Relationship Between Electrocochleography, Angular Insertion Depth, and Cochlear Implant Speech Perception Outcomes.

OBJECTIVES: Electrocochleography (ECochG), obtained before the insertion of a cochlear implant (CI) array, provides a measure of residual cochlear function that accounts for a substantial portion of variability in postoperative speech perception outcomes in adults. It is postulated that subsequent surgical factors represent independent sources of variance in outcomes. Prior work has demonstrated a positive correlation between angular insertion depth (AID) of straight arrays and speech perception under the CI-alone condition, with an inverse relationship observed for precurved arrays. The purpose of the present study was to determine the combined effects of ECochG, AID, and array design on speech perception outcomes. DESIGN: Participants were 50 postlingually deafened adult CI recipients who received one of three straight arrays (MED-EL Flex24, MED-EL Flex28, and MED-EL Standard) and two precurved arrays (Cochlear Contour Advance and Advanced Bionics HiFocus Mid-Scala). Residual cochlear function was determined by the intraoperative ECochG total response (TR) measured before array insertion, which is the sum of magnitudes of spectral components in response to tones of different stimulus frequencies across the speech spectrum. The AID was then determined with postoperative imaging. Multiple linear regression was used to predict consonant-nucleus-consonant (CNC) word recognition in the CI-alone condition at 6 months postactivation based on AID, TR, and array design. RESULTS: Forty-one participants received a straight array and nine received a precurved array. The AID of the most apical electrode contact ranged from 341° to 696°. The TR measured by ECochG accounted for 43% of variance in speech perception outcomes (p < 0.001). A regression model predicting CNC word scores with the TR tended to underestimate the performance for precurved arrays and deeply inserted straight arrays, and to overestimate the performance for straight arrays with shallower insertions. When combined in a multivariate linear regression, the TR, AID, and array design accounted for 72% of variability in speech perception outcomes (p < 0.001). CONCLUSIONS: A model of speech perception outcomes that incorporates TR, AID, and array design represents an improvement over a model based on TR alone. The success of this model shows that peripheral factors including cochlear health and electrode placement may play a predominant role in speech perception with CIs.

Frequency-to-Place Mismatch: Characterizing Variability and the Influence on Speech Perception Outcomes in Cochlear Implant Recipients.

OBJECTIVES: The spatial position of a cochlear implant (CI) electrode array affects the spectral cues provided to the recipient. Differences in cochlear size and array length lead to substantial variability in angular insertion depth (AID) across and within array types. For CI-alone users, the variability in AID results in varying degrees of frequency-to-place mismatch between the default electric frequency filters and cochlear place of stimulation. For electric-acoustic stimulation (EAS) users, default electric frequency filters also vary as a function of residual acoustic hearing in the implanted ear. The present study aimed to (1) investigate variability in AID associated with lateral wall arrays, (2) determine the subsequent frequency-to-place mismatch for CI-alone and EAS users mapped with default frequency filters, and (3) examine the relationship between early speech perception for CI-alone users and two aspects of electrode position: frequency-to-place mismatch and angular separation between neighboring contacts, a metric associated with spectral selectivity at the periphery. DESIGN: One hundred one adult CI recipients (111 ears) with MED-EL Flex24 (24 mm), Flex28 (28 mm), and FlexSOFT/Standard (31.5 mm) arrays underwent postoperative computed tomography to determine AID. A subsequent comparison was made between AID, predicted spiral ganglion place frequencies, and the default frequency filters for CI-alone (n = 84) and EAS users (n = 27). For CI-alone users with complete insertions who listened with maps fit with the default frequency filters (n = 48), frequency-to-place mismatch was quantified at 1500 Hz and angular separation between neighboring contacts was determined for electrodes in the 1 to 2 kHz region. Multiple linear regression was used to examine how frequency-to-place mismatch and angular separation of contacts influence consonant-nucleus-consonant (CNC) scores through 6 months postactivation. RESULTS: For CI recipients with complete insertions (n = 106, 95.5%), the AID (mean ± standard deviation) of the most apical contact was 428° ± 34.3° for Flex24 (n = 11), 558° ± 65.4° for Flex28 (n = 48), and 636° ± 42.9° for FlexSOFT/Standard (n = 47) arrays. For CI-alone users, default frequency filters aligned closely with the spiral ganglion map for deeply inserted lateral wall arrays. For EAS users, default frequency filters produced a range of mismatches; absolute deviations of ≤ 6 semitones occurred in only 37% of cases. Participants with shallow insertions and minimal or no residual hearing experienced the greatest mismatch. For CI-alone users, both smaller frequency-to-place mismatch and greater angular separation between contacts were associated with better CNC scores during the initial 6 months of device use. CONCLUSIONS: There is significant variability in frequency-to-place mismatch among CI-alone and EAS users with default frequency filters, even between individuals implanted with the same array. When using default frequency filters, mismatch can be minimized with longer lateral wall arrays and insertion depths that meet the edge frequency associated with residual hearing for CI-alone and EAS users, respectively. Smaller degrees of frequency-to-place mismatch and decreased peripheral masking due to more widely spaced contacts may independently support better speech perception with longer lateral wall arrays in CI-alone users.

