Effects of electrode configuration and place of stimulation on speech perception with cochlear prostheses

The effects of estimation accuracy, estimation approach, and number of selected channels using formant-priority channel selection for an "n-of-m" sound processing strategy for cochlear implants

Previously, selection of l channels was prioritized according to formant frequency locations in an l-of-n-of-m-based signal processing strategy to provide important voicing information independent of listening environments for cochlear implant (CI) users. In this study, ideal, or ground truth, formants were incorporated into the selection stage to determine the effect of accuracy on (1) subjective speech intelligibility, (2) objective channel selection patterns, and (3) objective stimulation patterns (current). An average +11% improvement (p < 0.05) was observed across six CI users in quiet, but not for noise or reverberation conditions. Analogous increases in channel selection and current for the upper range of F1 and a decrease across mid-frequencies with higher corresponding current, were both observed at the expense of noise-dominant channels. Objective channel selection patterns were analyzed a second time to determine the effects of estimation approach and number of selected channels (n). A significant effect of estimation approach was only observed in the noise and reverberation condition with minor differences in channel selection and significantly decreased stimulated current. Results suggest that estimation method, accuracy, and number of channels in the proposed strategy using ideal formants may improve intelligibility when corresponding stimulated current of formant channels are not masked by noise-dominant channels.

Apical Reference Stimulation: A Possible Solution to Facial Nerve Stimulation

OBJECTIVES

Postimplantation facial nerve stimulation is a common side-effect of intracochlear electrical stimulation. Facial nerve stimulation occurs when electric current intended to stimulate the auditory nerve, spread beyond the cochlea to excite the nearby facial nerve, causing involuntarily facial muscle contractions. Facial nerve stimulation can often be resolved through adjustments in speech processor fitting but, in some instances, these measures exhibit limited benefit or may have a detrimental effect on speech perception. In this study, apical reference stimulation mode was investigated as a potential intervention to facial nerve stimulation. Apical reference stimulation is a bipolar stimulation strategy in which the most apical electrode is used as the reference electrode for stimulation on all the other intracochlear electrodes.

DESIGN

A person-specific model of the human cochlea, facial nerve and electrode array, coupled with a neural model, was used to predict excitation of auditory and facial nerve fibers. These predictions were used to evaluate the effectiveness in reducing facial nerve stimulation using apical reference stimulation. Predictions were confirmed in psychoacoustic tests by determining auditory comfort and threshold levels for the apical reference stimulation mode while capturing electromyography data in two participants.

RESULTS

Models predicted a favorable outcome for apical reference stimulation, as facial nerve fiber thresholds were higher and auditory thresholds were lower, in direct comparison to conventional monopolar stimulation. Psychophysical tests also illustrated decreased auditory thresholds and increased dynamic range during apical reference stimulation. Furthermore, apical reference stimulation resulted in lower electromyography energy levels, compared to conventional monopolar stimulation, which suggests a reduction in facial nerve stimulation. Subjective feedback corroborated that apical reference stimulation alleviated facial nerve stimulation.

CONCLUSION

Apical reference stimulation may be a viable strategy to alleviate facial nerve stimulation considering the improvements in dynamic range and auditory thresholds, complemented with a reduction in facial nerve stimulation symptoms.

Perceptual learning of pitch provided by cochlear implant stimulation rate

Cochlear implant users hear pitch evoked by stimulation rate, but discrimination diminishes for rates above 300 Hz. This upper limit on rate pitch is surprising given the remarkable and specialized ability of the auditory nerve to respond synchronously to stimulation rates at least as high as 3 kHz and arguably as high as 10 kHz. Sensitivity to stimulation rate as a pitch cue varies widely across cochlear implant users and can be improved with training. The present study examines individual differences and perceptual learning of stimulation rate as a cue for pitch ranking. Adult cochlear implant users participated in electrode psychophysics that involved testing once per week for three weeks. Stimulation pulse rate discrimination was measured in bipolar and monopolar configurations for apical and basal electrodes. Base stimulation rates between 100 and 800 Hz were examined. Individual differences were quantified using psychophysically derived metrics of spatial tuning and temporal integration. This study examined distribution of measures across subjects, predictive power of psychophysically derived metrics of spatial tuning and temporal integration, and the effect of training on rate discrimination thresholds. Psychophysical metrics of spatial tuning and temporal integration were not predictive of stimulation rate discrimination, but discrimination thresholds improved at lower frequencies with training. Since most clinical devices do not use variable stimulation rates, it is unknown to what extent recipients may learn to use stimulation rate cues if provided in a clear and consistent manner.

Effects of a sequential cochlear implant of minimum comfort, impedance and electrically evoked compound action potential values of the initial cochlear implant

PURPOSE

To evaluate the impact of sequential second CI on the electrophysiological parameters of the initial CI.

METHODS

Totally, 30 children who received sequential CIs between January and July 2018 were included in the study. All patients received the same brand of CI (Advanced Bionics, HIRES 90K Advantage 1J). Of 16 CI electrodes, 3rd (E3), 7th (E7) and 11th (E11), and 15th (E15) electrodes which were corresponding to the apical, middle, and basal cochlea were used in the measurements. The tNRI, electrode impedance and M levels were recorded as the contralateral CI was switched off and on, respectively.

RESULTS

As the second CI was switched off, the impedance, tNRI and M values of initial CI 1st, 3rd and 6th months were not significantly different (p > 0.05). There was a significant difference between the impedance, tNRI and M values of initial CI as the second CI was switched on (p < 0.05).

CONCLUSION

Activation of the sequential second CI leads to a decrease in the tNRI and M levels of the initial CI. This condition can increase the efficiency obtained by CIs. However, these changes should be remembered during CI programming.

Systematic Review of Auditory Training in Pediatric Cochlear Implant Recipients

Objective The purpose of this systematic review is to evaluate the published research in auditory training (AT) for pediatric cochlear implant (CI) recipients. This review investigates whether AT in children with CIs leads to improvements in speech and language development, cognition, and/or quality of life and whether improvements, if any, remain over time post AT intervention. Method A systematic search of 7 databases identified 96 review articles published up until January 2017, 9 of which met the inclusion criteria. Data were extracted and independently assessed for risk of bias and quality of study against a PICOS (participants, intervention, control, outcomes, and study) framework. Results All studies reported improvements in trained AT tasks, including speech discrimination/identification and working memory. Retention of improvements over time was found whenever it was assessed. Transfer of learning was measured in 4 of 6 studies, which assessed generalization. Quality of life was not assessed. Overall, evidence for the included studies was deemed to be of low quality. Conclusion Benefits of AT were illustrated through the improvement in trained tasks, and this was observed in all reviewed studies. Transfer of improvement to other domains and also retention of benefits post AT were evident when assessed, although rarely done. However, higher quality evidence to further examine outcomes of AT in pediatric CI recipients is needed.

The perception of emotion and focus prosody with varying acoustic cues in cochlear implant simulations with varying filter slopes

This study aimed to find the optimal filter slope for cochlear implant simulations (vocoding) by testing the effect of a wide range of slopes on the discrimination of emotional and linguistic (focus) prosody, with varying availability of F0 and duration cues. Forty normally hearing participants judged if (non-)vocoded sentences were pronounced with happy or sad emotion, or with adjectival or nominal focus. Sentences were recorded as natural stimuli and manipulated to contain only emotion- or focus-relevant segmental duration or F0 information or both, and then noise-vocoded with 5, 20, 80, 120, and 160 dB/octave filter slopes. Performance increased with steeper slopes, but only up to 120 dB/octave, with bigger effects for emotion than for focus perception. For emotion, results with both cues most closely resembled results with F0, while for focus results with both cues most closely resembled those with duration, showing emotion perception relies primarily on F0, and focus perception on duration. This suggests that filter slopes affect focus perception less than emotion perception because for emotion, F0 is both more informative and more affected. The performance increase until extreme filter slope values suggests that much performance improvement in prosody perception is still to be gained for CI users.

