Bilateral Cochlear Implants: Cochlear Implant Team Perspectives

2. AG Bell 2010 Biennial ConventionOrlando, Florida June 25, 2010

3. Agenda Introduction: Definition of Terms Advantages of Binaural Hearing and Bilateral CIs Challenges of Bilateral CIs Candidacy Issues Surgical Issues Programming Issues: Initial Stimulation/Activation, Follow-Up Monitoring/Testing, Case Studies Assessment and Intervention Issues (Pediatric and Adult Audiologic/Aural Rehabilitation) Pediatric Outcomes (Auditory/Spoken Language) Adult Outcomes (HHIA pre-/post- CI) Parent Panel Question and Answers

4. LISTENING Listening With Two “Ears”

5. Bilateral Cochlear Implants (adapted from HOPE 2009) Utilization of Bilateral Cochlear Implants Recent Trend towards BILATERAL use of CI/s -- 1992: 0-1% -- 2007: 14-15% 70% of bilateral CI usage is among 18 years and under age group Bilateral % above applies to new surgeries (not total implanted base) (Source: Cochlear Americas estimates)

6. Definitions Unilateral CI Bimodal (CI and HA) Bilateral Sequential CIs Bilateral Simultaneous CIs

7. Advantages of Bilateral CI/s Improved hearing in quiet (binaural summation) Improved hearing in noise (binaural squelch, head shadow effect, and binaural redundancy) Improved sound lateralization Improved sound localization Assurance that the “better hearing ear” is implanted/”captured” Qualitative listening improvement (more “balanced”; “richer quality”; more “confident” feeling; and less fatigued)

8. Disadvantages of Bilateral CI/s Increased costs (2 devices, batteries, etc.) Multiple pieces of equipment to manage Surgical and medical risks Future developments No or limited “natural” hearing remaining Challenge – Reimbursement (US) Challenge – Different processing strategies & speech processors (with sequential bilateral CIs)

9. Candidacy Issues:Who is a Candidate? Must meet all criteria: Audiologic Criteria Communication Criteria Medical and Surgical Criteria Psychosocial Criteria

10. Pediatric CI Candidacy Criteria Ages: 12 months to 24 months Profound sensorineural hearing loss in both ears No medical contraindications Lack of progress in the development of auditory skills High motivation & appropriate expectations from family (Cochlear Candidacy Magnet)

11. Pediatric CI Candidacy Criteria Ages: 25 months to 17 years, 11 months Severe to profound SNHL in both ears LNT scores of 30% or less in best-aided condition (children, 5 years to 17 years, 11 months) MLNT scores of 30% or less in best-aided conditions (children, 25 months to 4 years, 11 months) Lack of progress in the development of auditory skills No medical contraindications High motivation & appropriate expectations (both child & family, when appropriate) (Cochlear Candidacy Magnet)

12. Adult Candidacy Criteria Moderate-to-profound sensorineural hearing loss in both ears Preoperative HINT sentences recognition scores of 50% or less in the ear to be implanted and 60% or less in the opposite ear or binaurally Pre-linguistic or post-linguistic onset of severe-to-profound hearing loss No medical contraindications A desire to be part of the hearing world

13. Surgical Issues

14. Cochlear Implant Team Surgeon Audiologists Speech-Language Pathologist / Auditory-Verbal Therapist Developmental Pediatrician Social Worker as needed Psychologist available when needed Educational personnel (Audiology, SLP, Teachers, etc.) Parents and Family (and the PATIENT!)

15. Bilateral CI/s - How Sequential Planned Decision put off to later (Is there such a thing as too late?) Simultaneous

16. Sequential Bilateral CI/s Reasons Do not want to give up “good” ear Want to “save” an ear for new technology Insurance issues Don’t want to be “off-line” for 2-4 weeks Wasn’t available when had first CI Bimodal hearing is GREAT but then lose hearing later in life

17. Simultaneous Bilateral CI/s Reasons More common in pediatrics: much better/ quicker auditory, speech, and language skills Anesthesia risks Ossification concerns

18. Surgical Concerns Vestibular Dysfunction Infections (including Meningitis) Tinnitus Loss of Taste CSF Leaks Anesthesia/Surgery Time Facial Paralysis No residual hearing Cosmetics

19. Surgical “Tricks” Prep both sides - cuts time No Anesthesia delays Only one dressing No equipment issues

20. Surgery Basics Outpatient procedure General anesthetic Minimal or no shaving of hair Small incision Not “brain surgery” Electrode arrays are designed to preserve delicate cochlea

21. General Patient Concerns / Questions How long is the surgery? Is it painful? What are the risks or side effects? Will I miss work/school? How soon can I “switch on”? How often does it not work? Am I too old? Any limitations on activities? How long will it last?

