A. Aschendorff, T. Wesarg, S. Kröger, R. Beck, R. Laszig, S. Arndt

Dept. of Otorhinolaryngolgoy and IMplant Center Freiburg

University of Freiburg

Key note:Bilateral restoration of hearing

Implant Center Freiburg (ICF)

• CI, ABI, implantable hearing devices• Re-habilitation and long-term-care• > 2500 CI patients • > 250 CI surgeries /y.• Adults + children • Center of competence Baden-

Württemberg• Interdisciplinary team: • ENT, audiology, speech and language

therapy, linguistics, psychology, music therapy, technicians… (n=44)

• certified rehabilitation center (BAR)

Age at surgery

• NHS, diagnostics and HA experience for 4 m., decision at 8 m.

• Surgical point of view: ideal at/around 10 m.• Surgical technique: atraumatic

• Specialized centers for surgery in the very young?

• Data on even earlier surgery? (Colletti et al. 2012…

Fact and fiction? – Age at surgery (Germany)

• Significant increase for surgeries <24 m. • to 2006: 25,2% <2 y., 2006-2012 46,3% < 2 y.• still, 53,7% of children are older than 24 m.• Reason? Late provision with HA, reservations against early surgery, add.

med. factors, progressive hearing loss! (Fitzpatrick et al. 2011)

2012

0

5

10

15

20

25

30

35

40

bis 2006, n=289 2006-2012, n=359

<12 M.

12-24 M.

24-36 M.

36-48 M.

48-60 M.

%

***

***

m 1,3 J. n=38

m 2,7 J. n=139

m 7,2 J. n= 86

m 45,4 J. n=199

Long term outcome vs. age at surgery

Monosyllables (> 5 y. post CI) Laszig et al. 2010, Dissertation R. Beck,Richter et al. 2002, Tajudeen et al. 2010, de Raeeve 2010, Colletti et al. 2011

Group A with superior resuts

Group D: adults, congenital as well as progress. HL

Bilateral CI

• Schafer et al. 2011 (Int J Audiol) "A meta-analysis to compare speech recognition in noise with bilateral cochlear implants and bimodal stimulation" (42 studies analysed):

• binaural advantages in bilaterale CI`s:• squelch (central noise reduction), summation, head-shadow effect • advantage compared to bimodal stimulation

• German "Guideline CI": bilateral CI whenever possible• German health insurance: bilateral CI in cases at risk of or with

obliteration/meningitis• all others: single-case decision, sequentially or simultaneously• All centers: increasing number of bilaterals, no combined approach• UK: National Paediatric Bilateral Cochlear Implant Audit

Bilateral situation in Freiburg• N= 2234 (Stand 09-2012)

• Mean intervall 1st to 2nd implant (all p. up to 18 y.): 5.9 years!• Since 2006: significant reduction to 1.7 y.• improved counseling• Aim: 2nd CI within 12 m.

Bilaterale n=446Kinder n=281Sequentiell Kinder n=229 Inte

rval

l in

Jah

ren,

Alte

r bi

s 1

2 J.

Late sequential BCI: Results OLSA at 70 dB in quiet, *progressive HL, n=15, mean interval between 1st and 2nd CI: 8 y., (r: 4-12 y.) Delay: necessary time to reach results of 1st ear or stable

longterm result

Not all will acchieve identical results, chance of drop out and, finally, rejection of 2nd implant

0102030405060708090

100M

B KB SZ* LL

EK* JB MF

SW PB MS

MSc

*AH JZ

FS* CS

1st CI

2nd CI*numbers

*develop

*develop

Delay: <1y. 1y. 2y. 3y. 4y.

The sequential problem

Late sequential BCI: negative effect visible at time interval of >12 M, Gordon et al. 2008

Bilateral advantage correlated to time between surgeries, interval >8 y. seems critical Steffens et al. 2008 (H, RB, FR)

Exemption: progressive hearing loss!

…and… where´s the beef?

• New field: auditory rehabilitation in single-sided deafness and asymmetric hearing loss

• Similar considerations, similar factors to influence results

Why bother?