Monopolar Detection Thresholds Predict Spatial Selectivity of Neural Excitation in Cochlear Implants: Implications for Speech Recognition

The objectives of the study were to (1) investigate the potential of using monopolar psychophysical detection thresholds for estimating spatial selectivity of neural excitation with cochlear implants and to (2) examine the effect of site removal on speech recognition based on the threshold measure. Detection thresholds were measured in Cochlear Nucleus® device users using monopolar stimulation for pulse trains that were of (a) low rate and long duration, (b) high rate and short duration, and (c) high rate and long duration. Spatial selectivity of neural excitation was estimated by a forward-masking paradigm, where the probe threshold elevation in the presence of a forward masker was measured as a function of masker-probe separation. The strength of the correlation between the monopolar thresholds and the slopes of the masking patterns systematically reduced as neural response of the threshold stimulus involved interpulse interactions (refractoriness and sub-threshold adaptation), and spike-rate adaptation. Detection threshold for the low-rate stimulus most strongly correlated with the spread of forward masking patterns and the correlation reduced for long and high rate pulse trains. The low-rate thresholds were then measured for all electrodes across the array for each subject. Subsequently, speech recognition was tested with experimental maps that deactivated five stimulation sites with the highest thresholds and five randomly chosen ones. Performance with deactivating the high-threshold sites was better than performance with the subjects' clinical map used every day with all electrodes active, in both quiet and background noise. Performance with random deactivation was on average poorer than that with the clinical map but the difference was not significant. These results suggested that the monopolar low-rate thresholds are related to the spatial neural excitation patterns in cochlear implant users and can be used to select sites for more optimal speech recognition performance.

Effect of current focusing on the sensitivity of inferior colliculus neurons to amplitude-modulated stimulation

In multichannel cochlear implants (CIs), current is delivered to specific electrodes along the cochlea in the form of amplitude-modulated pulse trains, to convey temporal and spectral cues. Our previous studies have shown that focused multipolar (FMP) and tripolar (TP) stimulation produce more restricted neural activation and reduced channel interactions in the inferior colliculus (IC) compared with traditional monopolar (MP) stimulation, suggesting that focusing of stimulation could produce better transmission of spectral information. The present study explored the capability of IC neurons to detect modulated CI stimulation with FMP and TP stimulation compared with MP stimulation. The study examined multiunit responses of IC neurons in acutely deafened guinea pigs by systematically varying the stimulation configuration, modulation depth, and stimulation level. Stimuli were sinusoidal amplitude-modulated pulse trains (carrier rate of 120 pulses/s). Modulation sensitivity was quantified by measuring modulation detection thresholds (MDTs), defined as the lowest modulation depth required to differentiate the response of a modulated stimulus from an unmodulated one. Whereas MP stimulation showed significantly lower MDTs than FMP and TP stimulation (P values <0.05) at stimulation ≤2 dB above threshold, all stimulation configurations were found to have similar modulation sensitivities at 4 dB above threshold. There was no difference found in modulation sensitivity between FMP and TP stimulation. The present study demonstrates that current focusing techniques such as FMP and TP can adequately convey amplitude modulation and are comparable to MP stimulation, especially at higher stimulation levels, although there may be some trade-off between spectral and temporal fidelity with current focusing stimulation.

Evaluating multipulse integration as a neural-health correlate in human cochlear-implant users: Relationship to spatial selectivity

The decrease of psychophysical detection thresholds as a function of pulse rate for a fixed-duration electrical pulse train is referred to as multipulse integration (MPI). The MPI slopes correlate with anatomical and physiological indices of cochlear health in guinea pigs with cochlear implants. The aim of the current study was to assess whether the MPI slopes were related to the spatial spread of activation by electrical stimulation. The hypothesis was that MPI is dependent on the total number of excitable neurons at the stimulation site, with broader neural excitation producing a steeper threshold decrease as a function of stimulation rate. MPI functions were measured at all stimulation sites in 22-site electrode arrays in human subjects. Some sites with steep MPI functions and other sites with shallow functions were assessed for spatial spread of excitation at 900 pps using a forward-masking paradigm. The results showed a correlation between the slopes of the forward-masking functions and the steepness of MPI, with broader stimulation predicting greater integration. The results are consistent with the idea that integration of multiple pulses in a pulse train relies on the number of excitable neurons at the stimulation site.

Relationships Among Peripheral and Central Electrophysiological Measures of Spatial and Spectral Selectivity and Speech Perception in Cochlear Implant Users

OBJECTIVES

The ability to perceive speech is related to the listener's ability to differentiate among frequencies (i.e., spectral resolution). Cochlear implant (CI) users exhibit variable speech-perception and spectral-resolution abilities, which can be attributed in part to the extent of electrode interactions at the periphery (i.e., spatial selectivity). However, electrophysiological measures of peripheral spatial selectivity have not been found to correlate with speech perception. The purpose of this study was to evaluate auditory processing at the periphery and cortex using both simple and spectrally complex stimuli to better understand the stages of neural processing underlying speech perception. The hypotheses were that (1) by more completely characterizing peripheral excitation patterns than in previous studies, significant correlations with measures of spectral selectivity and speech perception would be observed, (2) adding information about processing at a level central to the auditory nerve would account for additional variability in speech perception, and (3) responses elicited with spectrally complex stimuli would be more strongly correlated with speech perception than responses elicited with spectrally simple stimuli.

DESIGN

Eleven adult CI users participated. Three experimental processor programs (MAPs) were created to vary the likelihood of electrode interactions within each participant. For each MAP, a subset of 7 of 22 intracochlear electrodes was activated: adjacent (MAP 1), every other (MAP 2), or every third (MAP 3). Peripheral spatial selectivity was assessed using the electrically evoked compound action potential (ECAP) to obtain channel-interaction functions for all activated electrodes (13 functions total). Central processing was assessed by eliciting the auditory change complex with both spatial (electrode pairs) and spectral (rippled noise) stimulus changes. Speech-perception measures included vowel discrimination and the Bamford-Kowal-Bench Speech-in-Noise test. Spatial and spectral selectivity and speech perception were expected to be poorest with MAP 1 (closest electrode spacing) and best with MAP 3 (widest electrode spacing). Relationships among the electrophysiological and speech-perception measures were evaluated using mixed-model and simple linear regression analyses.

RESULTS

All electrophysiological measures were significantly correlated with each other and with speech scores for the mixed-model analysis, which takes into account multiple measures per person (i.e., experimental MAPs). The ECAP measures were the best predictor. In the simple linear regression analysis on MAP 3 data, only the cortical measures were significantly correlated with speech scores; spectral auditory change complex amplitude was the strongest predictor.

CONCLUSIONS

The results suggest that both peripheral and central electrophysiological measures of spatial and spectral selectivity provide valuable information about speech perception. Clinically, it is often desirable to optimize performance for individual CI users. These results suggest that ECAP measures may be most useful for within-subject applications when multiple measures are performed to make decisions about processor options. They also suggest that if the goal is to compare performance across individuals based on a single measure, then processing central to the auditory nerve (specifically, cortical measures of discriminability) should be considered.

A fast method for measuring psychophysical thresholds across the cochlear implant array

A rapid threshold measurement procedure, based on Bekesy tracking, is proposed and evaluated for use with cochlear implants (CIs). Fifteen postlingually deafened adult CI users participated. Absolute thresholds for 200-ms trains of biphasic pulses were measured using the new tracking procedure and were compared with thresholds obtained with a traditional forced-choice adaptive procedure under both monopolar and quadrupolar stimulation. Virtual spectral sweeps across the electrode array were implemented in the tracking procedure via current steering, which divides the current between two adjacent electrodes and varies the proportion of current directed to each electrode. Overall, no systematic differences were found between threshold estimates with the new channel sweep procedure and estimates using the adaptive forced-choice procedure. Test–retest reliability for the thresholds from the sweep procedure was somewhat poorer than for thresholds from the forced-choice procedure. However, the new method was about 4 times faster for the same number of repetitions. Overall the reliability and speed of the new tracking procedure provides it with the potential to estimate thresholds in a clinical setting. Rapid methods for estimating thresholds could be of particular clinical importance in combination with focused stimulation techniques that result in larger threshold variations between electrodes.

