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The performance of cochlear implant patients in background noise
OtolaryngologyHead and Neck Surgery Volume t21 Number 2
has a significant role in the clinical improvement of bronchial asthma in this group of patients. 9:16 AM
Laser-Assisted Outpatient Septoplasty YVES-VICTOR KAMAMI MD (presenter); Paris France
Objectives: Septoplasty has been used for decades as the preferred surgical technique for managing nasal septal deviation with obstruction to nasal airflow. Using subjective and objective criteria, this study evaluates a new simple practice of this operation, using the CO 2 laser with the patient under local anesthesia. Methods: This technique is devised to minimize and simplify surgery, with the patient under local anesthesia, on an outpatient basis. Ablation of the septum includes lasing of nasal mucosa, perichondrium, septal cartilage, and fibroconnective tissue. With an adequate selection of patients and an adequate technique, using scanning anticharring devices, laser septoplasty (LAOS) results have shown good surgical success rates. Results: From August 1995 to January 1999, I have developed and practiced LAOS in 1005 patients. Based on subjective patient questionnaire criteria, on anterior rhinoscopy, on intranasal endoscopy, and on preoperative and postoperative rhinometric parameters, LAOS results demonstrated significant clinical airway improvement in 91% of patients. There were no incidences of septal perforation and only a few cases of benign bleeding and synechia formation, which were easily treated. Conclusion: LAOS, introduced in the United States by Dr Yosef R Krespi in 1997, is less invasive than traditional septoplasty, with reduced surgical time, decreased patient recovery time, less morbidity, lower medical costs, and rapid return to full activity. It appears to be a safe, simple, quick, and predictable in-office procedure on anterior septal spurs for treating airway obstruction.
8:00 to 9:30 AM MCC Rooms 255-257 9
O t o l o g y Session WILLIAM R LAMEAR MD; WILLIAM H SLAI-rERY Ill MD (moderators)
8:00 AM
Advances in Cochlear Implantation via the Middle Fossa VITTORIO COLLETrl MD (presenter); MARCO CARNER MD; FIORINO FRANCESCO MD', SACCHE~O LUCA MD; GIARBINI NADIA MD; FRANCESCO CILURZO MD; Verona Italy
Objectives: The results of cochlear implantation via the middle fossa in 30 parents are described. Subjects presented with a bilateral radical mastoidectomy cavity (n = 5), fibroadhesive otitis media (n = 4), otosclerosis (n = 3), autoimmune inner ear disease (n = 5), previous cranial trauma (n = 2),
Scientific Sessions--Monday
P113
genetic prelingual deafness (n = 9), and inner ear malformations (n = 2). Methods: A middle fossa approach with a small cochleostomy was performed on the most superficial part of the basal turn. A Lauraflex implant (Philips Hearing Implants) was used in 3 patients, a Nucleus 24 M cochlear implant system (Cochlear Corp) in 12, a COMBI 40+ (MED-EL) with double electrode array in 8, and a Clarion implant (Advanced Bionics) in 7. The single electrode array was inserted through the cochleostomy to the cochlear apex and occupied a portion of the basal, as well as the middle and apical, turns. When the double electrode arrays were inserted, one was directed toward the apex and one toward the round window. Results: Telemetry and intraoperative recording of electrically evoked auditory responses (EABR) were performed at the end of surgery. Speech perception tests performed over a period of time ranging from 1 to 17 months after cochlear implant activation yielded better results in these patients than in a homogeneous group of postlingually deaf patients operated on via the traditional transmastoid route. Conclusion: This approach is suitable for auditory rehabilitation of subjects with a bilateral radical mastoidectomy cavity, chronic middle ear disease, patients suffering from inner ear malformations, and patients with partial obliteration of the cochlea in the basal turn. It led to major improvements in speech perception in all patients compared with patients operated on with the transmastoid approach and thus, given the present state of the art, it is the only approach that allows stimulation of the entire cochlea, including the middle and apical turns, where a greater survival rate of spiral ganglion cells is known to occur. 8:08 AM
