Minimally Traumatic Cochlear Implant Surgery: Expert Opinion in 2010 and 2020.

This study aimed to discover expert opinion on the surgical techniques and materials most likely to achieve maximum postoperative residual hearing preservation in cochlear implant (CI) surgery and to determine how these opinions have changed since 2010. A previously published questionnaire used in a study published in 2010 was adapted and expanded. The questionnaire was distributed to an international group of experienced CI surgeons. Present results were compared, via descriptive statistics, to those from the 2010 survey. Eighteen surgeons completed the questionnaire. Respondents clearly favored the following: round window insertion, slow array insertion, and the peri- and postoperative use of systematic antibiotics. Insertion depth was regarded as important, and electrode arrays less likely to induce trauma were preferred. The usefulness of dedicated soft-surgery training was also recognized. A lack of agreement was found on whether the middle ear cavity should be flushed with a non-aminoglycoside antibiotic solution or whether a sheath or insertion tube should be used to avoid contaminating the array with blood or bone dust. In conclusion, this paper demonstrates how beliefs about CI soft surgery have changed since 2010 and shows areas of current consensus and disagreement.

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.

Two-phase survey on the frequency of use and safety of MRI for hearing implant recipients.

PURPOSE: Magnetic resonance imaging (MRI) is often used to visualize and diagnose soft tissues. Hearing implant (HI) recipients are likely to require at least one MRI scan during their lifetime. However, the MRI scanner can interact with the implant magnet, resulting in complications for the HI recipient. This survey, which was conducted in two phases, aimed to evaluate the safety and performance of MRI scans for individuals with a HI manufactured by MED-EL (MED-EL GmbH, Innsbruck, Austria). METHODS: A survey was developed and distributed in two phases to HEARRING clinics to obtain information about the use of MRI for recipients of MED-EL devices. Phase 1 focused on how often MRI is used in diagnostic imaging of the head region of the cochlear implant (CI) recipients. Phase 2 collected safety information about MRI scans performed on HI recipients. RESULTS: 106 of the 126 MRI scans reported in this survey were performed at a field strength of 1.5 T, on HI recipients who wore the SYNCHRONY CI or SYNCHRONY ABI. The head and spine were the most frequently imaged regions. 123 of the 126 scans were performed without any complications; two HI recipients experienced discomfort/pain. One recipient required reimplantation after an MRI was performed using a scanner that had not been approved for that implant. There was only one case that required surgical removal of the implant to reduce the imaging artefact. CONCLUSION: Individuals with either a SYNCHRONY CI or SYNCHRONY ABI from MED-EL can safely undergo a 1.5 T MRI when it is performed according to the manufacturer's safety policies and procedures.

Hearing preservation cochlear implantation in children: The HEARRING Group consensus and practice guide.

OBJECTIVES: To provide multidisciplinary cochlear implant teams with a current consensus statement to support hearing preservation cochlear implantation (HPCI) in children, including those children with symptomatic partial deafness (PD) where the intention is to use electric-acoustic stimulation (EAS). The main objectives are to provide guidelines on who is a candidate, how to assess these children and when to implant if Med-El Flex electrode arrays are chosen for implantation. METHODS: The HEARRING group reviewed the current evidence and practice regarding the management of children to be considered for HPCI surgery emphasizing the assessment needed prior to implantation in order to demonstrate the benefits in these children over time. The consensus statement addresses following three key questions: (1) Should these children be treated? (2) How to identify these children? (3) How to manage these children? SUMMARY: The HEARRING group concludes that irrespective of the degree of residual hearing present, the concepts of hearing and structure preservation should be applied in every child undergoing cochlear implantation and that HPCI is a safe and reliable treatment option. Early detection and multidisciplinary assessment are key to the identification of children with symptomatic PD, these children should undergo HPCI as early as possible.

Cochlear implantation under local anaesthesia - Our experience and a validated patient satisfaction questionnaire.