Simulating the dual-peak excitation pattern produced by bipolar stimulation of a cochlear implant: effects on speech intelligibility

Several electrophysiological and psychophysical studies have shown that the spatial excitation pattern produced by bipolar stimulation of a cochlear implant (CI) can have a dual-peak shape. The perceptual effects of this dual-peak shape were investigated using noise-vocoded CI simulations in which synthesis filters were designed to simulate the spread of neural activity produced by various electrode configurations, as predicted by a simple cochlear model. Experiments 1 and 2 tested speech recognition in the presence of a concurrent speech masker for various sets of single-peak and dual-peak synthesis filters and different numbers of channels. Similarly as results obtained in real CIs, both monopolar (MP, single-peak) and bipolar (BP + 1, dual-peak) simulations showed a plateau of performance above 8 channels. The benefit of increasing the number of channels was also lower for BP + 1 than for MP. This shows that channel interactions in BP + 1 become especially deleterious for speech intelligibility when a simulated electrode acts both as an active and as a return electrode for different channels because envelope information from two different analysis bands are being conveyed to the same spectral location. Experiment 3 shows that these channel interactions are even stronger in wide BP configuration (BP + 5), likely because the interfering speech envelopes are less correlated than in narrow BP + 1. Although the exact effects of dual- or multi-peak excitation in real CIs remain to be determined, this series of experiments suggest that multipolar stimulation strategies, such as bipolar or tripolar, should be controlled to avoid neural excitation in the vicinity of the return electrodes.

Impact of electrode design and surgical approach on scalar location and cochlear implant outcomes

OBJECTIVES/HYPOTHESIS

Three surgical approaches: cochleostomy (C), round window (RW), and extended round window (ERW); and two electrodes types: lateral wall (LW) and perimodiolar (PM), account for the vast majority of cochlear implantations. The goal of this study was to analyze the relationship between surgical approach and electrode type with final intracochlear position of the electrode array and subsequent hearing outcomes.

STUDY DESIGN

Comparative longitudinal study.

METHODS

One hundred postlingually implanted adult patients were enrolled in the study. From the postoperative scan, intracochlear electrode location was determined and using rigid registration, transformed back to the preoperative computed tomography which had intracochlear anatomy (scala tympani and scala vestibuli) specified using a statistical shape model based on 10 microCT scans of human cadaveric cochleae. Likelihood ratio chi-square statistics were used to evaluate for differences in electrode placement with respect to surgical approach (C, RW, ERW) and type of electrode (LW, PM).

RESULTS

Electrode placement completely within the scala tympani (ST) was more common for LW than were PM designs (89% vs. 58%; P < 0.001). RW and ERW approaches were associated with lower rates of electrode placement outside the ST than was the cochleostomy approach (9%, 16%, and 63%, respectively; P < 0.001). This pattern held true regardless of whether the implant was LW or PM. When examining electrode placement and hearing outcome, those with electrode residing completely within the ST had better consonant-nucleus-consonant word scores than did patients with any number of electrodes located outside the ST (P = 0.045).

CONCLUSION

These data suggest that RW and ERW approaches and LW electrodes are associated with an increased likelihood of successful ST placement. Furthermore, electrode position entirely within the ST confers superior audiological outcomes.

LEVEL OF EVIDENCE

2b.

Measurements of monopolar and bipolar current spreads using forward-masking with a fixed probe

OBJECTIVES

This research employed a forward-masking paradigm to estimate the current spread of monopolar (MP) and bipolar (BP) maskers, with current amplitudes adjusted to elicit the same loudness. Since the spatial separation between active and return electrodes is smaller in BP than in MP configurations, the BP current spread is more localized and presumably superior in terms of speech intelligibility. Because matching the loudness requires higher current in BP than in MP stimulation, previous forward-masking studies show that BP current spread is not consistently narrower across subjects or electrodes within a subject.

METHODS

The present forward-masking measures of current spread differ from those of previous studies by using the same BP probe electrode configuration for both MP and BP masker configurations, and adjusting the current levels of the MP and BP maskers so as to match them in loudness. With this method, the estimate of masker current spread would not be contaminated by differences in probe current spread. Forward masking was studied in four cochlear implant patients, two females and two males, with speech recognition scores higher than 50%; that is, their auditory-nerve survival status was more than adequate to carry out the experiments.

RESULTS

The data showed that MP and BP masker configurations produce equivalent masking patterns (and current spreads) in three participants. A fourth participant displayed asymmetrical patterns with enhancement rather than masking in some cases, especially when the probe and masker were at the same location.

DISCUSSION

This study showed equivalent masking patterns for MP and BP maskers when the BP masker current amplitude was increased to match the loudness of the MP masker, and the same BP probe configuration is used with both maskers. This finding could help to explain why cochlear implant users often fail to accrue higher speech intelligibility benefit from BP stimulation.

Drug delivery to the inner ear

Bionic devices electrically activate neural populations to partially restore lost function. Of fundamental importance is the functional integrity of the targeted neurons. However, in many conditions the ongoing pathology can lead to continued neural degeneration and death that may compromise the effectiveness of the device and limit future strategies to improve performance. The use of drugs that can prevent nerve cell degeneration and promote their regeneration may improve clinical outcomes. In this paper we focus on strategies of delivering neuroprotective drugs to the auditory system in a way that is safe and clinically relevant for use in combination with a cochlear implant. The aim of this approach is to prevent neural degeneration and promote nerve regrowth in order to improve outcomes for cochlear implant recipients using techniques that can be translated to the clinic.

Monopolar intracochlear pulse trains selectively activate the inferior colliculus

Previous cochlear implant studies using isolated electrical stimulus pulses in animal models have reported that intracochlear monopolar stimulus configurations elicit broad extents of neuronal activation within the central auditory system-much broader than the activation patterns produced by bipolar electrode pairs or acoustic tones. However, psychophysical and speech reception studies that use sustained pulse trains do not show clear performance differences for monopolar versus bipolar configurations. To test whether monopolar intracochlear stimulation can produce selective activation of the inferior colliculus, we measured activation widths along the tonotopic axis of the inferior colliculus for acoustic tones and 1,000-pulse/s electrical pulse trains in guinea pigs and cats. Electrical pulse trains were presented using an array of 6-12 stimulating electrodes distributed longitudinally on a space-filling silicone carrier positioned in the scala tympani of the cochlea. We found that for monopolar, bipolar, and acoustic stimuli, activation widths were significantly narrower for sustained responses than for the transient response to the stimulus onset. Furthermore, monopolar and bipolar stimuli elicited similar activation widths when compared at stimulus levels that produced similar peak spike rates. Surprisingly, we found that in guinea pigs, monopolar and bipolar stimuli produced narrower sustained activation than 60 dB sound pressure level acoustic tones when compared at stimulus levels that produced similar peak spike rates. Therefore, we conclude that intracochlear electrical stimulation using monopolar pulse trains can produce activation patterns that are at least as selective as bipolar or acoustic stimulation.

Effects of the electrode location on tonal discrimination and speech perception of Mandarin-speaking patients with a cochlear implant

OBJECTIVES/HYPOTHESIS

This study assessed the effects of varying the electrode location on tonal discrimination and speech perception in Mandarin Chinese-speaking patients.

STUDY DESIGN

A controlled study with six experimental conditions.

METHODS

Seven Mandarin-speaking listeners who received a MED-EL cochlear implant (CI), ranging in age from 12.88 to 36.43 years (mean, 25.51 years), with an average of 5.28 years of device experience, participated this study. To evaluate the effects of electrode location, six experimental conditions each with the switch off at six different electrodes were designed. Identification tests of Mandarin lexical tones and words were performed.