22. Surgical Steps After prep, a small incision is made behind the ear to expose the mastoid bone and ear canal The mastoid bone is opened and key landmarks are identified A small hole 1 – 1.5mm is made into the cochlea to place the electrode    A small well is drilled in the temporal bone to hold the implant in place The implant is then placed into the well and the electrode is delicately placed into the cochlea The incision is closed with suture and a dressing placed that is removed the next morning

23. Optimal Cochleostomy Placement Inferior and slightly anterior to round window membraneInferior and slightly anterior to round window membrane

24. Proper Electrode Placement Contour Advance Electrode X-ray

25. Aftercare Schedule Few days: most people resume normal activities 2 weeks: remove the stitches, check surgery site 3-5 weeks: typical healing time of surgery site 2 (-4) weeks: activation/initial stimulation

26. Cochlear Implant Activation 24 hours - 4 weeks Most clinics choose 2 - 4 weeks post-surgery Many recipients continue to wear a hearing aid in the contralateral ear – HIP encourages this.

27. Factors Affecting CI Benefit Age at onset of deafness Pre-lingual Post-lingual Age at implantation Pre-implantation auditory status Duration of deafness Status of cochlea & etiology Motivation and commitment Lifelong attendance at follow-up appointments Education and rehabilitation programs

28. Results – Cost Effectiveness Compared to other therapies Compared to not implanting Cheng AK, et al. JAMA 2000;284:850-6

29. Programming Issues

30. Post-Surgery Audiology Appointments Initial Activation “Mapping”/ Programming session 1 week post-activation 1 month post-activation Every 3 months for the first year After the first year, Every 6 months for children Annually for adults

31. Initial Activation Check surgical site Initial maps created from intraoperative telemetry measures Globally increase levels based on patient report/reaction A map can be made for only one ear at a time Check that levels set for initial map is comfortable with both speech processors on Make progressively “louder” programs

32. “Mapping”/Programming Defined: Verb: the process of setting of the electrical stimulation levels appropriate for the patient to hear soft and comfortably loud sounds. Noun: (map) the product of “mapping” or programming, which determines how the cochlear implant will deliver stimulation

33. “Mapping”/Programming Session Bilateral simultaneous Evaluation and programming of each individual speech processor and both speech processors together Bilateral sequential Focus on “new” ear

34. How? Cochlear implants are programmed for each patient based on their auditory perceptions in response to electrical stimuli for each individual ear. A program or “map,” is created for the CI patient by setting threshold (T) and most comfortable loudness (C or M) levels for several different channels (pitches) Patients are seen on a regular basis to reprogram their cochlear implant throughout their lifetime.

35. Case Studies of Sequential CI/sPediatric Jordan; currently 3 years old Hearing History Referred on UNHS AU; family hx of childhood HL Diagnosed with profound SNHL AU at 2 months of age Fit with HAs at 4 months Received Right Cochlear Freedom CI in September 2007 (at age 1 year, 2 months) Began auditory therapy 1 week post-activation Parents and clinicians report child is “delighted” by sound Bilateral simultaneous- insurance issues??? QUICK EQUALIZATION OF EARSBilateral simultaneous- insurance issues??? QUICK EQUALIZATION OF EARS

36. Second Ear Received 2nd CI May 2009 (at age 2 years, 10 months) -- Approximately 1 year, 8 months between CI 1 and CI 2 -- Approximately 1 month post-activation, parents report Jordan is adjusting well to 2nd CI

37. Case Studies of Sequential CI/sPediatric Regan; now 11 years old Diagnosis of bilateral profound sensorineural HL at approximately 1 year of age Diagnosis of Connexin 26 Fit with bilateral hearing aids shortly after Received Advanced Bionics CI 1 at 21 months (1 year, 9 months) Received CI 2 (at age 7 years, 5 months) -- 5 years, 8 months after CI 1 EARS do not appear to have equalized for speech perception BUT LIFE BETTER WITH TWOEARS do not appear to have equalized for speech perception BUT LIFE BETTER WITH TWO

38. Case Studies of Sequential CI/sAdult Bob; currently 61 years old Progressive hearing loss CI 1- Left Cochlear Freedom in February 2006 CI 2- Right Cochlear Freedom in May 2009 3 years, 3 months between CI 1 and CI 2 Patient has upgraded to Nucleus 5 No difference in speech perception between ears pre or post CI Quality of life- with upgrade better understanding in noise Sound quality difference- better sound quality with upgrade, SECOND EAR THE BETTER EARQuality of life- with upgrade better understanding in noise Sound quality difference- better sound quality with upgrade, SECOND EAR THE BETTER EAR

