Cochlear implant-evoked cortical activation in children with cochlear nerve deficiency

Hearing implants in pediatrics with cochlear nerve deficiency: an updated systematic review

OBJECTIVE

Cochlear nerve deficiency (CND) accounts for about one-third of congenital hearing loss cases and presents several challenges during management. Currently, cochlear implant (CI) and auditory brainstem implants (ABI) represent the primary management options for CND. However, robust evidence on the outcomes of different CND management approaches remains limited. Therefore, this systematic review seeks to update and assess the effectiveness of various CND management approaches.

DATABASES REVIEWED

PubMed, Scopus, Web of Science, and CENTRAL databases.

METHODS

We conducted an online bibliographic search across these databases. We included both interventional and observational studies evaluating CND management outcomes.

RESULTS

Of the 25 studies included, there were retrospective chart reviews, prospective observational studies, and one phase I clinical trial. Most studies focused on children with cochlear nerve aplasia or hypoplasia, with one study including patients with CHARGE syndrome. The mean age at the time of operation ranged from 0.5 to 4.5 years. Tools like the categories of auditory performance (CAP), speech intelligibility rating (SIR), and speech perception category (SPC) were commonly employed. CI outcomes were reported in 17 studies, while ABI outcomes were reported in 4 studies. The study found that the outcomes of both interventions were variable across the included studies.

CONCLUSION

While CI is feasible and an option in children with CND, its overall effectiveness is limited in some cases like cochlear nerve aplasia. Conversely, ABI appears to be a promising alternative with better auditory, speech, and learning outcomes.

Cochlear Implantation in Pediatric Cochlear Nerve Deficiency: A Systematic Review and Meta-Analysis

OBJECTIVE

Cochlear nerve deficiency (CND) is commonly implicated in moderate-to-profound pediatric sensorineural hearing loss (SNHL). Although cochlear implantation (CI) was previously contraindicated in CND patients, recent studies have demonstrated the potential for auditory response to CI in a subset of CND patients, though clinical outcomes remain variable. This study aims to evaluate pre- and postoperative speech and auditory outcomes of CI in pediatric patients with bilateral SNHL and radiographically confirmed CND.

DATA SOURCES

Embase and Ovid MEDLINE.

REVIEW METHODS

A systematic review was conducted to identify studies reporting pre- and postoperative outcomes of children with CND confirmed by magnetic resonance imaging who underwent CI. A random-effects model was used to account for within- and between-study variance in speech and auditory outcomes.

RESULTS

After abstract screening of 818 distinct articles, 16 studies were selected for final inclusion, consisting of 248 patients with cochlear nerve hypoplasia or aplasia who underwent CI. Various speech perception and language development tests were investigated across studies (Speech Intelligibility Rating, Speech Perception Category, Speech Awareness Thresholds, Meaningful Auditory Integration Scale, Meaningful Use of Speech Scale, Categories of Auditory Performance, and Auditory Level). Pooled outcomes demonstrated improvement in speech perception after CI in pediatric patients with CND (SMD 2.18, 95% CI 1.68-2.69).

CONCLUSION

Indications for CI are expanding as research demonstrates benefit in populations previously thought inappropriate. Our study demonstrates global postoperative improvement in speech and auditory outcomes in children with bilateral SNHL and CND after CI.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Cochlear implantation programming characteristics and outcomes of cochlear nerve deficiency

PURPOSE

Due to the specificity of cochlear implantation (CI) programming parameters and outcomes in cochlear nerve deficiency (CND) patients, this study aimed to investigate the correlation between programming parameters and outcomes and further compare the difference between normal and CND groups.

METHODS

Ninety (95 ears) CND patients (normal cochlea, 39; malformed cochlea, 56) and seventy-nine (81 ears) normal cochlea patients who underwent CI surgery with either Med-El or Cochlear devices were included. The programming parameters and outcomes evaluated by the questionnaires were collected and compared among the normal CND, malformed CND, and normal groups in the two device groups, and their correlation was analyzed.

