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Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Questions? For any questions during this broadcast, please send an email to: teresa mcevoy@boystown org [email protected] Questions will be answered at the end of the presentation. Jeff Simmons, M.A., CCC‐A Audiologist, Cochlear Implant Clinical Coordinator 1 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Jeff Simmons, M.A., CCC‐A Audiologist, Cochlear Implant Clinical Coordinator Acoustic Auditory Pathway Cochlear Implant Function Headpiece ICS Speech Processor Electrode Array 2 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Cochlear Implant Candidacy • FDA criteria first set in 1985 for adults • Severe to profound hearing loss • Limited benefit from amplification – Aided speech perception for sentences Aided speech perception for sentences – <40 to 50% in implanted ear – <40 to 60% in “best aided condition” • Assume loss of residual hearing Today’s CI Recipients • Different from earlier implant candidates? • Expanding criteria – Improved outcomes with CIs Improved outcomes with CIs – more patients implanted with more residual hearing in the non‐implanted ear. • “Off Label” Changing Candidacy Novak et al., 2007 3 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Unilateral Or Bilateral? Need For Bimodal Stimulation? • Majority of CI recipients have unilateral implant • Consideration: Residual hearing in non‐implanted non implanted ear ear • Bimodal Stimulation – CI (electrical stimulation) in one ear – HA (acoustic stimulation) is used in the contralateral ear CI & HA Mutually Exclusive? • Common wisdom… – Two different kinds of signals – Hearing aid as a crutch? • Experience with early implant users – Dooley et al., 1993 l l – Lack of control of two independent devices • Pitch or loudness mismatch • Binaural interference 4 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Why Bilateral Stimulation? • Auditory system is designed to work with two sources of auditory input • How long have binaural HAs been standard of care? • Binaural advantage i l d – Redundancy/summation – Head shadow – Binaural squelch Benefits Of Binaural Hearing • Binaural = input from both ears and coordination by the nervous system • Sound localization • Improved speech perception in quiet and/or noise • Less listening effort • “Naturalness” of sound Why Does One Need Two? • CI does not restore normal hearing • Impact of unilateral deafness – Educational difficulties 10 x more likely – Increased chance of behavioral problems Increased chance of behavioral problems – Risk for speech‐language delays – Difficulty hearing in noise and tracking conversation in groups – Poor localization abilities 5 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Neuro‐Biological Effects • Auditory deprivation effects – Retrograde degeneration – Auditory neurons and cortex • Effects on binaural pathways Effects on binaural pathways – More extensive morphological changes than for bilateral loss – Imbalance in structures that receive binaural projections Bimodal Stimulation CI And Contralateral HA • Growing body of research supports benefit of combining acoustic and electric stim • Most listeners can integrate the two Most listeners can integrate the two – Potential to restore some binaural auditory functions – Even if hearing aid has not been used for a longer period of time 6 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Bimodal Stim vs. One CI Only • If recipient has residual hearing in non‐implant ear… – Improved speech understanding in noise – Improved localization ability – Less listening effort – More “natural” sound quality – Improved “distinctiveness of voices” – Music perception/enjoyment/appreciation Bimodal Stim & Localization • Many subjects demonstrate improved horizontal localization ability in the bimodal condition vs. CI alone condition • High degree of variability across individuals Benefits Of Low Frequencies • Is there a minimum amount of residual hearing needed to benefit from CI + HA? • Enough residual hearing for speech p perception with HA alone is NOT necessary p y • Greatest increment of benefit from adding frequencies below 125 to 300 Hz 7 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Benefits Of Low‐Frequencies • Low‐freq information is not well transmitted by cochlear implants • “Complementarity” of acoustic signal – F0 and F1 F0 and F1 – Pitch cues & voice segregation – Formant transitions – Information about voicing and manner Low Frequency Acoustic Information Zhang et al., 2010 Buchner et al., 2009 Typical Pattern Of Test Findings Monosyllable % Correct * • Firszt, Reeder, & Skinner (2008) • Speech perception ‐ y monosyllable words • CI + HA is better than CI or HA alone 8 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Bimodal