An Integrative Review of Current Practice Models and/or Process of Family-Centered Early Intervention for Children Who Are Deaf or Hard of Hearing.

Over the past few decades, there has been an increasing shift toward emphasizing the importance of the child's family taking an active role in the habilitation process through family-centered early intervention (FCEI) programs. Accordingly, the Health Professions Council of South Africa recommends that early intervention services following confirmation of hearing loss must be family-centered within a community-based model of service delivery that is culturally congruent. The aim of this study was to explore and document current evidence reflecting trends in FCEI for children who are deaf or hard of hearing (DHH) by identifying and describing current practice models and/or processes of FCEI for these children. This study describes our first steps in formulating a framework for FCEI for children who are DHH in South Africa. An integrative literature review was conducted. Sage, Science Direct, PubMed, and Google Scholar databases were searched for studies published in English between January 2009 and January 2019 reporting on FCEI programs for children who are DHH. Studies that focused on the following were excluded from the study: speech and language outcomes of children, youth, and adults who are DHH; education for children who are DHH; universal newborn hearing screening; professionals' roles in early hearing detection and intervention; diagnosis of hearing loss; and sign language. Kappa statistics were performed to determine agreement between reviewers. Twenty-two studies were included in the review. Cohen's kappa revealed a substantial agreement (κ = 0.8) between reviewers for data extraction and synthesis in terms of the articles that met the criteria for inclusion in the review. Findings were discussed under 5 themes: caregiver involvement; caregiver coaching/information sharing; caregiver satisfaction; challenges with FCEI; and telehealth. Generally, there is sufficient evidence for FCEI, with caregivers indicating the need for full involvement in their children's care. Methods of caregiver involvement involving caregiver coaching/information sharing need to be culturally and linguistically appropriate, with sensitivities around time and manner. This increases caregiver satisfaction with intervention programs and improves outcomes for children who are DHH. Challenges identified by the studies raise implications for early hearing detection and intervention programs, as well as Departments of Health and Social Welfare. These included logistical challenges, professional-related challenges, and caregiver-related challenges. Various aspects of FCEI have been reported in the review. Findings of these studies have significant implications for the formulation of quality FCEI programs to ensure contextually relevant and contextually responsive care of children who are DHH.

The impact of temporal fine structure and signal envelope on auditory motion perception.

The majority of psychoacoustic research investigating sound localization has utilized stationary sources, yet most naturally occurring sounds are in motion, either because the sound source itself moves, or the listener does. In normal hearing (NH) listeners, previous research showed the extent to which sound duration and velocity impact the ability of listeners to detect sound movement. By contrast, little is known about how listeners with hearing impairments perceive moving sounds; the only study to date comparing the performance of NH and bilateral cochlear implant (BiCI) listeners has demonstrated significantly poorer performance on motion detection tasks in BiCI listeners. Cochlear implants, auditory protheses offered to profoundly deaf individuals for access to spoken language, retain the signal envelope (ENV), while discarding temporal fine structure (TFS) of the original acoustic input. As a result, BiCI users do not have access to low-frequency TFS cues, which have previously been shown to be crucial for sound localization in NH listeners. Instead, BiCI listeners seem to rely on ENV cues for sound localization, especially level cues. Given that NH and BiCI listeners differentially utilize ENV and TFS information, the present study aimed to investigate the usefulness of these cues for auditory motion perception. We created acoustic chimaera stimuli, which allowed us to test the relative contributions of ENV and TFS to auditory motion perception. Stimuli were either moving or stationary, presented to NH listeners in free field. The task was to track the perceived sound location. We found that removing low-frequency TFS reduces sensitivity to sound motion, and fluctuating speech envelopes strongly biased the judgment of sounds to be stationary. Our findings yield a possible explanation as to why BiCI users struggle to identify sound motion, and provide a first account of cues important to the functional aspect of auditory motion perception.

Electro-haptic stimulation enhances speech recognition in spatially separated noise for cochlear implant users.

