Graeme Clark Collection
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ItemSpeech perception in implanted children: influence of preoperative residual hearing on outcomes [Abstract]( 1998)Since the first child was implanted with the Nucleus 22-channel prosthesis in Melbourne in 1985, several thousand children world-wide have now benefitted from this technology. More effective paediatric assessment and management procedures have now been developed, allowing cochlear implants to be offered to children under the age of 2 years. Improvements in speech processing strategy have also been implemented in the Nucleus implant system, resulting in increased mean speech perception benefits for implanted adults. Although a range of performance on formal measures of hearing, speech or language has been reported for children using implants, results from the first decade of implant experience consistently show that significant benefits are available to children receiving their implant at an early age. Reported speech perception results for implanted children show that a considerable proportion (60%) of paediatric patients in the Melbourne and Sydney clinics are able to understand some open-set speech using electrical stimulation alone. These results, and the upward trend of mean speech perception benefits shown for postlinguistically deafened adults have raised questions as to whether severely, or severely-to-profoundly deaf children currently using hearing aids would in fact benefit more from a cochlear implant. To investigate the potential influence of the degree of preoperative residual hearing on postoperative speech perception, results for all implanted children in the Melbourne and Sydney cochlear implant programs were analysed. Results showed that as a group, children with higher levels of preoperative residual hearing were consistently more likely to achieve open-set speech perception benefits. Potential factors in this finding could be higher levels of ganglion cell survival or greater patterning of the auditory pathways using conventional hearing aids prior to implantation. Conversely, children with the least preoperative residual hearing were less predictable, with some children achieving open-set perception, and others showing more limited closed-set benefits to perception. For these children, it is likely that preoperative residual hearing is of less significance than other factors in outcomes.
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ItemAided speech recognition abilities of adults with a severe or severe-to-profound hearing loss( 1998)Adults with severe or severe-to-profound hearing losses constitute between 11% and 13.5% of the hearing impaired population. A detailed investigation of the speech recognition of adults with severe (n = 20) or severe-to-profound (n = 14) hearing loss was conducted at The University of Melbourne. Each participant took part in a series of speech recognition tasks while wearing his or her currently fitted hearing aid(s). The assessments included closed-set tests of consonant recognition and vowel recognition, combined with open-set tests of nonosyllabic word recognition and sentence recognition. Sentences were presented in quiet listening conditions. Although the results demonstrated wide variability in performance, some general trends were observed. As expected vowels were generally well perceived compared with consonants. Monosyllabic word recognition scores for both the adults with a severe hearing impairment (M = 67.2%) and the adults with a severe-to profound hearing impairment (M = 38.6%) could be predicted from the segmental tests, with an allowance for lexical effects. Scores for sentences presented in quiet showed additional linguistic effects and a significant decrease in performance with the addition of background noise (from 82.9% to 74.1% for adults with a severe hearing loss and from 55.8% to 34.2% for adults with a severe-to-profound hearing loss). Comparisons were made between the participants and a group of adults using a multiple-channel cochlear implant. This comparison indicated that some adults with a severe or severe-to-profound hearing loss may benefit from the use of a cochlear implant. The results of this study support the contention that cochlear implant candidacy should not rely solely on audiometric thresholds.
