The Richard Ramsden Centre for Hearing Implants · Lise Henderson – Paediatric Coordinator and...
Transcript of The Richard Ramsden Centre for Hearing Implants · Lise Henderson – Paediatric Coordinator and...
The Richard Ramsden Centre for Hearing Implants
Manchester
Annual Report 2017-2018
COCHLEAR IMPLANT TEAM
Andrew Causon – Audiologist
Andy Cooper – Assistant Audiologist
Angela Fuller – Assistant Audiologist
Anne Stockbridge – Administrator
Christine Melling – Adolescent Coordinator and Speech & Language Therapist
Craig Went – Audiologist
Deanne Jayewardene-Aston – Audiologist
Deniece Walker – Administrator
Deborah Mawman – Adult Coordinator and Audiologist
Elizabeth Whittle – Audiologist
Emma Gray – Speech & Language Therapist
Emma Stapleton – Surgeon
Helen Ley – Speech & Language Therapist
Iain Bruce – Surgeon
Jayne Jones – Speech & Language Therapist
Karen Smith – Hearing Therapist
Kerri Millward – Audiologist
Lise Henderson – Paediatric Coordinator and Speech & Language Therapist
Martin O’Driscoll – Head of Department and Audiologist
Morag Lockley – Audiologist
Rebecca Bentley – Teacher of the Deaf / Auditory Verbal Therapist
Sarah Hornby – Audiologist
Simon Freeman – Surgeon
Simon Lloyd – Surgeon
Tamasin Brown – Audiologist
Unai Martinez de Estibariz – Audiologist
Vicki Carek – Clinical Psychologist
ADULT COCHLEAR IMPLANT PROGRAMME
Introduction
Cochlear implantation has been established in the UK for over 3 decades and
there are currently just over 17000 patients in the UK using cochlear implants
(see Figure 1). In the UK, cochlear implants are funded by NHS England (Ref:
D09/S/A) if patients meet the NICE guidance (Ref: TA166. This guidance is
currently under review.
Figure 1: Total number of maintained patients in the UK (from BCIG’s annual
data collection 2017-18)
The auditory implant programme in Manchester was established in 1988 by ENT
Consultant Richard Ramsden, using funding to provide cochlear implants obtained
from the HEAR (Help Ear & Allied Research) Charity. In the mid 1990’s government
resources became available to fund cochlear implants for patients with severe-
profound sensori-neural hearing loss. By the end of March 2018, 1274 adults have
received a cochlear or an auditory brainstem implant in Manchester manufactured by
Advanced Bionics, Cochlear and MED-EL.
10708
749
1914
3727
ADULTS - unilateral
ADULTS - bilateral
CHILDREN - unilateral
CHILDREN - bilateral
Criteria for referral to the adult programme for cochlear implants
There is no maximum age for referral and patients with additional needs are not
excluded (Ref: NICE TA166):
✦ Bilateral, severe to profound sensori-neural hearing loss (≥ 90 dB HL
at 2 and 4 kHz).
✦ Limited or no benefit from hearing aids (a score of 50% or less on
BKB sentence testing at a sound intensity of 70 dB SPL in the ear to
be implanted).
✦ Simultaneous bilateral cochlear implantation is recommended as an
option for adults who are blind or who have other disabilities that
increase their reliance on auditory stimuli as a primary sensory
mechanism for spatial awareness.
✦ Cochlear implantation is considered for adults only after an
assessment by a multidisciplinary team. As part of the assessment
adults should also have had a valid trial of an acoustic hearing aid for
at least 3 months (unless contraindicated or inappropriate).
Clinical activity between April 2017 and March 2018
✦ Procedures
During the 2017-18 financial year, a total of 115 cochlear implant procedures
were performed in adults. Figure 2 shows a breakdown of the types of surgeries
performed.