Studies ‐ Speech Perception • Gifford et al. (2007) – 11 adults with significant residual significant residual low‐frequency hearing – Bimodal benefits in quiet and noise Cost Effectiveness Rationale • Compared to bilateral CI, it is less expensive & less invasive • Is bimodal function as good as function with binaural CI? function with binaural CI? – Schafer et al., 2007 • Limited resources scenario: provide unilateral CIs to more patients vs. bilateral CIs to fewer patients. Bimodal Trend Growing percentage of CI recipients using a hearing aid in the non‐ implant ear 9 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Bimodal Stimulation • Most CI recipients can integrate electric and acoustic input • Some kind of device should be considered for the second ear of all unilateral implant recipients • Results will obviously be more limited with minimal residual hearing Bimodal Protocol? • Special considerations? • Independent or interdependent? • No widely accepted protocol or practices • Some published recommendations bl h d d – Ching et al., 2004 – Mok et al., 2006 – Ullauri et al., 2007 – Kielman et al., 2010 Ching Et Al.(2004) Procedure • 2‐step procedure: – Paired comparisons between frequency responses to determine preferred one for speech • NAL‐RP • More low‐freq gain • Less low‐freq gain – Loudness balancing procedure • Adjust overall HA gain • Compare HA to CI loudness 10 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Alternative Frequency Response Gain by Frequency 250 Hz Low Freq Boost NAL Low Freq Cut 500 Hz 1000 Hz 2000 Hz 4000 Hz +7 dB +4 dB +0 dB -6 dB -12 dB NAL gain NAL gain NAL gain NAL gain NAL gain -11 dB -5 dB -1 dB +5 dB +8 dB http://www.nal.gov.au/pdf/BimodalHearing-A-Guide-to-Fitting.pdf HA Fitting Considerations • Ching et al. (2004): – greater bimodal benefit (speech perception and localization) when HAs were fine‐tuned or “optimized” – Start with NAL‐RP and compare to alternate frequency responses – balance loudness for live speech 100 90 80 70 60 50 40 30 20 10 0 In noise In quiet Desired Sensation Level (DSL) • Focuses on audibility of speech signal • Allows visualization of audibility low‐ frequency component • Does not require input from patient Does not require input from patient • Has not been directly compared to NAL‐RP in study with bimodal users • Keilmann et al., 2010; Park et al., 2012 11 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Aided Audibility Aided Audibility • No audibility for p portion of LTASS above 1.1 to 1.5 kHz Keilmann Et Al. (2010) Procedure • Hearing aid set with DSL prescriptive method • CI and HA optimized separately, th t t d t th then tested together – Speech audiometry – Loudness scaling • Procedure not well‐detailed 12 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Bimodal Fitting Procedure • Differing procedures are in use • Most studies of bimodal stimulation demonstrate a benefit Loudness balancing may be difficult • Loudness balancing may be difficult to perform • Further study is needed to determine if there is a “best” procedure Bimodal Stimulation Case Example: Adult Patient Case Example: Background • • • • Female First seen at age 53 Progressive loss, unknown etiology Explored multiple options – Conventional amplification C ti l lifi ti – Frequency compression – FM • Difficulty communicating well enough to perform her job in sales 13 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Audiometric History Audiometric History Aided Speech Perception Scores by Test Condition Tests Administered Right Aid CNC Words Words: Phonemes: HINT Sentences Left Aid Binaural Aids DNT DNT 28% 57% 45% 66% 72% 14 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant 1 Month Post‐Op Thresholds: CI & Left Ear Speech Audibility 15 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Speech Audibility Speech Audibility Speech Audibility Audibility of speech spectrum up to ≈1800 Hz 16 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Pre‐CI vs. Post‐CI 100 90 80 70 60 50 40 30 20 10 0 HA Po HA CN C stCI CN C HI NT Po stCI HI NT Left Right * Binaural 100 90 80 70 60 50 40 30 20 10 0 R) es SN dB Does the hearing aid help? Bi o (+ 10 R) SN dB (+ 5 Bi o A Z Z A H IN T T IN Se nt en c ce te n Se n on em es H C NC Ph NC C s HA CI CI + HA W or ds Perccent Correct Current Speech Perception Patient Comments • “I don’t even ask for assistive listening devices any longer. It just doesn’t occur to me like it used to…” • “I need both the CI and the hearing aid for the best clarity of speech…” 17 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Bimodal Stimulation Case Example: Pediatric Patient Background • • • • • • Female, first seen at age 3;9 Family primarily Spanish speaking Concerns for unintelligible speech Hx of 2 previous audiograms WNL Hx of 2 previous audiograms WNL DPOAEs