Ángel Ramos Macías, Silvia Borkoski Barreiro, Juan Carlos Falcón González, Ángel Ramos de Miguel

AHL, SSD and Bimodal CI results in children

Complejo Hospitalario Universitario Insular Materno Infantil, Unidad de Hipoacusia- Servicio de ORL, Las Palmas, Spain

Las Palmas University. Gran Canaria. Spain

(Prof Angel Ramos)

BACKGROUND

Single Side Deafness (SSD) : Unilateral sensorineural profound hearing loss (USNHL) ,

means that an individual is able to hear from only one ear. Asymmetric Hearing Loss (AHL):

Diference between both ear hearing level Bimodal:

Hearing Aid in one side + C.I. In contralateral side.

Asymmetric hearing loss should degrade spatial hearing and has become an important experimental tool for probing the plasticity of the auditory system, both during development and adulthood. The rehabilitation methods used, to date, for SSD are conventional hearing aids with cross routing of the sound, (CROS-HA) and bone- anchored bone conduction systems (Baha®). Cochlear implantation (CI) is a new form of treatment for SSD patients with CI achieve significantly better results than with the Baha and the CROS-HA or than in the unaided situation. (Arndt; 2012)(Van den Heining 2011)(Ramos 2012)

BACKGROUND (Asymmetric Hearing Loss)

Binaural summation, squelch and head shadows effect and also the fact that the low frequency fine structure provided by hearing aids, helps a lot for voice and music appreciation. Firszt et al. 2013 Bimodal (electric and acoustic) and binaural (two ears) hearing gives better speech understanding in quiet, in noise and better localization Bimodal did not always protect against asymmetric cortical development . Binodal not always use timing cues. (Papsin ,2014) Immature human auditory cortex reorganizes, potentially permanently, with unilateral stimulation and that bilateral auditory input provided with limited delay can protect the brain from such changes (Gordon , 2012)

BACKGROUND (Bimodal)

Principal objective: To demonstrate that children in a bimodal situation, with substantial hearing (>70 % Speech Discrimantion) in the ear with HA, obtain clinically relevant speech perception benefit after Cochlear implantation in the contralateral side. Hypothesis 1: indication criteria for cochlear implantation can be enlarged in case of unilateral sensory neural profound deafness on the ear to be implanted and moderate to severe (grade 1) deafness on the contra-lateral ear in children. Hypothesis 2: A specific programming of the implant is needed to achieve best benefit of the stimulation

Study Objectives

Inclusion Criteria

Children with AHL in “Bimodal” situation All patients received unilateral C.I.(2004 y 2011) (conventional CI Criteria) (Nucleus Cochlear AG) 24 months follow up Age: 3,2 ( 2-11) 39 Children (12 Female ; 27 Male)

Exclusion Criteria - In the ear to be implanted

* Ossification or any other cochlear anomaly that might prevent complete insertion of the electrode array, as confirmed by medical examination and tests including MRI.

* Severe to profound hearing loss: related to meningitis, multiple sclerosis, posterior fossa tumors or central hearing related disorders (Vascular problems of systemic origin / Creutzfeldt-Jacob / Encephalitis)

- Signs of retro-cochlear or central origin to hearing impairment as confirmed by medical examination and tests including MRI. - Medical conditions that would contraindicate undergoing CI surgery (e.g. active middle ear infections, tympanic membrane perforation). - Psychological , neural or mental disorders that would contraindicate undergoing CI surgery as verified by psychologist - Additional handicaps that would prevent participation in evaluations

Study Design and Protocol •  Retrospective study

•  Bimodal Children all implanted initially unilaterally and keepimg the HA

•  Specific programming in order to improve CI and HA performance.

•  Test: (CI , HA , CI+HA)

- Pure tone audiometry /free field) . (0,5-1-2 Kz) - Disyllabic speech test score in quiet at 65 dB-SPL in the best aided

condition without lip reading (S00 ) - Sentence test score in quiet at 65 dB-SPL in the best aided

condition without lip reading (S00 )

Study Status (preliminary data) Groups (In all groups one ear meet the CI criteria.) Cotralateral ear:

HA best aided condition < 50% Disyllabic speech test score in quiet at 65 dB-SPL in the best aided condition without lip reading, in the best ear.

N= 27 ; age: 7.11 ( r:2-11) HA best aided condition <>50% <70% Disyllabic speech test score in quiet at 65

dB-SPL in the best aided condition without lip reading, in the best ear. N=3 ; age 6,9 (r:3-8) HA best aided condition >70% to normal , Disyllabic speech test score in quiet at

65 dB-SPL in the best aided condition without lip reading, in the best ear. N=9 ; age : 4,1 ( r:2-7)

Study Status (preliminary data) Study Status (preliminary data)

HA best aided condition < 50% Disyllabic speech test score in quiet at 65 dB-SPL in the best aided condition without lip reading, in the best ear.