RESULTS

Among experimental conditions with electrode lengths of 31, 23.8, and 16.6 mm, the CI subjects exhibited improved vowel and consonant identification in the condition of 31 mm, reflecting the apical location of electrodes. Specifically, the improvement was observed in the identification score for the vowel backness and height, as well as for the consonant place of articulation. Comparison among three settings with a same electrode length of 12.6 mm and the setting with stimulation to the midregion of the cochlea produces better words as well as the vowel and consonant identification compared with stimulation to basal and apical regions. However, no significant difference was observed for the lexical tone identification among conditions with different electrode location and stimulating region.

CONCLUSIONS

Less mismatch of the frequency-to-place alignment may account for the improvement of word identification in conditions with electrodes coverage to more apical location; and in conditions where the mid-region of the cochlea were stimulated.

Reducing current spread using current focusing in cochlear implant users

Cochlear implant performance in difficult listening situations is limited by channel interactions. It is known that partial tripolar (PTP) stimulation reduces the spread of excitation (SOE). However, the greater the degree of current focusing, the greater the absolute current required to maintain a fixed loudness. As current increases, so does SOE. In experiment 1, the SOE for equally loud stimuli with different degrees of current focusing is measured via a forward-masking procedure. Results suggest that at a fixed loudness, some but not all patients have a reduced SOE with PTP stimulation. Therefore, it seems likely that a PTP speech processing strategy could improve spectral resolution for only those patients with a reduced SOE. In experiment 2, the ability to discriminate different levels of current focusing was measured. In experiment 3, patients subjectively scaled verbal descriptors of stimuli of various levels of current focusing. Both discrimination and scaling of verbal descriptors correlated well with SOE reduction, suggesting that either technique have the potential to be used clinically to quickly predict which patients would receive benefit from a current focusing strategy.

Cochlear-implant spatial selectivity with monopolar, bipolar and tripolar stimulation

Sharp spatial selectivity is critical to auditory performance, particularly in pitch-related tasks. Most contemporary cochlear implants have employed monopolar stimulation that produces broad electric fields, which presumably contribute to poor pitch and pitch-related performance by implant users. Bipolar or tripolar stimulation can generate focused electric fields but requires higher current to reach threshold and, more interestingly, has not produced any apparent improvement in cochlear-implant performance. The present study addressed this dilemma by measuring psychophysical and physiological spatial selectivity with both broad and focused stimulations in the same cohort of subjects. Different current levels were adjusted by systematically measuring loudness growth for each stimulus, each stimulation mode, and in each subject. Both psychophysical and physiological measures showed that, although focused stimulation produced significantly sharper spatial tuning than monopolar stimulation, it could shift the tuning position or even split the tuning tips. The altered tuning with focused stimulation is interpreted as a result of poor electrode-to-neuron interface in the cochlea, and is suggested to be mainly responsible for the lack of consistent improvement in implant performance. A linear model could satisfactorily quantify the psychophysical and physiological data and derive the tuning width. Significant correlation was found between the individual physiological and psychophysical tuning widths, and the correlation was improved by log-linearly transforming the physiological data to predict the psychophysical data. Because the physiological measure took only one-tenth of the time of the psychophysical measure, the present model is of high clinical significance in terms of predicting and improving cochlear-implant performance.

Assessment of electrode placement and audiological outcomes in bilateral cochlear implantation

OBJECTIVE

The goal of this study was to use highly accurate nonrigid algorithms to locate the position of cochlear implant (CI) electrodes and correlate this with audiological performance.

PATIENTS

After obtaining institutional review board approval, adult patients who had bilateral CIs were identified, and those with preoperative temporal bone computed tomographic scans were asked to return for a postintervention computed tomography. Sixteen adult patients agreed. Demographics, cause of deafness, length of auditory deprivation, and audiological performance were recorded.

INTERVENTION

Using a nonrigid model of the shape variations of intracochlear anatomy, the location of the basilar membrane was specified in relationship to the electrode array. The number of electrodes within each compartment of the cochlea was correlated with hearing in noise and consonant-noun-consonant scores for the known confounding variable: length of deafness.

MAIN OUTCOMES

Mann-Whitney U tests of differences were used to compare the hearing performance resulting from implants completely in the scala tympani (ST) versus those not completely in the ST.

RESULTS

Of all implants, 62.5% were fully inserted in the ST; 34.4% were partially inserted into the ST and 3.1% was fully inserted in the scala vestibuli. Controlling for the known contributing variable of length of auditory deprivation, our results show that the location of electrodes in relationship to the scala is not predictive of audiological performance.

CONCLUSION

We have assessed electrode placement and correlated it with audiological outcome. The presence of the electrodes solely in the ST was not predictive of outcome. We estimate that it would take analyzing data of thousands of CI patients before any valid correlations can be made.

Binaural unmasking with multiple adjacent masking electrodes in bilateral cochlear implant users

Bilateral cochlear implant (BiCI) users gain an advantage in noisy situations from a second implant, but their bilateral performance falls short of normal hearing listeners. Channel interactions due to overlapping electrical fields between electrodes can impair speech perception, but its role in limiting binaural hearing performance has not been well characterized. To address the issue, binaural masking level differences (BMLD) for a 125 Hz tone in narrowband noise were measured using a pair of pitch-matched electrodes while simultaneously presenting the same masking noise to adjacent electrodes, representing a more realistic stimulation condition compared to prior studies that used only a single electrode pair. For five subjects, BMLDs averaged 8.9 ± 1.0 dB (mean ± s.e.) in single electrode pairs but dropped to 2.1 ± 0.4 dB when presenting noise on adjacent masking electrodes, demonstrating a negative impact of the additional maskers. Removing the masking noise from only the pitch-matched electrode pair not only lowered thresholds but also resulted in smaller BMLDs. The degree of channel interaction estimated from auditory nerve evoked potentials in three subjects was significantly and negatively correlated with BMLD. The data suggest that if the amount of channel interactions can be reduced, BiCI users may experience some performance improvements related to binaural hearing.

Anatomic verification of a novel method for precise intrascalar localization of cochlear implant electrodes in adult temporal bones using clinically available computed tomography

OBJECTIVES/HYPOTHESIS

We have previously described a novel, automated, nonrigid, model-based method for determining the intrascalar position of cochlear implant (CI) electrode arrays within human temporal bones using clinically available, flat-panel volume computed tomography (fpVCT). We sought to validate this method by correlating results with anatomic microdissection of CI arrays in cadaveric bones.

STUDY DESIGN

Basic science.

METHODS

Seven adult cadaveric temporal bones were imaged using fpVCT before and after electrode insertion. Using a statistical model of intracochlear anatomy, an active shape model optimization approach was employed to identify the scalae tympani and vestibuli on the preintervention fpVCT. The array position was estimated by identifying its midline on the postintervention scan and superimposing it onto the preintervention images using rigid registration. Specimens were then microdissected to demonstrate the actual array position.

RESULTS

Using microdissection as the standard for ascertaining electrode position, automatic identification of the basilar membrane coupled with postintervention fpVCT for electrode position identification accurately depicted the array location in all seven bones. In four specimens, the array remained within the scala tympani; in three, the basilar membrane was breached.

CONCLUSIONS

We have anatomically validated this automated method for predicting the intrascalar location of CI arrays using CT. Using this algorithm and pre- and postintervention CT, rapid feedback regarding implant location and expected audiologic outcomes could be obtained in clinical settings.

Role of electrode placement as a contributor to variability in cochlear implant outcomes

HYPOTHESIS

Suboptimal cochlear implant (CI) electrode array placement may reduce presentation of coded information to the central nervous system and, consequently, limit speech recognition.

BACKGROUND

Generally, mean speech reception scores for CI recipients are similar across different CI systems, yet large outcome variation is observed among recipients implanted with the same device. These observations suggest significant recipient-dependent factors influence speech reception performance. This study examines electrode array insertion depth and scalar placement as recipient-dependent factors affecting outcome.

METHODS

Scalar location and depth of insertion of intracochlear electrodes were measured in 14 patients implanted with Advanced Bionics electrode arrays and whose word recognition scores varied broadly. Electrode position was measured using computed tomographic images of the cochlea and correlated with stable monosyllabic word recognition scores.

