatial hearing remains one of the major challenges for bilateral cochlear implant (biCI) users, and early deaf patients in particular are often completely insensitive to interaural time differences (ITDs) delivered through biCIs. One popular hypothesis is that this may be due to a lack of early binaural experience. However, we have recently shown that neonatally deafened rats fitted with biCIs in adulthood quickly learn to discriminate ITDs as well as their normal hearing litter mates, and perform an order of magnitude better than human biCI users. Our unique behaving biCI rat model allows us to investigate other possible limiting factors of prosthetic binaural hearing, such as the effect of stimulus pulse rate and envelope shape. Previous work has indicated that ITD sensitivity may decline substantially at the high pulse rates often used in clinical practice. We therefore measured behavioral ITD thresholds in neonatally deafened, adult implanted biCI rats to pulse trains of 50, 300, 900 and 1800 pulses per second (pps), with either rectangular or Hanning window envelopes. Our rats exhibited very high sensitivity to ITDs at pulse rates up to 900 pps for both envelope shapes, similar to those in common clinical use. However, ITD sensitivity declined to near zero at 1800 pps, for both Hanning and rectangular windowed pulse trains. Current clinical cochlear implant (CI) processors are often set to pulse rates ≥ 900 pps, but ITD sensitivity in human CI listeners has been reported to decline sharply above ~ 300 pps. Our results suggest that the relatively poor ITD sensitivity seen at > 300 pps in human CI users may not reflect the hard upper limit of biCI ITD performance in the mammalian auditory pathway. Perhaps with training or better CI strategies good binaural hearing may be achievable at pulse rates high enough to allow good sampling of speech envelopes while delivering usable ITDs.

Training Programs for Improving Speech Perception in Noise: A Review

Understanding speech in the presence of noise is difficult and challenging, even for people with normal hearing. Accurate pitch perception, coding and decoding of temporal and intensity cues, and cognitive factors are involved in speech perception in noise (SPIN); disruption in any of these can be a barrier to SPIN. Because the physiological representations of sounds can be corrected by exercises, training methods for any impairment can be used to improve speech perception. This study describes the various types of bottom-up training methods: pitch training based on fundamental frequency (F0) and harmonics; spatial, temporal, and phoneme training; and top-down training methods, such as cognitive training of functional memory. This study also discusses music training that affects both bottom-up and top-down components and speech training in noise. Given the effectiveness of all these training methods, we recommend identifying the defects underlying SPIN disorders and selecting the best training approach.

Simulation of ITD-Dependent Single-Neuron Responses Under Electrical Stimulation and with Amplitude-Modulated Acoustic Stimuli

Interaural time difference (ITD) sensitivity with cochlear implant stimulation is remarkably similar to envelope ITD sensitivity using conventional acoustic stimulation. This holds true for human perception, as well as for neural response rates recorded in the inferior colliculus of several mammalian species. We hypothesize that robust excitatory-inhibitory (EI) interaction is the dominant mechanism. Therefore, we connected the same single EI-model neuron to either a model of the normal acoustic auditory periphery or to a model of the electrically stimulated auditory nerve. The model captured most features of the experimentally obtained response properties with electric stimulation, such as the shape of rate-ITD functions, the dependence on stimulation level, and the pulse rate or modulation-frequency dependence. Rate-ITD functions with high-rate, amplitude-modulated electric stimuli were very similar to their acoustic counterparts. Responses obtained with unmodulated electric pulse trains most resembled acoustic filtered clicks. The fairly rapid decline of ITD sensitivity at rates above 300 pulses or cycles per second is correctly simulated by the 3.1-ms time constant of the inhibitory post-synaptic conductance. As the model accounts for these basic properties, it is expected to help in understanding and quantifying the binaural hearing abilities with electric stimulation when integrated in bigger simulation frameworks.

Considerations for Fitting Cochlear Implants Bimodally and to the Single-Sided Deaf

When listening with a cochlear implant through one ear and acoustically through the other, binaural benefits and spatial hearing abilities are generally poorer than in other bilaterally stimulated configurations. With the working hypothesis that binaural neurons require interaurally matched inputs, we review causes for mismatch, their perceptual consequences, and experimental methods for mismatch measurements. The focus is on the three primary interaural dimensions of latency, frequency, and level. Often, the mismatch is not constant, but rather highly stimulus-dependent. We report on mismatch compensation strategies, taking into consideration the specific needs of the respective patient groups. Practical challenges typically faced by audiologists in the proposed fitting procedure are discussed. While improvement in certain areas (e.g., speaker localization) is definitely achievable, a more comprehensive mismatch compensation is a very ambitious endeavor. Even in the hypothetical ideal fitting case, performance is not expected to exceed that of a good bilateral cochlear implant user.

Lateralization of interaural level differences in children with bilateral cochlear implants

OBJECTIVES

To investigate the perception of interaural level differences (ILDs) in children with bilateral cochlear implants (BiCIs) and compare them to normal hearing peers. As intracranial shifts in perception of ILDs might have an effect on localization, this was further investigated.

METHODS

ILD responses on four different frequency bands (broadband, low-pass, mid-pass and high-pass) were measured in 9 children with BiCIs and 15 children with normal hearing. In the children with BiCIs, 7 of them were implanted sequentially and 2 of them simultaneously. The outcomes were compared with the outcomes from a previous study on advanced localization using the same stimuli as in the current study. The effect of chronological age, inter-implant delay and preoperative residual hearing were also taken into account.

RESULTS

No significant differences in ILD responses between children with BiCIs and children with normal hearing were found. For broadband stimuli, children with sequential BiCIs showed a significant shift in their response towards the first implant. A significant correlation was found between inter-implant delay and shift in ILD response for the broadband and high-pass stimuli. The shift in ILD response had no effect on localization.

CONCLUSION

Children with BiCIs are able to perceive ILD responses similar to those of normal hearing children. The inter-implant delay has a negative effect on the lateralization of the response towards the first implant side, indicative of deprivation of high-frequency sounds prior to receiving a second implant. This shift, however, is not associated with a shift in localization response.

Reweighting of Binaural Localization Cues in Bilateral Cochlear-Implant Listeners

Normal-hearing (NH) listeners rely on two binaural cues, the interaural time (ITD) and level difference (ILD), for azimuthal sound localization. Cochlear-implant (CI) listeners, however, rely almost entirely on ILDs. One reason is that present-day clinical CI stimulation strategies do not convey salient ITD cues. But even when presenting ITDs under optimal conditions using a research interface, ITD sensitivity is lower in CI compared to NH listeners. Since it has recently been shown that NH listeners change their ITD/ILD weighting when only one of the cues is consistent with visual information, such reweighting might add to CI listeners’ low perceptual contribution of ITDs, given their daily exposure to reliable ILDs but unreliable ITDs. Six bilateral CI listeners completed a multi-day lateralization training visually reinforcing ITDs, flanked by a pre- and post-measurement of ITD/ILD weights without visual reinforcement. Using direct electric stimulation, we presented 100- and 300-pps pulse trains at a single interaurally place-matched electrode pair, conveying ITDs and ILDs in various spatially consistent and inconsistent combinations. The listeners’ task was to lateralize the stimuli in a virtual environment. Additionally, ITD and ILD thresholds were measured before and after training. For 100-pps stimuli, the lateralization training increased the contribution of ITDs slightly, but significantly. Thresholds were neither affected by the training nor correlated with weights. For 300-pps stimuli, ITD weights were lower and ITD thresholds larger, but there was no effect of training. On average across test sessions, adding azimuth-dependent ITDs to stimuli containing ILDs increased the extent of lateralization for both 100- and 300-pps stimuli. The results suggest that low-rate ITD cues, robustly encoded with future CI systems, may be better exploitable for sound localization after increasing their perceptual weight via training.

