Perceptual benefit and functional outcomes for children using sequential bilateral cochlear implants

Objective. To evaluate the additional perceptual benefit provided to children through the use of two cochlear implants in comparison to one after 6 to 13 mo experience with sequential bilateral implants. Design: A second cochlear implant was received by 11 children. The principal selection criteria were being age 4 to 15 yr with a bilateral profound hearing loss and being a consistent user of a first implant with a commitment to use of a second implant. Horizontal localization was assessed by using pink noise bursts presented from a 180 degrees, eight-loudspeaker array. Speech perception was assessed by using a four-alternative forced-choice spondee test, with speech presented from in front and adaptive background noise presented from 90 degrees to the left or right. Both tests were completed in the first implant alone and bilateral conditions. A questionnaire measured the pre- to postoperative change in the parent's ratings of the child's performance in specific listening situations. Items were related to speech perception, spatial hearing, or other qualities of hearing. Regular parental reports of device use, attitude and performance were collected. Most subjects were assessed at 6 mo after surgery, with two assessed at 13 mo. Results: The 11 subjects demonstrated a great range of outcomes. For one subject, only anecdotal data were collected. Speech perception testing indicated that when noise was presented ipsilateral to the first implant, 8 of 10 subjects showed a benefit in the bilateral condition. None of the nine subjects tested showed a benefit when noise was contralateral to the first implant. Generally, there was no benefit to localization in the bilateral condition. For eight subjects, postoperative performance ratings were generally higher than preoperative ratings, particularly in the spatial hearing section. Anecdotal reports indicated that most subjects had a negative attitude toward, and gained limited experience with, the second implant alone. The subjects developed a range of speech perception skills, from detection to conversation level. Regarding the use of bilateral implants, attitudes were more positive and device use was consistent for eight subjects, and six parents reported some evidence of improved performance in daily life. Conclusions: Children over age 4 yr may gain significant additional benefit from a second implant, including improved speech perception in some noise contexts and functional advantages in daily life. There is, however, no evidence from this study to suggest that binaural listening skills, including localization, will develop during the first 6 mo. Furthermore, some children who may be committed users of a first implant may not adapt to or benefit from a second implant during the first 6 mo of device use. Although the factors influencing benefit cannot be clearly identified, limited preoperative auditory experience with the second ear, a delay of years between implants, relatively advanced age, and lack of second-implant-alone experience do not preclude benefit. Continued evaluation of these and additional subjects will clarify the factors that do contribute to benefit. Such information will be vital in helping families of implanted children to make an informed decision regarding a second implant.