Etiology, Severity, Audiogram Type, and Device Usage in Patients with Unilateral Moderate to Profound Sensorineural Hearing Loss in Japan

BACKGROUND

Few studies have reported on the etiology, severity, or device usage of unilateral sensorineural hearing loss (UHL) compared to bilateral hearing loss. Therefore, this study investigated the characteristics of UHL in adults and children.

METHODS

We performed a survey using questionnaires for secondary and tertiary otolaryngology institutions.

RESULTS

We included 15,981 patients (1549 children and 14,432 adults) from 196 institutions with otolaryngology residency programs and 2844 patients (336 children and 2508 adults) from 27 institutions with board members of the Japan Audiology Society. The latter submitted audiological data. Among children, most diagnoses were made at age 0. Approximately half of them had profound hearing loss, and 37 children (2.2%) used hearing devices. Among adults, the number of cases increased with age, but decreased when people reached their 80s and 90s. More than half of them had moderate hearing loss. Sudden sensorineural hearing loss was the most common cause of UHL of all ages; 4.4% of UHL patients used hearing devices, and most of the device users (98.6%) selected a conventional hearing aid.

CONCLUSIONS

Hearing aid use is limited in children and adults with UHL in Japan. There could be many candidates with UHL for intervention such as a cochlear implant.

Temporal quantization deteriorates the discrimination of interaural time differences

Cochlear implants (CIs) often replace acoustic temporal fine structure by a fixed-rate pulse train. If the pulse timing is arbitrary (that is, not based on the phase information of the acoustic signal), temporal information is quantized by the pulse period. This temporal quantization is probably imperceptible with current clinical devices. However, it could result in large temporal jitter for strategies that aim to improve bilateral and bimodal CI users' perception of interaural time differences (ITDs), such as envelope enhancement. In an experiment with 16 normal-hearing listeners, it is shown that such jitter could deteriorate ITD perception for temporal quantization that corresponds to the often-used stimulation rate of 900 pulses per second (pps): the just-noticeable difference in ITD with quantization was 177 μs as compared to 129 μs without quantization. For smaller quantization step sizes, no significant deterioration of ITD perception was found. In conclusion, the binaural system can only average out the effect of temporal quantization to some extent, such that pulse timing should be well-considered. As this psychophysical procedure was somewhat unconventional, different procedural parameters were compared by simulating a number of commonly used two-down one-up adaptive procedures in Appendix B.

Cortical auditory evoked responses in cochlear implant users with early-onset single-sided deafness: indicators of the development of bilateral auditory pathways

Cochlear implantation (CI) for early-onset single-sided deafness (SSD) provides a unique insight into the development and cortical reorganization of binaural pathways. This case series aimed to investigate the impact of duration of deafness on CI outcomes as measured by cortical evoked auditory potentials (CAEPs). Four adults with early-onset SSD were studied after CI. The adults had a duration of deafness of 22, 24, 42, and 38 years before implantation. CAEPs and speech perception in noise were used to investigate binaural cortical pathways and function. Our four patients lost their hearing at the ages of 3, 6, 5, and 6 (S1, S2, S3, and S4, respectively). CAEPs were present bilaterally in S2, S3, and S4. S1's, who had the least experience with a CI, cortical responses at 1 month after CI activation showed cortical responses from the CI ipsilateral pathway, but no responses from the CI contralateral pathway. At 3 and 6 months, S1 showed significant cortical responses from the CI contralateral pathway for two speech tokens. An improvement in speech perception in noise testing was observed in all four participants. This case series indicates that long duration of deafness for early-onset SSD is not a contraindication for CI and may not impact the long-term outcomes in this population. The electrical stimulation from the CI integrates with the normal-hearing ear to produce bilateral cortical projections and functional improvement in speech perception in noise. These early data provide surprisingly positive results and call for larger scale research to be carried out.

Speech Detection in Noise for Young Bilaterally Implanted Children: Is There Evidence of Binaural Benefit Over the Shadowed Ear Alone?

OBJECTIVES

To measure binaural benefit over the shadowed ear alone for young bilateral cochlear implant (CI) users. It was hypothesized that children who received bilateral CIs at a young age (<4 years), and had significant bilateral experience, would demonstrate lower detection thresholds for speech sounds in background noise in the bilateral CI over the unilateral CI condition when the added CI was ipsilateral to the noise source.