39. Case Studies of Simultaneous Adult Shirley Ann; 46 years old Hearing loss diagnosed at birth presumably due to hyperbilirubinemia Began wearing hearing aids at 2 ½ years of age Progressive hearing loss in both ears Stopped wearing hearing aid in left ear in 1/2008 due to dizziness and tinnitus Fluent in ASL; grew up attending an auditory-oral educational program Utilized a Phonak SuperFront PP-C-L-4 BTE in the right ear for sound awareness CANNOT IMAGINE LISTENING WITH JUST ONECANNOT IMAGINE LISTENING WITH JUST ONE

40. Bimodal (CI & HA) Brayden Bilateral profound hearing loss diagnosed at 16 months Fit with hearing aids within a month of diagnosis Received left Cochlear Freedom device at approximately 20 months of age (1 year, 8 months) Began auditory therapy one week post-activation Anecdoctal from parent and child- loves his hearing aid, prefers hearing aid to CIAnecdoctal from parent and child- loves his hearing aid, prefers hearing aid to CI

41. 4 Years Post-Activation

42. Goals for CI Programming To provide audibility for the range of speech sounds Comfort for all sounds (speech, environmental, music, etc.) Ultimately to provide a means for communication and spoken language development Balance loudness between ears

43. Follow-Up Visits Patient feedback Check implant sites Check external equipment Validation of programming / Assessment of performance Reprogramming Counseling Aural / Audiologic (Re) Habilitation

44. Evaluation of the Cochlear Implant Because – every dB counts! Immittance, objective measuresImmittance, objective measures

45. Validation of Programming Functional gain testing in soundfield Responses to NBN or warble tones from 250- 8000 Hz Speech perception All testing conducted with individual speech processors and binaurally

46. Validation of Programming Speech Perception Tests Ling thresholds ESP GASP MLNT LNT PB-K WIPI HINT-C HINT AzBio Infant–Toddler Meaningful Auditory Integration Scale (IT-MAIS)>> Word Associations by Syllable Perception (WASP)>> Minimal Pairs Test>> Auditory Numbers Test (ANT)>> Central Institute for the Deaf Everyday Sentences (CID Sentences)>> Common Phrases Test>> Meaningful Auditory Integration Scale (MAIS)>> Meaningful Use of Speech Scale (MUSS)>> Potato Head Task>> Infant–Toddler Meaningful Auditory Integration Scale (IT-MAIS)>> Word Associations by Syllable Perception (WASP)>> Minimal Pairs Test>> Auditory Numbers Test (ANT)>> Central Institute for the Deaf Everyday Sentences (CID Sentences)>> Common Phrases Test>> Meaningful Auditory Integration Scale (MAIS)>> Meaningful Use of Speech Scale (MUSS)>> Potato Head Task>>

47. Sentence Stimuli Sentence material Always administer 2 lists Administered at 60 dB SPL HINT Sentences: (A/The) boy fell from (a/the) window. 4 / 6 (A/The) wife helped her husband. 2 / 5 Big dogs can be dangerous. 3 / 5 AzBio Sentences: He got arsenic poisoning from eating canned fish. 5/8 Visual cues are quite powerful. 3/5

48. Reprogramming Check impedances at every visit Track changes or stability over time Telemetry=relates to the ability of the electrode to deliver current to the surrounding tissue Detection of short and open circuits

49. Telemetry Results Impedances within normal limits Short circuit Open circuit

50. “Flagged” Electrodes Relate impedance measurements to interventionRelate impedance measurements to intervention

51. Short Circuit

52. Open Circuit

53. Reprogramming Patient / Parent feedback Patient’s reactions to sounds Keen observation of the child during programming The audiologist’s past experience with other patients Audiometric test measures Ling 6 Sound Test CONSIDER MORE TIME- 2 appointment slots for bilateral CIs CONSIDER MORE TIME- 2 appointment slots for bilateral CIs

54. Reprogramming Parent/therapist/teacher reports Psychophysical measures of softest and most comfortable levels (loudness scales) Sweep across the upper levels and observe reaction Balance set levels between ears (for bimodal or bilateral patients)

