1. Key note: Bilateral restoration of hearing
A. Aschendorff, T. Wesarg, S. Kröger, R. Beck, R. Laszig, S. Arndt
Dept. of Otorhinolaryngolgoy and IMplant Center Freiburg
University of Freiburg

2. Implant Center Freiburg (ICF)
CI, ABI, implantable hearing devices
Re-habilitation and long-term-care
> 2500 CI patients
> 250 CI surgeries /y.
Adults + children
Center of competence Baden-Württemberg
Interdisciplinary team:
ENT, audiology, speech and language therapy, linguistics, psychology, music therapy, technicians… (n=44)
certified rehabilitation center (BAR)

3. Age at surgery
NHS, diagnostics and HA experience for 4 m., decision at 8 m.
Surgical point of view: ideal at/around 10 m.
Surgical technique: atraumatic
Specialized centers for surgery in the very young?
Data on even earlier surgery? (Colletti et al. 2012…

4. Fact and fiction? – Age at surgery (Germany)
2012 %
Significant increase for surgeries <24 m.
to 2006: 25,2% <2 y., ,3% < 2 y.
still, 53,7% of children are older than 24 m.
Reason? Late provision with HA, reservations against early surgery, add. med. factors, progressive hearing loss! (Fitzpatrick et al. 2011)

5. Long term outcome vs. age at surgery Monosyllables (> 5 y
Long term outcome vs. age at surgery Monosyllables (> 5 y. post CI) Laszig et al. 2010, Dissertation R. Beck, Richter et al. 2002, Tajudeen et al. 2010, de Raeeve 2010, Colletti et al. 2011
***
m 1,3 J. n=38
m 2,7 J. n=139
m 7,2 J. n= 86
m 45,4 J. n=199
Group A with superior resuts Group D: adults, congenital as well as progress. HL

6. Bilateral CI German "Guideline CI": bilateral CI whenever possible
Schafer et al (Int J Audiol) "A meta-analysis to compare speech recognition in noise with bilateral cochlear implants and bimodal stimulation" (42 studies analysed):
binaural advantages in bilaterale CI`s:
squelch (central noise reduction), summation, head-shadow effect
advantage compared to bimodal stimulation
German "Guideline CI": bilateral CI whenever possible
German health insurance: bilateral CI in cases at risk of or with obliteration/meningitis
all others: single-case decision, sequentially or simultaneously
All centers: increasing number of bilaterals, no combined approach
UK: National Paediatric Bilateral Cochlear Implant Audit

7. Bilateral situation in Freiburg
N= 2234 (Stand )
Mean intervall 1st to 2nd implant (all p. up to 18 y.): 5.9 years!
Since 2006: significant reduction to 1.7 y.
improved counseling
Aim: 2nd CI within 12 m.
Sequentiell Kinder n=229
Kinder n=281
Intervall in Jahren, Alter bis 12 J.
Bilaterale n=446

8. Late sequential BCI: Results OLSA at 70 dB in quiet,
Late sequential BCI: Results OLSA at 70 dB in quiet, *progressive HL, n=15, mean interval between 1st and 2nd CI: 8 y., (r: 4-12 y.) Delay: necessary time to reach results of 1st ear or stable longterm result
Not all will acchieve identical results, chance of drop out and, finally, rejection of 2nd implant
*develop
*develop
*numbers
Delay: <1y y y. 3y y.

9. The sequential problem
Bilateral advantage correlated to time between surgeries, interval >8 y. seems critical Steffens et al (H, RB, FR)
Late sequential BCI: negative effect visible at time interval of >12 M, Gordon et al. 2008
Exemption: progressive hearing loss!

10. …and… where´s the beef?
New field: auditory rehabilitation in single-sided deafness and asymmetric hearing loss
Similar considerations, similar factors to influence results

11. Why bother?
70-93% report difficulties for speech comprehension in noise, independent of age (Coletti et al. 1988; Ruscetta et al. 2005; Priwin et al. 2007; Wie et al. 2009)
12-41% of children require additional support in school (Bess & Tharpe 1986; Bovo et al. 1988)
22-35% of children have to repeat classes (Bess and Tharpe 1986; Brockhauser et al. 1991; Cho Lieu et al. 2004)
Misinterpretation hyperactivity
Results in adults are encouraging therapy in children as well

12. Incidence of unilateral HL in NHS
Unclear!
Berninger & Westling 2011:
NHS (6 y., >30.000)
bilateral HL 0.17%, unilateral 0.06% (Ratio 3:1)
Ghirri et al. 2011:
NHS, (>7000), unilat. HL 0.99/1000
Nie 2008, (China):
bilateral HL 2.22/1000, unilateral 2.74/1000 newborn

13. Etiology adults (n=101) n=93 postlingual, n=10 congenital, n=10 AHL

14. Freiburg: only n=8 qualified for a CI!
Etiology children (n=16) n=11 congenital, n=4 erworben, n=1 non organic
Etiology
(incl. 1 CHARGE)
Kutz et al. 2011: deficient nerve: limited results, absent nerve: poor results
Freiburg: only n=8 qualified for a CI!