Figure 2: Surgical procedures
✦ Explantations
Three explantations were carried out, all due to medical problems (D) based on
the International Classification of Reliability for Implanted Cochlear Implant
Receiver Stimulators (see figure 3). Two of the explanted patients were
successfully re-implanted. One patient continues to suffer from recurrent ear
infections in the implanted ear which may be related to a pre-existing medical
condition and their management is on-going.
Figure 3: International Classification of Reliability for Implanted Cochlear Implant
Receiver Stimulators (Battmer et al., 2010)
103
2 3
5 2
Cochlear Implantation(unilateral)
Cochlear Implantation(sequential)
Explantation
Re-implantation
Repositioning
✦ Devices
Excluding explantation and repositioning procedures, a total of 110 devices were
fitted in this financial year. Detailed charts on the types of internal devices,
manufacturers and type of speech processor are shown in figures 4 to 6.
Figure 4: Implant electrode arrays by type
Figure 5: Implants by manufacturer
68
3 1
24
4
10
0
20
40
60
80
Nu
mb
er o
f im
pla
nts
72
28
10
Medel
Cochlear
Advanced Bionics
Figure 6: Speech processors by configuration
✦ Demographics
The average and median age of the patients implanted was 56 years (range = 19
- 94 years). Figure 7 shows the age distribution of the implanted adult population
during the 2017-2018 financial year period.
Figure 7: Age of patient at implant
✦ Post-implant support
Patients typically attend 5 appointments with the adult team within their first six
weeks of implant use. During these appointments the speech processor is
103
7
Behind the ear
Off the ear
1
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23
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3
0
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18-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100
programmed and patients receive rehabilitation through an individualised
auditory and communication skills training programme with a therapist. Where
appropriate, the training programme includes tactics for using the telephone,
music therapy and advice about using assistive listening devices. Patients are
then followed up at three, nine and twenty-one months after their initial
activation. Additional rehabilitation sessions are offered to patients as required.
Following this, a patient led appointment is sent on an annual basis. Every 6
years the patient will be offered a speech processor upgrade.
✦ Outcomes
Speech perception and lip-reading function is measured using standardized
recorded test materials for each patient at the pre-implant stage. Following
implantation, the tests are repeated at one week, three months, nine months and
twenty-one months, and then annually as required. Patients who use English as
a second language, or who cannot communicate in English are evaluated in their
own language using language interpreters to translate the test materials to the
appropriate language.
Figure 8 shows the average scores obtained using the Bamford-Kowal-Bench
(BKB) sentence test in quiet at pre- and post-operative stages in this financial
period.
Figure 8: Speech perception scores
10.3
28.8
62.4
77.2
51.8
75.9
85.2
0
20
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60
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Pre-op 1 week 3 months 9 months
Bilateral Hearing Aids Cochlear Implant only Bimodal (Cochlear Implant + Hearing Aid)
Sound-field aided thresholds are also measured post operatively. Figure 9 shows
the average aided thresholds at the 1 week, 3 month and 9 month stage, as well
as their average pre-op unaided thresholds. Thresholds ≤ 40 dB HL at
frequencies between 250 and 8000 Hz allow good access to normal
conversational speech levels and everyday sounds and are considered optimal
for cochlear implant users.
Figure 9: Threshold levels at pre op and post stages
Service evaluation
A satisfaction questionnaire is sent to all newly implanted users at their 9 month post
implant stage to gauge their views on their cochlear implant progress and our service.
All responses are anonymous. Below are a few responses collected during the last
financial year:
91% of respondents report that their cochlear implant exceeded their
expectations or that it was too soon to comment.