RESULTS

In the CND group, a reduced stimulation rate, higher pulse width, and triphasic pulse were needed in some cases. The stimulus levels of the CND group were significantly higher than that of the normal group (p < 0.05), but the outcomes of the CND group were significantly worse than that of the normal group (p < 0.05), and the stimulus level was significantly correlated with the outcomes (p < 0.05). However, there was no difference between normal and malformed CND groups. The non-auditory response was observed in the CND group, especially the ones with malformations.

CONCLUSION

The CI programming parameters of some CND patients need to be adjusted, and a slower stimulation rate and higher pulse width are required sometimes. CND patients need a higher stimulus level than normal patients but their outcomes are poorer. Non-auditory response should be noticed in CND patients during programming.

Correlation between cortical auditory evoked potential and auditory speech performance in children with cochlear implants

OBJECTIVES

This study aimed to explore the correlation between the characteristics of cortical auditory evoked potential (CAEP) of children with cochlear implants (CIs) and auditory and speech rehabilitation performance by an objective evaluation technique and subjective auditory and speech skills measurements.

METHODS

All participants were recruited from Beijing Children's Hospital, Beijing, China. 19 children with CIs had their responses to the CAEP and MMN recorded. The LittlEARs® Auditory Questionnaire (LEAQ), Categories of Auditory Performance (CAP), Speech Intelligibility Rating Scale (SIR), Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS), and Meaningful Use of Speech Scale (MUSS) measures were taken to assess the children's speech and hearing abilities.

RESULTS

P1 and MMN of CAEP were negatively related to the duration of CI usage. The duration of CI usage and scores of auditory-verbal assessment questionnaires all showed significant relationships. Additionally, scores of these questionnaires were significantly inversely associated with the latency of P1 and MMN.

CONCLUSION

P1 and MMN could be used as objective methods to evaluate the effectiveness of hearing and speech rehabilitation in children with CIs. In particular to those who cannot give effectively feedback of auditory and verbal effects, these methods might have a certain guiding significance.

A Study of Outcome of Pediatric Cochlear Implantation in Patients with Cochleovestibular Nerve Deficiency

OBJECTIVES

A cochleovestibular nerve deficiency (CVND) could compromise stimulation of nerve by electrical pulses delivered from a cochlear implant, thereby hindering activity along auditory pathway. The evaluation of children with congenital hearing loss with a high-resolution magnetic resonance imaging is presently the investigative modality of choice to diagnose CVND. The aim of this study was to determine the outcomes in pediatric cochlear implant recipients with a diagnosis of CVND. The objectives included (1) to study the prevalence of CVND among children with prelingual congenital severe to profound hearing loss; (2) to assess post cochlear implantation (CI) outcomes in children with CVND using categories of auditory performance (CAP), speech intelligibility rating (SIR), and cortical auditory evoked potentials (CAEPs); and (3) to propose a management protocol for these children.

MATERIALS AND METHODS

All CI procedures performed during the study period in children 5 years or younger were included in study. All patients who were older than 5 years or had syndromic associations, multiple disabilities, second side or revision CI were excluded from the study. Children with unilateral cochleovestibular nerve aplasia and all other cases of CVND (type IIa and IIb) were advised to undergo CI on side with more radiologically robust nerve and/or cochlea anatomy. Children with bilateral CVND were included in group A, and age-matched cochlear implant candidates with normal cochleovestibular nerve anatomy were included in group B for statistical comparison of outcomes.

RESULTS

In group A, post CI CAP and SIR, CAEP amplitude and latency at 12 months showed statistically significant difference (p<0.05) compared with preoperative values. However, mean score of CAEP latency and amplitude and SIR score was worse for group A compared with group B at 12 months, which was statistically significant (p<0.05).

CONCLUSION

This study supports the fact that CI is a viable option to be offered in children with CVND (type IIa and IIb) for the development of auditory perception and speech.

Hearing Restoration in Cochlear Nerve Deficiency: the Choice Between Cochlear Implant or Auditory Brainstem Implant, a Meta-analysis

OBJECTIVE

To answer the dilemma clinician's face when deciding between cochlear implant (CI) and auditory brainstem implant (ABI) treatment options in patients with cochlear nerve deficiency (CND).

