Musicoterapia y otorrinolaringología

La musicoterapia es el uso profesional, planificado y estructurado de la música como intervención terapéutica, con el objetivo de mejorar la salud y calidad de vida del paciente o el grupo intervenido. Esta herramienta se basa en la evidencia de efectos neuroplásticos, psicológicos y cognitivos de la música en las personas. En las últimas décadas se ha encontrado evidencia de múltiples beneficios de musicoterapia como tratamiento adyuvante en medicina, entre ellos se destacan: reducción del dolor en enfermedades crónicas, oncológicas, procedimientos quirúrgicos y trabajo de parto, disminución de síntomas depresivos y ansiosos en trastornos del ánimo y demencia, mejoría de la sincronización motora y perceptiva en enfermedad de Parkinson, entre otros. La otorrinolaringología se ha establecido, asimismo, como un nicho plausible para musicoterapia. Actualmente existen numerosas líneas de investigación que se han dedicado a generar evidencia científica en torno a musicoterapia y su utilidad en diversos campos de la especialidad; esta revisión pretende recopilar y analizar dicha evidencia. Los resultados obtenidos en los diferentes estudios sugieren, con evidencia de calidad baja a moderada, que existen beneficios significativos en la utilización de esta herramienta en el tratamiento multimodal de tinnitus, manejo del dolor y ansiedad en procedimientos médico-quirúrgicos, y en la rehabilitación de pacientes con hipoacusia e implantes cocleares. Si bien se ha encontrado que la música es una modalidad terapéutica segura, barata y con beneficios que parecen ser prometedores, se requieren más estudios clínicos de buena calidad y validez para recomendar el uso de musicoterapia en otorrinolaringología.

Music therapy is the professional, planned, and structured use of music as a therapeutic intervention, with the objective of improving the health and quality of life of the patient or the intervened group. This tool is based on the evidence of neuroplastic, psychological and cognitive effects of music in people. In the last decades there has been evidence of multiple benefits of music therapy as an adjuvant treatment in medicine, among them: reduction of pain in chronic diseases, oncology, surgical procedures and labor, reduction of depressive and anxious symptoms in mood disorders and dementia, improvement of motor and perceptual synchronization in Parkinson's disease, among others. Otorhinolaryngology has also been established as a plausible niche for music therapy. Currently there are numerous research lines that have been devoted to generate scientific evidence on music therapy and its usefulness in various fields of the specialty, this review aims to compile and analyze such evidence. The results obtained in the different studies suggest, with low to moderate quality evidence, that there are significant benefits in the use of this tool in the multimodal treatment of tinnitus, pain and anxiety management in medical-surgical procedures, and in the rehabilitation of patients with hypoacusis and cochlear implants. Even though music has been found to be a safe and inexpensive therapeutic modality with benefits that appear to be promising, more clinical studies of good quality and validity are required to recommend the use of music therapy in otorhinolaryngology.

Satisfaction and quality of life in cochlear implant users with long sensory deprivation / Satisfação e qualidade de vida em usuários de implante coclear com longo tempo de privação sensorial

ABSTRACT Purpose The aim of the study was to verify the level of satisfaction of CI users with long periods of hearing deprivation, highlighting the positive and negative aspects of the use of the device and their quality of life. Methods This is a analytical research, of the type observational cross-sectional study. The study was performed with 24 patients from a private Institute of Otorhinolaryngology. Three surveys were applied: Satisfaction with Amplification in Daily Life (SADL), International Outcome Inventory - Cochlear Implant (IOI - CI) to assess cochlear implant satisfaction and WHOQOL- bref to assess the quality of life. The results in the pre and post lingual groups were compared. Results The highest degree of satisfaction was reported with regard to personal image, positive effects, and how the users feel about their CI. The lowest degree of satisfaction was reported regarding the cost-benefit of the CI and the competitive noise. In the WHOQOL-bref assessment, the highest scores were found in physical, psychological and social relations domains. When comparing the results of the surveys, the pre and post-lingual groups showed no difference in relation to the achieved scores. Conclusion The participants had a high level of satisfaction with the use of cochlear implants. The longer the sensory deprivation time, the greater the degree of satisfaction with the device. The use of the CI electronic device reflects on the individual's quality of life.

RESUMO Objetivo Verificar o nível de satisfação de usuários de IC com longos períodos de privação auditiva, destacando os aspectos positivos e negativos do uso do dispositivo e avaliar a qualidade de vida desses indivíduos. Método Trata-se de uma pesquisa analítica, do tipo estudo observacional transversal. O estudo foi realizado com 24 pacientes de um instituto privado de Otorrinolaringologia. Foram aplicados três questionários: Satisfaction with Amplification in Daily Life (SADL), International Outcome Inventory- Implante Coclear (IOI - IC) para avaliar a satisfação com o implante coclear e WHOQOL-bref para avaliar a qualidade de vida. Os resultados nos grupos pré e pós-lingual foram comparados. Resultados O maior grau de satisfação foi relatado em relação à imagem pessoal, efeitos positivos e como os usuários se sentem em relação ao seu IC. O menor grau de satisfação ocorreu em relação ao custo-benefício do IC e ao ruído competitivo. Na avaliação do WHOQOL-bref, os maiores escores foram encontrados nos domínios físico, psicológico e relações sociais. Os grupos pré e pós-lingual não apresentaram diferença em relação aos escores alcançados. Conclusão Os participantes apresentaram alto nível de satisfação com o uso do implante coclear. Quanto maior o tempo de privação sensorial maior o grau de satisfação com o dispositivo. O uso do dispositivo eletrônico de IC reflete melhora na qualidade de vida do indivíduo.

Speech perception and spoken language of children with auditory neuropathy spectrum disorder: a systematic literature review / Percepção da fala e linguagem de crianças com espectro da neuropatia auditiva: revisão sistemática da literatura

ABSTRACT Purpose: to analyze the test results of speech perception and spoken language in children with hearing loss and auditory neuropathy spectrum disorder, users of hearing aids or cochlear implants. Methods: a systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Consultation was performed in databases, considering studies from 1996 to 2021, selecting the studies that presented the results of speech perception or spoken language in children with bilateral auditory neuropathy spectrum disorder, with no structural alterations of the ear and/or vestibulocochlear nerve, or other associated impairments. Descriptive analysis was performed. Literature Review: among 1,422 studies found, 15 were included. Variability in the sample size, types of studies, evaluation procedures and methodological questions were observed. The cochlear implants and hearing aids contributed to the development of speech perception and spoken language in children with auditory neuropathy spectrum disorder, since skills such as auditory comprehension and speech intelligibility, were achieved. Conclusion: 15 studies suggest that cochlear implants and hearing aids may be effective for speech perception and spoken language development in children with auditory neuropathy spectrum disorder, with no other associated impairments. The need for further research with a high methodological rigor is highlighted.

