A Scoping Review of Studies Comparing Outcomes for Children With Severe Hearing Loss Using Hearing Aids to Children With Cochlear Implants.

OBJECTIVES: Clinical practice regarding children's candidature for cochlear implantation varies internationally, albeit with a recent global trend toward implanting children with more residual hearing than in the past. The provision of either hearing aids or cochlear implants can influence a wide range of children's outcomes. However, guidance on eligibility and suitability for implantation is often based on a small number of studies and a limited range of speech perception measures. No recent reviews have catalogued what is known about comparative outcomes for children with severe hearing-loss using hearing aids to children using cochlear implants. This article describes the findings of a scoping review that addressed the question "What research has been conducted comparing cochlear implant outcomes to outcomes in children using hearing aids with severe hearing-loss in the better-hearing ear?" The first objective was to catalogue the characteristics of studies pertinent to these children's candidature for cochlear implantation, to inform families, clinicians, researchers, and policy-makers. The second objective was to identify gaps in the evidence base, to inform future research projects and identify opportunities for evidence synthesis. DESIGN: We included studies comparing separate groups of children using hearing aids to those using cochlear implants and also repeated measures studies comparing outcomes of children with severe hearing loss before and after cochlear implantation. We included any outcomes that might feasibly be influenced by the provision of hearing aids or cochlear implants. We searched the electronic databases Medline, PubMed, and CINAHL, for peer-reviewed journal articles with full-texts written in English, published from July 2007 to October 2019. The scoping methodology followed the approach recommended by the Joanna Briggs Institute regarding study selection, data extraction, and data presentation. RESULTS: Twenty-one eligible studies were identified, conducted across 11 countries. The majority of children studied had either congenital or prelingual hearing loss, with typical cognitive function, experience of spoken language, and most implanted children used one implant. Speech and language development and speech perception were the most frequently assessed outcomes. However, some aspects of these outcomes were sparsely represented including voice, communication and pragmatic skills, and speech perception in complex background noise. Two studies compared literacy, two sound localization, one quality of life, and one psychosocial outcomes. None compared educational attainment, listening fatigue, balance, tinnitus, or music perception. CONCLUSIONS: This scoping review provides a summary of the literature regarding comparative outcomes of children with severe hearing-loss using acoustic hearing aids and children using cochlear implants. Notable gaps in knowledge that could be addressed in future research includes children's quality of life, educational attainment, and complex listening and language outcomes, such as word and sentence understanding in background noise, spatial listening, communication and pragmatic skills. Clinician awareness of this sparse evidence base is important when making management decisions for children with more residual hearing than traditional implant candidates. This review also provides direction for researchers wishing to strengthen the evidence base upon which clinical decisions can be made.

Cognitive Improvement After Cochlear Implantation in Older Adults With Severe or Profound Hearing Impairment: A Prospective, Longitudinal, Controlled, Multicenter Study.

OBJECTIVE: To compare the cognitive evolution of older adults with severe or profound hearing impairment after cochlear implantation with that of a matched group of older adults with severe hearing impairment who do not receive a cochlear implant (CI). DESIGN: In this prospective, longitudinal, controlled, and multicenter study, 24 older CI users were included in the intervention group and 24 adults without a CI in the control group. The control group matched the intervention group in terms of gender, age, formal education, cognitive functioning, and residual hearing. Assessments were made at baseline and 14 months later. Primary outcome measurements included the change in the total score on the Repeatable Battery for the Assessment of Neuropsychological Status for Hearing impaired individuals score and on its subdomain score to assess cognitive evolution in both groups. Secondary outcome measurements included self-reported changes in sound quality (Hearing Implant Sound Quality Index), self-perceived hearing disability (Speech, Spatial, and Qualities of Hearing Scale), states of anxiety and depression (Hospital Anxiety and Depression Scale), and level of negative affectivity and social inhibition (Type D questionnaire). RESULTS: Improvements of the overall cognitive functioning (p = 0.05) and the subdomain "Attention" (p = 0.02) were observed after cochlear implantation in the intervention group; their scores were compared to the corresponding scores in the control group. Significant positive effects of cochlear implantation on sound quality and self-perceived hearing outcomes were found in the intervention group. Notably, 20% fewer traits of Type D personalities were measured in the intervention group after cochlear implantation. In the control group, traits of Type D personalities increased by 13%. CONCLUSION: Intervention with a CI improved cognitive functioning (domain Attention in particular) in older adults with severe hearing impairment compared to that of the matched controls with hearing impairment without a CI. However, older CI users did not, in terms of cognition, bridge the performance gap with adults with normal hearing after 1 year of CI use. The fact that experienced, older CI users still present subnormal cognitive functioning may highlight the need for additional cognitive rehabilitation in the long term after implantation.