55. Softest Levels (T) and Most Comfortable Levels (M)

56. Programming

57. Bilateral Balancing

58. Objective Measures Electrophysiologic (NRT/NRI/ART) Measurement of how the nerve responds to stimulation Use cautiously to create MAP/s Can be used to help train a child for listening games ESRT Measurement of middle ear reflex to loud sounds Elicited electrically through the implant Requires a patient to be free of ear infections and to remain fairly still

59. NRT

60. Validation We must determine that programming levels are appropriate!

61. Validation After Programming Can check through the use of: Informal administration of Ling sounds, words, and phrases at a distance Formal aided detection of soft sounds in the test booth

62. Assessment

63. Ling Six (Seven) Sound Test Consider “NO SOUND” as the 7th Sound

64. Ling Six Sound Test

65. Early Speech Perception (ESP) (Moog & Geers, 1990)

66. Auditory Assessment Meaningful Auditory Integration Scale (MAIS) Robbins, Renshaw, & Berry, 1991 Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) Zimmerman-Phillips, Osberger & Robbins, 1997

67. Infant-Toddler Meaningful Auditory Integration Scale Zimmerman-Phillips, Osberger, & Robbins, (1997) Available from Advanced Bionics 10 Questions 0-4 Rating Scale (0=Never; 1=Rarely; 2=Occasionally; 3= Frequently; 4=Always)

68. Meaningful Auditory Integration Scale (Robbins; Robbins, Renshaw, & Berry, 1991) Available from Advanced Bionics Corporation Parent Interview 10 Questions (1a younger than age 5 years/ 1b older than age 5 years) 0-4 Rating Scale (0=Never; 1=Rarely; 2=Occasionally; 3=Frequently; 4=Always)

69. PEACH Parents’ Evaluation of Aural/Oral Performance of Children Ching & Hill, 2007 11 Peach Items (6 Quiet; 5 Noise) Frequency Ratings (n=5) of Reported Behavior (Never/Seldom/Sometimes/Often/Always) (0%, 25%, 50%, 75%, >75%)

70. PEACH Abstract The PEACH was developed to evaluate the effectiveness of amplification for infants and children with hearing impairment by a systematic use of parents’ observations. The internal consistency reliability was .88, and the test-retest correlation was .93. The PEACH can be used with infants as young as one month old and with school-aged children who have hearing loss ranging from mild to profound degree.

71. Test of Auditory Comprehension Ages 4-17 years Normative data based on age ranges and better ear PTA Stimuli on audiotape Screening task to start Hierarchical Ceiling: 2 consecutive subtest failures

73. Listening Comprehension Test 2 Ages: 6;0 through 11;11 Subtests Main Idea Details Reasoning Vocabulary Understanding Messages (From LinquiSystems)

74. Intervention

75. Integration ofCochlear Implants &/or Hearing AidsandAuditoryInterventionA “Perfect” Marriage

76. How Far We Have Come!

77. Levels of Auditory Hierarchy Detection Auditory Awareness Auditory Attention Distance Hearing Localization Auditory Association Auditory Discrimination Auditory Feedback Identification… (adapted from N. Caleffe-Schenck)

78. Levels of Auditory Hierarchy Auditory/Sequential Memory Auditory Closure Auditory Analysis Auditory Blending Auditory Figure Ground Auditory Tracking Auditory Processing Auditory Understanding/ Comprehension (adapted from Caleffe-Schenck)

79. Auditory Hierarchy Detection–to indicate the presence/ absence of sound (Alarm Clock / Wake-Up / Marching Games) Auditory Attention – to pay attention to auditory signals, especially speech, for an extended time. Identification – to indicate an understanding of what has been labeled or named or to label or name something. (L to L Sounds // Recognition / Identification)

80. Auditory Hierarchy Auditory Memory / Sequential Memory – to store and recall auditory stimuli or different length or number in exact order. Distance Hearing – to attend to sounds at a distance. (FM Issue) Localization – to localize the source of sound. (Bird Call Localization)

81. Auditory Hierarchy Auditory Figure Ground – to identify a primary speaker from a background of noise. Auditory Tracking – to follow along in the text of a book as it is read aloud by someone else or in conversation. (see De Filippo & Scott, 1978) Auditory Understanding / Auditory Comprehension – to synthesize the global meaning of spoken language and to relate it to known information.

82. Simultaneous Bilateral CI/s Almost always / full-time intervention with BOTH CIs Periodic -- BOTH CIs; Left CI-Only; Right CI-Only Ling 6 Sound Check / Word Identification Check (Q/N) / Tracking Check

83. Sequential Bilateral CI/s No one generalization / rule for intervention with patients with sequential bilateral CIs can possibly be the only answer /solution.