RESULTS

Electrode placement, primarily in terms of depth of insertion and scala tympani versus scala vestibuli location, varies widely across subjects. Lower outcome scores are associated with greater insertion depth and greater number of contacts being located in scala vestibuli. Three patterns of scalar placement are observed suggesting variability in insertion dynamics arising from surgical technique.

CONCLUSION

A significant portion of variability in word recognition scores across a broad range of performance levels of CI subjects is explained by variability in scalar location and insertion depth of the electrode array. We suggest that this variability in electrode placement can be reduced and average speech reception improved by better selection of cochleostomy sites, revised insertion approaches, and control of insertion depth during surgical placement of the array.

Lexical tone recognition with spectrally mismatched envelopes

It has been shown that frequency-place mismatch has detrimental effects on English speech recognition. The present study investigated the effects of mismatched spectral distribution of envelopes on Mandarin Chinese tone recognition using a noise-excited vocoder. In Experiment 1, speech samples were processed to simulate a cochlear implant with various insertion depths. The carrier bands were shifted basally relative to the analysis bands by 1-7 mm in the cochlea. Nine normal-hearing Mandarin Chinese listeners participated in this experiment. Basal shift of the carriers only slightly affected tone recognition. The resistance of tone recognition to spectral shift can be attributed to the overall amplitude contour cues that are independent from spectral manipulations. Experiment 2 examined the effects of frequency compression, where widened analysis bands by 2, 6, and 10 mm were compressively allocated to narrower carrier bands. Five of the 9 subjects participated in Experiment 2. It appears that the expanded frequency information especially on the low frequency end can compensate for the distortion from frequency compression. Thus, spectral shift might not pose a severe problem for tone recognition, and allocation of wider frequency range to include more low frequency information might be beneficial for tone recognition.

Psychophysical versus physiological spatial forward masking and the relation to speech perception in cochlear implants

OBJECTIVES

The primary goal of this study was to determine if physiological forward masking patterns in cochlear implants are predictive of psychophysical forward masking (PFM) patterns. It was hypothesized that the normalized amount of physiological masking would be positively correlated with the normalized amount of psychophysical masking for different masker-probe electrode separations. A secondary goal was to examine the relation between the spatial forward masking patterns and speech perception performance. It was hypothesized that subjects with less channel interaction overall (either psychophysically or physiologically) would have better speech perception ability because of better spectral resolution.

DESIGN

Data were collected for 18 adult cochlear implant recipients [N = 9 Clarion CII or HiRes 90K, N = 9 Nucleus 24R(CS)]. Physiological spatial forward masking patterns were obtained with the electrically evoked compound action potential (ECAP) through the implant telemetry system. PFM patterns were obtained using a three-interval, two-alternative forced-choice adaptive procedure. Both measures used a fixed probe electrode with varied masker location. For each subject, spatial forward masking patterns were obtained for three probe electrodes with five masker locations per probe.

RESULTS

On an individual basis, the correlation between ECAP FM and PFM was strong for 10 subjects (r = 0.68-0.85, p <or= 0.02), moderately strong for two subjects (r = 0.54-0.55, p = 0.06-0.07), and poor for six subjects (r = 0.13-0.45, p > 0.14). Results across subjects and electrodes showed a highly significant correlation between ECAP FM and PFM (r = 0.55, p < 0.0001); the correlation was strongest for basal electrodes. There was no significant correlation between speech perception and ECAP FM or PFM. Subjects whose ECAP FM patterns correlated well with PFM patterns generally had the poorest speech perception and subjects with the poorest correlations had the best speech perception.

CONCLUSIONS

ECAP FM and PFM patterns correlated well for two-thirds of the subjects. Although the group correlation was statistically significant, ECAP FM patterns only accounted for 30% of the variance in the PFM measures. This suggests that the ECAP measures alone are not sufficient for accurately predicting PFM patterns for individual subjects.

Cochlear-implant high pulse rate and narrow electrode configuration impair transmission of temporal information to the auditory cortex

In the most commonly used cochlear prosthesis systems, temporal features of sound are signaled by amplitude modulation of constant-rate pulse trains. Several convincing arguments predict that speech reception should be optimized by use of pulse rates > or approximately 2,000 pulses per second (pps) and by use of intracochlear electrode configurations that produce restricted current spread (e.g., bipolar rather than monopolar configurations). Neither of those predictions has been borne out in consistent improvements in speech reception. Neurons in the auditory cortex of anesthetized guinea pigs phase lock to the envelope of sine-modulated electric pulse trains presented through a cochlear implant. The present study used that animal model to quantify the effects of carrier pulse rate, electrode configuration, current level, and modulator wave shape on transmission of temporal information from a cochlear implant to the auditory cortex. Modulation sensitivity was computed using a signal-detection analysis of cortical phase-locking vector strengths. Increasing carrier pulse rate in 1-octave steps from 254 to 4,069 pps resulted in systematic decreases in sensitivity. Comparison of sine- versus square-wave modulator waveforms demonstrated that some, but not all, of the loss of modulation sensitivity at high pulse rates was a result of the decreasing size of pulse-to-pulse current steps at the higher rates. Use of a narrow bipolar electrode configuration, compared with the monopolar configuration, produced a marked decrease in modulation sensitivity. Results from this animal model suggest explanations for the failure of high pulse rates and/or bipolar electrode configurations to produce hoped-for improvements in speech reception.

Simulating the effect of spread of excitation in cochlear implants

A model was developed to simulate acoustically the effects of excitation spread in cochlear implants (CI). Based on neurophysiologic data, the proposed model simulates the electrical-current decay rate associated with broad and narrow types of excitation, such as those produced by monopolar and bipolar electrode configurations. The effect of excitation spread on speech intelligibility was simulated in normal-hearing subjects by varying the slopes of the synthesis bands in the noise vocoder. Sentences and monosyllabic words processed via 4-16 channels of stimulation with varying degrees of excitation spread were presented to normal-hearing listeners for identification. Results showed significant interaction between spectral resolution (number of channels) and spread of excitation. The effect of narrowing the excitation spread was minimal when the spectral resolution was sufficiently good (>8 channels) but it was significant when the spectral resolution was poor (4 channels). A significant decrement in performance was observed for extremely narrow excitation spread. This outcome is partly consistent with behavioral data obtained with cochlear implant studies in that CI users tend to do as well or better with monopolar stimulation than with bipolar stimulation.

Current focusing and steering: modeling, physiology, and psychophysics

Current steering and current focusing are stimulation techniques designed to increase the number of distinct perceptual channels available to cochlear implant (CI) users by adjusting currents applied simultaneously to multiple CI electrodes. Previous studies exploring current steering and current focusing stimulation strategies are reviewed, including results of research using computational models, animal neurophysiology, and human psychophysics. Preliminary results of additional neurophysiological and human psychophysical studies are presented that demonstrate the success of current steering strategies in stimulating auditory nerve regions lying between physical CI electrodes, as well as current focusing strategies that excite regions narrower than those stimulated using monopolar configurations. These results are interpreted in the context of perception and speech reception by CI users. Disparities between results of physiological and psychophysical studies are discussed. The differences in stimulation used for physiological and psychophysical studies are hypothesized to contribute to these disparities. Finally, application of current steering and focusing strategies to other types of auditory prostheses is also discussed.

Cochlear implants and brain plasticity

Cochlear implants have been implanted in over 110,000 deaf adults and children worldwide and provide these patients with important auditory cues necessary for auditory awareness and speech perception via electrical stimulation of the auditory nerve (AN). In 1942, Woolsey and Walzl presented the first report of cortical responses to localised electrical stimulation of different sectors of the AN in normal hearing cats, and established the cochleotopic organization of the projections to primary auditory cortex. Subsequently, individual cortical neurons in normal hearing animals have been shown to have well characterized input-output functions for electrical stimulation and decreasing response latencies with increasing stimulus strength. However, the central auditory system is not immutable, and has a remarkable capacity for plastic change, even into adulthood, as a result of changes in afferent input. This capacity for change is likely to contribute to the ongoing clinical improvements observed in speech perception for cochlear implant users. This review examines the evidence for changes of the response properties of neurons in, and consequently the functional organization of, the central auditory system produced by chronic, behaviourally relevant, electrical stimulation of the AN in profoundly deaf humans and animals.

