Patient and device factors contributing to electrically-evoked stapedial reflex thresholds in cochlear implanted adults.

INTRODUCTION: Optimal cochlear implant (CI) outcomes are due to, at least in part, appropriate device programming. Objective measures, such as electrically-evoked stapedial reflex thresholds (ESRTs), can be used to more accurately set programming levels. However, underlying factors that contribute to ESRT levels are not well understood. The objective of the current study is to analyze how demographic variables of patient sex and age, along with cochlear implant electrode location, influence electrically-evoked stapedial reflex thresholds (ESRTs) in adult cochlear implant users. METHODS: A single institution retrospective review was performed. Electronic medical records, cochlear implant programming records, and clinic database of post-operative computerized tomography were reviewed to gather information regarding patient demographics, ESRTs, and electrode array metrics including medial-lateral distance and scalar location. Linear mixed models were constructed to determine how demographic variables and electrode position influence ESRTs recorded in 138 adult CI recipients. RESULTS: ESRTs were significantly affected by recipient age, with older listeners demonstrating higher ESRT levels. On average, males had higher ESRT levels when compared to females. In a subset of the study sample, ESRT levels increased with increasing medial-lateral distance, however, there was not a statistically significant effect of electrode type (lateral/straight arrays compared to perimodiolar arrays). ESRTs were not affected by scalar location. DISCUSSION/CONCLUSIONS: The results suggest that key demographic and electrode position characteristics influence the level of ESRTs in adult CI recipients. While ESRTs are widely used to assist with CI programming, underlying factors are not well understood. The significant factors of aging and sex could be due to middle ear mechanics or neural health differences, however further data are needed to better understand these associations.

Association of Cognitive Impairment Screening Scores With Improvements in Speech Recognition and Quality of Life After Cochlear Implantation.

Importance: Many cochlear implant centers screen patients for cognitive impairment as part of the evaluation process, but the utility of these scores in predicting cochlear implant outcomes is unknown. Objective: To determine whether there is an association between cognitive impairment screening scores and cochlear implant outcomes. Design, Setting, and Participants: Retrospective case series of adult cochlear implant recipients who underwent preoperative cognitive impairment screening with the Montreal Cognitive Assessment (MoCA) from 2018 to 2020 with 1-year follow-up at a single tertiary cochlear implant center. Data analysis was performed on data from January 2018 through December 2021. Exposures: Cochlear implantation. Main Outcomes and Measures: Preoperative MoCA scores and mean (SD) improvement (aided preoperative to 12-month postoperative) in Consonant-Nucleus-Consonant phonemes (CNCp) and words (CNCw), AzBio sentences in quiet (AzBio Quiet), and Cochlear Implant Quality of Life-35 (CIQOL-35) Profile domain and global scores. Results: A total of 52 patients were included, 27 (52%) of whom were male and 46 (88%) were White; mean (SD) age at implantation was 68.2 (13.3) years. Twenty-three (44%) had MoCA scores suggesting mild and 1 (2%) had scores suggesting moderate cognitive impairment. None had been previously diagnosed with cognitive impairment. There were small to medium effects of the association between 12-month postoperative improvement in speech recognition measures and screening positive or not for cognitive impairment (CNCw mean [SD]: 48.4 [21.9] vs 38.5 [26.6] [d = -0.43 (95% CI, -1.02 to 0.16)]; AzBio Quiet mean [SD]: 47.5 [34.3] vs 44.7 [33.1] [d = -0.08 (95% CI, -0.64 to 0.47)]). Similarly, small to large effects of the associations between 12-month postoperative change in CIQOL-35 scores and screening positive or not for cognitive impairment were found (global: d = 0.32 [95% CI, -0.59 to 1.23]; communication: d = 0.62 [95% CI, -0.31 to 1.54]; emotional: d = 0.26 [95% CI, -0.66 to 1.16]; entertainment: d = -0.005 [95% CI, -0.91 to 0.9]; environmental: d = -0.92 [95% CI, -1.86 to 0.46]; listening effort: d = -0.79 [95% CI, -1.65 to 0.22]; social: d = -0.51 [95% CI, -1.43 to 0.42]). Conclusions and Relevance: In this case series, screening scores were not associated with the degree of improvement of speech recognition or patient-reported outcome measures after cochlear implantation. Given the prevalence of screening positive for cognitive impairment before cochlear implantation, preoperative screening can be useful for early identification of potential cognitive decline. These findings support that screening scores may have a limited role in preoperative counseling of outcomes and should not be used to limit candidacy.