The Performance of Cochlear Implant Patients in Background Noise BRUCE L FETrERMAN MD (presenter); ELIZABETHH DOMICO MS CCC-A; Memphis TN
Objectives: Providing better speech understanding in noisy environments is a recognized goal in the research and development of cochlear implant systems. Speech processing strategies for the Nucleus device, such as Spectral Peak (SPEAK), Advanced Combination Encoder (ACE), and Continuous Interleaved Sampling (CIS), and for the Clarion implant, such as CIS and Simultaneous Analog Stimulation (SAS), may allow improved perception in noise due to the redundancy of the acoustic information in the signal. Methods: Eighty-nine cochlear implant patients--61 Nucleus and 28 Clarion users--were tested with the City University of New York (CUNY) Sentences presented in the auditory-only condition in a sound-attenuated booth. Recorded sentences were presented at 70 dB SPL in quiet and with competing 8-talker babble set at a signal-to-noise ratios (SNR) of +10 dB HL and +5 dB HL. Patients were asked to
P114
OtolaryngologyHead and Neck Surgery August T999
Scientific Sessions--Monday
repeat back any words they understood, and the test was scored based on the number of words perceived. Each patient's subjective perception of understanding in noise in everyday life was assessed via a questionnaire. Results: Group mean scores were significantly different at each condition (P < 0.05): 79% of words correct in quiet, 64% correct at an SNR of +10 dB HL, and 38% correct at an SNR of +5 dB HL SNR. Binomial statistical analysis showed that 51% of patients demonstrated no difference in test scores for the quiet versus +10 dB SNR conditions. Questionnaire findings suggested that patients perceived noise to be a problem in their daily living situation, essentially regardless of their test performance level. Conclusion: Competing noise interferes with comprehension of connected speech for most cochlear implant patients. Even those patients who demonstrate very high comprehension in the presence of background noise during testing report difficulty understanding speech in noise in everyday life. Exercises that stress comprehension of connected speech in background noise, along with discussion of different strategies to aid in coping with noise interference, should be considered important components of cochlear implant rehabilitation.
0.0001). Mean age for the older group (n = 11) was 68.1 _+5.5. For the older group, and word recognition scores (CNC) before and after were 10.0% and 34.2%, respectively (P < 0.02); and sentence recognition scores (CID) before and after were 11.7% and 77.7% (P < 0.0001). Postscores for word (P = 0.62) and sentence (P = 0.87) recognition in the younger group versus the older group showed no significant difference. Conclusion: We conclude that the benefits of cochlear implantation are comparable in older adults (>60) versus younger adults (18-59). Both groups showed highly significant improvement in both word and sentence recognition scores. No significant differences were noted when comparing improvements in the younger group to the older group. These data imply that the benefits of improved hearing secondary to cochlear implantation are independent of age. 8:30 AM
Permodiolar Electrode: Prototype for the Next Generation of Implants CLAUDE N JOLLY PHD (presenter); WOLFGANG GSTOEI-rNER MD; WOLF-DIETER BAUMGARTNER MD; HAMZAVI JAFAR MD; Innsbruck Austria; Vienna Austria; Vienna Austria; Vienna Austria
8:16 AM
Cochlear Implant Performance in Older Adults ROBERT F LABADIE MD PHD (presenter); CAROL H GILMER MA CCC-A; VINCENT N CARRASCO MD; HAROLD C PILLSBURYIII MD; Chapel Hill NC