Cochlear implant electrode configuration effects on activation threshold and tonotopic selectivity

The multichannel design of contemporary cochlear implants (CIs) is predicated on the assumption that each channel activates a relatively restricted and independent sector of the deaf auditory nerve array, just as a sound within a restricted frequency band activates a restricted region of the normal cochlea The independence of CI channels, however, is limited; and the factors that determine their independence, the relative overlap of the activity patterns that they evoke, are poorly understood. In this study, we evaluate the spread of activity evoked by cochlear implant channels by monitoring activity at 16 sites along the tonotopic axis of the guinea pig inferior colliculus (IC). "Spatial tuning curves" (STCs) measured in this way serve as an estimate of activation spread within the cochlea and the ascending auditory pathways. We contrast natural stimulation using acoustic tones with two kinds of electrical stimulation either (1) a loose fitting banded array consisting of a cylindrical silicone elastomer carrier with a linear series of ring contacts; or (2) a space-filling array consisting of a tapered silicone elastomer carrier that is designed to fit snugly into the guinea pig scala tympani with a linear series of ball contacts positioned along it Spatial tuning curves evoked by individual acoustic tones, and by activation of each contact of each array as a monopole, bipole or tripole were recorded. Several channel configurations and a wide range of electrode separations were tested for each array, and their thresholds and selectivity were estimated. The results indicate that the tapered space-filling arrays evoked more restricted activity patterns at lower thresholds than did the banded arrays. Monopolar stimulation (one intracochlear contact activated with an extracochlear return) using either array evoked broad activation patterns that involved the entire recording array at current levels <6dBSL, but at relatively low thresholds. Bi- and tri-polar configurations of both array types evoked more restricted activity patterns, but their thresholds were higher than those of monopolar configurations. Bipolar and tripolar configurations with closely spaced contacts evoked activity patterns that were comparable to those evoked by pure tones. As the spacing of bipolar electrodes was increased (separations >1mm), the activity patterns became broader and evoked patterns with two distinct threshold minima, one associated with each contact.

Loudness growth observed under partially tripolar stimulation: model and data from cochlear implant listeners

Most cochlear implant strategies utilize monopolar stimulation, likely inducing relatively broad activation of the auditory neurons. The spread of activity may be narrowed with a tripolar stimulation scheme, wherein compensating current of opposite polarity is simultaneously delivered to two adjacent electrodes. In this study, a model and cochlear implant subjects were used to examine loudness growth for varying amounts of tripolar compensation, parameterized by a coefficient sigma, ranging from 0 (monopolar) to 1 (full tripolar). In both the model and the subjects, current required for threshold activation could be approximated by I(sigma)=Ithr(0)(1-sigmaK), with fitted constants Ithr(0) and K. Three of the subjects had a "positioner," intended to place their electrode arrays closer to their neural tissue. The values of K were smaller for the positioner users and for a "close" electrode-to-tissue distance in the model. Above threshold, equal-loudness contours for some subjects deviated significantly from a linear scale-up of the threshold approximations. The patterns of deviation were similar to those observed in the model for conditions in which most of the neurons near the center electrode were excited.

Cochlear Implant Channel Separation and Its Influence on Speech Perception – Implications for a New Electrode Design

There are a variety of factors which can influence cochlear implantation outcome. Channel interaction is one of the variables responsible for audiological performance deterioration in multichannel implants. Electrode design is--among others--one way to decrease the incidence of channel interaction. At present, electrodes differ in overall length, diameter, contact design and distribution, but none of the electrodes available have a distinct variability in the amount of space between contacts across the length of the electrode. The aim of this study was to investigate whether a new electrode design featuring larger contact spacing in the apical part of deeply inserted electrodes would lead to an increase in speech perception. Eighteen postlingually deafened patients fitted with MedEl Combi 40+ or MedEl Pulsar cochlear implants using the MedEl implementation of continuous interleaved sampling participated in this study. Patients were tested in 6 conditions, in which the channel spacing and distribution of electrode contacts in each patient were artificially varied by activating or deactivating different channels. Performance was tested immediately after each change in setup with a monosyllable and sentence test (Hochmaier, Schultz and Moser). Our results showed that the condition with the highest distance between contacts in the apical part (up to 6.4 mm instead of 2.4 mm) is the most effective for the matched map condition: the results improved statistically significantly for the sentence test from 72% in the standard 12-channel condition to 83.2% and from 40.8 to 50% for the monosyllable test. Based on these findings, we present a new electrode design which can help achieve further increases in speech perception with cochlear implants.

Frequency map for the human cochlear spiral ganglion: implications for cochlear implants

The goals of this study were to derive a frequency-position function for the human cochlear spiral ganglion (SG) to correlate represented frequency along the organ of Corti (OC) to location along the SG, to determine the range of individual variability, and to calculate an "average" frequency map (based on the trajectories of the dendrites of the SG cells). For both OC and SG frequency maps, a potentially important limitation is that accurate estimates of cochlear place frequency based upon the Greenwood function require knowledge of the total OC or SG length, which cannot be determined in most temporal bone and imaging studies. Therefore, an additional goal of this study was to evaluate a simple metric, basal coil diameter that might be utilized to estimate OC and SG length. Cadaver cochleae (n = 9) were fixed <24 h postmortem, stained with osmium tetroxide, microdissected, decalcified briefly, embedded in epoxy resin, and examined in surface preparations. In digital images, the OC and SG were measured, and the radial nerve fiber trajectories were traced to define a series of frequency-matched coordinates along the two structures. Images of the cochlear turns were reconstructed and measurements of basal turn diameter were made and correlated with OC and SG measurements. The data obtained provide a mathematical function for relating represented frequency along the OC to that of the SG. Results showed that whereas the distance along the OC that corresponds to a critical bandwidth is assumed to be constant throughout the cochlea, estimated critical band distance in the SG varies significantly along the spiral. Additional findings suggest that measurements of basal coil diameter in preoperative images may allow prediction of OC/SG length and estimation of the insertion depth required to reach specific angles of rotation and frequencies. Results also indicate that OC and SG percentage length expressed as a function of rotation angle from the round window is fairly constant across subjects. The implications of these findings for the design and surgical insertion of cochlear implants are discussed.

Speech recognition in normal hearing and sensorineural hearing loss as a function of the number of spectral channels

Speech recognition by normal-hearing listeners improves as a function of the number of spectral channels when tested with a noiseband vocoder simulating cochlear implant signal processing. Speech recognition by the best cochlear implant users, however, saturates around eight channels and does not improve when more electrodes are activated, presumably due to reduced frequency selectivity caused by channel interactions. Listeners with sensorineural hearing loss may also have reduced frequency selectivity due to cochlear damage and the resulting reduction in the nonlinear cochlear mechanisms. The present study investigates whether such a limitation in spectral information transmission would be observed with hearing-impaired listeners, similar to implant users. To test the hypothesis, hearing-impaired subjects were selected from a population of patients with moderate hearing loss of cochlear origin, where the frequency selectivity would be expected to be poorer compared to normal hearing. Hearing-impaired subjects were tested for vowel and consonant recognition in steady-state background noise of varying levels using a noiseband vocoder and as a function of the number of spectral channels. For comparison, normal-hearing subjects were tested with the same stimuli at different presentation levels. In quiet and low background noise, performance by normal-hearing and hearing-impaired subjects was similar. In higher background noise, performance by hearing-impaired subjects saturated around eight channels, while performance by normal-hearing subjects continued to increase up to 12-16 channels with vowels, and 10-12 channels with consonants. A similar trend was observed for most of the presentation levels at which the normal-hearing subjects were tested. Therefore, it is unlikely that the effects observed with hearing-impaired subjects were due to insufficient audibility or high presentation levels. Consequently, the results with hearing-impaired subjects were similar to previous results obtained with implant users, but only for background noise conditions.