• 70-93% report difficulties for speech comprehension in noise, independent of age (Coletti et al. 1988; Ruscetta et al. 2005; Priwin et al. 2007; Wie et al. 2009)

• 12-41% of children require additional support in school(Bess & Tharpe 1986; Bovo et al. 1988)

• 22-35% of children have to repeat classes (Bess and Tharpe 1986; Brockhauser et al. 1991; Cho Lieu et al. 2004)

• Misinterpretation hyperactivity• Results in adults are encouraging therapy in

children as well

Incidence of unilateral HL in NHS

•Unclear!•Berninger & Westling 2011:

• NHS (6 y., >30.000) • bilateral HL 0.17%, unilateral 0.06% (Ratio 3:1)

•Ghirri et al. 2011: • NHS, (>7000), unilat. HL 0.99/1000

•Nie 2008, (China): • bilateral HL 2.22/1000, unilateral 2.74/1000

newborn

Etiology adults (n=101)n=93 postlingual, n=10 congenital, n=10 AHL

progr. HL

sudden deafness

post surgery

AN

congenital, n=2 CND

Mumps

Meniere

chr. otitis media

LAV

trauma

labyrinthitis

meningitis

Rubella

otosclerosis

otox. medication

infection/unknown

0 5 10 15 20 25

Eti

olo

gy

Etiology children (n=16)n=11 congenital, n=4 erworben, n=1 non organic

unilateral LAV

congenital CMV

non organic

absent VIIIth nerve

unknown, cochlear deafness

0 1 2 3 4 5 6 7 8

Etio

log

y

(incl. 1 CHARGE)

Freiburg: only n=8 qualified for a CI!

Kutz et al. 2011: deficient nerve: limited results, absent nerve: poor results

Eiology children SSD I

Unilateral LAV in n=2 children

Etiology children SSD II

HRCT: IAM normal, MRI: CND/aplasia of VIIIth nerve, n=5

CHARGE, N VII aplasia R, N VIII aplasia L

• no therapy

• conventional CROS-HA

• BAHS for CROS Vanecloo et al. 2002

• Cochlear Implantation Vermeire et al. 2008;

Arndt et al. 2011Adults!

SSD: treatment options?

Rehabilitation in patients with unilateral deafness Study design

• primary objective: • audiometric test results (speech discrimination in noise, localisation)

• unaided, Baha, CROS-HA

• trial period for each device 3 weeks

(Baha BP100 headband/CROS-HA; Phonak Una M)

• CI recommended, if patients fitted the inclusion criteria

(duration of deafness ≤ 10 years, intact auditory nerve)

• secondary objective:• results after 12 months with chosen device (CROS; Baha; CI)

• comparison between the devices

• subjective evaluation with SSQ scale

Rehabilitation in patients with unilateral deafness Audiometric test

speech test• HSM-sentences in noise (Hochmair-Desoyer et al. 1997)• sentences @ 65 dB SPL, noise @ 65 dB SPL, SNR 0 dB • % correct answers

test setup

Rehabilitation in patients with unilateral deafness Localisation test

stimuli• OlSa sentences (Wagener et al. 1999)• mean sound level: 65 dB SPL• level randomisation: ± 6 dB SPL• localisation error [°]

test setup

Rehabilitation in patients with unilateral deafness Patientsoverall: 101 adult patients

mean duration of deafness: 10.31 years (1 month - 47.6 years)

decision CROS Baha CI

No. of patients after test trial(outside CI inclusion criteria)

12 (8)

19 (12)

45

No. of patients with 12 month results (outside CI inclusion criteria)

7 (3)

16 (8)

25

drop out 8

all devices rejected 12

not yet decided 5

~ 25 %

err

or

[°]

co

rre

ct

[%]

*

**

Speech discrimination and localisation results: CROS group (n=7)

err

or

[°]

co

rre

ct

[%]

*#**

*****

*

#

*

Speech discrimination and localisation results:Baha group (n=16)