Objectives: Hearing impairment is the fourth most common major chronic disability in senior citizens. Cochlear implants are indicated for elderly patients with severe-to-profound hearing loss. However, some health care providers believe that older patients cannot tolerate the surgery, are too old to learn to use a cochlear implant, and will ultimately perform poorly. To address these issues and document performance of older (>60 years) versus younger (18-59 years) adults, we undertook a retrospective analysis of our postlingual deaf adult cochlear implant patients. Methods: Adult patients with Clarion@ multichannel cochlear implants were included in the study based on meeting preoperative criteria for implantation (severe-to-profound hearing loss in better ear) as well as being able to participate in formal audiologic analysis consisting of sentence recognition (CID) and monosyllabic word recognition (CNC) both before and after implantation. Twelve younger adults (18-59 years old) were analyzed, as were 11 older adults (>60 years old). Performance scores were compared using Student's t tests. Results: Mean age for the younger group (n = 12) was 41.5 -+ 10.2 years (mean _+SD). For the younger group, and word recognition scores (CNC) before and after were 1.8% and 38.5%, respectively (P < 0.0001); and sentence recognition scores (CID) before and after were 14.8% and 79.8% (P <
Objectives: The future of the electrodes used in cochlear implants resides in the ability to surround the modiolar wall. Modeling of intracochlear stimulation and animal EABR data indicates that a perimodiolar electrode would lower psychoacoustic threshold, increases the dynamic range of stimulation, and reduce channel interaction. Further potential benefits expected include reduced power consumption to drive the implant, reduced side effects for the patient, implementation of innovative stimulation scheme, and better place coding of frequency. A larger number of electrodes may be effectively used. A perimodiolar electrode was designed and tested in vitro in an inner ear polymer model and in situ in temporal bones. Methods: The array is ellipsoid in cross section, tapered from base to apex, and has 2 facing rows of 12 contacts symmetrically distributed across the major axis of the oval carrier (24 electrodes total). A microgroove has been molded on the outer edge of the carrier and along its length. A 100-~m-diameter superelastic wire made of biocompatible nitinol is embedded into the microgroove. The wire is free to arch out of the groove except at the base and apex of the electrode. Following insertion of the array along the lateral wall, a retropositioning technique is used to displace the electrode toward the lateral wall. The technique is a push-hold-pull method: push the array into the scala tympani, hold the nitinol wire firmly with microforceps, and retract the electrode array until it is wrapped around the inner wall. Results: A sequence of x-rays taken in vitro in a polymer model of the cochlea shows the electrode insertion and the subsequent dynamic retropositioning. In its final state, the
has a significant role in the clinical improvement of bronchial asthma in this group of patients. 9:16 AM
Laser-Assisted Outpatient Septoplasty YVES-VICTOR KAMAMI MD (presenter); Paris France
Objectives: Septoplasty has been used for decades as the preferred surgical technique for managing nasal septal deviation with obstruction to nasal airflow. Using subjective and objective criteria, this study evaluates a new simple practice of this operation, using the CO 2 laser with the patient under local anesthesia. Methods: This technique is devised to minimize and simplify surgery, with the patient under local anesthesia, on an outpatient basis. Ablation of the septum includes lasing of nasal mucosa, perichondrium, septal cartilage, and fibroconnective tissue. With an adequate selection of patients and an adequate technique, using scanning anticharring devices, laser septoplasty (LAOS) results have shown good surgical success rates. Results: From August 1995 to January 1999, I have developed and practiced LAOS in 1005 patients. Based on subjective patient questionnaire criteria, on anterior rhinoscopy, on intranasal endoscopy, and on preoperative and postoperative rhinometric parameters, LAOS results demonstrated significant clinical airway improvement in 91% of patients. There were no incidences of septal perforation and only a few cases of benign bleeding and synechia formation, which were easily treated. Conclusion: LAOS, introduced in the United States by Dr Yosef R Krespi in 1997, is less invasive than traditional septoplasty, with reduced surgical time, decreased patient recovery time, less morbidity, lower medical costs, and rapid return to full activity. It appears to be a safe, simple, quick, and predictable in-office procedure on anterior septal spurs for treating airway obstruction.