Effect of electrode configuration on psychophysical forward masking in cochlear implant listeners

Bipolar stimulation has been thought to be more beneficial than monopolar stimulation for speech coding in cochlear implants, on the basis of its more restricted current flow. The present study examined whether bipolar stimulation would indeed lead to reduced channel interaction in a behavioral forward masking experiment tested in four Nucleus 24 users. The masker was fixed on one channel and three masker levels that were balanced for loudness between the configurations were chosen. As expected, masking was maximal when the masker and probe channels were spatially close and decreased as they were separated. However, overall masking patterns did not consistently demonstrate sharper tuning with bipolar stimulation than monopolar. This implies that the spatial extent of a bipolar current field is not consistently narrower than that of an equally loud monopolar stimulus; therefore, it should not be assumed that bipolar stimulation leads to reduced channel interaction. Notably, bipolar masking patterns appeared to display more variations across channels, possibly influenced more by anatomical and neural irregularities near electrode contacts than monopolar masking patterns. The present psychophysical results provide a theoretical basis regarding the widespread use (and success) of monopolar configurations by implant users.

Efficacy of a cochlear implant simultaneous analog stimulation strategy coupled with a monopolar electrode configuration

OBJECTIVES

The present study was performed to evaluate the efficacy and clinical feasibility of using monopolar stimulation with the Clarion Simultaneous Analog Stimulation (SAS) strategy in patients with cochlear implants.

METHODS

Speech recognition by 10 Clarion cochlear implant users was evaluated by means of 4 different speech processing strategy/electrode configuration combinations; ie, SAS and Continuous Interleaved Sampling (CIS) strategies were each used with monopolar (MP) and bipolar (BP) electrode configurations. The test measures included consonants, vowels, consonant-nucleus-consonant words, and Hearing in Noise Test sentences with a +10 dB signal-to-noise ratio. Additionally, subjective judgments of sound quality were obtained for each strategy/configuration combination.

RESULTS

All subjects but 1 demonstrated open-set speech recognition with the SAS/MP combination. The group mean Hearing in Noise Test sentence score for the SAS/MP combination was 31.6% (range, 0% to 92%) correct, as compared to 25.0%, 46.7%, and 37.8% correct for the CIS/BP, CIS/MP, and SAS/BP combinations, respectively. Intersubject variability was high, and there were no significant differences in mean speech recognition scores or mean preference ratings among the 4 strategy/configuration combinations tested. Individually, the best speech recognition performance was with the subject's everyday strategy/configuration combination in 72% of the applicable cases. If the everyday strategy was excluded from the analysis, the subjects performed best with the SAS/MP combination in 37.5% of the remaining cases.

CONCLUSIONS

The SAS processing strategy with an MP electrode configuration gave reasonable speech recognition in most subjects, even though subjects had minimal previous experience with this strategy/configuration combination. The SAS/MP combination might be particularly appropriate for patients for whom a full dynamic range of electrical hearing could not be achieved with a BP configuration.

Effects of stimulation mode, level and location on forward-masked excitation patterns in cochlear implant patients

In multi-channel cochlear implants, electrical current is delivered to appropriate electrodes in the cochlea to approximate the spatial representation of speech. Theoretically, electrode configurations that restrict the current spread within the cochlea (e.g., bi- or tri-polar stimulation) may provide better spatial selectivity, and in turn, better speech recognition than configurations that produce a broader current spread (e.g., monopolar stimulation). However, the effects of electrode configuration on supra-threshold excitation patterns have not been systematically studied in cochlear implant patients. In the present study, forward-masked excitation patterns were measured in cochlear implant patients as functions of stimulation mode, level and location within the cochlea. All stimuli were 500 pulses-per-second biphasic pulse trains (200 micros/phase, 20 micros inter-phase gap). Masker stimuli were 200 ms in duration; the bi-polar configuration was varied from narrow (BP+1) to wide (BP+17), depending on the test condition. Probe stimuli were 20 ms in duration and the masker-probe delay was 5 ms; the probe configuration was fixed at BP+1. The results indicated that as the distance between the active and return electrodes in a bi-polar pair was increased, the excitation pattern broadened within the cochlea. When the distance between active and return electrodes was sufficiently wide, two peaks were often observed in the excitation pattern, comparable to non-overlapping electric fields produced by widely separated dipoles. Analyses of the normalized data showed little effect of stimulation level on the shape of the excitation pattern.

A temporal bone study of insertion trauma and intracochlear position of cochlear implant electrodes. I: Comparison of Nucleus banded and Nucleus Contour electrodes

In recent years, new designs of cochlear implant electrodes have been introduced in an attempt to improve efficiency and performance by locating stimulation sites closer to spiral ganglion neurons and deeper into the scala tympani. The goal of this study was to document insertion depth, intracochlear position and insertion trauma with the Nucleus Contour electrode and to compare results to those observed with the earlier generation Nucleus banded electrode. For this comparison eight Nuclears banded electrodes and 18 Contour electrodes were implanted in cadaver temporal bones using a realistic surgical exposure. Two experienced cochlear implant surgeons and two otology fellows with specialized training in cochlear implant surgery were selected for the study to represent a range of surgical experience similar to that of surgeons currently performing the procedure throughout the world. Following insertion of the electrodes, specimens were imaged using plain film X-ray, embedded in acrylic resin, cut in radial sections with the electrodes in place, and each cut surface was polished. Insertion depth was measured in digitized X-ray images, and trauma was assessed in each cross-section. The Contour electrode inserted more deeply (mean depth=17.9 mm or 417 degrees ) than the banded electrode (mean depth=15.3 mm or 285 degrees ). The incidence and severity of trauma varied substantially among the temporal bones studied. However, the nature and frequency of injuries observed with the two devices were very similar. The Contour electrode was clearly positioned closer to the modiolus than the banded model, and also appeared easier to use. Based on this difference in position and data from previous studies we conclude that the Contour electrode may provide lower thresholds and improved channel selectivity, but the incidence of trauma remains a problem with the newer design. The relative influences of electrode positioning and neural degeneration that may result from trauma are as yet unclear.

Current-level discrimination using bipolar and monopolar electrode configurations in cochlear implants

This study examined current-level discrimination ability in listeners with cochlear implants using bipolar and monopolar electrode configurations. Current-level discrimination ability was measured as a function of electrode configuration (monopolar and bipolar), stimulation site (8 and 16) and level (5%, 15%, 25%, 50% and 80% of the dynamic range). Weber fractions usually decreased with increasing level. Differences in Weber fractions between monopolar and bipolar configurations were observed for listeners with short durations of deafness (<5 years). For these listeners, in the bipolar condition at the more-apical site 16, Weber fractions remained constant with increasing level, and the Weber fractions at low levels were smaller than in other conditions. We suggest that nerve density was better and the nerve-to-site-of-action-potential distance was smaller in these cases such that more fibers could be recruited with a unit increase in current level, leading to better current-level sensitivity.

Multichannel place pitch sensitivity in cochlear implant recipients

Cochlear implant recipients perceive a rise in pitch when the site of stimulation is moved from the apex toward the base. The place pitch sensitivity is typically measured using the stimulation of single channels. However, all current cochlear implant devices stimulate multiple channels simultaneously or with pulses temporally interleaved. The primary goal of the present study is to test whether the sensitivity of a cochlear implant recipient to changes in perceived pitch associated with changes of place of excitation improves or deteriorates when the number of active channels is increased, compared with stimulation with only one active channel. Place pitch sensitivity was recorded in four Nucleus CI24 subjects as a function of number of active channels (from 1 to 8). Just noticeable differences were estimated from a constant stimuli 2AFC pitch-ranking experiment with roving loudness. Reference and comparison stimuli contained the same number of active channels but were shifted one or two electrodes toward the base or toward the apex. The place pitch sensitivity was measured using monopolar stimulation at two locations along the electrode array. To minimize cues related to loudness, the multichannel stimuli were loudness balanced relative to the single-channel stimuli presented at C-level. The number of active channels did not affect place pitch sensitivity. This is consistent with a model that compares the edges of the excitation pattern irrespective of the overlap between excitation patterns. There was a significant difference in sensitivity to place pitch among subjects. The average just noticeable differences of place pitch, extrapolated from a fitting procedure, for the subjects ranged from 0.25 mm to 0.46 mm.

