Professional Documents
Culture Documents
Neurotology
Cochlear Implantation
1st International Electro-Acoustic Workshop
Toulouse, December 810, 2005
Guest Editor
Bernard Fraysse, Toulouse, France
Contents
Cover illustration
Temporal bone section showing the Nucleus Hybrid-L research electrode designed for hearing preservation.
For details see articles by Briggs et al., pp. 4248, and Lenarz et al., pp. 3441.
IV
Audiology
Audiol Neurotol 2006;11(suppl 1):1 Published online: October 6, 2006
Neurotology
DOI: 10.1159/000095605
Editorial
References
Ching T, Dillon H, Bryne D: Speech recognition Hogan C, Turner CW: High-frequency amplifi- Summers V: Do tests for cochlear dead regions
of hearing-impaired listeners: predictions cation: benefits for hearing-impaired listen- provide important information for fitting
from audibility and the limited role of high- ers. J Acoust Soc Am 1998;104:432441. hearing aids? J Acoust Soc Am 2004; 115:
frequency amplification. J Acoust Soc Am Liberman MC, Dodds LW: Single-neuron label- 14201423.
1998;103:11281140. ing and chronic cochlear pathology. III. Ste- Turner CW, Brus SL: Providing low- and mid-
Erber NP: Speech envelope cues as an acoustic reocilia damage and alterations of threshold frequency speech information to listeners
aid to lipreading for profoundly deaf chil- tuning curves. Hear Res 1984;16:5574. with sensorineural hearing loss. J Acoust Soc
dren. J Acoust Soc Am 1972;51:12241227. Miller GA, Nicely PE: An analysis of perceptual Am 2001;109:29993006.
Fu QJ, Shannon RF, Wang X: Effects of noise and confusions among some English consonants. Turner CW, Gantz BJ, Vidal C, Behrens A:
spectral resolution on vowel and consonant J Acoust Soc Am 1955;27:338352. Speech recognition in noise for cochlear im-
recognition: acoustic and electric hearing. J Miller RL, Schilling JR, Franck KR, Young ED: plant listeners: benefits of residual acoustic
Acoust Soc Am 1998;104:35863596. Effects of acoustic trauma on the representa- hearing. J Acoust Soc Am 2004; 115: 1729
Gantz BJ, Turner CW, Gfeller KE, Lowder MW: tion of the vowel/eh/ in cat auditory nerve. J 1735.
Preservation of hearing in cochlear implant Acoust Soc Am 1997;101:36023616. Turner CW, Souza PE, Forget LN: Use of tempo-
surgery: advantages of combined electrical Qin MK, Oxenham AJ: Effects of simulated co- ral envelope cues in speech recognition by
and acoustical speech processing. Laryngo- chlear-implant processing on speech recep- normal and hearing-impaired listeners. J
scope 2005;115:796802. tion in fluctuating maskers. J Acoust Soc Am Acoust Soc Am 1995;97:25682576.
Henry BA, Turner CW, Behrens A: Spectral peak 2003;114:446454. Vickers D, Moore BCJ, Baer T: Effects of low-
resolution and speech recognition in quiet: Santi PA, Ruggero MA, Nelson DA, Turner CW: pass filtering on the intelligibility of speech
normal hearing, hearing impaired and co- Kanamycin and bumetanide ototoxicity; an- in quiet for people with and without dead re-
chlear implant listeners. J Acoust Soc Am atomical, physiological, and behavioral cor- gions at high frequencies. J Acoust Soc Am
2005;118:11111121. relates. Hear Res 1982;7:261279. 2001;110:11641175.
Skinner MW: Speech intelligibility in noise-in-
duced hearing loss: effects of high-frequency
amplification. J Acoust Soc Am 1980; 67:
306317.
Frequency, Hz
250 500 1000 2000 4000
noise has a better signal-to-noise ratio (SNR) than the tributing to sentence perception in noise [Kong et al.,
other ear. The brain can selectively attend to the ear with 2005]. Furthermore, studies that examined speech infor-
a better SNR. This head shadow effect can give an ad- mation transmission in consonant perception revealed
vantage of about 3 dB on average. Even when the SNR that significantly more voicing and manner information
at both ears are similar, binaural listeners can make use were received when listeners used bimodal hearing de-
of interaural time/phase differences to partially reduce vices compared to using CIs alone [Incert, 2003; Ching et
the impact of noise in speech perception. This binaural al., 2001]. Because existing sound-processing schemes for
squelch effect can give a 12 dB advantage. The interau- CIs convey inaccurate and inconsistent pitch cues [Mc-
ral time and level differences for sounds coming to the Dermott, 2004], the use of a hearing aid combined with
two ears from different locations can also be used by a CI has been shown to lead to improved ability in musi-
the binaural auditory system to specify the source of cal tune recognition [Kong et al., 2005; McDermott,
sounds. 2005].
There is now accumulating evidence demonstrating Most of the previous studies reported findings based
that binaural benefits for speech perception and sound on small numbers of participants. This paper was aimed
localization are possible for people who use binaural/bi- at presenting an overview of binaural advantages in
modal hearing devices [for a summary, see Ching et al., speech perception and localization from a sizeable sam-
2004a]. Previous reports showed that binaural localiza- ple by drawing together four studies on children and
tion was better than monaural localization, and binaural adults. Information about how to fit a hearing aid to com-
speech perception was better than monaural perfor- plement the use of a CI in the contralateral ear would be
mance for speech perception in quiet and in noise, both provided together with conclusions on who should have
for adults and children. The improvements were due to binaural/bimodal fitting.
effects of redundancy and head shadow. Access to binau-
ral squelch, however, is limited by the deficient represen-
tation of timing information in existing CIs. Neither Patients and Methods
children nor adults were able to use interaural time dif-
ference cues for binaural speech perception [Ching et al., Between 2000 and 2005, 29 children and 21 adults who re-
2005a]. ceived a CI in one ear were evaluated. The methods and results
have been described in detail in four publications [Ching et al.,
In addition to binaural advantages, there is some evi- 2001, 2004b, 2005a, b]. Briefly, the subjects received a Nucleus
dence showing that a hearing aid and a CI provide com- CI22 or CI24 device in one ear, and were fitted with a hearing aid
plementary information. Acoustic amplification with a in the other ear based on the NAL-RP prescription [Byrne and
hearing aid provides adequate low-frequency informa- Dillon, 1986; Byrne et al., 1991]. The hearing thresholds of the
tion whereas electrical stimulation with a CI does not nonimplanted ear of the subjects are given in table 1. A system-
atic procedure for optimizing a hearing aid to complement a CI
[Vandali et al., 2005; Kong et al., 2005]. Low-frequency was implemented for each individual [Ching et al., 2001, 2004c].
information relating to voice pitch has been found to en- The subjects experience of using bimodal hearing devices varied
hance the segregation of competing voices thereby con- from 8 weeks to 8.8 years (mean = 2.5 years, SD = 2.1).
Evaluation of speech perception was carried out by presenting used a CI with a hearing aid (CIHA). The hearing aid in the non-
BKB sentences in 8-talker babble noise. The subjects were re- implanted ear was switched off when the subjects were evaluated
quired to repeat verbatim the sentences heard. For assessing bin- in the CI condition.
aural redundancy effects, speech and noise were presented from
the same loudspeaker positioned at 0 azimuth at a distance of
1 m at 10 dB SNR. For assessing the combined effects of binaural
redundancy and head shadow, speech and noise were presented Results
separately from two loudspeakers placed at 860 azimuth at
10 dB SNR. Speech was presented from the side closer to the hear- Speech Perception
ing aid and noise from the side closer to the CI. This test configu-
ration was chosen because it maximized the potential contribu- Figure 1 shows the advantage arising from binaural
tion of a hearing aid by providing a better SNR at the ear with a redundancy for 25 children and 11 adults when they lis-
hearing aid than that with a CI. If the binaural auditory system tened to sentences in babble noise at 10 dB SNR. Perfor-
was able to attend to the ear with a better SNR, the binaural/bi- mance was scored as proportion of keywords correctly
modal performance would be expected to be better than the per- repeated. On average, the adults improved from 0.57 (CI)
formance with a CI alone. If no advantage were obtained even in
this favorable condition, then the use of bimodal hearing devices to 0.74 (CIHA), and the children improved from 0.47 (CI)
could be considered ineffective. to 0.59 (CIHA).
Sound localization on the horizontal plane was assessed by us- Analysis of variance using CIHA and CI scores as de-
ing an array of 11 loudspeakers spanning an 180 arc located in an pendent variables, and device (CIHA vs. CI) and age
anechoic chamber. All loudspeakers were closely matched using (child vs. adult) as categorical variables revealed a sig-
software-controlled digital filters. The subject was seated directly
facing the centre of the array, at a distance of about 1 m. Pink noise nificant main effect of device (p ! 0.0001). The effect of
pulses were presented from one of the loudspeakers in random age was not significant (p 1 0.05). The results indicate
order. The nominal presentation level was 70 dB SPL, with actual that both children and adults perceived speech better
levels varying randomly around the nominal level by 83 dB. Sub- when they used bimodal hearing devices than when they
jects had to identify the loudspeaker from which the sound origi- listened with a CI alone.
nated. Performance was scored as number of loudspeakers be-
tween the stimulus and the response, expressed in degrees. Figure 2 shows the binaural advantages arising from
All evaluations of speech perception and localization were head shadow and binaural redundancy for 18 children
carried out when the subjects used a CI alone, and also when they and 15 adults when they listened to sentences in babble
Horizontal Localization
Figure 3 shows the mean results in terms of RMS er-
rors in localization for 29 children and 18 adults.
