Pediatric Auditory Brainstem Implant Surgery

Auditory brainstem implants: an analysis of adverse events in the MAUDE database

OBJECTIVE

Auditory Brainstem Implants (ABI) are used to restore hearing in patients lacking appropriate cochlear anatomy and/or cochlear nerve. The objective of this study was to examine the Manufacture and User Facility Device Experience (MAUDE) database to analyze adverse events.

STUDY DESIGN

This is a study of a multi-institutional database maintained by the US FDA.

SETTING

A database analysis was performed via collaboration of multiple clinicians at tertiary referral centers.

METHODS

The MAUDE database was queried for Medical Device Reports (MDRs) relating to ABIs. MDRs were identified using the advanced search term "Implant, Auditory Brainstem" and reviewing all reports with the basic search term "Brainstem Implant". All collected reports were individually reviewed.

RESULTS

A total of 265 individual patient reports were reviewed, of which 55 reports met inclusion criteria. Reports regarding audiologic outcome included failure to provide hearing benefit (n = 27), implant failure/device malfunction (n = 10), and device non-use (n = 6). Postoperative complications included local skin infection (n = 3), CSF leak (n = 3), elevated ICP (n = 1), surgical site dehiscence (n = 1), swelling (n = 1), seroma formation requiring drainage (n = 1), and meningitis (n = 2). Two patients had dislodged magnets during 1.5 Tesla MRI acquisition. There were 35 instances of full explantation of the device and 1 partial removal; 13 patients had a new device implanted following explantation.

CONCLUSIONS

Poor hearing results, device failure, and non-use were commonly reported causes for explanation in this analysis. This information can aid physicians in counseling patients and family members and managing device expectations.

Speech intelligibility of children with an auditory brainstem implant: a triple-case study

Auditory brainstem implantation (ABI) is a relative recent development in paediatric hearing restoration. Consequently, young-implanted children's productive language has not received much attention. This study investigated speech intelligibility of children with ABI (N = 3) in comparison to children with cochlear implants (CI) and children with typical hearing (TH). Spontaneous speech samples were recorded from children representing the three groups matched on cumulative vocabulary level. Untrained listeners (N = 101) rated the intelligibility of one-word utterances on a continuous scale and transcribed each utterance. The rating task yielded a numerical score between 0 and 100, and similarities and differences between the listeners' transcriptions were captured by a relative entropy score. The speech intelligibility of children with CI and children with TH was similar. Speech intelligibility of children with ABI was well below that of the children with CI and TH. But whereas one child with ABI's intelligibility approached that of the control groups with increasing lexicon size, the intelligibility of the two other children with ABI did not develop in a similar direction. Overall, speech intelligibility was only moderate in the three groups of children, with quite low ratings and considerable differences in the listeners' transcriptions, resulting in high relative entropy scores.

Hearing and language development in children with brainstem implants: a systematic review

OBJECTIVE

To present scientific evidence, based on a systematic review of the literature, on the benefit of brainstem implants in auditory rehabilitation and language development in children.

METHODS

A systematic search was used to identify studies that contain information about the benefit of brainstem implants in the auditory rehabilitation and language development of children. The review was conducted based on a structured literature search, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist. The search was carried out in the PubMed, Web of Science and Scopus databases, using the combination "Auditory brainstem implants" AND "Pediatric", without restriction of language, period, and location. The quality assessment of the articles was performed using the Study Quality Assessment Tools.

RESULTS

Regarding hearing, children with brainstem implants showed sound detection, access to most speech sounds, basic auditory perception skills, recognition of ambient sounds, recognition of some frequently used words and phrases, in addition to some closed-set word discrimination capability. Expressive and comprehensive language were identified in children using auditory brainstem implants, increasing significantly in the short and long terms in most cases; however, in some of the children, such skills remained stable.

CONCLUSION

The auditory brainstem implant can be considered an effective alternative for children with cochlear malformation and/or auditory nerve deficiency and for those who cannot benefit from cochlear implant surgery.

Intraword Variability in Children With Auditory Brainstem Implants: A Longitudinal Comparison With Children With Cochlear Implants

PURPOSE

Intraword variability designates the phenomenon that a particular target word is produced variably by a child at one point in the child's development. In this study, the amount of intraword variability is studied longitudinally in children with auditory brainstem implants (ABIs). Auditory brainstem implantation is a relative recent technique in pediatric hearing restoration. Therefore, little is known about the phonological development of these children's speech.