STUDY DESIGN

Case study supplemented with literature review and meta-analysis.

SETTING

Tertiary referral center.

PATIENT(S)

Child with CHARGE syndrome and congenital deafness.

INTERVENTION(S)

ABI as there was no benefit after bilateral cochlear implantation.

MAIN OUTCOME MEASURES

Speech and language development, quality of life.

RESULTS

In one ear the cochleovestibular nerve was present on magnetic resonance imaging (MRI) without preoperative ABR responses. In the contra lateral ear the nerve could not be identified, despite present ABR responses. Nevertheless, there was no positive outcome with CI. The patient had improved speech and language and quality of life with ABI. Of the 108 patients with CND and CI identified in the literature review, 25% attained open-set speech perception, 34% attained closed-set speech perception, and 41% detected sounds or less. The appearance of the cochlear nerve on MRI was a useful predictor of success, with cochlear nerve aplasia on MRI associated with a smaller chance of a positive outcome post cochlear implantation compared with patients with cochlear nerve hypoplasia.

CONCLUSION

Although patients with (apparent) cochlear nerve aplasia are less likely to benefit from CI, CI before ABI is supported as some patients attain closed or open-set levels of speech perception after cochlear implantation.

The Electrically Evoked Auditory Change Complex Evoked by Temporal Gaps Using Cochlear Implants or Auditory Brainstem Implants in Children With Cochlear Nerve Deficiency

OBJECTIVES

This study aimed to (1) establish the feasibility of measuring the electrically evoked auditory change complex (eACC) in response to temporal gaps in children with cochlear nerve deficiency (CND) who are using cochlear implants (CIs) and/or auditory brainstem implants (ABIs); and (2) explore the association between neural encoding of, and perceptual sensitivity to, temporal gaps in these patients.

DESIGN

Study participants included 5 children (S1 to S5) ranging in age from 3.8 to 8.2 years (mean: 6.3 years) at the time of testing. All subjects were unilaterally implanted with a Nucleus 24M ABI due to CND. For each subject, two or more stimulating electrodes of the ABI were tested. S2, S3, and S5 previously received a CI in the contralateral ear. For these 3 subjects, at least two stimulating electrodes of their CIs were also tested. For electrophysiological measures, the stimulus was an 800-msec biphasic pulse train delivered to individual electrodes at the maximum comfortable level (C level). The electrically evoked responses, including the onset response and the eACC, were measured for two stimulation conditions. In the standard condition, the 800-msec pulse train was delivered uninterrupted to individual stimulating electrodes. In the gapped condition, a temporal gap was inserted into the pulse train after 400 msec of stimulation. Gap durations tested in this study ranged from 2 up to 128 msec. The shortest gap that could reliably evoke the eACC was defined as the objective gap detection threshold (GDT). For behavioral GDT measures, the stimulus was a 500-msec biphasic pulse train presented at the C level. The behavioral GDT was measured for individual stimulating electrodes using a one-interval, two-alternative forced-choice procedure.

RESULTS

The eACCs to temporal gaps were recorded successfully in all subjects for at least one stimulating electrode using either the ABI or the CI. Objective GDTs showed intersubject variations, as well as variations across stimulating electrodes of the ABI or the CI within each subject. Behavioral GDTs were measured for one ABI electrode in S2 and for multiple ABI and CI electrodes in S5. All other subjects could not complete the task. S5 showed smaller behavioral GDTs for CI electrodes than those measured for ABI electrodes. One CI and two ABI electrodes in S5 showed comparable objective and behavioral GDTs. In contrast, one CI and two ABI electrodes in S5 and one ABI electrode in S2 showed measurable behavioral GDTs but no identifiable eACCs.

CONCLUSIONS

The eACCs to temporal gaps were recorded in children with CND using either ABIs or CIs. Both objective and behavioral GDTs showed inter- and intrasubject variations. Consistency between results of eACC recordings and psychophysical measures of GDT was observed for some but not all ABI or CI electrodes in these subjects.