DESIGN

Children receiving bilateral CIs at the Eye and Ear Hospital Clinic in Melbourne were invited to participate in a wider research project evaluating outcomes; those participating in the wider project who were bilaterally implanted by 4 years and were approximately 2 years postoperative were included in the present study. For 20 participants, detection signal to noise ratios (SNRs) were measured for speech presented from in front and noise from 90° in at least 3 of 4 device/noise conditions, namely left CI/noise right and right CI/noise left, plus bilateral CIs/noise right and bilateral CIs/noise left.

RESULTS

As some participants could only complete testing in 3 conditions within the 1 test block, the unilateral versus bilateral comparison was performed for 1 CI (i.e., 1 noise direction) for 15 participants and for both CIs (i.e., noise left and noise right) for 5 participants. Group analysis indicated no significant difference in detection SNR between the unilateral and bilateral CI conditions when adding the left CI or right CI (for the overall group) or when adding the first or second CI (for the 15 participants with sequential bilateral CIs). Separate analyses indicated no significant difference in detection SNR between the unilateral and bilateral CI conditions for the majority of individuals; this occurred irrespective of whether the analysis indicated that the CI added in the bilateral condition was poorer-performing, better-performing, or not significantly different compared with the other CI. Four individuals demonstrated a significant improvement in the bilateral condition when the CI added in the bilateral condition was a better-performing (n = 1), poorer-performing (n = 2), or not significantly different CI (n = 1). There was no relationship between the detection SNR difference between each CI and the detection SNR difference between the unilateral and bilateral conditions.

CONCLUSIONS

The hypothesis of a lower detection SNR in the bilateral condition was not supported by the group results or by the results for the majority of individuals. For the 4 participants who did demonstrate benefit over the shadowed ear alone, that benefit cannot be separated from the potential benefit gained as a result of the CI added in the bilateral condition being the better-performing CI for 1 of the 4. Variation in outcomes could not be related to demographic factors for this group, which was relatively homogeneous for age at bilateral CI and experience; an older, more experienced group may demonstrate greater binaural benefit in these conditions. These results can be used during counseling for families regarding postoperative expectations for young children, especially in the first 2 years.

Binaural sensitivity in children who use bilateral cochlear implants

Children who are deaf and receive bilateral cochlear implants (BiCIs) perform better on spatial hearing tasks using bilateral rather than unilateral inputs; however, they underperform relative to normal-hearing (NH) peers. This gap in performance is multi-factorial, including the inability of speech processors to reliably deliver binaural cues. Although much is known regarding binaural sensitivity of adults with BiCIs, less is known about how the development of binaural sensitivity in children with BiCIs compared to NH children. Sixteen children (ages 9-17 years) were tested using synchronized research processors. Interaural time differences and interaural level differences (ITDs and ILDs, respectively) were presented to pairs of pitch-matched electrodes. Stimuli were 300-ms, 100-pulses-per-second, constant-amplitude pulse trains. In the first and second experiments, discrimination of interaural cues (either ITDs or ILDs) was measured using a two-interval left/right task. In the third experiment, subjects reported the perceived intracranial position of ITDs and ILDs in a lateralization task. All children demonstrated sensitivity to ILDs, possibly due to monaural level cues. Children who were born deaf had weak or absent sensitivity to ITDs; in contrast, ITD sensitivity was noted in children with previous exposure to acoustic hearing. Therefore, factors such as auditory deprivation, in particular, lack of early exposure to consistent timing differences between the ears, may delay the maturation of binaural circuits and cause insensitivity to binaural differences.