Analysis of variance using the error score for the CIHA
and the CI conditions as dependent variables, and device
(CIHA vs. CI) and age (child vs. adult) as categorical vari-
Fig. 3. Mean localization error for CI and CIHA. The horizontal
line depicts chance performance. U = Children; ) = adults. Verti-
ables indicated that the main effect of age and condition
cal bars denote 0.95 confidence intervals. was significant (p ! 0.02, p ! 0.00001, respectively). The
interaction was not significant (p 1 0.05). On average, the
localization ability of both the child and adult groups
with CI alone were not significantly different (p 1 0.05),
with both groups performing at chance level. Post-hoc
analysis using the Tukeys honest significant difference
noise at 10 dB SNR. The subjects included 14 children test indicated that both groups located sounds better with
and 11 adults who participated in the previous experi- CIHA than with CI alone (p ! 0.002, p ! 0.005, respec-
ment and additionally 4 children and 4 adults. Perfor- tively).
mance was scored as proportion of keywords correctly We examined whether people who obtained greater
repeated. On average, the adults improved from 0.22 (CI) binaural benefits in localization also demonstrated better
to 0.38 (CIHA), and the children improved from 0.39 (CI) speech perception in noise by performing a regression
to 0.54 (CIHA). analysis between the difference scores for localization
Analysis of variance using CIHA and CI scores as de- (CIHA CI errors) and the difference scores for speech
pendent variables, and device (CIHA vs. CI) and age perception (CIHA CI scores). On average, localization
(child vs. adult) as categorical variables revealed a sig- was not associated with use of binaural redundancy in
nificant main effect of device (p ! 0.0001). The main ef- speech perception (p 1 0.05). However, improved local-
fect of age was not significant (p 1 0.05). For both chil- ization was significantly correlated with enhanced per-
dren and adults, speech perception with binaural/bimod- ception of speech in spatially separated noise ( = 0.38,
al hearing devices was significantly better than that with p ! 0.02).
a CI alone.
To examine whether speech benefits were related to
the amount of residual hearing of the subjects, we per- Discussion
formed a correlation analysis between three-frequency
average hearing thresholds (0.5, 1, 2 kHz) in the nonim- The evidence summarized above clearly shows signif-
planted ear of the subjects and speech benefits (CIHA icant benefits in speech perception in noise and horizon-
CI scores) for both the condition when speech and noise tal localization that arise from access to head shadow and
were presented from the same loudspeaker and from binaural redundancy cues when a hearing aid is worn
spatially separated loudspeakers. Although the amount with a CI in opposite ears. Both children and adults de-
of speech benefits decreased with increase in hearing rived binaural advantages from using bimodal hearing
loss, the negative correlations were not significant for devices. Further, the improved speech perception in noise
both conditions of presentation (r = 0.33, p 1 0.05, and with bimodal hearing may be related also to the comple-
Byrne D, Dillon H: The National Acoustic Labo- Ching TYC, Incerti P, Hill M, Brew J: Fitting and Dillon H: NAL-NL1: a new procedure for fitting
ratories (NAL) new procedure for selecting evaluating a hearing aid for recipients of uni- non-linear hearing aids. Hear J 1999; 52: 10
the gain and frequency response of a hearing lateral cochlear implants: the NAL approach. 16.
aid. Ear Hear 1986;7:257265. 2. Bimodal hearing should be standard for Incert P: Binaural benefits in consonant recogni-
Byrne D, Parkinson A, Newall P: Modified hear- most cochlear implant users. Hear Rev tion for adults who use cochlear implants
ing aid selection procedure for severe/pro- 2004a;11:3240, 63. and hearing aids in opposite ears; disserta-
found hearing losses; in Studebaker G, Bess Ching TYC, Incerti P, Hill M, Priolo S: Binaural tion, Macquarie University, 2003.
F, Beck L (eds): The Vanderbilt Hearing Aid benefits for adults who use hearing aids and Kong YY, Stickney GS, Zeng FG: Speech and
Report II. Baltimore, York Press, 1991. cochlear implants in opposite ears. Ear Hear melody recognition in binaurally combined
Ching TYC: The evidence calls for making bin- 2004b;25:921. acoustic and electric hearing. J Acoust Soc
aural-bimodal fittings routine. Hear J 2005; Ching TYC, Psarros C, Hill M, Dillon H, Incerti Am 2005;117:13511361.
58:3241. P: Should children who use cochlear im- McDermott H: Music perception with cochlear
Ching TYC, Hill M, Brew J, Incerti P, Priolo S, plants wear hearing aids in the opposite ear? implants: a review. Trends Amplif 2004; 8:
Rushbrook E, Forsythe L: The effect of audi- Ear Hear 2001;22:365380. 4982.
tory experience on speech perception, local- Ching TYC, van Wanrooy E, Hill M, Dillon H: McDermott H: Perceiving melody remains chal-
ization, and functional performance of chil- Binaural redundancy and inter-aural time lenging for implant wearers. Hear J 2005;58:
dren who use a cochlear implant and a difference cues for patients wearing a cochle- 6574.
hearing aid in opposite ears. Intern J Audiol ar implant and a hearing aid in opposite ears. Vandali AE, Sucher C, Tsang DJ, McKay CM,
2005b;44:513520. Intern J Audiol 2005a;44:677690. Chew JWD, McDermott HJ: Pitch ranking
Ching TYC, Hill M, Dillon H, van Wanrooy E: ability of cochlear implant recipients: a com-
Fitting and evaluating a hearing aid for re- parison of sound-processing strategies. J
cipients of unilateral cochlear implants: the Acoust Soc Am 2005;117:31263138.
NAL approach. 1. Hear Rev 2004c;11:1422,
58.
yses were based only upon those instruments identified by each Instrument Recognition
participant as familiar prior to testing. No feedback was given on No significant differences were found as a function of
accuracy during testing.
device or strategy for the LE group; therefore, all the de-
vices and strategies were collapsed into one LE group for
analyses. As figure 2 indicates, there was a consistent pat-
Results tern, with the LE group as least accurate, and the NH
group as most accurate. The Kruskal-Wallis test indicat-
Real-World Song Recognition ed significant differences among the three groups (p !
No significant differences were found as a function of 0.0001) on instrument recognition including all three fre-
device or strategy for the LE group; therefore, all the LE quency ranges.1 Multiple comparison tests indicated that
devices and strategies were collapsed into one LE group the LE group was significantly less accurate (p ! 0.0001)
for analyses. Due to small sample sizes, nonnormality of than the NH group at all 3 frequency ranges; the LE group
the data, and unequal group variances, nonparametric was significantly less accurate than the Hybrid group in
statistics were used. The Kruskal-Wallis test indicated the low and high frequency ranges (p ! 0.0005). The Hy-
significant differences among the three groups (p ! brid group was significantly less accurate than the NH
0.0001) on recognition of songs in the lyrics condition group at medium and high frequencies (p ! 0.001).
(fig. 1). We performed multiple comparison tests among
the three groups using the Wilcoxon rank sum test with
a Bonferroni adjusted -level. The NH group was signif-
icantly more accurate for real world song recognition 1 Interpretation of the overlapping error bars in figure 2 should take into
with lyrics than the LE group (p ! 0.0001). In the no lyr- account the use of a nonparametric test based on ranks and the small sam-
ple sizes. As is well known, when there are small sample sizes, individual
ics condition, there were also significant differences values can have dramatic effects on the mean and the standard deviation.
among the three groups (p ! 0.0001). Both the NH and In this case, an extreme value caused the standard deviation to become in-
the Hybrid groups were significantly more accurate for flated. The overlapping of the error bars is a direct result of these extreme
values. Therefore, the diagram does not give an exact description of what is
real-world song recognition than the LE group (p ! being tested, but the general idea can clearly be seen in that the bars them-
0.0001). selves are different.
References
Bchler M, Lai WK, Dillier N: Music perception Gfeller KE, Turner CW, Woodworth G, Mehr M, Kong Y, Stickney G, Zeng F: Speech and melody
with cochlear implants (poster). ZNZ Sym- Fearn R, Knutson J F, Witt SA, Stordahl J: recognition in binaurally combined acoustic
posium, Zurich, 2004. www.unizh.ch/orl/ Recognition of familiar melodies by adult and electric hearing. J Acoust Soc Am 2005;
publications/publications.html. cochlear implant recipients and normal 117:13511361.
Dillier N: Combining cochlear implants and hearing adults. Cochlear Implants Int McDermott H: Music perception with cochlear
hearing instruments. Proc 3rd Int Pediatr 2002a;3:2953. implants: a review. Trends Amplif 2004; 8:
Conf, Chicago, November 2004, pp 163 Gfeller KE, Witt SA, Woodworth G, Mehr M, 4981.
172. and Knutson JF: The effects of frequency, in- Qin MK, Oxenham AJ: Effects of simulated co-
Gantz B, Turner C, Gfeller K, Lowder M: Preser- strumental family, and cochlear implant chlear-implant processing on speech recep-
vation of hearing in cochlear implant sur- type on timbre recognition and appraisal. tion in fluctuating maskers. J Acoust Soc Am
gery: advantages of combined electrical and Ann of Otol Rhinol Laryngol 2002b;111: 2003;114:446454.
acoustical speech processing. Laryngoscope 349356. Turner CW, Gantz BJ, Vidal C, Behrens A, Hen-
2005;115:796802. Henry BA, Turner CW, Behrens A: Spectral peak ry BA: Speech recognition in noise for co-
Gfeller KE, Knutson JF, Woodworth G, Witt S, resolution and speech recognition in quiet: chlear implant listeners: benefits of residual
DeBus B: Timbral recognition and appraisal normal hearing, hearing impaired and co- acoustic hearing. J Acoust Soc Am 2004;115:
by adult cochlear implant users and normal- chlear implant listeners. J Acoust Soc Am 17291735.
ly hearing adults. J Am Acad Audiol 1998; 2005;118:11111121. Wilson B: Cochlear implant technology; in
119. Kong Y, Cruz R, Jones J, Zeng F: Music percep- Niparko JK, Kirk KI, Mellon NK, Robbins
Gfeller KE, Olszewski CA, Rychener M, Sena K, tion with temporal cues in acoustic and elec- AM, Tucci DL, Wilson BS (eds): Cochlear
Knutson JF, Witt S, Macpherson BJ: Recog- tric hearing. Ear Hear 2004;25:173185. Implants: Principles & Practices. New York,
nition of real-world musical excerpts by co- Lippincott, Williams & Wilkins 2000, pp
chlear implant recipients and normal-hear- 109118.
ing adults. Ear Hear 2005;26:237250.