Intracochlear Electrocochleography: Response Patterns During Cochlear Implantation and Hearing Preservation.

OBJECTIVES: Electrocochleography (ECochG) obtained through a cochlear implant (CI) is increasingly being tested as an intraoperative monitor during implantation with the goal of reducing surgical trauma. Reducing trauma should aid in preserving residual hearing and improve speech perception overall. The purpose of this study was to characterize intracochlear ECochG responses throughout insertion in a range of array types and, when applicable, relate these measures to hearing preservation. The ECochG signal in cochlear implant subjects is complex, consisting of hair cell and neural generators with differing distributions depending on the etiology and history of hearing loss. Consequently, a focus was to observe and characterize response changes as an electrode advances. DESIGN: In 36 human subjects, responses to 90 dB nHL tone bursts were recorded both at the round window (RW) and then through the apical contact of the CI as the array advanced into the cochlea. The specific setup used a sterile clip in the surgical field, attached to the ground of the implant with a software-controlled short to the apical contact. The end of the clip was then connected to standard audiometric recording equipment. The stimuli were 500 Hz tone bursts at 90 dB nHL. Audiometry for cases with intended hearing preservation (12/36 subjects) was correlated with intraoperative recordings. RESULTS: Successful intracochlear recordings were obtained in 28 subjects. For the eight unsuccessful cases, the clip introduced excessive line noise, which saturated the amplifier. Among the successful subjects, the initial intracochlear response was a median 5.8 dB larger than the response at the RW. Throughout insertion, modiolar arrays showed median response drops after stylet removal while in lateral wall arrays the maximal median response magnitude was typically at the deepest insertion depth. Four main patterns of response magnitude were seen: increases > 5 dB (12/28), steady responses within 5 dB (4/28), drops > 5 dB (from the initial response) at shallow insertion depths (< 15 mm deep, 7/28), or drops > 5 dB occurring at deeper depths (5/28). Hearing preservation, defined as < 80 dB threshold at 250 Hz, was successful in 9/12 subjects. In these subjects, an intracochlear loss of response magnitude afforded a prediction model with poor sensitivity and specificity, which improved when phase, latency, and proportion of neural components was considered. The change in hearing thresholds across cases was significantly correlated with various measures of the absolute magnitudes of response, including RW response, starting response, maximal response, and final responses (p's < 0.05, minimum of 0.0001 for the maximal response, r's > 0.57, maximum of 0.80 for the maximal response). CONCLUSIONS: Monitoring the cochlea with intracochlear ECochG during cochlear implantation is feasible, and patterns of response vary by device type. Changes in magnitude alone did not account for hearing preservation rates, but considerations of phase, latency, and neural contribution can help to interpret the changes seen and improve sensitivity and specificity. The correlation between the absolute magnitude obtained either before or during insertion of the ECochG and the hearing threshold changes suggest that cochlear health, which varies by subject, plays an important role.

Residual Cochlear Function in Adults and Children Receiving Cochlear Implants: Correlations With Speech Perception Outcomes.

OBJECTIVES: Variability in speech perception outcomes with cochlear implants remains largely unexplained. Recently, electrocochleography, or measurements of cochlear potentials in response to sound, has been used to assess residual cochlear function at the time of implantation. Our objective was to characterize the potentials recorded preimplantation in subjects of all ages, and evaluate the relationship between the responses, including a subjective estimate of neural activity, and speech perception outcomes. DESIGN: Electrocochleography was recorded in a prospective cohort of 284 candidates for cochlear implant at University of North Carolina (10 months to 88 years of ages). Measurement of residual cochlear function called the "total response" (TR), which is the sum of magnitudes of spectral components in response to tones of different stimulus frequencies, was obtained for each subject. The TR was then related to results on age-appropriate monosyllabic word score tests presented in quiet. In addition to the TR, the electrocochleography results were also assessed for neural activity in the forms of the compound action potential and auditory nerve neurophonic. RESULTS: The TR magnitude ranged from a barely detectable response of about 0.02 µV to more than 100 µV. In adults (18 to 79 years old), the TR accounted for 46% of variability in speech perception outcome by linear regression (r = 0.46; p < 0.001). In children between 6 and 17 years old, the variability accounted for was 36% (p < 0.001). In younger children, the TR accounted for less of the variability, 15% (p = 0.012). Subjects over 80 years old tended to perform worse for a given TR than younger adults at the 6-month testing interval. The subjectively assessed neural activity did not increase the information compared with the TR alone, which is primarily composed of the cochlear microphonic produced by hair cells. CONCLUSIONS: The status of the auditory periphery, particularly of hair cells rather than neural activity, accounts for a large fraction of variability in speech perception outcomes in adults and older children. In younger children, the relationship is weaker, and the elderly differ from other adults. This simple measurement can be applied with high throughput so that peripheral status can be assessed to help manage patient expectations, create individually-tailored treatment plans, and identify subjects performing below expectations based on residual cochlear function.

