An outcomes study of cochlear implants in deaf patients. Audiologic, economic, and quality-of-life changes

Profiling of the Functional Status of Hearing Impaired Children Using Cochlear Implant in the Indian Scenario- an ICF Perspective

The aim of the study was to assess the functional outcome of children who underwent Auditory verbal therapy followed by cochlear implantation using The Parents' views and experiences with pediatric cochlear implant questionnaire (PVECIQ). Hearing impaired children who have completed minimum of 5 years of auditory verbal training (AVT) after cochlear implantation was taken up for the study. There were totally 30 males and 20 females, the average age at implantation for these children ranged from 1 year to 5yrs. The Parents' views and experiences with pediatric cochlear implant questionnaire (PVECIQ) was administered by interviewing the parents after taking a written informed consent. The mean scores for each statement and its standard deviation were found out. Distribution across the five response categories was also analysed for each statement to identify the strength of opinion.The percentage of responses under each response category was also calculated. The present study evaluated both hearing and non-hearing aspects of hearing loss under the perspective of ICF. The study has given feedback on the areas where good outcome is shown after use of cochlear implant for 5 years and also the areas where they still experience difficulties and need ongoing support. Even though the children acquired language to a degree capable of communication with others in the society, the speech intelligibility has been a concern for parents. Since CI does not restore normal anatomy of hearing, Children using CI will require ongoing professional and economical support throughout their life, tailored to individual needs of the child to have a better quality of life.

Validity and reliability of the Turkish version of the parental perspective scale for children with cochlear implants

OBJECTIVE

This study aimed to translate the "Children with Cochlear Implant: Parental Perspectives (CCIPP)" scale into Turkish and evaluate its validity and reliability.

MATERIAL AND METHODS

Parents of 378 children between the ages of 2 and 18, who had used cochlear implants for at least one year, filled out the Turkish version of the scale. The original scale was translated from English to Turkish. Explanatory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed to examine the scale construct validity. For the evaluation of the scale reliability, internal consistency and test-retest reliability measures were evaluated with Cronbach's alpha (α) and correlation, respectively.

RESULTS

The reliability coefficients of the dimensions are between 0.237 and 0.678. The test-retest correlation coefficient of 0.875 was obtained. As a result of factor analysis, ten sub-dimensions were determined, corresponding to the original ten domains defined in the CCIPP scale. The Kaiser-Meyer-Olkin (KMO) sample adequacy coefficient calculated in the sub-factor analysis was determined to be 0.850. The dimensions obtained according to the result of the Bartlett test in which the significance of the factor structures was tested (test value: 9596.996, degrees of freedom (df): 2628, p < 0.001) are structurally significant. CFA confirmed the accuracy of the ten-dimensional structures (Comparative Fit Index (CFI) = 0.901; Incremental Fit Index (IFI) = 0.902; Root Mean Square Error of Approximation (RMSEA) = 0.054).

CONCLUSION

The Turkish version of the scale has good validity and reliability and can be used to examine parents' perspectives on cochlear implants.

Health State Utility Values Associated with Cochlear Implants in Adults: A Systematic Review and Network Meta-Analysis

OBJECTIVES

The cost-effectiveness of bilateral cochlear implants in adults remains uncertain despite established clinical benefits. In cost-effectiveness studies, benefit is often measured by change in health state utility value (HSUV), a single number summary of health-related quality of life anchored at 0 (state of being dead) and 1 (perfect health). Small differences in bilateral cochlear implant HSUV change conclusions of published models, and invalid estimates can therefore mislead policy and funding decisions. As such, we aimed to review and synthesize published HSUV estimates associated with cochlear implants.

DESIGN

We included observational or experimental studies reporting HSUV for adult patients (age ≥18 years) with at least moderate-profound sensorineural hearing loss in both ears who received unilateral or bilateral cochlear implants. We searched MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases up to May 1, 2021. Study and participant characteristics and HSUV outcomes were extracted. Narrative synthesis is reported for all studies. A Bayesian network meta-analysis was conducted to generate pooled estimates for the mean difference in HSUV for three comparisons: (1) unilateral cochlear implant versus preimplant, (2) bilateral cochlear implants versus preimplant, (3) bilateral versus unilateral cochlear implants. Our principal measure was pooled mean difference in HSUV.

RESULTS

Thirty-six studies reporting unique patient cohorts were identified. Health Utilities Index, 3 (HUI-3) was the most common HSUV elicitation method. HSUV from 19 preimplant mean estimates (1402 patients), 19 unilateral cochlear implant mean estimates (1701 patients), and 5 bilateral cochlear implants mean estimates (83 patients) were pooled to estimate mean differences in HUI-3 HSUV by network meta-analysis. Compared with preimplant, a unilateral cochlear implant was associated with a mean change in HSUV of +0.17 (95% credible interval [CrI] +0.12 to +0.23) and bilateral cochlear implants were associated with a mean change of +0.25 (95% CrI +0.12 to +0.37). No significant difference in HSUV was detected for bilateral compared with unilateral cochlear implants (+0.08 [95% CrI -0.06 to +0.21]). Overall study quality was moderate.

CONCLUSIONS

The findings of this review and network meta-analysis comprise the best-available resource for parameterization of cost-utility models of cochlear implantation in adults and highlight the need to critically evaluate the validity of available HSUV instruments for bilateral cochlear implant populations.Protocol registration: PROSPERO (CRD42018091838).

Underinsurance in children is associated with worsened quality of life after cochlear implantation

IMPORTANCE

Research has suggested that early cochlear implantation is associated with improved language outcomes. Select studies demonstrate that this translates into a higher quality of life following implantation. Previous work from our group has shown that underinsurance represents a risk factor for worsened auditory and language outcomes for implantees. However, to our knowledge, the effect of insurance status on quality of life outcomes following cochlear implantation has not been evaluated.

OBJECTIVE

To assess quality of life outcomes for children receiving cochlear implants, accounting for age at implantation, insurance status, gender, surgeon, number of implants and duration of follow-up since implantation.

DESIGN

A retrospective study using the Glasgow Children's Benefit Inventory (GCBI), a validated questionnaire measuring quality of life across four domains: learning, emotion, vitality and physical heath. Multivariate linear regression was used to examine the effects of age at implantation, insurance status, number of implants, sex, surgeon, and duration of follow-up on GCBI scores. Age at implantation was assessed as both a continuous and dichotomous variable, comparing children implanted by 12 months of age with those implanted after 12 months.