Reweighting of Binaural Localization Cues Induced by Lateralization Training

Normal-hearing listeners adapt to alterations in sound localization cues. This adaptation can result from the establishment of a new spatial map of the altered cues or from a stronger relative weighting of unaltered compared to altered cues. Such reweighting has been shown for monaural vs. binaural cues. However, studies attempting to reweight the two binaural cues, interaural differences in time (ITD) and level (ILD), yielded inconclusive results. This study investigated whether binaural-cue reweighting can be induced by lateralization training in a virtual audio-visual environment. Twenty normal-hearing participants, divided into two groups, completed the experiment consisting of 7 days of lateralization training, preceded and followed by a test measuring the binaural-cue weights. Participants' task was to lateralize 500-ms bandpass-filtered (2-4 kHz) noise bursts containing various combinations of spatially consistent and inconsistent binaural cues. During training, additional visual cues reinforced the azimuth corresponding to ITDs in one group and ILDs in the other group and the azimuthal ranges of the binaural cues were manipulated group-specifically. Both groups showed a significant increase of the reinforced-cue weight from pre- to posttest, suggesting that participants reweighted the binaural cues in the expected direction. This reweighting occurred within the first training session. The results are relevant as binaural-cue reweighting likely occurs when normal-hearing listeners adapt to new acoustic environments. Reweighting might also be a factor underlying the low contribution of ITDs to sound localization of cochlear-implant listeners as they typically do not experience reliable ITD cues with clinical devices.

Transmission of Binaural Cues by Bilateral Cochlear Implants: Examining the Impacts of Bilaterally Independent Spectral Peak-Picking, Pulse Timing, and Compression

Acoustic hearing listeners use binaural cues—interaural time differences (ITDs) and interaural level differences (ILDs)—for localization and segregation of sound sources in the horizontal plane. Cochlear implant users now often receive two implants (bilateral cochlear implants [BiCIs]) rather than one, with the goal to provide access to these cues. However, BiCI listeners often experience difficulty with binaural tasks. Most BiCIs use independent sound processors at each ear; it has often been suggested that such independence may degrade the transmission of binaural cues, particularly ITDs. Here, we report empirical measurements of binaural cue transmission via BiCIs implementing a common “n-of-m” spectral peak-picking stimulation strategy. Measurements were completed for speech and nonspeech stimuli presented to an acoustic manikin “fitted” with BiCI sound processors. Electric outputs from the BiCIs and acoustic outputs from the manikin’s in-ear microphones were recorded simultaneously, enabling comparison of electric and acoustic binaural cues. For source locations away from the midline, BiCI binaural cues, particularly envelope ITD cues, were found to be degraded by asymmetric spectral peak-picking. In addition, pulse amplitude saturation due to nonlinear level mapping yielded smaller ILDs at higher presentation levels. Finally, while individual pulses conveyed a spurious “drifting” ITD, consistent with independent left and right processor clocks, such variation was not evident in transmitted envelope ITDs. Results point to avenues for improvement of BiCI technology and may prove useful in the interpretation of BiCI spatial hearing outcomes reported in prior and future studies.

Effects of Bilateral Automatic Gain Control Synchronization in Cochlear Implants With and Without Head Movements: Sound Source Localization in the Frontal Hemifield

Purpose For bilaterally implanted patients, the automatic gain control (AGC) in both left and right cochlear implant (CI) processors is usually neither linked nor synchronized. At high AGC compression ratios, this lack of coordination between the two processors can distort interaural level differences, the only useful interaural difference cue available to CI patients. This study assessed the improvement, if any, in the utility of interaural level differences for sound source localization in the frontal hemifield when AGCs were synchronized versus independent and when listeners were stationary versus allowed to move their heads. Method Sound source identification of broadband noise stimuli was tested for seven bilateral CI patients using 13 loudspeakers in the frontal hemifield, under conditions where AGCs were linked and unlinked. For half the conditions, patients remained stationary; in the other half, they were encouraged to rotate or reorient their heads within a range of approximately ± 30° during sound presentation. Results In general, those listeners who already localized reasonably well with independent AGCs gained the least from AGC synchronization, perhaps because there was less room for improvement. Those listeners who performed worst with independent AGCs gained the most from synchronization. All listeners performed as well or better with synchronization than without; however, intersubject variability was high. Head movements had little impact on the effectiveness of synchronization of AGCs. Conclusion Synchronization of AGCs offers one promising strategy for improving localization performance in the frontal hemifield for bilaterally implanted CI patients. Supplemental Material https://doi.org/10.23641/asha.14681412.

Electro-Haptic Stimulation: A New Approach for Improving Cochlear-Implant Listening

Cochlear implants (CIs) have been remarkably successful at restoring speech perception for severely to profoundly deaf individuals. Despite their success, several limitations remain, particularly in CI users' ability to understand speech in noisy environments, locate sound sources, and enjoy music. A new multimodal approach has been proposed that uses haptic stimulation to provide sound information that is poorly transmitted by the implant. This augmenting of the electrical CI signal with haptic stimulation (electro-haptic stimulation; EHS) has been shown to improve speech-in-noise performance and sound localization in CI users. There is also evidence that it could enhance music perception. We review the evidence of EHS enhancement of CI listening and discuss key areas where further research is required. These include understanding the neural basis of EHS enhancement, understanding the effectiveness of EHS across different clinical populations, and the optimization of signal-processing strategies. We also discuss the significant potential for a new generation of haptic neuroprosthetic devices to aid those who cannot access hearing-assistive technology, either because of biomedical or healthcare-access issues. While significant further research and development is required, we conclude that EHS represents a promising new approach that could, in the near future, offer a non-invasive, inexpensive means of substantially improving clinical outcomes for hearing-impaired individuals.

Microsecond interaural time difference discrimination restored by cochlear implants after neonatal deafness

Spatial hearing in cochlear implant (CI) patients remains a major challenge, with many early deaf users reported to have no measurable sensitivity to interaural time differences (ITDs). Deprivation of binaural experience during an early critical period is often hypothesized to be the cause of this shortcoming. However, we show that neonatally deafened (ND) rats provided with precisely synchronized CI stimulation in adulthood can be trained to lateralize ITDs with essentially normal behavioral thresholds near 50 μs. Furthermore, comparable ND rats show high physiological sensitivity to ITDs immediately after binaural implantation in adulthood. Our result that ND-CI rats achieved very good behavioral ITD thresholds, while prelingually deaf human CI patients often fail to develop a useful sensitivity to ITD raises urgent questions concerning the possibility that shortcomings in technology or treatment, rather than missing input during early development, may be behind the usually poor binaural outcomes for current CI patients.

