International Hearing Society

60th Annual Convention & Expo

September 15-17, 2011

The Importance of Binaural

Hearing

Theodore Mason, M.D. Springfield, Massachusetts

September 17, 2011

Presentation Overview

• Definition of Terms

• Importance of Binaural Hearing

• Bilateral Hearing with Hearing Aids

• Implantable Hearing Solutions

– Bimodal Hearing

– Bilateral Hearing

• Candidacy Criteria

• Clinical Management

• Summary

Bimodal use is on the rise

Rationale for bimodal fittings:

• Expanding candidacy criteria

• Improved CI technology/performance

• Improved power aids w/ DSP + feedback cancellation

Potential benefits:

• Better hearing performance in background noise¹

• Music appreciation²

1. Tyler, R, et al. (2002) Patients utilizing a hearing aid and a cochlear implant: Speech perception and localization. Ear Hear, 23:98-105.

2. Sucher, C., McDermott, H. (2009) Bimodal stimulation: Benefits for Music Perception and Sound Quality. Coch Impl Intl, 10 (Suppl.1): 96-99.

Bilateral is a consideration

• 5% of adults who qualified for cochlear

implantation and pursued treatment were

bilaterally implanted1

– Based upon internal data of three

manufacturers

– 36,398 pursued unilateral and 1,882 pursued

bilateral

1. Peters et al (2010). Worldwide Trends in Bilateral Cochlear Implantation. Laryngoscope Supplement, 120; S17-S44.

Definition of Terms

A Few Terms Explained

• Bilateral: Both ears

• Bilateral cochlear implantation: CIs placed

in each cochlea of an individual patient

• Bimodal: Two different modes of stimulation

• Bimodal Hearing/Bimodal Devices: CI in

one ear, Hearing Aid (HA) on the other ear

• Binaural Hearing/Binaural Processing*:

Integration in the central auditory pathways of

bilateral sound input

* A CI and an optimally fitted HA on the non-implanted ear, two

normally hearing ears, two hearing aids, or two CIs can provide

binaural processing for some patients.

A Few Terms Explained

Side One Side Two

Bilateral

Cochlear

Implants

Cochlear Implant Cochlear Implant

Bimodal Cochlear Implant Hearing Aid

Binaural

Hearing/

Processing

Cochlear Implant or

Hearing Aid may

provide binaural

processing

Cochlear Implant

or

Hearing Aid may

provide binaural

processing

*Binaural Hearing assumes processing of two

signals throughout the central auditory system

Cochlear Implant Candidacy

Criteria

Adult Candidacy Criteria

• Adults: Individuals 18 years of age or older who have bilateral

sensorineural hearing impairment and obtain limited benefit from

appropriate binaural hearing aids.

• These individuals typically have moderate to profound hearing loss in

the low frequencies and profound (≥ 90 dB HL) hearing loss in the

mid to high speech frequencies.

• Limited benefit from amplification is defined by test scores of 50%

correct or less in the ear to be implanted (60% or less in the best-

aided listening condition) on tape-recorded tests of open set sentence

recognition

Evolution of Adult Candidacy Criteria

1985 1990 1998 (CI24M) 2000 (CI24R/CA ) to

Current (CI512)

ONSET of

Hearing Loss

Postlinguistic Postlinguistic Pre &

Postlinguistic

Pre & Postlinguistic

DEGREE of

SNHL

Profound Profound Severe-Profound Moderate-to-profound

-bilateral sensorineural

hearing loss

ADULT Open-

set sentences

0% 0% 40% or less < 50% sentence

recognition in ear to be

implanted (aided)

< 60% in contralateral

ear and binaurally (aided)

Audiometric candidacy ranges

Moderate-to-profound SNHL in both ears

Speech recognition criteria

Limited benefit from

amplification defined as

preoperative test scores:

<50% sentences in ear to be

implanted

<60% bilaterally (best aided

condition)

Medicare criteria differs slightly:

≤ 40% sentence recognition in

the ear to be implanted (aided)

Adult Candidacy Criteria

Aided Scores*

HINT 12%

CUNY

CNC

19%

0%

Pre-op

*Performed in best aided condition

Scores

HINT 87%

CUNY

CNC

92%

78%

Post CI

A - best aided C - CI right ear

Note: Left side is dead ear

52 y.o. CI – Right Ear

Case Study

The Importance of Binaural

Hearing

What is Binaural Hearing?