SETTING

Children's National Health System in Washington, DC, a tertiary academic referral center.

PARTICIPANTS

The GCBI was administered telephonically to parents/guardians of prelingually deaf children aged 2-16 years who received cochlear implants at the center between January 1, 2008 and December 31, 2018.

RESULTS

Of 169 prelingually deafened implantee children who met inclusion criteria, parents/guardians of 64 (37.9%) responded to the questionnaire. After excluding children with late implantation (≥7 years age at CI) and missing GCBI responses, the final analytic sample consisted of 57 children. The mean age (SD) of the children at the time of the study was 3.3 (1.9) years, 63.2% were publicly insured, and 73.7% were implanted after 12 months of age. Average duration of follow-up was 3.9 (2.8) years. On a scale of -100 to +100, GCBI scores ranged from 41.7 to 95.8 (mean (SD), 64.0 (10.3)). Public health insurance (β, -5.8 [95% CI, -10.6 to -0.01]), and older age at the time of implantation (β, -0.1 [95% CI, -0.3 to 0.0]), particularly implantation following 12 months of age (p < 0.05), were significantly associated with lower GCBI scores after implantation.

CONCLUSION

Publicly insured recipients of cochlear implants and children implanted at an older age, particularly after 12 months of age, experienced significantly lower quality of life measures.

Cross-cultural adaptation of the Nijmegen cochlear implant questionnaire into Turkish language: validity, reliability and effects of demographic variables

Purpose

The purpose of this study was to evaluate the validity and reliability of the Turkish version of the Nijmegen Cochlear Implant Questionnaire (Tr-NCIQ) and reveal the demographic factors contributing to the outcomes.

Methods

A group of 118 cochlear implant users aged between 18 and 70 years filled the Tr-NCIQ and the Turkish Hearing Handicapped Inventory for Adults (the Tr-HHI-Adult) via electronic survey. Cross-cultural adaptation of the Tr-NCIQ was performed. The reliability and validity of the questionnaire were evaluated utilizing internal consistency coefficient, split-half method, and predictive validity.

Results

The overall Cronbach’s alpha coefficient of the scale was 0.91, and the Spearman-Brown coefficient was 0.91. A moderately significant and negative correlation was present between the basic sound perception, speech production, self-esteem, activity, and social interactions subdomain scores and the HHI-Adult scores. Patients with post-lingual onset of hearing loss had significantly better results than those with pre-lingual onset, in the advanced sound perception subdomain. In addition, bilateral cochlear implant users had better results than the unilateral and bimodal users in the speech production subdomain and then the bimodal users in the self-esteem subdomain. There was no effect of age, duration of implant use, age at implantation, and the daily usage of cochlear implant (CI) on the quality-of-life outcomes.

Conclusion

The Tr-NCIQ is a reliable and valid tool to evaluate the subjective quality of life in CI users. In addition, as a standardized instrument, it can be easily self-administered both in clinical practice and for research purposes.

Application of Ambulatory Phonation Monitoring (APM) in the measurement of daily speaking-time and voice intensity before and after cochlear implant in deaf adult patients

OBJECTIVE

to evaluate the changes in daily voice production, analysed through the Ambulatory Phonation Monitoring (APM), and their relationship with Quality of Life (QOL) measurements in a group of profound deaf patients treated with Cochlear Implant (CI).

METHODS

A total of 12 consecutive post-lingual deaf patients (8 females and 4 males) treated with CI for bilateral severe-to-profound hearing loss were enrolled. Each patient was evaluated before and after 6 months of CI use. In particular, the daily voice production evaluation was performed using the APM, while QOL information were gathered from the Italian version of the Nijmegen Cochlear Implant Questionnaire (I-NCIQ).

RESULTS

Significant differences in the APM results obtained before and after CI were found. In particular, a significant decrease of the mean amplitude and a significant increase of the daily phonation time and percentage of phonation time were demonstrated after CI use in all the patients. A significant improvement in the I-NCIQ scores was demonstrated after CI use and significant correlations among I-NCIQ scores and the APM parameters were found.

CONCLUSIONS

The APM could be useful in the evaluation of the benefits of cochlear implantation and may represents an indicator of deaf patient participation. In addition, the daily voice production's modifications after CI and their significant relations with the changes in QOL measurements could be useful in treatment planning as well as during pre- and post-operative counselling.

Statistical considerations for crowdsourced perceptual ratings of human speech productions

Crowdsourcing has become a major tool for scholarly research since its introduction to the academic sphere in 2008. However, unlike in traditional laboratory settings, it is nearly impossible to control the conditions under which workers on crowdsourcing platforms complete tasks. In the study of communication disorders, crowdsourcing has provided a novel solution to the collection of perceptual ratings of human speech production. Such ratings allow researchers to gauge whether a treatment yields meaningful change in how human listeners' perceive disordered speech. This paper will explore some statistical considerations of crowdsourced data with specific focus on collecting perceptual ratings of human speech productions. Random effects models are applied to crowdsourced perceptual ratings collected in both a continuous and binary fashion. A simulation study is conducted to test the reliability of the proposed models under differing numbers of workers and tasks. Finally, this methodology is applied to a data set from the study of communication disorders.

Value within otolaryngology: Assessment of the cost-utility analysis literature

Objective

To assess the characteristics and quality of cost utility analyses (CUA) related to otolaryngology within the CEA registry and to summarize their collective results.

Methods

All cost-utility analyses published between 1976 and 2011 contained in the Cost-Effectiveness Analysis Registry (CEA Registry) were evaluated. Topics that fall within the care of an otolaryngologist were included in the review regardless of the presence of an otolaryngologist author. Potential associations between various study characteristics and CEA registry quality scores were evaluated using the Pearson product moment correlation coefficient.

Results

Sixty-one of 2913 (2.1%) total CUA publications screened were related to otolaryngology. Eighteen of 61 (29.5%) publications included an otolaryngologist as an author. Fourteen studies agreed on the cost effectiveness of at least unilateral cochlear implantation and six of seven (85.7%) studies demonstrated the cost effectiveness of continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). Forty-six percent (28 of 61) of all manuscripts were published between 2008 and 2011. A more recent publication year was associated with a higher CEA registry quality score while the presence of an otolaryngologist author and journal impact factor had no significant correlation with the quality of the CUA.

Conclusion

Based on current evidence in the CEA registry, unilateral cochlear implantation for hearing loss and CPAP for OSA are both cost-effective therapeutic interventions. Although CUAs in otolaryngology have increased in quantity and improved in quality in more recent years, there is a relative lack of CUAs in otolaryngology in comparison to other subspecialties.

