Determining treatment choices after the cochlear implant evaluation process.

OBJECTIVES: Determine the proportion of patients starting the cochlear implant evaluation (CIE) process proceeding to cochlear implantation.Determine which patient factors are associated with undergoing cochlear implantation. METHODS: Retrospective case series of all patients scheduled for a CIE within a tertiary academic neurotology practice between January 1, 2014 and April 30, 2016. Management pathways of patients undergoing CIE were examined. RESULTS: Two hundred thirty-seven adult patients were scheduled for CIE during the study period. Two hundred twenty-six patients started the evaluation process, and 203 patients completed full evaluation. Of patients that completed CIE, 166/203 (82%) met criteria for implantation and 37/203 (18%) did not meet criteria. Fifty-nine patients out of 166 patients (36%) meeting criteria did not receive implants and 107/166 (64%) underwent implantation, yielding an overall implantation rate of 47% (107/226) among patients scheduled for CIE. Common reasons for deferring CI among candidates included failure to show up for preoperative appointment (24%), choosing hearing aids as an alternative (22%), patient refusal (21%) and insurance issues (17%). Overall, CIE led to a new adjunctive hearing device (CI or hearing aid) in 113 (113/203, 56%) cases. CONCLUSION: Fifty-six (113/203) percent of patients who underwent CIE at an academic medical center underwent CI surgery or received an adjunctive hearing device, but 36% (59/166) of candidates did not receive a CI. Patients who forewent CI despite meeting candidacy criteria did so due to cost/insurance issues, or due to preference for auditory amplification rather than CI. LEVEL OF EVIDENCE: 4.

Extended Middle Cranial Fossa Approach for Placement of Auditory Brainstem Implants.

OBJECTIVE: Traditionally, auditory brainstem implants (ABIs) have been placed via the translabyrinthine or retrosigmoid approaches. In select patients, a modified extended middle cranial fossa (xMCF) approach with tentorial ligation may be advantageous for vestibular schwannoma (VS) resection and auditory rehabilitation. This manuscript describes the application of this modification of the MCF approach for simultaneous VS resection and ABI placement. PATIENTS: Patients with neurofibromatosis type 2, profound bilateral sensorineural hearing loss, single functioning sigmoid/jugular venous system, and giant (>4 cm) VS. INTERVENTIONS: Simultaneous VS resection and ABI placement via a modified xMCF approach with tentorial ligation. MAIN OUTCOME MEASURES: Extent of tumor removal and brainstem decompression, access to lateral recess of the fourth ventricle, functional hearing improvement, surgical complications. RESULTS: Two patients met indications and underwent surgery. There were no immediate or delayed surgical complications. Both had subtotal tumor removal with significant decompression of the brainstem and ABI placement. One patient achieved voice and environmental sound awareness at 35 to 55 dbHL across frequencies. The second patient presented with failure to thrive and multiple lower cranial neuropathies in addition to the above-listed indications. She was hospitalized multiple times after surgery due to failure to thrive and recurrent aspiration pneumonia. Her device was never activated, and she expired 1 year after surgery. CONCLUSIONS: The xMCF with tentorial ligation is an additional approach for tumor resection and ABI placement in selected patients with neurofibromatosis type 2. Future studies will further define when this approach is most applicable as well as the challenges and pitfalls.

Real-World Compliance With Follow-up in 2,554 Cochlear Implant Recipients: An Analysis of the HERMES Database.