Human temporal bones (n = 7) were harvested from fresh ca- used to define the distance from the OC to the center of the SG,
daver specimens within 24 h postmortem and fixed by immersion to examine the morphology and locate the points at base and apex
in 10% phosphate-buffered formalin. Only one cochlea (left or where SG terminates. Next, the SG was measured along the series
right) was studied from each cadaver, to better assess individual of points defining its center in the digital images, and the trajec-
variability. The round window was opened as soon as possible to tories of the radial nerve fibers were traced to define a series of
facilitate diffusion of the fixative into the cochlea. The labyrinth frequency-matched coordinates along the OC and SG.
was isolated and the otic capsule bone was drilled away to blue
line the cochlea. Specimens were then stained with osmium te-
troxide (1% in 0.1 M phosphate buffer, pH 7.4) to visualize the ra-
dial nerve fibers. The cochlea was microdissected to expose the Results
cochlear duct, and a marker (small notch in the stria vascularis)
was created in the upper basal coil at the point nearest to the ves- As shown in table 1, the OC lengths measured in the
tibule (V). The specimens were decalcified for 2436 h to further
improve visibility of the radial nerve fibers within the osseous calibrated digital images demonstrated considerable in-
spiral lamina and then embedded in epoxy. Each cochlea was bi- tersubject variability, and ranged from 30.5 to 36.87 mm.
sected through the modiolus, and the individual half-coils were The mean length of the OC was 33.31 8 2.38 (SD) mm
removed from the block and remounted on a glass slide in a sur- for the group of 7 cochlear specimens studied to date. In
face preparation that contained both the OC and adjacent SG. All contrast, the average length of the SG was only 13.9 8
cuts through the specimens were made using razor blades so that
tissue loss was negligible. Digital images of each piece of the sur- 0.79 mm (n = 6), with a range of 12.5414.62 mm. Thus,
face preparation were captured and calibrated by capturing an on average, the SG was only 41% as long as the OC, and
image of a stage micrometer at the same magnification and super- this ratio was fairly similar in cochleae of different sizes.
imposing this image on the specimen images. The OC was mea- Direct morphometric analysis demonstrated that Rosen-
sured directly in the digital images by tracing along its approxi- thals canal terminated and no SG cell somata were found
mate center (along the tops of the pillar cells, if visible) beginning
at the basal extreme of the basilar membrane and measuring each directly radial to the most basal 2% and the most apical
segment of the surface preparation (fig. 1). Semi-thin radial sec- 11% of the OC, on average.
tions were cut at regular intervals along the cochlear spiral and
Specimen
7R 4R 5R 8R 15L 14R 6R mean
Data collected in 7 cochleae indicate relatively large intersubject variability in OC and SG lengths, but a fairly consistent ratio be-
tween the lengths of the two structures. Dissection error resulted in damage to the basal SG in specimen 6R and precluded measuring
SG length. The marker in the stria vascularis for V was lost during processing of the cochlea and could not be identified in specimen
14R.
Frequency-matched coordinates on the OC and SG 0.0014x2 + 1.43x, where y = percentage distance from base
were determined by directly tracing the trajectories of of the SG and x = percentage distance from base of the
radial nerve fibers at numerous points along the cochlear OC. Since Greenwoods function defines frequency for
spiral in the digital images. These data are presented in the OC, SG frequency can then be calculated.
figure 2. Percentage length along the SG was found to re- As anticipated, the frequency-position function for
late consistently and predictably to percentage length the SG is quite different from that of the basilar mem-
along the OC, with minimal intrasubject and intersubject brane for a large proportion of the cochlea, and particu-
variability. The data were fit by a cubic function that was larly for the apical third of the cochlea. During cochlear
constrained to begin at the point x = 0, y = 0, to end at dissections, an anatomical reference point was created by
x = 100, y = 100 and to be monotonic: y = 5.7E-05x3 + marking the site on the stria vascularis of the upper bas-
References
Bredberg G: Cellular pattern and nerve supply of lengths of organ of Corti, outer wall, inner Ulehlova L, Voldrich L, Janisch R: Correlative
the human organ of Corti. Acta Otolaryngol wall, and Posenthals canal. Ann Otol Rhinol study of sensory cell density and cochlear
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Escud B, James C, Deguine O, Cochard N, Eter Ketten D, Skinner MW, Wand G, Vannier MW, Wardrop P, Whinney D, Rebscher SJ, Luxford W,
E, Fraysse B: The size of the cochlea and pre- Gates GA, Neely JG: In vivo measures of co- Leake PA: A temporal bone study of inser-
dictions of insertion depth angles for cochle- chlear length and insertion depth of nucleus tion trauma and intracochlear position of
ar implant electrodes. Audiol Neurotol 2006; cochlear implant electrode arrays. Ann Otol cochlear implant electrodes. II. Comparison
11(suppl 1):2733. Rhinol Laryngol 1998; 107:116. of Spiral ClarionTM and HiFocus IITM elec-
Greenwood DD: A cochlear frequency-position Skinner MW, Ketten DR, Holden LK, Harding trodes. Hear Res 2005b;203:6879.
function for several species 29 years later. GW, Smith PG, Gates GA, Neely JG, Kletz- Wardrop P, Whinney D, Rebscher SJ, Roland JT
JASA 1990;87:25922605. ker GR, Brunsden B, Blocker B: CT-derived Jr, Luxford W, Leake PA: A temporal bone
Hardy M: The length of the organ of Corti in estimation of cochlear morphology and elec- study of insertion trauma and intracochlear
man. Am J Anat 1988;62:291311. trode array position in relation to word rec- position of cochlear implant electrodes. I.
Kawano A, Seldon HL, Clark GM: Computer- ognition in Nucleus-22 recipients. JARO Comparison of Nucleus banded and Nucleus
aided three-dimensional reconstruction in 2002;3:332350. ContourTM electrodes. Hear Res 2005a;203:
human cochlear maps: measurement of the 5467.
Binaural Mismatches of Frequency-to-Place Mapping posed on sinusoidal carriers. Carrier frequencies were set at the
The frequency-to-place map distortions considered so logarithmic center of each unshifted band, and at frequencies
shifted upwards to represent a 6-mm basalward basilar mem-
far have all been monaural. When an implant is used in brane shift from the center of each shifted band. Six normal lis-
conjunction with a contralateral hearing aid, or with bi- teners received 5 h of training with live-voice connected discourse
lateral implants, it is readily conceivable that the two ears tracking with speech presented through this binaurally mis-
would be operating with different frequency-to-place matched processor.
maps. We have examined such a situation in a further
simulation study [Faulkner et al., 2005]. Here we simulate Results
two ears in which one is subjected to a basalward place Intelligibility scores for words in simple BKB sentenc-
shift. The issue of interest is whether normal listeners can es are shown in figure 2. Although subjects did show sta-
learn to combine cues from this binaurally mismatched tistically significant improvements in their performance
mapping. with the binaurally mismatched processor over 5 h of
training, and also showed signs of improvement when
Method hearing only the 3 shifted bands, performance with the
In order for the successful integration of cues to be readily ob- binaurally mismatched processor never rose above the
served, each ear received limited spectral information. A total of performance seen with only the 3 unshifted bands. At the
6 analysis bands covering a frequency range of 2005000 Hz were final post-training session, BKB sentence scores with
interleaved between the two ears so that each ear had access only these two processors were statistically indistinguishable.
to 3 spectral bands, with the carriers to one ear shifted upwards
to represent a 6-mm basalward basilar membrane displacement. Additional tests with more difficult IEEE sentences
Envelopes were extracted from each analysis band using half- showed the same outcome, and since with these materials
wave rectification and a 32-Hz 3rd order low-pass filter and im- maximum performance never exceeded 70% correct, this
Discussion
References
Dorman MF, Loizou PC, Rainey D: Simulating Fu QJ, Shannon RV: Effects of electrode configu- Rosen S, Faulkner A, Wilkinson L: Perceptual
the effect of cochlear-implant electrode in- ration and frequency allocation on vowel adaptation by normal listeners to upward
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Faulkner A, Rosen S, Norman C: The right infor- Fu QJ, Shannon RV, Galvin JJ: Perceptual learn- Acoust Soc Am 1999;106:36293636.
mation may matter more than frequency- ing following changes in the frequency-to- Shannon RV, Galvin JJ, Baskent D: Holes in
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array insertion. Ear Hear 2006;27:139152. Gantz BJ, Turner C: Combining acoustic and GW, Smith PG, Gates GA, Neely JG, Kletz-
Faulkner A, Rosen S, Saul L: Perceptual adapta- electrical speech processing: Iowa/nucleus ker GR, Brunsden B, Blocker B: CT-derived
tion to a binaurally-mismatched frequency- hybrid implant. Acta Otolaryngol 2004; 124: estimation of cochlear morphology and elec-
to-place map: what is learned? Conference 344347. trode array position in relation to word rec-
on Implantable Auditory Prostheses, Asilo- Greenwood DD: A cochlear frequency-position ognition in Nucleus-22 recipients. J Assoc
mar, August 2005. function for several species 29 years later. J Res Otolaryngol 2002;3:332350.
Faulkner A, Rosen S, Stanton D: Simulations of Acoust Soc Am 1990;87:25922605. Smith M, Faulkner A: Perceptual adaptation by
tonotopically-mapped speech processors for Ketten DR, Vannier MW, Skinner MW, Gates normally hearing listeners to a simulated
cochlear implant electrodes varying in in- GA, Wang G, Neely JG: In vivo measures of hole in hearing. J Acoust Soc Am 2006, in
sertion depth. J Acoust Soc Am 2003; 13: cochlear length and insertion depth of Nu- press.
10731080. cleus cochlear implant electrode arrays. Ann Sridhar D, Stakhovskaya O, Leake PA: A fre-
French NR, Steinberg JC: Factors governing the Otol Rhinol Laryngol 1998; 175:116. quency-position function for the human co-
intelligibility of speech. J Acoust Soc Am Offeciers E, Morera C, Muller J, Huarte A, Shal- chlear spiral ganglion. Audiol Neurotol
1947;19:90119. lop J, Cavalle L: International consensus on 2006;11(suppl 1):1620.
Fu QJ, Galvin JJ: The effects of short-term train- bilateral cochlear implants and bimodal
ing for spectrally mismatched noise-band stimulation Second Meeting Consensus on
speech. J Acoust Soc Am 2003; 113: 1065 Auditory Implants, 1921 February 2004,
1072. Valencia, Spain. Acta Otolaryngol 2005;125:
918919.