84. Bilateral Cochlear Implants See Loud & Clear! (2007) Pediatric Bilateral Sequential Cochlear Implants at the Cleveland Clinic by DMG

85. Activities Activities

86. Intervention Considerations with CI 2 * Therapy with “old/initial” CI (CI 1) OFF Kuhn-Inacker, Shehata-Dieler, Mueller, & Helms (2004) suggested that separate intensive training with the new system is needed in order to balance out the hearing competence of the second CI with that of the first. Therapy with Both CIs How much time with CI 2-Only? – the “great” debate/controversery

87. Activity “Considerations” Closed to Open Set Predictable to Unpredictable Familiar to Unfamiliar Slower Rate to Normal Rate Repetition to No Repetition Close to Distant Location Quiet to Noisy Environment (adapted from HOPE EI, 2009)

88. Start-Up Intervention Considerations with CI 2 Start With The Basics Presence / Absence of Sound Ling 6 Sounds -- if needed, pair error contrasts/discrimination tasks moving towards exact identification of all 6 sounds Early Speech Perception (ESP)-type tasks - Pattern perception with varying number of syllables; spondee contrasts; monosyllables (REMEMBER: vary size of field – may need to be limited at first)

89. More Intervention Considerations with CI 2 Move Towards Closed Set Activities -- colors, #s, names, U.S. States / Presidents, blackjack, poker, & other card games Open Set Activities Auditory Connected Discourse Tracking (Both CIs; CI 1 – ONLY; CI 2 – ONLY – if possible / if not possible – start with auditory & visual before auditory-only with CI 2)

90. Videotape Samples -- Mallory Both CI/s; CI 1-ONLY; CI 2-ONLY Ling Six Sounds ESP – Subtests 1/2/3 CNC Words CI 2-ONLY Fun! Tracking

91. Adult Audiologic / Aural Rehabilitation Half hour appointment (no fee for appt.) Approximately 1 month post-activation Complete post-HHIA Briefly assess auditory skills: Ling 6 Sounds, ESP (Subtest 1, 2, or 3 depending on ability)

92. Adult Audiologic / Aural Rehabilitation Informed of available AR services from various resources, including CI companies Advised to inform local emergency services about auditory status of individuals in the home Advised to invest in “Medical Alert”-type bracelet Re-Informed about dangers of MRIs Receive “HIP Adult AR Packet”

93. HIP Adult AR Packet Material Online Resources for Assistive Listening Devices & Alerting Devices Serve Many Needs (Brown, 2008) Sprint CapTel® 800i Telephone brochure Medical Alert Bracelet brochure (with recommendation of noting hearing loss and that an MRI should NOT be conducted without prior notification with medical personnel familiar with the internal magnet of the CI)

94. HIP Adult AR Packet Material List of websites for AR practice Other Adult AR resources available for purchase Practice guidelines for audio books (highest recommendation!) List of local movie theaters which provide services (captions/ assistive listening devices)

95. HIP Adult AR Packet Material Advanced Bionics: Music Resources; Listening Room; Aural Rehabilitation Programs and Tools brochure Cochlear Americas: Rehab. Products and Services; Phone with Confidence; CIs and Music: Some Helpful Tips; Sound and Way Beyond Flyer MED-EL: Telephone Training Tips; Smart Tips for CI Users; BRIDGE Product catalog and order form

96. Outcomes

97.  Pediatric Outcomes

98. Adult Outcomes Adult Outcomes

99. Parent Panel Corey and Sharon Brady (Parents of Regan & Ryan) Loren and Heidi Chylla (Parents of Zachary & Mallory) Monica Svets (along w/husband Rob – Parents of Anna) Introduction of kids with dataIntroduction of kids with data

100. Additional Issues Patients issues Auditory Neuropathy Spectrum Disorder Multiple Disabilities Pre-candidacy testing issues EABR and MRI Vestibular work-up

101. Bilateral CI Guidelines “Therapy and Educational Guidelines for Bilateral Cochlear Implantation” By Nancy Caleffe-Schenck, M.Ed., CCC-A, Cert. AVt Getting Started Laying the Foundation Core Concepts Therapy and Educational Tips Activities for Auditory Comprehension Unique Considerations for Bilateral Implantation Simultaneous Implantation Sequential Implantation Therapy and Teaching Tips for Sequential Implantation Listening With Both Implants (see Kuhn-Inacker et al., 2004)

