The Importance of Bilateral Cochlear Implantation in Children who are Profoundly Deaf in Both Ears. Karen A. Gordon
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1 The Importance of Bilateral Cochlear Implantation in Children who are Profoundly Deaf in Both Ears Karen A. Gordon
2 DIRECTORS Blake Papsin Karen Gordon Vicky Papaioannou RESEARCH ASSISTANT Stephanie Jewell STUDENTS Daniel Wong Patrick Yoo Michael Deighton Salima Jiwani Parvaneh Abbasalipour Nikolaus Wolter Francis Manno Melissa Polonenko Morrison Steele Carol Duong Gurvinder Toor Hena Kazmi Katie McCann Brian Wong Cochlear Implant Team Local - SickKids Bob Harrison Tracy Stockley Mark Crawford Maureen Dennis COLLABORATORS TEAM CLINICIANS Sharon Cushing Adrian James Susan Blaser Gina Sohn Naureen Sohail Laurie MacDonald Mary Lynn Feness Pat Di Santos Valerie Simard Nancy Greenwald- Hood Susan Druker Local - external Sandra Trehub Frank Russo International Robert Cowan Richard van Hoesel
3 Children need binaural hearing
4 Can we promote binaural hearing with bilateral cochlear implants? Sequential implants n=156 Age at 1st implant = 3.3 ± 3.1 yrs Age at 2 nd implant = 9.3 ± 4.7 yrs Inter-implant delay = 5.9 ± 3.8 yrs Simultaneous implants n=166 Age at implant = 2.8 ± 3.2 Recruitment as of May 2012
5 Spatial unmasking: better hearing in noise (noise at 0 ) vs. (noise at 90 )
6 Spatial unmasking: better hearing in noise (noise at 0 ) vs. (noise at 90 )
7 Spatial unmasking: better hearing in noise (noise at 0 ) vs. (noise at 90 )
8 Spatial unmasking SNR (db) Spatial release from masking Noise moved to 1st implanted ear Noise moved to 2nd implanted ear P< sequential simultaneous normal Chadha et al., Otol NeuroOtol, 2011
9 Spatial unmasking SNR (db) Spatial release from masking 11 Noise moved to 1st implanted ear Noise moved to 2nd implanted ear P< sequential simultaneous normal Chadha et al., Otol NeuroOtol, 2011
10 Spatial unmasking SNR (db) Spatial release from masking Noise moved to 1st implanted ear Noise moved to 2nd implanted ear P=0.001 P> sequential simultaneous normal Chadha et al., Otol NeuroOtol, 2011
11 How does binaural hearing work? Sound reach one ear before the other and at different levels These cues must be detected by the central auditory system
12 Can we promote binaural hearing with bilateral cochlear implants? Auditory Cortex Medial Geniculate Body Inferior Colliculus Lateral Lemniscus Superior Olivary Complex
13 Will binaural processing be limited by deafness in early development? Reduced activity Activity no longer reduced Lee, et al., Nature, 2001
14 Neural competition in development Development Sherman, Nature Neuroscience 3, (2000)
15 Neural competition in development Development Maturity Sherman, Nature Neuroscience 3, (2000)
16 Unilaterally driven development
17 Neural competition in development Development Maturity in auditory brainstem with 2 years CI use Sherman, Nature Neuroscience 3, (2000)
18 Restricted auditory brainstem plasticity after 2 years of unilateral implant use Unilateral CI use: nil Unilateral CI use: 6-12 months Unilateral CI use: > 2 years Gordon, et al., 2010
19 Auditory evoked cortical responses are abnormal in the naïve ear Experienced ear Naïve ear P CI naïve P2 naive P2 P1 N1 Cz All other channels N N1 CI naive naïve
20 Imaging brain activity in cochlear implant users Latency Phonak (ms) Latin American Pediatric Conference III, Buenos Aires, Argentina, October 11-13, 2012
21 Imaging brain activity in cochlear implant users
22 Abnormal cortical activity after right cochlear implant use Clicks/pulses presented to right ear Right CI Users (n=8) Normal Hearing (n=7) % Activity in Left Auditory Cortex [(R-L)/(R+L)x100]
23 Normal cortical lateralization after simultaneous bilateral cochlear implantation Contralateral Contralateral
24 Increasing abnormality in cortical activity with unilateral cochlear implant use Ipsilateral Contralateral Ipsilateral Contralateral
25 Significant change in cortical activity with 1.5 years unilateral cochlear implant use Ipsilateral Contralateral Ipsilateral Contralateral 1.48 yrs 1.37 yrs
26 Participant Group Bilateral input goes to dominant hemisphere after 2+ years unilateral stimulation Long Delay Lateralization of Cortical Responses by Stimulus Side Left cortex Right cortex Left/CI-2 Stim Bilateral Right/CI-1 Stim Dipole in each hemisphere Short Delay Simultaneous Normal Lateralization %
27 Abnormal auditory development with unilateral implant use Dominance of contralateral auditory cortex Lack of inhibitory binaural processing during development Sequential bilateral CI 1st CI
28 Abnormal auditory development with unilateral implant use Dominance of contralateral auditory cortex Sequential bilateral CI 1st CI Ipsilateral cortex?
29
30 CI1 CI1
31 Proportion of responses Perception of binaural cues restored by simultaneous bilateral implantation Left Responses Normal Hearing (n=9) Right Responses Sequential bilateral cochlear implant (n=19) Left leading Right leading Left leading Right leading Inter-aural Timing Differences (us) Salloum et al., Ear and Hearing, 2010
32 Proportion of responses Perception of binaural cues restored by simultaneous bilateral implantation Left Responses Right Responses Normal Hearing Sequential bilateral Simultaneous bilateral (n=9) cochlear implant (n=19) cochlear implant (n=8) Left leading Right leading Left leading Right leading Left leading Right leading Inter-aural Timing Differences (us) Salloum et al., Ear and Hearing, 2010
33 Response Rate Response Rate Perception of binaural cues restored by simultaneous bilateral implantation Left Responses Right Responses Normal Hearing Left Responses Right Responses Simultaneous Bilateral CI Left Right Inter-aural/implant Level Difference (db/cu) us +400 us us us Inter-aural/implant Timing Difference
34 Non-auditory benefits of simultaneous implantation Hospital cost-savings 35% over sequential procedures Similar length of stay as unilateral procedures (~ 1 day) No increased complications (Ramsden, et al., 2009) Increased parental satisfaction compared with 2 surgeries in short period. One course of programming and therapy
35 Summary and Conclusions There is a sensitive developmental period for bilateral auditory input Simultaneous bilateral cochlear implantation Allows symmetric development of auditory brainstem and cortex Protects the brain from abnormal reorganization Promotes binaural hearing Provides significant cost savings over sequential procedures Sequential bilateral cochlear implantation Does not reverse effects of unilateral stimulation Abnormal asymmetry of brainstem and cortical activity Abnormal binaural processing
36 Conclusion Simultaneous bilateral cochlear implantation offers a cost-effective way to promote symmetric development and function along the bilateral auditory pathways and to establish binaural hearing for children who are deaf.
37 Thank you to all of our participants
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