Electrically Evoked Auditory Event-Related Responses in Patients with Auditory Brainstem Implants: Morphological Characteristics, Test-Retest Reliability, Effects of Stimulation Level, and Association with Auditory Detection

OBJECTIVE

This study aimed to (1) characterize morphological characteristics of the electrically evoked cortical auditory event-related potentials (eERPs) and explore the potential association between onset eERP morphology and auditory versus nonauditory stimulation; (2) assess test-retest reliability of onset eERPs; (3) investigate effects of stimulation level on onset eERPs; and (4) explore the feasibility of using the onset eERP to estimate the lowest stimulation level that can be detected for individual stimulating electrodes in patients with auditory brainstem implants (ABIs).

DESIGN

Study participants included 5 children (S1 to S5) and 2 adults (S6 to S7) with unilateral Cochlear Nucleus 24M ABIs. Pediatric ABI recipients ranged in age from 2.6 to 10.2 years (mean: 5.2 years) at the time of testing. S6 and S7 were 21.2 and 24.6 years of age at the time of testing, respectively. S6 and S7 were diagnosed with neurofibromatosis II (NF2) and implanted with an ABI after a surgical removal of the tumors. All pediatric subjects received ABIs after being diagnosed with cochlear nerve deficiency. The lowest stimulation level that could be detected (behavioral T level) and the estimated maximum comfortable level (C level) was measured for individual electrodes using clinical procedures. For electrophysiological measures, the stimulus was a 100-msec biphasic pulse train that was delivered to individual electrodes in a monopolar-coupled stimulation mode at stimulation levels ranging from subthreshold to C levels. Electrophysiological recordings of the onset eERP were obtained in all subjects. For studies evaluating the test-retest reliability of the onset eERP, responses were measured using the same set of parameters in two test sessions. The time interval between test sessions ranged from 2 to 6 months. The lowest stimulation level that could evoke the onset eERP was defined as the objective T level.

RESULTS

Onset eERPs were recorded in all subjects tested in this study. Inter- and intrasubject variations in morphological characteristics of onset eERPs were observed. Onset eERPs with complex waveforms were recorded for electrodes that evoked nonauditory sensations, based on feedback from subjects, as well as for electrodes without any indications of nonauditory stimulations. Onset eERPs in patients with ABIs demonstrated good test-retest reliability. Increasing stimulation levels resulted in increased eERP amplitudes but showed inconsistent effects on response latencies in patients with ABIs. Objective and behavioral T levels were correlated.

CONCLUSIONS

eERPs could be recorded in both non-NF2 and NF2 patients with ABIs. eERPs in both ABI patient groups show inter- and intrasubject variations in morphological characteristics. However, onset eERPs measured within the same subject in this study tended to be stable across study sessions. The onset eERP can potentially be used to estimate behavioral T levels in patients with ABIs. Further studies with more adult ABI recipients are warranted to investigate whether the onset eERP can be used to identify electrodes with nonauditory stimulations.

Temporal Response Properties of the Auditory Nerve in Implanted Children with Auditory Neuropathy Spectrum Disorder and Implanted Children with Sensorineural Hearing Loss

OBJECTIVE

This study aimed to (1) characterize temporal response properties of the auditory nerve in implanted children with auditory neuropathy spectrum disorder (ANSD), and (2) compare results recorded in implanted children with ANSD with those measured in implanted children with sensorineural hearing loss (SNHL).

DESIGN

Participants included 28 children with ANSD and 29 children with SNHL. All subjects used cochlear nucleus devices in their test ears. Both ears were tested in 6 children with ANSD and 3 children with SNHL. For all other subjects, only one ear was tested. The electrically evoked compound action potential (ECAP) was measured in response to each of the 33 pulses in a pulse train (excluding the second pulse) for one apical, one middle-array, and one basal electrode. The pulse train was presented in a monopolar-coupled stimulation mode at 4 pulse rates: 500, 900, 1800, and 2400 pulses per second. Response metrics included the averaged amplitude, latencies of response components and response width, the alternating depth and the amount of neural adaptation. These dependent variables were quantified based on the last six ECAPs or the six ECAPs occurring within a time window centered around 11 to 12 msec. A generalized linear mixed model was used to compare these dependent variables between the 2 subject groups. The slope of the linear fit of the normalized ECAP amplitudes (re. amplitude of the first ECAP response) over the duration of the pulse train was used to quantify the amount of ECAP increment over time for a subgroup of 9 subjects.