Binaural release from masking with single- and multi-electrode stimulation in children with cochlear implants

Cochlear implants (CIs) provide children with access to speech information from a young age. Despite bilateral cochlear implantation becoming common, use of spatial cues in free field is smaller than in normal-hearing children. Clinically fit CIs are not synchronized across the ears; thus binaural experiments must utilize research processors that can control binaural cues with precision. Research to date has used single pairs of electrodes, which is insufficient for representing speech. Little is known about how children with bilateral CIs process binaural information with multi-electrode stimulation. Toward the goal of improving binaural unmasking of speech, this study evaluated binaural unmasking with multi- and single-electrode stimulation. Results showed that performance with multi-electrode stimulation was similar to the best performance with single-electrode stimulation. This was similar to the pattern of performance shown by normal-hearing adults when presented an acoustic CI simulation. Diotic and dichotic signal detection thresholds of the children with CIs were similar to those of normal-hearing children listening to a CI simulation. The magnitude of binaural unmasking was not related to whether the children with CIs had good interaural time difference sensitivity. Results support the potential for benefits from binaural hearing and speech unmasking in children with bilateral CIs.

How to quantify binaural hearing in patients with unilateral hearing using hearing implants

Application of bilateral hearing devices in bilateral hearing loss and unilateral application in unilateral hearing loss (second ear with normal hearing) does not a priori lead to binaural hearing. An overview is presented on several measures of binaural benefits that have been used in patients with unilateral or bilateral deafness using one or two cochlear implants, respectively, and in patients with unilateral or bilateral conductive/mixed hearing loss using one or two percutaneous bone conduction implants (BCDs), respectively. Overall, according to this overview, the most significant and sensitive measure is the benefit in directional hearing. Measures using speech (viz. binaural summation, binaural squelch or use of the head shadow effect) showed minor benefits, except for patients with bilateral conductive/mixed hearing loss using two BCDs. Although less feasible in daily practise, the binaural masking level difference test seems to be a promising option in the assessment of binaural function.

Interaural envelope correlation change discrimination in bilateral cochlear implantees: effects of mismatch, centering, and onset of deafness

Bilateral cochlear implant (CI) listeners can perform binaural tasks, but they are typically worse than normal-hearing (NH) listeners. To understand why this difference occurs and the mechanisms involved in processing dynamic binaural differences, interaural envelope correlation change discrimination sensitivity was measured in real and simulated CI users. In experiment 1, 11 CI (eight late deafened, three early deafened) and eight NH listeners were tested in an envelope correlation change discrimination task. Just noticeable differences (JNDs) were best for a matched place-of-stimulation and increased for an increasing mismatch. In experiment 2, attempts at intracranially centering stimuli did not produce lower JNDs. In experiment 3, the percentage of correct identifications of antiphasic carrier pulse trains modulated by correlated envelopes was measured as a function of mismatch and pulse rate. Sensitivity decreased for increasing mismatch and increasing pulse rate. The experiments led to two conclusions. First, envelope correlation change discrimination necessitates place-of-stimulation matched inputs. However, it is unclear if previous experience with acoustic hearing is necessary for envelope correlation change discrimination. Second, NH listeners presented with CI simulations demonstrated better performance than real CI listeners. If the simulations are realistic representations of electrical stimuli, real CI listeners appear to have difficulty processing interaural information in modulated signals.

Binaural fusion and listening effort in children who use bilateral cochlear implants: a psychoacoustic and pupillometric study

Bilateral cochlear implants aim to provide hearing to both ears for children who are deaf and promote binaural/spatial hearing. Benefits are limited by mismatched devices and unilaterally-driven development which could compromise the normal integration of left and right ear input. We thus asked whether children hear a fused image (ie. 1 vs 2 sounds) from their bilateral implants and if this “binaural fusion” reduces listening effort. Binaural fusion was assessed by asking 25 deaf children with cochlear implants and 24 peers with normal hearing whether they heard one or two sounds when listening to bilaterally presented acoustic click-trains/electric pulses (250 Hz trains of 36 ms presented at 1 Hz). Reaction times and pupillary changes were recorded simultaneously to measure listening effort. Bilaterally implanted children heard one image of bilateral input less frequently than normal hearing peers, particularly when intensity levels on each side were balanced. Binaural fusion declined as brainstem asymmetries increased and age at implantation decreased. Children implanted later had access to acoustic input prior to implantation due to progressive deterioration of hearing. Increases in both pupil diameter and reaction time occurred as perception of binaural fusion decreased. Results indicate that, without binaural level cues, children have difficulty fusing input from their bilateral implants to perceive one sound which costs them increased listening effort. Brainstem asymmetries exacerbate this issue. By contrast, later implantation, reflecting longer access to bilateral acoustic hearing, may have supported development of auditory pathways underlying binaural fusion. Improved integration of bilateral cochlear implant signals for children is required to improve their binaural hearing.