RESUMO Objetivo: analisar os resultados de testes percepção da fala e linguagem falada de crianças com espectro da neuropatia auditiva, usuárias de aparelho de amplificação sonora individual ou implante coclear. Métodos: revisão sistemática da literatura, baseada no guideline Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Levantaram-se, em bases de dados, estudos entre 1996 e 2021, que apresentavam os resultados de percepção da fala ou linguagem falada de crianças com espectro da neuropatia auditiva bilateral, sem alterações estruturais da orelha/nervo vestíbulo-coclear, ou comprometimentos associados. Os dados foram analisados descritivamente. Revisão da Literatura: dentre 1422 estudos encontrados, 15 foram incluídos. Observou-se variabilidade no tamanho das amostras, tipos de estudos, procedimentos de avaliação e questões metodológicas. O implante coclear e o aparelho de amplificação sonora individual contribuíram para o desenvolvimento da percepção da fala e linguagem falada de crianças com espectro da neuropatia auditiva, pois foram alcançadas habilidades, como a compreensão auditiva e inteligibilidade da fala. Conclusão: 15 estudos sugeriram que o implante coclear e o aparelho de amplificação sonora individual podem ser efetivos para o desenvolvimento da percepção da fala e linguagem falada de crianças com espectro da neuropatia auditiva sem outros comprometimentos associados. Ressalta-se a necessidade de pesquisas com alto rigor metodológico.

Cochlear implant complications in a low-income area of Brazil

SUMMARY OBJECTIVE: The primary objective was to analyze and report on the complications that occurred in the cochlear implant surgeries performed at a large philanthropic teaching hospital located in a low-income area of Brazil. METHODS: A historical cohort study that analyzed surgical records of 432 patients of all age groups and both genders who received unilateral cochlear implant in a tertiary referral center that serves only Brazil's Public Health Care System patients, from February 2009 to December 2017. RESULTS: A total of 67 (15.5%) complications occurred in the cochlear implant surgeries, with 21 (5.4%) major complications. Minor complications occurred in 50 (12%) cases. The most frequent major complication was receiver-stimulator displacement (four cases). There were three cases of hardware failure. Only one case of meningitis and one case of facial nerve paralysis (grade VI in House-Brackmann scale) were found. Six patients needed to be explanted due to a major complication. The relative risk of major complications in the population aged 60 years and older was 4.41 (1.53-12.72; 95% confidence interval [CI]). CONCLUSIONS: Elderly patients suffered more complications than younger patients. receiver-stimulator displacement and dizziness were the most frequent complications (major and minor, respectively). The overall complication rates were comparable to those in the literature. Age as an isolated risk factor for complications in cochlear implant surgery is a path to be explored in future observations.

Desenvolvimento de habilidades auditivas de crianças no primeiro ano após o implante coclear unilateral e bilateral / Development of children's auditory skills in the first year after unilateral and bilateral cochlear implant

RESUMO Objetivo identificar se as diferenças no desenvolvimento da aquisição das habilidades auditivas iniciais em crianças após o implante coclear, unilateral ou bilateral, podem ser evidenciadas durante o primeiro ano de uso. Métodos estudo longitudinal retrospectivo de levantamento de prontuários. Foram incluídas crianças que receberam o implante coclear antes dos 4 anos de idade, separadas em dois grupos. O primeiro, composto por crianças implantadas unilateralmente e o segundo, por crianças implantadas bilateral e simultaneamente. Foram coletados os dados referentes à escala IT-MAIS (Infant-Toddler Meaningful Auditory Integration Scale) antes da cirurgia e três meses, seis meses e um ano após a cirurgia. Esses resultados foram comparados com os marcadores clínicos já existentes. Além disso, as famílias foram classificadas segundo a Escala de Avaliação de Envolvimento Familiar. Resultados foram avaliados os resultados de 29 crianças com implante coclear bilateral e 30 crianças com implante coclear unilateral. A pontuação obtida no IT-MAIS dos dois grupos foi semelhante aos marcadores clínicos. Quanto à Escala de Avaliação de Envolvimento Familiar, houve diferença, mostrando que as famílias do grupo dos bilaterais estavam mais envolvidas. Conclusão no primeiro ano de uso do implante coclear, o desenvolvimento da aquisição das habilidades auditivas iniciais das crianças implantadas bilateralmente não diferiu do desenvolvimento de crianças implantadas unilateralmente, sugerindo que as habilidades auditivas iniciais são passíveis de desenvolvimento com entrada auditiva unilateral.

ABSTRACT Purpose To identify the development of initial auditory skills in children with unilateral and bilateral cochlear implant during the first year of use. Methods Retrospective longitudinal study of medical records of children who received cochlear implant under the age of four, separated into two groups. The first, composed of children implanted unilaterally and the second, by children implanted and simultaneously. Data on the IT-MAIS scale (Infant-Toddler Meaningful Auditory Integration Scale) were collected before surgery and three months, six months and one year after surgery. These results were compared with the existing Clinical Markers. In addition, the family's classification was noted, according to the Family Involvement Assessment Scale. Results The data of 29 children with bilateral cochlear implant and 30 children with unilateral cochlear implant were evaluated. The IT-MAIS score of the two groups was similar to the Clinical Markers. Regarding the Family Involvement Assessment Scale, there was a difference, showing that families in the bilateral group were more involved. Conclusion In the first year of use of the cochlear implant, the development of children implanted bilaterally did not differ from the development of children implanted unilaterally, suggesting that initial auditory skills are likely to develop with unilateral auditory input.

