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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