OBJECTIVES: Cochlear implantation (CI) under local anaesthetic (LA) has previously been shown to be a successful and safe option for a specific group of patients (e.g. elderly and significant co-morbidity). We aim to discuss our practice and obtain qualitative information about patient experience from our cohort of patients at the Yorkshire Auditory Implant Service (YAIS). METHODS: Retrospective chart review to include demographics, co-morbidities and physiological parameters were recorded and used to calculate P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) scores. The Iowa Satisfaction with Anaesthesia Scale (ISAS) questionnaire was distributed to all patients who received CI under LA and subsequently analysed. RESULTS: Seven patients received CI under LA at YAIS. This included five males and two females. The mean age was 79 years (range 26 -93). The mean P-POSSUM mortality and morbidity for this cohort was 2.4 and 34.9%, respectively. The average ISAS score was +1.72 (where range of -3 is completely dissatisfied and +3 is completely satisfied). DISCUSSION: We discuss our cohort and show that patients receiving CI have a favourable experience when LA is used. CI under LA is a viable and safe option for more elderly patients and those who are deemed at high risk of morbidity or mortality associated with a general anaesthetic. CONCLUSIONS: The data regarding validated patient experience obtained from this study can be used to help counsel patients that may be offered CI under LA.

Inside implant criteria or not? - Detection of non-organic hearing loss during cochlear implant assessment.

OBJECTIVES: The diagnosis of non-organic hearing loss (NOHL) is a difficult but important issue during the assessment process for cochlear implantation (CI). We aim to identify the key factors in identifying patients with NOHL during CI assessment and present our local screening protocol for NOHL. METHODS: A retrospective review of patients referred to the Yorkshire Auditory Implant Service (YAIS) between 2003 and 2015 who were subsequently diagnosed with NOHL during the assessment. Patient demographic data, audiological and functional assessments were assessed. RESULTS: Thirty-two patients were included in the study. Mean age was 43 years (range 14-82 years). Male to female ratio was 1:1.7. Indicators of possible NOHL included a sudden deterioration in hearing (n = 21; 66%), mismatches in observed behaviour and either pure-tone audiogram (PTA) (n = 27; 84%) or functional testing (n = 20; 80%) and stapedial reflexes below reported audiological thresholds (n = 12; 46%). A mismatch in functional hearing and PTA was seen in 72% of patients. Patients with suspected NOHL were referred for further objective testing. All 23 patients who underwent objective testing had better hearing levels compared to reported hearing thresholds thus placing them outside of implant criteria. Five candidates were found to have normal hearing thresholds. DISCUSSION: NOHL can present a significant challenge to the implant team, particularly in the subgroup with a pre-existing organic hearing loss with non-organic overlay. We discuss the common features in this cohort of patients. CONCLUSIONS: To facilitate the identification of patients with NOHL, the YAIS has developed a screening protocol.

Patient management for cochlear implant recipients in audiology departments: A practice review.

OBJECTIVES: To determine and evaluate the time clinics needed to complete the sub-processes involved in the first-fitting and follow-up fitting of people with a cochlear implant. METHODS: Eight HEARRING clinics completed a questionnaire recording how long it took to complete the sub-processes involved in first-fitting and follow-up fitting cochlear implant recipients. The mean times of clinics and procedures were then compared. RESULTS: Questionnaires on 77 patients were completed. Clinics varied widely on time spent on each sub-process in both first- and follow-up fittings. Total first-fitting times were similar across clinics. Follow-up fitting times varied more across clinics although this may have been due to differences in questionnaire interpretation. DISCUSSION: If a patient management plan can help increasingly busy cochlear implant clinics provide high-quality care more efficiently, essential first steps are determining which procedures are generally performed and how long their performance takes. Until reliable data are gathered, constructing a patient management plan or reaping the potential benefits of its use will remain elusive; clinics will have to find what solutions they can to meet rising workload demands. CONCLUSION: The variation in time spent on each sub-process may suggest that some clinics have more efficient workflow procedures. Compiling a best practice for each process could be instrumental in creating a professional process management plan that would increase efficiency without sacrificing quality of care.

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.

Quality standards for bone conduction implants.