Produção da fala de crianças e adolescentes de um programa de reabilitação auditiva / Speech production of children and adolescents from an auditory rehabilitation program

RESUMO Objetivo caracterizar a produção da fala de crianças e adolescentes usuários de aparelho de amplificação sonora individual (AASI) ou implante coclear (IC) de um programa de reabilitação auditiva. Métodos estudo observacional transversal. Foram analisadas amostras de fala de 15 participantes de um programa de reabilitação auditiva, que consistiam na prova de fonologia do ABFW (ABFW - Teste de Linguagem Infantil nas Áreas de Fonologia, Vocabulário, Fluência e Pragmática) e na fala espontânea, adaptada do Protocolo de Avaliação de Voz do Deficiente Auditivo. Foi aplicado o teste de Wilcoxon para comparar os índices de Porcentagem de Consoantes Corretas (PCC) e Porcentagem de Consoantes Corretas revisado (PCC-r) das provas de fonologia e o teste de Mann-Whitney para comparar os referidos índices, em relação aos graus de inteligibilidade da fala espontânea. Também foi analisada a variabilidade de produção dos fonemas das provas de fonologia. Resultados verificou-se desvio leve nos índices de PCC e PCC-r para as provas de fonologia, com escores superiores para o PCC-r. Os participantes com médias maiores que 85% alcançaram inteligibilidade "Boa" e participantes com médias entre 85% e 50% apresentaram inteligibilidade "Regular/Insuficiente". Os usuários de AASI não produziram adequadamente os fonemas /s/, /z/, /Ʒ/ /ɲ/, /l, /ʎ/, arquifonema /S/ e arquifonema /R/ e os usuários de IC, os fonemas /ʎ/ e arquifonema /R/. Conclusão o grupo estudado apresentou desvio leve nos índices de PCC e PCC-r, com médias superiores, quando considerada a distorção como acerto. Participantes com inteligibilidade "Boa" apresentaram maiores escores de PCC e PCC-r. Usuários de AASI não produziram fonemas fricativos adequadamente. Foram observadas produções com variação linguística social e regional.

ABSTRACT Purpose To characterize the speech production of children and adolescents from an auditory rehabilitation program who use hearing aids (HA) or cochlear implant (CI). Methods Cross-sectional observational study. Speech samples from 15 participants of a hearing rehabilitation program were analyzed through the phonology test of the ABFW Test and spontaneous conversation, which were adapted from the Protocol for the Evaluation of Voice in Subjects with Hearing Impairment. The Wilcoxon test was used to compare the Percentage of Consonants Correct (PCC) and the Percentage of Consonants Correct-revised (PCC-r) indexes of the phonology test, and the Mann-Whitney test was used to compare these indexes to the degrees of intelligibility of spontaneous conversation. The variability of production of the phonemes of the phonology tests was also analyzed. Results There was a mild deviation in the PCC and PCC-r indexes for the phonology tests, with higher scores for the PCC-r. Participants with averages greater than 85% achieved "Good" intelligibility, and participants with averages between 85% and 50% had "Regular/Insufficient" intelligibility. The HA users did not properly produce the phonemes /s/, /z/, /Ʒ/ /ɲ/, /l, /ʎ/, the archiphoneme /S/, and the archiphoneme /R/. The CI users did not properly produce the phonemes /ʎ/ and the archiphoneme /R/. Conclusion The group had a mild deviation in the PCC and PCC-r indexes, with higher means when the distortion was considered correct. Participants with "Good" intelligibility had higher PCC and PCC-r scores. HA users did not produce fricative phonemes properly. There were productions with a social and regional linguistic variation.

Clinical implications of intraoperative eABRs to the Evo®-CI electrode array recipients / Implicações clínicas do eABR intraoperatório para usuários do feixe de eletrodos Evo

Abstract Introduction Electrically evoked auditory brainstem responses provide reliable clinical information to assist professionals in the auditory rehabilitation of cochlear implant users. Objective This study aimed to investigate intraoperative evoked auditory brainstem response recordings in Evo®-cochlear implant electrode array recipients and its correlation with their behavioral levels and auditory performance. Methods This is a retrospectivey study. Intraoperative evoked auditory brainstem responses were recorded in adult Evo®-cochlear implant electrode array recipients. Wave V latencies, amplitudes and interpeak III-V intervals were recorded in three different electrode locations and compared to the sentence recognition scores obtained from subjects after six months of device use. Evoked auditory brainstem responses thresholds were also recorded and compared to the behaviorally determined levels of the subjects in the sound processor activation. Results Evoked auditory brainstem responses thresholds were significantly correlated with both, behavioral T- and C-levels and they were recorded at audible electrical stimulation levels in all subjects. There was a significant correlation between interpeak III-V interval recorded in the apical electrode and sentence recognition scores of the subjects. Conclusions Intraoperative evoked auditory brainstem responses can be used to establish audible levels for fitting the sound processor in Evo®-cochlear implant recipients and it could help professionals to plan further actions aiming to improve their auditory performance.

Resumo Introdução Os potenciais auditivos de tronco encefálico evocados eletricamente fornecem informações clínicas confiáveis que auxiliam no processo de reabilitação auditiva de usuários de implante coclear. Objetivo Investigar o registro intraoperatório dos potenciais auditivos de tronco encefálico evocados eletricamente em usuários do feixe de eletrodos Evo® e sua correlação com os níveis comportamentais e desempenho auditivo dos indivíduos. Método Estudo retrospectivo. Os potenciais auditivos de tronco encefálico intraoperatórios foram registrados em usuários adultos de implante coclear com feixe de eletrodos Evo®. As latências e amplitudes da onda V e os intervalos interpico III-V foram registrados em três diferentes eletrodos e comparados às pontuações de reconhecimento de sentenças após 6 meses de uso do implante coclear. Os limiares dos eABRs foram comparados aos níveis comportamentais dos indivíduos na ativação do processador de som. Resultados Os limiares do eABR foram significativamente correlacionados aos níveis comportamentais T e C e registrados em níveis de estimulação elétrica audíveis em todos os indivíduos. Houve uma correlação significativa entre o intervalo interpico III-V no eletrodo apical e a pontuação de reconhecimento de sentenças dos indivíduos. Conclusões O eABR intraoperatório pode ser usado para estabelecer níveis audíveis de estimulação elétrica na ativação do processador sonoro em usuários de implante coclear‐Evo® e pode auxiliar os profissionais no planejamento de ações visando melhorar o desempenho auditivo nesses pacientes.