Hundreds of thousands of profoundly hearing-impaired people perceive sounds through electrical stimulation of the auditory nerve using a cochlear implant (CI). However, CI users are often poor at understanding speech in noisy environments and separating sounds that come from different locations. We provided missing speech and spatial hearing cues through haptic stimulation to augment the electrical CI signal. After just 30 min of training, we found this "electro-haptic" stimulation substantially improved speech recognition in multi-talker noise when the speech and noise came from different locations. Our haptic stimulus was delivered to the wrists at an intensity that can be produced by a compact, low-cost, wearable device. These findings represent a significant step towards the production of a non-invasive neuroprosthetic that can improve CI users' ability to understand speech in realistic noisy environments.

The effect of a coding strategy that removes temporally masked pulses on speech perception by cochlear implant users.

Speech recognition in noisy environments remains a challenge for cochlear implant (CI) recipients. Unwanted charge interactions between current pulses, both within and between electrode channels, are likely to impair performance. Here we investigate the effect of reducing the number of current pulses on speech perception. This was achieved by implementing a psychoacoustic temporal-masking model where current pulses in each channel were passed through a temporal integrator to identify and remove pulses that were less likely to be perceived by the recipient. The decision criterion of the temporal integrator was varied to control the percentage of pulses removed in each condition. In experiment 1, speech in quiet was processed with a standard Continuous Interleaved Sampling (CIS) strategy and with 25, 50 and 75% of pulses removed. In experiment 2, performance was measured for speech in noise with the CIS reference and with 50 and 75% of pulses removed. Speech intelligibility in quiet revealed no significant difference between reference and test conditions. For speech in noise, results showed a significant improvement of 2.4 dB when removing 50% of pulses and performance was not significantly different between the reference and when 75% of pulses were removed. Further, by reducing the overall amount of current pulses by 25, 50, and 75% but accounting for the increase in charge necessary to compensate for the decrease in loudness, estimated average power savings of 21.15, 40.95, and 63.45%, respectively, could be possible for this set of listeners. In conclusion, removing temporally masked pulses may improve speech perception in noise and result in substantial power savings.

Formant frequency discrimination with a fine structure sound coding strategy for cochlear implants.

Recent sound coding strategies for cochlear implants (CI) have focused on the transmission of temporal fine structure to the CI recipient. To date, knowledge about the effects of fine structure coding in electrical hearing is poorly charactarized. The aim of this study was to examine whether the presence of temporal fine structure coding affects how the CI recipient perceives sound. This was done by comparing two sound coding strategies with different temporal fine structure coverage in a longitudinal cross-over setting. The more recent FS4 coding strategy provides fine structure coding on typically four apical stimulation channels compared to FSP with usually one or two fine structure channels. 34 adult CI patients with a minimum CI experience of one year were included. All subjects were fitted according to clinical routine and used both coding strategies for three months in a randomized sequence. Formant frequency discrimination thresholds (FFDT) were measured to assess the ability to resolve timbre information. Further outcome measures included a monosyllables test in quiet and the speech reception threshold of an adaptive matrix sentence test in noise (Oldenburger sentence test). In addition, the subjective sound quality was assessed using visual analogue scales and a sound quality questionnaire after each three months period. The extended fine structure range of FS4 yields FFDT similar to FSP for formants occurring in the frequency range only covered by FS4. There is a significant interaction (p = 0.048) between the extent of fine structure coverage in FSP and the improvement in FFDT in favour of FS4 for these stimuli. FS4 Speech perception in noise and quiet was similar with both coding strategies. Sound quality was rated heterogeneously showing that both strategies represent valuable options for CI fitting to allow for best possible individual optimization.

Comparison of electrode impedance measures between a dexamethasone-eluting and standard Cochlear™ Contour Advance® electrode in adult cochlear implant recipients.