Spatial Release From Informational and Energetic Masking in Bimodal and Bilateral Cochlear Implant Users

Purpose Spatially separating speech and background noise improves speech understanding in normal-hearing listeners, an effect referred to as spatial release from masking (SRM). In cochlear implant (CI) users, SRM has often been demonstrated using asymmetric noise configurations, which maximize benefit from head shadow and the potential availability of binaural cues. In contrast, SRM in symmetrical configurations has been minimal to absent in CI users. We examined the interaction between two types of maskers (informational and energetic) and SRM in bimodal and bilateral CI users. We hypothesized that SRM would be absent or "negative" using symmetrically separated noise maskers. Second, we hypothesized that bimodal listeners would exhibit greater release from informational masking due to access to acoustic information in the non-CI ear. Method Participants included 10 bimodal and 10 bilateral CI users. Speech understanding in noise was tested in 24 conditions: 3 spatial configurations (S₀N₀, S₀N_45&315, S₀N_90&270) × 2 masker types (speech, signal-correlated noise) × 2 listening configurations (best-aided, CI-alone) × 2 talker gender conditions (different-gender, same-gender). Results In support of our first hypothesis, both groups exhibited negative SRM with increasing spatial separation. In opposition to our second hypothesis, both groups exhibited similar magnitudes of release from informational masking. The magnitude of release was greater for bimodal listeners, though this difference failed to reach statistical significance. Conclusions Both bimodal and bilateral CI recipients exhibited negative SRM. This finding is consistent with CI signal processing limitations, the audiologic factors associated with SRM, and known effects of behind-the-ear microphone technology. Though release from informational masking was not significantly different across groups, the magnitude of release was greater for bimodal listeners. This suggests that bimodal listeners may be at least marginally more susceptible to informational masking than bilateral CI users, though further research is warranted.

Evaluating the Impact of Age, Acoustic Exposure, and Electrical Stimulation on Binaural Sensitivity in Adult Bilateral Cochlear Implant Patients

Deafness in both ears is highly disruptive to communication in everyday listening situations. Many individuals with profound deafness receive bilateral cochlear implants (CIs) to gain access to spatial cues used in localization and speech understanding in noise. However, the benefit of bilateral CIs, in particular sensitivity to interaural time and level differences (ITD and ILDs), varies among patients. We measured binaural sensitivity in 46 adult bilateral CI patients to explore the relationship between binaural sensitivity and three classes of patient-related factors: age, acoustic exposure, and electric hearing experience. Results show that ILD sensitivity increased with shorter years of acoustic exposure, younger age at testing, or an interaction between these factors, moderated by the duration of bilateral hearing impairment. ITD sensitivity was impacted by a moderating effect between years of bilateral hearing impairment and CI experience. When age at onset of deafness was treated as two categories (<18 vs. >18 years of age), there was no clear effect for ILD sensitivity, but some differences were observed for ITD sensitivity. Our findings imply that maximal binaural sensitivity is obtained by listeners with a shorter bilateral hearing impairment, a longer duration of CI experience, and potentially a younger age at testing. 198/200.

Improving Interaural Time Difference Sensitivity Using Short Inter-pulse Intervals with Amplitude-Modulated Pulse Trains in Bilateral Cochlear Implants

Interaural time differences (ITDs) at low frequencies are important for sound localization and spatial speech unmasking. These ITD cues are not encoded in commonly used envelope-based stimulation strategies for cochlear implants (CIs) using high pulse rates. However, ITD sensitivity can be improved by adding extra pulses with short inter-pulse intervals (SIPIs) in unmodulated high-rate trains. Here, we investigated whether this improvement also applies to amplitude-modulated (AM) high-rate pulse trains. To this end, we systematically varied the temporal position of SIPI pulses within the envelope cycle (SIPI phase), the fundamental frequency (F0) of AM (125 Hz and 250 Hz), and AM depth (from 0.1 to 0.9). Stimuli were presented at an interaurally place-matched electrode pair at a reference pulse rate of 1000 pulses/s. Participants performed an ITD-based left/right discrimination task. SIPI insertion resulted in improved ITD sensitivity throughout the range of modulation depths and for both male and female F0s. The improvements were largest for insertion at and around the envelope peak. These results are promising for conveying salient ITD cues at high pulse rates commonly used to encode speech information.

Temporal-pitch sensitivity in electric hearing with amplitude modulation and inserted pulses with short inter-pulse intervals

Listeners with cochlear implants (CIs) typically show poor sensitivity to the temporal-envelope pitch of high-rate pulse trains. Sensitivity to interaural time differences improves when adding pulses with short inter-pulse intervals (SIPIs) to high-rate pulse trains. In the current study, monaural temporal-pitch sensitivity with SIPI pulses was investigated for six CI listeners. Amplitude-modulated single-electrode stimuli, representing the coding of the fundamental frequency (F0) in the envelope of a high-rate carrier, were used. Two SIPI-insertion approaches, five modulation depths, two typical speech-F0s, and two carrier rates were tested. SIPI pulses were inserted either in every amplitude-modulation period (full-rate SIPI) to support the F0 cue or in every other amplitude-modulation period (half-rate SIPI) to circumvent a potential rate limitation at higher F0s. The results demonstrate that full-rate SIPI pulses improve temporal-pitch sensitivity across F0s and particularly at low modulation depths where envelope-pitch cues are weak. The half-rate SIPI pulses did not circumvent the limitation and further increased variability across listeners. Further, no effect of the carrier rate was found. Thus, the SIPI approach appears to be a promising approach to enhance CI listeners' access to temporal-envelope pitch cues at pulse rates used clinically.

Bimodal Hearing or Bilateral Cochlear Implants? Ask the Patient

OBJECTIVE

The objectives of this study were to assess the effectiveness of various measures of speech understanding in distinguishing performance differences between adult bimodal and bilateral cochlear implant (CI) recipients and to provide a preliminary evidence-based tool guiding clinical decisions regarding bilateral CI candidacy.

DESIGN

This study used a multiple-baseline, cross-sectional design investigating speech recognition performance for 85 experienced adult CI recipients (49 bimodal, 36 bilateral). Speech recognition was assessed in a standard clinical test environment with a single loudspeaker using the minimum speech test battery for adult CI recipients as well as with an R-SPACE 8-loudspeaker, sound-simulation system. All participants were tested in three listening conditions for each measure including each ear alone as well as in the bilateral/bimodal condition. In addition, we asked each bimodal listener to provide a yes/no answer to the question, "Do you think you need a second CI?"

RESULTS

This study yielded three primary findings: (1) there were no significant differences between bimodal and bilateral CI performance or binaural summation on clinical measures of speech recognition, (2) an adaptive speech recognition task in the R-SPACE system revealed significant differences in performance and binaural summation between bimodal and bilateral CI users, with bilateral CI users achieving significantly better performance and greater summation, and (3) the patient's answer to the question, "Do you think you need a second CI?" held high sensitivity (100% hit rate) for identifying likely bilateral CI candidates and moderately high specificity (77% correct rejection rate) for correctly identifying listeners best suited with a bimodal hearing configuration.