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ItemSteady-state evoked potential and behavioural hearing thresholds in a group of children with absent click-evoked auditory brain stem response( 1998)Objective: 1) To examine the distribution of behavioural hearing thresholds in a group of children who had shown no click-evoked auditory brain stem response (ABR) at maximum presentation levels. 2) To describe the relationship between the 90 Hz steady-state evoked potential (SSEP) and behavioural thresholds in these subjects. Design: A retrospective study based on clinical findings obtained from 108 infants and young children. Each of these children had shown no recordable ABR to clicks presented at maximum levels (100 dB nHL). SSEP audiograms were obtained using AM/FM tones at the octave frequencies 250 to 4000 Hz. The results of these evoked potential assessments were compared with hearing thresholds established behaviourally. Results: Click-ABR assessment could not differentiate between the subjects in our sample with total hearing losses and those with useful residual hearing. Although some of the ears were anacusic, more than a quarter showed residual hearing ate each of the audiometric frequencies. Furthermore, at least 10% of the behavioural thresholds at each frequency fell within the moderate/severe hearing loss range. A far closer relationship was observed between SSEP and hearing thresholds. On occasions where the SSEP was absent at maximum levels, 99.5% of the ears showed either a total loss or a behavioural threshold within 10 dB of that level. When an SSEP was obtained, the hearing threshold was typically within 5 dB of the SSEP threshold. Conclusion: The results suggested that in our group of selected subjects, the SSEP technique was able to assess ears with only minimal amounts of residual hearing. Where the brevity of the acoustic click limits both its frequency specificity and its presentation level, the modulated tones used for SSEP testing allow accurate, frequency-specific assessment at high presentation levels.
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ItemAdults with a severe-to-profound hearing impairment: investigating the effects of linguistic context on speech perception( 1998)Linguistic context is known to influence speech perception abilities in adults with normal hearing. Recent reports question the importance of context for adults with a severe-to-profound hearing impairment. The severe reduction and distortion in acoustic input may result in the listener perceiving insufficient acoustic-phonetic cues to allow access to higher level linguistic processing. To investigate this further, a detailed study of the speech recognition of adults with a severe-to-profound hearing impairment (N=34) was undertaken. A series of aided speech recognition tasks, sequentially examined the different levels of processing in the speech perception chain. The investigation concluded that the effects of severe-to-profound hearing impairment did not reduce the listener's ability to take advantage of contextual cues. There was, however, wide variability between participants in the utilisation of contextual processing. This indicates that to estimate "real-life" speech perception skills, an evaluation of contextual processing ability is required.
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ItemSpeech perception differences between adults with a substantial hearing impairment and users of multiple-channel cochlear implant [Abstract]( 1998)Decent improvements in the performance of users of multiple-channel cochlear implants has led to speculation that people with a severe or severe-to-profound hearing impairment, may achieve better speech perception with a cochlear implant than with conventional hearing aids. In order to investigate this possibility a detailed investigation of the aided performance of adults with a severe or severe-to-profound hearing impairment was conducted in the Department of Otolaryngology (University of Melbourne). In total thirty-four adults took part in the speech perception tests. To aid statistical analysis and to facilitate discussion, the participants were divided into a severe group (61-80 dB HL) (n = 20) and a severe-to-profound group (81-100 dB HL,) (n = 14). All participants took part in a range of speech perception measures including closed-set vowel and consonant tests, open-set word (CNC) tests, and open-set sentence (CUNY) tests (in quiet conditions and in presence of +10 dB SNR background noise). Comparisons of mean scores were made between the adults with a severe or severe-to profound hearing impairment and a comparable group of multiple channel cochlear implant users. The results indicated that there were significant differences between the groups and that many of these differences were dependent on the types of tests used. Additional discussion will take place regarding the issues involved in providing multiple-channel cochlear implants to adults with a severe or severe-to-profound hearing impairment.
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ItemSpeech recognition in adults with a severe hearing impairment [Abstract]( 1998)Adults with a severe hearing impairment comprise between 11.0% and 13.5% of the hearing-impaired population. From the perspective of audiological rehabilitation, understanding their difficulties offers many challenges. To investigate this population, a detailed investigation of the speech recognition of adults with severe hearing loss (N = 34) was conducted at The University of Melbourne. For the purposes of this study severe hearing impairment was defined as an average loss in the better ear of between 61 and 100 dB HL. Each participant took part in a series of speech recognition tasks while wearing their currently fitted hearing aids. The assessments included closed-set tests of consonant recognition and vowel recognition, combined with open-set tests of consonant recognition and vowel recognition, combined with open-set tests of monosyllabic word recognition, sentence recognition and the Connected Speech Test version 2 (CSTv2). Tests at the sentence level were also conducted in background noise (four-talkers superimposed) to replicate environments more typical of everyday listening conditions. Investigation of the results indicated a wide variability in performance between the participants on each of the speech perception measures. There were, however, some general trends which could be observed. As expected vowels were generally well perceived compared with consonants. Monosyllabic word recognition scores for the participants could be predicted from the segmental tests with an allowance for lexical effects. Scores for sentences presented in quiet showed additional linguistic effects and a significant decrease (p < .05) in performance with the addition of background noise. Additionally, the CSTv2 provided further insights into speech perception processes through the addition of further facilitative context. Discussion will also take place regarding the processes involved in speech perception and whether this population, despite severe auditory handicap are able to utilise restricted auditory input for higher level lexical processes.