RESULTS

Pulse train-evoked ECAPs were measured in all but 8 subjects (5 with ANSD and 3 with SNHL). ECAPs measured in children with ANSD had smaller amplitude, longer averaged P2 latency and greater response width than children with SNHL. However, differences in these two groups were only observed for some electrodes. No differences in averaged N1 latency or in the alternating depth were observed between children with ANSD and children with SNHL. Neural adaptation measured in these 2 subject groups was comparable for relatively short durations of stimulation (i.e., 11 to 12 msec). Children with ANSD showed greater neural adaptation than children with SNHL for a longer duration of stimulation. Amplitudes of ECAP responses rapidly declined within the first few milliseconds of stimulation, followed by a gradual decline up to 64 msec after stimulus onset in the majority of subjects. This decline exhibited an alternating pattern at some pulse rates. Further increases in pulse rate diminished this alternating pattern. In contrast, ECAPs recorded from at least one stimulating electrode in six ears with ANSD and three ears with SNHL showed a clear increase in amplitude over the time course of stimulation. The slope of linear regression functions measured in these subjects was significantly greater than zero.

CONCLUSIONS

Some but not all aspects of temporal response properties of the auditory nerve measured in this study differ between implanted children with ANSD and implanted children with SNHL. These differences are observed for some but not all electrodes. A new neural response pattern is identified. Further studies investigating its underlying mechanism and clinical relevance are warranted.

Effect of Different References on Auditory-Evoked Potentials in Children with Cochlear Implants

Background: Nose reference (NR), mastoid reference (MR), and montage average reference (MAR) are usually used in auditory event-related potential (AEP) studies with a recently developed reference electrode standardization technique (REST), which may reduce the reference effect. For children with cochlear implants (CIs), auditory deprivation may hinder normal development of the auditory cortex, and the reference effect may be different between CIs and a normal developing group.

Methods: Thirteen right-side-CI children were recruited, comprising 7 males and 6 females, ages 2–5 years, with CI usage of ~1 year. Eleven sex- and age-matched healthy children were recruited for normal controls; 1,000 Hz pure tone evoked AEPs were recorded, and the data were re-referenced to NR, left mastoid reference (LMR, which is the opposite side of the implanted cochlear), MAR, and REST. CI artifact and P1–N1 complex (latency, amplitudes) at Fz were analyzed.

Results: Confirmed P1–N1 complex could be found in Fz using NR, LMR, MAR, and REST with a 128-electrode scalp. P1 amplitude was larger using LMR than MAR and NR, while no statistically significant difference was found between NR and MAR in the CI group; REST had no significant difference with the three other references. In the control group, no statistically significant difference was found with different references. Group difference of P1 amplitude could be found when using MR, MAR, and REST. For P1 latency, no significant difference among the four references was shown, whether in the CI or control group. Group difference in P1 latency could be found in MR and MAR. N1 amplitude in LMR was significantly lower than NR and MAR in the control group. LMR, MAR, and REST could distinguish the difference in the N1 amplitude between the CI and control group. Contralateral MR or MAR was found to be better in differentiating CI children versus controls. No group difference was found for the artifact component.

Conclusions: Different references for AEP studies do not affect the CI artifact. In addition, contralateral MR is preferable for P1–N1 component studies involving CI children, as well as methodology-like studies.

The electrically evoked cortical auditory event-related potential in children with auditory brainstem implants

OBJECTIVE

This study explored the feasibility of measuring electrically evoked cortical auditory event-related potentials (eERPs) in children with auditory brainstem implants (ABIs).