Response Changes During Insertion of a Cochlear Implant Using Extracochlear Electrocochleography.

OBJECTIVES: Electrocochleography is increasingly being utilized as an intraoperative monitor of cochlear function during cochlear implantation (CI). Intracochlear recordings from the advancing electrode can be obtained through the device by on-board capabilities. However, such recordings may not be ideal as a monitor because the recording electrode moves in relation to the neural and hair cell generators producing the responses. The purposes of this study were to compare two extracochlear recording locations in terms of signal strength and feasibility as intraoperative monitoring sites and to characterize changes in cochlear physiology during CI insertion. DESIGN: In 83 human subjects, responses to 90 dB nHL tone bursts were recorded both at the round window (RW) and then at an extracochlear position-either adjacent to the stapes or on the promontory just superior to the RW. Recording from the fixed, extracochlear position continued during insertion of the CI in 63 cases. RESULTS: Before CI insertion, responses to low-frequency tones at the RW were roughly 6 dB larger than when recording at either extracochlear site, but the two extracochlear sites did not differ from one another. During CI insertion, response losses from the promontory or adjacent to the stapes stayed within 5 dB in ≈61% (38/63) of cases, presumably indicating atraumatic insertions. Among responses which dropped more than 5 dB at any time during CI insertion, 12 subjects showed no response recovery, while in 13, the drop was followed by partial or complete response recovery by the end of CI insertion. In cases with recovery, the drop in response occurred relatively early (<15 mm insertion) compared to those where there was no recovery. Changes in response phase during the insertion occurred in some cases; these may indicate a change in the distributions of generators contributing to the response. CONCLUSIONS: Monitoring the electrocochleography during CI insertion from an extracochlear site reveals insertions that are potentially atraumatic, show interaction with cochlear structures followed by response recovery, or show interactions such that response losses persist to the end of recording.

Effect of Cochlear Implantation on Quality of Life in Adults with Unilateral Hearing Loss.

OBJECTIVE: Patients with moderate-to-profound sensorineural hearing loss in 1 ear and normal hearing in the contralateral ear, known as unilateral hearing loss (UHL) or single-sided deafness (SSD), may experience improved quality of life with the use of a cochlear implant (CI) in the affected ear. Quality of life assessment before and after implantation may reveal changes to aspects of hearing beyond those explicitly evaluated with behavioral measures. METHODS: The present report completed 2 experiments investigating quality of life outcomes in CI recipients with UHL. The first experiment assessed quality of life during the 1st year of device use with 3 questionnaires: the Speech, Spatial, and Qualities of Hearing Scale (SSQ), the Abbreviated Profile of Hearing Aid Benefit (APHAB), and the Tinnitus Handicap Inventory. Twenty subjects were evaluated preoperatively and 1, 3, 6, 9, and 12 months post-activation. Quality of life results were compared over the study period using traditional scoring methods and the SSQ pragmatic subscales. Subscales specific to localization and speech perception in noise were compared to behavioral measures at the preoperative and 12-month intervals. The 2nd experiment evaluated quality of life preoperatively and at the 12-month interval for CI recipients with UHL and CI recipients with bilateral hearing loss, including conventional CI users and those listening with electric-acoustic stimulation (EAS). The 3 cohorts differed in CI candidacy criteria, including the amount of residual hearing in the contralateral ear. RESULTS: For subjects with moderate-to-profound UHL, receipt of a CI significantly improved quality of life, with benefits noted as early as 1 month after initial activation. The UHL cohort reported less perceived difficulty at the pre- and postoperative intervals than the conventional CI and EAS cohorts, which may be due to the presence of the normal-hearing ear. Each group experienced a significant benefit in quality of life on the APHAB with CI use. CONCLUSIONS: Cochlear implantation in cases of substantial UHL may offer significant improvements in quality of life. Quality of life measures revealed a reduction in perceived tinnitus severity and subjective improvements in speech perception in noise, spatial hearing, and listening effort. While self-report of difficulties were lower for the UHL cohort than the conventional CI and EAS cohorts, subjects in all 3 groups reported an improvement in quality of life with CI use.