Cross-cultural adaptation and validation of the Nijmegen Cochlear Implant Questionnaire into Italian

The NCIQ is a quantifiable self-assessment health-related quality of life instrument specific for cochlear implant users. The aim of this study was to culturally adapt the NCIQ into Italian (I-NCIQ). A prospective instrument validation study was conducted. Cross-cultural adaptation and validation were accomplished. Cronbach α was used to test internal consistency in 51 CI users and in a control group composed by 38 post-lingual deaf adult on a waiting list for a CI. ICC test was used for test-retest reliability analysis. Kruskal-Wallis test with Mann-Whitney post hoc were used to compare the I-NCIQ scores in CI users before and after the cochlear implantation and in control patients. I-NCIQ scores obtained in CI users were compared with the results of Italian version of disyllabic testing without lip-reading and without masking. Good internal consistency and good test-retest reliability were found. I-NCIQ scores obtained in the 51 CI users after implantation were consistently higher than those obtained before implantation and in the control group. Moreover, no differences were found in the results of I-NCIQ obtained in the group of 51 CI users before implantation and in the group of control patients on post hoc Mann-Whitney analysis. Positive correlations between I-NCIQ scores and the results of disyllabic testing without lip-reading and without masking were found. The I-NCIQ is a reliable, valid, self-administered questionnaire for the measurement of QOL in CI users; its application is recommended.

Targeting cholesterol homeostasis to fight hearing loss: a new perspective

Sensorineural hearing loss (SNHL) is a major pathology of the inner ear that affects nearly 600 million people worldwide. Despite intensive researches, this major health problem remains without satisfactory solutions. The pathophysiological mechanisms involved in SNHL include oxidative stress, excitotoxicity, inflammation, and ischemia, resulting in synaptic loss, axonal degeneration, and apoptosis of spiral ganglion neurons. The mechanisms associated with SNHL are shared with other neurodegenerative disorders. Cholesterol homeostasis is central to numerous pathologies including neurodegenerative diseases and cholesterol regulates major processes involved in neurons survival and function. The role of cholesterol homeostasis in the physiopathology of inner ear is largely unexplored. In this review, we discuss the findings concerning cholesterol homeostasis in neurodegenerative diseases and whether it should be translated into potential therapeutic strategies for the treatment of SNHL.

Analysis of the performance of post-lingually deafened patients with Nurotron(®) Venus™ cochlear implants

OBJECTIVE

The aim of this study was to analyze the safety and effectiveness of a new cochlear implant (CI) system developed in China, the Nurotron Venus device.

MATERIAL AND METHODS

Fifteen post-lingually deafened patients received Nurotron Venus CIs in our hospital. The safety and effectiveness of the devices were evaluated within 2 years after implantation. Patients' hearing thresholds were assessed. In addition, the speech perception performance of Nurotron Venus CI recipients was compared with that of 15 Cochlear Nucleus CI24 recipients.

RESULTS AND CONCLUSION

During 2 years of observation, all the Nurotron recipients used their devices regularly and effectively. The aided hearing thresholds of all the recipients were within the speech spectrum. The average scores of HOPE sentences and HOPE monosyllable words tests among Nurotron CI recipients were 82.88 ± 21.40% and 56.67 ± 9.77%, respectively. The average scores among Cochlear Nucleus CI24 recipients were 87.33 ± 14.44% and 52.8 ± 12.76%, respectively. There was no statistically significant difference in the speech test scores between these two groups when assessed using the t test. The Nurotron Venus cochlear implant system worked safely and effectively. The speech perception of Nurotron recipients was similar to that of the other CI system recipients.

Pediatric cochlear implantation: expanding applications and outcomes

Cochlear implantation is a revolutionary yet time-sensitive treatment for deaf children that must be performed within a critical window of time, in early life, for a congenitally deafened child to receive maximum benefit. Potential candidates should therefore be referred for evaluation early. Primary reasons for delay of cochlear implantation include slow referrals for care, parental delays, and payer delays. It is vital that all newborn children undergo hearing screening to identify deaf children at birth, and for parents, health care providers, and health care payers to be educated about the indications, important benefits, and reasonable risks of cochlear implantation for deaf children.

Social hearing measured with the Performance Inventory for Profound and Severe Loss: a comparison between adult multichannel cochlear implant patients and users of acoustical hearing aids

The objective of this study was to investigate social hearing in successful users of multichannel cochlear implants (CIs) and to compare the scores with those of a group of hearing-impaired adults using acoustical hearing aids (HAs). Out of 88 patients who had undergone surgery, 75 CI users with a mean age of 55 years and a mean pre-operative hearing level of 113dB in the better ear were compared with 59 users of acoustical HAs with a mean age of 56 years and a mean hearing level of 82dB in the better ear. Seven CI patients were non-users and were excluded from the study. The Performance Inventory for Profound and Severe Loss, a questionnaire that measures different aspects of hearing handicap, was used. The CI group scored significantly better than the HA group in three of six evaluated categories, measuring subjective intensity of sounds, speech with visual cues, and response to auditory failure. Awareness of environmental sounds, speech with no visual cues and personal reactions did not differ significantly. The group of successful CI users scored higher on a self-report measure than did a group of users of acoustical HAs with moderate- severe-profound deafness. The best CI users scored better than the best HA users, and the worst CI users scored worse than the worst HA users.

Dimensão afetiva da pessoa com surdez adquirida, antes e após o implante coclear

Este estudo teve como objetivo averiguar, antes e após o uso do implante coclear, a dimensão afetiva em pacientes adultos com surdez adquirida, no que diz respeito às modalidades dos sentimentos egoicos, sentimentos em relação ao próximo, sentimentos de temporalidade e estados de ânimo. Participaram 44 adultos que realizaram o implante coclear no Centro de Pesquisas Audiológicas do Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo de Bauru. Concluiu-se que, na vivência da surdez, houve predomínio de sentimentos negativos e de um clima afetivo de tensão e depressão, que levava o sujeito a uma vinculação negativa, de assintonia com o mundo. Entretanto, na vivência com o implante coclear, houve predomínio de sentimentos positivos e de um clima afetivo de tranquilidade e contentamento, observando-se uma vinculação positiva do sujeito e sintonia com o mundo.

