Jeroen J. Briaire

The importance of human cochlear anatomy for the results of modiolus-hugging multichannel cochlear implants.

Hypothesis The fact that the anatomy of the basal turn of the human cochlea, especially, is essentially different from that of other species is likely to influence the outcome of cochlear implantation. Background Multichannel cochlear implants give better speech understanding than single-channel devices. They are intended to make use of the tonotopic organization of the cochlea by selectively stimulating subpopulations of the auditory nerve. At higher stimulus levels and with monopolar stimulation, excitation of nerve fibers from other turns may interfere with this concept, especially with modiolus-hugging electrodes. Methods A three-dimensional spiraling computer model of the human cochlea, based on histologic data, was used to test the spatial selectivity and the dynamic range before cross-turn stimulation takes place for the Clarion HiFocus implant with and without a positioner. The results were compared with a similar model of the guinea pig cochlea. Results In humans (in contrast to the guinea pig), a well-designed modiolus-hugging electrode yielded reduced current thresholds and high spatial selectivity without reduction of the useful dynamic range. The apical turn of the human cochlea, however, is largely comparable in this respect with the guinea pig cochlea, where cross-turn stimulation reduces the dynamic range substantially. Conclusion The clinical success of cochlear implantation in humans and the favorable results with modiolus-hugging devices depend on the anatomy of the human cochlea.

Initial evaluation of the Clarion CII cochlear implant: Speech perception and neural Response imaging

Objective To evaluate the new Clarion® CII cochlear implant with the perimodiolar HiFocus® electrode array, including both speech perception outcomes and the device’s capabilities of measuring the electrically evoked compound action potential (eCAP) of the auditory nerve (Neural Response Imaging, NRI). Design The speech perception scores on CVC words without lip reading were monitored prospectively for the 10 postlingually deaf patients implanted with the Clarion CII device in the period July 2000 until May 2001 in the Leiden University Medical Center. Preoperative and postoperative NRI recordings were made, applying various combinations of monopolar stimulating and recording electrodes with the alternating polarity paradigm available in the test bench software. Results Nine patients preferred the CIS, one the PPS strategy, none the SAS strategy. With their favorite strategy they acquired significant open set speech understanding within a few weeks, resulting in an average CVC phoneme score of 84% (word score 66%) at the end of the study (follow-up 3 to 11 mo). In speech-shaped noise, the average phoneme recognition threshold (PRT) was reached at a signal to noise ratio just below 0 dB. The NRI recordings had clear N1 and P1 peaks if there was at least one contact between the stimulating and recording electrodes, necessitating just 15 sweeps for a reliable recording. We observed considerable inter-patient and inter-electrode variability, but for a given situation NRI input/output curves were stable over time. More apical contacts generally elicited larger eCAPs. Response amplitudes tended to peak at recording sites around apical and basal stimulating electrodes, suggesting a limited spread of excitation. Preliminary recordings with the forward masking paradigm were consistent with the ones with the alternating polarity scheme. Conclusions The Clarion CII is a promising cochlear implant with which our first 10 patients have obtained excellent speech perception results. The NRI system yields high quality signals with a limited number of sweeps at a high sampling rate.

Field patterns in a 3D tapered spiral model of the electrically stimulated cochlea.

Despite the fact that cochlear implants are widely and successfully used in clinical practice, relatively little is known to date about the electric field patterns they set up in the cochlea. Based upon the available measurements and modelling results, the scala tympani is usually considered to be a preferential current pathway that acts like a leaky transmission line. Therefore, most authors assume the current thresholds to decay exponentially along the length of the scala tympani. Here we present potential distributions calculated with a fully three-dimensional, spiralling volume conduction model of the guinea pig cochlea, and try to identify its preferential current pathways. The relatively well conducting scala tympani turns out to be the main one indeed, but the exponential decay (J approximately e(-z)) of current is only a good description of the far-field behaviour. In the vicinity of the electrodes, i.e. near the fibres that are most easily excited, higher current densities are found, that are best described by a spherical spread of the current (J approximately 1/R(2)). The results are compared with those obtained with a variant of our previous, rotationally symmetric, model and with measurements in the literature. The implications of the findings are discussed in the light of simulated neural responses.