Cochlear Implantation in Cases of Unilateral Hearing Loss: Initial Localization Abilities.

OBJECTIVES: The present study evaluated early auditory localization abilities of cochlear implant (CI) recipients with normal or near-normal hearing (NH) in the contralateral ear. The goal of the study was to better understand the effect of CI listening experience on localization in this population. DESIGN: Twenty participants with unilateral hearing loss enrolled in a prospective clinical trial assessing outcomes of cochlear implantation (ClinicalTrials.gov Identifier: NCT02203305). All participants received the MED-EL Standard electrode array, were fit with an ear-level audio processor, and listened with the FS4 coding strategy. Localization was assessed in the sound field using an 11-speaker array with speakers uniformly positioned on a horizontal, semicircular frame. Stimuli were 200-msec speech-shaped noise bursts. The intensity level (52, 62, and 72 dB SPL) and sound source were randomly interleaved across trials. Participants were tested preoperatively, and 1, 3, and 6 months after activation of the audio processor. Performance was evaluated in two conditions at each interval: (1) unaided (NH ear alone [NH-alone] condition), and (2) aided, with either a bone conduction hearing aid (preoperative interval; bone conduction hearing aid + NH condition) or a CI (postoperative intervals; CI + NH condition). Performance was evaluated by comparing root-mean-squared (RMS) error between listening conditions and between measurement intervals. RESULTS: Mean RMS error for the soft, medium, and loud levels were 66°, 64°, and 69° in the NH-alone condition and 72°, 66°, and 70° in the bone conduction hearing aid + NH condition. Participants experienced a significant improvement in localization in the CI + NH condition at the 1-month interval (38°, 35°, and 38°) as compared with the preoperative NH-alone condition. Localization in the CI + NH condition continued to improve through the 6-month interval. Mean RMS errors were 28°, 25°, and 28° in the CI + NH condition at the 6-month interval. CONCLUSIONS: Adult CI recipients with normal or near-normal hearing in the contralateral ear experienced significant improvement in localization after 1 month of device use, and continued to improve through the 6-month interval. The present results show that binaural acclimatization in CI users with unilateral hearing loss can progress rapidly, with marked improvements in performance observed after only 1 month of listening experience.

Is "no response" on diagnostic auditory brainstem response testing an indication for cochlear implantation in children?

OBJECTIVES: To compare the results of a "no response" (NR) result on auditory brainstem response (ABR) testing with those of behavioral pure-tone audiometry and ultimate clinical tracking to cochlear implantation (CI). DESIGN: Retrospective review of pediatric patients who underwent multifrequency ABR testing in a 5 year span. Total of 1143 pediatric patients underwent ABR testing during the study period and 105 (9.2%) were identified with bilateral NR based on absent responses to both click and tone burst stimuli. For the children with NR, various clinical parameters were evaluated as these children progressed through the CI evaluation process. Children were grouped based on whether they underwent ABRs for diagnostic or for confirmatory purposes. RESULTS: Of the 105 children who met inclusion criteria, 94 had sufficient follow-up to be included in this analysis. Ninety-one (96.8%) of 94 children with bilateral NR ABRs were ultimately recommended for and received a CI. Three (3.2%) children were not recommended for implantation based on the presence of multiple comorbidities rather than auditory factors. None of the children (0%) had enough usable residual hearing to preclude CI. For those who had diagnostic ABRs, the average time at ABR testing was 5.4 months (SD 6.2, range 1-36) and the average time from ABR to CI was 10.78 months (SD 5.0, range 3-38). CONCLUSIONS: CI should tentatively be recommended for children with a bilateral NR result with multifrequency ABR, assuming confirmatory results with behavioral audiometric testing. Amplification trials, counseling, and auditory-based intervention therapy should commence but not delay surgical intervention, as it does not appear to change the eventual clinical course. Children not appropriate for this "fast-tracking" to implantation might include those with significant comorbidities, auditory neuropathy spectrum disorder, and unreliable or poorly correlated results on behavioral audiometric testing.

Otolaryngic Allergy Patient Journey Mapping: A Framework for Allergy Immunotherapy Adherence.