OBJECTIVE: To compare the difference in electrode impedance across discrete time points to 24 months post-activation for two groups of adult cochlear implant recipients, one using an investigational perimodiolar (Contour Advance®) array augmented with 40% concentration weight per weight (w/w) dexamethasone (the Drug Eluting Electrode, 'DEE' Group), and the other the commercially available Contour Advance ('Control' Group). DESIGN: Ten adult subjects were implanted with the DEE and fourteen with the Control. Electrode impedances were measured intra-operatively, one-week post-surgery, at initial activation (approximately two-weeks post-surgery), and at approximately one, three, six, 12 and 24 months post-activation. Two different impedance measurements were obtained: 1) in MP1+2 mode using Custom Sound programming software; and 2) 4-point impedance measures utilising BP+2 stimulation mode with recording on non-stimulating electrodes. Data were analysed with respect to both impedance averaged across all electrodes, and impedance for electrodes grouped into basal, middle and apical sections. RESULTS: Group mean MP1+2 impedance for the DEE was significantly lower than for the Control at all post-operative time points examined, and for each of the basal, middle and apical cochlear regions. Group mean 4-point impedance was significantly lower for the DEE than the Control in the basal region at six, 12 and 24 months post-activation and in the middle region at 12- and 24-months post-activation. The pattern of change in MP1+2 impedance differed significantly in the early post-operative period prior to device activation. A significant 4.8 kOhm reduction in impedance between surgery and one-week was observed for the DEE group but not for the Control. A 2.0 kOhm increase between the one and two week post-operative time points was observed for the Control but not for the DEE group. CONCLUSION: While rates of adoption of different surgical approaches differed between the groups and this may have had a confounding effect, the results suggest that passive elution of dexamethasone from the investigational device was associated with a change in the intracochlear environment following surgical implantation of the electrode array, as evidenced by the lower electrode impedance measures.

Dynamic current steering with phantom electrode in cochlear implants.

Phantom electrode (PE) stimulation can extend the lower limit of pitch perception with cochlear implants (CIs) by using simultaneous out-of-phase stimulation of the most apical primary electrode and the adjacent basal compensating electrode. The total electrical field may push the excitation pattern beyond the most apical electrode to elicit a lower pitch, depending on the ratio of current between the compensating and primary electrodes (i.e., the compensation coefficient σ). This study tested the hypothesis that dynamic current steering of PE stimuli can be implemented by varying σ over time to encode spectral details in low frequencies. To determine the range of σ for current steering and the corresponding current levels, Experiment 1 tested CI users' loudness balance and pitch ranking of static PE stimuli with σ from 0 to 0.6 in steps of 0.2. It was found that the equal-loudness most comfortable level significantly increased with σ and can be modeled by a piecewise linear function of σ. Consistent with the previous findings, higher σ elicited either lower or similar pitches without salient pitch reversals than lower σ. Based on the results of Experiment 1, Experiment 2 created flat, rising, and falling pitch contours of 300-1000 ms using dynamic PE stimuli with time-varying σ from 0 to 0.6 and equal-loudness current levels. In a pitch contour identification (PCI) task, CI users scored 80% and above on average. Increasing the stimulus duration from 300 to 1000 ms slightly but did not significantly improve the PCI scores. Across subjects, the 1000-ms PCI scores in Experiment 2 were significantly correlated with the cumulative pitch-ranking sensitivity in Experiment 1. It is thus feasible to use dynamic current steering with PE to encode low-frequency pitch cues for CI users.

Binaural cue sensitivity in cochlear implant recipients with acoustic hearing preservation.

Bilateral acoustic hearing in cochlear implant (CI) recipients with hearing preservation may allow access to binaural cues. Sensitivity to acoustic binaural cues has been shown in some listeners combining electric and acoustic stimulation (EAS), yet remains poorly understood and may be subject to limitations imposed by the electrical stimulation and/or amplification asymmetries. The purpose of this study was to investigate the effect of stimulus level, frequency-dependent gain, and the addition of unilateral electrical stimulation on sensitivity to low-frequency binaural cues. Thresholds were measured for interaural time and level differences (ITD and ILD) carried by a low-frequency, bandpass noise (100-800 Hz). 16 adult CI EAS listeners (mean age = 50.2 years) each participated in three listening conditions: acoustic hearing only at 90 dB SPL, acoustic hearing only at 60 dB SPL with frequency-dependent gain, and acoustic hearing plus unilateral CI at 60 dB SPL with frequency-dependent gain applied to the acoustic channels only. Results revealed thresholds within the ecologically relevant ITD and/or ILD range for most EAS listeners. No significant effects of presentation level, frequency-dependent gain, or the addition of unilateral electrical stimulation on the resultant thresholds for ITDs or ILDs were observed at the group level. Correlational analyses related ITD and ILD thresholds to the degree of EAS benefit (i.e., advantage of acoustic hearing in the implanted ear) for speech recognition in diffuse noise. There was a significant relationship between EAS benefit and ITD thresholds, but no statistically significant relationship between EAS benefit and ILD thresholds. In summary, the results of this study are not consistent with our previous data obtained with simulated EAS in normal-hearing listeners, which showed significant binaural interference by a unilateral electrical "distractor" (Van Ginkel et al., 2019). The difference between studies suggests that chronic exposure to unilateral electrical stimulation combined with bilateral acoustic stimulation may reduce interference effects, perhaps because listeners adapt to the presence of the constant but binaurally incongruous CI stimulus. These results are consistent with past studies that demonstrated no interference in spatial hearing tasks due to the addition of a unilateral CI in adult EAS listeners.