102. Bilateral CI Therapy Guidelines Auditory Rehabilitation Therapy Guidelines for Optimizing the Benefits of Binaural Hearing By Leo De Raeve Introduction Auditory Training for Binaural Hearing Skills Training with Softer Sounds & Speech Speech Perception Training with Background Noise Training Localization Examples of Localization Training Activities Influence of Time-Delay Between Implant Procedures on Rehabilitation Sequential Stimulation/Implantation Simultaneous Stimulation/Implantation Incidental Learning In the Classroom Conclusion

103. Some Take-Home Messages FMs in conjunction with HAs for these severe-to-profound kiddos Repeat AEPs as the surgical date approaches If surgically/medically acceptable – simultaneous bilateral CIs sooner than later

104. Your Life In Stereo(The Bilateral Difference) “Movie/DVD” Hear From the Experts (available from Cochlear Americas) Features SKYE and her family – along with members of the CCF HIP Team “Baking therapy into every aspect of her life”!

105. References Advanced Bionics Corporation. (2004). Hearing with two ears: Technical advances for bilateral cochlear implantation. Retrieved December 8, 2009, from: http://www.advancedbionics.com/printables/Bilateral.pdf Aristegui, M., & Denia, A. (2005). Simultaneous cochlear implantation and translabyrinthine removal of vestibular schwannoma in an only hearing ear: report of two cases (neurofibromatosis type 2 and unilateral vestibular schwannoma). Otology & Neurotology, 26(2), 205-210. Armstrong, M., Pegg, P., James, C., & Blamey, P. (1997). Speech perception in noise with implant and hearing aid. The American Journal of Otology, 18(Supplement 6), S140- S141. Balkany, T., Hodges, A., Telischi, F., Hoffman, R., Madell, J., Parisier, S., et al. (2008). William House cochlear implant study group: Position statement on bilateral cochlear implantation. Otology & Neurology, 29(2), 107-108. Bichey, B.G., & Miyamoto, R.T. (2008). Outcomes in bilateral cochlear implantation. Otolaryngology- Head and Neck Surgery, 138(5), 655-661.

106. References Budenz, C.L., Roland, J.T. Jr, Babb, J., Baxter, P., & Waltzman., S.B. (2009). Effect of cochlear implant technology in sequentially bilaterally implanted adults. Otology & Neurology, 30(6), 731-735. Ching, T.Y.C., Incerti, P., & Hill, M. (2004). Binaural benefits for adults who use hearing aids and cochlear implants in opposite ears. Ear & Hearing, 25(1), 9-21. Ching, T.Y.C., Psarros, C., Hill, M., Dillon, H., & Incerti, P. (2001). Should children who use cochlear implants wear hearing aids in the opposite ear? Ear & Hearing, 22(5), 365-380. Ching, T.Y.C., van Wanrooy, E., Hill, M., Dillon, H., & Incerti, P. (2006). Performance in children with hearing aids or cochlear implants: Bilateral stimulation and binaural hearing. International Journal of Audiology, 45(Supplement 1), S108-S112. Dunn, C.C., Tyler, R.S., Oakley, S., Gantz, B.J., & Noble, W. (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 & Hearing, 29(3), 352-359.

107. References Dunn, C.C., Tyler, R.S., & Witt, S.A. (2005). Benefit of wearing a hearing aid on the unimplanted ear in adult users of a cochlear implant. Journal of Speech, Language, and Hearing Research, 48, 668-680. Dunn, C.C., Tyler, R.S., Witt, S.A., & Gantz, B.J. (2006). Effects of converting bilateral cochlear implant subjects to a strategy with increased rate and number of channels. The Annals of Otology, Rhinology, and Laryngology, 115(6), 425- 432. Eapen, R.J., Buss, E., Adunka, M.C., Pillsbury III, H.C., & Buchman, C.A. (2009). Hearing-in-noise benefits after bilateral simultaneous cochlear implantation continue to improve 4 years after implantation. Otology & Neurology, 30(2), 153- 159. Francis, H.W., Yeagle, J.D., Bowditch, S., & Niparko, J.K. (2005). Cochlear implant outcome is not influenced by choice of ear. Ear & Hearing, 26(Supplement 4), 7S- 16S. Galvin, K.L., Mok, M., & Dowell, R.C. (2007). Perceptual benefit and functional outcomes for children using sequential bilateral cochlear implants. Ear & Hearing, 28(4), 470-482.