BACKGROUND: Traditional paradigms of care recommend close audiology follow-up and regular speech perception outcomes assessment indefinitely for cochlear implant (CI) recipients after device activation. However, there is scant published data on actual compliance with this paradigm in clinical practice. METHODS: A multi-center cochlear implant database was queried to identify follow-up rates after cochlear implantation. Follow-up rates where speech perception outcomes assessment occurred at 1-, 3-, 6-, 12-, 18-, and 24-months post-activation were determined by tabulating observed follow-up divided by expected follow-up (O/E ratio) expressed as a percentage. To determine all-cause audiology follow-up rates (with or without testing speech perception outcomes assessment), the database patients from two participating centers (one private practice and one academic center) were similarly analyzed using electronic health record (EHR) data to calculate O/E rates where audiology follow-up occurred for any reason. RESULTS: O/E follow-up rates where speech perception outcomes assessment occurred was 42, 40, 31, 29, 5, and 22% for 1-, 3-, 6-, 12-, 18-, and 24-months post-activation, respectively (n = 2,554). All-cause audiology follow-up rates (with or without speech perception outcomes assessment) using EHR-confirmed data from two individual centers were 97, 94, 81, 66, 41, and 35% at 1-, 3-, 6-, 12-, 18-, and 24-months post-activation visits, respectively (n = 118). CONCLUSIONS: Compliance with audiology follow-up and speech perception outcomes assessment is generally low and decreases significantly as time post-activation increases. Future paradigms of care for CI should be designed recognizing the significant attrition that occurs with CI follow-up.

The Effect of Side of Implantation on the Cortical Processing of Frequency Changes in Adult Cochlear Implant Users.

Cochlear implants (CI) are widely used in children and adults to restore hearing function. However, CI outcomes are vary widely. The affected factors have not been well understood. It is well known that the right and left hemispheres play different roles in auditory perception in adult normal hearing listeners. It is unknown how the implantation side may affect the outcomes of CIs. In this study, the effect of the implantation side on how the brain processes frequency changes within a sound was examined in 12 right-handed adult CI users. The outcomes of CIs were assessed with behaviorally measured frequency change detection threshold (FCDT), which has been reported to significantly affect CI speech performance. The brain activation and regions were also examined using acoustic change complex (ACC, a type of cortical potential evoked by acoustic changes within a stimulus), on which the waveform analysis and the standardized low-resolution brain electromagnetic tomography (sLORETA) were performed. CI users showed activation in the temporal lobe and non-temporal areas, such as the frontal lobe. Right-ear CIs could more efficiently activate the contralateral hemisphere compared to left-ear CIs. For right-ear CIs, the increased activation in the contralateral temporal lobe together with the decreased activation in the contralateral frontal lobe was correlated with good performance of frequency change detection (lower FCDTs). Such a trend was not found in left-ear CIs. These results suggest that the implantation side may significantly affect neuroplasticity patterns in adults.

Is Hard Failure Still a Common Indication for Revision Surgery in Adult Cochlear Implant Recipients?

OUTCOME OBJECTIVES: STUDY DESIGN:: Retrospective chart review. SETTING: Single tertiary care center, 2001 to 2016. PATIENTS: Adult CI recipients were assessed. Inclusion required ≥1 revision surgeries, operative note(s), and postrevision follow-up of 6 months. INTERVENTIONS: Therapeutic/rehabilitative. MAIN OUTCOMES MEASURES: Indications for revision (HF, SF, WC, and MM) were tabulated. The incidence of each was compared between cohorts implanted before/after 2011. Additional outcomes included implant usage, explantation rates, and postrevision speech scores. RESULTS: Four hundred thirty-two patients received 512 CIs. Of these, 30 patients required 38 revisions. Median time to revision was 24.5 months. Frequency by indication was HF (n = 14), SF (n = 12), WC (n = 8), and MM (n = 4). The overall revision rate was 7.4%. There was a significant decline in overall revisions for patients implanted before/after 2011 (10.4 versus3.5%; p = 0.009). No patients implanted after 2011 experienced a HF (p = 0.002). Patients with WC/MM had significantly shorter time to revision compared with patients with HF/SF (p = 0.04). The overall median follow-up was 24 months. Twenty-three of 30 patients are still using their revised CI. Patients revised for HF and MM achieved the best outcomes. CONCLUSION: 7.4% of adult CI recipients required revision surgery. Explantation/immediate reimplantation was an effective management strategy. While HF was the most common indication overall, no patients implanted after 2011 have suffered this complication. The overall revision rate has significantly declined since 2011.