METHOD

The intraword variability is investigated in three children with ABI, in comparison to children with cochlear implants, matched on lexical development. Intraword variability is measured using relative entropy in order to take into account the frequency distribution in children's productions.

RESULT

Results showed considerable variation between the three children with ABI. Still, all children had higher levels of intraword variability in their spontaneous speech productions as compared to children with cochlear implants.

CONCLUSION

It seems that children with ABI are lagging behind their phonological development in reference to children with cochlear implants.

Revision Surgery for Pediatric Nontumor Auditory Brainstem Implant Users: Audiological, Rehabilitative, and Surgical Outcomes

OBJECTIVE

To report the audiological, rehabilitative, and surgical outcomes of revision surgery for pediatric auditory brainstem implant (ABI) users.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

Five pediatric ABI users who had revision surgery for device malfunctions.

INTERVENTIONS

Revision surgery for ABI malfunctions.

MAIN OUTCOME MEASURES

The findings of free-field audiometry with the device, the Meaningful Auditory Integration Scale, and the pattern discrimination, word identification, sentence recognition, and expressive and receptive language tests before the device failure and after revision surgery were obtained from the patient records and compared.

RESULTS

The revision rate for pediatric ABI was 6.45%. The Meaningful Auditory Integration Scale and expressive-receptive language scores showed improvements following revision surgery, while the aided thresholds, pattern perception, and word identification scores did not change. Individual differences in performance for these measures were observed.

CONCLUSION

Equal or improved performance after the revision surgeries in the current study showed that revision surgery is successful and important for pediatric ABI users. It is essential to consider remedying the loss of auditory input in sensitive periods of pediatric development.

Consonant and vowel production in the spontaneous speech productions of children with auditory brainstem implants

Auditory brainstem implantation provides hearing sensations in children and adults with anomalies of the auditory nerves. In children, perceptual benefits have been established, and research already demonstrated (limited) effects on children's speech production. The current study extends the literature by scrutinizing the phonological development of three children with ABI. Spontaneous speech samples were used to establish their phonemic inventories of vowels, word-initial consonants and word-final consonants, both independently of the target phoneme and relative to the target phoneme. The three children produced all vowels with longer device use and larger vocabulary size. Word-initial and word-final consonants appeared in the three children's spontaneous productions. However, the segmental accuracy was only moderate in the children's productions.

Word characteristics and speech production accuracy in children with auditory brainstem implants: a longitudinal triple case report

Auditory brainstem implants (ABI) in children in the first years of life is a recent innovation. Analyses of their speech and language development on the basis of spontaneous language samples are still largely lacking. The aim was to investigate the phonological complexity of the words children with ABI use in their spontaneous speech, and to compare their accuracy with that of children with cochlear implants (CI) and children with normal hearing (NH). Longitudinal recordings of spontaneous speech were collected of three children with ABI. Children with ABI target mainly words of low phonological complexity in their spontaneous speech, just as children with NH and children with CI do. The complexity of the words they attempt increases over time, but this development is less outspoken in comparison to children with CI and NH at the same hearing ages. The accuracy of the ABI children's word productions is situated in the lower ranges of the 95% confidence intervals of the NH and the CI groups, and - depending on the specific measure - even fall below the 95% border. The ABI intervention appears to be beneficial in the three cases studied, although their development is slow compared to children with CI and NH.

Pediatric Auditory Brainstem Implant Users Compared With Cochlear Implant Users With Additional Disabilities

OBJECTIVES

To evaluate long-term language development in children with prelingual deafness who received auditory brainstem implants (ABIs) compared with children who received cochlear implants (CIs) at the same hospital. Additional non-auditory disabilities were taken into account.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

Ten children with bilateral malformations of the cochlea and/or cochlear nerve who received ABIs, including seven with additional disabilities, and 147 children with CIs as a reference group, including 22 children with additional disabilities.

INTERVENTION

ABIs were implanted at 1.3 to 6.2 years of age. Follow-up ranged from 1.1 to 7.7 years.

MAIN OUTCOME MEASURES

Receptive and expressive language abilities were assessed using the Infant Toddler Meaningful Auditory Integration Scale (IT-MAIS), the Categories of Auditory Performance (CAP), the Meaningful Use of Speech Scale (MUSS), and the Speech Intelligibility Rate (SIR).

RESULTS

Of the 10 children with ABIs, seven had long-term follow-up data. Within 1 year, six of the seven children with ABIs could identify sounds, respond to speech, and use their voice to attract attention. Language skills developed at a slower rate than in children with CIs and reached the same competence level when additional disabilities were absent. These language skills matched, on average, those of children with CIs with additional disabilities.