CONCLUSIONS

Clinics cannot rely on current clinical measures of speech understanding, with a single loudspeaker, to determine bilateral CI candidacy for adult bimodal listeners nor to accurately document bilateral benefit relative to a previous bimodal hearing configuration. Speech recognition in a complex listening environment, such as R-SPACE, is a sensitive and appropriate measure for determining bilateral CI candidacy and also likely for documenting bilateral benefit relative to a previous bimodal configuration. In the absence of an available R-SPACE system, asking the patient whether or not s/he thinks s/he needs a second CI is a highly sensitive measure, which may prove clinically useful.

The Effects of Dynamic-range Automatic Gain Control on Sentence Intelligibility With a Speech Masker in Simulated Cochlear Implant Listening

OBJECTIVES

"Channel-linked" and "multi-band" front-end automatic gain control (AGC) were examined as alternatives to single-band, channel-unlinked AGC in simulated bilateral cochlear implant (CI) processing. In channel-linked AGC, the same gain control signal was applied to the input signals to both of the two CIs ("channels"). In multi-band AGC, gain control acted independently on each of a number of narrow frequency regions per channel.

DESIGN

Speech intelligibility performance was measured with a single target (to the left, at -15 or -30°) and a single, symmetrically-opposed masker (to the right) at a signal-to-noise ratio (SNR) of -2 decibels. Binaural sentence intelligibility was measured as a function of whether channel linking was present and of the number of AGC bands. Analysis of variance was performed to assess condition effects on percent correct across the two spatial arrangements, both at a high and a low AGC threshold. Acoustic analysis was conducted to compare postcompressed better-ear SNR, interaural differences, and monaural within-band envelope levels across processing conditions.

RESULTS

Analyses of variance indicated significant main effects of both channel linking and number of bands at low threshold, and of channel linking at high threshold. These improvements were accompanied by several acoustic changes. Linked AGC produced a more favorable better-ear SNR and better preserved broadband interaural level difference statistics, but did not reduce dynamic range as much as unlinked AGC. Multi-band AGC sometimes improved better-ear SNR statistics and always improved broadband interaural level difference statistics whenever the AGC channels were unlinked. Multi-band AGC produced output envelope levels that were higher than single-band AGC.

CONCLUSIONS

These results favor strategies that incorporate channel-linked AGC and multi-band AGC for bilateral CIs. Linked AGC aids speech intelligibility in spatially separated speech, but reduces the degree to which dynamic range is compressed. Combining multi-band and channel-linked AGC offsets the potential impact of diminished dynamic range with linked AGC without sacrificing the intelligibility gains observed with linked AGC.

Improving Localization and Speech Reception in Noise for Bilateral Cochlear Implant Recipients

This study looked at different methods to preserve interaural level difference (ILD) cues for bilateral cochlear implant (BiCI) recipients. One possible distortion to ILD is from automatic gain control (AGC). Localization accuracy of BiCI recipients using default versus increased AGC threshold and linked AGCs versus independent AGCs was examined. In addition, speech reception in noise was assessed using linked versus independent AGCs and enabling and disabling Autosensitivity™ Control. Subjective information via a diary and questionnaire was also collected about maps with linked and independent AGCs during a take-home experience. Localization accuracy improved in the increased AGC threshold and the linked AGCs conditions. Increasing the AGC threshold resulted in a 4° improvement in root mean square error averaged across all speaker locations. Using linked AGCs, BiCI participants experienced an 8° improvement for all speaker locations and a 19° improvement at the speaker location most affected by the AGC. Speech reception threshold in noise improved by an average of 2.5 dB when using linked AGCs versus independent AGCs. In addition, the effect of linked AGCs on speech in noise was compared with that of Autosensitivity™ Control. The Speech, Spatial, and Qualities of Hearing Scale-12 question comparative survey showed an improvement when using maps with linked AGCs. These findings support the hypothesis that ILD cues may be preserved by increasing the AGC threshold or linking AGCs.

Sequential stream segregation with bilateral cochlear implants

Sequential stream segregation on the basis of binaural 'ear-of-entry', modulation rate and electrode place-of-stimulation cues was investigated in bilateral cochlear implant (CI) listeners using a rhythm anisochrony detection task. Sequences of alternating 'A' and 'B' bursts were presented via direct electrical stimulation and comprised either an isochronous timing structure or an anisochronous structure that was generated by delaying just the 'B' bursts. 'B' delay thresholds that enabled rhythm anisochrony detection were determined. Higher thresholds were assumed to indicate a greater likelihood of stream segregation, resulting specifically from stream integration breakdown. Results averaged across subjects showed that thresholds were significantly higher when monaural 'A' and 'B' bursts were presented contralaterally rather than ipsilaterally, and that diotic presentation of 'A', with a monaural 'B', yielded intermediate thresholds. When presented monaurally and ipsilaterally, higher thresholds were also found when successive bursts had mismatched rather than matched modulation rates. In agreement with previous studies, average delay thresholds also increased as electrode separation between bursts increased when presented ipsilaterally. No interactions were found between ear-of-entry, modulation rate and place-of-stimulation. However, combining moderate electrode difference cues with either diotic-'A' ear-of-entry cues or modulation-rate mismatch cues did yield greater threshold increases than observed with any of those cues alone. The results from the present study indicate that sequential stream segregation can be elicited in bilateral CI users by differences in the signal across ears (binaural cues), in modulation rate (monaural cues) and in place-of-stimulation (monaural cues), and that those differences can be combined to further increase segregation.

Auditory motion tracking ability of adults with normal hearing and with bilateral cochlear implants

Adults with bilateral cochlear implants (BiCIs) receive benefits in localizing stationary sounds when listening with two implants compared with one; however, sound localization ability is significantly poorer when compared to normal hearing (NH) listeners. Little is known about localizing sound sources in motion, which occurs in typical everyday listening situations. The authors considered the possibility that sound motion may improve sound localization in BiCI users by providing multiple places of information. Alternatively, the ability to compare multiple spatial locations may be compromised in BiCI users due to degradation of binaural cues, and thus result in poorer performance relative to NH adults. In this study, the authors assessed listeners' abilities to distinguish between sounds that appear to be moving vs stationary, and track the angular range and direction of moving sounds. Stimuli were bandpass-filtered (150-6000 Hz) noise bursts of different durations, panned over an array of loudspeakers. Overall, the results showed that BiCI users were poorer than NH adults in (i) distinguishing between a moving vs stationary sound, (ii) correctly identifying the direction of movement, and (iii) tracking the range of movement. These findings suggest that conventional cochlear implant processors are not able to fully provide the cues necessary for perceiving auditory motion correctly.

The Effect of Simulated Interaural Frequency Mismatch on Speech Understanding and Spatial Release From Masking

OBJECTIVE

The binaural-hearing system interaurally compares inputs, which underlies the ability to localize sound sources and to better understand speech in complex acoustic environments. Cochlear implants (CIs) are provided in both ears to increase binaural-hearing benefits; however, bilateral CI users continue to struggle with understanding speech in the presence of interfering sounds and do not achieve the same level of spatial release from masking (SRM) as normal-hearing listeners. One reason for diminished SRM in CI users could be that the electrode arrays are inserted at different depths in each ear, which would cause an interaural frequency mismatch. Because interaural frequency mismatch diminishes the salience of interaural differences for relatively simple stimuli, it may also diminish binaural benefits for spectral-temporally complex stimuli like speech. This study evaluated the effect of simulated frequency-to-place mismatch on speech understanding and SRM.