absent 1500‐8000 Hz, bilaterally Initial ABR indicated severe to profound bilateral hearing loss Behavioral Audiogram 18 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Amplification Fitting No high-frequency audibility Based on “estimated” thresholds CI Candidacy Evaluation No Response CI Right at Age 4:6 19 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Benefit from Bimodal Stim? Aided Audibility Aided Audibility • Audibility of LTASS up to above 1.1 ‐ 1.5 kHz 20 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant CI and HA No Response for Left First Year Post‐Op CI • Consistent use of CI and HA • Subjectively performs better bimodally than CI alone • Total Communication program in school Total Communication program in school • English skills surpassing Spanish • Progress in auditory skills per ESP Auditory Skills Development 21 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant Summary • Cochlear implants do have application in patients with residual hearing • Acoustic signal from a hearing aid can be used to supplement the electrical signal pp g from a cochlear implant • Bimodal benefits may show up best in noisy listening situations Summary • Subjects report on “real‐life” advantages (even those with no measurable speech perception benefit). • HAs may need to be adjusted to optimize performance. performance • Bimodal benefits may be immediate or may evolve over time. • Even patients who have not used amplification for a few years may receive bimodal benefit. Summary • Research suggests that bimodal fitting should be considered for patients with CIs who have useable residual hearing in the non‐implanted ear. • Bimodal stimulation is recommended for patients with residual hearing and good HA performance in non‐CI ear, those who want to restore binaural hearing and all young children. 22 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant References • Büchner A, Schüssler M, Battmer RD, et al. (2009). Impact of low‐frequency hearing. Audiology & Neurotology, 14(suppl 1), 8‐13. • Ching TY, Hill M, Dillon H, et al. (2004). Fitting and g g p evaluating a hearing aid for recipients of a unilateral cochlear implant: The NAL approach. The Hearing Review, 11(7), 14‐22, 58. • Dooley GJ, Blamey PH, Seligman PM, et al. (1993). Combined electrical and acoustical stimulation using a bimodal prosthesis. Archives of Otolaryngology Head and Neck Surgery, 119, 55‐59. References • Firszt JB, Reeder RM, Skinner MW (2008). Restoring hearing symmetry with two cochlear implants or one cochlear implant and a contralateral hearing aid. Journal of Rehabilitation Research and Development, 45, 749‐768. • Gifford RH, Dorman MF, McKarns SA, et al. (2007). Combined electric and contralateral acoustic hearing: Combined electric and contralateral acoustic hearing: Word and sentence recognition with bimodal hearing. Journal of Speech, Language, and Hearing Research, 50, 835‐843. • Keilmann, AM, Bohnert AM, Gosepath J, et al. (2009). Cochlear implant and hearing aid: A new approach to optimizing the fitting in this bimodal situation. European Archives of Otorhinolaryngology, 266, 1879‐1884. References • Mok M, Grayden D, Dowell RC, et al. (2006). Speech perception for adults who use hearing aids in conjunctio with cochlear implants in opposite ears. Journal of Speech, Language, and Hearing Research, 49, 338‐351. • Novak MA, Black JM, Koch DB. (2007). Standard cochlear implantation of adults with residual low‐frequency implantation of adults with residual low frequency hearing: hearing: Implications for combined electro‐acoustic stimulation. Otology & Neurotology, 28, 609‐614. • Park LR, Teagle HFB, Buss E, et al. (2012). Effects of frequency compression hearing aids for unilaterally implanted children with acoustically amplified residual hearing in the nonimplanted ear. Ear & Hearing. doi: 10.1097/AUD.0b013e31824a3b97 23 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant References • Ullauri A, Crofts H, Wilson K, at al. (2007). Bimodal benefits of cochlear implant and hearing aid (on the non‐implanted ear): A pilot study to develop a protocol and test battery. Cochlear Implants International, 8(1), 29‐37. • Zhang T, Dorman MF, Spahr AJ. (2010). Informatio nfrom the voice fundamental frequency (F0) region accounts for the majority of the benefit when acoustic stimulation is added to electric stimulation. Ear & Hearing, 31, 63‐69. Jeffrey L. Simmons, M.A., CCC‐A Boys Town National Research Hospital 555 North 30th Street 555 North 30 Omaha, Nebraska 68131 [email protected] Jeff Simmons, M.A., Audiologist, Cochlear Implant Clinical Coordinator 24 Bimodal Hearing: A Hearing Aid In Conjunction With A Cochlear Implant A production of the Lied Learning & Technology Center at Boys Town National Research Hospital 555 North 30th Street Omaha, NE 68131 25