• Inputs from each ear travel up

ipsilateral and contralateral brainstem

pathways where the 2 inputs are

compared and processed at various

nuclei before reaching the auditory

cortex.

• Binaural hearing allows the listener to

take advantage of a variety of auditory

cues such as interaural level and time

differences that result in specific

benefits.

• Improved speech perception in quiet and in noise, from:

– Binaural redundancy/summation effects

– Spatial separation (binaural squelch and head shadow effects)

• Improved sound localization

• Improved:

– Ease of listening,

– Perceived benefit and satisfaction

– Quality of life

Potential Benefits of Binaural Hearing

Measured Effects of Binaural Hearing

• Head Shadow Effect is a physical phenomenon

– This occurs when the head obstructs sounds arriving at the ears from

different locations. Binaural hearing allows the listener to always have

available the ear with the better signal-to-noise ratio (SNR)

• Binaural Redundancy and Binaural Squelch Effects are products of

central auditory processing

– These occur when inputs from both ears are analyzed throughout the

auditory pathways

– These are signs of the ability of the auditory nervous system to

integrate, fuse, and use information from the two ears

– In effect helps the brain “tease out” the desired auditory signal from the

background noise

Sound arrives earlier

and louder Sound arrives later and softer

• Using the ear with the better SNR in spatially

separated speech and noise • With one implant or hearing in only one ear in certain listening situations

the implanted ear or hearing ear may have the less favorable SNR

• Spatial separation benefits can occur from the head shadow effect and

having 2 functioning cochleae

Head Shadow Effect

Listening using the

ear with the better

SNR to improve

performance

• Large and robust benefit of

head shadow1

Head Shadow Effect Speech

Noise

1. Litovsky et al (2006). Simultaneous bilateral implantation in adults: a multicenter clinical study. Ear Hear. 27(6):714-31.

• Simply means two ears are better than

one when speech or speech in noise are

from the same location, because each ear

receives the same input

• Several studies have shown a significant

binaural summation (redundancy) effect for

understanding words and sentences

compared to listening with either cochlear

implant alone1,2

1. Litovsky, R, et al. (2006). Simultaneous bilateral cochlear implantation in adults: A multicenter clinical study. Ear Hear, 27(6), 714-731.

2. Dunn, C, et al. (2008). Comparison of speech recognition and localization performance in bilateral and unilateral cochlear implant users

matched on duration of deafness and age at implantation. Ear Hear, 29(3): 352-359.

Binaural Redundancy Effect

• Auditory system’s ability to use

redundant information for better performance when the same signal arrives at both ears

• Difference between bilateral and better ear performance in spatially coincident speech, or speech and noise

Speech

and Noise

Binaural Redundancy Effect

Binaural Squelch

Advantage of adding the ear with the poorer SNR compared to listening with the better SNR ear alone

• Buss et al (2008) saw

emergence of binaural

squelch effect in some

subjects between the 6 and 12

mo test intervals, with a highly

significant mean increase in

magnitude of the advantage,

from 3.3% to 10.6%1

1. Buss, E, et al. (2008). Multicenter U.S. bilateral Med-El cochlear implantation study: Speech perception over the first year of use. Ear Hear,

29(1): 20–32.

Noise

Speech

Poorer SNR Better SNR

Bilateral Hearing with

Hearing Aids

Bilateral Hearing

• Bilateral hearing refers to the ability to

receive a signal on two sides, this can be

achieved using:

– Two normally hearing ears

– Two hearing aids or Baha® devices

– A cochlear implant and a hearing aid (bimodal

hearing)

– Two cochlear implants

Bilateral Hearing with Hearing

Aids • In 1990 Vanderbilt University and the Department of Veterans

Affairs cosponsored a conference designed to address current

clinical and research issues on hearing aids

• Following the conference, a consensus statement was developed on

hearing aid selection procedures for adults.