Factors Affecting Sound-Source Localization in Children With Simultaneous or Sequential Bilateral Cochlear Implants.

OBJECTIVES: The study aimed to determine the effect of interimplant interval and onset of profound deafness on sound localization in children with bilateral cochlear implants, controlling for cochlear implant manufacturer, age, and time since second implant. DESIGN: The authors conducted a retrospective, observational study using routinely collected clinical data. Participants were 127 bilaterally implanted children aged 4 years or older, tested at least 12 mo post- second implant. Children used implants made by one of three manufacturers. Sixty-five children were simultaneously implanted, of whom 43% were congenitally, bilaterally profoundly deaf at 2 and 4 kHz and 57% had acquired or progressive hearing loss. Sixty-two were implanted sequentially (median interimplant interval = 58 mo, range 3-143 mo) of whom 77% had congenital and 23% acquired or progressive bilateral profound deafness at 2 and 4 kHz. Children participated in a sound-source localization test with stimuli presented in a random order from five loudspeakers at -60, -30, 0, +30, and +60 degrees azimuth. Stimuli were prerecorded female voices at randomly roved levels from 65 to 75 dB(A). Root mean square (RMS) errors were calculated. Localization data were analyzed via multivariable linear regression models, one applied to the whole group and the other to just the simultaneously implanted children. RESULTS: Mean RMS error was 25.4 degrees (SD = 12.5 degrees) with results ranging from perfect accuracy to chance level (0-62.7 degrees RMS error). Compared with simultaneous implantation, an interimplant interval was associated with worse localization by 1.7 degrees RMS error per year (p < 0.001). Compared with congenital deafness, each year with hearing thresholds better than 90 dB HL at 2 and 4 kHz bilaterally before implantation led to more accurate localization by 1.3 degrees RMS error (p < 0.005). Every year post-second implant led to better accuracy by 1.6 degrees RMS error (p < 0.05). Med-El was associated with more accurate localization than Cochlear by 5.8 degrees RMS error (p < 0.01) and with more accurate localization than Advanced Bionics by 9.2 degrees RMS error (p < 0.05). CONCLUSIONS: Interimplant interval and congenital profound hearing loss both led to worse accuracy in sound-source localization for children using bilateral cochlear implants. Interimplant delay should therefore be minimized for children with bilateral profound hearing loss. Children presenting with acquired or progressive hearing loss can be expected to localize better via bilateral cochlear implants than their congenitally deaf peers.

Time course from cochlear implant surgery to non-use for congenitally deaf recipients implanted as children over ten years ago.

Objective: To determine the time-course from first cochlear implantation to non-use, to characterise non-users' receptive and expressive communication, and document known risk factors for inconsistent use, for congenitally deaf non-users of cochlear implants implanted as children at least ten years ago. Methods: Retrospective service evaluation. All congenitally deaf patients who received a first cochlear implant as children at least ten years ago at a regional service, and were currently non-users, were identified. They were characterised in terms of ages at implantation and non-use, known risk factors for inconsistent CI use or CI non-use, and outcome measures were the Meaningful Auditory Integration Scale (MAIS) and Meaningful Use of Speech Scale (MUSS) scores. Results: Seventeen patients met the inclusion criteria. They were implanted from 1990 to 2006. Median age at implantation was 4 years (range: 2-11), median age at non-use was 17 years (range: 9-31), and median duration of use was 8.5 years (range: 4-25). All used sign or gesture as their primary expressive and receptive communication modes. In addition, each child had at least one other known risk factor for inconsistent CI use. At 3 years post-implantation, mean Parent-rated MAIS scores were 76.5% (N = 14), and mean MUSS scores were 43.1% (N = 9). Discussion: This cohort included cases where CI use was rejected following longer periods of time than previously reported, highlighting a need for long-term support, particularly around the ages of life transitions. Studies conducted when the earliest cohort of paediatric CI users were younger, and studies reliant on parent or patient reports, may under-estimate long-term non-use rates. No non-users were identified among congenitally-deaf children implanted 10-15 years ago. Further research is warranted to explore relationships between risk factors, including communication mode, and non-use to inform expectation setting and candidacy selection.