OBJECTIVES: Allergen-specific immunotherapy (AIT) is an effective treatment for allergic disease but requires long treatment duration and premature cessation is of significant concern. Drivers of premature cessation remain poorly understood and no predictive models currently exist. We hypothesized that a novel patient journey map and de novo real-time patient electronic health status instruments (eHSIs) could effectively capture patient perceived cost, commitment, and treatment benefit to identify individual patients at risk for premature AIT cessation. STUDY TYPE: Cross-Sectional Observational Study. METHODS: A single Otolaryngology allergy immunotherapy (AIT) program was studied over 5 years. Instances of premature cessation were classified. An Otolaryngic Allergy Patient Journey Map was developed to identify and target automated, real-time, patient-reported, electronic health status instrument responses. RESULTS: Data capture was robust, with 61,406 data points collected and an eHSI survey completion rate of 81.3%. However, based on correlation analysis and logistic regression alone, real-time eHSI responses were not predictive of individual patient premature AIT cessation. A total of 597 AIT patients discontinued treatment prematurely: 64.4% stopping within the first year. Specifically, 74.0%-76.3% of subcutaneous AIT patients and 88.5%-100% of sublingual AIT patients did not complete the minimum recommended treatment duration of 3 years. CONCLUSION: Patient journey mapping can aid in the design of longitudinal care models and patient engagement strategies. Yet, eHSI patient responses of perception of AIT cost, benefit, and convenience did not correlate with the likelihood of premature treatment cessation. Our imperfect clinical intuition may not account for the dynamic drivers of premature AIT discontinuation. Future development of predictive tools feed by large patient-centric data sets may be incorporated into routine practice resulting in delivery of a more streamlined and personalized approach with reduced premature AIT cessation, improved outcomes, and reduced health care expenditures. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Cochlear Implantation for Unilateral and Asymmetric Hearing Loss: Long-Term Subjective Benefit.

OBJECTIVES: Assess the long-term patterns of perceived tinnitus severity and subjective benefit for adult cochlear implant (CI) users with asymmetric or unilateral hearing loss (AHL or UHL). METHODS: Forty adults underwent cochlear implantation as part of a prospective clinical trial assessing the outcomes of CI use in cases of AHL (n = 20) and UHL (n = 20). Subjective measures included the Tinnitus Handicap Inventory (THI), the Speech, Spatial, & Qualities of Hearing Scale (SSQ), and the Abbreviated Profile of Hearing Aid Benefit (APHAB). Responses were obtained preoperatively and at routine intervals out to 5 years post-activation. RESULTS: For subjective benefit, participants with AHL and UHL reported a significant improvement as compared to preoperative abilities, which was maintained with long-term CI use. For perceived tinnitus severity, participants with AHL and UHL reported a significant reduction with CI use as compared to preoperative perceptions. The perceived tinnitus severity significantly differed for the AHL and UHL cohorts over time. This pattern of results is likely influenced by the worse perceived severity levels for the UHL cohort preoperatively and the fluctuating perceived severity levels for some participants in the AHL cohort post-activation. CONCLUSION: Adults with AHL and UHL report an early, significant reduction in perceived tinnitus severity and improvement in quality of life with CI use that is generally maintained with long-term device use. Questionnaires such as the THI, SSQ, and APHAB may contribute to a more holistic assessment of the benefits of cochlear implantation in this population. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:2792-2797, 2023.

Assessment of cochlear synaptopathy by electrocochleography to low frequencies in a preclinical model and human subjects.

Cochlear synaptopathy is the loss of synapses between the inner hair cells and the auditory nerve despite survival of sensory hair cells. The findings of extensive cochlear synaptopathy in animals after moderate noise exposures challenged the long-held view that hair cells are the cochlear elements most sensitive to insults that lead to hearing loss. However, cochlear synaptopathy has been difficult to identify in humans. We applied novel algorithms to determine hair cell and neural contributions to electrocochleographic (ECochG) recordings from the round window of animal and human subjects. Gerbils with normal hearing provided training and test sets for a deep learning algorithm to detect the presence of neural responses to low frequency sounds, and an analytic model was used to quantify the proportion of neural and hair cell contributions to the ECochG response. The capacity to detect cochlear synaptopathy was validated in normal hearing and noise-exposed animals by using neurotoxins to reduce or eliminate the neural contributions. When the analytical methods were applied to human surgical subjects with access to the round window, the neural contribution resembled the partial cochlear synaptopathy present after neurotoxin application in animals. This result demonstrates the presence of viable hair cells not connected to auditory nerve fibers in human subjects with substantial hearing loss and indicates that efforts to regenerate nerve fibers may find a ready cochlear substrate for innervation and resumption of function.

Insertion Depth and Cochlear Implant Speech Recognition Outcomes: A Comparative Study of 28- and 31.5-mm Lateral Wall Arrays.