Sensitivity to interaural envelope correlation changes in bilateral cochlear-implant users

Provision of bilateral cochlear implants (CIs) to people who are deaf is partially justified by improved abilities to understand speech in noise when comparing bilateral vs unilateral listening conditions. However, bilateral CI listeners generally show only monaural head shadow with little improvement in speech understanding due to binaural unmasking. Sensitivity to change in interaural envelope correlation, which is related to binaural speech unmasking, was investigated. Bilateral CI users were tested with bilaterally synchronized processors at single, pitch-matched electrode pairs. First, binaural masking level differences (BMLDs) were measured using 1000 pulse-per-second (pps) carriers, yielding BMLDs of 11.1 ± 6.5 and 8.5 ± 4.2 dB for 10- and 50-Hz bandwidth masking noises, respectively. Second, envelope correlation change just-noticeable differences (JNDs) were measured. Stimuli presented at 1000 pps yielded lower JNDs than those presented at 100 pps. Furthermore, perfectly correlated reference stimuli produced lower JNDs than uncorrelated references, and uncorrelated references generally produced immeasurable JNDs. About 25% of JNDs measured in the CI listeners were in the range of JNDs observed in normal-hearing listeners presented CI simulations. In conclusion, CI listeners can perceive changes in interaural envelope correlation, but the poor performance may be a major limiting factor in binaural unmasking tested to date in realistic listening environments.

What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills?

As a result of neonatal hearing screening and subsequent early cochlear implantation (CI) profoundly deaf children have access to important information to process auditory signals and master spoken language skills at a young age. Nevertheless, auditory, linguistic and cognitive outcome measures still reveal great variability in individual achievements: some children with CI(s) perform within normal limits, while others lag behind. Understanding the causes of this variation would allow clinicians to offer better prognoses to CI candidates and efficient follow-up and rehabilitation. This paper summarizes what we can expect of normally developing children with CI(s) with regard to spoken language, bilateral and binaural auditory perception, speech perception and cognitive skills. Predictive factors of performance and factors influencing variability are presented, as well as some novel data on cognitive functioning and speech perception in quiet and in noise. Subsequently, we discuss technical and non-technical issues which should be considered in the future in order to optimally guide the child with profound hearing difficulties. This article is part of a Special Issue entitled <Lasker Award>.

Binaural hearing with electrical stimulation

Bilateral cochlear implantation is becoming a standard of care in many clinics. While much benefit has been shown through bilateral implantation, patients who have bilateral cochlear implants (CIs) still do not perform as well as normal hearing listeners in sound localization and understanding speech in noisy environments. This difference in performance can arise from a number of different factors, including the areas of hardware and engineering, surgical precision and pathology of the auditory system in deaf persons. While surgical precision and individual pathology are factors that are beyond careful control, improvements can be made in the areas of clinical practice and the engineering of binaural speech processors. These improvements should be grounded in a good understanding of the sensitivities of bilateral CI patients to the acoustic binaural cues that are important to normal hearing listeners for sound localization and speech in noise understanding. To this end, we review the current state-of-the-art in the understanding of the sensitivities of bilateral CI patients to binaural cues in electric hearing, and highlight the important issues and challenges as they relate to clinical practice and the development of new binaural processing strategies. This article is part of a Special Issue entitled <Lasker Award>.