Spiral ganglion neuron survival and function in the deafened cochlea following chronic neurotrophic treatment

Cochlear implants electrically stimulate residual spiral ganglion neurons (SGNs) to provide auditory cues for the severe-profoundly deaf. However, SGNs gradually degenerate following cochlear hair cell loss, leaving fewer neurons available for stimulation. Providing an exogenous supply of neurotrophins (NTs) has been shown to prevent SGN degeneration, and when combined with chronic intracochlear electrical stimulation (ES) following a short period of deafness (5 days), may also promote the formation of new neurons. The present study assessed the histopathological response of guinea pig cochleae treated with NTs (brain-derived neurotrophic factor and neurotrophin-3) with and without ES over a four week period, initiated two weeks after deafening. Results were compared to both NT alone and artificial perilymph (AP) treated animals. AP/ES treated animals exhibited no evidence of SGN rescue compared with untreated deafened controls. In contrast, NT administration showed a significant SGN rescue effect in the lower and middle cochlear turns (two-way ANOVA, p < 0.05) compared with AP-treated control animals. ES in combination with NT did not enhance SGN survival compared with NT alone. SGN function was assessed by measuring electrically-evoked auditory brainstem response (EABR) thresholds. EABR thresholds following NT treatment were significantly lower than animals treated with AP (two-way ANOVA, p = 0.033). Finally, the potential for induced neurogenesis following the combined treatment was investigated using a marker of DNA synthesis. However, no evidence of neurogenesis was observed in the SGN population. The results indicate that chronic NT delivery to the cochlea may be beneficial to cochlear implant patients by increasing the number of viable SGNs and decreasing activation thresholds compared to chronic ES alone.

The cost of cochlear implantation: a review of methodological considerations

Objectives. Cost studies can provide useful guidance, so long as they adhere to accepted methodology. Cochlear implants (CIs) are electronic devices introduced surgically into the inner ear. It is a relevant example to review cost study analyses because of its costliness. The aim of this study was to review relevant published cost studies of CI to analyze the method used. Methods. First, we described the key points of cost study methodology. Cost studies relating to CI were systematically reviewed, focussing on an analysis of the different methods used. Results. The methods, data sources, and estimated cost categories in each study varied widely. The paper showed that cost studies adopted significantly different approaches to estimate costs of CI, reflecting a lack of consensus on the methodology of cost studies. Conclusion. To increase its credibility, closer agreement among researchers on the methodological principles of cost studies would be desirable.

Bilateral cochlear implantation: current concepts, indications, and results

The optimal treatment for bilateral hearing loss continues to evolve as cochlear implant (CI) and hearing aid technologies advance, as does our understanding of the central auditory system. Ongoing discussions continue on the validity and feasibility of bilateral CI in terms of performance, justification of need, medical/surgical safety concerns, and economics. The purpose of this review article is to provide an update on the advantages and disadvantages of bilateral CI and to provide a discussion on timing (simultaneous vs. sequential), technology (bimodal vs. binaural) and feasibility. Binaural advantages are found in both adult and pediatric bilateral CI recipients, the greatest being the head shadow effect and improvements in localization and loudness summation. This theoretically offers an advantage over their unilateral implanted counterparts in terms of improved sound localization and enhanced speech perception under noisy conditions. Most investigators agree that bilateral stimulation during critical periods of development is paramount for optimizing auditory functioning in children. Currently, bilateral CI is widely accepted as a safe and effective means of bilateral auditory stimulation.

Performance and benefit as outcome measures following cochlear implantation in non-traditional adult candidates: a pilot study

OBJECTIVES

To measure the reported benefit in quality of life (QoL) and audiological performance in a group of 'non-traditional' patients undergoing cochlear implantation, and compare the results with those of patients satisfying established criteria for implantation.

DESIGN

Longitudinal retrospective observational study.

PATIENTS

Ten consecutive early-deafened, late-implanted patients, here termed 'non-traditional' patients, with a mean age of 31.3 years (range 15-52 years) and implant experience from 8 to 76 months (mean 40.9 months).

METHODS

The Glasgow Benefit Inventory (GBI) was used to evaluate benefit in QoL. Auditory performance tests consisted of: (a) recognition of environmental sounds using the UCL/RNID lists; (b) speech pattern perception using the Three Alternative Forced Choice Test; (c) speech discrimination using modified CUNY sentences in two conditions: lip-reading alone and lip-reading with the implant. Lip-reading enhancement scores were extrapolated.

RESULTS

GBI scores varied widely from 3 to 67, with a mean of 38.9, which is comparable to the mean score of 40 reported for 'traditional' candidates. Half the subjects were totally satisfied with their implant (scoring 100), and the mean satisfaction rating was 82.7. The mean scores obtained in environmental sound discrimination (40.5%) were a little below those of conventional, 'traditional' candidates, while those for speech pattern perception (73%) were within a comparable range. In contrast all ten subjects scored zero on open-set speech perception tests after implantation. The mean lip-reading enhancement score (7.6%) was significantly below that achieved by 'traditional' cochlear implant candidates.

CONCLUSION

This group of 'non-traditional' adults demonstrates measured benefit in QoL, which is comparable to that achieved by 'traditional' candidates, but is not accompanied by a parallel improvement in performance on speech perception tasks. These results suggest that factors other than auditory performance may be equally important from the patient's perspective, and that some patients who might be considered poor candidates may still derive considerable benefit. It is suggested that benefit and performance be viewed as separate outcomes in this 'non-traditional' population.

Psychometric validity of the Cochlear Implant Function Index (CIFI): a quality of life assessment tool for adult cochlear implant users

OBJECTIVE

The Cochlear Implant Function Index (CIFI) is created to assess adult cochlear implant (CI) auditory effectiveness in real world situations. Our objective is to evaluate the CIFI as a reliable psychometric tool to assess 1) reliance on visual assistance, 2) telephone use, 3) communication at work, 4) 'hearing' in noise, 5) in groups, and 6) in large room settings.

STUDY DESIGN

Based upon Guttman scaling properties, the CIFI elicits implanted respondent's functional level with auditory independence from Level 1 (still requiring signing) to level 4 (without any help beyond CI). A blinded, retrospective questionnaire is anonymously answered by cochlear implant recipients.

SETTING

CI centers of tertiary care medical centers, CI support group, and an interactive web page of a hearing and speech center in a large metropolitan region.

SUBJECTS

245 respondents from a varied adult CI population implanted for one month to 19 years prior to answering the questionnaire.

INTERVENTION

An assessment tool of CI function.