• “Unless clear contraindications exist, binaural hearing aids

should be considered the preferred fitting for the prospective

hearing aid user.1”

– Bilateral hearing aid fittings have been standard practice in the

hearing aid industry for years!

1. Hawkins, DB et al. Vanderbilt/VA Hearing Aid Conference 1990 Consensus Statement. ASHA 1991, 37-38.

Bilateral Hearing with Hearing

Aids • For patients with bilateral hearing loss, bilateral hearing aid fittings have

been the standard practice for many years

• Reasons for bilateral hearing aid fittings include1:

– Better understanding of speech

– Better understanding in group and noisy situations

– Better ability to tell the direction of sound

– Better sound quality

– Wider hearing range

– Better sound identification

– Keep both ears active resulting in potentially less hearing loss

deterioration

– Hearing is less tiring and listening more pleasant

– Feeling of balanced hearing

– Consumer preference

– Customer satisfaction

1. As reported by the Better Hearing Institute, http://www.betterhearing.org/hearing_solutions/binaural.cfm?printfriendly=1

Determining the binaural hearing solution

• We know that Two Ears

ARE Better Than One – This may mean different things

for different individuals. It could

mean:

• Using two hearing aids/Bahas®

• Using a cochlear implant and a

hearing aid

• Using two cochlear implants

How do you

determine

which

scenario is

best for each

patient?

Clinical Considerations

Binaural Hearing

Solution

Bimodal

Hearing Aid & CI

Bilateral

CI Bilateral

Hearing Aid

Unilateral

Hearing Aid

Unilateral

Hearing Aid

Why only one hearing solution?

Implantable Hearing

Solutions

8.4 million Hearing Aid (HA) users in

U.S.1

More potential for Bimodal users than you think

• Severe to profound hearing loss in the US

8.4m ~840,000 severe to profound 2 (10%)

840k

~523,000 potential

cochlear implant candidates3

523k

1. Kochkin, S. (2009) MarkeTrak VIII: 25 Year Trends in the Hearing Health Market. The Hearing Review, October.

2. Blanchfield, B.B., et. Al. (2001). The severely to profoundly hearing-impaired population in the United States: Prevalence estimates and demographics. JAAA. 12, 183-189.

3. Cochlear internal estimates.

Bimodal versus Bilateral:

Candidacy Considerations • Current status

– Unanimous agreement by panel that bilateral implantation provided improved auditory perception in the majority of cases1

• When to consider bimodal devices?2

– Residual hearing in the non-implanted ear

– Good HA performance in that ear

– When there is any possibility of benefit

• When to consider bilateral implantation?

– Little or no residual hearing in non-implant ear

– No significant benefit, or even a decrement in performance, from hearing aid use in the non-implant ear

1. Consensus on auditory implants. 2007. June 14-16, 2007, Marseille France.

2. Offeciers, E, et al. (2005). International consensus on bilateral cochlear implants and bimodal stimulation. Acta Oto-Laryngol, 125: 918-919.

Bimodal Hearing:

More Common Today

• Broadened indications for implant candidacy: more individuals with potentially useable residual hearing – 80% (42 of 53) used bimodal hearing for >8

hours on average and all rated the bimodal condition superior to CI alone1

–60% (15 of 24) of bimodal users report using hearing aid more than 50% of the time2

• Reviews of existing literature support fitting of a contralateral hearing aid as the first line of treatment to CI recipients with residual hearing3,4

1. Cowan, R, Chin-Lenn,J. (2004). Pattern and prevalence of hearing aid use post implantation in adult cochlear implant users. Aust NZ J Audiol Suppl : 48.

2. Fitzpatrick, et al. (2009). Users experience of a cochlear implant combined with a hearing aid. Intl J Audioloogy, 48, 172-182.

3. Schafer EC et al. (2007). A meta-analytic comparison of binaural benefits between bilateral cochlear implants and bimodal stimulation. J Am Acad Audiol. Oct;18(9):760-76.