DESIGN

Eleven normal-hearing listeners were tested on a speech understanding task. There was a female target talker who spoke five-word sentences from a closed set of words. There were two interfering male talkers who spoke unrelated sentences. Nonindividualized head-related transfer functions were used to simulate a virtual auditory space. The target was presented from the front (0°), and the interfering speech was either presented from the front (colocated) or from 90° to the right (spatially separated). Stimuli were then processed by an eight-channel vocoder with tonal carriers to simulate aspects of listening through a CI. Frequency-to-place mismatch ("shift") was introduced by increasing the center frequency of the synthesis filters compared with the corresponding analysis filters. Speech understanding was measured for different shifts (0, 3, 4.5, and 6 mm) and target-to-masker ratios (TMRs: +10 to -10 dB). SRM was calculated as the difference in the percentage of correct words for the colocated and separated conditions. Two types of shifts were tested: (1) bilateral shifts that had the same frequency-to-place mismatch in both ears, but no interaural frequency mismatch, and (2) unilateral shifts that produced an interaural frequency mismatch.

RESULTS

For the bilateral shift conditions, speech understanding decreased with increasing shift and with decreasing TMR, for both colocated and separate conditions. There was, however, no interaction between shift and spatial configuration; in other words, SRM was not affected by shift. For the unilateral shift conditions, speech understanding decreased with increasing interaural mismatch and with decreasing TMR for both the colocated and spatially separated conditions. Critically, there was a significant interaction between the amount of shift and spatial configuration; in other words, SRM decreased for increasing interaural mismatch.

CONCLUSIONS

A frequency-to-place mismatch in one or both ears resulted in decreased speech understanding. SRM, however, was only affected in conditions with unilateral shifts and interaural frequency mismatch. Therefore, matching frequency information between the ears provides listeners with larger binaural-hearing benefits, for example, improved speech understanding in the presence of interfering talkers. A clinical procedure to reduce interaural frequency mismatch when programming bilateral CIs may improve benefits in speech segregation that are due to binaural-hearing abilities.

Dietrich M, Dorman MF. Speech Understanding in Noise for Adults With Cochlear Implants: Effects of Hearing Configuration, Source Location Certainty, and Head Movement

Purpose

The primary purpose of this study was to assess speech understanding in quiet and in diffuse noise for adult cochlear implant (CI) recipients utilizing bimodal hearing or bilateral CIs. Our primary hypothesis was that bilateral CI recipients would demonstrate less effect of source azimuth in the bilateral CI condition due to symmetric interaural head shadow.

Method

Sentence recognition was assessed for adult bilateral (n = 25) CI users and bimodal listeners (n = 12) in three conditions: (1) source location certainty regarding fixed target azimuth, (2) source location uncertainty regarding roving target azimuth, and (3) Condition 2 repeated, allowing listeners to turn their heads, as needed.

Results

(a) Bilateral CI users exhibited relatively similar performance regardless of source azimuth in the bilateral CI condition; (b) bimodal listeners exhibited higher performance for speech directed to the better hearing ear even in the bimodal condition; (c) the unilateral, better ear condition yielded higher performance for speech presented to the better ear versus speech to the front or to the poorer ear; (d) source location certainty did not affect speech understanding performance; and (e) head turns did not improve performance. The results confirmed our hypothesis that bilateral CI users exhibited less effect of source azimuth than bimodal listeners. That is, they exhibited similar performance for speech recognition irrespective of source azimuth, whereas bimodal listeners exhibited significantly poorer performance with speech originating from the poorer hearing ear (typically the nonimplanted ear).

Conclusions

Bilateral CI users overcame ear and source location effects observed for the bimodal listeners. Bilateral CI users have access to head shadow on both sides, whereas bimodal listeners generally have interaural asymmetry in both speech understanding and audible bandwidth limiting the head shadow benefit obtained from the poorer ear (generally the nonimplanted ear). In summary, we found that, in conditions with source location uncertainty and increased ecological validity, bilateral CI performance was superior to bimodal listening.

Better-ear glimpsing with symmetrically-placed interferers in bilateral cochlear implant users

For a frontal target in spatially symmetrically placed interferers, normal hearing (NH) listeners can use "better-ear glimpsing" to select time-frequency segments with favorable signal-to-noise ratio in either ear. With an ideal monaural better-ear mask (IMBM) processing, some studies showed that NH listeners can reach similar performance as in the natural binaural listening condition, although interaural phase differences at low frequencies can further improve performance. In principle, bilateral cochlear implant (BiCI) listeners could use the same better-ear glimpsing, albeit without exploiting interaural phase differences. Speech reception thresholds of NH and BiCI listeners were measured in three interferers (speech-shaped stationary noise, nonsense speech, or single talker) either co-located with the target, symmetrically placed at ±60°, or independently presented to each ear, with and without IMBM processing. Furthermore, a bilateral noise vocoder based on the BiCI electrodogram was used in the same NH listeners. Headphone presentation and direct stimulation with head-related transfer functions for spatialization were used in NH and BiCI listeners, respectively. Compared to NH listeners, both NH listeners with vocoder and BiCI listeners showed strongly reduced binaural benefit from spatial separation. However, both groups greatly benefited from IMBM processing as part of the stimulation strategy.

Introducing Short Interpulse Intervals in High-Rate Pulse Trains Enhances Binaural Timing Sensitivity in Electric Hearing

Common envelope-based stimulation strategies for cochlear implants (CIs) use relatively high carrier rates in order to properly encode the speech envelope. For such rates, CI listeners show poor sensitivity to interaural time differences (ITDs), which are important for horizontal-plane sound localization and spatial unmasking of speech. Based on the findings from previous studies, we predicted that ITD sensitivity can be enhanced by including pulses with short interpulse intervals (SIPIs), to a 1000-pulses-per-second (pps) reference pulse train. We measured the sensitivity of eight bilateral CI listeners to ITD while systematically varying both the rate at which SIPIs are introduced ("SIPI rate") and the time interval between the two pulses forming a SIPI ("SIPI fraction"). Results showed largely enhanced ITD sensitivity relative to the reference condition, with the size of the improvement increasing with decreasing SIPI rate and decreasing SIPI fraction. For the lowest SIPI fraction, insertion of extra pulses brought ITD sensitivity to the level measured for low-rate pulse trains with rates matching the SIPI rates. The results appear promising for the goal of enhancing ITD sensitivity with envelope-based CI strategies by inserting SIPI pulses at strategic times in speech stimuli.

Spatial Release From Masking in Adults With Bilateral Cochlear Implants: Effects of Distracter Azimuth and Microphone Location

PURPOSE

The primary purpose of this study was to derive spatial release from masking (SRM) performance-azimuth functions for bilateral cochlear implant (CI) users to provide a thorough description of SRM as a function of target/distracter spatial configuration. The secondary purpose of this study was to investigate the effect of the microphone location for SRM in a within-subject study design.