Longitudinal Speech Recognition Changes After Cochlear Implant: Systematic Review and Meta-analysis.

OBJECTIVES: To examine patterns of change and plateau in speech recognition scores in postlingually hearing impaired adult cochlear implant recipients. The study also examines variations in change patterns for different speech materials and testing conditions. STUDY DESIGN: Used systematic review with meta-analysis. METHODS: Articles in English reporting speech recognition scores of adults with postlingual hearing loss at pre-implantation and at least two post-implantation time points were included. Statistically significant changes were determined by meta-analysis and the 95% confidence interval. RESULTS: A total of 22 articles representing 1954 patients were included. Meta-analysis of mean difference demonstrated significant improvements in speech recognition score for words in quiet (37.4%; 95% confidence interval [34.7%, 40.7%]), sentences in quiet (49.4%; 95% confidence interval [44.9%, 53.9%]), and sentences in noise (30.8%; 95% confidence interval [25.2%, 36.4%]) from pre-op to 3 months. Scores continued to increase from 3 to 12 months but did not reach significance. Similarly, significant improvements from pre-op to 3 months were observed for consonant nucleus consonant (CNC) words in quiet (37.1%; 95% confidence interval [33.8%, 40.4%]), hearing in noise test (HINT) sentences in quiet (46.5%; 95% confidence interval [37.0%, 56.0%]), AzBio sentences in quiet (45.9%; 95% confidence interval [44.2%, 47.5%]), and AzBio sentences in noise (26.4%; 95% confidence interval [18.6%, 34.2%]). HINT sentences in noise demonstrated improvement from pre-op to 3 months (35.1%; 95% confidence interval [30.0%, 40.3%]) and from 3 to 12 months (15.5%; 95% confidence interval [7.2%, 23.8%]). CONCLUSIONS: Mean speech recognition scores demonstrate significant improvement within the first 3 months, with no further statistically significant improvement after 3 months. However, large individual variation should be expected and future research is needed to explain the sources of these individual differences. Laryngoscope, 133:1014-1024, 2023.

Using Clinical Audiologic Measures to Determine Cochlear Implant Candidacy.

INTRODUCTION: Only a small percentage (6-10%) of patients who are candidates receive cochlear implants (CIs). One potential reason contributing to low usage rates may be confusion regarding which patients to refer for CI evaluation. The extent to which information provided by standard clinical audiologic assessments is sufficient for selecting appropriate CI evaluation referrals is uncertain. The objective of this study is to evaluate the capacity of standard clinical audiologic measures to differentiate CI candidates from noncandidates. METHOD: The study design is a retrospective review of a prospectively maintained CI database from a university-based tertiary medical center of 518 patients undergoing CI evaluations from 2012 to 2020. Each ear of each patient was treated as an independent value. Receiver operating characteristic (ROCs) curves were constructed using aided AzBio sentence recognition scores in quiet and aided AzBio +10 dB signal-to-noise ratio scores <60% as binary classifiers for CI candidacy. For each ROC, we examined the capacity of multiple pure-tone thresholds, pure-tone average (PTA), and CNC word recognition scores (WRSs) measured under earphones to determine CI candidacy. Area under the curve ROC (AUC-ROC) values were calculated to demonstrate the capacity of each model to differentiate CI candidates from noncandidates. RESULTS: Variables with the greatest capacity to accurately differentiate CI candidates from noncandidates using aided AzBio in quiet scores were earphone CNC WRS, earphone pure-tone threshold at 1,000 Hz, and earphone PTA (AUC-ROC values = 0.86-0.88). Using aided AzBio +10 scores as the measure for candidacy, only CNC word recognition had a fair capacity to identify candidates (AUC-ROC value = 0.73). Based on the ROCs, a 1,000 Hz pure-tone threshold >50 dB HL, PTA >57 dB HL, and a monosyllabic WRS <60% can each serve as individual indicators for referral for CI evaluations. CONCLUSION: The current study provides initial indicators for referral and a first step at developing evidence-based criteria for CI evaluation referral using standard audiologic assessments.