4. Ching et al (2007). Binaural-Bimodal Fitting or Bilateral Implantation for Managing Severe to Profound Deafness: A Review. Trends in Amplification, Vol. 11, No. 3, 161-192

• Localization and spatial hearing

• Interaural time, intensity, phase differences at the 2 ears

• Complimentary cues

• Combining low-frequency information from the hearing aid

with high-frequency information from the implant can help,

for example by separating voices in noise

• Sound quality, music perception and enjoyment

• Improved quality by adding fundamental frequency,

acoustic pitch and fine temporal structure not available

through current cochlear implants

Potential Advantages of Bimodal Hearing1,2

1. Ching et al (2007). Binaural-Bimodal Fitting or Bilateral Implantation for Managing Severe to Profound Deafness: A Review. Trends in Amplification, Vol. 11, No. 3, 161-192.

2. Fitzpatrick, et al. (2009). Users experience of a cochlear implant combined with a hearing aid. Intl J Audiology, 48, 172-182.

Bimodal Speech Recognition1

• 19 Nucleus 24 recipients using a well-fit digital HA on the contralateral ear

• Test measures: roaming speech recognition task and localization

– Stimuli: CNC words presented at a roving level of 60 dB SPL (+/- 3 dB),

presented randomly from an array of 10 loudspeakers

– Subjects cued with “ready” and allowed to turn toward the loud speaker prior to

repeating the stimulus word

– Localization: subject identified the loud speaker location by speaker number

– Conditions: HA, CI and CI+HA

• Mean speech recognition results

– HA = 12% words, 37% phonemes

– CI = 39% words, 66% phonemes

– CI+HA = 53% words, 76% phonemes

– Conditions were significantly different from each other for both words and

phonemes

– No subject performed poorer with CI+HA than either monaural condition

1. Potts et al. (2009) Recognition and localization of speech by adult cochlear implant recipients wearing a digital hearing aid in the

nonimplanted ear (bimodal hearing) J Am Acad Audiol. 2009 Jun;20(6):353-73.

*60dB SPL #+10/SNR

dnt = did not test

R L AU

WRS % 0 32 36

HINT-Q*

%

0 50 50

A – Aided SF

C - CI right ear

Pre-op best aided

R-

CI

L-

HA AU

WRS % 80 32 dnt

HINT-Q*

%

92 48 100

HINT-N#

CI+HA

80 dnt 100

Post-op (6 mos)

36 y.o. CI Right Ear + HA Left Ear

Case Study

Bimodal Localization1

• Localization abilities reported as RMS error

– HA = 61° error

– CI = 54° error

– CI+HA = 39° error

• CI+HA localization was significantly better than either

monaural condition

• The HA and CI conditions were not significantly

different

• Important to maximize audibility with HA through 2 kHz

1. Potts et al. (2009) Recognition and localization of speech by adult cochlear implant recipients wearing a digital hearing aid in the

nonimplanted ear (bimodal hearing) J Am Acad Audiol. 2009 Jun;20(6):353-73.

• In general implant recipients perform poorly on tests of pitch perception and melody recognition1

• In a study of Music Perception in Nucleus® CI Users:

– Bimodal users performed significantly better on all tests than those using only electrical stimulation2

• Comparison of CI and CI+HA on familiar melody recognition show the majority of recipients had significant improvements in the CI+HA condition3

– Some data suggesting amount of benefit is related to amount of contralateral residual hearing

Bimodal Sound Quality and Music Perception

1. Gfeller, K (2007). Accuracy of Cochlear Implant Recipients on Pitch Perception, Melody Recognition, and Speech Reception in Noise. Ear and

Hearing; 28(3).

2. Cochlear Americas Multicenter Study on the Evaluation of the UW-CAMP Music Test, 2007 [data on file]. Lane Cove, Australia: Cochlear Ltd.

3. El Fata F et al. (2009). How much residual hearing is 'useful' for music perception with cochlear implants? Audiol Neurootol;14 Suppl 1:14-21.