METHOD

Speech recognition was measured in 12 adults with bilateral CIs for 11 spatial separations ranging from -90° to +90° in 20° steps using an adaptive block design. Five of the 12 participants were tested with both the behind-the-ear microphones and a T-mic configuration to further investigate the effect of mic location on SRM.

RESULTS

SRM can be significantly affected by the hemifield origin of the distracter stimulus-particularly for listeners with interaural asymmetry in speech understanding. The greatest SRM was observed with a distracter positioned 50° away from the target. There was no effect of mic location on SRM for the current experimental design.

CONCLUSION

Our results demonstrate that the traditional assessment of SRM with a distracter positioned at 90° azimuth may underestimate maximum performance for individuals with bilateral CIs.

Mixed stimulation rates to improve sensitivity of interaural timing differences in bilateral cochlear implant listeners

Normal hearing listeners extract small interaural time differences (ITDs) and interaural level differences (ILDs) to locate sounds and segregate targets from noise. Bilateral cochlear implant listeners show poor sensitivity to ITDs when using clinical processors. This is because common clinical stimulation approaches use high rates [∼1000 pulses per-second (pps)] for each electrode in order to provide good speech representation, but sensitivity to ITDs is best at low rates of stimulation (∼100-300 pps). Mixing rates of stimulation across the array is a potential solution. Here, ITD sensitivity for a number of mixed-rate configurations that were designed to preserve speech envelope cues using high-rate stimulation and spatial hearing using low rate stimulation was examined. Results showed that ITD sensitivity in mixed-rate configurations when only one low rate electrode was included generally yielded ITD thresholds comparable to a configuration with low rates only. Low rate stimulation at basal or middle regions on the electrode array yielded the best sensitivity to ITDs. This work provides critical evidence that supports the use of mixed-rate strategies for improving ITD sensitivity in bilateral cochlear implant users.

Corrective binaural processing for bilateral cochlear implant patients

Although bilateral cochlear implant users receive input to both ears, they nonetheless have relatively poor localization abilities in the horizontal plane. This is likely because of the two binaural cues, they have good sensitivity to interaural differences of level (inter-aural level differences, or ILDs), but not those of time (inter-aural time differences; ITDs). Here, localization performance is assessed in six bilateral cochlear implant patients when instantaneous ITDs are measured and converted to ILDs, a strategy that results in larger-than-typical ILDs. The added ILDs are corrective, in that they are derived from individual listener performance across both frequency and azimuth, so that they are small where a listener performs well, and increase as performance deviates from ideal. Results show significantly improved localization performance as a result of this strategy, with two of the six listeners achieving levels of performance typically observed in NH listeners.

Perceived improvements and challenges following sequential bilateral cochlear implantation in children and adults

OBJECTIVE

Semi-structured interviews were conducted with sequentially implanted bilateral cochlear-implant (biCI) recipients to examine functional aspects of communication that are affected by listening with one versus two CIs.

DESIGN

Participants were 15 adult biCI recipients and parents of 30 children (categorized into three groups by age) with biCIs. All CI users had sequential placement of biCIs with at least six months' experience with the first CI before activation of the second device, and at least three months' experience with both CIs prior to the interview. The parent/paediatric and adult interviews were all conducted by the same examiner. Electronic transcripts of the interview responses were coded for perceived changes or lack thereof in 23 behaviours following biCI. Extent of reported benefit was quantified for each subject within and across these behaviours and at the group level as a function of age.

RESULTS

Most adults and parents of children reported multiple functional changes following biCI use, and changes often translated to enhanced social communication. Nearly all participants were consistent users of biCIs, and were satisfied with their perceived gains in communicating in everyday settings. Most reported ongoing challenges listening in noisy settings. Although many reports on children paralleled those of adults, developmental differences were apparent. Thirteen percent of adults and twenty percent of parents of children in each of the respective groups reported low levels of change.

CONCLUSIONS

Results suggest that many biCI users experience meaningful functional benefits that may be underestimated by traditional outcome measures. We suggest the need to expand measurement approaches to better quantify the nature of these benefits.

Temporal effects in interaural and sequential level difference perception

Temporal effects in interaural level difference (ILD) perception are not well understood. While it is often assumed that ILD sensitivity is independent of the temporal stimulus properties, a reduction of ILD sensitivity for stimuli with a high modulation rate has been reported (known under the term binaural adaptation). Experiment 1 compared ILD thresholds and sequential-level-difference (SLD) thresholds using 300-ms bandpass-filtered pulse trains (centered at 4 kHz) with rates of 100, 400, and 800 pulses per second (pps). In contrast to the SLD thresholds, ILD thresholds were elevated at 800 pps, consistent with literature data that had previously been attributed to binaural adaptation. Experiment 2 showed better ILD sensitivity for pulse trains than for pure tones, suggesting that amplitude modulation enhances ILD sensitivity. The present ILD data and binaural adaptation data from the literature were predicted by a model combining well-established auditory periphery front-ends with an interaural comparison stage. The model also accounted for other published ILD data, including target ILD thresholds in diotic forward and backward fringes and ILD thresholds with different amounts of interaural correlation. Overall, a variety of temporal effects in ILD perception, including binaural adaptation, appear to be largely attributable to monaural peripheral auditory processing.

Envelope-based inter-aural time difference localization training to improve speech-in-noise perception in the elderly

Background: Many elderly individuals complain of difficulty in understanding speech in noise despite having normal hearing thresholds. According to previous studies, auditory training leads to improvement in speech-in-noise perception, but these studies did not consider the etiology, so their results cannot be generalized. The present study aimed at investigating the effectiveness of envelopebased interaural time difference (ITD ENV) localization training on improving ITD threshold and speech-in-noise perception. Methods: Thirty-two elderly males aged 55 to 65 years with clinically diagnosed normal hearing at 250-2000 Hertz, who suffered from speech-in-noise perception difficulty participated in this study. These individuals were randomly divided into training and control groups: 16 elderlies in the experimental group received envelope-based interaural time difference localization training in 9 sessions, but 16 matched elderlies in the control group did not receive any training. The ITD ENV threshold and spatial word recognition score (WRS) in noise were analyzed before and after the localization training. Results: Findings demonstrated that following the training program, the interaural time difference envelope threshold and spatial word recognition score (WRS) in noise were improved significantly in the experimental group (p≤ 0.001). Moreover, a significant difference was detected in interaural time difference envelope threshold and spatial word recognition score (WRS) in noise (p≤ 0.001) before and after the training in the experimental group. Conclusion: The results of the present study revealed the effectiveness of envelope- based interaural time difference localization training in localization ability and speech in noise perception in the elderlies with normal hearing up to 2000 Hz who suffered from speech-in-noise perception difficulty.