The consequences of neural degeneration regarding optimal cochlear implant position in scala tympani: a model approach.

Cochlear implant research endeavors to optimize the spatial selectivity, threshold and dynamic range with the objective of improving the speech perception performance of the implant user. One of the ways to achieve some of these goals is by electrode design. New cochlear implant electrode designs strive to bring the electrode contacts into close proximity to the nerve fibers in the modiolus: this is done by placing the contacts on the medial side of the array and positioning the implant against the medial wall of scala tympani. The question remains whether this is the optimal position for a cochlea with intact neural fibers and, if so, whether it is also true for a cochlea with degenerated neural fibers. In this study a computational model of the implanted human cochlea is used to investigate the optimal position of the array with respect to threshold, dynamic range and spatial selectivity for a cochlea with intact nerve fibers and for degenerated nerve fibers. In addition, the model is used to evaluate the predictive value of eCAP measurements for obtaining peri-operative information on the neural status. The model predicts improved threshold, dynamic range and spatial selectivity for the peri-modiolar position at the basal end of the cochlea, with minimal influence of neural degeneration. At the apical end of the array (1.5 cochlear turns), the dynamic range and the spatial selectivity are limited due to the occurrence of cross-turn stimulation, with the exception of the condition without neural degeneration and with the electrode array along the lateral wall of scala tympani. The eCAP simulations indicate that a large P(0) peak occurs before the N(1)P(1) complex when the fibers are not degenerated. The absence of this peak might be used as an indicator for neural degeneration.

Pitch Comparisons between Electrical Stimulation of a Cochlear Implant and Acoustic Stimuli Presented to a Normal-hearing Contralateral Ear

Four cochlear implant users, having normal hearing in the unimplanted ear, compared the pitches of electrical and acoustic stimuli presented to the two ears. Comparisons were between 1,031-pps pulse trains and pure tones or between 12 and 25-pps electric pulse trains and bandpass-filtered acoustic pulse trains of the same rate. Three methods—pitch adjustment, constant stimuli, and interleaved adaptive procedures—were used. For all methods, we showed that the results can be strongly influenced by non-sensory biases arising from the range of acoustic stimuli presented, and proposed a series of checks that should be made to alert the experimenter to those biases. We then showed that the results of comparisons that survived these checks do not deviate consistently from the predictions of a widely-used cochlear frequency-to-place formula or of a computational cochlear model. We also demonstrate that substantial range effects occur with other widely used experimental methods, even for normal-hearing listeners.

Unraveling the electrically evoked compound action potential

With the advent of eCAP recording tools such as NRT and NRI for cochlear implants, neural monitoring has become widely used to ascertain the integrity of the neural/electrode interface as well as for assisting in the setting of program levels. The basic concepts of eCAP recordings are deduced from the acoustical equivalent of the electrocochleogram. There are, however, indications that under electrical stimulation some of these do not hold, like the unitary response concept (i.e., the principle that every fiber produces the same contribution to the eCAP). Computer modeling has proven to be a valuable tool for gaining insight into the functioning of electrical stimulation. In this study the extension of a three-dimensional human cochlea, incorporating back-measuring capabilities, is described. Using this new model, the contribution of single fiber action potentials (SFAPs) to the measured eCAP is investigated. The model predicts that contrary to common belief--the compound action potential as measured by the cochlear implant system does not necessarily reflect the propagated action potential along the auditory nerve.

Cochlear Implant Outcomes and Quality of Life in Adults with Prelingual Deafness

Objectives: To evaluate sound and speech perception and quality of life in prelingually deafened adults implanted with state of the art devices. To investigate which patient factors influence postoperative performance.

Anatomic considerations of cochlear morphology and its implications for insertion trauma in cochlear implant surgery.