Telehealth rehabilitation for adults with cochlear implants in response to the Covid-19 pandemic: platform selection and case studies.

BACKGROUND: Effective information giving and goal setting before cochlear implantation and individualised rehabilitation following implantation are both crucial for shaping patients' expectations and optimising outcomes. The Covid-19 pandemic led to temporary cessation of face to face clinic appointments. This created a need for telehealth rehabilitation for adults whose hearing loss presents unique communication challenges. AIMS: We describe the piloting and implementation of telehealth rehabilitation within an adult cochlear implant service. METHOD: Video conferencing and telehealth tools were assessed in terms of security, accessibility and functionality. Written support materials were developed. Telehealth sessions were piloted with lay volunteers. During service implementation, feedback was collected from patients and staff. OUTCOMES & RESULTS: A video call platform was identified that was supported by the host Trust and also met the rehabilitation service's needs. A telehealth service was successfully implemented, ensuring continuity of care during lockdown. We share the platform selection framework used, practical lessons learned and patient support materials. CONCLUSION: .Telehealth rehabilitation facilitated a well-received, effective service for adult cochlear implant patients. It is predicted that the benefits of telehealth rehabilitation will last beyond the lockdown restrictions posed by Covid-19.

Evolution of Type D Personality Traits After Cochlear Implantation in Severely Hearing Impaired Adults 55 Years and Older: An Exploratory Prospective, Longitudinal, Controlled, Multicenter Study.

PURPOSE: To study the evolution of type D personality traits in older adults after cochlear implantation compared with a control group of severely hearing impaired older adults who did not receive a cochlear implant (CI). The influence of COVID-19 on this evolution was also explored. Type D personality combines a high degree of negative affectivity (NA) and social inhibition (SI). METHODS: In this prospective, longitudinal, controlled multicenter exploratory study, 76 older CI users and 21 severely hearing impaired controls without CI were included. The CI group and the control group did not differ significantly regarding age, formal education, residual hearing, Type D Scale-14 (DS14) total score, NA, and SI at baseline. Type D personality traits were assessed with the DS14 at baseline (T0) and 14 months later (T14). RESULTS: Type D personality traits differed significantly over time between the CI group and the control group (p < 0.001). In the CI group, the DS14 total score (mean delta T = -6.63; p < 0.001), NA (mean delta T = -3.26; p < 0.001), and SI (mean delta T = -3.37; p < 0.001) improved significantly over time (delta T = T14-T0), whereas no significant difference was found in the control group. Significantly fewer subjects were categorized as type D personalities in the CI group (delta T = -12; p = 0.023) at T14, whereas no significant change was found in the control group (delta T = 3; p = 0.250). COVID-19 did not influence the evolution of type D personality traits significantly in the CI group. CONCLUSION: Cochlear implantation has a positive effect on type D personality traits in older adults with a severe-to-profound hearing impairment.

Systematic review of outcome domains and instruments used in designs of clinical trials for interventions that seek to restore bilateral and binaural hearing in adults with unilateral severe to profound sensorineural hearing loss ('single-sided deafness').