The effects of cognitive effort on academic performance of learners with cochlear implants in a private mainstream school in Gauteng

This research investigated the phenomenon of learners with cochlear implants and their challenges with cognitive effort in private mainstream schools in Gauteng. Many learners with cochlear implants encounter academic and social challenges at school, despite the advanced technology. Objectives: This study aimed to explore how learners with cochlear implants experience cognitive effort and whether it impacts their academic potential. Methods: Research was conducted using a phenomenological design. Phenomenography was used as theoretical framework to perceive, interpret and understand experiences of the cochlear implant recipients. The six former learners who were recipients of cochlear implants were selected using purposive sampling. Semi structured interviews were utilised to gather information, which was analysed using thematic content analysis. Results: Five themes emerged from the analysis, namely auditory challenges, cognitive functioning, peer interactions, emotional health and concealed disability. This article only presents the first theme of cognitive functioning and highlights three subthemes related to cognitive effort. Findings show that many learners struggled with their concentration span and fatigue, as a result of their cognitive effort difficulties. Conclusion: This study demonstrated how learners with cochlear implants face challenges with cognitive effort at their mainstream schools. It indicates the need for awareness of and training on educating learners with cochlear implants to help them reach their academic potential. Contribution: This study contributes a unique focus on learners with cochlear implants in mainstream schools in South Africa. The study highlights that cognitive effort of learners with cochlear implants influenced their capabilities to multitask and retain information, despite the effort they have to put into listening. Further research should be conducted to develop interventions that could lesson cognitive effort while increasing learner productivity. The article responds to disability studies and inclusive education

Percepção e atuação de professores sobre o aluno com perda auditiva na escola / Teachers' perception and action toward the student with hearing loss at school / Percepción y desempeño de los maestros sobre los estudiantes con pérdida auditiva en la escuela

Introdução: O aluno com perda auditiva que utiliza a comunicação oral pode necessitar de diferentes adequações na escola e condutas adequadas são fundamentais para o seu desenvolvimento. Visto que o professor é importante nesse processo e sua formação não o capacita para atuar com esses alunos, torna-se relevante a parceria entre as áreas da Saúde e Educação. Objetivo: Verificar a percepção e a atuação dos professores sobre o seu aluno com perda auditiva, usuário de aparelho de amplificação sonora individual (AASI) e/ou implante coclear (IC), que utiliza comunicação oral. Método: Participaram 42 professores que atuavam com alunos com perda auditiva em escolas públicas do município de Marília. Os dados foram obtidos por meio do questionário de acompanhamento mensal e de reuniões com a equipe escolar. As respostas foram categorizadas e analisada a frequência de ocorrência. Foi aplicado o Teste de Igualdade de Duas Proporções, admitindo-se como significância (p<0,05). Resultados: Observou-se que o questionário de acompanhamento mensal permitiu o registro das informações de forma detalhada, em relação às reuniões, com frequência de ocorrência estatisticamente significante para as categorias "Acadêmica" (p=0,024), "Comunicação" (p<0,001) e "Participação em sala" (p=0,034). Os professores apresentaram relatos com frequência de ocorrência variável, para cada categoria. Conclusão: Os achados deste estudo em relação à percepção e à atuação dos professores demonstraram respostas aos aspectos com frequência de ocorrência substancialmente diferentes, as quais não conotam uma atuação focada nas necessidades do aluno com perda auditiva que utiliza comunicação oral, no ambiente escolar.

Introduction: The student with hearing loss who uses oral communication might need different adaptations at school and appropriate conducts are essential for their development. Since the teachers are important in this process and their training does not enable them to work with these students, the partnership between the areas of Health and Education is relevant. Objective: To verify the perception and actions of the teachers towards their students with hearing loss, users of hearing aids (HA) and/or cochlear implant (CI), who use oral communication. Methods: Forty-two (42) teachers who taught students with hearing loss in public schools in Marília participated in this study. The data was obtained through the monthly monitoring questionnaire and meetings with school staff. The answers were categorized, and the frequency of occurrence was analyzed. The Two-Proportion Equality Test was applied and assuming a level of significance (p<0.05). Results: It was observed that the monthly follow-up questionnaire allowed the recording of information in detail, in relation to meetings, with frequency of statistically significant occurrence for the "Academic" (p=0.024), "Communication" (p<0.001) and "Participation in the classroom" (p=0.034) categories. The teachers presented reports with variable frequency of occurrence for each category. Conclusion: The findings of this study in relation to the perception and action of teachers showed responses to the aspects evaluated with substantially different frequency of occurrence, indicating a lack of action focused on the needs of students with hearing loss who use oral communication at school.

Introduccion: El estudiante con pérdida auditiva que usa la comunicación oral puede necesitar diferentes adaptaciones en la escuela y los comportamientos adecuados son fundamentales para su desarrollo. Dado que el maestro es importante en este proceso y su formación no le permite trabajar con estos estudiantes, la alianza entre las áreas de Salud y Educación cobra relevancia. Objetivo: Verificar la percepción y desempeño de los maestros sobre su estudiante con pérdida auditiva, usuario de audífono y/o implante coclear (IC), que utiliza la comunicación oral. Metodos: En este estudio participaron cuarenta y dos maestros que enseñaron a estudiantes con pérdida auditiva en escuelas públicas en Marília. Los datos se obtuvieron a través del cuestionario de seguimiento mensual y reuniones con el equipo escolar. Las respuestas se categorizaron y se analizó la frecuencia de ocurrencia. Se aplicó el Test de Igualdad de Dos Proporciones, asumiendo significancia (p <0.05). Resultados: Se observó que el cuestionario de seguimiento mensual permitió registrar información detalladamente, en relación a las reuniones, con una frecuencia de ocurrencia estadísticamente significativa para las categorías "Académico" (p = 0.024), "Comunicación" (p <0.001) y "Participación en el aula" (p = 0,034). Los maestros presentaron informes con frecuencia variable de ocurrencia, para cada categoría. Conclusión: Los hallazgos de este estudio en relación a la percepción y desempeño de los maestros evidenciaron respuestas a aspectos con frecuencia de ocurrencia sustancialmente diferente, que no connotan una acción enfocada en las necesidades de los estudiantes con pérdida auditiva que utilizan la comunicación oral en el ámbito escolar.