8:00 to 9:30 AM MCC Rooms 255-257 9
O t o l o g y Session WILLIAM R LAMEAR MD; WILLIAM H SLAI-rERY Ill MD (moderators)
8:00 AM
Advances in Cochlear Implantation via the Middle Fossa VITTORIO COLLETrl MD (presenter); MARCO CARNER MD; FIORINO FRANCESCO MD', SACCHE~O LUCA MD; GIARBINI NADIA MD; FRANCESCO CILURZO MD; Verona Italy
Objectives: The results of cochlear implantation via the middle fossa in 30 parents are described. Subjects presented with a bilateral radical mastoidectomy cavity (n = 5), fibroadhesive otitis media (n = 4), otosclerosis (n = 3), autoimmune inner ear disease (n = 5), previous cranial trauma (n = 2),
Scientific Sessions--Monday
P113
genetic prelingual deafness (n = 9), and inner ear malformations (n = 2). Methods: A middle fossa approach with a small cochleostomy was performed on the most superficial part of the basal turn. A Lauraflex implant (Philips Hearing Implants) was used in 3 patients, a Nucleus 24 M cochlear implant system (Cochlear Corp) in 12, a COMBI 40+ (MED-EL) with double electrode array in 8, and a Clarion implant (Advanced Bionics) in 7. The single electrode array was inserted through the cochleostomy to the cochlear apex and occupied a portion of the basal, as well as the middle and apical, turns. When the double electrode arrays were inserted, one was directed toward the apex and one toward the round window. Results: Telemetry and intraoperative recording of electrically evoked auditory responses (EABR) were performed at the end of surgery. Speech perception tests performed over a period of time ranging from 1 to 17 months after cochlear implant activation yielded better results in these patients than in a homogeneous group of postlingually deaf patients operated on via the traditional transmastoid route. Conclusion: This approach is suitable for auditory rehabilitation of subjects with a bilateral radical mastoidectomy cavity, chronic middle ear disease, patients suffering from inner ear malformations, and patients with partial obliteration of the cochlea in the basal turn. It led to major improvements in speech perception in all patients compared with patients operated on with the transmastoid approach and thus, given the present state of the art, it is the only approach that allows stimulation of the entire cochlea, including the middle and apical turns, where a greater survival rate of spiral ganglion cells is known to occur. 8:08 AM
The Performance of Cochlear Implant Patients in Background Noise BRUCE L FETrERMAN MD (presenter); ELIZABETHH DOMICO MS CCC-A; Memphis TN
Objectives: Providing better speech understanding in noisy environments is a recognized goal in the research and development of cochlear implant systems. Speech processing strategies for the Nucleus device, such as Spectral Peak (SPEAK), Advanced Combination Encoder (ACE), and Continuous Interleaved Sampling (CIS), and for the Clarion implant, such as CIS and Simultaneous Analog Stimulation (SAS), may allow improved perception in noise due to the redundancy of the acoustic information in the signal. Methods: Eighty-nine cochlear implant patients--61 Nucleus and 28 Clarion users--were tested with the City University of New York (CUNY) Sentences presented in the auditory-only condition in a sound-attenuated booth. Recorded sentences were presented at 70 dB SPL in quiet and with competing 8-talker babble set at a signal-to-noise ratios (SNR) of +10 dB HL and +5 dB HL. Patients were asked to
P114
OtolaryngologyHead and Neck Surgery August T999
Scientific Sessions--Monday
repeat back any words they understood, and the test was scored based on the number of words perceived. Each patient's subjective perception of understanding in noise in everyday life was assessed via a questionnaire. Results: Group mean scores were significantly different at each condition (P < 0.05): 79% of words correct in quiet, 64% correct at an SNR of +10 dB HL, and 38% correct at an SNR of +5 dB HL SNR. Binomial statistical analysis showed that 51% of patients demonstrated no difference in test scores for the quiet versus +10 dB SNR conditions. Questionnaire findings suggested that patients perceived noise to be a problem in their daily living situation, essentially regardless of their test performance level. Conclusion: Competing noise interferes with comprehension of connected speech for most cochlear implant patients. Even those patients who demonstrate very high comprehension in the presence of background noise during testing report difficulty understanding speech in noise in everyday life. Exercises that stress comprehension of connected speech in background noise, along with discussion of different strategies to aid in coping with noise interference, should be considered important components of cochlear implant rehabilitation.
