Predicting Performance and Non-Use in Prelingually Deaf and Late-Implanted Cochlear Implant Users

American Cochlear Implant Alliance Task Force: Recommendations for Determining Cochlear Implant Candidacy in Adults

The indications for cochlear implantation have expanded over time due to evidence demonstrating identification and implantation of appropriate cochlear implant (CI) candidates lead to significant improvements in speech recognition and quality of life (QoL). However, clinical practice is variable, with some providers using outdated criteria and others exceeding current labeled indications. As a results, only a fraction of those persons who could benefit from CI technology receive it. This document summarizes the current evidence for determining appropriate referrals for adults with bilateral hearing loss into CI centers for formal evaluation by stressing the importance of treating each ear individually and a "revised 60/60 rule". By mirroring contemporary clinical practice and available evidence, these recommendations will also provide a standardized testing protocol for CI candidates using a team-based approach that prioritizes individualized patient care. This manuscript was developed by the Adult Cochlear Implantation Candidacy Task Force of the American Cochlear Implant Alliance using review of the existing literature and clinical consensus. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:S1-S14, 2024.

Usher syndrome: Genetic diagnosis and current therapeutic approaches

Usher Syndrome (USH) is the most common deaf-blind syndrome, affecting approximately 1 in 6000 people in the deaf population. This genetic condition is characterized by a combination of hearing loss (HL), retinitis pigmentosa, and, in some cases, vestibular areflexia. Among the subtypes of USH, USH type 1 is considered the most severe form, presenting profound bilateral congenital deafness, vestibular areflexia, and early onset RP. USH type 2 is the most common form, exhibiting congenital moderate to severe HL for low frequencies and severe to profound HL for high frequencies. Conversely, type 3 is the rarest, initially manifesting mild symptoms during childhood that become more prominent in the first decades of life. The dual impact of USH on both visual and auditory senses significantly impairs patients’ quality of life, restricting their daily activities and interactions with society. To date, 9 genes have been confirmed so far for USH: MYO7A, USH1C, CDH23, PCDH15, USH1G, USH2A, ADGRV1, WHRN and CLRN1. These genes are inherited in an autosomal recessive manner and encode proteins expressed in the inner ear and retina, leading to functional loss. Although non-genetic methods can assist in patient triage and disease extension evaluation, genetic and molecular tests play a pivotal role in providing genetic counseling, enabling appropriate gene therapy, and facilitating timely cochlear implantation (CI). The CRISPR/Cas9 system and viral-based gene replacement therapy have recently emerged as highly promising techniques for treating USH. Regarding drug therapy, PTC-124 and Nb54 have been identified as promising drug interventions for genetic HL in USH. Simultaneously, CI has proven to be critical in the restoration of hearing. This review aims to summarize the genetic and molecular diagnosis of USH and highlight the importance of early diagnosis in guiding appropriate treatment strategies and improving patient prognosis.

Can Mandarin-speaking prelingual deaf adults benefit from cochlear implant?

BACKGROUND

With advances in cochlear implant (CI) technology, prelingual deaf adults may experience improved speech perception and quality of life (QoL). It is still a challenge for Mandarin-speaking CI user with tone recognition due to CI technology focused on intonation language.

OBJECTIVES

To evaluate the long-term post-CI auditory performance and social-emotional benefits in prelingual deaf Mandarin-speaking adults and the difference between them and post-lingual deaf adults.

MATERIAL AND METHODS

Fifty-five adult implanted ears were included (forty-six postlingual deaf group; nine prelingual deaf group). Post-CI long-term outcomes were using vowels, consonants, disyllabic words, Mandarin monosyllable words, categories of audiology performance, speech intelligibility rating, subjective social-emotional questionnaires.

RESULTS

Post-CI auditory performance and speech intelligibility of prelingual deafness adults was significantly inferior to that of those with postlingual deafness. However, both groups presented improved social-emotional benefits, with no significant difference between both groups.

CONCLUSIONS

Adult CI recipients who deaf before the age of 4 can experience benefits in social-emotional life functioning, regardless of their limited auditory performance and speech intelligibility. Therefore, prelingual Mandarin-speaking deaf adults, especially those using oral communication, can be considered as relative indications for cochlear implantation.

SIGNIFICANCE

To clarify and validate the benefits among Mandarin-speaking prelingual deaf adult recipients.

