Cochlear Implant Stimulation Parameters Play a Key Role in Reducing Facial Nerve Stimulation.

A percentage (i.e., 5.6%) of Cochlear Implant (CI) users reportedly experience unwanted facial nerve stimulation (FNS). For some, the effort to control this problem results in changing stimulation parameters, thereby reducing their hearing performance. For others, the only viable solution is to deactivate the CI completely. A growing body of evidence in the form of case reports suggests that undesired FNS can be effectively addressed through re-implantation with an Oticon Medical (OM) Neuro-Zti implant. However, the root of this benefit is still unknown: is it due to surgical adjustments, such as varied array geometries and/or positioning, or does it stem from differences in stimulation parameters and/or grounding? The OM device exhibits two distinct features: (1) unique stimulation parameters, including anodic leading pulses and loudness controlled by pulse duration-not current-resulting in lower overall current amplitudes; and (2) unconventional grounding, including both passive (capacitive) discharge, which creates a pseudo-monophasic pulse shape, and a 'distributed-all-polar' (DAP) grounding scheme, which is thought to reduce current spread. Unfortunately, case reports alone cannot distinguish between surgical factors and these implant-related ones. In this paper, we present a novel follow-up study of two CI subjects who previously experienced FNS before re-implantation with Neuro-Zti implants. We used the Oticon Medical Research Platform (OMRP) to stimulate a single electrode in each subject in two ways: (1) with traditional monopolar biphasic cathodic-first pulses, and (2) with distinct OM clinical stimulation. We progressively increased the stimulation intensity until FNS occurred or the sound became excessively loud. Non-auditory/FNS sensations were observed with the traditional stimulation but not with the OM clinical one. This provides the first direct evidence demonstrating that stimulation parameters and/or grounding-not surgical factors-play a key role in mitigating FNS.

The relationship between electrical auditory brainstem responses and perceptual thresholds in Digisonic® SP cochlear implant users.

Determining the electrical stimulation levels is often a difficult and time-consuming task because they are normally determined behaviorally - a particular challenge when dealing with pediatric patients. The evoked stapedius reflex threshold and the evoked compound action potential have already been shown to provide reasonable estimates of the C- and T-levels, although these estimates tend to overestimate the C- and T-levels. The aim of this study was to investigate whether the evoked auditory brainstem response (eABR) can also be used to reliably estimate a patient's C- and T-levels. The correlation between eABR detection thresholds and behaviorally measured perceptual thresholds was statistically significant (r = 0.71; P < 0.001). In addition, eABR Wave-V amplitude increased with increasing stimulation level for the three loudness levels tested. These results show that the eABR detection threshold can be used to estimate a patient's T-levels. In addition, Wave-V amplitude could provide a method for estimating C-levels in the future. The eABR objective measure may provide a useful cochlear implant fitting method - particularly for pediatric patients.

Using personal response systems to assess speech perception within the classroom: an approach to determine the efficacy of sound field amplification in primary school classrooms.

OBJECTIVES: The assessment of the combined effect of classroom acoustics and sound field amplification (SFA) on children's speech perception within the "live" classroom poses a challenge to researchers. The goals of this study were to determine: (1) Whether personal response system (PRS) hand-held voting cards, together with a closed-set speech perception test (Chear Auditory Perception Test [CAPT]), provide an appropriate method for evaluating speech perception in the classroom; (2) Whether SFA provides better access to the teacher's speech than without SFA for children, taking into account vocabulary age, middle ear dysfunction or ear-canal wax, and home language. DESIGN: Forty-four children from two school-year groups, year 2 (aged 6 years 11 months to 7 years 10 months) and year 3 (aged 7 years 11 months to 8 years 10 months) were tested in two classrooms, using a shortened version of the four-alternative consonant discrimination section of the CAPT. All children used a PRS to register their chosen response, which they selected from four options displayed on the interactive whiteboard. The classrooms were located in a 19th-century school in central London, United Kingdom. Each child sat at their usual position in the room while target speech stimuli were presented either in quiet or in noise. The target speech was presented from the front of the classroom at 65 dBA (calibrated at 1 m) and the presented noise level was 46 dBA measured at the center of the classroom. The older children had an additional noise condition with a noise level of 52 dBA. All conditions were presented twice, once with SFA and once without SFA and the order of testing was randomized. White noise from the teacher's right-hand side of the classroom and International Speech Test Signal from the teacher's left-hand side were used, and the noises were matched at the center point of the classroom (10sec averaging [A-weighted]). Each child's expressive vocabulary age and middle ear status were measured individually and each child's home language and any special educational needs were recorded. RESULTS: All children were able to use the PRS handsets, and the CAPT speech perception test was sufficiently sensitive to highlight differences in perception in the different listening conditions. Scores were higher in quiet than in any noise condition. Results showed that group performance was significantly better with SFA than without it. The main demographic predictor of performance was expressive vocabulary age. SFA gave more benefit to the poorer performers in the group. There were no significant effects on performance relating to middle ear status or home language; however, the size of the population was too small to be able to fully explore these aspects in greater detail. CONCLUSION: PRS together with the CAPT provides a sensitive measure for in situ speech perception testing within the classroom. Vocabulary age has a large effect on a child's ability to perceive the speech signal. SFA leads to improved speech perception, when the speech signal has been degraded because of poor acoustics or background noise and has a particularly large effect for children with lower vocabulary ages.

Measurement of the distribution of medial olivocochlear acoustic reflex strengths across normal-hearing individuals via otoacoustic emissions.