The effect of interaural fluctuation rate on correlation change discrimination

While bilateral cochlear implants (CIs) provide some binaural benefits, these benefits are limited compared to those observed in normal-hearing (NH) listeners. The large frequency-to-electrode allocation bandwidths (BWs) in CIs compared to auditory filter BWs in NH listeners increases the interaural fluctuation rate available for binaural unmasking, which may limit binaural benefits. The purpose of this work was to investigate the effect of interaural fluctuation rate on correlation change discrimination and binaural masking-level differences in NH listeners presented a CI simulation using a pulsed-sine vocoder. In experiment 1, correlation-change just-noticeable differences (JNDs) and tone-in-noise thresholds were measured for narrowband noises with different BWs and center frequencies (CFs). The results suggest that the BW, CF, and/or interaural fluctuation rate are important factors for correlation change discrimination. In experiment 2, the interaural fluctuation rate was systematically varied and dissociated from changes in BW and CF by using a pulsed-sine vocoder. Results indicated that the interaural fluctuation rate did not affect correlation change JNDs for correlated reference noises; however, slow interaural fluctuations increased correlation change JNDs for uncorrelated reference noises. In experiment 3, the BW, CF, and vocoder pulse rate were varied while interaural fluctuation rate was held constant. JNDs increased for increasing BW and decreased for increasing CF. In summary, relatively fast interaural fluctuation rates are not detrimental for detecting changes in interaural correlation. Thus, limiting factors to binaural benefits in CI listeners could be a result of other temporal and/or spectral deficiencies from electrical stimulation.

Accessibility to cochlear implants in Belgium: state of the art on selection, reimbursement, habilitation, and outcomes in children and adults

Belgium, and especially the northern region called Flanders, has been a center of expertise in cochlear implants and early hearing screening for many years. Some of their surgeons and engineers were pioneers in the development of cochlear implants and in 1998 Flanders was the first region in Europe to implement a universal hearing screening program for all neonates. The Belgian National Institute for Health and Disability Insurance has reimbursed cochlear implants in children and adults since 1994 and bilateral implantation in children under the age of 12 years since February 2010. These deaf children, screened and implanted early, achieve higher auditory, speech and language outcomes and increasing numbers are going to regular schools using fewer interpreters. In 2010, 93% of severe-to-profound deaf preschool children in Flanders had received cochlear implants and 25% had bilateral implants. Although on average twice as many adults as children are implanted a year in Belgium, we have less research data available from this adult population. Also very little is published about the growth curves and minimal rehabilitation requirements (intensity, duration etc.) after implantation for both children and adults. So, there still remain many challenges for the future.

Single-sided deafness leads to unilateral aural preference within an early sensitive period

Unilateral deafness has a high incidence in children. In addition to children who are born without hearing in one ear, children with bilateral deafness are frequently equipped only with one cochlear implant, leaving the other ear deaf. The present study investigates the effects of such single-sided deafness during development in the congenitally deaf cat. The investigated animals were either born with unilateral deafness or received a cochlear implant in one ear and were subjected to chronic monaural stimulation. In chronically stimulated animals, implantation ages were at the following three critical developmental points: 'early' during the peak of functional cortical synaptogenesis in deaf animals; 'intermediate' at the age when synaptic activity in the deaf cats dropped to the level of hearing control cats and finally, 'late' at the age when the evoked synaptic activity fell below the level of hearing control cats. After periods of unilateral hearing, local field potentials were recorded from the cortical surface using a microelectrode at ∼100 recording positions. Stimulation was with cochlear implants at both ears. The measures evaluated were dependent only on the symmetry of aural input: paired differences of onset latencies and paired relations of peak amplitudes of local field potentials. A massive reorganization of aural preference in favour of the hearing ear was found in these measures if the onset of unilateral hearing was early (before or around the peak of functional synaptogenesis). The effect was reduced if onset of unilateral hearing was in the intermediate period, and it disappeared if the onset was late. In early onset of unilateral deafness, the used ear became functionally dominant with respect to local field potential onset latency and amplitude. This explains the inferior outcome of implantations at the second-implanted ear compared with first-implanted ear in children. However, despite a central disadvantage for the deaf ear, it still remained capable of activating the auditory cortex. Appropriate training may thus help to improve the performance at the second-implanted ear. In conclusion, periods of monaural stimulation should be kept as short as possible, and training focused on the deaf ear should be introduced after delayed second implantation in children.