Complicaciones del implante coclear en adultos y niños del Hospital Universitario Doctor Peset de Valencia, España, desde el 2001 al 2020 / Complications of the cochlear implant in adults and children in the Hospital Universitario Doctor Peset de Valencia, Spain, from 2001 to 2020

RESUMEN Introducción: La cirugía del implante coclear es un método efectivo para la rehabilitación auditiva de los pacientes con hipoacusia neurosensorial severo-profunda, en los que el rendimiento con los audífonos no es suficiente. Aunque la implantación coclear es una técnica segura, es importante conocer sus posibles complicaciones, entre ellas la infección del colgajo o la parálisis facial. Objetivo: Analizar las complicaciones de los pacientes con implante coclear intervenidos en un hospital universitario terciario: El Hospital Universitario Doctor Peset de Valencia, desde enero de 2001 a marzo de 2020. Metodología: Estudio observacional descriptivo de las complicaciones en una muestra de 134 pacientes con implantación coclear en el Hospital Universitario Doctor Peset de Valencia, en un periodo de 20 años. En el análisis estadístico se utilizó estadística descriptiva. Para demostrar diferencias significativas entre variables empleamos el programa R. Se utilizó el test χ2 para proporciones, considerando significativo un valor p < 0.05. Resultados: 134 pacientes fueron implantados. La frecuencia global de complicaciones fue del 17.9%, 4.5% fueron complicaciones mayores y 13.4% fueron complicaciones menores. La complicación más frecuente fue la desactivación o inserción incompleta de algunos electrodos. Discusión: Las proporciones de complicaciones del estudio entran dentro de los rangos encontrados en la literatura (14.9-18.3%). La frecuencia de complicaciones mayores es inferior al 5%, proporción similar a la obtenida en nuestra serie. Conclusiones: El implante coclear es una técnica quirúrgica segura para la rehabilitación de pacientes con hipoacusia severa, aunque no está exenta de riesgo, por lo que se debe conocer sus potenciales complicaciones. MÉD.UIS.2021;34(2):19-28.

ABSTRACT Introduction: Cochlear implantation is an effective method for hearing rehabilitation in patients with severe neurosensory hearing loss in which hearing aids do not provide good discrimination. Although cochlear implantation is a safe technique, adverse effects related to surgery have been described, including flap infection or facial paralysis. Objective: To analyze the complications of cochlear implanted patients in a tertiary university hospital: The Hospital Universitario Doctor Peset of Valencia, from January 2001 to March 2020. Methodology: This is a descriptive observational study of the complications in a sample of 134 patients with cochlear implant surgery in The Hospital Universitario Doctor Peset of Valencia in a period of 20 years. Descriptive statistics were used in the statistical analysis. To demonstrate significant differences between variables we used the R program. The χ2 test was used for proportions, considering significant a p value < 0.05. Results: 134 patients were implanted. The global frequency of complications was 17.9%, 4.5% were major complications and 13.4% were minor complications. The most frequent complication was inactivation or incomplete insertion of some electrodes. Discussion: Our complication rate is within the range published in the literature (14.9-18.3%). The major complication rate is 5% which is similar to our series. Conclusions: The cochlear implant is a safe surgical technique for the rehabilitation of patients with severe neurosensory hearing loss, although it is not riskless, therefore, one must know that complication are possible. MÉD.UIS.2021;34(2):19-28

Implantes cocleares: prioridad para niños con pérdida sensorial dual en Cuba / Cochlear implants: priority for children with dual sensory loss in Cuba

RESUMEN Fundamento: desde el año 2005 se crea el Programa Cubano de Implantes Cocleares para niños sordos y sordociegos, con prioridad para niños con pérdida sensorial dual. Objetivo: describir el comportamiento de la pérdida sensorial dual en niños del Programa Cubano de Implantes Cocleares. Métodos: se realizó un estudio observacional, descriptivo, retrospectivo de niños con pérdida sensorial dual que recibieron implante coclear entre febrero de 2005 y marzo de 2013 en Cuba. De las historias clínicas y la base de datos del programa fue obtenida la información que permitió elaborar el informe. Con antelación, se ilustran los primeros resultados sobre neuroplasticidad obtenidos con potencial evocado somatosensorial de nervio mediano realizado con parte del protocolo de estudio de investigación preimplante coclear en el Programa Cubano de Implantes Cocleares. Resultados: con el programa se han beneficiado 27 niños con pérdida sensorial dual con implantes cocleares, con cobertura a todas las provincias del país. Seis niños presentaron una enfermedad asociada, predominaron los factores pre/peri-natales y el síndrome de Usher como principales agentes causales de la sordoceguera. La pérdida auditiva fue prelocutiva en 24 niños, confirmada y caracterizada mediante electroaudiometría. Los estudios de imágenes de oídos no mostraron malformaciones. La implantación fue unilateral, sobre todo el oído derecho, sin complicaciones quirúrgicas en ninguno de los niños. Mientras que el estudio de neuroplasticidad evidencia reorganización cortical somestésica en niños con pérdida sensorial dual. Conclusiones: el Programa Cubano de Implantes Cocleares ha logrado un trabajo sostenido en la evaluación e implantación de niños con pérdida sensorial dual, distinguiéndose la investigación sobre neuroplasticidad, la cual ha dado evidencias de representación cortical somestésico preimplante coclear en estos niños. Ello será útil para evaluar la reorganización cortical post-implante coclear y correlacionarlo con el aprovechamiento del uso del implante coclear.

ABSTRACT Background : since 2005 the Cuban Cochlear Implant Program for deaf and deaf-blind children has been created, with priority for children with dual sensory loss. Objective: is to describe the work of the Cuban Cochlear Implant Program with children with dual sensory loss. Methods : a descriptive, retrospective study of children with dual sensory loss who received a cochlear implant between February 2005 and March 2013 in Cuba. The information to conform this descriptive report was obtained from the clinical histories and the database of the program; it also illustrates the first results on neuroplasticity obtained with the somatosensory evoked potential of the median nerve carried out with part of the pre-cochlear implant research study protocol in the Cuban Cochlear Implant Program. Results : the program has benefited 27 children with dual sensory loss with cochlear implants, covering all provinces of the country. Six children presented an associated pathology, with pre/peri-natal factors and Usher Syndrome as the main causal agents of deaf-blindness. Hearing loss was pre-lingual in 24 children, confirmed and characterized by electro-audiometry. No malformations were found in the ear images. The implantation was unilateral, mostly the right ear, without surgical complications in all the children. While the neuroplasticity study shows somesthetic cortical reorganization in children with dual sensory loss. Conclusions : the Cuban Cochlear Implant Program has achieved sustained work in the evaluation and implantation of children with dual sensory loss, a distinctive aspect being the research on neuroplasticity, which has provided evidence of somesthetic cortical representation pre-cochlear implantation in these children. This will be useful to assess cortical reorganization post- cochlear implant and correlate it with the use of the cochlear implant.