MAIN OUTCOME MEASURE

A coefficient of reproducibility (CR) for the Guttman scale format equal or greater than 0.90, indicating good scalability.

RESULTS

CR in the CIFI was above 0.90. Effective scalability and mean scores from 2.5 to 3.5 for the six areas examined (1.00-4.00) were achieved.

CONCLUSION

The psychometric properties of this user friendly survey demonstrate consistently good scalability. Based on these findings, the CIFI provides a validated tool that can be used for systematic comparisons between groups of patients or for follow-up outcomes in patients who use cochlear implants. Further study is indicated to correlate CIFI scores with sound and speech perception scores.

Living with cochlear implants: experiences of 17 adult patients in Sweden

The aim of this grounded theory study was to gain a deeper understanding of what it means to profoundly deaf adults to undergo cochlear implantation and their experience of living with it daily. The aim of grounded theory is theorizing, i.e. constructing from data an explanatory scheme that systematically integrates various concepts and their relationships. The study group consisted of 10 women and seven men (age 29-78 years; mean age 56.5 years), who had had their cochlear implant (CI) for between 1 and 12 years (mean 4.1 years). Open taped interviews were carried out and analysed. The core category, coming back to life, defines a psychological process basic to existence, elucidating the existential value of hearing, including perceived harmony in life and becoming a part of the living world as important dimensions. This core concept is related to four additional emerging categories in a temporal order. Preventing disappointment concerns the decision to undergo the operation governed by the conception of having nothing to lose combined with low expectations of successful outcomes. Waiting in silence relates to experiences during the postoperative period such as sensations from the head and uncertainty about the outcome of surgery. The 'switch-on' was experienced as a significant revelation and the emotionally loaded starting point for their coming back to life. Retraining the brain concerns the lengthy audiovisual learning process. finally resulting in 'a car sounding like a car'. Strengthening of self-worth concerns psychosocial outcomes of cochlear implantation, in terms of less dependency and increased social participation. CIs provide a substantial improvement in the quality of life, as identified in the emerging generic process of coming back to life, fundamental for psychological existence.

The efficacy of a structured group therapy intervention in improving communication and coping skills for adult cochlear implant recipients

This paper reports on an evaluation of a structured group therapy intervention for adult cochlear implant (CI) recipients designed to improve overall communication and coping skills. 33 adult CI recipients (14 males, 19 females; mean age 61; 1-14 years since Cl) participated in a 2-day structured group therapy intervention with a follow-up session 4 weeks later. Measures were: communication behaviors (CPHI), assertiveness (Rathus), depression (DASS), and behavior during conversation (Dyalog). TCI personality traits were utilized as predictors of change. Repeated measures analyses showed that participants demonstrated significant improvements on measures of assertiveness, emotional well-being, and coping behaviors at 3 months post-intervention that persisted at a 12-month follow-up. Several personality traits predicted change. Although subjects had presumably adapted to their cochlear implants and had learned communication strategies in hearing rehabilitation programs, the improvements on several measures suggest that a structured group therapy intervention can enhance outcome following cochlear implantation.

The economics of cochlear implant management in France: a multicentre analysis

This study assessed the direct medical cost of cochlear implantation in children and adults in France. A prospective multicentre study involving 19 French University Hospitals included 268 children and 201 adults who were severely to profoundly hearing-impaired. Medical resources utilisation included diagnostic tests, in-patient care, device implants, adverse events and follow-up visits for rehabilitation in the 1st year. The mean costs were <euro>34,686 per child and <euro>31,946 per adult. The cost of device implant represents 64.4% and 68.8% of the total cost for children and adults, respectively. The current reform of financing of the healthcare system requires detailed knowledge of the costs of interventions, hence the costs of cochlear implantation should be factored into resource allocation decisions. Differences in our results compared to other studies can be explained mostly by methodological differences in cost analyses.

'Transforming' self and world: a phenomenological study of a changing lifeworld following a cochlear implant

After 50 years of being profoundly deaf, Patricia (Pat) finds her world 'transformed'-literally and metaphorically-when she receives a cochlear implant. Her sense of self and the taken-for-granted, comfortable world she knew before surgery disappear and she is thrown into an alien, surreal existence full of hyper-noise. Entry into this new world of sounds proves a mixed blessing as Pat struggles to come to terms with her changing relationships, not only with others (who now feel somehow 'different' to her) but also with herself. On good days, she is exhilarated by all her sensory gains and her feeling of being more connected with and to the world. On bad days she is distracted and overwhelmed by the intrusive noise and she is forcibly confronted with the painful reality of her own disability (past and present). The challenge she confronts is not simply the cognitive-perceptual one of learning to discriminate between sounds. Pat must also re-orientate herself and learn to cope with her transformed self and world. She must undertake a journey to come to terms with her past, present and future being. Pat shared her story with me and together we undertook collaborative existential phenomenological research, co-creating a narrative of her journey over the year and a half following her implant. This paper presents this narrative followed by an existential analysis of Pat's disrupted, changing lifeworld.

Outcomes in bilateral cochlear implantation

OBJECTIVE

The objective of this study was to explore improvements in quality of life and the cost-utility of bilateral cochlear implantation.

STUDY DESIGN AND SETTING

A prospective case-control study was conducted on 23 bilateral cochlear implant patients with the Mark III health utility index.

RESULTS

Results indicate a 0.48 mean gain in health utility after bilateral cochlear implantation and a discounted cost per quality adjusted life year of $24,859 in this cohort of patients. With a comparison of patient scores for unilateral and bilateral use, improvements in the domains of hearing, speech, emotion, and cognition were noted, resulting in a mean gain in health utility of 0.11.

CONCLUSIONS

This study found an improvement in quality of life and a favorable cost-utility associated with bilateral cochlear implantation in patients with profound hearing loss. These patients showed additional improvements in quality of life after they received their second implant.

CLINICAL SIGNIFICANCE

This is the first study that showed improvements in quality of life and a favorable cost-utility after bilateral cochlear implantation in patients with profound hearing loss.

Cost-utility analysis of cochlear implants in Korea using different measures of utility

CONCLUSIONS

All cost-utility ratios obtained using the various measures of utility except quality well-being (QWB) were below 25,000 dollars per quality-adjusted life year (QALY). Therefore, treatment of post-lingual deaf adults with cochlear implants improves the quality of life at a reasonable direct cost and appears to produce net savings for Korean society.

OBJECTIVES

To determine the quality of life and the cost consequences of cochlear implants for deaf adults.