Cochlear Implant Outcomes: Quality of Life in Prelingually Deafened, Late-Implanted Patients

AIMS

Reevaluating and expanding cochlear implantation's (CI) indication while measuring the quality of life (QoL) outcomes regarding the parent's point of view of prelingually deafened, late-implanted patients, which are widely known to showcases a limited improvement in speech recognition.

MATERIALS AND METHODS

A retrospective descriptive and analytic study to assess QoL outcomes from CI in 64 early deafened, late-implanted patients, according to their parent's perspective, between January 2009 and December 2019, using the Nottingham Pediatric Cochlear Implant Program (Nottingham University Hospital, Nottingham, United Kingdom) "Children with cochlear implantation: parents perspective."

RESULTS

The most represented age interval is the 5 and 7 interval and the mean age is 10.09 years. There was no sex predominance, with rural origin and high school academicals level preponderance. Fourteen children had experienced neonatal icterus, eight had meningitis, and seven were the result of related marriage. The age of the first consultation was typically over 2 years old, with only 45 schooled children. Age had a significantly statistic correlation between Self-reliance and Well-being and happiness subscales. History of receiving aid and speech therapy has a clear correlation with Self-reliance, Well-being and happiness, and Communication and Education. Schooling statuses, sex, age of appearance, and communication mode were not correlated to any subscale score, and with the exception of Effect of implantation, all the other "Children with cochlear implantation: parent's perspective" subscales were intercorrelated.

CONCLUSION

Properly validated QoL assessments for CI are a must, as outcomes of CI expand beyond audiometric performances to include the improvement of QoL.

Improving speech perception for hearing-impaired listeners using audio-to-tactile sensory substitution with multiple frequency channels

Cochlear implants (CIs) have revolutionised treatment of hearing loss, but large populations globally cannot access them either because of disorders that prevent implantation or because they are expensive and require specialist surgery. Recent technology developments mean that haptic aids, which transmit speech through vibration, could offer a viable low-cost, non-invasive alternative. One important development is that compact haptic actuators can now deliver intense stimulation across multiple frequencies. We explored whether these multiple frequency channels can transfer spectral information to improve tactile phoneme discrimination. To convert audio to vibration, the speech amplitude envelope was extracted from one or more audio frequency bands and used to amplitude modulate one or more vibro-tactile tones delivered to a single-site on the wrist. In 26 participants with normal touch sensitivity, tactile-only phoneme discrimination was assessed with one, four, or eight frequency bands. Compared to one frequency band, performance improved by 5.9% with four frequency bands and by 8.4% with eight frequency bands. The multi-band signal-processing approach can be implemented in real-time on a compact device, and the vibro-tactile tones can be reproduced by the latest compact, low-powered actuators. This approach could therefore readily be implemented in a low-cost haptic hearing aid to deliver real-world benefits.

Long-term speech perception performance in prelingually deafened adult cochlear implant recipients

To investigate the postoperative long-term outcomes after an average of 9.2 years following cochlear implantation (CI) in prelingually deafened adults, along with preimplantation factors predicting postoperative outcomes.

Twenty-six prelingually deafened adults who underwent CI at >18 years were compared with those who had undergone CI in childhood (<9 years) and were >10 years old. Outcome measures includedhearing thresholds, preoperative and postoperative aided hearing level (HL), speech discrimination score (SDS), and Categories of Auditory Performance (CAP) scores. Correlation analyses were performed on the following: SDS results, aided HL, school attendant status, implant manufacturers, and speech processor models.

Improvement was achieved in the aided HL and SDS results, although these results were not better than those of the child group. CAP score was also statistically significantly improved after CI. Statistically significant correlation between the preoperative SDS and postoperative HL with CI results was observed. In other words, the better the preoperative SDS results, the better the postoperative SDS results.

Prelingually deafened adults achieved considerable improvement through CI. It is important to understand that patients achieving better hearing with a well-fitted hearing aid and good SDS performance before surgery may be good candidates for CI.