CONCLUSION

For deaf children with bilateral inner ear malformations, ABIs provide satisfactory auditory input. Children with ABIs are able to develop receptive and expressive language skills comparable to those of children with CIs with additional disabilities. Using this knowledge, preoperative parent counselling can be refined.

Three-Dimensional Surface Reconstruction of the Human Cochlear Nucleus: Implications for Auditory Brain Stem Implant Design

Objective  The auditory brain stem implant (ABI) is a neuroprosthesis placed on the surface of the cochlear nucleus (CN) to provide hearing sensations in children and adults who are not candidates for cochlear implantation. Contemporary ABI arrays are stiff and do not conform to the curved brain stem surface. Recent advancements in microfabrication techniques have enabled the development of flexible surface arrays, but these have only been applied in animal models. Herein, we measure the surface curvature of the human CN and adjoining regions to assist in the design and placement of next-generation conformable clinical ABI arrays. Three-dimensional (3D) reconstructions from ultrahigh T1-weighted brain magnetic resonance imaging (MRI) sequences and histologic reconstructions based on postmortem adult human brain stem specimens were used. Design  This is a retrospective review of radiologic data and postmortem histologic axial sections. Setting  This is set at the tertiary referral center. Participants  Data were acquired from healthy adults. Main Outcome Measures  The main outcome measures are principal curvature values (Kmin and Kmax) and global radius of curvature. Results  The CN was successfully extracted and rendered as a 3D surface in all cases. Significant curvatures of the CN in both histologic and radiographic reconstructions were found with global radius of curvature ranging from 2.08 to 8.5 mm. In addition, local curvature analysis revealed that the surface is highly complex. Conclusion  Detailed rendering of the human CN is feasible using histology and 3D MRI reconstruction and highlights complex surface topography that is not recapitulated by contemporary stiff ABI arrays.

Auditory brainstem implantation in children with hearing loss: Effect on speech production

Auditory brainstem implantation (ABI) is a recent technique in children's hearing restoration. Up till now the focus in the literature has mainly been the perceptual outcomes after implantation, whereas the effect of ABI on spoken language is still an almost unexplored area of research. This study presents a one-year follow-up of the volubility of two children with ABI. The volubility of signed and oral productions is investigated and oral productions are examined in more detail. Results show clear developmental trends in both children, indicating a beneficial effect of ABI on spoken language development.

Expressive Vocabulary Growth After Pediatric Auditory Brainstem Implantation in Two Cases' Spontaneous Productions: A Comparison With Children With Cochlear Implants and Typical Hearing

Auditory brainstem implants (ABI) are recently being used to restore hearing of children with a congenital hearing loss, due to for instance the absence of auditory nerves. Thus far, the literature has focused on perceptual outcomes. The present study is among the first ones to investigate the spoken language development after implantation. The lexical development of children with ABI is examined longitudinally in comparison to children with typical hearing and children with cochlear implants. Results show that children with ABI still have smaller spoken vocabularies as compared to (hearing) age-matched children with cochlear implants and children with typical hearing. Implications will be discussed.

Induction of smell through transethmoid electrical stimulation of the olfactory bulb

BACKGROUND

Anosmia has an estimated prevalence of 5% of the general population. Outside of inflammatory causes, therapeutic options are limited despite research advances. Bypassing peripheral neuronal damage through central stimulation is a potential therapeutic option that has shown success in other sensory systems, most notably with hearing. We performed a pilot study to determine the feasibility of inducing smell through artificial electrical stimulation of the olfactory bulbs in humans.

METHODS

Subjects with a history of sinus surgery, including total ethmoidectomy, with intact ability to smell were enrolled. The ability to smell was confirmed with a 40-item smell identification test. Awake subjects underwent nasal endoscopy and either a monopolar or bipolar electrode was positioned at 3 areas along the lateral lamella of the cribriform plate within the ethmoid sinus cavity. A graded stimulation current of 1-20 mA at 3.17 Hz was administered while cortical evoked potential (CEP) recordings were collected. Subjective responses of perceived smell along with reports of discomfort were recorded. Subjects with artificially induced smell underwent repeat stimulation after medically induced anosmia.

RESULTS

Five subjects (age, 43-72 years) were enrolled. Three subjects reported smell perception smell with electrical stimulation. This was reproducible after inducing anosmia, but CEP recordings could not provide objective support. All subjects tolerated the study with minimal discomfort.

