Gifford René H
Vanderbilt University Medical Center, 1215 21 Avenue South, 9302 MCE South, Nashville, TN 37232.
Curr Otorhinolaryngol Rep. 2020 Dec;8(4):385-394. doi: 10.1007/s40136-020-00314-6. Epub 2020 Oct 2.
This review describes speech perception and language outcomes for children using bimodal hearing (cochlear implant (CI) plus contralateral hearing aid) as compared to children with bilateral CIs and contrasts said findings with the adult literature. There is a lack of clinical evidence driving recommendations for bimodal versus bilateral CI candidacy and as such, clinicians are often unsure about when to recommend a second CI for children with residual acoustic hearing. Thus the goal of this review is to identify scientific information that may influence clinical decision making for pediatric CI candidates with residual acoustic hearing.
Bilateral CIs are considered standard of care for children with bilateral severe-to-profound sensorineural hearing loss. For children with aidable acoustic hearing-even in just the low frequencies-an early period of bimodal stimulation has been associated with significantly better speech perception, vocabulary, and language development. HA audibility, however, is generally poorer than that offered by a CI resulting in interaural asymmetry in speech perception, head shadow, as well as brainstem and cortical activity and development. Thus there is a need to optimize "two-eared" hearing while maximizing a child's potential with respect to hearing, speech, and language while ensuring that we limit asymmetrically driven auditory neuroplasticity. A recent large study of bimodal and bilateral CI users suggested that a period of bimodal stimulation was only beneficial for children with a better-ear pure tone average (PTA) ≤ 73 dB HL. This 73-dB-HL cutoff applied even to children who ultimately received bilateral CIs.
Though we do not yet have definitive guidelines for determining bimodal versus bilateral CI candidacy, there is increasing evidence that 1) bilateral CIs yield superior outcomes for children with bilateral severe-to-profound hearing loss and, 2) an early period of bimodal stimulation is beneficial for speech perception and language development, but only for children with better-ear PTA ≤ 73 dB HL. For children with residual acoustic hearing, even in just the low-frequency range, rapid sequential bilateral cochlear implantation following a trial period with bimodal stimulation will yield best outcomes for auditory, language, and academic development. Of course, there is also an increasing prevalence of cochlear implantation with acoustic hearing preservation allowing for combined electric and acoustic stimulation even following bilateral implantation.
本综述描述了使用双耳模式听力（人工耳蜗（CI）加对侧助听器）的儿童与双侧人工耳蜗植入儿童的言语感知和语言结果，并将这些结果与成人文献进行对比。目前缺乏临床证据来指导关于双耳模式与双侧人工耳蜗植入候选资格的推荐，因此，临床医生常常不确定何时为有残余听觉的儿童推荐第二次人工耳蜗植入。因此，本综述的目的是确定可能影响有残余听觉的小儿人工耳蜗植入候选者临床决策的科学信息。
双侧人工耳蜗植入被认为是双侧重度至极重度感音神经性听力损失儿童的标准治疗方案。对于有可助听残余听觉的儿童——即使仅在低频范围——早期的双耳模式刺激已被证明与显著更好的言语感知、词汇和语言发展相关。然而，助听器的可听度通常比人工耳蜗差，这导致言语感知、头影效应以及脑干和皮层活动及发育方面的双耳不对称。因此，有必要在最大化儿童听力、言语和语言潜力的同时优化“双耳”听力，同时确保我们限制由不对称驱动的听觉神经可塑性。最近一项针对双耳模式和双侧人工耳蜗使用者的大型研究表明，一段时间的双耳模式刺激仅对较好耳纯音平均听阈（PTA）≤73 dB HL的儿童有益。这个73 dB HL的阈值甚至适用于最终接受双侧人工耳蜗植入的儿童。
尽管我们尚未有确定的指南来决定双耳模式与双侧人工耳蜗植入的候选资格，但越来越多的证据表明：1）双侧人工耳蜗植入对双侧重度至极重度听力损失的儿童产生更好的结果；2）早期的双耳模式刺激对言语感知和语言发展有益，但仅适用于较好耳PTA≤73 dB HL的儿童。对于有残余听觉的儿童，即使仅在低频范围，在经过一段时间的双耳模式刺激试验后快速序贯双侧人工耳蜗植入将为听觉、语言和学业发展带来最佳结果。当然，保留听觉的人工耳蜗植入的患病率也在增加，即使在双侧植入后也允许电刺激和声学刺激相结合。