100% of respondents report using their cochlear implant every day (all day
long or part of the day)
91% of respondents report obtaining great benefit from their cochlear implant
100% of respondents feel it was worthwhile having a cochlear implant
0
20
40
60
80
100
120
250 500 1000 2000 4000 8000
Hea
rin
g Le
vel (
dB
HL)
Frequencies (Hz)
Pre Op 1 Week 3 Months 9 Months
100% of respondents would recommend a cochlear implant to a friend or
relative if they had a similar hearing problem
100% of respondent were satisfied with the treatment/support that they
received from the staff on the cochlear implant programme
100% of respondents rated the treatment/support that the staff at the cochlear
implant programme provided as very good
Below are statements from respondents with regards to why they felt this treatment
was worthwhile:
“For so much of my life I have felt foolish and odd because I could not hear so I would
withdraw into myself.
“Their support has brought me out into the sunshine”
“It has given me my life back. I can go out now and be part of a conversation where
before you are isolated”
“I am no longer excluded from conversation”
“It has given me confidence to go places alone. it has completely changed my and
that of my family”
“I can now hold a conversation clearly and not afraid to be in company”
Among the disadvantages noted by cochlear implants users, the following were
reported: one patient reported short battery life, another patient noted louder but non-
troublesome tinnitus and one other patient reported discomfort when wearing their
device.
PAEDIATRIC COCHLEAR IMPLANT PROGRAMME
Introduction
The Paediatric Programme at the RRCHI was established in October 1991 and to March
2016, 864 children (ages 0-11) have received cochlear implants on the programme.
Members of the team have experience in working with children of widely differing age,
history of hearing loss, cultural and educational background. We also work with children
with a wide range of additional disabilities.
All patients referred to the Paediatric Programme undergo a full audiological assessment
involving a series of appointments with the team. All children with congenital hearing losses
would normally be expected to be wearing appropriately-fitted high powered hearing aids
throughout the assessment process. Diagnostic habilitation may be used to assess the
current benefit a child receives from hearing aids as well as to identify additional factors
which may affect learning with a cochlear implant system. In addition, as part of the
assessment programme, the child will undergo an MRI (Magnetic Resonance Imaging)
scan in order to confirm the presence of a cochlear nerve, and determine the suitability of
the inner ear to receive an implant. Some children may also require a CT scan but this is
not routinely undertaken. For children with a sudden, acquired hearing loss (particularly
following meningitis, where there risk of cochlear ossification leading to surgical
complications) a fast track programme is in place to enable surgical priority.
Criteria for referral to the paediatric programme for cochlear implants
Criteria are selected according to evidence-based practice and experience. They are set to
ensure that those children who receive a cochlear implant are those most likely to obtain
benefit from the device. The younger a child is when he/she receives a cochlear implant,
the more successful the outcome is likely to be. A child who receives a cochlear implant at
the age of 4 years will be less likely to successfully acquire fluent spoken language than a
child who receives a cochlear implant at the age of 18 months.
We would therefore recommend that any child, however young, who is suspected of having
a significant hearing impairment should be referred to the cochlear implant team as soon as
possible. This will allow the cochlear implant team to begin carrying out assessments, and
informing parents about cochlear implants, in parallel with the ongoing audiological
assessments and hearing aid fitting being carried out by the child’s local services.
In cases where a child receives a unilateral implant, the Paediatric Programme encourages
children to continue wearing a contralateral hearing aid if they have residual hearing in the
non-implanted ear.
None of the criteria outlined below exclude children with additional physical disabilities or
learning difficulties. Referrals for assessment are accepted for:
• Referral from first ABR where levels indicate cochlear implant may be appropriate.
• Children who were born with a profound hearing loss, receive no significant benefit
from hearing aid and are under the age of 4 years at the time of referral
• Children under the age of 10 years who were born with normal hearing and have
acquired a profound hearing loss, e.g. following meningitis. A child with a suspected
hearing loss following meningitis should, of course, be referred for assessment
immediately so that cochlear implant surgery can be fast-tracked in the event of any
ossification of the cochlea.