***R2 = 0.57
540
Small A = 8.25 mm
7.0 1.60 Medium
Ratio A/B
360
6.0 1.40 ~100
** R2 = 0.19 270
180
5.0 1.20
8
6 90 ~5 mm
4
2
0 0
7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 0 5 10 15 20 25
Distance A (mm) Linear distance along lateral wall (L/mm)
Fig. 2. Summary data for distances A and B measured for 42 in- Fig. 3. Insertion depth angle versus distance along the lateral wall
dividuals. Distance B is plotted against distance A (top, filled cir- for small, medium and large cochleae. Inset (top right): scaled
cles). Ratio A/B is plotted against distance A (middle, open representations of the arc of the lateral wall as may be followed by
squares). Significant linear correlations are shown (solid diagonal straight electrode arrays up to 20 and 15 mm, respectively, in
lines). Separate histograms of distance A are plotted for male and small (dotted line) or large (solid line) cochleae.
female ears (bottom, diamonds and crosses, respectively).
the HRCT images (0.250.3 mm), and thus no inference entire outer wall from base to apex without requiring
could be made about real differences in cochlear size be- multiple sections of simple or logarithmic spirals [Xu et
tween the two ears. For the data analysis which followed, al., 2000; Yoo et al., 2000].
distances A and the perpendicular distance B (mean dif- r = A ! c/( + c), (1)
ference 0.22 mm) were averaged between ears for each
individual. where r is the radial distance from the nominal centre of
A statistically significant mean difference was found the modiolus to the outer wall, A is distance A and is
between male and female ears for both distance A (9.43 the angle in radians from the round window as in fig-
vs. 9.05 mm, respectively, two-sample t, unequal varianc- ure 1. c is a constant derived from the ratio A/B. For the
es p ! 0.05) and distance B (7.15 vs. 6.86 mm, p = 0.01). purpose of good approximation, the mean ratio A/B =
No significant mean difference was found for the ratio 1.32 gives a value c ; 4.1 rad. c is a function of c given
A/B (mean 1.32), indicating no particular difference in by:
morphology. A summary of the data for distances A and c = c (c + )/(2c + ). (2)
B is given in figure 2. The mean distance A was 9.23 mm
(SD 0.53), and B 6.99 mm (SD 0.37). Substituting constants and applying calculus, the
There was a statistically significant correlation be- length L of the spiral arc for a particular angle expressed
tween distance A and distance B (r2 = 0.57, p ! 0.001), in degrees is approximated by:
and between distance A and the ratio A/B (r2 = 0.19, p ! L = 2.62 A ! loge (1.0 + /235) (3)
0.01), where the ratio A/B tended to increase as A in-
creased. Thus, the path length L of the lateral wall of the co-
A spiral function (equation 1) was used to model the chlea may be modeled using equation 3 for a given dis-
line tracing the outer wall or lateral wall of the cochlea. tance A and insertion depth angle (fig. 3). Figure 3 may
This single function provides a good fit to the path of the be used to predict the insertion depth angle obtained for
Adunka O, Unkelbach MH, Mack MG, et al: Pre- Gstoettner W, Kiefer J, Baumgartner WD, Pok S, Ketten DR, Skinner MW, Wang G, Vannier MW,
dicting basal cochlear length for electric- Peters S, Adunka O: Hearing preservation in Gates GA, Neely JG: In vivo measures of co-
acoustic stimulation. Arch Otolaryngol cochlear implantation for electric acoustic chlear length and insertion depth of Nucleus
Head Neck Surg 2005;131:488492. stimulation. Acta Otolaryngol 2004; 124: cochlear implant electrode arrays. Ann Otol
Dimopoulos P, Muren C: Anatomic variations of 348352. Rhinol Laryngol 1998; 107:116.
the cochlea and relations to other temporal Hardy M: The length of the organ of Corti in Skarzynski H, Lorens A, Piotrowska A: A new
bone structures. Acta Radiol 1990; 31: 439 man. Am J Anat 1938;62:291311. method of partial deafness treatment. Med
444. James C, Albegger K, Battmer R, Burdo S, Sci Monit 2003;9:CS20CS24.
Fraysse B, Ramos A, Sterkers O, et al: Residual Deggouj N, Deguine O, Dillier N, Gersdorff Xu J, Xu SA, Cohen LT, Clark GM: Cochlear
hearing conservation and electro-acoustic M, Laszig R, Lenarz T, Manrique Rodriguez view: postoperative radiography for cochlear
stimulation with the Nucleus 24 Contour M, Mondain M, Offeciers E, Ramos Macias implantation. Am J Otol 2000;21:4956.
Advance cochlear implant. Otol Neurotol A, Ramsden R, Sterkers O, von Wallenberg Yoo SK, Wang G, Rubinstein JT, Vannier MW:
2006;27:624633. E, Weber B, Fraysse B: Preservation of resid- Three-dimensional geometric modeling of
Greenwood DD: A cochlear frequency-position ual hearing with cochlear implantation: how the cochlea using helico-spiral approxima-
function for several species 29 years later. J and why. Acta Otolaryngol 2005; 125: 481 tion. IEEE Trans Biomed Eng 2000;47:1392
Acoust Soc Am 1990;87:25922605. 491. 1402.
Kawano A, Seldon HL, Clark GM: Computer-
aided three-dimensional construction in
human cochlear maps: measurement of the
lengths of organ of Corti outer wall, inner
wall and Rosenthals canal. Ann Otol Rhinol
Laryngol 1996;105:701709.
electrode is grasped at the wing with a special forceps designed by frequencies with useful residual hearing (threshold !80 dB). The
the senior author (Storz company) and inserted under direct vi- CI should cover the remaining frequency range. The frequency to
sion up to the stop point. Steroids (cortisone 500 mg i.v.) are ad- electrode allocation is adapted to the residual hearing. The first
ministered intraoperatively. The expected benefit of this approach (lowest) frequency channel not covered by the HA is mapped to
is a reduction of risks associated with the normal cochleostomy the most apical electrode of the Hybrid-L implant. Channels be-
(drilling, removal of bone dust, mechanical trauma and suction low this cut-off channel are not transmitted by the CI.
of perilymph). It also guarantees a proper positioning of the array A single subject repeated measures design is being used. Mea-
in the scala tympani. The silastic wing is fixed into a bone groove sured are unaided pure tone thresholds and speech performance
at the lower rim of the posterior tympanotomy (fig. 2). using different modes of electroacoustic stimulation. Speech rec-
ognition is tested using the Freiburg Monosyllabic Word test in
Temporal Bone Insertion Study quiet at 65 dB, the HSM sentence test in noise with a fixed signal-
The electrode was inserted in 22 temporal bones to evaluate to-noise ratio of +10 dB and the Oldenburg sentence test (OLSA)
the insertion characteristics and the risk of trauma to intraco- in noise (adaptive with noise fixed at 65 dB).
chlear structures. This was the basis to decide for the start of a This study is conducted in accordance with ISO 14155 (Inter-
human clinical study. Four of the 22 electrodes were prototypes national Standard for Clinical Investigation of Medical Devices)
without the positive stop but with the same characteristics as de- and follows the GCP guidelines. Medical Ethics Committee writ-
scribed above. These four electrodes have been inserted up to the ten approval and competent authority approval according to na-
last electrode contact. tional laws have been granted before the start of the study.
Two surgeons performed 10 temporal bone insertions (4 with-
out stopper) at the Medizinische Hochschule Hannover (MHH)
and 12 at the University of Melbourne (UM) [see Briggs et al., this
issue, pp. 4248]. Results
Fresh frozen human temporal bones were prepared and the
surgical procedure was performed as described above. After-
Temporal Bone Insertion Study
wards, the bones were embedded in resin and sectioned parallel
to the modiolus axis with the electrode in place. Serial cuts were Minimal or no resistance was observed during inser-
made perpendicular to the electrode spiral. Each cross-section tion of the electrodes. A full insertion depth could be
was photographed to document the position of the electrode rela- achieved with a single stroke insertion without buckling
tive to the walls of the cochlea [Stver et al., 2005]. in the proximal region, which might occur with other
Clinical Evaluation straight electrodes (fig. 3c).
After the temporal bone insertion study, the clinical trial start- Temporal bone analysis showed no or less damage to
ed first at the MHH and later at the UM. The objectives of the cochlea structures compared to insertion of other Nucle-
clinical trial are: us electrodes (fig. 3a, b). The electrode carrier was ade-
To evaluate the preservation of residual hearing over time in quately positioned in the scala tympani under the basilar
severely hearing-impaired subjects implanted with the Nucle-
us Hybrid-L System. membrane with modiolus facing electrode contacts. No
To determine whether speech understanding can be enhanced sign of damage to intracochlear structures was observed
by combined electrical and acoustical stimulation while main- in 21 (95.5%) of the temporal bones. There were no cases
taining preoperative levels of acoustic hearing. of basilar membrane perforation [Briggs et al., this issue,
A total of 20 patients are planned who fulfill the selection cri- pp. 4248]. Specific findings were found in 2 cases; with
teria summarized in table 1. There are no audiometric restrictions
for the contralateral ear. a tip fold-over without damage to the cochlear structures
All recipients are implanted with a Nucleus Freedom Hybrid- in the 1st case and with slight damage to the lateral wall
L implant. The patients are then fitted with an ITE HA only for of the scala tympani in the 2nd case.
ly to the full range of frequencies and pitches. An ex- 27.5% for Freiburg Monosyllables and 0.65 dB for the
ample of aided thresholds for wobble tones measured OLSA was achieved.
in the free sound field for the CI alone, the ipsilateral Bilateral hearing (combined mode) using the HA on
HA alone and the combination of both is shown in the nonimplanted ear showed an additional improve-
figure 5. ment over the Hybrid condition of 13.3% for the HSM
Speech recognition tests of the first patient 1 month and 3 dB for the OLSA (fig. 6). The overall improvement
after initial fitting showed a clear benefit of the combined in speech recognition for the best aided condition post-
condition (CI + both HA) compared to the preoperative operatively compared to preoperatively was 34.9% for the
situation. Postoperatively, the patient showed speech un- HSM sentence test and 4.3 dB for the OLSA. The speech
derstanding with the CI alone of 40% monosyllables, scores also demonstrate a preservation of functional
62.3% for the HSM sentence test in noise and 0.7 dB for hearing.
the OLSA in noise. In the electroacoustic Hybrid condi-
tion (CI + ipsilateral HA), a further improvement of
Adunka O, Kiefer J, Unkelbach MH, Radeloff A, Greenwood DD: Critical bandwidth and fre- Lenarz T, Aschendorff A, Roland T, Briggs R:
Gstttner W: Evaluating cochlear implant quency coordinates of the basilar membrane. Surgical Techniques for the Nucleus 24
trauma to the scala vestibule. Clin Otolaryn- J Acoust Soc Am 1961;33:13441356. Contour AdvanceTM. Cochlear Ltd, 2004.
gol 2005;30:121127. Gstttner W, Kiefer J, Baumgartner WD, Pok S, Morera C, Manrique M, Ramos A, Garcia-Ibanez
Adunka O, Kiefer J Unkelbach MH, Radeloff A, Peters S, Adunka O: Hearing preservation in L, Cavalle L, Huarte A, Castello C, Estrada
Lehnert T, Gstttner W: Evaluation of an cochlear implantation for electreic acoustic E: Advantages of binaural hearing provided
electrode design for the combined electric- stimulation. Acta Otolaryngol 2004; 124: through bimodal stimulation via a cochlear
acoustic stimulation. Laryngorhinootologie 348352. implant and a conventional hearing aid: a 6-
2004;83:653658. Hartrampf R, Dahm MC, Battmer RD, Gnade- month comparative study. Acta Otolaryngol
Briggs RJS, Tykocinski M, Stidham K, Roberson, berg D, Strauss-Schier A, Rost U, Lenarz T: 2005;125:596606.