OBJECTIVES: 1) To compare speech recognition outcomes between cochlear implant (CI) recipients of 28- and 31.5-mm lateral wall electrode arrays, and 2) to characterize the relationship between angular insertion depth (AID) and speech recognition. STUDY DESIGN: Retrospective review. SETTING: Tertiary academic referral center. PATIENTS: Seventy-five adult CI recipients of fully inserted 28-mm (n = 28) or 31.5-mm (n = 47) lateral wall arrays listening with a CI-alone device. INTERVENTIONS: Cochlear implantation with postoperative computed tomography. MAIN OUTCOME MEASURES: Consonant-nucleus-consonant (CNC) word recognition assessed with the CI-alone at 12 months postactivation. RESULTS: The mean AID of the most apical electrode contact for the 31.5-mm array recipients was significantly deeper than the 28-mm array recipients (628° vs 571°, p < 0.001). Following 12 months of listening experience, mean CNC word scores were significantly better for recipients of 31.5-mm arrays compared with those implanted with 28-mm arrays (59.5% vs 48.3%, p = 0.004; Cohen's d = 0.70; 95% CI [0.22, 1.18]). There was a significant positive correlation between AID and CNC word scores (r = 0.372, p = 0.001), with a plateau in performance observed around 600°. CONCLUSIONS: Cochlear implant recipients implanted with a 31.5-mm array experienced better speech recognition than those with a 28-mm array at 12 months postactivation. Deeper insertion of a lateral wall array appears to confer speech recognition benefit up to ∼600°, with a plateau in performance observed thereafter. These data provide preliminary evidence of the insertion depth necessary to optimize speech recognition outcomes for lateral wall electrode arrays among CI-alone users.

Long-Term Improvement in Localization for Cochlear Implant Users with Single-Sided Deafness.

OBJECTIVES/HYPOTHESIS: To assess whether early, significant improvements in sound source localization observed in cochlear implant (CI) recipients with normal hearing (NH) in the contralateral ear are maintained after 5 years of CI use. STUDY DESIGN: Prospective, repeated measures study. METHODS: Participants were recruited from a sample of CI + NH listeners (n = 20) who received their device as part of a prospective clinical trial investigating outcomes of CI use for adult cases of single-sided deafness. Sound source localization was assessed annually after the clinical trial endpoint (1-year post-activation). Listeners were asked to indicate the perceived sound source for a broadband noise burst presented randomly at varied intensity levels from one of 11 speakers along a 180° arc. Performance was quantified as root-mean-squared (RMS) error. RESULTS: Linear mixed models showed superior post-activation performance was maintained with long-term CI use as compared to preoperative abilities (P < .001). Unexpectedly, a significant improvement (P = .009) in sound source localization was observed over the long-term post-activation period (1-5 years). To better understand these long-term findings, the response patterns for the 11 participants who were evaluated at the 1- and 5-year visits were reviewed. This subgroup demonstrated a significant improvement in RMS error (P = .020) and variable error (P = .031), indicating more consistent responses at the 5-year visit. CONCLUSION: Adult CI + NH listeners experience significant improvements in sound source localization within the initial weeks of listening experience, with additional improvements observed after long-term device use. The present sample demonstrated significant improvements between the 1-year and 5-year visits, with greater accuracy and consistency noted in their response patterns. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2453-2458, 2022.

Worldwide Variation in Cochlear Implant Candidacy.

BACKGROUND: The aim of this study was to find out how candidacy criteria have evolved differently across the globe. METHODS: Candidacy criteria and outcome measurements applied in 19 HEARRING clinics were analyzed. RESULTS: Candidacy criteria vary between clinics. Overall, both bilateral implantation and cochlear implantation in patients with single-sided deafness are becoming more frequent. CONCLUSION: Standardized outcome measurement instruments need to be applied to provide access to the hearing world to all patients with hearing loss who would benefit from cochlear implantation.

Incidence of Complete Insertion in Cochlear Implant Recipients of Long Lateral Wall Arrays.