• Unilateral implant recipients who attempt but

discontinue hearing aid use in the contralateral ear

– <25% of 72 unilateral implant recipients with residual hearing (PTA <110 dB) used their hearing aid more than 50% of the time1

– 40% of implant recipients with a PTA of < 100 dB reported consistent hearing aid use 1

• Documented lack of improvement or a decrement in performance in the bimodal condition compared to the unilateral CI condition

When to Move from Bimodal to Bilateral CIs?

1. Fitzpatrick, et al. (2009). Users experience of a cochlear implant combined with a hearing aid. Intl J Audioloogy, 48, 172-182.

Trends with Binaural Hearing Solutions

• Bimodal fitting

recommendations

are increasingly

becoming the

standard of care

• For a small

population, Bilateral

implantation may

be appropriate and

is a growing trend

1. Tyler, R, et al. (2002) Patients utilizing a hearing aid and a cochlear implant: Speech perception and localization. Ear Hear, 23:98-105.

2. Sucher, C., McDermott, H. (2009) Bimodal stimulation: Benefits for Music Perception and Sound Quality. Coch Impl Intl, 10 (Suppl.1): 96-99.

Adult Candidacy Considerations for CI’s

• To ensure maximal potential for

binaural processing, the most desirable

candidates have1:

– Post-lingual onset of hearing loss

– Relatively short duration of profound

hearing loss (e.g. less than 15 years),

– or consistent and continued use of

amplification in both ears up to

implantation

1. Cochlear White Paper, Rationale for Bilateral Cochlear Implantation in Children and Adults. by B. Robert Peters, 2006.

Bilateral Hearing with Cochlear Implants

• The potential benefits of bilateral hearing

with cochlear implants are much the same

as bilateral hearing with hearing aids.

• Benefits of bilateral cochlear implants may

include:

– Improved speech understanding in

noise

– Improved sound localization

– Improved patient- perceived

outcomes

– Patient never without sound

– Sound more balanced

– Hearing speakers from both sides

Demonstrated

in numerous

studies

Improved Speech Recognition with Bilateral Cochlear Implants1

• Study compared outcomes of 33 adults with bilateral CIs with 40 adults with unilateral CI

• Improved speech recognition in quiet

– On average:

• Adults scored 19% higher on sentences

• Adults scored 24% higher on words

– Than did unilateral cochlear implant users

1. Dunn CC et al, (2008). Comparison of Speech Recognition and Location Performance in Bilateral and Unilateral Cochlear Implant Users Matched on Duration of Deafness and Age at Implantation. Ear and Hearing. 29(3):352-359.

Improved Speech Understanding in Noise

with Bilateral Cochlear Implants

• Data showing improvement in speech

understanding in noise for some patients with

bilateral cochlear implants were reported in the

literature as early as 19881

• In research studies, improvement in speech

understanding in noise is largely due to the head

shadow effect, and to a lesser extent for some

patients, the binaural squelch effect and the

binaural redundancy effect2,3

• Improvements have been demonstrated in many

recent studies in both adults and children2-4

1. Balkany T, Boggess W, Dinner B (1988). Binaural cochlear implantation: comparison of 3M/House and Nucleus 22 devices with evidence of sensory integration.

Laryngoscope, Oct; 98(10): 1040-1043.

2. Litovsky, R et al. (2009) Spatial hearing and speech intelligibility in bilateral cochlear implant users. Ear and Hearing,30, 419-431.

3. Dunn, et al. (2010). Bilateral and Unilateral Cochlear Implant Users Compared on Speech Perception in Noise. Ear & Hearing, 31(2), 296-298.

4. Johnston JC, et al. (2009). Bilateral paediatric cochlear implants: a critical review. Int J Audiol. 48(9):601-17.

Improved Speech Understanding in Noise

with Bilateral Cochlear Implants1

• 15 bilateral subjects evaluated after 3 & 6 months experience

• Speech recognition using BKB-SIN test

– Speech at 65 dB SPL from a loudspeaker at 0 degrees (frontal)

and noise from either 0 degrees or +/- 90 degrees (sides)

– SNR for 50% correct determined when listening with each

implant alone and while listening with both implants

• Findings:

– Significant benefit of listening with two ears in spatially separated

speech in noise (defined as >3.1 dB advantage in the bilateral

condition over unilateral conditions)

– Benefit was greater after 6 months listening experience than

after only 3 months listening experience

1. Litovsky, R et al. (2009). Spatial hearing and speech intelligibility in bilateral cochlear implant users. Ear and Hearing,30, 419-431.