JB: Cochleostomy site: implications for elec- Insertion depth of the Nucleus electrode ar- Parkinson AJ, Arcaroli J, Staller SJ, Arndt PL,
trode placement and hearing preservation. ray and relative performance. Ann Otol Rhi- Cosgriff A, Ebinger K: The Nucleus 24
Acta Otolaryngol 2005;125:870876. nol Laryngol Suppl 1995;166:277280. ContourTM cochlear implant system: adult
Byrne D, Parkinson A, Newall P: Hearing aid Hogan CA, Turner CW: High-frequency audi- clinical trial results. Ear Hear 2002; 23
gain and frequency response requirements bility: benefits for hearing-impaired listen- (suppl):4148.
for the severely/profoundly hearing-im- ers. J Acoust Soc Am 1998;104:432441. Pau HW, Just T, Lehnhardt E, Hessel H, Behrend
paired. Ear Hear 1990;11:4049. James C, Albegger K, Battmer R, Burdo S, D: An endosteal electrode for cochlear im-
Ching TYC, Dillon H, Byrne D: Speech recogni- Deggouj N, Deguine O, Dillier N, Gersdorff plantation in cases with residual hearing?
tion of hearing-impaired listeners: predic- M, Laszig R, Lenarz T, Manrique Rodriguez Feasibility study: preliminary temporal bone
tion from audibility and the limited role of M, Mondain M, Offeciers E, Ramos Macias experiments. Otol Neurotol 2005; 26: 448
high-frequency amplification. J Acoust Soc A, Ramsden R, Sterkers O, von Wallenberg 454.
Am 1998;103:11281140. E, Weber B, Fraysse B: Preservation of resid- Ruh S, Battmer RD, Strauss-Schier A, Lenarz T:
Choi CH, Oghalai JS: Predicting the effect of ual hearing with cochlear implantation: how Cochlear implant in patients with residual
post-implant cochlear fibrosis on residual and why. Acta Otolaryngol 2005; 125: 481 hearing. Laryngorhinootologie 1997; 76:
hearing. Hear Res 2005;205:193200. 491. 347350.
Dowell RC, Hollow R, Winton E: Outcomes for Khan AM, Handzel O, Burgess BJ, Damian D, Stver T, Issing P, Graurock G, Erfurt P, ElBel-
cochlear implant users with significant re- Eddington DK, Nadol JB Jr: Is word recogni- tagy Y, Paasche G, Lenarz T: Evaluation of
sidual hearing: implications for selection cri- tion correlated with the number of surviving the advance off-stylet insertion technique
teria in children. Arch Otolaryngol Head spiral ganglion cells and electrode insertion and the cochlear insertion tool in temporal
Neck Surg 2004;130:575581. depth in human subjects with cochlear im- bones. Otol Neurotol 2005; 26:11611170.
Gantz BJ, Turner C: Combining acoustic and plants? Laryngoscope 2005;115:672677. Turner CW, Cummings KJ: Speech audibility for
electrical hearing. Laryngoscope 2003; 113: Kiefer J, Gstoettner W, Baumgartner W, Pok SM, listeners with high-frequency hearing loss.
17261730. Tillein J, Ye Q, von Ilberg C: Conservation of Am J Audiol 1999;8:4756.
Gantz BJ, Turner C: Combining acoustic and low-frequency hearing in cochlear implanta- Von Ilberg C, Kiefer J, Tillein J, Pfenningdorff T,
electrical speech processing: Iowa/Nucleus tion. Acta Otolaryngol 2004;124:272280. Hartmann R, Stuerzebecher E, Klinke R:
hybrid implant. Acta Otolaryngol 2004; 124: Lehnhardt E: Intracochlear placement of cochle- Electric-acoustic stimulation of the auditory
344347. ar implant electrodes in soft surgery tech- system. New technology for severe hearing
Gantz BJ, Turner C, Gfeller KE, Lowder MW: nique. HNO 1993;41:356359. loss. ORL J Otorhinolaryngol Relat Spec
Preservation of hearing in cochlear implant 1999;61:334340.
surgery: advantages of combined electrical
and acoustical speech processing. Laryngo-
scope 2005;115:796802.
tion within the cochlea and then to examine for the pres- formalin, dehydrated in ethanol using serial concentrations pro-
ence of intracochlear trauma using previously established gressing from 70 to 100% and immersed in degassed epoxy resin
to achieve acrylic fixation. Vacuum is applied so that the epoxy
histologic sectioning techniques. mixture infiltrates the cochlea completely.
After embedding the specimens were X-rayed to assess the
correct plane for sectioning. Excess portions of the temporal bone
specimens within the epoxy blocks were trimmed to leave only
Materials and Methods the cochleae. After appropriate orientation the resized blocks
were re-embedded such that the cochlear central axis was ori-
Temporal bone safety studies were performed concurrently at ented parallel to the plane of sectioning, which is perpendicular
the University of Melbourne and Medizinische Hochschule Han- to the electrode array.
nover. Eighteen fresh frozen human temporal bones were thawed The cochlear specimens were then serially sectioned using a
and prepared for cochlear implantation using a standard trans- grinding technique with a section thickness of 200 m. For each
mastoid facial recess surgical technique. In each specimen the section examined the specimen was polished and stained with
RWM was exposed. This was achieved by a complete facial recess toluidine blue and light microscopy and photography performed.
dissection with skeletonization of the chorda tympani and facial In some specimens serial sectioning was performed through the
nerve. Initially, the round window niche was identified; the lat- entire cochlea, in which case the ascending basal turn was exam-
eral bony overhang of sinus tympani was removed anterior to the ined in the same plane as the initial reference plane. In other spec-
facial nerve and inferior to the pyramid to allow clear visualiza- imens, after the modiolar section was passed, the remaining spec-
tion of the round window niche. The bony lip of the niche was imen was rotated 90 and the specimen further sectioned perpen-
drilled with a 1-mm diamond burr to fully expose the RWM. In dicular to the ascending basal turn.
the majority of specimens a mucosal fold or false membrane was
present and was removed from the niche to expose the true mem-
brane.
In 6 specimens a scala tympani cochleostomy measuring ap-
proximately 1 mm was created immediately inferior to the RWM. Results
Care was taken to avoid bone dust entering the basal turn.
To examine the trajectory of insertion, electrode insertions in In all but one specimen a full electrode insertion was
Melbourne were performed under fluoroscopic control with vid- achieved with the surgeons noting minimal or no sig-
eo recording of both the microsurgical procedure and the fluoro- nificant resistance. In one cochleostomy specimen, after
scopic image. For the RWM insertions an initial vertical incision
was made in the inferior aspect of the membrane using a 21 gauge initial full insertion, the electrode sprang back a few mil-
hypodermic needle. For all electrode insertions the electrode was limeters but subsequently remained in position when the
held by the proximal flange wing using standard jewellers for- array was pushed back to its previous insertion level. In
ceps. one RWM insertion there appeared to be initial resis-
Following electrode insertion the temporal bone specimen tance at the RWM, possibly because the membrane inci-
was rotated in the X-ray beam to allow fluoroscopic examination
parallel to the basal turn to confirm scala tympani position of the sion was too small. Fluoroscopic analysis demonstrated
array. An additional high-resolution X-ray was taken perpendicu- that with the RWM insertions, the electrode does contact
lar to the cochlea to measure insertion depth in degrees around the modiolus in the proximal basal turn before the tip of
the modiolus. The electrode array was then secured by application the electrode contacts the lateral scala wall, after which
of histoacryl glue to the proximal electrode cable at the facial re- the distal electrode maintains a lateral wall position
cess level.
In each bone the stapes foot plate was removed to allow perfu- around the ascending basal turn. These findings were
sion of the fixative, dehydrating solutions and the acrylic resin confirmed on histologic analysis (fig. 2). In the cochleos-
throughout the cochlea. The specimens were then fixed in 10% tomy specimens the electrode passes in a mid- or lateral
4 5
Fig. 2. Round window insertion electrode position. Note the peri- Fig. 5. Section showing electrode lying in subendosteal position
modiolar electrode location in the proximal basal turn. lateral to spiral ligament.
Fig. 3. Cochleostomy insertion electrode postion. Note the mid- Fig. 6. a Electrode at RWM. Note the vertical alignment of the
scala tympani location in the proximal basal turn. delicate osseous spiral lamina (OSL) and its proximity to the
Fig. 4. Electrode tip fold-over. Note intact basilar membrane. RWM. b Electrode at cochleostomy. Note the proximity of the co-
chleostomy (dashed line C) to the spiral ligament (SL, arrow).
Adunka O, Gsttoetner W, Hambeck M, Unkel- Gstoettner W, Kiefer J, Baumgartner WD, Pok S, Kiefer J, Gstoettner W, Baumgatner W, Pok SM,
bach MH, Radeloff A, Kiefer J; Preservation Peters S, Adunka O: Hearing preservation in Tillein J, Ye Q, von Ilberg C: Conservation of
of basal cochlear structures in cochlear im- cochlear implantation for electric acoustic low frequency hearing in cochlear implanta-
plantation. ORL J Otorhinolaryngol Relat stimulation. Acta Otolaryngol 2004; 124: tion. Acta Otolaryngol 2004;124:272280.
Spec 2004;66:306312. 348352. Neumann M, Aschendorff A, Schipper J, Laszig
Baskent D, Shannon RV: Interactions between Gstoettner W, Plenk H Jr, Franz P, Hamzavi J, R, Klenzner T: The influence of insertion
electrode insertion depth and frequency- Baumgartner W, Czerny C, Ehrenberger K: depth on the preservation of residual hearing
place mapping. J Acoust Soc Am 2005; 117: Cochlear implant deep electrode insertion: after cochlear implantation. Laryngorhi-
14051416. extent of insertional trauma. Acta Otolaryn- notologie 2005; 84:113116.