Trends in cochlear implants

More than 60,000 people worldwide use cochlear implants as a means to restore functional hearing. Although individual performance variability is still high, an average implant user can talk on the phone in a quiet environment. Cochlear-implant research has also matured as a field, as evidenced by the exponential growth in both the patient population and scientific publication. The present report examines current issues related to audiologic, clinical, engineering, anatomic, and physiologic aspects of cochlear implants, focusing on their psychophysical, speech, music, and cognitive performance. This report also forecasts clinical and research trends related to presurgical evaluation, fitting protocols, signal processing, and postsurgical rehabilitation in cochlear implants. Finally, a future landscape in amplification is presented that requires a unique, yet complementary, contribution from hearing aids, middle ear implants, and cochlear implants to achieve a total solution to the entire spectrum of hearing loss treatment and management.

Electrode configuration influences action potential initiation site and ensemble stochastic response properties

The configuration of intracochlear electrodes used to electrically stimulate the auditory nerve influences the ensemble fiber response. For example, monopolar stimulation produces lower thresholds and greater spread of excitation than does bipolar stimulation. We used two approaches to investigate how the ensemble of auditory-nerve fibers responds to stimulation delivered by different electrode configurations. As the electrically evoked compound action potential (ECAP) reflects the ensemble response of the nerve, we used its morphology and changes with stimulus level to assess issues related to site-of-excitation and fiber recruitment. In our first approach, feline ECAPs were obtained using a nucleus-style banded electrode array. ECAP latency functions indicated that bipolar stimulation can initiate action potentials at more peripheral sites than does monopolar stimulation. We observed double-peaked ECAPs with bipolar and tripolar stimulation, suggesting excitation of both peripheral and central neural processes. Finally, we observed in some cases a tendency for monopolar stimulation to produce wider ECAP potentials, consistent with the notion that monopolar stimulation excites a broader spatial extent of the fiber population. In our second approach, we applied a simple model to published surveys of single-fiber responses to provide insight into the stochastic properties of the ensemble response. Our results suggest that broader recruitment of fiber activity produced by monopolar stimulation results in a population response with more probabilistic response characteristics and ensemble spike jitter. These observations and our ECAP results are consistent with reports of perceptual advantages attributed to monopolar or other less-focused modes of stimulation.

Features of stimulation affecting tonal-speech perception: implications for cochlear prostheses

Tone languages differ from English in that the pitch pattern of a single-syllable word conveys lexical meaning. In the present study, dependence of tonal-speech perception on features of the stimulation was examined using an acoustic simulation of a CIS-type speech-processing strategy for cochlear prostheses. Contributions of spectral features of the speech signals were assessed by varying the number of filter bands, while contributions of temporal envelope features were assessed by varying the low-pass cutoff frequency used for extracting the amplitude envelopes. Ten normal-hearing native Mandarin Chinese speakers were tested. When the low-pass cutoff frequency was fixed at 512 Hz, consonant, vowel, and sentence recognition improved as a function of the number of channels and reached plateau at 4 to 6 channels. Subjective judgments of sound quality continued to improve as the number of channels increased to 12, the highest number tested. Tone recognition, i.e., recognition of the four Mandarin tone patterns, depended on both the number of channels and the low-pass cutoff frequency. The trade-off between the temporal and spectral cues for tone recognition indicates that temporal cues can compensate for diminished spectral cues for tone recognition and vice versa. An additional tone recognition experiment using syllables of equal duration showed a marked decrease in performance, indicating that duration cues contribute to tone recognition. A third experiment showed that recognition of processed FM patterns that mimic Mandarin tone patterns was poor when temporal envelope and duration cues were removed.

Speech recognition with the nucleus 24 SPEAK, ACE, and CIS speech coding strategies in newly implanted adults

OBJECTIVE

The objective of this study was to determine whether 1) the SPEAK, ACE or CIS speech coding strategy was associated with significantly better speech recognition for individual subjects implanted with the Nucleus CI24M internal device who used the SPrint speech processor, and 2) whether a subject's preferred strategy for use in everyday life provided the best speech recognition.

DESIGN

Twelve postlinguistically deaf, newly implanted adults participated. Initial preference for the three strategies was obtained with paired-comparison testing on the first day of implant stimulation with seven of eight U.S. subjects. During the first 12 wk, all subjects used each strategy alone for 4 wk to give them experience with the strategy and to identify preferred speech processor program parameters and settings that would be used in subsequent testing. For the next 6 wk, subjects used one strategy at a time for 2-wk intervals in the same order they had for the first 12 wk. At the end of each 2-wk interval, speech recognition testing was conducted with all three strategies. At the end of the 6 wk, all three strategies were placed on each subject's processor, and subjects were asked to compare listening with these three programs in as many situations as possible for the next 2 wk. When they returned, subjects responded to a questionnaire asking about their preferred strategy and responded to two lists of medial consonants using each of the three strategies. The U.S. subjects also responded to two lists of medial vowels with the three strategies.

RESULTS

Six of the 12 subjects in the present study had significantly higher CUNY sentence scores with the ACE strategy than with one or both of the other strategies; one of the 12 subjects had a significantly higher score with SPEAK than with ACE. In contrast, only two subjects had significantly higher CNC word and phoneme scores with one or two strategies than with the third strategy. One subject had a significantly higher vowel score with the SPEAK strategy than with the CIS strategy; and no subjects had significantly higher consonant scores with any strategy. Seven of 12 subjects preferred the ACE strategy, three preferred the SPEAK strategy, and two preferred the CIS strategy. Subjects' responses on a questionnaire agreed closely with strategy preference from comparisons made in everyday life. There was a strong relation between the preferred strategy and scores on CUNY sentences but not for the other speech tests. For all subjects, except one, the preferred strategy was the one with the highest CUNY sentence score or was a strategy with a CUNY score not significantly lower than the highest score.

CONCLUSIONS

Despite differences in research design, there was remarkably close agreement in the pattern of group mean scores for the three strategies for CNC words and CUNY sentences in noise between the present study and the Conversion study (Arndt, Staller, Arcaroli, Hines, & Ebinger, Reference Note 1). In addition, essentially the same percentage of subjects preferred each strategy. For both studies, the strategy with which subjects had the highest score on the CUNY sentences in noise evaluation was strongly related to the preferred strategy; this relation was not strong for CNC words, CNC phonemes, vowels or consonants (Skinner, Arndt, & Staller, 2002). These results must be considered within the following context. For each strategy, programming parameters preferred for use in everyday life were determined before speech recognition was evaluated. In addition, implant recipients had experience listening with all three strategies in many situations in everyday life before choosing a preferred strategy. Finally, 11 of the 12 subjects strongly preferred one of the three strategies. Given the results and research design, it is recommended that clinicians fit each strategy sequentially starting with the ACE strategy so that the preferred programming parameters are determined for each strategy before recipients compare pairs of strategies. The goal is to provide the best opportunity for individuals to hear in everyday life within a clinically acceptable time period (e.g., 6 wk).

Cochlear implants and brain stem implants

This chapter describes the development of two implantable prosthetic neurostimulators which, in the last 20 years, have revolutionised the management of severe-to-profound sensorineural deafness. We have witnessed their rapid evolution from the realms of esoteric laboratory abstraction, with many critics and little perceived clinical use, to a routine treatment which is safe, effective and, indeed, cost effective. It is one of the great triumphs of biomedical and surgical collaboration, and is without any doubt the greatest ever advance in the treatment of deafness.