Long-Term Non-Users of Transcutaneous Auditory Implants: Thirty Years of Experience at a Single Institution

Background: Although it is a recognized phenomenon, there is little published in the literature on the discontinuation of auditory implant use. Aim: To evaluate the incidence of device non-use of transcutaneous auditory implants. Patients and Methods: This is a retrospective study of all living individuals (children and adults) implanted at the La Paz Hospital (Madrid, Spain) between 1992-2015, with a follow-up examination endpoint of December 2022. 356 device recipients were included: 316 with cochlear implants (CI), 22 with middle-ear implants (Vibrant Soundbridge, VSB), and 18 with bone conduction implants (Bonebridge, BB). Results: Nine CI recipients (2.8%) were identified as non-users (mean follow-up 15.1 ± 5.4 years). The reasons for non-use were implant failure and reimplantation rejection, lack of benefit, non-attendance of rehabilitation sessions, loss of the audio processor, and cognitive and linguistic difficulties. None of them experienced any surgical complications. Six VSB recipients (27.3%) were device non-users (mean follow-up 11.4 ± 2.1 years). All of them experienced device failure or surgical complications. To date, none of the BB recipients is a non-user (mean follow-up 8.6 ± 1.1 years). Conclusion: The rates of non-use of transcutaneous auditory implants vary widely between different types of implants. Given the small proportion of non-users, information on what are the predictive factors could not be determined. The reasons for non-use should be carefully documented and used to guide careful patient selection to reduce the risk of non-use in future candidates.

Analysis of outcomes for communication mode in cochlear implant in prelingually deafened adults

OBJECTIVE

Recent studies have suggested that speech perception outcomes after cochlear implantation (CI) in prelingually deafened adults have improved with advances in CI technology and speech processing strategies. However, the outcomes vary from case to case. Communication mode has been reported in many studies as the factor that related to the post CI outcomes. This study aimed at investigating the post CI outcomes and the progress during 2 years for each communication mode.

MATERIAL AND METHODS

The subjects were 17 prelingually deafened adults undergoing CI at our hospital between April 2013 and March 2019. We investigated preoperative factors affecting post CI outcomes. Also we analyzed post CI outcomes for each communication mode and compared preoperative factors for each communication mode.

RESULTS

Communication mode and preoperative discrimination score were the factor affecting on postoperative discrimination score. The speech perception score after CI improved significantly in the oral and lip-reading group and total communication group. The speech perception scores in postlingually deafened adults improved significantly during the first six months and became to plateau after CI. On the other hand, the scores of prelingually deafened adults tended to improve gradually after six months postoperatively. Furthermore, the degree of improvement and progress differed by each communication mode.

CONCLUSION

The communication mode is important factors in predicting outcomes in prelingually deafened adults after CI. Long-term auditory training is important for prelingually deafened adults who use visual information as their preoperative method of communication.

Candidacy for Cochlear Implantation in Prelingual Profoundly Deaf Adult Patients

Cochlear implantation is usually not recommended for prelingual profoundly deaf adults, although some of these patients might benefit from it. This study aims to define the candidates for cochlear implantation in this population. This retrospective study reviewed 34 prelingual profoundly deaf patients who had received a cochlear implant at 32 ± 1.7 years old (16−55), with at least 1 year of follow-up. Speech perception and quality of life were assessed before and 3, 6, and 12 months after cochlear implantation, then every year thereafter. According to the word speech intelligibility in quiet (WSI) 1 year after implantation, two groups were identified: good performer (GP) with WSI ≥ 50% (n = 15), and poor performer (PP) with WSI ≤ 40% (n = 19). At the 1 year mark, mean WSI improved by 28 ± 4.6% (−20−100) (p < 0.0001). In GP, the intelligibility for words and sentences, communication and quality of life scales improved. In PP, the communication scale improved, but not auditory performance or quality of life. GP and PP differed pre-operatively in speech production, communication abilities, and WSI in best-aided conditions. In prelingual profoundly deaf adults, a dramatic auditory performance benefit could be expected after cochlear implantation if the patients have some degree of speech intelligibility in aided conditions and have developed oral communication and speech production.

Factors influencing rehabilitation effect in prelingually deafened late implanted cochlear implant users, and the construction of a nomogram

OBJECTIVES

Our study aimed to identify potential factors that may influence rehabilitation outcomes in late-implanted adolescents and adults with prelingual deafness and to construct a user-friendly nomogram.

DESIGN

This cross-sectional study included 120 subjects under 30 years of age who had received cochlear implantation at a single medical center. The Categories of Auditory Performance (CAP) scale was used to evaluate the rehabilitation outcomes. A nomogram was constructed by using the R and EmpowerStats software.