Blamey P, Dooley, Parisi, Clark G: Pitch compar- gol 1997;117:274277. Skarzynski H, Lorens, A, DHaese P, Walkowiak
isons of acoustically and electrically evoked Gstoettner W, Pok SM, Peters S, Kiefer J, Adunka A, Piotrowska A, Sliwa L, Anderson I: Pres-
auditory sensations. Hear Res 1996; 99: 139 O: Cochlear implantation with preservation ervation of residual hearing in children and
150. of residual deep frequency hearing. HNO post-lingually deafened adults after cochlear
Briggs R, Tykocinski M, Saunders E, Dahm MC, 2005;53:784790. implantation: an initial study. ORL 2002;64:
Hellier W, Pyman B: Surgical implications of James C, Albegger K , Battmer R, Burdo S, 247253.
perimodiolar electrode designs: avoiding in- Deggouj N, Deguine O, Dillier N, Gersdorff Tykocinski M, Saunders E, Cohen L, Treaba C,
tracochlear damage and scala vestibuli in- M, Laszig R, Lenarz T, Rodriguez MM, Mon- Briggs RJS, Gibson P: The Contour electrode
sertions. Cochlear Implant Int 2001; 2: 135 dain M, Offeciers E, Macias AR, Ramsden R, array, safety study and initial patient trials
149. Sterkers O, Von Wallenberg E, Weber B, using a new peri-modiolar electrode design.
Briggs RJS, Tykocinski M, Stidham K, Roberson Fraysse B: Preservation of residual hearing Otol Neurotol 2001; 21:205211.
JB: Cochleostomy site: implications for elec- with cochlear implantation: how and why. Von Ilberg C, Kiefer J, Tillein J, Pfenningdorff T,
trode placement and hearing preservation. Acta Otolaryngol 2005;125:481491. Hartmann R, Sturzebecher E, Klinke R:
Acta Otolaryngol 2005;125:870876. James C, Blamey P, Shallop J, Incerti P, Nicholas Electric-acoustic stimulation of the auditory
Dahm MC, Xu J, Tykocinski M, Shepherd RK, AM: Contralateral masking in cochlear im- system. New technology for severe hearing
Clark GM: Post mortem study of the intraco- plant users with residual hearing in the non- loss. ORL J Otorhinolaryngol Relat Spec
chlear position of the Nucleus Standard 33 implanted ear. Audiol Neurootol 2001; 6:87 1999;61:334340.
electrode array. Proc 5th Eur Symp Paediatr 97. Webb RL, Clark GM, Shepherd RK, Franz BK,
Cochlear Implantat, Antwerp, June 2000. Kennedy DW: Multichannel intracochlear elec- Pyman BC: The biologic safety of the Co-
Gantz BJ, Turner C, Gfeller KE, Lowder MW: trodes: mechanism of insertion trauma. La- chlear Corporation multiple electrode intra-
Preservation of hearing in cochlear implant ryngoscope 1987;97:4249. cochlear implant. Am J Otol 1988; 9:813.
surgery: advantages of combined electrical
and acoustical speech processing. Laryngo-
scope 2005;115:796802.
Discussion
Results
This paper documents complete preservation of resid-
A total number of 23 patients with significant residual ual hearing in 9 of 23 patients implanted for EAS. Al-
hearing according to our protocol (15 females, 8 males; though 3 of the 9 patients have less than 2 years experi-
mean age at implantation 49.9 years; range 25.977.3 ence (fig. 1gi), these patients are considered as having
years) were implanted between 1999 and 2005 at the Uni- stable long-term preservation of residual hearing. The pa-
versity of Frankfurt and could be included in this evalu- tients with partial hearing preservation (fig. 2) all had
ation. Sixteen patients were implanted in the right ear some initial hearing loss immediately after implantation
and 7 patients received an implant in the left ear. The which then proceeded in some cases. Thus, completely
minimum follow-up time was 6 months after implanta- preserved immediate postoperative hearing may be used
tion. as a predictor for its long-term stability.
Despite swelling of the cochlear endosteum in one Acute postoperative deafness was encountered in less
case, no specific intraoperative findings or postoperative than 10% of our cases. In about 20% of our patients, pro-
surgical complications were observed. Electrodes were gression of sensorineural hearing impairment lead to de-
inserted 1824 mm, which did not always result in 360 layed deafness in the implanted ear after 718 months.
insertions obviously due to significant differences in The reason for preserving hearing in some cases and los-
cochlear size and shape among patients [Zrunek et al., ing it in others is not clear yet. All surgeries were per-
1980]. As mentioned before, a high-resolution computed formed by 2 surgeons (W.K.G. and J.K.) who shared their
tomography protocol was introduced in the late course of experience.
the study to predict the length of insertion in order to To provide efficient combination of electric and acous-
achieve more exact 360 insertions [Adunka et al., tic stimulation, stable long-term hearing preservation
2005]. seems to be of great importance. Patients need more time
At the final follow-up interval, patients were grouped to adapt to EAS than to conventional cochlea implants.
according to their individual long-term hearing preser- Previously, EAS results including short-term hearing
vation outcome. Of the 23 patients, 9 (39.1%) showed preservation outcomes from two centers have been pub-
complete hearing preservation under the terms of our lished [Kiefer et al., 2005; Gstoettner et al., 2004]. The
protocol (average pure-tone threshold shift at 250 current paper, on the other hand, reports on patients who
750 Hz compared to preoperative hearing less than had been implanted in Frankfurt only. Therefore, varia-
10 dB) over 770 months (mean 29 months; fig. 1). tions in patient selection, surgical procedure, and medi-
In 7 patients, (30.4%) residual low-frequency hearing cal management have been minimized.
at the final evaluation was found to be partially preserved Another approach to EAS is shorter electrode inser-
(average low-frequency hearing loss 115 dB but clear ip- tions of 610 mm. In a multi-center trial involving this
silateral low-frequency acoustic hearing detectable) and concept [Gantz et al., 2005], out of 21 patients, one showed
20 20 30
30 30
40 24*
40 40
50 50 50
60 30 60 27 60
70 70 70
80 80 80
90 90 90
100 100 100
110 110 110
d 120 e 120 f 120
10
Hearing loss (dB HL)
20 20
Hearing loss (dB HL)
20 30 30
30 40 40
40
19 50 14 50 7
50
60 60 60
70 70 70
80 80 80
90 90 90
100 100 100
110 110 110
g 120 h 120 i 120
Fig. 1. Audiograms pre- and postoperatively and after 770 months of patients with complete hearing preserva-
tion. The patient indicated by an asterisk had a complete preservation of the inner ear function as demonstrat-
ed by bone conduction measurement. An additional air-bone gap of 15 dB is not illustrated on the audiogram.
U = Before operation; S = after operation; d = months after implantation.
a delayed 30-dB drop in average pure-tone thresholds chlear implant alone may not provide sufficient speech
and another lost hearing completely after 2.5 months. perception abilities.
Thus, their rate of hearing preservation is superior when Very recently, first results of a multicenter trial inves-
compared to deeper insertions as used in this study. How- tigating preservation of residual hearing after implanta-
ever, very limited insertions bear controversies as how to tion with a standard length perimodiolar electrode (Nu-
proceed in cases of complete hearing loss, since the co- cleus Contour Advance electrode) have been reported
20 20 20
30 30 30
40 40 40
50 9 50 9 50 6
60 60 60
70 70 70
80 80 80
90 90 90
100 100 100
110 110 110
d 120 e 120 f 120
Frequency (Hz)
100 10000
10
0
10
Hearing loss (dB HL)
20
30
40
50 6
60 Pre-op Post-op Months after implantation
70
80
90
100
110
g 120
Fig. 2. Audiograms pre- and postoperatively and after 670 months of patients with partial hearing preserva-
tion. U = Before operation; S = after operation; d = months after implantation.
[James et al., 2005]. Insertion depths in this study were confirm the result of relatively atraumatic insertions with
1719 mm (300430). Although perimodiolar electrodes modified perimodiolar electrodes [Adunka et al., in
seem to increase cochlear trauma [Gstoettner et al., 2001; press]. Yet, long-term hearing preservation outcomes are
Richter et al., 2001; Aschendorff et al., 2003], in this study expected with interest.
only 2 of 12 patients had total hearing loss due to unex- One of the most important steps of EAS surgery seems
pected difficulties during surgery and half of the patients to be atraumatic opening of the scala tympani [Briggs et
retained sufficient hearing for effective ipsilateral bimod- al., 2005]. Alternatively, opening of the round window
al stimulation. A more recent cadaver study was able to membrane [Skarzynski et al., 2003] could be a safe access
20 20 20
30 30 30
40 9 40 7 40
50 50 50
60 60 60 Post-op
70 70 70
80 80 80
90 90 90
100 100 100
110 110 110
d 120 e 120 f 120
Frequency (Hz)
100 10000
10
0
10
Hearing loss (dB HL)
20
30
40 Post-op
50 Pre-op Post-op Months after until deafness
60
70
80
90
100
110
g 120
Fig. 3. Audiograms pre- and postoperatively. Two patients with early onset of deafness directly after implanta-
tion and 5 patients with late onset of deafness after 718 months after implantation. U = Before operation; S =
after operation; d = months until deafness.
to scala tympani, avoiding trauma to osseous spiral lam- At present, basic science and research are trying to de-
ina and to the basilar membrane [Adunka et al., 2004c]. pict the exact mechanisms and importance of factors
However, basal cochlear anatomy including the round leading to hearing loss after electrode insertion. Inter-
window area shows great variations [Zrunek et al., 1980]. ruption of particular pathways that result in hearing loss
Its exposure through the facial recess seems limited in is the ultimate goal [Scarpidis et al., 2003]. Recent animal
some cases and thus an approach through the ear canal experiments [Eshraghi et al., 2005] suggest that hearing
including raising a tympanomeatal flap might enhance loss after cochlear implantation occurs in two stages: an
visibility. early stage during or immediately after surgery and a de-
Correct (%)
60
50
40
30
20
10
0
a b c d e f g h Mean
Subject
Fig. 4. Pre- and postoperative results of Freiburger monosyllables discrimination for patients with
complete preservation of residual hearing. Subjects with at least 1 year of EAS experience are in-
cluded. ah correspond to figure 1.
layed stage occurring within the first few weeks after im- sures are employed. Complete hearing loss in the acute
plantation. It is believed that protection from hair cell postoperative setting and progression of initially pre-
apoptosis might alter the delayed pathway positively served hearing to complete deafness over time was ob-
[Scarpidis et al., 2003]. Hence, pharmacological treat- served in a small subgroups of patients.
ment of hearing loss is currently one of the main topics
in patient-oriented inner ear research. As part of it, path-
ways to delivery future pharmaceuticals to their site of Acknowledgments
action, e.g. the cochlear duct, are currently under inves-
The authors wish to thank Dr. Ingeborg Hochmair, Dipl. Ing.
tigation [Paasche et al., 2006]. Although sophisticated vi-
Marcus Schmidt, Claude Jolly and the entire clinical research de-
ral vectors might be the foundation of inner ear treatment partment from MED-EL for their continued effort and their un-
in the future [Staecker et al., 2004], much simpler routes limited support for this project. We also would like to thank Blake
like topical drug application onto the cochleostomy open- Wilson, BS, and Dewey Lawson, PhD, for their dedication, exper-
ing during surgery as described in this report are cur- tise, and support. Finally, we would like to acknowledge PD Dr.