PATIENTS AND METHODS

We performed a cost-utility analysis using data from 11 post-lingual deaf adults who had received cochlear implants between 1990 and 2002 in Seoul, Korea. The average age of the participants was 49.6 years. The main outcome was the direct cost per QALY calculated using the visual analog scale (VAS), health utility index (HUI), EuroQol (EQ-5D) measure and QWB measure. Costs and utility were discounted 3% annually.

RESULTS

Recipients used implants for an average of 5.6 years. The mean VAS, HUI, EQ-5D, and QWB score increased by 0.33 (from 0.27 before implantation to 0.60 at survey), 0.36 (0.29 to 0.65), 0.26 (0.52 to 0.78), and 0.16 (0.45 to 0.61), respectively. The discounted direct cost was 22,320 dollars, which yielded a cost-utility ratio of 19,223 dollars per QALY using VAS, 17,387 dollars per QALY using HUI, 24,604 dollars per QALY using EQ-5D, and 40,474 dollars per QALY using QWB.

Health-related quality of life and hearing aids: a tutorial

Health-related quality-of-life (HRQoL) instruments measure the impact of a disorder and treatment on several attributes that are thought to constitute the self-perceived health status of an individual. This tutorial reviews the conceptual framework of HRQoL, including the challenges associated with defining and measuring HRQoL, specifically as it applies to audiologic care. A relatively new instrument, the World Health Organization-Disability Assessment Schedule II, will be discussed as a potentially valuable instrument to measure the impact of hearing loss and hearing aid intervention on self-perceived HRQoL.

Speech perception in elderly patients following cochlear implantation

CONCLUSIONS

Elderly patients benefit from cochlear implantation in terms of speech perception and quality of life. Age alone should be no contraindication for implantation.

OBJECTIVE

There have been concerns whether elderly patients may perform poorly after cochlear implantation due to degenerative processes in the central and peripheral auditory systems. The purpose of this study was to analyze the benefits of cochlear implantation in elderly patients in comparison to younger recipients.

MATERIAL AND METHODS

We examined 26 postlingually deafened adults aged > 65 years who received a cochlear implant at our center regarding preoperative findings, comorbidities, postoperative complications and quality of life. Speech perception was assessed by means of multi- and monosyllabic word recognition and compared to the results obtained by younger patients.

RESULTS

The surgical procedure was well tolerated by all patients without notable perioperative complications. In terms of speech perception, no significant differences between the elderly patients and younger recipients were noted. All patients found that cochlear implantation had a positive impact on their quality of life.

Cochlear Implantation in Severe Traumatic Brain Injury and Paranoid Schizophrenia: Two Case Studies

In view of the demanding instruction and training requirements associated with cochlear implantation, patients with cognitive impairments have typically been considered to be poor candidates for this procedure. This presumption persists in part because experience and research in this area are limited. We describe our experience with implanting cochlear devices in 2 patients who had significant psychological impairments; 1 patient had experienced a severe brain injury, and the other had paranoid schizophrenia. Nevertheless, both patients were able to follow the implant training program, and they experienced different degrees of improvement in their hearing. We discuss our preoperative evaluations of these patients and the key factors that led to our decision to proceed with surgery.

Cochlear Implants and Quality of Life: A Prospective Study

OBJECTIVE

To evaluate changes in quality of life, anxiety, and depression after cochlear implantation in adults.

DESIGN

Twenty-seven postlingually deafened adults who had received a MED-EL Combi 40+ implant were investigated. One generic Health-Related Quality of Life measure, the SF-36, two disease-specific measures, the Patient Quality of Life Form (PQLF) and the Index Relative Questionnaire Form (IRQF) completed by a near relative to the patient, in addition to a domain specific measure, the Hopkins Symptom Check List 25 items (HSCL-25), were used in a prospective study. The subjects were investigated before surgery and 12 to 15 months after surgery.

RESULTS

The scores were significantly better after surgery in four of six categories of the PQLF. In the IRQF, where a family member of the cochlear implant recipient was studied, the scores were significantly better in four of five categories. There was a significant improvement in the HSCL-25 scores after surgery. In the SF-36, only one of eight scales showed significant improvement.

CONCLUSIONS

Cochlear implants were associated with statistically significant improvement in quality of life in postlingually deafened adults. The improvements were largest in the categories concerning communication, feelings of being a burden, isolation, and relations to friends and family. The implants also improved the relatives' daily lives. There was a statistically significant reduction in degree of depression and anxiety. Reduction in anxiety and depression was associated with gain in quality of life.

[Bioethical issues in pediatric cochlear implants]

The use of cochlear implants can modify significantly the way in which deaf children relate with the outside world through psychological, linguistic and cognitive changes. The main question about this subject is the ethical controversy with regards to who has the right to make such a decision for a young child. We present the children evaluated at our hospital in order to assess the cochlear implant option. That population was of 37 implanted children, 10 children waiting for surgery and 21 rejected children. We describe and analyze from the bioethical bases and methodology the problems found: decision of no implant in children of hearing parents, the deaf culture point of view, the mature minor doctrine, teenagers, social and cultural problems, multihandicapped children and responsibility of the implants team.

Changes in quality of life and the cost-utility associated with cochlear implantation in patients with large vestibular aqueduct syndrome

OBJECTIVE

A group of 20 patients with large vestibular aqueduct syndrome was identified at the Indiana University School of Medicine. The major objective of this study was to explore the improvements in quality of life associated with cochlear implantation in patients with large vestibular aqueduct syndrome, as well as the cost-utility of cochlear implantation in this group.

SETTING

A total of 70 patients were identified with large vestibular aqueduct syndrome through analysis of thin-section computed tomography of the temporal bone over the past 6 years at this medical center. Data collected from the medical records for each patient included demographic data, hearing-related statistics, implantation data, and audiometric data. Sixteen children and adults with large vestibular aqueduct syndrome had undergone cochlear implantation before the beginning of this study, and the remaining 54 children and adults were identified as undergoing treatment of progressive or fluctuant sensorineural hearing loss. Health utility indexes used in this analysis were taken through the use of the Ontario Health Utility Index, Mark III. The range of costs used for cost-utility analysis was derived from the costs of cochlear implantation at this medical center, as well as from costs associated with implantation published in the medical literature.