Improved Sound Localization with

Bilateral Cochlear Implants

• Improved sound localization with bilateral cochlear

implants has been reported in the literature since the

1990s1

• Improvement in localization ability is due to integrating

independent information from each ear throughout the

auditory pathways

• This ability has been demonstrated in multiple recent

studies with cochlear implant recipientse.g.2,3

1. van Hoesel RJ, Clark, FM (1995). Fusion and lateralization study with two binaural cochlear implant patients. Ann Otol Rhinol Laryngol Suppl. Sep;166:233-5.

2. Dunn CC et al, Comparison of Speech Recognition and Localization Performance in Bilateral and Unilateral Cochlear Implant Users Matched on Duration of Deafness and Age

at Implantation. Ear and Hearing. 29(3):352-359, 2008.

3. Verschuur, CA, et al. (2005). Auditory Localization Abilities in Bilateral Cochlear Implant Recipients. Otology & Neurology, 26:965-971.

Improved Localization with Bilateral Cochlear Implants1

• Study compared outcomes of 33 adults with bilateral CI with 40 adults with unilateral CI

• Findings:

– Enhanced sound localization

• Adults with bilateral cochlear implants had significantly more success identifying the location of sounds

• Average localization precision was 25 degrees more accurate than unilateral subjects

1. Dunn CC et al, Comparison of Speech Recognition and Location Performance in Bilateral and Unilateral Cochlear Implant Users Matched on Duration of Deafness and Age at Implantation. Ear and Hearing. 29(3):352-359, 2008.

With a second CI,

precision in localizing

sound

more than doubles!

Mean angular error:

Improved Localization with Bilateral

Cochlear Implants1

1. Verschuur, CA, et al. (2005). Auditory Localization Abilities in Bilateral Cochlear Implant Recipients. Otology & Neurology, 26:965-971.

Patient-Perceived Outcomes

• Favorable patient-perceived outcomes with bilateral

implants have been reported in the literature since

19921

• Improvements in self-perceived outcomes are likely

due to increased performance outcomes and

localization abilities

• Positive bilateral outcomes have been demonstrated

in multiple recent studies with cochlear implant

recipients2,3

• Patient-perceived outcome data are based on self-

assessment metrics and as a result, results can be

variable

1. Green et al. (1992). Binaural cochlear implants. Am J Otol. 1992 Nov;13(6):502-6.

2. Litovsky et al. (2006). Simultaneous bilateral cochlear implantation in adults: A multicenter study. Ear & Hearing. 27(6): 714-731.

3. Noble et al. (2008). Hearing handicap ratings among different profiles of adult cochlear implant users. Ear & Hearing. 29(1): 112-120.

Patient-Perceived Outcomes1

• Retrospective study using factor analysis from two

questionnaires

– Hearing Handicap Inventory for the Elderly

(HHIE)

– Hearing Handicap Questionnaire (HHQ)

• 35 bilateral recipients, 106 unilateral recipients, 42

with one cochlear implant and one hearing aid

• Findings:

– The least perceived handicap reported was by

the bilateral implant group

– Bilateral group also perceived significantly less

handicap than the other groups on the Social

Restriction subscores

1. Noble et al. (2008). Hearing handicap ratings among different profiles of adult cochlear implant users. Ear & Hearing. 29(1): 112-120.

Patient-Perceived Outcomes1

• APHAB questionnaire data collected during a multi-center

study of 37 simultaneously implanted adult cochlear implant

users (using Nucleus 24)

• First administered after a 3 week period during which bilateral

CI recipients used only one implant (the better ear) then was

re-administered after a period of using the bilateral implants

again

• Findings:

– Subjects perceived their performance with the bilateral

implants as significantly better than with a unilateral implant

on the best-performing ear on all three communication

subscales of the APHAB

– No significant difference on the Aversiveness of Sounds

subscale

1. Litovsky et al. (2006). Simultaneous bilateral cochlear implantation in adults: A multicenter study. Ear & Hearing. 27(6): 714-731.