RESULTS

Univariate analysis indicated higher rates of auditory performance improvement in younger aged subjects. Residual hearing and regular implant use were more frequently seen among subjects with auditory performance improvement. Multivariate analysis identified residual hearing (Hazard Ratio, 6.11; 95% Confidence Interval, 1.83-20.41; P<0.01), age group (Hazard Ratio, 0.31; 95% Confidence Interval, 0.14-0.83; P=0.02) and regular CI use (Hazard Ratio, 7.79; 95% Confidence Interval, 2.50-24.20; P<0.01) as independent predictors for auditory performance improvement. The nomogram's predictive performance was satisfactory as shown by the calibration curve and Receiver operating characteristic (ROC) curve.

CONCLUSIONS

Factors such as residual hearing, younger age, and regular CI use are associated with auditory performance improvement in this cochlear implant user population. The nomogram model also demonstrates a satisfactory predictive performance.

[Update cochlear-implantation: indications and surgical aspects]

In childhood, inadequately rehabilitated hearing loss leads to impaired language acquisition and social, mental and emotional development. In adults, social withdrawal due to limited communication skills is often a consequence of unsatisfactory hearing rehabilitation. Therefore, in patients with profound hearing loss, the indication for cochlear implantation should be considered. Technical advances in cochlear implant development, as well as in microsurgical techniques and the rehabilitation process, have led to an expansion of indications in recent years. Adequate hearing rehabilitation is associated not only with an improvement in hearing function and speech understanding, but also with an increase in quality of life at all ages. In patients with unilateral profound hearing loss, cochlear implantation leads to an improvement of speech understanding and localization ability as well as to a reduction of the head shadow effect and tinnitus. The indication process, surgical treatment and the subsequent rehabilitation process require interprofessional cooperation in specialized centers.

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.

Cochlear Implantation

BACKGROUND

Hearing impairment that is too severe to be adequately treated with conventional hearing aids can lead, in children, to severe developmental disturbances of hearing and language, and, in adults, to communicative and social deprivation. Recent advances in medical device technology and in microsurgical techniques have led to an expansion of the indications for cochlear implantation (CI) for adults with progressive hearing loss in older age, and to a restructuring of the process of care for these patients in Germany.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, as well as on the CI guidelines and CI "white book" of the German Society of Otolaryngology and Head and Neck Surgery.

RESULTS

Early and accurate diagnosis is crucial for the successful auditory rehabilitation of high-grade hearing impairment. In children, a key role is played by newborn auditory screening, which is mandatory in Germany and enables the provision of a CI in the first year of life when necessary. 86% of the children receiving a CI achieve linguistic comprehension of fluently spoken sentences. For adults, positive prognostic factors for hearing after the provision of a CI include a highly motivated patient, "postlingual" onset of the hearing impairment (i.e., after the acquisition of language), and a brief duration of deafness. Auditory rehabilitation is associated with significant improvement, not just of hearing and of the comprehension of spoken language, but also of quality of life, particularly in elderly patients. For patients of any age with bilateral hearing loss, CIs should be provided on both sides, if possible. The more common complications of the procedure, with a probability of 2-4% each, are technical implant defects, dizziness, and wound-healing disturbances.

CONCLUSION

Cochlear implantation, performed in specialized centers, is a safe and reliable technique and regularly enables the successful rehabilitation of hearing in both children and adults.

What can we learn from adult cochlear implant recipients with single-sided deafness who became elective non-users?

Objective: This retrospective study investigates the incidence of elective cochlear implant (CI) non-use amongst a cohort of adult CI recipients with single-sided deafness (SSD), identifies the causes that led to non-use, and assesses how non-use could be prevented. Methods: All adults with SSD who received a CI between 2008 and 2018 and who became elective CI non-users were included. Elective non-users were defined as CI recipients who decided to stop using their CI or, if explantation was necessary, refused reimplantation. Results: 5/114 (4.4%) adults with SSD who received a CI became elective non-users. The 5 non-users were a mean 44.2 years old (range 33-70 years) at implantation, had a mean duration of deafness of 7.1 years (range 0.5-20 years) at implantation, and used their CI for a mean 11.5 months (range 1.5-60 months) before (fully) discontinuing use. The primary cause of elective non-use was postoperative discouragement due to unrealistic expectations (4 participants) regarding sound perception with the CI or about the greater than expected level of commitment necessary for rehabilitation. Conclusions: Elective non-use among adult CI recipients with single-sided deafness was very rare and could be further prevented by comprehensive counselling to ensure that candidates have realistic expectations about the rehabilitation requirements and the outcomes with the CI.