Forward masking patterns by low and high-rate stimulation in cochlear implant users: Differences in masking effectiveness and spread of neural excitation.

The goal of the present study was to compare forward masking patterns by stimulation of low and high rates in cochlear implant users. Postlingually deafened Cochlear Nucleus® device users participated in the study. In experiment 1, two maskers of different rates (250 and 1000 pulses per second) were set at levels that produced equal masking for a probe presented at the same electrode as the maskers. This aligned the two masking functions at the on-site probe location. Then their forward masking patterns for the far probes were compared. Results showed that slope of the masked probe-threshold decay as a function of probe-masker separation was steeper for the high-rate than the low-rate masker. A linear model indicated that this difference in spread of neural excitation (SOE) was accounted for by two factors that were not correlated with each other. One factor was that the low-rate masker required a considerably higher current level to be equally effective in masking as the high-rate masker. The second factor was the effect of stimulation rate on loudness, i.e., integration of multiple pulses. This was consistent with our hypothesis that if an increase in stimulation rate does not result in an increased total neural response, then it is unlikely that the change in rate would change spatial distribution of the neural activity. Interestingly, the difference in masking effectiveness of the maskers predicted subjects' speech recognition. Poorer performers were those who showed more comparable masking effects by maskers of different rates. The difference in the masking effectiveness may indirectly measure the auditory neurons' excitability, which predicts speech recognition. In experiment 2, SOE of the high-rate and low-rate maskers were compared at a level that is clinically relevant, i.e., equal loudness. At equal loudness, high-rate stimulation not only produced an overall greater amount of forward masking, but also a shallower decay of masking with probe-masker separation (wider SOE), compared to low rate. The difference in SOE was the opposite to the findings from experiment 1. Whether the maskers were calibrated for equal masking or loudness, the absolute current level was always higher for the low-rate masker, which suggests that the SOE patterns cannot be explained by current spread alone. The fact that high-rate stimulation produced greater masking and wider SOE at equal loudness may explain why using high stimulation rates has not produced consistent benefits for speech recognition, and why lowering stimulation rate from the manufacturer's default sometimes results in improved speech recognition for subjects.

Bilateral bone conduction stimulation provides reliable binaural cues for localization.

This study aimed to characterize binaural hearing abilities with bone conduction stimulation in simulated conductive hearing loss. Bone conduction hearing devices (BCDs) are a common method of rehabilitating conductive hearing loss. However, little is known about the access these devices provide to binaural cues. To study the ability of BCDs to restore access to binaural cues in conductive loss, normal hearing listeners were plugged unilaterally and bilaterally and localization ability was assessed using a non-surgical BCD attached to the mastoid/s via an adhesive (MED-EL, Corp). The results demonstrate that 1) application of the BCD in simulated unilateral conductive hearing loss does not restore access to binaural cues, evidenced by poor localization abilities. 2) bilateral application of BCDs in simulated bilateral conductive hearing loss provides access to binaural cues, 2) unilateral application of BCDs in simulated bilateral conductive hearing loss disrupts these cues and impairs localization performance, The transcutaneous stimulation of the adhesive BCD resulted in decreased access to sound compared to the normal open ear, resulting in asymmetries in aided versus non-aided hearing thresholds. Symmetrical hearing results in improved localization abilities, while asymmetric hearing disrupts sound localization abilities.

Psychoacoustic and electrophysiological electric-acoustic interaction effects in cochlear implant users with ipsilateral residual hearing.