15. Eiology children SSD I
Unilateral LAV in n=2 children

16. Etiology children SSD II
HRCT: IAM normal, MRI: CND/aplasia of VIIIth nerve, n=5
CHARGE, N VII aplasia R, N VIII aplasia L

17. SSD: treatment options?
no therapy
conventional CROS-HA
BAHS for CROS
Vanecloo et al. 2002
Cochlear Implantation
Vermeire et al. 2008; Arndt et al. 2011
Adults! 17

18. Rehabilitation in patients with unilateral deafness Study design
primary objective:
audiometric test results (speech discrimination in noise, localisation)
unaided, Baha, CROS-HA
trial period for each device 3 weeks
(Baha BP100 headband/CROS-HA; Phonak Una M)
CI recommended, if patients fitted the inclusion criteria
(duration of deafness ≤ 10 years, intact auditory nerve)
secondary objective:
results after 12 months with chosen device (CROS; Baha; CI)
comparison between the devices
subjective evaluation with SSQ scale

19. Rehabilitation in patients with unilateral deafness Audiometric test
test setup
speech test
HSM-sentences in noise (Hochmair-Desoyer et al. 1997)
65 dB SPL, 65 dB SPL, SNR 0 dB
 % correct answers

20. Rehabilitation in patients with unilateral deafness Localisation test
test setup
stimuli
OlSa sentences (Wagener et al. 1999)
mean sound level: 65 dB SPL
level randomisation: ± 6 dB SPL
 localisation error [°]

21. Rehabilitation in patients with unilateral deafness Patients
overall: adult patients
mean duration of deafness: years (1 month years)
decision
CROS
Baha CI
No. of patients after test trial
(outside CI inclusion criteria) 12
(8) 19
(12) 45
No. of patients with 12 month results (outside CI inclusion criteria) 7
(3) 16 25
drop out 8
all devices rejected
not yet decided 5
~ 25 %

22. Speech discrimination and localisation results: CROS group (n=7)* * *
correct [%]
error [°]

23. Speech discrimination and localisation results: Baha group (n=16)** * # ** * * * ** #
error [°]
correct [%]

24. Speech discrimination and localisation results: CI group (n=25)
*** ** **
***
*** # *
***
*** **
*** *
*** ** ** *
*** *
correct [%]
error [°]

25. Comparison of speech discrimination and localisation: Results after 12-month device use# *
error [°]
correct [%]

26. Comparison of speech discrimination and localisation: Results after 12-month device use#
***
*** * # #
*** * *
correct [%]
error [°]

27. Correlation of benefit (aided - unaided speech understanding) in noise in relation vs. duration of deafness
CROS
Baha CI
benefit/ %
duration of deafness/ years

28. Correlation of speech understanding in SciNnh vs
Correlation of speech understanding in SciNnh vs. duration of deafness after 12 months CI use
r=-0, (p=0,001, **)
SV / % = -5, * duration of deafness / years ,667
otosclerosis

29. Correlation of benefit (binaural/12 months CI use) - monaural /preop) to duration of deafness
r=-0, (p=0,001947, **)
SV Benefit / % = -4, * duration of deafness / years ,505605
labyrinthitis

30. Subjective evaluation after 12-month device use - SSQ scale
***
***
*** ** * * * *
speech spatial quality

31. Conclusion after 12 months device experience:
superior results with CI in speech discrimination in all conditions
significant improvement in localisation with CI
outcome/ rehabilitation time may be correlated to duration of deafness, training necessary
patients with long duration of deafness rather benefit from Baha or CROS device
CI with long duration of deafness: more data necessary
 critical question: duration of deafness to still recommend CI
If patients are within inclusion criteria for CI:
first choice  CI
second choice  Baha or CROS (better results with Baha)
Baha and CROS cannot prevent deprivation of the auditory pathway

32. …and in children? Speech in quiet (n=3)
Freiburg 70 dB
child 3 (6 y., congenital, Göttinger I, per audio input , 70 dB):
3 m.: 40% monosyllables
6 m.: 50 % monosyllables

33. SSD children vs. adults:
Results after 12 m., acquired deafness
Unknown: development in congential deafness? Sensitive phases? Maximum duration of deafness?
Kind Kind Erwachsene (n=22) CI
***
unaided
with CI
65 dB, Pegelrandom.
stimuli
noise CI
Sprache
Lärm
child child 2 adults (n=22) **
65 dB, S/N 0 33

34. Bilateral restoration of hearing
In bilateral HL: bilateral CI or bimodal stimulation
Results: UK BCI Audit
New: auditory rehabilitation in SSD and AHL
Evaluation similar to regular CI, MRI necessary
Pseudostereophonic BAHS, CROS, Bonebridge with poorer results, but may be indicated in special cases
Age, duration of deafness, prior surgery like AN, aplasia of VIIIth nerve, ossification…
Training necessary
Children:
congenital SSD: early treatment, results?
acquired SSD: results comparable to adults

35. Unaided speech understanding in noise in relation to duration of deafness
CROS
Baha CI
% correct
duration of deafness/ years