• Children under the age of 10 years who have had some benefit from hearing aids in
the past, but whose hearing has deteriorated to the point where powerful hearing aids
are no longer helpful and / or have shown benefit for language learning through
consistent use of powerful hearing aids but who might receive significantly more
auditory information from a cochlear implant (NB. These patients should show
evidence that they have learnt spoken language through listening, thus demonstrating
the integrity of the auditory pathway)
• Children diagnosed with ANSD and have consistent behavioural hearing thresholds
bilaterally in the severe-profound SNHL range (≥90dBHL at 2 and 4 kHz) should
always be referred to the cochlear implant programme. There is no minimum age of
referral but it is still important to refer these children early. Children with ANSD and
with additional needs should not be excluded. Children with ANSD can also be
referred to the implant programme if they are making poor progress with their hearing
aids despite having unaided thresholds outside implant criteria. We classify poor
progress as:
Unable to consistently discriminate the ling sounds
Unable to imitate pattern perception (duration and number of syllables in a
word)
Only able to understand simple instructions with visual cues e.g. pointing
Not making the appropriate progress with spoken language development with
their hearing aids
Have not achieved behavioral hearing levels by 14 months of age.
• Children with one ear in the profound range and the other ear in the moderate /
severe range. We accept referrals of all children who meet this criteria, but those over
the age of 4 must be developing spoken language.
• Children with auditory nerves dysplasia. Children with suspected thin or absent
nerves should also be referred to the paediatric team. We can assess these children
using electronic auditory brainstem response to assess the ability of the auditory
nerve to carry auditory responses. If good traces are obtained then these children may
be still eligible for a cochlear implant. Those with absent nerves or have poor eABR
traces can then be referred for an Auditory Brainstem Implant if the parents and
professionals feel it is appropriate.
Please note:
• Early referral is encouraged (from ABR if possible / appropriate) and is extremely
important to help children who need a cochlear implant to get one as quickly as
possible.
• If you are unsure about a referral or unable to obtain behavioural levels please speak
to us beforehand or send a referral. We are happy to see people for second opinions.
• That children aged 10 years and over should be referred to the Adolescent
Programme.
Clinical activity between April 2017 and March 2018
✦ Surgeries
A total of 55 children (a total of 89 cochlear implants) have been implanted during this
financial year. A detailed info-graphic on the types of implants, processors and
configuration of implantation is shown below.
Figure 10: Breakdown of implanted ears for children implanted in 2017-2018
Bilateral, 34
Unilateral, 14
Sequential, 1 Reimplant, 6
Figure 11: Breakdown of internal implants for children implanted in 2017-2018
Figure 12: External devices for children newly implanted in 2017-2018 (excluding
reimplants)
✦ Demographics
The average age of paediatric cochlear implant patients was 3 years (range = 9
months - 8 years 10 months). Figures 13 and 14 show the age distribution and
Advanced Bionics, HR 90K
Advantage Hi Focus
1J, 1
Advanced Bionics, Hi Focus Ultra
MS, 2
Medel, Synchrony Flex 28, 5 Cochlear,
CI522, 47
Advanced Bionics,
Neptune, 1
Advanced Bionics, Naida, 1
Medel, Opus 2, 1
Cochlear, CP910, 46
hearing loss aetiology of the implanted children population at the RRCHI during the
2017-2018 financial year period.
Figure 13: Age distribution of children receiving cochlear implants for the first time (reimplant and sequential patients not included)
Figure 14: Aetiology of children receiving unilateral or bilateral cochlear implants (reimplant and sequential patients not included)
BVVL = Brown Vialetto Van Laere Syndrome, ANSD = Auditory Neuropathy Spectrum
Disorder, CMV = Cytomegalovirus, WVA = widen vestibular aqueducts
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Aetiologies
✦ Outcomes – Implant Use
We carry out the Brief Assessment of Parental Perception (BAPP) after 2 years of
implant use. This is a questionnaire gives the parents perception of their child’s
implant use and willingness to wear implant and whether they would recommend a
cochlear implant to other parents. It also asks for comparisons in their child’s in
behaviour, contentment, communication learning and getting on with friends pre-
implant compared to post. After 2 years of use, all patients wore their processor(s) at
least some of the day, with the majority wearing it full time. The willingness for
paediatric patients to wear their processor(s) at 2 years of use can be seen in Figure
15. The majority are very keen to wear. One hundred percent of the parents who
completed the questionnaire would recommend cochlear implantation to another
family in a similar situation.