Hypothesis: The goal of this study is to analyze the 3-dimensional anatomy of the cochlear spiral and to investigate the consequences of its course to insertion trauma during cochlear implantation. Background: Insertion trauma in cochlear implant surgery is a feared surgical risk, potentially causing neural degeneration and altered performance of the implant. In literature, insertion trauma is reported to occur at specific locations. This has been ascribed to surgical technique and electrode design in relation to the size of the scala tympani. This study investigates whether there is an underlying anatomic substrate serving as a potential source for insertion trauma at these specific locations. Methods: The 3-dimensional path of the cochlear spiral of 8 human temporal bones was determined by segmentation, skeletonization, distance mapping, and wave propagation technique applied on microcomputer tomography images. Potential pressure points along this path were estimated with linear regression. Results: The cochlear lumen shows a noncontinuous spiraling path leading to potential pressure points during cochlear implantation at the basilar membrane in the region of 180 to 225 (12-14 mm) and 725 degrees (22-26 mm) and at the floor of the scala tympani around 0 to 90, 225 to 270, and 405 to 450 degrees. Conclusion: Our data favor the idea that the intrinsic 3-dimensional cochlear morphology contributes to the risk for insertion trauma during cochlear implantation at specific locations.

Optimizing the Number of Electrodes with High-rate Stimulation of the Clarion CII Cochlear Implant

Objective—This blind crossover study evaluates the effect of the number of electrodes of the Clarion CII cochlear implant on speech perception in silence and in noise using a “high-rate” continuous interleaved sampling (CIS) strategy. Material and Methods—Nine users of this implant with 3–11 months of experience of an 8-channel CIS strategy [833 pulses per second (pps)/channel, 75 μs/phase] were fitted in a random order with 8-, 12- and 16-channel CIS strategies (±1400 pps/channel, 21 μs/phase). After 1 month of exclusive use of each strategy the performance was tested with consonant–vowel–consonant words in silence (sound only) and in speech-shaped background noise with signal-to-noise ratios (SNRs) of +10, +5, 0 and −5 dB. Results—With “high-rate” strategies most patients’ speech understanding in noise improved, although the optimum number of electrodes was highly variable. Generally, faster performers benefited from more active electrodes, whilst slower performers deteriorated. If each patients optimal strategy was determined by a weighted sum of the test results at +10, +5 and 0 dB SNR, the average phoneme score improved from 57% to 72% at a SNR of +5 dB, and from 46% to 56% at a SNR of 0 dB. The average phoneme score in silence was ≈85% for all strategies. Conclusion—We conclude that speech perception (especially in noise) can improve significantly with “high-rate” speech processing strategies, provided that the optimum number of electrodes is determined for each patient individually.

Simultaneous and non-simultaneous dual electrode stimulation in cochlear implants: evidence for two neural response modalities

Conclusion: There are two modalities of dual electrode stimulation: a shifting, continuous excitation, which is the desired effect, and a split excitation with considerable variation in loudness. The first one most likely occurs in the basal turn, with adjacent contacts, stimulated simultaneously rather than sequentially. Objectives: This study examines the effects on place pitch and loudness of simultaneous current steering and sequential stimulation. These can give cochlear implant patients access to more perceptual channels than physical contacts in the electrode array. Materials and methods: For both lateral wall and perimodiolar electrodes, simultaneous current steering as well as sequential stimulation, place pitch and loudness of the percept were predicted with a computational model of the implanted human cochlea. The loudness predictions were validated with psychophysical loudness balancing experiments. Results: Simultaneous stimulation with adjacent electrode contacts in the basal end of the cochlea was generally able to produce a single, gradually shifting intermediate pitch percept. Simultaneous stimulation beyond the first cochlear turn, sequential stimulation and simultaneous stimulation with non-adjacent electrode contacts often produced two regions of excitation. In the case of sequential stimulation the total amount of current to reach most comfortable loudness was raised, both in the model and in the patients.