Cochlear implant users with ipsilateral residual hearing combine acoustic and electric hearing in one ear, this is called electric-acoustic stimulation (EAS). In EAS users, masking can be shown for electric probes in the presence of acoustic maskers and vice versa. Masking effects in acoustic hearing are generally attributed to nonlinearities of the basilar membrane and hair cell adaptation effects. However, similar masking patterns are observed more centrally in electric hearing. Consequently, there is no consensus so far on the level of interaction between the two modalities. Animal studies have shown that electric-acoustic interaction effects can result in reduced physiological responses in the cochlear nerve and the inferior colliculus. In CI users with residual hearing, it has recently become feasible to record intracochlear potentials with a high spatial resolution via the implanted electrode array. An investigation of the electrophysiological effects during combined electric-acoustic stimulation in humans might be used to assess peripheral mechanisms of masking. Seventeen MED-EL Flex electrode users with ipsilateral residual hearing participated in both a behavioral and a physiological electric-acoustic masking experiment. Psychoacoustic methods were used to measure the changes in behavioral thresholds due to the presence of a masker of the opposing modality. Subjects were stimulated electrically with unmodulated pulse trains using a research interface and acoustically with pure tones delivered via headphones. Auditory response telemetry was used to obtain objective electrophysiological changes of electrically evoked compound action potential and electrocochleography for electric, acoustic and combined electric-acoustic presentation in the same subjects. Behavioral thresholds of probe tones, either electric or acoustic, were significantly elevated in the presence of acoustic or electric maskers, respectively. 15 subjects showed significant electric threshold elevation with acoustic masking that did not depend on the electric-acoustic frequency difference (EAFD), a measure for the proximity of stimulation sites in the cochlea. Electric masking showed significant threshold elevation in eleven subjects, which depended significantly on EAFD. In the electrophysiological masking experiment, reduced responses to electric and acoustic stimulation with additional stimulation of the opposing modality were observed. Results showed a similar asymmetry as the psychoacoustic masking experiment. Response reduction was smaller than threshold elevation, especially for electric masking. Some subjects showed reduced responses to acoustic stimulation with electric masking, especially for small EAFD. The reduction of electrically evoked responses was significant in some subjects. No correlation was observed between psychoacoustic and electrophysiological masking results. From present study, it can be concluded that both electric and acoustic stimulation mask each other when presented simultaneously. Electrophysiological measurements indicate that masking effects are already to some extent present in the periphery.

Rol de la información auditiva en el control motor del sistema del equilibrio en pacientes con implantes cocleares / Role of auditory information in motor control of the balance system in patients with cochlear implants / Papel das informações auditivas no controle motor do sistema de equilíbrio em pacientes com implante coclear

Revisión de nuestros hallazgos experimentales sobre la relación entre audición y control motor del equilibrio en usuarios de implantes cocleares (UIC). Se realizó posturografía en 34 UIC en dos condiciones sensoriales:1- Implante encendido (ON). 2- Implante apagado (OFF) Se usó como medida el consumo de energía (CE) de la señal del centro de presión corporal. La marcha se analizó mediante la prueba de 10 m, implementada con: A - implante ON y ruido ambiental (EN), B - Implante ON, EN y Tarea dual cognitiva (DT) y C-implante OFF. Se registró la velocidad de marcha (GV) usando acelerómetros en los pies y la región retrosacra. Estadística: Se utilizaron las pruebas de Wilcoxon y Mann-Whitney y el nivel de significación fue p = 0.05. El análisis de la postura en la adolescencia mostró un ajuste adaptativo, disminuyendo la CE con el IC-ON.p = < 0,05, mientras con el CI-OFF no hubo disminución p => 0,05. En adultos, CI- OFF tuvieron valores más altos de CE en edades mayores, mientras que el CE no se incrementó con la edad con el CI-ON. En la marcha, la GV con el implante ON en EN solo disminuyó en UIC solo en aquellos que estaban implantado después de los 3 años. La UIC implantada antes de esta edad mostró un comportamiento de la marcha similar en comparación con los sujetos con audición normal como control. La información auditiva interviene en la postura y el comportamiento motor de la marcha, hechos que se analizan en esta revisión.