108. References Gantz, B.J., Tyler, R.S., Rubinstein, J.T., Wolaver, A., Lowder, M., Abbas, P., et al. (2002). Binaural cochlear implants placed during the same operation. Otology & Neurology, 23(2), 169-180. Graham, J., Vickers, D., Eyles, J., Brinton, J., Al Malky, G., Aleksy, W., et al. (2009). Bilateral sequential cochlear implantation in the congenitally deaf child: Evidence to support the concept of a ‘critical age’ after which the second ear is less likely to provide an adequate level of speech perception on its own. Cochlear Implants International, 10(3), 119-141. Grieco-Calub, T.M., Saffran, J.R., & Litovsky, R.Y. (2009). Spoken word recognition in toddlers who use cochlear implants. Journal of Speech, Language, and Hearing Research, 52, 1390-1400. Hamzavi, J., Pok, S.M., Gstoettner, W., & Baumgartner, W. (2004). Speech perception with a cochlear implant used in conjunction with a hearing aid in the opposite ear. International Journal of Audiology, 43(2), 61-65. Holt, R.F., Kirk, K.I., Eisenberg, L.S., Martinez, A.S., & Campbell, W. (2005). Spoken word recognition development in children with residual hearing using cochlear implants and hearing aids in opposite ears. Ear & Hearing, 26(Supplement 4), 82S-91S.

109. References Johnston, J.C., Durieux-Smith, A., Angus, D., O’Connor, A., & Fitzpatrick, E. (2009). Bilateral paediatric cochlear implants: A critical review. International Journal of Audiology, 48(9), 601-617. Laske, R.D., Veraguth, D., Dillier, N., Binkert, A., Holzmann, D., & Huber, A.M. (2009). Subjective and objective results after bilateral cochlear implantation in adults. Otology & Neurotology, 30(3), 313-318. Litovsky, R.Y., Johnstone, P.M., Godar, S., Agrawal, S., Parkinson, A., Peters, R., et al. (2006). Bilateral cochlear implants in children: Localization acuity measured with minimum audible angle. Ear & Hearing, 27(1), 43-59. Litovsky, R.Y., Johnstone, P.M., & Godar, S.P. (2006). Benefits of bilateral cochlear implants and/or hearing aids in children. International Journal of Audiology, 45(Supplement 1), S78-S91. Litovsky, R.Y., Parkinson, A., Arcaroli, J., Peters, R., Lake, J., Johnstone, P., et al. (2004). Bilateral cochlear implants in adults and children. Archives of Otolaryngology- Head and Neck Surgery, 130, 648-655.

110. References Litovsky, R.Y., Parkinson, A., Arcaroli, J., & Sammeth, C. (2006). Simultaneous bilateral cochlear implantation in adults: A multicenter clinical study. Ear & Hearing, 27(6), 714-731. Nicholas, J.G., & Geers, A.E. (2007). Will they catch up? The role of age at cochlear implantation in the spoken language development of children with severe to profound hearing loss. Journal of Speech, Language, and Hearing Research, 50, 1048-1062. Offeciers, E., Morera, C., Muller, J., Huarte, A., Shallop, J., & Cavalle, L. (2005) International consensus on bilateral cochlear implants and bimodal stimulation. Acta Oto-Laryngologica, 125, 918-919. Peters, B.R., Litovsky, R., Parkinson, A., & Lake, J. (2007). Importance of age and postimplantation experience on speech perception measures in children with sequential bilateral cochlear implants. Otology & Neurotology, 28(5), 649-657. Ramsden, R., Greenham, P., O’Driscoll, M., Mawman, D., Proops, D., Craddock, L., et al. (2005). Evaluation of bilaterally implanted adult subjects with Nucleus 24 cochlear implant system. Otology & Neurology, 26(5), 988-998.

111. References Robbins, A.M., Koch, D.B., Osberger, M.J., Zimmerman-Phillips, S., & Kishon-Rabin, L. (2004). Effect of age of cochlear implantation on auditory skill development in infants and toddlers. Archives of Otolaryngology- Head and Neck Surgery, 130, 570-574. Schauwers, K., Govaerts, P.J., & Gillis, S. (Eds.). (2002). Language acquisition in very young children with a cochlear implant. Antwerp Papers in Linguistics, 102, 1-73. Scherf, F.W.A.C., van Deun, L., van Wieringen, A., Wouters, J., Desloovere, C., Dhooge, I., et al. (2009). Functional outcome of sequential bilateral cochlear implantation in young children: 36 months postoperative results. International Journal of Pediatric Otorhinolaryngology, 73, 723-730. Schleich, P., Nopp, P., & D’Haese. (2004). Head shadow, squelch, and summation effects in bilateral users of the MED-EL COMBI 40/40+ cochlear implant. Ear & Hearing, 25(3), 197-204. Schoen, F., Mueller, J., Helms, J., & Nopp, P. (2005). Sound localization and sensitivity to interaural cues in bilateral users of the Med-El Combi 40/40+ cochlear implant system. Otology & Neurotology, 26(3), 429-437.