A clinical test for the strength of the medial olivocochlear reflex (MOCR) might be valuable as a predictor of individuals at risk for acoustic trauma or for explaining why some people have trouble understanding speech in noise. A first step in developing a clinical test for MOCR strength is to determine the range and variation of MOCR strength in a research setting. A measure of MOCR strength near 1 kHz was made across a normal-hearing population (N = 25) by monitoring stimulus-frequency otoacoustic emissions (SFOAEs) while activating the MOCR with 60 dB SPL wideband contralateral noise. Statistically significant MOCR effects were measured in all 25 subjects; but not all SFOAE frequencies tested produced significant effects within the time allotted. To get a metric of MOCR strength, MOCR-induced changes in SFOAEs were normalized by the SFOAE amplitude obtained by two-tone suppression. We found this "normalized MOCR effect" varied across frequency and time within the same subject, sometimes with significant differences between measurements made as little as 40 Hz apart or as little as a few minutes apart. Averaging several single-frequency measures spanning 200 Hz in each subject reduced the frequency- and time-dependent variations enough to produce correlated measures indicative of the true MOCR strength near 1 kHz for each subject. The distribution of MOCR strengths, in terms of SFOAE suppression near 1 kHz, across our normal-hearing subject pool was reasonably approximated by a normal distribution with mean suppression of approximately 35% and standard deviation of approximately 12%. The range of MOCR strengths spanned a factor of 4, suggesting that whatever function the MOCR plays in hearing (e.g., enhancing signal detection in noise, reducing acoustic trauma), different people will have corresponding differences in their abilities to perform that function.

Bias due to noise in otoacoustic emission measurements.

Measurements of otoacoustic emission (OAE) magnitude are often made at low signal/noise ratios (SNRs) where measurement noise generates bias and variability errors that have led to the misinterpretation of OAE data. To gain an understanding for these errors and their effects, a two part investigation was carried out. First, the nature of OAE measurement noise was investigated using human data from 50 stimulus-frequency OAE experiments involving medial olivocochlear reflex (MOCR) activation. The noise was found to be reasonably approximated by circular Gaussian noise. Furthermore, when bias errors were taken into account, measurement variability was not found to be affected by MOCR activation as had been previously reported. Second, to quantify the errors circular Gaussian noise produces for different methods of OAE magnitude estimation for distortion-product, stimulus-frequency, and spontaneous OAEs, simulated OAE measurements were analyzed via four different magnitude estimation methods and compared. At low SNRs (below -6 dB), estimators involving Rice probability density functions produced less biased estimates of OAE magnitudes than conventional estimation methods, and less total rms error-particularly for spontaneous OAEs. They also enabled the calculation of probability density functions for OAE magnitudes from experimental data.

Time-course of the human medial olivocochlear reflex.

The time-course of the human medial olivocochlear reflex (MOCR) was measured via its suppression of stimulus-frequency otoacoustic emissions (SFOAEs) in nine ears. MOCR effects were elicited by contralateral, ipsilateral or bilateral wideband acoustic stimulation. As a first approximation, MOCR effects increased like a saturating exponential with a time constant of 277+/-62 ms, and decayed exponentially with a time constant of 159+/-54 ms. However, in ears with the highest signal-to-noise ratios (4/9), onset time constants could be separated into "fast," tau= approximately 70 ms, "medium," tau = approximately 330 ms, and "slow," tau = approximately 25 s components, and there was an overshoot in the decay like an under-damped sinusoid. Both the buildup and decay could be modeled as a second order differential equation and the differences between the buildup and decay could be accounted for by decreasing one coefficient by a factor of 2. The reflex onset and offset delays were both approximately 25 ms. Although changing elicitor level over a 20 dB SPL range produced a consistent systematic change in response amplitude, the time course did not show a consistent dependence on elictor level, nor did the time-courses of ipsilaterally, contralaterally, and bilaterally activated MOCR responses differ significantly. Given the MOCR's time-course, it is best suited to operate on acoustic changes that persist for 100's of milliseconds.

Medial olivocochlear efferent reflex in humans: otoacoustic emission (OAE) measurement issues and the advantages of stimulus frequency OAEs.

Otoacoustic emissions (OAEs) are useful for studying medial olivocochlear (MOC) efferents, but several unresolved methodological issues cloud the interpretation of the data they produce. Most efferent assays use a "probe stimulus" to produce an OAE and an "elicitor stimulus" to evoke efferent activity and thereby change the OAE. However, little attention has been given to whether the probe stimulus itself elicits efferent activity. In addition, most studies use only contralateral ( re the probe) elicitors and do not include measurements to rule out middle-ear muscle (MEM) contractions. Here we describe methods to deal with these problems and present a new efferent assay based on stimulus frequency OAEs (SFOAEs) that incorporates these methods. By using a postelicitor window, we make measurements in individual subjects of efferent effects from contralateral, ipsilateral, and bilateral elicitors. Using our SFOAE assay, we demonstrate that commonly used probe sounds (clicks, tone pips, and tone pairs) elicit efferent activity, by themselves. Thus, results of efferent assays using these probe stimuli can be confounded by unwanted efferent activation. In contrast, the single 40 dB SPL tone used as the probe sound for SFOAE-based measurements evoked little or no efferent activity. Since they evoke efferent activation, clicks, tone pips, and tone pairs can be used in an adaptation efferent assay, but such paradigms are limited in measurement scope compared to paradigms that separate probe and elicitor stimuli. Finally, we describe tests to distinguish middle-ear muscle (MEM) effects from MOC effects for a number of OAE assays and show results from SFOAE-based tests. The SFOAE assay used in this study provides a sensitive, flexible, frequency-specific assay of medial efferent activation that uses a low-level probe sound that elicits little or no efferent activity, and thus provides results that can be interpreted without the confound of unintended efferent activation.