Review of publications of our group about the relationship between the auditory input and the balance motor control in subjects with profound hearing loss and cochlear implant users (UIC). A population of 34 UIC in which posturography in two different sensory information was performed, 1-Implant turned on (ON) giving acoustic information. 2-Implant turned off (OFF) and without auditory input. Energy consumption (CE) of the body center of pressure signal was used as measurement. Gait assessment was analyzed by the 10 m test, implemented with: A- Implant turned ON and environmental noise (EN). B- Implant ON, EN and cognitive dual task (DT) and C- Implant OFF with accelerometers in the feet and sacrum region to measure the gait velocity (GV). Statistics: Wilcoxon and Mann-Whitney test were used and significance level was p=0.05. Posture analysis for different ages in adolescence showed an adaptive adjustment, decreasing the EC significantly when the CI is ON (p<0.05). With the implant turned OFF, changes were not significant (p>0.05). In adults, (implant OFF) had higher values of CE related with age, while the CE did not show increment of CE with age when receiving auditory input with the implant ON. UIC implanted after being 3 years old showed a significant decrease in GV. The UIC implanted before this age showed similar gait behavior compared to normal hearing subjects as control. The auditory information intervenes in posture and gait motor behavior, facts which are analyzed in this review.

Revisão de publicações de nosso grupo sobre a relação entre a entrada auditiva e o controle motor do equilíbrio em indivíduos com perda auditiva profunda e usuários de implante coclear (UIC). Uma população de 34 UIC em que foi realizada a posturografia em duas informações sensoriais diferentes, o 1-Implant ativado (ON) fornece informações acústicas. 2-O implante foi desativado (OFF) e sem entrada auditiva. O consumo de energia (CE) do sinal do centro de pressão corporal foi utilizado como medida. A avaliação da marcha foi analisada pelo teste de 10 m, implementado com: A- Implante ligado e ruído ambiental (EN). B- Implante ON, EN e tarefa dupla cognitiva (TD) e C- Implante OFF com acelerômetros na região dos pés e sacro para medir a velocidade da marcha (GV). Estatísticas: Foram utilizados os testes de Wilcoxon e Mann-Whitney e o nível de significância foi de p = 0,05. A análise da postura para diferentes idades na adolescência mostrou um ajuste adaptativo, diminuindo significativamente a CE quando o IC está ligado (p <0,05). Com o implante desligado, as alterações não foram significativas (p> 0,05). Nos adultos, o (implante OFF) apresentou maiores valores de EC relacionados à idade, enquanto o CE não apresentou incremento do CE com a idade ao receber entrada auditiva com o implante ON. A UIC implantada após os 3 anos de idade mostrou uma diminuição significativa no GV. A UIC implantada antes dessa idade mostrou comportamento de marcha semelhante em relação aos indivíduos com audição normal como controle. As informações auditivas intervêm no comportamento motor da postura e da marcha, fatos analisados nesta revisão.

Impact of stimulus frequency and recording electrode on electrocochleography in Hybrid cochlear implant users.

This report explores the impact of recording electrode position and stimulus frequency on intracochlear electrocochleography (ECoG) responses recorded from six Nucleus L24 Hybrid CI users. Acoustic tone bursts (250 Hz, 500 Hz, 750 Hz, and 1000 Hz) were presented to the implanted ear via an insert earphone. Recordings were obtained from intracochlear electrodes 6 (most basal), 8, 10, 12, 14, 16, 18, 20, and 22 (most apical). Responses to condensation and rarefaction stimuli were subtracted from one another to emphasize hair cell responses (CM/DIF) and added to one another to emphasize neural responses (ANN/SUM). For a fixed stimulus frequency, the CM/DIF and ANN/SUM magnitudes increased as the recording electrode moved apically. For a fixed recording electrode, as the stimulus frequency was lowered, response magnitudes increased. The CM/DIF and ANN/SUM response phase were generally stable across recording electrodes, although substantial phase shifts were noted for a few conditions. Given the recent interest in ECoG for assessing peripheral auditory function in CI users, the impact of stimulus frequency and recording electrode position on response magnitude should be considered. Results suggest optimal ECoG responses are obtained using the most apical recording electrode and a low frequency acoustic stimulus (250 Hz or 500 Hz).

Electro-haptic enhancement of speech-in-noise performance in cochlear implant users.