CONCLUSION

This is the first report of induced smell through transethmoid electrical stimulation of the olfactory bulb. These results provide a proof of concept for efforts in development of an olfactory implant system.

Early experience and health related quality of life outcomes following auditory brainstem implantation in children

OBJECTIVE

To assess auditory brainstem implant (ABI) outcomes in children with a prospective study.

METHODS

Twelve patients with cochlear nerve deficiency received an auditory brainstem implant. Patients were evaluated with age appropriate speech perception and production assessments, and health related quality of life (HRQoL) surveys for parents of subjects and for subjects if age appropriate.

RESULTS

Twelve patients received an ABI without major complications. Eleven out of twelve received some auditory benefit from their ABI. Parental HRQoL ratings were positive for all domains with the exception of communication. Self reported overall HRQoL metrics from two subjects were also positive.

CONCLUSIONS

ABI is a good option for patients who are not eligible for or fail CI. Our findings show that despite varying degrees of postoperative performance, HRQoL ratings were positive. The presence of additional disabilities and health problems resulted in less positive HRQoL outcomes. Our results emphasize the need to assess outcomes in these patients beyond speech perception and communication.

Assessing the Benefit-Risk Profile for Pediatric Implantable Auditory Prostheses

BACKGROUND/AIMS

Children with congenital cochleovestibular abnormalities associated with profound hearing loss have few treatment options if cochlear implantation does not yield benefit. An alternative is the auditory brainstem implant (ABI). Regulatory authority device approvals currently include a structured benefit-risk assessment. Such an assessment, for regulatory purposes or to guide clinical decision making, has not been published, to our knowledge, for the ABI and may lead to the design of a research program that incorporates regulatory authority, family, and professional input.

METHODS

Much structured benefit-risk research has been conducted in the context of drug trials; here we apply this approach to device studies. A qualitative framework organized benefit (speech recognition, parent self-report measures) and risk (surgery- and device-related) information to guide the selection of candidates thought to have potential benefit from ABI.

RESULTS

Children with cochleovestibular anatomical abnormalities are challenging for appropriate assessment of candidacy for a cochlear implant or an ABI. While the research is still preliminary, children with an ABI appear to slowly obtain benefit over time. A team of professionals, including audiological, occupational, and educational therapy, affords maximum opportunity for benefit.

CONCLUSIONS

Pediatric patients who have abnormal anatomy and are candidates for an implantable auditory prosthetic require an individualized, multisystems review. The qualitative benefit-risk assessment used here to characterize the condition, the medical need, potential benefits, risks, and risk management strategies has revealed the complex factors involved. After implantation, continued team support for the family during extensive postimplant therapy is needed to develop maximum auditory skill benefit.

Diagnosis and Management of Congenital Sensorineural Hearing Loss

Hearing loss is the most common sensory disorder in the USA. The diagnosis of congenital hearing loss starts with newborn hearing screening, which is best performed with auditory brainstem evoked responses in order to avoid the risk of missing auditory neuropathy spectrum disorder. A careful history and physical exam can occasionally help reveal the etiology for congenital hearing loss. Imaging studies, either CT temporal bones or MRI of the internal auditory canals without gadolinium, and genetic testing, in particular for connexin 26, connexin 30, and Pendred syndrome, are the most useful diagnostic tests. Management of congenital hearing loss involves early fitting of amplification. Early cochlear implantation, preferably before 2 years of age, should be strongly considered for children with bilateral severe hearing loss.

Outcomes following Pediatric Auditory Brainstem Implant Surgery: Early Experiences in a North American Center

There are no approved Food and Drug Administration indications for pediatric auditory brainstem implant (ABI) surgery in the United States. Our prospective case series aims to determine the safety and feasibility of ABI surgery in pediatric patients <5 years old with congenital deafness at a tertiary North American center. The inclusion criterion was pre- or postlinguistic deafness in children not eligible for cochlear implantation. Seventeen candidates were evaluated (mean ± SD: age, 2.52 ± 0.39 years). Four patients underwent ABI surgery (age, 19.2 ± 3.43 months), including 4 primary procedures and 1 revision for device failure. Spontaneous device failure occurred in another subject postoperatively. No major/minor complications occurred, including cerebrospinal fluid leak, facial nerve injury, hematoma, and nonauditory stimulation. All subjects detected sound with environmental awareness, and several demonstrated babbling and mimicry. Poor durability of older implants underscores need for updated technology.