Calidad de vida en niños del Programa Cubano de Implantes Cocleares / Quality of life in children of the Cuban Cochlear Implant Program

RESUMEN Fundamento: los estudios publicados sobre los resultados del Programa Cubano de Implantes Cocleares hacen referencia a evaluaciones audiológicas y quirúrgicas, lo que carece de la dimensión que aportaría conocer, el impacto del programa en la calidad de vida de los niños implantados y familia. Objetivo: determinar el impacto del Programa Cubano de Implantes Cocleares en la calidad de vida de los niños implantados y su familia. Métodos: se realizó un estudio descriptivo, prospectivo, longitudinal (pre- y post-implante coclear) a partir de la aplicación del cuestionario de calidad de vida del proyecto internacional pediátrico Cochlear paediatric implanted recipient observational study y la prueba de categorías del rendimiento auditivo, mediante un análisis de varianza de medidas repetidas. Resultados: el estudio evidencia que los implantes cocleares impactan en la familia y la calidad de vida de los niños, con mejora significativa tan temprano como seis meses post-implante coclear y mayores beneficios al año de implantados, respaldado por los hallazgos en la prueba de categorías del rendimiento auditivo, mientras que las expectativas de los padres se ajustan según avanza la rehabilitación post-implante coclear. Conclusiones: los implantes cocleares impactan en la calidad de vida del niño y su familia en la medida que avanza el programa de rehabilitación post-implante, al ajustarse a las expectativas de los padres o tutores, los cuales reportan cambios positivos en el desarrollo de las actividades diarias del niño, efecto sostenido en el tiempo.

ABSTRACT Background: the studies published on the results of the Cuban Cochlear Implants Program refer to audiological and surgical evaluations, lacking the dimension that knowing about the impact of cochlear implants on the quality of life of children and their family. Objective: to determine the impact in the Cuban Cochlear Implants Program on the quality of life of children and their family. Methods: it was carried out a descriptive, prospective, longitudinal study (pre- and post-cochlear implant) from the application of a quality of life questionnaire of the international pediatric project cochlear pediatric implanted recipient observational study and the categories auditory performance test, being applied an analysis of variance of repeated measures. Results: the study shows that cochlear implants impact on the quality of life of children and family, and improves significantly as early as six months post-cochlear implant, with greater benefits one year after implantation, supported by the findings of the categories auditory performance test. While parental expectations are adjusted as post-cochlear implant rehabilitation progresses. Conclusions: cochlear implants impact on the quality of life of the child and family with the post-implant rehabilitation program progresses, adjusting the expectations of the parents or child's guardian, who report positive changes in the development of their daily activities, a sustained effect in the time.

Balancing the Loudness in Speech Processors and Contralateral Hearing Aids in Users of Unilateral Cochlear Implants

Abstract Introduction The use of cochlear implants and hearing aids (bimodal) has been growing with the expansion of the indication for them, and it is important to ensure protocols so that there is a balance of the loudness regarding the two devices. Objective To evaluate if the limited complex sounds present in the frequency bands of the current devices enable the balance of the loudness in adult users of bimodal stimulation, and to analyze if speech recognition improves after balancing. Methods A prospective cross-sectional study with convenience sampling. The sample was composed of 25 adults who had used either a cochlear implant for at least 6 months or a contralateral hearing aid, with a mean age of 46 years. The balancing of the loudness was performed in an acoustic room with the computer's sound box (0° azimuth at 70 dB SPL). The instrumental sounds were filtered through eight different frequency bands. The patients used both hearing devices and were asked if the sound was perceived to be louder in one of the ears or centrally. The speech test was evaluated with sentence silence (65 dB SPL) and/or noise signal ratio of 0 dB/+ 10 dB in free field at 0° azimuth, before and after balancing. Results: Out of the 25 patients, 5 failed to achieve balance at every tested frequency, and 3 achieved balance at almost every frequency, except 8 kHz. There was a significant difference between the speech recognition test only in silence before and after balancing. Conclusion: Most patients achieved sound equalization at all evaluated frequencies under the complex-sound protocol. Additionally, most patients experienced improved speech recognition after balancing.

Cochlear Implants in Patients with Fluctuant or Progressive Hearing Loss on the Better Ear

Abstract Introduction Cochlear implants have been proposed for cases of unilateral hearing loss, especially in patients with tinnitus impairment. Several studies have shown that they result in definite improvement of sound localization and speech understanding, both in quiet and noisy environments. On the other hand, there are few references regarding cochlear implants in patients whose better ears present hearing loss. Objective To report the audiological outcomes of three patients with unilateral deafness, in whom the better ears presented hearing losses, submitted to cochlear implants. Methods Three patients with unilateral profound hearing loss underwent a cochlear implant performed by the same surgeon. Results The patients' data are presented in detail. Conclusion The indications for cochlear implants are becoming more diverse with the expansion of clinical experience and the observation that they definitely help patients with special hearing problems.

Comparison of Relative Loudness Judgment in Children using Listening Devices with Typically Developing Children

Abstract Introduction Loudness perception is considered important for the perception of emotions, relative distance and stress patterns. However, certain digital hearing devices worn by those with hearing impairment may affect their loudness perception. This could happen in devices that have compression circuits to make loud sounds soft and soft sounds loud. These devices could hamper children from gaining knowledge about loudness of acoustical signals. Objective To compare relative loudness judgment of children using listening devices with age-matched typically developing children. Methods The relative loudness judgment of sounds created by day-to-day objects were evaluated on 60 children (20 normal-hearing, 20 hearing aid users, & 20 cochlear implant users), utilizing a standard group comparison design. Using a two-alternate forced-choice technique, the children were required to select picturized sound sources that were louder. Results The majority of the participants obtained good scores and poorer scores were mainly obtained by children using cochlear implants. The cochlear implant users obtained significantly lower scores than the normal-hearing participants. However, the scores were not significantly different between the normal-hearing children and the hearing aid users as well as between the two groups with hearing impairment. Conclusion Thus, despite loudness being altered by listening devices, children using non-linear hearing aids or cochlear implants are able to develop relative loudness judgment for acoustic stimuli. However, loudness growth for electrical stimuli needs to be studied.

La vuelta de los sonidos casi a los 100 años. ¿Cuál va a ser el límite?