Figure 15: Paediatric patients’ willingness to wear their after 2 years of use
✦ Outcomes – Aided Levels
The paediatric patients are seen regularly in their first year of implant use to establish
good listening levels. We categorize good listening levels to be between 20 and 40 dB
HL using sound field testing (warble tone). With some children who have
Percentage of paediatric patients willingness to wear their processor(s) after their second year of use
Very keen
Keen
Neutral
Reluctant
Very reluctant
developmental delay it is often not possible to test aided levels. We therefore rely on
objective and behavioral testing to establish that the processor is set optimally for the
patient. Figure 16a shows the average aided levels achieved 1 year post implant.
These levels are also checked at two years of use and remain stable (Figure 16b)
Figure 16: a) Average aided levels for the first year of implant use
Figure 16: b) Average aided levels for the second year of implant use
Within the first year of implant use, 100 % of paediatric patient that were able to do
behavioural testing achieved average aided thresholds of 40 dB HL or better.
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Aid
ed le
vel (
dB
HL)
Frequency (Hz)
Average aided levels of paediatric patients after the second year of use
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Aid
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vel (
dB
HL)
Frequency (Hz)
Average aided levels of paediatric patients after the second year of use
✦ Post-Implant Support
Children are generally offered regular habilitation sessions during their first three
years of cochlear implant use. These sessions are designed to ensure that the child
obtains maximum benefit from the cochlear implant. Therapists work with parents or
caregivers to help the child to develop spoken language through listening. Our
habilitation programme is based on Auditory Verbal Therapy. Children also have
regular appointments for reprogramming of the speech processor.
Over time primary responsibility for a child’s habilitation programme is handed back to
the local support services. However, the implant team is always available to provide
advice, support and training to local professionals if required/requested. Children
continue to be seen annually by the cochlear implant team for equipment checks,
reprogramming and speech perception assessments.
✦Outcomes – PLS
The Preschool Language Scales is standardized on normally hearing children aged
from infancy to 6 years 11 months. The purpose of this assessment is to assess
children’s receptive and expressive language capabilities. Responses range from
parental report to picture selection and completion of open-ended sentences. The
high level of contact between the team and children in their first two years of cochlear
implant use enables habilitationists to pinpoint a child’s current level of development.
For longer term implant users, reports from parents and local support professionals,
together with the child’s performance on standardized assessments administered at
the annual review, are used to determine their level of attainment on the scale. Figure
17 shows the outcomes of the PLS preimplant, and 1 and 2 years of implant use. The
data show that the children on average of their age equivalent scores are catching up
to their chronological age.
Figure 17: Average difference between chronological age and language age as a
percentage for paediatric patients at preimplant and 1 and 2 years post implant use
-70
-60
-50
-40
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-20
-10
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preimplant 1 year 2 year
Dif
fere
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e P
LS)
Difference between chronological age and language as a percentage (if at 0 % no difference between chronological
age and language score on the PLS) 2017-18
AUDITORY BRAINSTEM IMPLANT PROGRAMME
Introduction
The implant centre in Manchester has the largest population of auditory
brainstem implant (ABI) users in the UK. The majority of these patients have
Neurofibromatosis Type 2.
The auditory brainstem implant (ABI) depicted in figure 18 evolved from cochlear
implant technology to address the problems of rehabilitating patients with total
deafness with a damaged or absent cochlear nerve, and are therefore unsuitable
for cochlear implantation. The great majority of these patients suffer from the
genetic disorder called neurofibromatosis type 2 (NF2). NF2 affects one in
33,000 people and is characterised by the development of bilateral vestibular
schwannomas (tumours on the hearing and balance nerves). More recently other
indications for ABI have been approved including cochlear nerve aplasia or
severe dysplasia in infants, extreme degrees of inner ear dysplasia even in the
presence of normal looking auditory nerves, severe cochlear obliteration from
otosclerosis or meningitis, and head injury with cochlear nerve avulsion. These
conditions prevent effective cochlear implantation.