METHODS

Participants were selected from the total population of patients with large vestibular aqueduct syndrome at this center who were postlingually deafened and who currently had severe hearing loss. Two groups were formed. These groups comprised either cochlear implant patients with large vestibular aqueduct syndrome or patients with large vestibular aqueduct syndrome currently using hearing aids. Ten of the 16 cochlear implant patients and 10 of the remaining 54 patients with large vestibular aqueduct syndrome met these criteria. Mark III health utility indexes were distributed to patients in each group and scored. Those health utility indexes not completed by the patients were scored by proxy, using the audiologist at this center who was the most familiar with the patient. Changes in quality of life associated with cochlear implantation were derived by comparison of the health utility index results of the two groups. Cost-utility measures were then made using discounted costs per quality-of-life years (QALYs) (5%), and a sensitivity analysis was performed that evaluated changes in scoring done by proxy. The cost-utility results were then compared with the cost-utilities derived from similar studies and associated with other disease states.

RESULTS

Although both groups of patients had significant hearing loss, the hearing aid group had a better mean pure-tone average. The mean pure-tone average for the hearing aid group was 70.8 dB (SD 24.4), and the mean pure-tone average for the cochlear implant group was 107.0 dB (SD 21.7). Seven of the 20 health utility indexes were scored by proxy. Results from the base case indicate a 0.20 gain in health utility from cochlear implantation (hearing aid = 0.62, cochlear implant = 0.82, p = 0.037), resulting in a discounted cost per QALY of $12,774. Sensitivity analysis of the proxy scoring indicated that decreasing the hearing score one level on the health utility index resulted in a gain in health utility with cochlear implantation of 0.15, resulting in a discounted cost per QALY of $17,832. A decrease of the hearing score by two levels on the health utility survey resulted in no significant gain in quality of life with cochlear implantation.

CONCLUSION

This study found an improvement in quality of life associated with cochlear implantation in postlingually deafened patients with large vestibular aqueduct syndrome. By weighing this improvement in quality of life against the significant difference noted between the pure-tone averages of each group, further strength can be given to this conclusion. This gain in quality of life, as well as the results derived for the cost-utility of cochlear implantation, was similar to that in previous published studies of cochlear implantation in all types of patients. These results also indicate a favorable cost-utility when compared with published data about other disease states. As patients with large vestibular aqueduct syndrome progress to profound levels of hearing loss, these results indicate that cochlear implantation can be offered as a beneficial, life-improving therapy.

Impact of Ménière's disease on quality of life

OBJECTIVE

To describe health-related quality of life among patients with Ménière's disease in whom conventional therapy failed and who requested further medical intervention.

STUDY DESIGN

Pretreatment interviews to establish baseline quality of life characteristics before medical intervention.

SETTING

Tertiary referral center.

PATIENTS

19 adult patients, 12 women and 7 men, whose ages ranged from 32 to 83 years.

INTERVENTIONS

Pretreatment baseline interviews.

MAIN OUTCOME MEASURES

Quality of Well-being Scale, SF-12 Physical and SF-12 Mental scores, Center for Epidemiologic Studies-Depression Scale.

RESULTS

The Quality of Well-being score (0.561) indicated a loss of well-being from 1 to 0.561 = 43.9% in patients with Ménière's disease as compared with people with no symptoms and full functional status. The hypothesis that Quality of Well-being scores on days on which patients had symptoms characteristic of acute Ménière's disease episodes were lower than Quality of Well-being scores on days on which they did not report such symptoms was supported (p = 0.000). The reported SF-12 Physical mean score (38.9) was greater than 1 standard deviation below the general mean of 50, and the SF-12 Mental score (44.2) was 0.5 standard deviation below the general mean of 50. The Center for Epidemiologic Studies-Depression Scale score was 23, with a score 16 or greater indicating clinically significant depression.

CONCLUSIONS

The results suggest that the condition of patients with Ménière's disease may be measured by these instruments, that the instruments are in substantial agreement about the serious impairment in patients' quality of life, and that the days with acute episodes of Ménière's disease symptoms are significantly worse than the days without such symptoms. Treating physicians indicated surprise at the breadth and the level of debilitation characteristic of these patients with Ménière's disease.

Outcomes and patient-based hearing status in conductive hearing loss

OBJECTIVES/HYPOTHESIS

To study hearing status and quality of life outcomes in patients with conductive hearing loss (CHL), and to develop a prognostic disease severity staging system for use in future clinical outcomes studies in CHL.

STUDY DESIGN

Clinical outcomes research study in three stages: 1) Prospective development and psychometric validation of a disease-specific hearing status outcomes instrument for CHL. 2) Prospective observational outcomes study of patient-based hearing status and quality of life (QOL) outcomes after treatment of CHL. 3) Development of a prognostic disease-severity staging system to stratify patients into groups of similar treatment outcome.

METHODS

Psychometric instrument validation: assessment of test-retest reliability, internal consistency reliability, content, construct and criterion validity, and responsiveness to change. Statistical assessment of the impact of CHL on patient-based hearing status and QOL, and the change in hearing status and QOL after treatment. Using data from the prospective study and multivariate regression, identification of pretreatment independent variables, which predict good outcome after treatment, and development of a severity staging system.

RESULTS

Test-retest reliability (r >0.70) and internal consistency reliability (alpha >0.70) were adequate for both subscales of the hearing status instrument. Construct validity was demonstrated by adequate convergent/divergent validity with other health status instruments on multi-item multitrait correlation matrixes. Criterion validity was demonstrated using audiometric threshold data. Responsiveness to change was demonstrated using the standardized response mean after treatment (SRM = 0.40 and 0.61 for the two subscales). Emotional hearing status and social/situational hearing status improved significantly after treatment of CHL: emotional score, 31.1 to 56.6 (P < .001); social/situational score, 56.7 to 63.7 (P = .01). Mean QOL subscale scores for patients with CHL were not significantly different from healthy populations, and global QOL scores did not change significantly after treatment of CHL. Using proportional improvement in emotional hearing status as an outcome, we identified several pretreatment factors that predicted good outcome (i.e., larger proportional improvement): level of pretreatment emotional hearing status, presence of sensorineural component of HL, and etiology of CHL (otosclerosis vs. all other causes). Some hypothesized predictive independent factors, such as bilateral HL, audiometric threshold level, pretreatment functional status, employment status, age, and duration of HL, were not identified as significant predictors of outcome in the multivariate analysis. We constructed a prognostic disease severity staging system in which the three predictor variables were each given a score of 0 or 1, and these three scores were added to obtain the disease stage (stage 0, 1, 2, or 3). Higher disease stage indicated more severe disease or a lower proportional improvement in emotional hearing status after treatment. This staging system appropriately stratified patients into groups of similar outcome after treatment (P = .02) and has significant potential use for future outcomes research on CHL.