BACKGROUND: This systematic review aimed to identify, compare and contrast outcome domains and outcome instruments reported in studies investigating interventions that seek to restore bilateral (two-sided) and/or binaural (both ears) hearing in adults with single-sided deafness (SSD). Findings can inform the development of evidence-based guidance to facilitate design decisions for confirmatory trials. METHODS: Records were identified by searching MEDLINE, EMBASE, PubMed, CINAHL, ClinicalTrials.gov, ISRCTN, CENTRAL, WHO ICTRP and the NIHR UK clinical trials gateway. The search included records published from 1946 to March 2020. Included studies were those as follows: (a) recruiting adults aged 18 years or older diagnosed with SSD of average threshold severity worse than 70 dB HL in the worse-hearing ear and normal (or near-normal) hearing in the better-hearing ear, (b) evaluating interventions to restore bilateral and/or binaural hearing and (c) enrolling those adults in a controlled trial, before-and-after study or cross-over study. Studies that fell just short of the participant eligibility criteria were included in a separate sensitivity analysis. RESULTS: Ninety-six studies were included (72 full inclusion, 24 sensitivity analysis). For fully included studies, 37 exclusively evaluated interventions to re-establish bilateral hearing and 29 exclusively evaluated interventions to restore binaural hearing. Overall, 520 outcome domains were identified (350 primary and 170 secondary). Speech-related outcome domains were the most common (74% of studies), followed by spatial-related domains (60% of studies). A total of 344 unique outcome instruments were reported. Speech-related outcome domains were measured by 73 different instruments and spatial-related domains by 43 different instruments. There was considerable variability in duration of follow-up, ranging from acute (baseline) testing to 10 years after the intervention. The sensitivity analysis identified no additional outcome domains. CONCLUSIONS: This review identified large variability in the reporting of outcome domains and instruments in studies evaluating the therapeutic benefits and harms of SSD interventions. Reports frequently omitted information on what domains the study intended to assess, and on what instruments were used to measure which domains. TRIAL REGISTRATION: The systematic review protocol is registered on PROSPERO (International Prospective Register of Systematic Reviews): Registration Number CRD42018084274 . Registered on 13 March 2018, last revised on 7th of May 2019.

Face and content validity analysis of the Speech, Spatial and Qualities of Hearing Scale for Parents (SSQ-P) when used in a clinical service without interviews or week-long observation periods.

OBJECTIVES: To assess the face and content validity of the Speech, Spatial and Qualities of Hearing Scale for Parents (SSQ-P) when used in a clinical setting without the recommended interviews and observation periods. METHODS: SSQ-P responses completed by 145 parents of children with bilateral cochlear implants (aged between 5 and 16 years old) were analysed. To assess face validity, the proportion of missing/ambiguous and alternative responses was recorded for each of the 23 items. Where additional written comments were included in responses, a thematic-based analysis was used to identify reasons for the missing/ambiguous or alternative responses. Content validity was assessed using item response theory (IRT), with items having information score less than 0.5 and discrimination score less than 2.0 identified as poorly performing items. RESULTS: All items of the SSQ-P exhibited some proportion of missing/ambiguous or alternative responses, with six items having >10% missing/ambiguous or alternative responses. IRT identified thirteen items that performed poorly in terms of information and discrimination. These included four of the six items with the most missing/ambiguous or alternative responses. CONCLUSIONS: SSQ-P items that performed worse tended to describe scenarios that parents perceived as too specific, too vague or hazardous. Without the recommended administration via interviews following three week-long observation periods, parents found these items difficult to complete. The SSQ-P is therefore not recommended for use without the recommended administration method. However, several items performed well in terms of face and content validity, despite independent parent completion without formal observation periods. Thematic analysis suggested that minor re-wording might improve the face validity of items with high content validity but a high proportion of missing/ambiguous or alternative responses. Therefore, the results of the analyses form the basis on which a shortened version of the SSQ-P, more suitable for use in a clinical setting, could be developed in future studies.

Changes in sound-source localization for children with bilateral severe to profound hearing loss following simultaneous bilateral cochlear implantation.