CONCLUSION: Bone conduction implants are useful in patients with conductive and mixed hearing loss for whom conventional surgery or hearing aids are no longer an option. They may also be used in patients affected by single-sided deafness. OBJECTIVES: To establish a consensus on the quality standards required for centers willing to create a bone conduction implant program. METHOD: To ensure a consistently high level of service and to provide patients with the best possible solution the members of the HEARRING network have established a set of quality standards for bone conduction implants. These standards constitute a realistic minimum attainable by all implant clinics and should be employed alongside current best practice guidelines. RESULTS: Fifteen items are thoroughly analyzed. They include team structure, accommodation and clinical facilities, selection criteria, evaluation process, complete preoperative and surgical information, postoperative fitting and assessment, follow-up, device failure, clinical management, transfer of care and patient complaints.

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.

Outcomes with bilateral cochlear implantation following sudden dual sensory loss after ethylene glycol poisoning.

Acute loss of vision accompanied by profound loss of hearing is fortunately rare, but has a catastrophic effect on both the patient and their family. Re-establishing communication and spatial awareness are high priorities. We describe the case of a 45 year-old man who presented as a result of poisoning by ethylene glycol. Following assessment by clinicians who learned the deaf-blind alphabet in order to communicate, he had his hearing successfully rehabilitated with simultaneous bilateral cochlear implants. The patient recovered the ability to understand speech near perfectly in quiet, to attend to the ear giving the clearer signal in noise, and to localise sources of sound. The patient reported that the latter skill facilitated mobility. This is the first reported case of a patient with acute dual sensory loss due to ethylene glycol poisoning benefiting from bilateral cochlear implants.

Effectiveness of computer-based auditory training for adult users of cochlear implants.

Cochlear implantation is effective at restoring partial hearing to profoundly deaf adults, but not all patients receive equal benefit. The present study evaluated the effectiveness of a computer-based self-administered training package that was designed to improve speech perception among adults who had used cochlear implants for more than three years. Eleven adults were asked to complete an hour of auditory training each day, five days a week, for a period of three weeks. Two training tasks were included, one based around discriminating isolated words, and the other around discriminating words in sentences. Compliance with the protocol was good, with eight out of eleven participants completing approximately 15 hours of training, as instructed. A significant improvement of eight percentage points was found on a test of consonant discrimination, but there were no significant improvements on sentence tests or on a test of vowel discrimination. Self-reported benefits were variable and generally small. Further research is needed to establish whether auditory training is particularly effective for identifiable sub-groups of cochlear-implant users.

The cost and analysis of nonuse of cochlear implants.

OBJECTIVE: Analysis of the cost implications and reasons for nonuse of cochlear implants in an established cochlear implant unit. STUDY DESIGN: Clinical data were analyzed retrospectively to construct a table of cochlear implant use over time to identify nonuse and to suggest the reasons for this. SETTING: Yorkshire Cochlear Implant Service is a tertiary referral center. PATIENTS: Three hundred forty consecutively implanted patients from 1990 to 2005. MAIN OUTCOME MEASURES: Life table analysis showed that most children used their implant (p = 0.7 during 11 yr). However, 11 of 155 children and 2 of 185 adults became nonusers during the period of study. The 11 children stopped because of age at implant, educational placement, and family support. Two adults stopped because of psychological issues and inability to adapt to the signal. Surgical and implant costs have initial impact, with subsequent years' costs reflecting programming issues and maintenance. When considering nonuse, there are 2 effects: first, no more costs are incurred, and second, no more years of use are accumulated. Thus, nonuse reduces both costs and years. Costs of gaining a year of use as a function of time showed that there was little financial impact from the 11 children nonusers. As a ratio of "no nonuse" and observed "nonuse" in children, the ratio is 1.07 by 13 years of implantation (7%). The adult group was too few to analyze. CONCLUSION: The nonuse added 7% to the average cost. Retrospective audit identifies that patient selection by a multidisciplinary team is crucial to reducing nonuse.

Cochlear implantation--United Kingdom and Ireland surgical survey.

Cochlear implantation has now become a routine procedure in the management of severe to profound deafness. An initial survey was carried out in late 1997 of the surgeons carrying out implantation in the United Kingdom and Ireland, requesting details of medical and surgical aspects of cochlear implantation. A follow-up survey was conducted in early 2002 to evaluate any changes in clinical practice. The reported results show a low surgical complication rate in both children and adults. Reasons for this are discussed.