CONCLUSIONS

We have developed and validated a patient-based hearing status outcomes instrument for use in CHL. We have measured hearing status and quality of life outcomes after treatment of CHL, and we have developed a prognostic disease severity staging system that predicts the improvement in emotional hearing status after treatment of CHL.

Cochlear implant patients and quality of life

During the last two decades, cochlear implants have been available for profoundly hearing-impaired patients who do not benefit from conventional hearing aids. The quality of life of these implantees has not been extensively studied, and has not been studied at all in Finland. To assess their quality of life, the Nottingham Health Profile questionnaire was sent to all adult implanted patients in Finland. Implantees tended to have more favourable average pain, emotional reaction and mobility indexes in each age group studied than the average population. Social-isolation seemed to be more common in the youngest and oldest age groups of implantees. Apparently, implantees are physically healthier than the average population. However, a bias caused by the strict selection of implant candidates cannot be excluded.

Accuracy of terminology and methodology in economic analyses in otolaryngology

OBJECTIVE

Economic studies increasingly guide health care resource allocation decisions. Because rigorous adherence to accepted definitions and research techniques is critical to ensure accuracy, we evaluated the terminology and methods of otolaryngology economic analyses.

STUDY DESIGN

A total of 71 articles published from 1990 to 1999 in 6 peer-reviewed otolaryngology journals with terms such as "cost-effective" in their title or representing economic analyses were reviewed for terminology and use of established methodology guidelines.

RESULTS

Over half (35 of 66) of terms such as "cost-effective" were used incorrectly, and 60% of articles (39 of 64) confused "charge" and "cost" data. Eleven percent (7 of 64) of papers specified the perspective of their analysis. About half (17 of 30) reported a summary measure such as a cost-effectiveness ratio. Only one third (23 of 63) performed sensitivity analyses.

CONCLUSION

Adherence to accepted definitions and research methods is inconsistent, although we did note moderate improvements in making the distinction between costs and charges, defining of study perspective, and performing sensitivity analysis.

SIGNIFICANCE

Greater attention to both terminology and methodology can enhance the quality of economic analyses and ultimately improve certain resource allocation decisions.

Development and application of a health-related quality-of-life instrument for adults with cochlear implants: the Nijmegen cochlear implant questionnaire

OBJECTIVE

The goal was to develop a quantifiable, self-assessment health-related quality of life (QoL) instrument for use in cochlear implant (CI) users.

DESIGN

Three principal domains were distinguished: physical, psychological, and social. Forty-five postlingually deaf adult multichannel CI users and 46 deaf candidates on the waiting list for CIs (control group) participated in the study.

RESULTS

Retrospective scores for the CI group corresponded very well with the scores for the control group. Current QoL scores were substantially higher for all 6 subdomains. Internal consistency and testretest reliability coefficients proved to be satisfactory, and the ability to detect clinical changes with the Nijmegen Cochlear Implantation Questionnaire (NCIQ) proved to be good.

CONCLUSIONS

The psychometric characteristics of the NCIQ proved to be reliable and probably valid and sensitive to clinical changes. The data obtained with the NCIQ reflected that the instrument was able to detect that a CI had significant effects on several health-related QoL aspects, including the social and psychological domains.

Redefining the survival of the fittest: communication disorders in the 21st century

OBJECTIVES

To determine the economic effect on the US economy of the cost of caring for people with communication disorders as well as the cost of lost or degraded employment opportunities for people with such disorders, including disorders of hearing, voice, speech, and language.

STUDY DESIGN

Survey of available historical and contemporary governmental and scholarly data concerning work force distribution and the epidemiology of disorders of hearing, voice, speech, and language.

METHOD

Analysis of epidemiological and economic data for industrialized countries, North America, and the United States.

RESULTS

Communication disorders are estimated to have a prevalence of 5% to 10%. People with communication disorders may be more economically disadvantaged than those with less severe disabilities The data suggest that people with severe speech disabilities are more often found to be unemployed or in a lower economic class than people with hearing loss or other disabilities. Communication disorders may cost the United States from $154 billion to $186 billion per year, which is equal to 2.5% to 3% of the Gross National Product.

CONCLUSIONS

Communication disorders reduce the economic output of the United States, whose economy has become dependent on communication-based employment. This trend will increase during the next century. The economic cost and the prevalence rates of communication disorders in the United States indicate that they will be a major public health challenge for the 21st century.

Communications disorders and the interactions and relation(s) to other disorders susceptibility

Communication is the action and process of transmitting a message and the way in which this message is received and interpreted. We observe the social character of this action and its effectiveness. Evidently, in order to make communication effective, it is necessary for the attitude of the receiver to be socially, ideologically and psychologically receptive. Communication and language are practically two indistinguishable terms. In the case of a deaf child, the learning of cognitive abilities depends absolutely on how his environment educates him. Today we depend on new communication skills and their particular mission and meaning with reference to otolaryngology. In the age of communication in the 21st century, society will direct its resources toward strategy of preventive and medical care that will optimize the population's health communication. Otolaryngology will continue to grow and prosper by responding to these pressing human and social needs and building upon communications, and by incorporating them in this new domain, of language, thus we will be able to find the medical and surgical cures for communication disorders.

Ethics of cochlear implantation in young children: a review and reply from a Deaf-World perspective

This article examines ethical dilemmas related to cochlear implant surgery in children. These dilemmas arise from the existence of a linguistic and cultural minority called the Deaf World. Organizations of culturally Deaf adults in the United States and abroad, as well as the World Federation of the Deaf, have, on ethical grounds, strongly criticized the practice of cochlear implant surgery in children. Three ethical dilemmas are examined. (1) The surgery is of unproven value for the main significant benefit sought, language acquisition, whereas the psychological, social, and linguistic risks have not been assessed. Thus the surgery appears to be innovative, but innovative surgery on children is ethically problematic. (2) It is now widely recognized that the signed languages of the world are full-fledged natural languages, and the communities that speak those languages have distinct social organizations and cultures. Deaf culture values lead to a different assessment of pediatric cochlear implant surgery than do mainstream (hearing) values, and both sets of values have standing. (3) The fields of otology and audiology want to provide cochlear implants to Deaf children but also, their leaders say, want to protect Deaf culture; those appear to be conflicting goals in principle because, if there were perfect implants, the ranks of the Deaf World would diminish.