112. References Senn, P., Kompis, M., Vischer, M., & Haeusler, R. (2005). Minimum audible angle, just noticeable interaural differences and speech intelligibility with bilateral cochlear implants using clinic speech processors. Audiology & Neurology, 10, 342-352. Sharma, A., Dorman, M.F., & Kral, A. (2005). The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hearing Research, 203, 134-143. Spahr, A.J., Dorman, M.F., & Loiselle, L.H. (2007). Performance of patients using different cochlear implant systems: Effects of input dynamic range. Ear & Hearing, 28(2), 260-275. Steffens, T., Lesinski-Schiedat, A., Strutz, J., Aschendorff, A., Klenzner, T., Tuhl, S., et al. (2008). The benefits of sequential bilateral cochlear implantion for hearing-impaired children. Acta Oto-Laryngologica, 128, 164-176. Summerfield, A.Q., Marshall, D.H., Barton, G.R., & Bloor, K.E. (2002). A cost-utility scenario analysis of bilateral cochlear implantation. Archives of Otolaryngology-Head and Neck Surgery, 128, 1255-1262.

113. References Tyler, R.S., Dunn, C.C., Witt, S.A., & Nobel, W.G. (2007). Speech perception and localization with adults with bilateral sequential cochlear implants. Ear & Hearing, 28(Supplement 2), 86S-90S. Tyler, R.S., Gantz, B.J., Rubinstein, J.T., Wilson, B.S., Parkinson, A.J., Wolaver, A., et al. (2002). Three-month results with bilateral cochlear implants. Ear & Hearing, 23(Supplement 1), 80S-89S. Tyler, R.S., Parkinson, A.J., Wilson, B.S., Witt, S., Preece, J.P., & Noble, W. (2002). Patients utilizing a hearing aid and cochlear implant: Speech perception and localization. Ear & Hearing, 23(2), 98-105. Van Hoesel, R.J.M., & Tyler, R.S. (2003). Speech perception, localization, and lateralization with bilateral cochlear implants. Acoustical Society of America, 113(3), 1617-1630. Vermeire, K., Brokx, J.P.L., Van de Heyning, R.H., Cochet, E., & Carpentier, H. (2003). Bilateral cochlear implantation in children. International Journal of Pediatric Otorhinolaryngology, 67, 67-70.

114. References Verschuur, C.A., Lutman, M.E., Ramsden, R., Greenham, P., & O’Driscoll. (2005). Auditory localization abilities in bilateral cochlear implant recipients. Otology & Neurotology, 26(5), 965-971. Wackym, P.A., Runge-Samuelson, C.L., Firszt, J.B., Alkaf, F.M., & Burg, L.S. (2007). More challenging speech-perception tasks demonstrate binaural benefit in bilateral cochlear implant users. Ear & Hearing, 28(Supplement 2), 80S-85S. Wolfe, J., Baker, S., Caraway, T., Kasulis, H., Mears, A., Smith, J., et al. (2007). 1-year postactivation results for sequentially implanted bilateral cochlear implant users. Otology & Neurotology, 28(5), 589-596. Wolfe, J., & Schafer, E.C. (2010). Programming cochlear implants. San Diego, CA: Plural Publishing. Zeitler, D.M., Kessler, M., A., Terushkin, V., Roland, J.T. Jr., Svirsky, M.A., Lalwani, A.K., et al. (2008). Speech perception benefits of sequential bilateral cochlear implantation in children and adults: A retrospective analysis. Otology & Neurotology, 29(3), 314- 325.

115. Bilateral CI References Rationale for Studying Bilateral Cochlear Implantation in Children by R. Peters, M.D. Bibliography of bilateral research Cochlear White Paper: Outcomes Using Bilateral Cochlear Implants in Adults Cochlear White Paper: Rationale for Bilateral Cochlear Implants in Children and Adults (All of the above are pdf “downloadable” from Cochlear website)

116. Bilateral Websites http://bilateral.cochlear.com/5.html www.bionicear.com/printables/ reimbursement/BilateralCIBibliography-092006.pdf

117. Cleveland Clinic Hearing Implant Program (HIP)9500 Euclid Ave., Desk A-71Cleveland, OH 44195 216-444-5371 Rachel Bibler, Au.D. biblerr@ccf.org Donald Goldberg, Ph.D. goldbed@ccf.org Peter Weber, M.D. weberp@ccf.org