Martin Mack for his assistance in the radiological aspects of this
rently used. Better residual hearing of future EAS candi-
study.
dates, however, demands a simpler, yet more direct route
of drug application. Hence, extensive research has fo-
cused on the feasibility of intracochlear drug application,
which might soon become clinically available.
Conclusions
Adunka O, Gstoettner W, Hambek M, et al: Pres- Gantz BJ, Turner CW: Combining acoustic and Lehnhardt E: Intracochlear placement of cochle-
ervation of basal inner ear structures in co- electrical hearing. Laryngoscope 2003; 113: ar implant electrodes in soft surgery tech-
chlear implantation. ORL J Otorhinolaryn- 17261730. nique (in German). HNO 1993;41:356359.
gol Relat Spec 2004a;66: 306312. Gantz BJ, Turner C, Gfeller KE, et al: Preserva- Paasche G, Bogel L, Leinung M, et al: Substance
Adunka O, Kiefer J, Unkelbach MH, et al: Devel- tion of hearing in cochlear implant surgery: distribution in a cochlea model using differ-
opment and evaluation of an improved co- advantages of combined electrical and acous- ent pump rates for cochlear implant drug de-
chlear implant electrode design for electric tical speech processing. Laryngoscope 2005; livery electrode prototypes. Hear Res 2006;
acoustic stimulation. Laryngoscope 2004b; 115:796802. 212:7482.
114:12371241. Greenwood DD: A cochlear frequency-position Richter B, Jaekel K, Aschendorff A, et al: Cochle-
Adunka O, Pillsbury CH, Kiefer J: Combining function for several species 29 years later. J ar structures after implantation of a peri-
perimodiolar electrode placement and atrau- Acoust Soc Am 1990;87:25922605. modiolar electrode array. Laryngoscope
matic insertion properties in cochlear im- Greenwood DD: Comparing octaves, frequency 2001;111:837843.
plantation fact or fantasy? Acta Otolaryn- ranges, and cochlear-map curvature across Scarpidis U, Madnani D, Shoemaker C, et al: Ar-
gol, in press. species. Hear Res 1996;94:157162. rest of apoptosis in auditory neurons: impli-
Adunka O, Unkelbach MH, Mack M, et al: Co- Gstoettner WK, Adunka O, Franz P, et al: Peri- cations for sensorineural preservation in co-
chlear implantation via the round window modiolar electrodes in cochlear implant sur- chlear implantation. Otol Neurotol 2003;24:
membrane minimizes trauma to cochlear gery. Acta Otolaryngol 2001;121:216219. 409417.
structures: a histologically controlled inser- Gstoettner W, Kiefer J, Baumgartner WD, et al: Skarzynski H, Lorens A, Piotrowska A: A new
tion study. Acta Otolaryngol 2004c;124: Hearing preservation in cochlear implanta- method of partial deafness treatment. Med
807812. tion for electric acoustic stimulation. Acta Sci Monit 2003;9:CS20CS24.
Adunka O, Unkelbach MH, Mack MG, et al: Pre- Otolaryngol 2004;124:348352. Staecker H, Brough DE, Praetorius M, et al: Drug
dicting basal cochlear length for electric- Hodges AV, Schloffman J, Balkany T: Conserva- delivery to the inner ear using gene therapy.
acoustic stimulation. Arch Otolaryngol tion of residual hearing with cochlear im- Otolaryngol Clin North Am 2004; 37: 1091
Head Neck Surg 2005;131:488492. plantation. Am J Otol 1997;18:179183. 1108.
Aschendorff A, Klenzner T, Richter B, et al: Eval- James C, Albegger K, Battmer R, et al: Preserva- von Ilberg C, Kiefer J, Tillein J, et al: Electric-
uation of the HiFocus electrode array with tion of residual hearing with cochlear im- acoustic stimulation of the auditory system.
positioner in human temporal bones. J Lar- plantation: how and why. Acta Otolaryngol New technology for severe hearing loss. ORL
yngol Otol 2003; 117:527531. 2005;125:481491. J Otorhinolaryngol Relat Spec 1999; 61: 334
Briggs RJ, Tykocinski M, Stidham K, et al: Co- Kiefer J, Gstoettner W, Baumgartner W, et al: 340.
chleostomy site: implications for electrode Conservation of low-frequency hearing in Zrunek M, Lischka M, Hochmair-Desoyer I, et
placement and hearing preservation. Acta cochlear implantation. Acta Otolaryngol al: Dimensions of the scala tympani in rela-
Otolaryngol 2005;125:870876. 2004;124:272280. tion to the diameters of multichannel elec-
Eshraghi AA, Polak M, He J, et al: Pattern of Kiefer J, Pok M, Adunka O, et al: Combined elec- trodes. Arch Otorhinolaryngol 1980; 229:
hearing loss in a rat model of cochlear im- tric and acoustic stimulation of the auditory 159165.
plantation trauma. Otol Neurotol 2005; 26: system: results of a clinical study. Audiol
442447; discussion 447. Neurootol 2005;10:134144.
80
70
60
50
Fig. 2. Individual and mean percent cor-
rect recognition scores for lists of words 40
presented in quiet at 65 dB SPL. Scores are 30
shown for the implant ear only with the
contralateral ear plugged. The ipsilateral 20
HA was removed and the ipsilateral ear 10
plugged for the CI alone condition. * p ! NA NA NA
0.05, significant mean difference, two- 0
tailed paired t test. Error bars = 1 standard P3 P6 P8 P9 P 17 P 18 P 37 Me a n
deviation. NA = Not available.
References
Armstrong M, Pegg P, James C, Blamey P: Speech James C, Albegger K, Battmer R, Burdo S, UK Cochlear Implant Study Group: Criteria of
perception in noise with implant and hear- Deggouj N, Deguine O, Dillier N, Gersdorff candidacy for unilateral cochlear implanta-
ing aid. Am J Otol 1997;18:S140S141. M, Laszig R, Lenarz T, Manrique Rodriguez tion in postlingually deafened adults. I. The-
Blamey P, Arndt P, Bergeron F, et al: Factors af- M, Mondain M, Offeciers E, Ramos Macias ory and measures of effectiveness. Ear Hear
fecting auditory performance of postlinguis- A, Ramsden R, Sterkers O, von Wallenberg 2004a;25:310335.
tically deaf adults using cochlear implants. E, Weber B, Fraysse B: Preservation of resid- UK Cochlear Implant Study Group: Criteria of
Audiol Neurootol 1996;1:293306. ual hearing with cochlear implantation: candidacy for unilateral cochlear implanta-
Ching TY, Incerti P, Hill M: Binaural benefits for How and why. Acta Otolaryngol 2005; 125: tion in postlingually deafened adults. II.
adults who use hearing aids and cochlear im- 481491. Cost-effectiveness analysis. Ear Hear
plants in opposite ears. Ear Hear 2004; 25: Kiefer J, Gstoettner W, Baumgartner W, Pok SM, 2004b;25:336360.
921. Tillein J, Ye Q, von Ilberg C: Conservation of Vandali AE, Sucher C, Tsang DJ, McKay CM,
Dunn CC, Tyler RS, Witt SA: Benefit of wearing low-frequency hearing in cochlear implanta- Chew JW, McDermott HJ: Pitch ranking
a hearing aid on the unimplanted ear in adult tion. Acta Otolaryngol 2004;124:272280. ability of cochlear implant recipients: a com-
users of a cochlear implant. J Speech Lang Kong YY, Stickney GS, Zeng FG: Speech and parison of sound-processing strategies. J
Hear Res 2005;48:668680. melody recognition in binaurally combined Acoust Soc Am 2005;117:31263138.
Fraysse B, Ramos A, Sterkers O, et al: Residual acoustic and electric hearing. J Acoust Soc von Ilberg C, Kiefer J, Tillein J, et al: Electric-
hearing conservation and electro-acoustic Am 2005;117:13511361. acoustic stimulation of the auditory system.
stimulation with the Nucleus 24 Contour Skarzynski H, Lorens A, Piotrowska A: A new ORL 1999;61:334340.
Advance cochlear implant. Otol Neurotol method of partial deafness treatment. Med Xu J, Xu SA, Cohen LT, Clark GM: Cochlear
2006;27:624633. Sci Monit 2003;9:CS20CS24. view: postoperative radiography for cochlear
Gantz BJ, Turner CW: Combining acoustic and implantation. Am J Otol 2000;21:4956.
electrical hearing. Laryngoscope 2003; 113: Yukawa K, Cohen L, Blamey P, Pyman B, Tung-
17261730. vachirakul V, OLeary S: Effects of insertion
Gstoettner W, Kiefer J, Baumgartner WD, Pok S, depth of cochlear implant electrodes upon
Peters S, Adunka O: Hearing preservation in speech perception. Audiol Neurootol 2004;
cochlear implantation for electric acoustic 9:163172.
stimulation. Acta Otolaryngol 2004; 124:
348352.
Methods
Selection Criteria
A multicenter FDA clinical trial using the Iowa/Nucleus Hy-
brid implant is now ongoing in the United States. The trial has
been conducted in two phases. The selection criteria have been
expanded in phase 2 and the cochlear implant was modified to
incorporate the new Freedom speech processing chip. In the
Fig. 1. Expanded audiometric selection criteria for Hybrid II im- phase 2 implant the auxiliary reserve electrode was eliminated.
plant FDA clinical trial (dark gray) and original audiometric se- The audiologic selection criteria for both FDA clinical trials are
lection criteria for Hybrid I FDA clinical trial (light gray). Subjects shown in figure 1. The phase 1 selection criteria included CNC
must have between 10 and 60% CNC word recognition in the im- monosyllabic word scores between 550% in the implant ear and
plant ear and not more than 80% CNC word recognition in the up to 60% in the contralateral ear. In phase 2 the CNC word scores
contralateral ear. were expanded to 1060% in the implant ear and up to 80% in the
contralateral ear. Twenty-five subjects were recruited into phase
1 and 22 have been implanted in phase 2 as of December 1, 2005.