DESIGN

Five children with unilateral ABIs ranging in age from 2.8 to 10.2 years (mean: 5.2 years) participated in this study. The stimulus was a 100-msec biphasic pulse train that was delivered to individual electrodes in a monopolar stimulation mode. Electrophysiological recordings of the onset eERP were conducted in all subjects.

RESULTS

The onset eERP was recorded in four subjects who demonstrated auditory perception. These eERP responses showed variations in waveform morphology across subjects and stimulating electrode locations. No eERPs were observed in one subject who received no auditory sensation from ABI stimulation.

CONCLUSIONS

eERPs can be recorded in children with ABIs who develop auditory perception. The morphology of the eERP can vary across subjects and also across stimulating electrode locations within subjects.

Developmental and cross-modal plasticity in deafness: evidence from the P1 and N1 event related potentials in cochlear implanted children

Cortical development is dependent on extrinsic stimulation. As such, sensory deprivation, as in congenital deafness, can dramatically alter functional connectivity and growth in the auditory system. Cochlear implants ameliorate deprivation-induced delays in maturation by directly stimulating the central nervous system, and thereby restoring auditory input. The scenario in which hearing is lost due to deafness and then reestablished via a cochlear implant provides a window into the development of the central auditory system. Converging evidence from electrophysiologic and brain imaging studies of deaf animals and children fitted with cochlear implants has allowed us to elucidate the details of the time course for auditory cortical maturation under conditions of deprivation. Here, we review how the P1 cortical auditory evoked potential (CAEP) provides useful insight into sensitive period cut-offs for development of the primary auditory cortex in deaf children fitted with cochlear implants. Additionally, we present new data on similar sensitive period dynamics in higher-order auditory cortices, as measured by the N1 CAEP in cochlear implant recipients. Furthermore, cortical re-organization, secondary to sensory deprivation, may take the form of compensatory cross-modal plasticity. We provide new case-study evidence that cross-modal re-organization, in which intact sensory modalities (i.e., vision and somatosensation) recruit cortical regions associated with deficient sensory modalities (i.e., auditory) in cochlear implanted children may influence their behavioral outcomes with the implant. Improvements in our understanding of developmental neuroplasticity in the auditory system should lead to harnessing central auditory plasticity for superior clinical technique.

Unilateral cochlear nerve deficiency in children

OBJECTIVE

Cochlear nerve deficiency (CND) is increasingly diagnosed in children with sensorineural hearing loss (SNHL). We sought to determine the prevalence of CND, its imaging characteristics, and correlations with audiologic phenotype in children with unilateral SNHL.

DESIGN

Case series with chart review.

SETTING

Tertiary pediatric hospital.

SUBJECTS/METHODS

In 128 consecutive children with unilateral SNHL who underwent high-resolution magnetic resonance imaging, the diameters, area, and signal intensity of the cochlear nerve (CN) were measured and normalized to the ipsilateral facial nerve. Presence of CND was determined by comparison to normative data. Relationships among hearing loss severity, progression, and nerve size were investigated.

RESULTS

Cochlear nerve deficiency was present in 26% of children with unilateral SNHL. Its prevalence was higher (48%) in severe to profound SNHL, especially when in infants (100%). Width of the bony cochlear nerve canal (BCNC) correlated strongly with relative CN diameter, density, and area (R = 0.5); furthermore, a narrow BCNC (<1.7 mm) strongly predicted CND. Severity of hearing loss modestly correlated with nerve size, although significant variability was observed. Progression never occurred unless there were other inner ear malformations, whereas in the non-CND group, it occurred in 22%. Ophthalmologic abnormalities were very common (67%) in CND children, particularly oculomotor disturbances.

CONCLUSION

Cochlear nerve deficiency is a common cause of unilateral SNHL, particularly in congenital unilateral deafness. Width of the BCNC effectively predicts CND, a finding useful when only computed tomography imaging is available. In an ear with CND, hearing can be expected to remain stable over time. Diagnosis should prompt evaluation by an ophthalmologist.