Factors That Influence Second-side Cochlear Implant Speech Recognition Outcomes.

OBJECTIVE: Assess relationships between patient, hearing, and cochlear implant (CI)-related factors and second-side CI speech recognition outcomes in adults who are bilaterally implanted. STUDY DESIGN: Retrospective review of a prospectively maintained CI database. SETTING: Tertiary academic center. PATIENTS: One hundred two adults receiving bilateral sequential or simultaneous CIs. OUTCOME MEASURES: Postimplantation consonant-nucleus-consonant (CNC) word and AzBio sentence scores at ≥12 months. RESULTS: Of patient, hearing and CI-specific, factors examined only postimplantation speech recognition scores of the first CI were independently associated with speech recognition performance of the second CI on multivariable regression analysis (CNC: ß = 0.471[0.298, 0.644]; AzBio: ß = 0.602[0.417, 0.769]). First-side postoperative CNC scores explained 24.3% of variation in second CI postoperative CNC scores, while change in first CI AzBio scores explained 40.3% of variation in second CI AzBio scores. Based on established 95% confidence intervals, 75.2% (CNC) and 65.9% (AzBio) of patients score equivalent or better with their second CI compared to first CI performance. Age at implantation, duration of hearing loss, receiving simultaneous versus sequential CIs, and preoperative residual hearing (measured by pure-tone average and aided speech recognition scores) were not associated with 12 month speech recognition scores at 12 months. CONCLUSIONS: The degree of improvement in speech recognition from first CI may predict speech recognition with a second CI. This provides preliminary evidence-based expectations for patients considering a second CI. Counseling should be guarded given the remaining unexplained variability in outcomes. Nonetheless, these data may assist decision making when considering a second CI versus continued use of a hearing aid for an unimplanted ear. LEVEL OF EVIDENCE: III.

When to replace legacy cochlear implants for technological upgrades: Indications and outcomes.

OBJECTIVE: To determine indications, surgical efficacy, and audiologic outcomes of replacing Advanced Bionics Clarion C1.2 internal devices (Advanced Bionics, LLC, Valencia, CA) as a means of technology upgrade. STUDY DESIGN: Retrospective review, case series. METHODS: Ten patients were initially implanted as a child (mean age = 3.87 years) and underwent cochlear implant reimplantation (CIR) with current Advanced Bionics internal device as a young adult (mean duration of implant use = 15.66 years). Demographic data and pre- and post-CIR speech perception scores were collected. RESULTS: Technology upgrade was the primary (9) or secondary (1) motivation for CIR. No surgical complications were noted, and full insertion was obtained in nine cases. Intraoperative impedance levels and neural response imaging measures were within normal limits for eight patients. At most recent post-CIR follow-up evaluation, all patients (100%) performed within or better than the 95% confidence interval of their pre-CIR word and sentence recognition scores; and 55.6%, 50.0%, and 50.0% of patients performed above the 95% confidence interval of their pre-CIR scores for the CNC words, sentences in quiet, and sentences in noise, respectively. CONCLUSION: Post-CIR audiological benefit was stable or improved compared to pre-CIR results in all categories by 3 months after reactivation. Given these results, patients who are unable to use the most current external processors due to incompatibility with a legacy internal device could consider reimplanation to optimize their overall performance with a cochlear implant. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:748-753, 2019.

Evaluation of Outcome Variability Associated With Lateral Wall, Mid-scalar, and Perimodiolar Electrode Arrays When Controlling for Preoperative Patient Characteristics.