OBJECTIVE: High rates of partial insertion have been reported for cochlear implant (CI) recipients of long lateral wall electrode arrays, presumably caused by resistance encountered during insertion due to cochlear morphology. With recent advances in long-electrode array design, we sought to investigate (1) the incidence of complete insertions among patients implanted with 31.5-mm flexible arrays and (2) whether complete insertion is limited by cochlear duct length (CDL). STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. METHODS: Fifty-one adult CI recipients implanted with 31.5-mm flexible lateral wall arrays underwent postoperative computed tomography to determine the rate of complete insertion, defined as all contacts being intracochlear. CDL and angular insertion depth (AID) were compared between complete and partial insertion cohorts. RESULTS: Most cases had a complete insertion (96.1%, n = 49). Among the complete insertion cohort, the median CDL was 33.6 mm (range, 30.3-37.9 mm), and median AID was 641° (range, 533-751°). Two cases of partial insertion had relatively short CDL (31.8 mm and 32.3 mm) and shallow AID (542° and 575°). Relatively shallow AID for the 2 cases of partial insertion fails to support the idea that CDL alone prevents a complete insertion. CONCLUSION: Complete insertion of a 31.5-mm flexible array is feasible in most cases and does not appear to be limited by the range of CDL observed in this cohort. Future studies are needed to estimate other variations in cochlear morphology that could predict resistance and failure to achieve complete insertion with long arrays.

Influence of Cochlear Implant Use on Perceived Listening Effort in Adult and Pediatric Cases of Unilateral and Asymmetric Hearing Loss.

OBJECTIVE: Assess the influence of cochlear implant (CI) use on the perceived listening effort of adult and pediatric subjects with unilateral hearing loss (UHL) or asymmetric hearing loss (AHL). STUDY DESIGN: Prospective cohort. SETTING: Tertiary referral center. PATIENTS: Adults and children with UHL or AHL. INTERVENTION: Cochlear implantation. Subjects received their CI as part of a clinical trial assessing the effectiveness of cochlear implantation in cases of UHL and AHL. MAIN OUTCOME MEASURES: Responses to the Listening Effort pragmatic subscale on the Speech, Spatial, and Qualities of Hearing Scale (SSQ) or SSQ for Children with Impaired Hearing (SSQ-C) were compared over the study period. Subjects or their parents completed the questionnaires preoperatively and at predetermined postactivation intervals. For the adult subjects, responses were compared to word recognition in quiet and sentence recognition in noise. RESULTS: Forty adult subjects (n = 20 UHL, n = 20 AHL) and 16 pediatric subjects with UHL enrolled and underwent cochlear implantation. Subjects in all three groups reported a significant reduction in perceived listening effort within the initial months of CI use (p < 0.001; η2 ≥ 0.351). The perceived benefit was significantly correlated with speech recognition in noise for the adult subjects with UHL at the 12-month interval (r(20) = .59, p = 0.006). CONCLUSIONS: Adult and pediatric CI recipients with UHL or AHL report a reduction in listening effort with CI use as compared to their preoperative experiences. Use of the SSQ and SSQ-C Listening Effort pragmatic subscale may provide additional information about a CI recipient's experience beyond the abilities measured in the sound booth.

Long-Term Influence of Electrode Array Length on Speech Recognition in Cochlear Implant Users.

OBJECTIVES/HYPOTHESIS: Results from a prospective trial demonstrated better speech recognition for cochlear implant (CI) recipients implanted with a long lateral wall electrode array compared to subjects with a short array after 1 year of listening experience. As short array recipients may require an extended adaptation period, this study investigated whether differences in speech recognition continued through 4 years of CI use. STUDY DESIGN: Long-term follow-up of a prospective randomized trial. METHODS: Subjects were randomized to receive a MED-EL medium (24 mm) or standard (31.5 mm) array. Linear mixed models compared speech recognition between cohorts with word recognition in quiet and sentence recognition in noise at 1, 3, 6, 12, 24, and 48 months postactivation. Postoperative imaging and electric frequency filters were reviewed to assess the influence of frequency-to-place mismatch and angular separation between neighboring contacts, a metric associated with peripheral spectral selectivity. RESULTS: Long (31.5 mm) array recipients demonstrated superior speech recognition out to 4 years postactivation. There was a significant effect of angular separation between contacts, with more closely spaced contacts associated with poorer speech recognition. There was no significant effect of mismatch, yet this may have been obscured by changes in frequency filters over time. CONCLUSIONS: Conventional MED-EL CI recipients implanted with 31.5-mm arrays experience better speech recognition than 24-mm array recipients, initially and with long-term listening experience. The benefit conferred by longer arrays in the present cohort can be partially attributed to more widely spaced electrode contacts, presumably a result of reduced channel interaction. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:892-897, 2021.

Initial Hearing Preservation Is Correlated With Cochlear Duct Length in Fully-inserted Long Flexible Lateral Wall Arrays.