Binaural timing information in electric hearing at low rates: Effects of inaccurate encoding and loudness

Stimulation strategies for cochlear implants potentially impose timing limitations that may hinder the correct encoding and representation of interaural time differences (ITDs) in realistic bilateral signals. This study aimed to specify the tolerable room for inaccurate encoding of ITDs at low rates by investigating the perceptual degradation due to the removal of individual pulses at various levels of loudness. Unmodulated, 100-pulses-per-second pulse trains were presented at a single, interaurally pitch-matched electrode pair. In experiment I, ITD thresholds were measured applying different degrees of bilateral, interaurally-uncorrelated pulse removal. The ITD sensitivity deteriorated with increasing degree of pulse removal, with significant deterioration for degrees of 16% or greater. In experiment II, the interaction between loudness and pulse removal was investigated. Louder stimuli yielded better ITD sensitivity, however, no further improvement was found for stimuli louder than "medium." When removing 8% of the pulses, the ITD sensitivity deteriorated significantly across the entire loudness range tested. A loudness-induced compensation for the deterioration of ITD sensitivity due to pulse removal seems to be feasible for soft stimuli but not for medium or loud stimuli. Overall, our findings suggest that the degree of pulse removal employed in low-rate channels within coding strategies should not exceed 8%.

Extent of lateralization at large interaural time differences in simulated electric hearing and bilateral cochlear implant users

Normal-hearing (NH) listeners are able to localize sound sources with extraordinary accuracy through interaural cues, most importantly interaural time differences (ITDs) in the temporal fine structure. Bilateral cochlear implant (CI) users are also able to localize sound sources, yet generally at lower accuracy than NH listeners. The gap in performance can in part be attributed to current CI systems not faithfully transmitting interaural cues, especially ITDs. With the introduction of binaurally linked CI systems, the presentation of ITD cues for bilateral CI users is foreseeable. The current study therefore investigated extent-of-lateralization percepts elicited in bilateral CI listeners when presented with single-electrode pulse-trains carrying controlled ITD cues. The results were compared against NH listeners listening to broadband stimuli as well as simulations of CI listening. Broadband stimuli in NH listeners were perceived as fully lateralized within the natural ITD range. Using simulated as well as real CI stimuli, however, only a fraction of the full extent of lateralization range was covered by natural ITDs. The maximum extent of lateralization was reached at ITDs as large as twice the natural limit. The results suggest that ITD-enhancement might be a viable option for improving localization abilities with future binaural CI systems.

United Kingdom national paediatric bilateral project: Demographics and results of localization and speech perception testing

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.

Using ILD or ITD Cues for Sound Source Localization and Speech Understanding in a Complex Listening Environment by Listeners With Bilateral and With Hearing-Preservation Cochlear Implants

PURPOSE

To assess the role of interaural time differences and interaural level differences in (a) sound-source localization, and (b) speech understanding in a cocktail party listening environment for listeners with bilateral cochlear implants (CIs) and for listeners with hearing-preservation CIs.

METHODS

Eleven bilateral listeners with MED-EL (Durham, NC) CIs and 8 listeners with hearing-preservation CIs with symmetrical low frequency, acoustic hearing using the MED-EL or Cochlear device were evaluated using 2 tests designed to task binaural hearing, localization, and a simulated cocktail party. Access to interaural cues for localization was constrained by the use of low-pass, high-pass, and wideband noise stimuli.

RESULTS

Sound-source localization accuracy for listeners with bilateral CIs in response to the high-pass noise stimulus and sound-source localization accuracy for the listeners with hearing-preservation CIs in response to the low-pass noise stimulus did not differ significantly. Speech understanding in a cocktail party listening environment improved for all listeners when interaural cues, either interaural time difference or interaural level difference, were available.

CONCLUSIONS

The findings of the current study indicate that similar degrees of benefit to sound-source localization and speech understanding in complex listening environments are possible with 2 very different rehabilitation strategies: the provision of bilateral CIs and the preservation of hearing.

Bilateral Loudness Balancing and Distorted Spatial Perception in Recipients of Bilateral Cochlear Implants

OBJECTIVE

To determine whether bilateral loudness balancing during mapping of bilateral cochlear implants (CIs) produces fused, punctate, and centered auditory images that facilitate lateralization with stimulation on single-electrode pairs.

DESIGN

Adopting procedures similar to those that are practiced clinically, direct stimulation was used to obtain most-comfortable levels (C levels) in recipients of bilateral CIs. Three pairs of electrodes, located in the base, middle, and apex of the electrode array, were tested. These electrode pairs were loudness-balanced by playing right-left electrode pairs sequentially. In experiment 1, the authors measured the location, number, and compactness of auditory images in 11 participants in a subjective fusion experiment. In experiment 2, the authors measured the location and number of the auditory images while imposing a range of interaural level differences (ILDs) in 13 participants in a lateralization experiment. Six of these participants repeated the mapping process and lateralization experiment over three separate days to determine the variability in the procedure.

RESULTS

In approximately 80% of instances, bilateral loudness balancing was achieved from relatively small adjustments to the C levels (≤3 clinical current units). More important, however, was the observation that in 4 of 11 participants, simultaneous bilateral stimulation regularly elicited percepts that were not fused into a single auditory object. Across all participants, approximately 23% of percepts were not perceived as fused; this contrasts with the 1 to 2% incidence of diplacusis observed with normal-hearing individuals. In addition to the unfused images, the perceived location was often offset from the physical ILD. On the whole, only 45% of percepts presented with an ILD of 0 clinical current units were perceived as fused and heard in the center of the head. Taken together, these results suggest that distortions to the spatial map remain common in bilateral CI recipients even after careful bilateral loudness balancing.

CONCLUSIONS

The primary conclusion from these experiments is that, even after bilateral loudness balancing, bilateral CI recipients still regularly perceive stimuli that are unfused, offset from the assumed zero ILD, or both. Thus, while current clinical mapping procedures for bilateral CIs are sufficient to enable many of the benefits of bilateral hearing, they may not elicit percepts that are thought to be optimal for sound-source location. As a result, in the absence of new developments in signal processing for CIs, new mapping procedures may need to be developed for bilateral CI recipients to maximize the benefits of bilateral hearing.

Balancing current levels in children with bilateral cochlear implants using electrophysiological and behavioral measures

Children have benefited from bilateral cochlear implants (CIs) over unilateral CIs despite often missing important periods in bilateral auditory development. This suggests a remarkable perceptual ability by children to "work around" abnormal changes in the auditory pathways. Nonetheless, these children rely primarily on interaural level differences as interaural timing cues are more difficult to access or detect. Mismatched levels provided to the two implants could distort interaural level cues thus compromising the benefits of bilateral CI use. We asked whether "balanced" or "centered" perception of bilateral input can be predicted by physiological or behavioral measures. Twenty-four children who had used unilateral CIs for 9.21 ± 2.66 years prior to bilateral implantation participated. "Balanced bilateral levels" were identified by responses occurring with a probability of 50% on the right side of the head and 50% on the left in a two choice lateralization task. Loudness judgments of current presented unilaterally by each implant were measured on a continuous visual scale. Maximum wave eV amplitudes were evoked unilaterally by each implant and matched amplitudes were identified. Balanced bilateral levels were predicted within 10 Clinical Units (CU) in 9 of 13 (69%) children using matched wave eV amplitudes. Bilaterally balanced levels were reasonably predicted by similar loudness judgments (<10% difference between CIs) in only 6 of 13 (46%) children. Results indicate that matching amplitudes of physiological responses can produce a balanced perception of bilateral input despite unilateral strengthening of the auditory pathways and can potentially be used clinically to provide a first approximation of balance/centered levels.