Cochlear implant (CI) users receive only limited sound information through their implant, which means that they struggle to understand speech in noisy environments. Recent work has suggested that combining the electrical signal from the CI with a haptic signal that provides crucial missing sound information ("electro-haptic stimulation"; EHS) could improve speech-in-noise performance. The aim of the current study was to test whether EHS could enhance speech-in-noise performance in CI users using: (1) a tactile signal derived using an algorithm that could be applied in real time, (2) a stimulation site appropriate for a real-world application, and (3) a tactile signal that could readily be produced by a compact, portable device. We measured speech intelligibility in multi-talker noise with and without vibro-tactile stimulation of the wrist in CI users, before and after a short training regime. No effect of EHS was found before training, but after training EHS was found to improve the number of words correctly identified by an average of 8.3%-points, with some users improving by more than 20%-points. Our approach could offer an inexpensive and non-invasive means of improving speech-in-noise performance in CI users.

Measuring temporal response properties of auditory nerve fibers in cochlear implant recipients.

Auditory nerve fibers' (ANFs) refractoriness and facilitation can be quantified in electrically evoked compound action potentials (ECAPs) recorded via neural response telemetry (NRT). Although facilitation has been observed in animals and human cochlear implant (CI) recipients, no study has modeled this in human CI users until now. In this study, recovery and facilitation effects at different masker and probe levels for three test electrodes (E6, E12 and E18) in 11 CI subjects were recorded. The ECAP recovery and facilitation were modeled by exponential functions and the same function used for +10 CL masker offset condition can be applied to all other masker offsets measurements. Goodness of fit was evaluated for the exponential functions. A significant effect of probe level was observed on a recovery time constant which highlights the importance of recording the recovery function at the maximum acceptable stimulus level. Facilitation time constant and amplitude showed no dependency on the probe level. However, facilitation was stronger for masker level at or around the threshold of the ECAP (T-ECAP). There was a positive correlation between facilitation magnitude and amplitude growth function (AGF) slope, which indicates that CI subjects with better peripheral neural survival have stronger facilitation.

Why and how music can be used to rehabilitate and develop speech and language skills in hearing-impaired children.

This paper presents evidence for a strong connection between the development of speech and language skills and musical activities of children and adolescents with hearing impairment and/or cochlear implants. This conclusion is partially based on findings for typically hearing children and adolescents, showing better speech and language skills in children and adolescents with musical training, and importantly, showing increases of speech and language skills in children and adolescents taking part in musical training. Further, studies of hearing-impaired children show connections between musical skills, involvement in musical hobbies, and speech and language skills. Even though the field is still lacking large-scale randomised controlled trials on the effects of musical interventions on the speech and language skills of children and adolescents with hearing impairments and cochlear implants, the current evidence seems enough to urge speech therapists, music therapists, music teachers, parents, and children and adolescents with hearing impairments and/or cochlear implants to start using music for enhancing speech and language skills. For this reason, we give our recommendations on how to use music for language skill enhancement in this group.

Impact of room acoustic parameters on speech and music perception among participants with cochlear implants.

OBJECTIVES: Besides numerous other factors, listening experience with cochlear implants is substantially impaired by room acoustics. Even for persons without hearing impairment, the perception of auditory scenes, for example, concerning speech intelligibility, acoustic quality or audibility, is considerably influenced by room acoustics. For CI users, complex listening environments are usually associated with heavy losses. The aim of the present study was to determine room acoustic criteria that particularly influence speech pleasantness for CI users. DESIGN: Accordingly, speech material of the Oldenburg Sentence Test (Oldenburger Satztest, OLSA) as well as basic music material (major and minor triads) were auralized using the software Auratorium which allows auralization of simulated rooms. The constructed rooms for speech stimuli were based on the standard DIN 18041:2016-03 concerning acoustic quality in rooms, the binding standard referred to by room acoustic consultants in Germany, which also includes specifications for inclusive applications in schools. For the music perception tests, two typical concert halls of different sizes were modelled. The auralized test stimuli were unilaterally presented to 10 CI users via their auxiliary input as well as to 18 participants with typical hearing via headphones (control group). Speech pleasantness was evaluated using modified MUSHRA tests. Concerning music perception, chord discrimination was tested using paired comparisons. RESULTS: A strong preference of small source to listener distances by CI users was found, but no significant preference for room acoustic attenuation which exceeded the recommended for inclusive applications in schools. The analyses of the energy-time-structures suggested that a dense concentration of early reflections makes a beneficial impact on CI listeners' pleasantness ratings. Music materials were distinguished more consistently without any room acoustic impact, while any room acoustic impact led to performance close to chance level. This effect is probably due to spectral smearing effects caused by reverberation. CONCLUSIONS: These results suggest that in terms of pleasantness of speech, for CI-users, source-to-listener distance is the more influential parameter than room attenuation which goes beyond the German standard recommendation. Reflections from which CI users can benefit seem to occur much earlier than those from which NH listeners benefit. Future studies on chord discrimination concerning room acoustics are needed.