Clinical Management

Hearing Healthcare Team

Hearing Healthcare Team

Who’s on the Team?

Hearing Healthcare Team

Who’s on the Team?

Hearing Instrument Specialist

Hearing Healthcare Team

Who’s on the Team?

ENT Physician

Hearing Healthcare Team

Who’s on the Team?

Cochlear Implant Audiologist

Hearing Healthcare Team

Who’s on the Team?

Patient

Hearing Healthcare Team

Hearing Instrument Specialist

Patient

ENT Physician

Cochlear Implant Audiologist

Hearing Healthcare Team

A Happy Patient

Our Team

• Dr Mason and partner physicians

• In-office audiologists

• Baystate Medical Center Cochlear Implant

Program

• Community audiologists and hearing

instrument specialists

• Patients!

Clinical Management of the Bimodal Patient

• All hearing healthcare professionals should feel comfortable in providing a bimodal hearing solution

– With changing trends, it is very likely that you will continue to treat this patient population

• Know a brief history…

– When were they implanted

– What is their ability

– Overall satisfaction levels

• Remember the following…

– A unilateral cochlear implant patient has already met a best aided binaural speech discrimination score of <60% prior to cochlear implantation

– Patient must have a bilateral severe to profound sensorineural hearing loss

6 Steps to a Bimodal Patient

Step 1: Create 3 HA Programs

Step 2: Match Loudness

Step 3: Determine Preferred HA Program

Step 4: Balance Loudness for CI + HA

Step 5: Fine Tune the HA for Bilateral Comfort

Step 6: Counsel on Continued HA Use

Step 1: Create 3 HA Programs

To start: Make sure the HA and CI are both ON

• Program 1: Prescription of Choice

• Program 2: Low Frequency Cut

-6 dB/octave below 2k Hz

• Program 3: Low Frequency Boost

+6 dB/octave below 2k Hz

Verify fit by using probe microphone.

Step 2: Match Loudness

To start: HA ON and CI OFF

• Balance HA programs 2 and 3 to program 1

• Adjust the HA gain of programs 2 and 3 until the

patient reports equal loudness when compared to

program 1

• This is a task for loudness only

Step 3: Preferred HA Program

To start: HA ON and CI OFF

• Have the patient listen to all 3 HA programs

• Which program provides the best sound quality

and/or speech understanding?

• This becomes the “preferred” program

Step 4: Balance Loudness

To start: HA and CI OFF

• Turn CI ON first, then turn HA ON

– things may sound a bit loud

• Point to the side where speech is loudest and adjust

HA gain accordingly

– If they point to CI, increase HA gain

– If they point to HA, decrease HA gain

• Aim for equal loudness between ears

Step 5: Fine Tune for Comfort

To start: Both HA and CI ON

• Present recorded speech at 50 dB SPL

– Adjust compression ratio/threshold to maintain

equal loudness between HA and CI

• Present recorded speech at 85 dB SPL

– Adjust MPO to not exceed loudness discomfort

levels

Step 6: Counsel on HA Use

• Counsel on the benefits of binaural hearing

• Set appropriate expectations of speech understanding

with the cochlear implant vs. the hearing aid

• Discuss binaural assistive listening devices (i.e., HATIS)

• Encourage a HA fine tuning appointment following

every cochlear implant mapping session

Summary

Key Messages

• TWO ears are better than ONE

• Bilateral hearing aids are the standard of care

• Bimodal hearing is an option for those who qualify

for cochlear implantation

• The potential benefits of hearing with bilateral

cochlear implants are much the same as hearing with

bilateral hearing aids.

Thank you!

Theodore Mason MD

Ear, Nose & Throat Surgeons of

Western New England

www.entassociates.org

www.cochlear.com

Download presentation slides at www/ihsinfo.org/convention

Questions?