Auditory Model-Based Sound Direction Estimation With Bilateral Cochlear Implants

Users of bilateral cochlear implants (CIs) show above-chance performance in localizing the source of a sound in the azimuthal (horizontal) plane; although localization errors are far worse than for normal-hearing listeners, they are considerably better than for CI listeners with only one implant. In most previous studies, subjects had access to interaural level differences and to interaural time differences conveyed in the temporal envelope. Here, we present a binaural model that predicts the azimuthal direction of sound arrival from a two-channel input signal as it is received at the left and right CI processor. The model includes a replication of a clinical speech-coding strategy, a model of the electrode-nerve interface and binaural brainstem neurons, and three different prediction stages that are trained to map the neural response rate to an azimuthal angle. The model is trained and tested with various noise and speech stimuli created by means of virtual acoustics. Localization error patterns of the model match experimental data and are explicable largely in terms of the nonmonotonic relationship between interaural level difference and azimuthal angle.

Development of Sound Localization Strategies in Children with Bilateral Cochlear Implants

Localizing sounds in our environment is one of the fundamental perceptual abilities that enable humans to communicate, and to remain safe. Because the acoustic cues necessary for computing source locations consist of differences between the two ears in signal intensity and arrival time, sound localization is fairly poor when a single ear is available. In adults who become deaf and are fitted with cochlear implants (CIs) sound localization is known to improve when bilateral CIs (BiCIs) are used compared to when a single CI is used. The aim of the present study was to investigate the emergence of spatial hearing sensitivity in children who use BiCIs, with a particular focus on the development of behavioral localization patterns when stimuli are presented in free-field horizontal acoustic space. A new analysis was implemented to quantify patterns observed in children for mapping acoustic space to a spatially relevant perceptual representation. Children with normal hearing were found to distribute their responses in a manner that demonstrated high spatial sensitivity. In contrast, children with BiCIs tended to classify sound source locations to the left and right; with increased bilateral hearing experience, they developed a perceptual map of space that was better aligned with the acoustic space. The results indicate experience-dependent refinement of spatial hearing skills in children with CIs. Localization strategies appear to undergo transitions from sound source categorization strategies to more fine-grained location identification strategies. This may provide evidence for neural plasticity, with implications for training of spatial hearing ability in CI users.

Limitations on Monaural and Binaural Temporal Processing in Bilateral Cochlear Implant Listeners

Monaural rate discrimination and binaural interaural time difference (ITD) discrimination were studied as functions of pulse rate in a group of bilaterally implanted cochlear implant users. Stimuli for the rate discrimination task were pulse trains presented to one electrode, which could be in the apical, middle, or basal part of the array, and in either the left or the right ear. In each two-interval trial, the standard stimulus had a rate of 100, 200, 300, or 500 pulses per second and the signal stimulus had a rate 35 % higher. ITD discrimination between pitch-matched electrode pairs was measured for the same standard rates as in the rate discrimination task and with an ITD of +/− 500 μs. Sensitivity (d′) on both tasks decreased with increasing rate, as has been reported previously. This study tested the hypothesis that deterioration in performance at high rates occurs for the two tasks due to a common neural basis, specific to the stimulation of each electrode. Results show that ITD scores for different pairs of electrodes correlated with the lower rate discrimination scores for those two electrodes. Statistical analysis, which partialed out overall differences between listeners, electrodes, and rates, supports the hypothesis that monaural and binaural temporal processing limitations are at least partly due to a common mechanism.

The effects of asymmetric hearing on bilateral brainstem function: findings in children with bimodal (electric and acoustic) hearing

As implantation criteria are broadening to include children with asymmetric hearing loss, it is important to determine the degree of residual hearing needed to protect the bilateral auditory pathways for binaural hearing and whether there is a sensitive period in development for implantation in these children. We have been studying these questions in a growing cohort of children. In the present study, auditory brainstem responses were recorded in 21 children who had 2.2 ± 2.2 years of bimodal hearing. Responses were evoked by 11-Hz acoustic clicks presented to the non-implanted ear and with biphasic electric pulses presented to the implanted ear. Twelve of these children also completed a behavioural task in which they were asked to which side of their heads bilaterally presented clicks/pulses that varied in interaural level or timing lateralized. All children experienced a delay in the non-implanted ear that resulted in 2.0 ± 0.35 ms longer peak latencies. These were further prolonged in 7 children as measured by longer interwave latencies from this ear than from the implanted ear. Despite large asymmetries in timing of brainstem activity between the two ears, all children perceived changes in interaural level differences. They were unable to detect differences in interaural timing cues. Symmetric brainstem function suggests bilateral development was preserved in some children. Future work will explore whether these children have better potential for developing binaural hearing using bimodal input.

Binaural enhancement for bilateral cochlear implant users

OBJECTIVES

Bilateral cochlear implant (BCI) users receive limited binaural cues and, thus, show little improvement to speech intelligibility from spatial cues. The feasibility of a method for enhancing the binaural cues available to BCI users is investigated. This involved extending interaural differences of levels, which typically are restricted to high frequencies, into the low-frequency region.

DESIGN

Speech intelligibility was measured in BCI users listening over headphones and with direct stimulation, with a target talker presented to one side of the head in the presence of a masker talker on the other side. Spatial separation was achieved by applying either naturally occurring binaural cues or enhanced cues.

RESULTS

In this listening configuration, BCI patients showed greater speech intelligibility with the enhanced binaural cues than with naturally occurring binaural cues.

CONCLUSIONS

In some situations, it is possible for BCI users to achieve greater speech intelligibility when binaural cues are enhanced by applying interaural differences of levels in the low-frequency region.

Self-reported spatial hearing abilities across different cochlear implant profiles

PURPOSE

The goal of this study was to determine how self-reported spatial hearing abilities differ across various cochlear implant (CI) profiles and to examine the degree of subjective benefit following cochlear implantation across different groups of CI users.

METHOD

This was a retrospective study of subjective spatial hearing ability of CI recipients. The subjects consisted of 99 unilateral CI users, 49 bilateral CI users, 32 subjects with a CI and contralateral hearing aid (bimodal users), and 37 short-electrode CI users. All subjects completed the Spatial Hearing Questionnaire (Tyler, Perreau, & Ji, 2009), a questionnaire assessing spatial hearing ability, after implantation, and a subset of the subjects completed the questionnaire pre- and postimplantation.

RESULTS

Subjective spatial hearing ability was rated higher for the bilateral and short electrode CI users compared to the unilateral and bimodal users. There was no significant difference in subjective spatial hearing performance between the bilateral and short electrode CI users and the unilateral CI and bimodal users. A separate analysis of pre- and postimplant performance revealed that all CI groups reported significant improvements in spatial hearing ability after implantation.

CONCLUSION

This study suggests that there are substantial differences in perceived spatial hearing ability among unilateral and bimodal CI users compared with bilateral and short electrode CI users.