Figure 18: The auditory brainstem implant and external speech processor
The ABI stimulates the cochlear nucleus complex on the brainstem directly and
bypasses any damaged or absent cochlear nerve. The ABI electrode array is
placed on the surface of the cochlear nucleus complex on the floor of the
foramen of Luschka in the lateral recess of the fourth ventricle of the brainstem
(see figure 19).
Figure 19: Placement position of the auditory brainstem implant
The external speech processor for an ABI is activated about 6 weeks post-
surgery and patients undertake a similar programme of tuning and rehabilitation
to cochlear implant patients. The ABI provides limited speech understanding for
patients although it can help patients to understand speech better with lipreading
(see figure 20). It also helps patients to hear and identify everyday sounds.
Figure 20: Comparison of CUNY scores (N = 49) using the ABI only, lipreading
(LR) only and the ABI with lip-reading (Ramsden et al., 2016)
Manchester is one of only two centres in the UK commissioned to provide ABI’s.
For adults, the ABI surgery takes place at Salford Royal NHS Foundation Trust
and for children the surgery takes place and the Royal Manchester Children’s
Hospital. The ABI programming and rehabilitation takes place within the Richard
Ramsden Centre for Hearing Implants.
To date, the team has performed 82 ABI surgeries in 73 adults and 9 children.
MEDIA AND PUBLIC RELATIONS
In November 2016, Channel 4 broadcasted an observational documentary LIVE
from the Richard Ramsden Hearing Implant Centre titled “Breaking the Silence”.
The programme allowed viewers to share the moment eight patients heard for
the first time when their cochlear implant was switched on. Staff and patients
from the Manchester implant centre as well as other centers from around the UK
(see picture 21), were involved in the ground breaking documentary.
Picture 21: Some of the clinicians involved in the live broadcast programme
This documentary can be viewed online in the following link:
http://www.channel4.com/programmes/breaking-the-silence-live/on-
demand/63119-002
Following the live broadcast, our Head of Department, Martin O’Driscoll,
appeared on the BBC Breakfast TV programme to talk about the benefits of
cochlear implantation.
Picture 22: Martin O’Driscoll at the BBC One Breakfast show
REFERENCES
Management of Cochlear Nerve Hypoplasia and Aplasia Freeman SR, Sennaroglu L. Adv Otorhinolaryngol. 2018;81:81-92. doi: 10.1159/000485542. Epub 2018 Apr 6.
Hearing preservation cochlear implantation in children: The HEARRING Group consensus and practice guide Rajan G, Tavora-Vieira D, Baumgartner WD, Godey B, Müller J, O'Driscoll M, Skarzynski H, Skarzynski P, Usami SI, Adunka O, Agrawal S, Bruce I, De Bodt M, Caversaccio M, Pilsbury H, Gavilán J, Hagen R, Hagr A, Kameswaran M, Karltorp E, Kompis M, Kuzovkov V, Lassaletta L, Yongxin L, Lorens A, Manoj M, Martin J, Mertens G, Mlynski R, Parnes L, Pulibalathingal S, Radeloff A, Raine CH, Rajeswaran R, Schmutzhard J, Sprinzl G, Staecker H, Stephan K, Sugarova S, Zernotti M, Zorowka P, Van de Heyning P. Cochlear Implants Int. 2018 Jan;19(1):1-13. doi: 10.1080/14670100.2017.1379933. Epub 2017 Oct 26.
