RESUMO
OBJECTIVES: Adult cochlear implant (CI) recipients obtain varying levels of speech perception from their device. Adult CI users adapt quickly to their CI if they have no peripheral "bottom-up" or neurocognitive "top-down" limiting factors. Our objective here was to understand the influence of limiting factors on the progression of sentence understanding in quiet and in noise, initially and over time. We hypothesized that the presence of limiting factors, detected using a short test battery, would predictably influence sentence recognition with practical consequences. We aimed to validate the test battery by comparing the presence of limiting factors and the success criteria of >90% sentence understanding in quiet 1 month after activation. DESIGN: The study was a single-clinic, cross-sectional, retrospective design incorporating 32 adult unilateral Nucleus CI users aged 27 to 90 years (mean = 70, SD = 13.5). Postoperative outcome was assessed through sentence recognition scores in quiet and in varying signal to noise ratios at 1 day, 1 to 2 months, and up to 2 years. Our clinic's standard test battery comprises physiological and neurocognitive measures. Physiological measures included electrically evoked compound action potentials for recovery function, spread of excitation, and polarity effect. To evaluate general cognitive function, inhibition, and phonological awareness, the Montreal Cognitive Assessment screening test, the Stroop Color-Word Test, and tests 3 and 4 of the French Assessment of Reading Skills in Adults over 16 years of age, respectively were performed. Physiological scores were considered abnormal, and therefore limiting, when total neural recovery periods and polarity effects, for both apical and basal electrode positions, were >1.65 SDs from the population mean. A spread of excitation of >6 electrode units was also considered limiting. For the neurocognitive tests, scores poorer than 1.65 SDs from published normal population means were considered limiting. RESULTS: At 1 month, 13 out of 32 CI users scored ≥90% sentence recognition in quiet with no significant dependence on age. Subjects with no limiting peripheral or neurocognitive factors were 8.5 times more likely to achieve ≥90% score in quiet at 1 month after CI switch-on (p = 0.010). In our sample, we detected 4 out of 32 cases with peripheral limiting factors that related to neural health or poor electrode-neural interface at both apical and basal positions. In contrast, neurocognitive limiting factors were identified in 14 out of 32 subjects. Early sentence recognition scores were predictive of long-term sentence recognition thresholds in noise such that limiting factors appeared to be of continuous influence. CONCLUSIONS: Both peripheral and neurocognitive processing factors affect early sentence recognition after CI activation. Peripheral limiting factors may have been detected less often than neurocognitive limiting factors because they were defined using sample-based criteria versus normal population-based criteria. Early performance was generally predictive of long-term performance. Understanding the measurable covariables that limit CI performance may inform follow-up and improve counseling. A score of ≥90% for sentence recognition in quiet at 1 month may be used to define successful progress; whereas, lower scores indicate the need for diagnostic testing and ongoing rehabilitation. Our findings suggest that sentence test scores as early as 1 day after activation can provide vital information for the new CI user and indicate the need for rehabilitation follow-up.
RESUMO
OBJECTIVE: Normal-hearing subjects listening to acoustic simulations of cochlear implants (CI) can obtain sentence recognition scores near 100% in quiet and in 10 dB signal-to-noise ratio (SNR) noise with acute exposure. However, average sentence recognition scores for real CI listeners are generally lower, even after months of experience, and there is a high degree of heterogeneity. Our aim was to identify the relative importance and strength of factors that prevent CI listeners from achieving early, 1-mo scores as high as those for normal-hearing-listener acoustic simulations. DESIGN: Sentence recognition scores (100 words/list, 65 dB SPL) using CI alone were collected for all adult unilateral CI listeners implanted in our center over a 5-yr period. Sentence recognition scores in quiet and in 10 dB SNR 8-talker babble, collected from 1 to 12 mo, were reduced to a single dependent variable, the "initial" score, via logarithmic regression. "Initial" scores equated to an improved estimate of 1-mo scores, and integrated the time to rise above zero score for poorer performing subjects. Demographic, device, and medical data were collected for 118 subjects who met standard CI candidacy criteria. Computed tomography of the electrode array allowing determination of the insertion depth as an angle, and the presence or absence of scala dislocation was available for 96 subjects. Predictive factors for initial scores were selected using stepwise multiple linear regression. The relative importance of predictive factors was estimated as partial r with a low bias method, and statistical significance tested with type II analysis of variance. RESULTS: The etiologies chronic otitis and autoimmune disease were associated with lower, widely variable sentence recognition scores in the long-term. More than 60% of CI listeners scored >50/100 in quiet at 1 mo. Congenital hearing loss was associated with significantly lower initial scores in quiet (r 0.23, p < 0.001), as was longer duration of hearing loss (r 0.12, p < 0.001, -0.76 pts per year). Initial scores were negatively correlated with insertion depth (r 0.09, p < 0.001, -0.1 pts per degree), with the highest initial scores being obtained for insertion depths of 300° to 400°. A much greater proportion of scala dislocations was found for perimodiolar arrays compared with straight arrays. Scores were negatively correlated with the proportion of the active electrode array found in scala vestibuli for Nucleus perimodiolar devices (r 0.14, p < 0.01, coefficient -25). Similar overall results were obtained for sentence recognition scores in noise (+10 dB SNR). The intercept value for the obtained regression functions indicated that CI listeners with the least limiting factors generally scored ~95/100 in quiet and ~90/100 in noise. In addition, CI listeners with insertion angles as low as 315° to 360° could obtain sentence recognition scores >80/100 even at 1 day after activation. Insertion depths of 360° were estimated to produce frequency-place mismatches of about one octave upward shift. CONCLUSIONS: Patient-related factors etiology and duration of deafness together explained ~40% of the variance in early sentence recognition scores, and electrode position factors ~20%. CI listeners with insertion depths of about one turn obtained the highest early sentence recognition scores in quiet and in noise, and these were comparable with those reported in the literature for normal-hearing subjects listening to 8 to 12 channel vocoder simulations. Differences between device brands were largely explained by differences in insertion depths. This indicates that physiological frequency-place mismatches of about one octave are rapidly accommodated by CI users for understanding sentences, between 1 day to 1 mo postactivation, and that channel efficiency may be significantly poorer for more deeply positioned electrode contacts.