OBJECTIVE: Determine the impact of electrode array selection on audiometric performance when controlling for baseline patient characteristics. STUDY DESIGN: Retrospective evaluation of a prospective cochlear implant (CI) database (January 1, 2012-May 31, 2017). SETTING: Tertiary Care University Hospital. PATIENTS: Three hundred twenty-eight adult CI recipients. INTERVENTIONS/MAIN OUTCOMES MEASURED: Hearing outcomes were measured through unaided/aided pure tone thresholds and speech recognition testing before and after cochlear implantation. All reported postoperative results were performed at least 6 months after CI activation. All device manufacturers were represented. RESULTS: Of the 328 patients, 234 received lateral wall (LW) arrays, 46 received perimodiolar (PM) arrays, and 48 received mid-scalar (MS) arrays. Patients receiving PM arrays had significantly poorer preoperative earphone and aided PTAs and SRTs, and aided Consonant-Nucleus-Consonant(CNC) word and AzBio +10 SNR scores compared with patients receiving LW arrays (all p ≤ 0.04), and poorer PTAs and AzBio +10 SNR scores compared with MS recipients (all p ≤ 0.02). No preoperative audiological variables were found to significantly differ between MS and LW patients. After controlling for preoperative residual hearing and speech recognition ability in a hierarchical multiple regression analysis, no statistically significant difference in audiological outcomes was detected (CNC words, AzBio quiet, or AzBio +10 SNR) among the three electrode array types (all p > 0.05). CONCLUSION: While previous studies have demonstrated superior postoperative speech recognition scores in LW electrode array recipients, these differences lose significance when controlling for baseline hearing and speech recognition ability. These data demonstrate the proclivity for implanting individuals with greater residual hearing with LW electrodes and its impact on postoperative results.

Use of Adult Patient Focus Groups to Develop the Initial Item Bank for a Cochlear Implant Quality-of-Life Instrument.

Importance: No instrument exists to assess quality of life (QOL) in adult cochlear implant (CI) users that has been developed and validated using accepted scientific standards. Objective: To develop a CI-specific QOL instrument for adults in accordance with the Patient Reported Outcomes Measurement Information System (PROMIS) guidelines. Design, Setting, and Participants: As required in the PROMIS guidelines, patient focus groups participated in creation of the initial item bank. Twenty-three adult CI users were divided into 1 of 3 focus groups stratified by word recognition ability. Three moderator-led focus groups were conducted based on grounded theory on December 3, 2016. Two reviewers independently analyzed focus group recordings and transcripts, with a third reviewer available to resolve discrepancies. All data were reviewed and reported according to the Consolidated Criteria for Reporting Qualitative Research. The setting was a tertiary referral center. Main Outcomes and Measures: Coded focus group data. Results: The 23 focus group participants (10 [43%] female; mean [range] age, 68.1 [46.2-84.2] years) represented a wide range of income levels, education levels, listening modalities, CI device manufacturers, duration of CI use, and age at implantation. Data saturation was determined to be reached before the conclusion of each of the focus groups. After analysis of the transcripts, the central themes identified were communication, emotion, environmental sounds, independence and work function, listening effort, social isolation and ability to socialize, and sound clarity. Cognitive interviews were carried out on 20 adult CI patients who did not participate in the focus groups to ensure item clarity. Based on these results, the initial QOL item bank and prototype were developed. Conclusions and Relevance: Patient focus groups drawn from the target population are the preferred method of identifying content areas and domains for developing the item bank for a CI-specific QOL instrument. Compared with previously used methods, the use of patient-centered item development for a CI-specific QOL instrument will more accurately reflect patient experience and increase our understanding of how CI use affects QOL.

Effects of Age and Implanted Ear on Speech Recognition in Adults with Unilateral Cochlear Implants.

The objective of this study was to examine how age and implanted ear contribute to functional outcomes with cochlear implantation (CI). A retrospective review was performed on 96 adults who underwent unilateral CI. Older adults with right-ear implants had higher Hearing in Noise Test (HINT) scores at 1 year by 10.3% (p = 0.06). When adjusted to rationalized arcsine units (rau), right-ear HINT scores in older adults were higher by 12.1 rau (p = 0.04). Older adults had an 8.9% advantage on the right side compared to the left in post- versus preimplant scores for consonant-vowel nucleus-consonant words (p = 0.05). No significant differences were observed for younger adults. In conclusion, although adults of all ages experience improvements in speech perception following CI, there might be a subtle but consistent right-ear advantage in older adults.