Review of outcomes and measurement instruments in cochlear implantation studies Schaefer S, Henderson L, Graham J, Broomfield S, Cullington H, Schramm D, Waltzman S, Bruce I. Cochlear Implants Int. 2017 Sep;18(5):237-239. doi: 10.1080/14670100.2017.1353761. Epub 2017 Jul 25. No abstract available.
Hearing optimisation in neurofibromatosis type 2: A systematic review Lloyd SKW, King AT, Rutherford SA, Hammerbeck-Ward CL, Freeman SRM, Mawman DJ, O'Driscoll M, Evans DG. Clin Otolaryngol. 2017 Dec;42(6):1329-1337. doi: 10.1111/coa.12882. Epub 2017 Apr 26.
United Kingdom national paediatric bilateral project: Results of professional rating scales and parent questionnaires Cullington HE, Bele D, Brinton JC, Cooper S, Daft M, Harding J, Hatton N, Humphries J, Lutman ME, Maddocks J, Maggs J, Millward K, O'Donoghue G, Patel S, Rajput K, Salmon V, Sear T, Speers A, Wheeler A, Wilson K. Cochlear Implants Int. 2017 Jan;18(1):23-35. doi: 10.1080/14670100.2016.1265189. Epub 2017 Jan 18.
Consensus statement: Long-term results of ABI in children with complex inner ear malformations and decision making between CI and ABI Sennaroğlu L, Colletti V, Lenarz T, Manrique M, Laszig R, Rask-Andersen H, Göksu N, Offeciers E, Saeed S, Behr R, Bayazıt Y, Casselman J, Freeman S, Kileny P, Lee DJ, Shannon RV, Kameswaran M, Hagr A, Zarowski A, Schwartz MS, Bilginer B, Kishore A, Sennaroğlu G, Yücel E, Saraç S, Ataş A, Colletti L, O'Driscoll M, Moon IS, Gärtner L, Huarte A, Nyberg G, Mocan BÖ, Atay G, Bajin MD, Çınar BÇ, Batuk MÖ, Yaralı M, Aydınlı FE, Aslan F, Kirazlı MC, Özkan HB, Hans JM, Kosaner J, Polak M. Cochlear Implants Int. 2016 Jul;17(4):163-171. Epub 2016 Jul 21. No abstract available.
Preliminary assessment of the feasibility of using AB words to assess candidacy in adults Vickers DA, Riley A, Ricaud R, Verschuur C, Cooper S, Nunn T, Webb K, Muff J, Harris F, Chung M, Humphries J, Langshaw A, Poynter-Smith E, Totten C, Tapper L, Ridgwell J, Mawman D, de Estibariz UM, O'Driscoll M, George N, Pinto F, Hall A, Llewellyn C, Miah R, Al-Malky G, Kitterick PT. Cochlear Implants Int. 2016 Apr;17 Suppl 1:17-21. doi: 10.1080/14670100.2016.1161143.
Self-Reported Listening-Related Effort and Fatigue in Hearing-Impaired Adults. Alhanbali S1, Dawes P, Lloyd S, Munro KJ. Ear Hear. 2017 Jan/Feb;38(1):e39-e48
Auditory Brainstem Implantation in Neurofibromatosis Type 2: Experience From the Manchester Programme Ramsden RT, Freeman SR, Lloyd SK, King AT, Shi X, Ward CL, Huson SM, Mawman DJ, O'Driscoll MP, Evans DG, Rutherford SA; Manchester Neurofibromatosis Type 2 Service. Otol Neurotol. 2016 Oct;37(9):1267-74. doi: 10.1097/MAO.0000000000001166.
TA166 - Cochlear implants for children and adults with severe to profound deafness National Institute of Clinical Excellence. Published date: 28 January 2009 (https://www.nice.org.uk/guidance/ta166)
D09/S/A - NHS standard contract for cochlear implants NHS Commissioning Board, 2013 (https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/04/d09-ear-surg-coch-0414.pdf)
Figure XXX: BKB sentence scores (auditory alone)