OBJECTIVES: To characterize the relationship between cochlear duct length (CDL) and initial hearing preservation among cochlear implant recipients of a fully inserted 31.5 mm flexible lateral wall electrode array. STUDY DESIGN: Retrospective review. SETTING: Tertiary academic referral center. PATIENTS: Adult cochlear implant recipients who presented preoperatively with unaided hearing detection thresholds of ≤ 65 dB HL at 125 Hz and underwent cochlear implantation with a 31.5 mm flexible lateral wall array. INTERVENTION: Cochlear implantation with a hearing preservation surgical approach. MAIN OUTCOME MEASURES: Computed tomography was reviewed to determine CDL. Hearing preservation was characterized by the shift in low-frequency pure-tone average (LFPTA; 125, 250, and 500 Hz), and shift in individual unaided hearing detection thresholds at 125, 250, and 500 Hz. RESULTS: Nineteen patients met the criteria for inclusion. The mean CDL was 34.2 mm (range: 30.8-36.5 mm). Recipients experienced a mean LFPTA shift of 27.6 dB HL (range: 10-50 dB HL). Significant, negative correlations were observed between CDL and smaller threshold shifts at individual frequencies and LFPTA (p ≤ 0.048). CONCLUSION: A longer CDL is associated with greater likelihood of preserving low-frequency hearing with long arrays. Low-frequency hearing preservation is feasible with fully inserted long flexible arrays within the initial months after cochlear implantation. Preoperative measurement of CDL may facilitate a more individualized approach in array selection to permit optimal cochlear coverage while enhancing hearing preservation outcomes.

Contemporary analysis of otolaryngic allergy.

OBJECTIVES: Investigate the current trends in otolaryngic allergy (OA). STUDY DESIGN: Cross-sectional survey. METHODS: Survey of active AAOA membership. RESULTS: Response rate was 27.3%. Regional response distribution rates were proportional to the AAOA membership distribution within the United States (R2 = 0.95; P < 0.001), with no significant regional response bias demonstrated (P = 0.428). Self-reported duration to OA competency was 5.8 years. Physicians reporting OA competency were more likely to be board-certified (P < 0.001) and have AAOA fellowship status (P < 0.001). The AAOA was reported to be the most valuable educational resource toward achieving OA competency, with residency training being least valuable (P < 0.001). 91.5% of respondents' practices offered OA services. Subcutaneous injections predominated at twice the utilization of sublingual immunotherapy. Allergy immunotherapy tablets were rarely utilized. Home allergy shots were offered by 45.2% of respondents. In-office immunotherapy vial compounding was preferred (95.8%) to third-party vendors. 94% of AAOA respondents identified patient compliance to be an issue within OA. Non-inhalant allergy service integration included food allergy (63.5%), asthma (44.9%), allergic fungal sinusitis (43.8%), penicillin allergy (18%), stinging insect allergy (12.6%), and aspirin desensitization (3.9%). CONCLUSION: Reported duration to OA competency after residency was surprisingly long. Further investigation of current and future educational/clinical training is warranted given clinical integration reported for OA. Otolaryngology is in the unique position to develop a comprehensive sino-allergy evidence-based strategy integrating the extensive diagnostic and medical treatment arms alongside the surgical expertise of the specialty within a clinical sino-allergy home concept. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:283-289, 2020.

Electrode Array Type and Its Impact on Impedance Fluctuations and Loss of Residual Hearing in Cochlear Implantation.

HYPOTHESIS/OBJECTIVE: Determine variables associated with electrode impedance fluctuations and loss of residual hearing in cochlear implant (CI) recipients. BACKGROUND: CI recipients with postoperative hearing preservation demonstrate superior speech perception with an electric-acoustic stimulation (EAS) device as compared with a CI-alone device. Maintaining superior speech perception over time relies on long-term hearing preservation; therefore, understanding variables that may contribute to loss of residual hearing is needed. Recent reports suggest a relationship between changes in electrode impedance and loss of residual hearing. The variables influencing this relationship have yet to be determined. METHODS: Review of pediatric and adult CI cases from 2013 to 2016 who presented with preoperative residual hearing. Regression analysis was performed to evaluate effects of array type (lateral wall vs. perimodiolar), manufacturer, age at implantation, and preoperative hearing on impedance. The correlation between peak impedance change and change in low-frequency hearing was determined. RESULTS: One hundred forty-six CI recipients presented with preoperative residual hearing. A multivariate regression analysis demonstrated a statistically significant association between preoperative hearing thresholds (p = 0.017), device manufacturer (p = 0.011), and array type (p = 0.038) on postoperative impedance changes. Hearing preservation rates and change in impedance differed by electrode array type. The association between peak impedance changes and loss of residual hearing differed between manufacturers (R = 0.208, p = 0.029 vs. R = 0.016, p = 0.609). CONCLUSION: Impedance fluctuation appears to be a marker for loss of residual hearing for specific electrode array types and manufacturers. Specific arrays may affect the cochlear microenvironment differently, with different effects on postoperative hearing preservation.