Resumen El implante coclear (IC) es el tratamiento estándar para las sorderas profundas en niños y adultos. En adultos mayores esta indicación ha pasado a ser cada día más común. Se describe un abordaje para implantes cocleares en adultos mayores usando como hilo conductor el caso clínico de una mujer de 98 años y 9 meses con hipoacusia neurosensorial severa que ya no se beneficiaba de sus audífonos. Las evaluaciones fueron conducidas por las áreas de otología, cardiología, neurología y anestesiología. Con las aprobaciones de las áreas médicas, la cirugía de implante coclear en el oído izquierdo fue realizada con anestesia local y sedación. No hubo complicaciones intra ni postoperatorias. La rápida recuperación permitió el alta al segundo día posoperatorio. El implante fue activado al mes de operada con todos los electrodos estando activos. Se lograron umbrales para tonos puros de 25 dB HL en campo libre y discriminación en silencio con IC en oído izquierdo y audífono en oído derecho para frases del 76% y para palabras familiares del 100%. El implante coclear fue una alternativa adecuada para esta paciente, posiblemente la implantada de mayor edad en el mundo, y debe ser considerado una alternativa razonable para el adulto mayor con sordera profunda. La decisión quirúrgica debe estar enfocada en las condiciones generales de salud más que en la edad cronológica.

Abstract Cochlear implant (IC) is the standard treatment for profound deafness in children and adults. In the elderly this indication is becoming more common every day. An approach to cochlear implants in the elderly is described, using as a common thread the case of a 98 years and 9 months old woman with severe bilateral gradually progressive sensorineural hearing loss who did not benefit from her hearing aids. She underwent comprehensive multispecialty medical evaluation including otolaryngology, neurology, cardiology and anesthesiology. She underwent cochlear implantation under local anesthesia and sedation. No intra or postoperative complications occurred. Recovery was quick and she was discharged on the second postoperative day. The device was activated at 1-month post-surgery and all electrodes were active. Free field thresholds for pure tones were 25 dB HL and discrimination in silence with IC in left ear and hearing aid in right ear for sentences were 76% and for familiar words 100%. Cochlear implantation resulted in an adequate alternative for this elderly patient, possibly the oldest implanted individual in the world. Cochlear implantation should be considered a reasonable alternative for elderly patients with profound hearing loss. The surgical decision should focus more on the general health conditions than on the chronological age.

Neural Recovery Function of the Auditory Nerve in Cochlear Implant Surgery: Comparison between Prelingual and Postlingual Patients

Abstract Introduction Cochlear implants (CIs) enable objective measures of the neural function in implanted patients through the measurements of the neural response telemetry (NRT) and of the Auditory nerve Recovery Function (REC). These measurements help in programming the speech processor and understanding the auditory system. Objective To compare the NRT and the REC in prelingual and postlingual implanted patients. Methods An observational, descriptive and prospective study was carried out. The NRT and the REC (through the T0, A, and tau parameters) were evaluated in individuals submitted to CI surgery, who were divided into two groups: prelingual and postlingual patients. Results In total, 46 patients were evaluated. Data analysis showed no statistically significant difference between the NRT measurements and the T0, A, and Tau of the REC in the comparison between the two groups, except for the NRT in the basal cochlear region. Conclusion There was no statistically significant difference in the REC in pre- and postlingual patients.

Rehabilitación auditiva y comprensión de textos, un reto en los niños sordos con implante coclear / Hearing rehabilitation and reading understanding: a challenge for deaf children with cochlear implants

RESUMEN Introducción: los niños con sordera severa y profunda reclaman de una rehabilitación auditiva y lingüística muy particular, desde entornos inclusivos que les permita tener acceso a todos los sonidos del medio, esto incluye el habla y la mejora de sus habilidades comunicativas para la comprensión y expresión del lenguaje. Objetivo: valorar la efectividad de un cuaderno de actividades dirigido a la rehabilitación auditiva y la comprensión de textos en niños sordos con implante coclear del municipio Pinar del Río. Métodos: se realizó un estudio de corte pedagógico, con el análisis de contenido, la observación científica, entrevista, estadística descriptiva y batería de exploración del lenguaje de los deficientes auditivos, en una muestra de cinco niños sordos con implante coclear, cinco logopedas y seis maestros de las escuelas primarias, en el período del 2017 hasta el 2018. Resultados: como una posible respuesta a las insuficiencias que presentaron los niños en el proceso de rehabilitación auditiva y comprensión de textos, se elaboró un cuaderno de actividades como vía para el desarrollo de la lectura y construcción de significados, con una visión integradora de la lengua española escrita y múltiples posibilidades de aplicación en la atención logopédica integral. Conclusiones: la utilización del cuaderno de actividades constató su valor teórico, metodológico y práctico, al confirmar niveles superiores en el desarrollo de la rehabilitación auditiva y la comprensión de textos en los niños sordos con implante coclear del municipio Pinar del Río.

ABSTRACT Introduction: children with severe and deep deafness demand a particular hearing and linguistic rehabilitation, from inclusive environments, allowing them to have access to all the sounds of the environment, including speech and the development of their communication skills for the understanding and expression of language. Objective: to assess the effectiveness of a notebook of activities aimed at hearing rehabilitation and reading understanding in deaf children with cochlear implants in Pinar del Río municipality. Methods: a pedagogical study was carried out, using the analysis of contents, scientific observation, interview, descriptive statistics and the series of language exploration for the hearing impaired, in a sample of 5 deaf children with cochlear implant, 5 speech therapists and 6 primary school teachers, during 2017 to 2018. Results: as a possible solution to the deficiencies the children presented in the process of hearing rehabilitation and reading understanding, a notebook of activities was created as a way to develop reading and concept of meanings, with a complete vision of the written Spanish language and multiple possibilities of application in the comprehensive speech therapy care. Conclusions: the use of the notebook of activities proved its theoretical, methodological and practical values, confirming higher levels in the development of hearing rehabilitation and reading understanding in deaf children with cochlear implant in Pinar del Río municipality.