0.0001). Mean age for the older group (n = 11) was 68.1 _+5.5. For the older group, and word recognition scores (CNC) before and after were 10.0% and 34.2%, respectively (P < 0.02); and sentence recognition scores (CID) before and after were 11.7% and 77.7% (P < 0.0001). Postscores for word (P = 0.62) and sentence (P = 0.87) recognition in the younger group versus the older group showed no significant difference. Conclusion: We conclude that the benefits of cochlear implantation are comparable in older adults (>60) versus younger adults (18-59). Both groups showed highly significant improvement in both word and sentence recognition scores. No significant differences were noted when comparing improvements in the younger group to the older group. These data imply that the benefits of improved hearing secondary to cochlear implantation are independent of age. 8:30 AM
Permodiolar Electrode: Prototype for the Next Generation of Implants CLAUDE N JOLLY PHD (presenter); WOLFGANG GSTOEI-rNER MD; WOLF-DIETER BAUMGARTNER MD; HAMZAVI JAFAR MD; Innsbruck Austria; Vienna Austria; Vienna Austria; Vienna Austria
8:16 AM
Cochlear Implant Performance in Older Adults ROBERT F LABADIE MD PHD (presenter); CAROL H GILMER MA CCC-A; VINCENT N CARRASCO MD; HAROLD C PILLSBURYIII MD; Chapel Hill NC
Objectives: Hearing impairment is the fourth most common major chronic disability in senior citizens. Cochlear implants are indicated for elderly patients with severe-to-profound hearing loss. However, some health care providers believe that older patients cannot tolerate the surgery, are too old to learn to use a cochlear implant, and will ultimately perform poorly. To address these issues and document performance of older (>60 years) versus younger (18-59 years) adults, we undertook a retrospective analysis of our postlingual deaf adult cochlear implant patients. Methods: Adult patients with Clarion@ multichannel cochlear implants were included in the study based on meeting preoperative criteria for implantation (severe-to-profound hearing loss in better ear) as well as being able to participate in formal audiologic analysis consisting of sentence recognition (CID) and monosyllabic word recognition (CNC) both before and after implantation. Twelve younger adults (18-59 years old) were analyzed, as were 11 older adults (>60 years old). Performance scores were compared using Student's t tests. Results: Mean age for the younger group (n = 12) was 41.5 -+ 10.2 years (mean _+SD). For the younger group, and word recognition scores (CNC) before and after were 1.8% and 38.5%, respectively (P < 0.0001); and sentence recognition scores (CID) before and after were 14.8% and 79.8% (P <
Objectives: The future of the electrodes used in cochlear implants resides in the ability to surround the modiolar wall. Modeling of intracochlear stimulation and animal EABR data indicates that a perimodiolar electrode would lower psychoacoustic threshold, increases the dynamic range of stimulation, and reduce channel interaction. Further potential benefits expected include reduced power consumption to drive the implant, reduced side effects for the patient, implementation of innovative stimulation scheme, and better place coding of frequency. A larger number of electrodes may be effectively used. A perimodiolar electrode was designed and tested in vitro in an inner ear polymer model and in situ in temporal bones. Methods: The array is ellipsoid in cross section, tapered from base to apex, and has 2 facing rows of 12 contacts symmetrically distributed across the major axis of the oval carrier (24 electrodes total). A microgroove has been molded on the outer edge of the carrier and along its length. A 100-~m-diameter superelastic wire made of biocompatible nitinol is embedded into the microgroove. The wire is free to arch out of the groove except at the base and apex of the electrode. Following insertion of the array along the lateral wall, a retropositioning technique is used to displace the electrode toward the lateral wall. The technique is a push-hold-pull method: push the array into the scala tympani, hold the nitinol wire firmly with microforceps, and retract the electrode array until it is wrapped around the inner wall. Results: A sequence of x-rays taken in vitro in a polymer model of the cochlea shows the electrode insertion and the subsequent dynamic retropositioning. In its final state, the