The CNC words are presented by audition only, in a soundfield at
70 dB SPL. Individuals who fall within this study group must
Recent findings by the University of Iowa Cochlear speak English. Similar audiometric testing is obtained 1 month
Implant Team have highlighted the importance of resid- after operation at the initial setting of the device, at 3, 9, 12, 18
months, and then yearly following implantation. At each test in-
ual low-frequency hearing for understanding in noise as
terval the conditions include hearing aids only, implant only,
well as appreciation of music [Gantz and Turner, 2003, hearing aid + implant in the ipsilateral ear, hearing aid contralat-
2004; Gantz et al., 2005; Turner et al., 2004; Turner and eral + implant (bimodal), and bilateral hearing aids + implant
Gantz, 2004, 2005]. Residual acoustic low-frequency (combined mode).
hearing contains important fine spectral information
that enables the listener to distinguish a single talker Surgical Implantation
from surrounding noise [Turner et al., 2004], and to iden- Placement of the 10-mm short electrode implant is performed
in a similar manner to the standard device with several important
tify fine pitch changes that are essential to recognition of exceptions as previously described [Gantz et al., 2005]. The posi-
melody [Gfeller et al., this issue, pp. 1215]. The 10-mm tion and technique of creating the cochleostomy is critical to pre-
Iowa/Nucleus Hybrid electrode was designed to be mini- serving residual hearing. Surgical techniques used should be sim-
mally invasive and only enter the descending basal turn ilar to a drill-out stapedectomy. The cochleostomy drilling is
of the scala tympani. Low-frequency hearing preserva- done at a slow speed, no suction of perilymph near the cochleos-
tomy is allowed, and advancement of the electrode should be done
tion has been accomplished using this electrode. Results slowly with the direction of the electrode placement parallel to the
with this electrode demonstrate that pure tone thresholds plane of the posterior external canal wall. The cochleostomy is
can be preserved as well as residual acoustic word dis- created 2 mm anterior to the round window in the inferior por-
crimination [Gantz and Turner, 2004]. This approach tion of the scala tympani. It is important to visualize the entire
differs from those using a longer electrode [Gstoettner et round window prior to creating the cochleostomy. The anterior
floor of the round window membrane assists in outlining the
al., 2004]. Individuals implanted with the 10-mm elec- floor of the scala tympani. It is also important to recognize that
trode are able to combine acoustic plus electric speech the basal turn of the cochlea traverses medially from the round
processing, resulting in enhanced hearing in quiet, in window as it advances toward the ascending basal turn. The posi-
noise, and enjoyment of music. tion of the basal turn is approximately parallel to a line drawn
The Iowa/Nucleus Hybrid 10-mm implant has now down the posterior external canal wall. The cochleostomy is cre-
ated in the inferior medial portion of the scala tympani. The
been implanted in 48 severely hearing-impaired individ- opening into the scala tympani is only 0.5 mm. When a bluish
uals in the United States under an FDA-controlled proto- color of the scala tympani is identified, a 0.5-mm burr is used to
col (as of November 1, 2006). This short communication create a cochleostomy, preserving the endosteum. The final layer
teresting to see if there is eventual improvement with more accurate frequency resolution than electric stimu-
more experience. Two of the individuals that have not lation [Henry et al., 2005], which is hypothesized to im-
gained benefit have a history of high-frequency hearing prove the ability to separate the target voice from back-
loss of more than 40 years duration and 1 lost hearing ground noise. The experimental measure was to deter-
prior to 16 years of age. The high frequency loss in this mine the signal-to-noise ratio (SNR) required for 50%
individual might be congenital. understanding of easy spondee words, presented in either
The performance over time of 11 subjects (with 12 steady background noise or competing voices. This task
months or more experience) implanted at the University is described more completely in Turner et al. [2004].
of Iowa is shown in figure 4. The average preoperative Thus, a lower SNR is a better score. In figure 5, the SNRs
CNC word score of this group is 32% correct using two for various groups of listeners sorted by device type and
hearing aids. Those who have reached 12 months of use degree of hearing loss are presented. The long electrode
of the device have an average of 72% on CNC using two users in this comparison (n = 20) are an unselected group
hearing aids plus the implant (combined condition). of standard cochlear implant users and the patients with
Subjects who have more than 1 year of experience are a moderate or greater hearing loss used a hearing aid.
achieving an average of 75% correct words on CNC Also included are the 14 long-term Hybrid users tested at
monosyllabic word test in the combined condition. All Iowa (11 long-term implanted at Iowa plus 3 who traveled
hearing was lost during a viral infection in subject 8. to Iowa from other centers for testing). One striking find-
This individual more than doubled his preoperative ing was that the mean value for the Hybrid users is with-
score with two hearing aids using the implant in one ear in 2 dB of the mean value for a group of mild-moderate
and a hearing aid in the other (bimodal condition). Al- sensorineural hearing loss patients, and that this is a con-
most all subjects display improvement over time and in siderable advantage over the large group of long electrode
some there is substantial improvement during the 2nd users.
year of use. An even more convincing demonstration is to com-
The benefit of preserving residual acoustic hearing is pare all the long-term Hybrid users tested at Iowa who
particularly evident when one looks at the recognition of have preserved residual hearing (n = 14) with a group of
speech in noise. The preserved residual hearing provides the highest performing long-electrode users (n = 10) who
References
Adunka O, Unkelbach M, Radeloff A, Wilson B, Gantz BJ, Turner CW, Gfeller KE, Lowder MW: Thornton AR, Raffin MJM: Speech-discrimina-
Gstoettner W: Outcomes of hearing preser- Preservation of hearing in cochlear implant tion scores modeled as a binomial variable. J
vation and cochlear vulnerability in cochle- surgery: advantages of combined electrical Speech Hear Res 1978;21:507518.
ar implant recipients. 10th Symposium on and acoustical speech processing. Laryngo- Turner CW, Gantz B: Preservation of residual
Cochlear Implants in Children, Dallas, scope 2005;115:796802. acoustic hearing in cochlear implantation.
March 2005. Gstoettner W, Kiefer J, Baumgartner W, Pok S, Cochlear Implants International Congress
Gantz BJ, Turner CW: Combining acoustic and Peters S, Adunka O: Hearing preservation in Series 2004;1273:243246.
electrical hearing. Laryngoscope 2003; 113: cochlear implantation for electric acoustic Turner CW, Gantz BJ: Combined acoustic and
17261730. stimulation. Acta Otolaryngol 2004; 124: electric hearing for severe high-frequency
Gantz BJ, Turner CW: Combining acoustic and 348352. hearing loss. Audiol Today 2005;17:1415.
electric speech processing: Iowa/Nucleus Henry BA, Turner CW, Behrens A: Spectral peak Turner CW, Gantz BJ, Vidal C, Behrens A, Hen-
Hybrid Implant. Acta Otolaryngol 2004; 24: resolution and speech recognition in quiet: ry BA: Speech recognition in noise for co-
344347. normal hearing, hearing impaired and co- chlear implant listeners: benefits of residual
chlear implant listeners. J Acoust Soc Am acoustic hearing. J Acoust Soc Am 2004;115:
2005;118:11111121. 17291735.
Kiefer J, Gstoettner W, Baumgartner W, et al:
Conservation of low-frequency hearing in
cochlear implantation. Acta Otolaryngol
2004;124:272280.
Discussion
Round Table 1: hearing loss in both ears with thresholds within 5 dB. For
Benefits and Issues in Combined Electroacoustic these patients, a 34 dB advantage in signal-to-noise ratio
Stimulation was found when using the Hybrid implant with the ipsi-
lateral hearing aid compared to the contralateral aid.
Chair: E. Offeciers However, while much is now known about fitting a
Panel: T. Ching, N. Dillier, D. Fabry, M. Manrique, hearing aid contralateral to a cochlear implant, the pro-
O. Sterkers, C. Turner cedures for ipsilateral fitting are not so well defined. As
is the case for a contralateral hearing aid fitting, the ipsi-
The panel discussed the expected benefits from com- lateral fitting will probably need to be optimized for use
bining acoustic and electrical stimulation in cochlear im- with the implant.
plant patients with some residual hearing. One of the difficulties facing cochlear implant clinics
is that clinicians generally do not have a good working
Why combine a hearing aid and cochlear implant, and knowledge of hearing aids and the recent advances in
should the hearing aid be fitted to the ipsilateral or contra- digital aids. Therefore, if a candidate has worn the same
lateral ear to the implant? hearing aid for more than about 5 years, then the hearing
The consensus of the panel was that hearing aids aid should be updated prior to making a decision about
should be fitted to both ears if possible to maximize the implanting that ear because the candidate may not be
binaural hearing benefits from acoustic stimulation. Re- properly fitted. There is a need for a better convergence
sults from teams in Iowa, Toulouse, Paris and Melbourne between hearing aid and cochlear implant technologies
have shown benefit from using bilateral hearing aids by cochlear implant clinicians. This will ensure that the
combined with a unilateral implant for speech perception candidate receives an accurate assessment of hearing aid
in noise. Benefits were not as large when testing in quiet, benefit prior to implantation, and that the benefits from
suggesting that the acoustic signal was particularly help- residual hearing plus a cochlear implant are obtained af-
ful in extracting speech from background noise. The pa- ter implantation.
tients also found the sound quality of music and voices
better using bilateral hearing aids with their cochlear im- Should a cochlear implant be fitted to the better or poor-
plant. er ear in the congenitally deaf child, given that the better
At the University of Iowa, USA, the benefits of ipsilat- ear can be fitted with a hearing aid?
eral versus contralateral hearing aids in patients using the In the past, it was often considered appropriate to im-
10-mm Nucleus Hybrid cochlear implant have been stud- plant the ear with more residual hearing because that
ied. An adaptive speech-in-noise test was used. Unfortu- (better) ear had received some stimulation. As both ears
nately, the hearing losses were not symmetrical for the typically had a profound hearing loss, the loss of residual
majority of patients. As the poorer ear was implanted, hearing was not considered as important as prior audi-
this introduced a bias of better performance in the con- tory experience.
tralateral fitted ear. Four patients had a symmetrical
Subject Index