BACKGROUND: Sound localization is a valuable skill that children can develop to some extent via bilateral cochlear implants (biCIs). However, little is known regarding the change that can be expected in sound-source localization accuracy (SLA) pre- and post-biCI for children with bilateral, severe-to-profound hearing impairment who spent their early years listening via bilateral hearing aids (biHAs). This study therefore aimed to prospectively assess SLA in a group of children before, and at one year after, receiving simultaneous biCIs. METHODS: Ten children aged 5-18 years were tested. SLA was assessed using loudspeakers positioned at -60, -30, 0, +30, and +60 degrees azimuth. Root mean square (RMS) errors and percentage correct scores were calculated. Changes in SLA were analysed via paired t-tests and potential relationships between hearing threshold levels (HTLs) and SLA via correlation analyses. Response distributions via biHAs and biCIs were examined via scatterplots. RESULTS: The mean within-subject changes in SLA were a significant improvement in RMS error of 11.9° (p < 0.05) and in per cent correct by 21.5% (p < 0.05). Scatterplots demonstrated a trend towards better localization of sounds from 0° azimuth via biCIs compared to via biHAs. No significant associations were found between any measures of SLA and HTLs. CONCLUSIONS: The findings of the present study demonstrate that simultaneous biCIs lead to improved sound localization in children with bilateral, severe to profound sensorineural hearing loss who previously used biHAs. SLA via biHAs or biCIs could not be predicted from children's audiograms, and therefore should be measured directly.

Changes in children's speech discrimination and spatial release from masking between 2 and 4 years after sequential cochlear implantation.

OBJECTIVE: To document changes in speech reception thresholds (SRTs) and spatial release from masking (SRM) for sequentially implanted children at 2 and 4 years after they received their second cochlear implant (CI2). METHODS: Participants were 17 children who consistently used two sequentially implanted and optimally programmed CIs. SRTs were measured monaurally in quiet and binaurally in noise using the adaptive McCormick toy discrimination test. Speech signals were presented from 0° azimuth and noise from 0°, +90° or  -90° azimuth. SRM was calculated from SRTs in noise. Measurements were made at 2 and 4 year post-CI2. RESULTS: There were significant improvements over time in SRTs in quiet, SRTs in noise and SRM. SRTs in quiet improved more for CI2 than for the first implant (CI1). SRTs in noise and SRM improved more when noise was presented closest to CI1 than when closest to CI2. Performance became more symmetrical over time. DISCUSSION: Despite prolonged periods of unilateral auditory deprivation sequentially implanted children exhibited continued improvement in SRT and SRM. These results are valuable in setting expectations for and counselling families of children considering sequential CIs.

The effect of early auditory experience on the spatial listening skills of children with bilateral cochlear implants.

OBJECTIVES: Both electrophysiological and behavioural studies suggest that auditory deprivation during the first months and years of life can impair listening skills. Electrophysiological studies indicate that 3½ years may be a critical age for the development of symmetrical cortical responses in children using bilateral cochlear implants. This study aimed to examine the effect of auditory experience during the first 3½ years of life on the behavioural spatial listening abilities of children using bilateral cochlear implants, with reference to normally hearing children. Data collected during research and routine clinical testing were pooled to compare the listening skills of children with bilateral cochlear implants and different periods of auditory deprivation. METHODS: Children aged 4-17 years with bilateral cochlear implants were classified into three groups. Children born profoundly deaf were in the congenital early bilateral group (received bilateral cochlear implants aged ≤3½ years, n=28) or congenital late bilateral group (received first implant aged ≤3½ years and second aged >3½ years, n=38). Children with some bilateral acoustic hearing until the age of 3½ years, who subsequently became profoundly deaf and received bilateral cochlear implants, were in the acquired/progressive group (n=16). There were 32 children in the normally hearing group. Children completed tests of sound-source localization and spatial release from masking (a measure of the ability to use both ears to understand speech in noise). RESULTS: The acquired/progressive group localized more accurately than both groups of congenitally deaf children (p<0.05). All three groups of children with cochlear implants showed similar spatial release from masking. The normally hearing group localized more accurately than all groups with bilateral cochlear implants and displayed more spatial release from masking than the congenitally deaf groups on average (p<0.05). CONCLUSION: Children with bilateral cochlear implants and early experience of acoustic hearing showed more accurate localization skills, on average, than children born profoundly deaf.