Binaural unmasking of multi-channel stimuli in bilateral cochlear implant users

Previous work suggests that bilateral cochlear implant users are sensitive to interaural cues if experimental speech processors are used to preserve accurate interaural information in the electrical stimulation pattern. Binaural unmasking occurs in adults and children when an interaural delay is applied to the envelope of a high-rate pulse train. Nevertheless, for speech perception, binaural unmasking benefits have not been demonstrated consistently, even with coordinated stimulation at both ears. The present study aimed at bridging the gap between basic psychophysical performance on binaural signal detection tasks on the one hand and binaural perception of speech in noise on the other hand. Therefore, binaural signal detection was expanded to multi-channel stimulation and biologically relevant interaural delays. A harmonic complex, consisting of three sinusoids (125, 250, and 375 Hz), was added to three 125-Hz-wide noise bands centered on the sinusoids. When an interaural delay of 700 μs was introduced, an average BMLD of 3 dB was established. Outcomes are promising in view of real-life benefits. Future research should investigate the generalization of the observed benefits for signal detection to speech perception in everyday listening situations and determine the importance of coordination of bilateral speech processors and accentuation of envelope cues.

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.

Bilateral cochlear implantation in the ferret: a novel animal model for behavioral studies

Bilateral cochlear implantation has recently been introduced with the aim of improving both speech perception in background noise and sound localization. Although evidence suggests that binaural perception is possible with two cochlear implants, results in humans are variable. To explore potential contributing factors to these variable outcomes, we have developed a behavioral animal model of bilateral cochlear implantation in a novel species, the ferret. Although ferrets are ideally suited to psychophysical and physiological assessments of binaural hearing, cochlear implantation has not been previously described in this species. This paper describes the techniques of deafening with aminoglycoside administration, surgical implantation of an intracochlear array and chronic intracochlear electrical stimulation with monitoring for electrode integrity and efficacy of stimulation. Experiments have been presented elsewhere to show that the model can be used to study behavioral and electrophysiological measures of binaural hearing in chronically implanted animals. This paper demonstrates that cochlear implantation and chronic intracochlear electrical stimulation are both safe and effective in ferrets, opening up the possibility of using this model to study potential protective effects of bilateral cochlear implantation on the developing central auditory pathway. Since ferrets can be used to assess psychophysical and physiological aspects of hearing along with the structure of the auditory pathway in the same animals, we anticipate that this model will help develop novel neuroprosthetic therapies for use in humans.

Binaural masking level differences in actual and simulated bilateral cochlear implant listeners

At present commercially available bilateral cochlear implants (CIs) improve their users' speech understanding in noise but they employ two independent speech processors that cannot provide accurate and appropriate interaural level and time differences as seen binaurally in normal hearing (NH) listeners. Previous work suggests that binaural cues are accessible to bilateral CI users when presented to single pairs of pitch-matched electrodes, but the scope was limited and the mechanisms remained unclear. In this study, binaural masking level differences (BMLDs) were measured in five bilateral Nucleus-24 CI users over multiple pairs of pitch-matched electrodes. Average BMLD was 4.6+/-4.9 dB, but large individual variability prevented significance (p=0.09). Considering just the 125 Hz condition, as in previous work, phase (N0S0 vs N0Spi) and electrode effects were significant. Compared with simulated bilateral CI users, actual bilateral CI users had proportionally higher thresholds for N0Spi than N0S0. Together the present results suggest that the performance gap in BMLDs between CI and NH listeners is not due to a lack of sufficient acoustic cues in the temporal envelope domain but to a true binaural deficit related to a central mechanism in deprived binaural processing.

Functional outcome of sequential bilateral cochlear implantation in young children: 36 months postoperative results

OBJECTIVE

To examine the effects of sequential bilateral cochlear implantation (CI) on the life of young children after 36 months of bilateral implant use.

METHOD

Thirty-five children were assessed prior to and 3 until 36 months after activation of the second CI. Main outcome measures were: the Categories of Auditory Performance (CAP), Speech Intelligibility Rating (SIR), communication mode, classroom placement, parent reports and the Würzburg questionnaire. Results were analysed separately for children younger and older than 6 years at the time of the second implantation.

RESULTS

At the 3-year test interval, 80% of the younger children attended mainstream schools and were comprehensible for all listeners. They all used oral communication and almost 70% of them could have a conversation over the telephone. After 3 years of bilateral implant use less than 50% of the older children obtained the highest score on the SIR and CAP. Approximately 70% of them was integrated in mainstream schools and used oral communication. All parents reported a more natural communication and an improved quality of life.

CONCLUSIONS

Sequential bilateral implantation seems to offer a wide range of participation benefits to all children and facilitates the social intercourse with their hearing environment.