***

err

or

[°]

co

rre

ct

[%]

***

*********

***#**** *

*****

*** ***** *

*

Speech discrimination and localisation results: CI group (n=25)

Comparison of speech discrimination and localisation: Results after 12-month device use

err

or

[°]

co

rre

ct

[%]

#

*

err

or

[°]

co

rre

ct

[%]

*

# *# ****** ***

*#

Comparison of speech discrimination and localisation: Results after 12-month device use

-20

0

20

40

60

80

100

0 10 20 30 40 50

bene

fit/

%

duration of deafness/ years

CROS Baha CI

Correlation of benefit (aided - unaided speech understanding) in noise in relation vs. duration of deafness

0 1 2 3 4 5 6 7 8 9 100

10

20

30

40

50

60

70

80

90

100

CI 12 months (n=25) Linear (CI 12 months (n=25))

duration of deafness/ years

% c

orr

ec

t Correlation of speech understanding in SciNnh vs. duration of deafness after 12 months CI use

r=-0,616649 (p=0,001, **)

otosclerosis

SV / % = -5,336999 * duration of deafness / years + 63,667

0 1 2 3 4 5 6 7 8 9 10

-20

0

20

40

60

80

100

duration of deafness/ years

Be

ne

fit

Correlation of benefit (binaural/12 months CI use) - monaural /preop) to duration of deafness

labyrinthitis

r=-0,589063 (p=0,001947, **)

SV Benefit / % = -4,679889 * duration of deafness / years + 52,505605

Subjective evaluation after 12-month device use - SSQ scale

speech spatial quality

******

****

****

*

Conclusion after 12 months device experience:

▫ superior results with CI in speech discrimination in all conditions▫ significant improvement in localisation with CI

▫ outcome/ rehabilitation time may be correlated to duration of deafness, training necessary

▫ patients with long duration of deafness rather benefit from Baha or CROS device

▫ CI with long duration of deafness: more data necessary critical question: duration of deafness to still recommend CI

If patients are within inclusion criteria for CI:▫ first choice CI▫ second choice Baha or CROS (better results with Baha)

▫ Baha and CROS cannot prevent deprivation of the auditory pathway

…and in children? Speech in quiet (n=3)

Freiburg monosyllables @ 70 dB

child 3 (6 y., congenital, Göttinger I, per audio input , 70 dB):• 3 m.: 40% monosyllables• 6 m.: 50 % monosyllables

Kind 1 Kind 20%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 0%

50%

35%

65%

50% unversorgt

6 Monate

12 Monate

SSD children vs. adults: Results after 12 m., acquired deafnessUnknown: development in congential deafness? Sensitive phases? Maximum duration of deafness?

0

10

20

30

40

50

60

70

80

90

100

child 1 child 2 adults(n=22)

child 1 child 2 adults(n=22)

child 1 child 2 adults(n=22)

% co

rrect

Reihe1 Reihe2

stimuli

noise

CI

Sprache Lärm

child 1 child 2 adults (n=22)

**

HSM @ 65 dB, S/N 0

Kind 1 Kind 2 Erwachsene (n=22)0

10

20

30

40

50

60

70

80

90

100

child 1 child 2 adults (n=22)

% c

orre

ct

Reihe1 Reihe2 CI

***

unaided with CI

OLSA @ 65 dB, Pegelrandom.

Bilateral restoration of hearing

• In bilateral HL: bilateral CI or bimodal stimulation• Results: UK BCI Audit• New: auditory rehabilitation in SSD and AHL • Evaluation similar to regular CI, MRI necessary• Pseudostereophonic BAHS, CROS, Bonebridge with poorer results, but may be indicated in special cases

• Age, duration of deafness, prior surgery like AN, aplasia of VIIIth nerve, ossification…

• Training necessary• Children:

• congenital SSD: early treatment, results? • acquired SSD: results comparable to adults

0

10

20

30

40

0 10 20 30 40 50

Unaided speech understanding in noise in relation to duration of deafness

% c

orre

ct

duration of deafness/ years

CROS Baha CI