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Key note: Bilateral restoration of hearing

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.

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Key note: Bilateral restoration of hearing

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  1. 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

  2. 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)

  3. 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…

  4. 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 %

  5. 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 m 2,7 J. n=139 m 45,4 J. n=199 m 7,2 J. n= 86 m 1,3 J. n=38 *** *** Group A with superior resuts Group D: adults, congenital as well as progress. HL

  6. 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

  7. Bilateral situation in Freiburg Intervall in Jahren, Alter bis 12 J. Kinder n=281 Bilaterale n=446 Sequentiell Kinder n=229 • 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.

  8. 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 *develop *develop *numbers Delay: <1y. 1y. 2y. 3y. 4y.

  9. The sequential problem Bilateral advantagecorrelatedto time betweensurgeries, interval >8 y. seemscritical Steffens et al. 2008 (H, RB, FR) Late sequential BCI: negative effect visible at time interval of >12 M, Gordon et al. 2008 Exemption: progressive hearingloss!

  10. …and… where´s the beef? • New field: auditory rehabilitation in single-sided deafness and asymmetric hearing loss • Similar considerations, similar factors to influence results

  11. 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

  12. 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

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

  14. Etiology children (n=16)n=11 congenital, n=4 erworben, n=1 non organic Etiology (incl. 1 CHARGE) Kutz et al. 2011: deficient nerve: limited results, absent nerve: poor results Freiburg: only n=8 qualified for a CI!

  15. Eiology children SSD I Unilateral LAV in n=2 children

  16. Etiology children SSD II HRCT: IAM normal, MRI: CND/aplasia of VIIIth nerve, n=5 CHARGE, N VII aplasia R, N VIII aplasia L

  17. SSD: treatment options? • no therapy • conventional CROS-HA • BAHS for CROS Vanecloo et al. 2002 • Cochlear Implantation Vermeire et al. 2008; Arndt et al. 2011 Adults!

  18. 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

  19. Rehabilitation in patients with unilateral deafness Audiometric test test setup • speech test • HSM-sentences in noise (Hochmair-Desoyer et al. 1997) • sentences @ 65 dB SPL, noise @ 65 dB SPL, SNR 0 dB •  % correct answers

  20. Rehabilitation in patients with unilateral deafness Localisation test test setup • stimuli • OlSa sentences (Wagener et al. 1999) • mean sound level: 65 dB SPL • level randomisation: ± 6 dB SPL •  localisation error [°]

  21. Rehabilitation in patients with unilateral deafness Patients overall: 101 adult patients mean duration of deafness: 10.31 years (1 month - 47.6 years) ~ 25 %

  22. Speech discrimination and localisation results: CROS group (n=7) * * * error [°] correct [%]

  23. Speech discrimination and localisation results:Baha group (n=16) ** * * ** # * * ** # error [°] correct [%]

  24. Speech discrimination and localisation results: CI group (n=25) *** ** ** *** # *** *** * ** *** *** *** * ** ** * * *** error [°] correct [%]

  25. Comparison of speech discrimination and localisation: Results after 12-month device use # * error [°] correct [%]

  26. Comparison of speech discrimination and localisation: Results after 12-month device use # *** *** # * # *** * * correct [%] error [°]

  27. Correlation of benefit (aided - unaided speech understanding) in noise in relation vs. duration of deafness CROS CI Baha benefit/ % duration of deafness/ years

  28. otosclerosis Correlation of speech understanding in SciNnh vs. duration of deafness after 12 months CI use r=-0,616649 (p=0,001, **) SV / % = -5,336999 * duration of deafness / years + 63,667

  29. Correlation of benefit (binaural/12 months CI use) - monaural /preop) to duration of deafness r=-0,589063 (p=0,001947, **) SV Benefit / % = -4,679889 * duration of deafness / years + 52,505605 labyrinthitis

  30. Subjective evaluation after 12-month device use - SSQ scale *** *** *** * * ** * * speech spatial quality

  31. 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

  32. …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

  33. Sprache Lärm noise stimuli CI CI OLSA @ 65 dB, Pegelrandom. HSM @ 65 dB, S/N 0 *** ** Kind 1 Kind 2 Erwachsene (n=22) child 1 child 2 adults (n=22) unaided with CI SSD children vs. adults: Results after 12 m., acquired deafness Unknown: development in congential deafness? Sensitive phases? Maximum duration of deafness?

  34. 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

  35. Unaided speech understanding in noise in relation to duration of deafness CROS CI Baha % correct duration of deafness/ years

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