N= 27 N=25 : went to bilateral CI . (3-18 month after 1sr CI) N=2 : Bimodal (“poor” results)

HA best aided condition >70% to normal , Disyllabic speech test score in quiet at 65 dB-SPL in the best aided condition without lip reading, in the best ear.

N=9 N=7 : Good Results ( “SSD condition”) N=2 : “Poor” Results (Not benefit )

Study Status (preliminary data)

HA best aided condition < 50% Disyllabic speech test score in quiet at 65 dB-SPL in the best aided condition without lip reading, in the best ear.

N= 27 N=25 : went to bilateral CI . (3-18 month after 1sr CI) N=2 : Bimodal (“poor” results)

Mean    91%  CI  .  86%  CI.      96%  Binaural    2nd  CI  was  performed  between  3rd  and  18th    

0  

25  

50  

75  

100  

1   3   5   7   9   11  13  15  17  19  21  23  25  

R.E  L.E.  Binaural  

Ini$al  condi$on:  HA  best  aided  condiHon  <  50%      

Disyllabic  speech  test  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  CI  +  CI  (n=25)  

Ini$al  condi$on:  HA  best  aided  condiHon  <  50%      

Disyllabic  speech  test  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  HA  +  CI  (n=2)  

0  

25  

50  

75  

100  

1   2  

100   85  

32  48  

100   95  

CI  HA  Binaural  

0  

25  

50  

75  

100  

1   2  

82   75  

12  28  

85  70  

CI  HA  Binaural  

Ini$al  condi$on:  HA  best  aided  condiHon  <  50%      

Sentence  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  HA  +  CI  (n=2)  

HA best aided condition >70% to normal , Disyllabic speech test score in quiet at 65 dB-SPL in the best aided condition without lip reading, in the best ear.

N=9 N=7 : Good Results ( “SSD condition”) N=2 : “Poor” Results (Not benefit )

*2  y.o   *4        y.o  *3,5  y.o.  

RESULTS (preliminary data)

RESULTS (preliminary data)

RESULTS (preliminary data) GOOD  RESULTS  “SSD”  

“Poor”  RESULTS  

0  13  25  38  50  63  75  88  

100  

1   2  

55  65  70   70  70   70  

CI  HA  Binaural  

Ini$al  condi$on:  HA  best  aided  condiHon  >  70%      Disyllabic  speech  test  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  CI  +  HA  (n=2)(“Poor”)  

0  

25  

50  

75  

100  

1   2  

50  60  56   59  

68   65  

CI  HA  Binaural  

Ini$al  condi$on:  HA  best  aided  condiHon  >  70%      Sentence  test  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  CI  +  HA  (n=2)(“Poor”)  

0.  

25.  

50.  

75.  

100.  

1   2   3   4   5   6   7   M  

CI  (M:  93,5)  

HA  (M:  85,2)  

BINAURAL  (M:96,4)  

Ini$al  condi$on:  HA  best  aided  condiHon  >  70%      Disyllabic  speech  test  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  CI  +  HA  (n=2)(“SSD”)  

0  

25  

50  

75  

100  

1   2   3   4   5   6   7   M  

CI  (M:  94)  

HA  (M:  89)  

BINAURAL  (M:  97)  

Ini$al  condi$on:  HA  best  aided  condiHon  >  70%      Sentence  test  score  in  quiet  at  65  dB-­‐SPL  in  the  best  aided  condiHon  without  lip  reading,  in  the  best  ear    ;  CI  +  HA  (n=2)(“SSD”)  

H.A.  In  Pure  tone  audiometry  free  field)  .  (0,5-­‐1-­‐2  Kz)            

Children in a bimodal situation, with substantial hearing (>70 % Speech Discrimination) in the ear with HA (SSD situation), obtain clinically relevant speech perception benefit after cochlear implantation in the contralateral side. It seems that cochlear implantation in some children with unilateral deafness may provide some of the benefits of binaural hearing if implantation occurs within the critical period for bilateral auditory development.

CONCLUSION

Children with peri-postlingual unilateral deafness rapidly integrated the normal acoustic hearing with the electrical signal from the cochlear implant and showed binaural benefits. Younger child with congenital unilateral deafness showed some clinical evidence of binaural integration Older children with congenital deafness have not shown important benfits. binaural benefits.

CONCLUSION

SSD  and  CI  (  ..to  evaluate…)   (more  studies  are  needed)  

NOT  Recommended     Recomended    CONGENITAL     AQCUIRED    

PRELINGUAL     PERI  -­‐  POSTLINGUAL    

>3-­‐4  Years     <  3  Years  (Hearing  depriva$on  period)    

CONCLUSION

High resolution CT Scan & MRI is needed in all unilateral cases 58% cochlear nerve dysfunction in Unilateral cases (More tan in bilateral) (Laszig 2014. ) 42% of unilateal cases wwere found ti have: enlarged vestibular aqueducts, Mondini, superior semicircular canal dehiscences . ( Haffey T;2013)

CONCLUSION

Thank  you