Adaptation to noise in amplitude modulation detection without the medial olivocochlear reflex.

The detection of amplitude modulation (AM) in quiet or in noise improves when the AM carrier is preceded by noise, an effect that has been attributed to the medial olivocochlear reflex (MOCR). We investigate whether this improvement can occur without the MOCR by measuring AM sensitivity for cochlear implant (CI) users, whose MOCR effects are circumvented as a result of the electrical stimulation provided by the CI. AM detection thresholds were measured monaurally for short (50 ms) AM probes presented at the onset (early condition) or delayed by 300 ms (late condition) from the onset of a broadband noise. The noise was presented ipsilaterally, contralaterally and bilaterally to the test ear. Stimuli were processed through an experimental, time-invariant sound processing strategy. On average, thresholds were 4 dB better in the late than in the early condition and the size of the improvement was similar for the three noise lateralities. The pattern and magnitude of the improvement was broadly consistent with that for normal hearing listeners [Marrufo-Pérez et al., 2018, J Assoc Res Otolaryngol 19:147-161]. Because the electrical stimulation provided by CIs is independent from the middle-ear muscle reflex (MEMR) or the MOCR, this shows that mechanisms other than the MEMR or the MOCR can facilitate AM detection in noisy backgrounds.

Individualised active communication education (I-ACE): another clinical option for adults with hearing impairment with a focus on problem solving and self-management.

Objective: This clinical note describes the Individualised - Active Communication Education (I-ACE) programme designed to improve problem solving and self-management in adults with hearing impairment. Design: The I-ACE was offered to adult clients seeking help for the first time and effects were measured for participants using self-report questionnaires: the Client Oriented Scale of Improvement (goal attainment), the Hearing Handicap Questionnaire (hearing disability), and the International Outcome Inventory - Alternative Interventions (outcomes) immediately after programme completion and 3 months later. Participants also provided qualitative feedback about I-ACE. Study sample: Twenty-three participants completed I-ACE, with 22 completing all self-report questionnaires and 23 participants providing qualitative feedback. Results: The participants reported positive outcomes and goal attainment, but no change in hearing disability post-programme. The effects were maintained 3 months later. Qualitative feedback indicated that I-ACE supported participants in recognising and increasing awareness of their hearing difficulties and in developing potential solutions to these difficulties. Participants also enjoyed the opportunity to involve communication partners. Conclusion: I-ACE is an appropriate option for adults with hearing impairment who wish to become more aware of their hearing difficulties and how to solve them.

Long-term subjective loneliness in adults after hearing loss treatment.

Objective: While hearing loss is associated with loneliness, the long term impact of hearing loss interventions remains unknown. We investigated levels of loneliness in adults at baseline, 6-months, 1-year and 5-years after receiving a hearing aid (HA) or cochlear implant (CI). Design: In this 5-year follow-up to the Studying Multiple Outcomes after Aural Rehabilitative Treatment study, participants completed the University of California, Los Angeles (UCLA) Loneliness Scale at baseline, 6-months, 1-year, and 5-year time points. Generalized estimating equations modeled the population average UCLA score over time. Study Sample: Analytic cohort of 115 participants (74% of original 156) 50 years or older who received a HA or CI at baseline and completed at least one follow up visit. Results: Loneliness scores were not different at 5 years versus baseline for HA users. CI users showed significantly reduced loneliness at 6-months and 1-year from baseline and with no significant difference at 5 years. Conclusion: Over 5 years, we observed no increase in loneliness from baseline in a cohort of adults receiving HAs and CIs. Short-term reduction in loneliness in CI users was demonstrated. Future randomized trials are needed to definitively assess the impact of treated versus untreated hearing loss on loneliness.