Application value of magnetic resonance hydrography of the inner ear in cochlear implantation

SUMMARY OBJECTIVE This study aims to investigate the application value of magnetic resonance (MR) hydrography of the inner ear in cochlear implantation. METHODS 146 patients were enrolled. MR hydrography and spiral CT examinations for the intracranial auditory canal were performed before surgery, and all imaging results were statistically analyzed in order to explore the application value of MR hydrography of the inner ear in cochlear implantation. RESULTS 146 patients (292 ears) were examined. Among these patients, 13 were diagnosed with abnormal vestibular aqueducts (20 ears) by MR hydrography, while five were diagnosed with this disease by CT; 15 patients were diagnosed with inner ear malformation (19 ears) by MR hydrography, while 11 were diagnosed by CT (four were misdiagnosed); five patients were diagnosed with internal acoustic canal stenosis (eight ears) by MR hydrography, while two were diagnosed by CT (three were misdiagnosed); and four patients were diagnosed with cochlear fibrosis (five ears) by MR hydrography, while four were diagnosed by CT (four ears). The correct rate of diagnosis was 77.40% (113/146) based on CT, while the rate was 93.84% (137/146) based on MR hydrography. CONCLUSIONS MR hydrography imaging technique can be applied to the preoperative evaluation of cochlear implantation, providing accurate and reliable anatomic information on the inner membranous labyrinth and nerves in the internal acoustic canal and an accurate basis for the diagnosis of cochlear fibrosis and nerve development. This has a guiding significance for the selection of treatment schemes.

RESUMO OBJETIVO Este estudo visa investigar o valor da aplicação da hidrografia por ressonância magnética (RM) do ouvido interno no implante coclear. MÉTODOS Cento e quarenta e seis pacientes foram inscritos. Os exames da hidrografia por RM e do CT espiral para o canal auditivo intracraniano foram executados antes da cirurgia, e todos os resultados da imagem foram analisados estatisticamente, a fim de explorar o valor da aplicação da hidrografia por RM do ouvido interno no implante coclear. RESULTADOS Centro e quarenta e seis pacientes (292 ouvidos) foram examinados. Dentre esses pacientes, 13 foram diagnosticados com aquedutos vestibulares anormais (20 ouvidos) pela hidrografia por RM, enquanto cinco pacientes foram diagnosticados com esta doença pelo CT; 15 pacientes foram diagnosticados com malformação do ouvido interno (19 ouvidos) pela hidrografia por RM, enquanto 11 pacientes foram diagnosticados por CT (quatro foram diagnosticados erroneamente); cinco pacientes foram diagnosticados com estenose de canal acústico interno (oito ouvidos) pela hidrografia por RM, enquanto dois pacientes foram diagnosticados por CT (três foram diagnosticados erroneamente); e quatro pacientes foram diagnosticados com fibrose coclear (cinco ouvidos) pela hidrografia por RM, enquanto quatro foram diagnosticados por CT (quatro ouvidos). A taxa correta de diagnóstico foi de 77,40% (113/146) com base no CT, enquanto a taxa foi de 93,84% (137/146) com base na hidrografia por RM. CONCLUSÕES A técnica de imagem da hidrografia por RM pode ser aplicada à avaliação pré-operatória do implante coclear, que pode fornecer informações anatômicas precisas e confiáveis sobre o labirinto membranoso interno e os nervos no canal acústico interno, além de uma base exata para o diagnóstico da fibrose coclear e do desenvolvimento do nervo. Isso tem um significado orientador para a seleção de esquemas de tratamento.

Evaluación de la percepción musical por estimulación acústica vs. eléctrica / Evaluation of musical perception by acoustic vs. electrical stimulation

Objetivo: evaluar las diferencias en la percepción musical entre la estimulación sonora eléctrica frente a la acústica. Materiales y métodos: se recolectó información de pacientes adultos con implante coclear unilateral, con oído contralateral sano o hipoacusia leve y con un tiempo de rehabilitación auditiva mayor a 12 meses. Se les aplicaron escalas de reconocimiento musical, de calidad de vida Glasgow Benefit Inventory (GBI), identificación de tono, ritmo, instrumentos y canciones. Resultados y conclusiones: se recolectaron datos de 6 pacientes con edades entre 37-73 años, promedio de tonos puros (PTA, por sus siglas en inglés) en oído sano <40 dB y porcentaje de máxima discriminación (SDS, por sus siglas en inglés): 100 % sin cambios en el postoperatorio. El oído implantado con un rango de PTA postoperatorio entre 40 y 58,3 dB y SDS entre 70-90 %. Se aplicó la escala GBI, en donde la mayoría de los pacientes obtuvieron resultados positivos con un rango entre +41 y -13. La mayoría de los pacientes aumentaron la frecuencia de escucha musical post-implantación (4/6 pacientes). La mitad de los pacientes reportaron mejoría en el papel que desempeña la música en sus vidas. En el reconocimiento del tono y del ritmo en el oído implantado se encontraron resultados similares posterior a la implantación con respecto al oído sano, con medianas de 17/20 frente a 16/20 en patrones tonales y 18,5/20 frente a 18/20 en patrones rítmicos. El reconocimiento de las canciones fue mejor con la letra que sin la letra en el oído implantado (8/8 frente a 7/8, respectivamente). El reconocimiento de instrumentos en el oído implantado fue 4,5/8 instrumentos frente a 7,5/8 en el oído sano.

Objective: To evaluate the differences in musical perception between electrical and acoustic sound stimulation. Materials and methods: Adult patients with unilateral cochlear implant, healthy or mild hearing loss in the contralateral ear and rehabilitation time greater than 12 months were evaluated. Musical recognition scales, quality of life Glasgow Benefit Inventory (GBI) and identification of tone, rhythm, instruments, and songs were applied. Results and conclusions: 6 patients were collected, ages between 37-73 years, healthy ear with a pure tone average (PTA) <40 dB, speech discrimination score (SDS): 100 % without changes in the postoperative period. The Implanted ear with average PTA between 40­58.3 dB and SDS between 70-90 % post-implantation. The GBI scale was applied where most of the patients obtained positive results, with a range between +41 and -13. Most of the patients improved the frequency of music-listening after implantation (4/6 patients). Half of the patients reported improvement in the role music plays in their lives. In the recognition of the tone and rhythm in the implanted ear, similar results were found after the implantation with respect to the healthy ear, with medians of 17/20 vs. 16/20 in tonal patterns and 18.5/20 vs. 18/20 in rhythmic patterns. The recognition of the songs was better with the lyrics than without the lyrics in the implanted ear, with medians of 8/8 vs. 7/8. The recognition of instruments in the implanted ear was 4.5/8 vs. 7.5/8 in the healthy ear.