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ItemSpeech perception & indirect benefits for severely hearing impaired children using cochlear implants [Abstract]( 1998)The benefits to speech perception, speech production, communication, and quality of life were investigated for severely hearing impaired children using cochlear implants and hearing aids. For the youngest children, assessments of psychological status, and use of a battery of cognitive and language tests were important factors in determining performance benefits prior to the child developing speech. For older children, the effects of increased one-to-one oral habilitation, and systematic encouragement of parental involvement were also investigated. Results suggested that parental support for consistent device use was an important factor in producing outcomes. Children with residual hearing were more likely to achieve open-set perception. Each child was also assessed for changes in quality of life, through use of a standardized health utility instrument. Results from the group were collated, and teamed with a costing assessment for the procedure, which allowed a complete cost-utility analysis to be completed. Results suggested that indirect benefits, such as the effects on speech production, usual activities, lower concentration, and less distress were ranked as more important than changes to hearing in a number of the children. Costs per QALY were consistent with those reported in the literature, and suggested that the cochlear implant is highly cost-effective as a medical technology.
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ItemObjective hearing level estimation in infants with severe to profound impairment: role of Steady State Evoked Potential threshold testing [Abstract]( 1998)Accurate determination of hearing levels in potential cochlear implant candidates is an important part of pre-operative investigation. This is particularly the case for children younger than two years of age in whom speech perception testing is not possible. We have found the Steady-State Evoked Potential (SSEP) technique to be a reliable and accurate objective measure of residual hearing. Threshold estimation using the click-evoked auditory brainstem response cannot quantify hearing loss in the severe to profound range because of the presentation level restriction (? 100 dBnHL) and the broadband stimulus. The SSEP technique employs modulated tones at levels as high as 120 dBHL and can be used to estimate the audiograms of subjects with little or no residual hearing and absent click-auditory brainstem responses. We have demonstrated a strong relationship between behavioural and SSEP thresholds and believe that the procedure provides an important safeguard in the paediatric selection process. The possible exception is in children with retrocochlear abnormalities such as �Auditory Neuropathy�. In these subjects we have found poorer correlation between SSEP and behavioural thresholds.
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ItemPerformance benefits and costs for children using cochlear implants and hearing aids [Abstract]( 1998)The value of cochlear implants as an established clinical option for profoundly hearing impaired adults and children has been supported by significant research results over a number of years which has clearly established the benefits available (U.S. National Institutes of Health Consensus Statement 1995). Benefit has traditionally been considered as the direct impact of the cochlear implant procedure on speech perception, or in the case of children, on the use of that auditory information to develop understandable speech and to acquire a knowledge of language. As a consequence of continuing research to improve hardware and speech processing strategies, mean scores on open-set tests of monosyllables or sentence materials for implanted adults using the cochlear implant alone without lipreading have continued to show an upwards trend. In response to the increased mean scores in quiet, perception tests in background noise are now being used as a more accurate direct measure of the potential benefits of cochlear implants to severely-to-profoundly hearing-impaired candidates. Consideration should also be given to indirect benefits, such as reduction in the stress of listening and lipreading, improved performance at work, enhanced opportunity to maintain speech, or in children to develop speech which is understandable to the general community, and the social effects of reducing the isolating effects of profound deafness. Measurement of indirect benefit can be combined with an analysis of the costs of the procedure, enabling evaluation of the implant procedure from a cost-utility standpoint, and a comparison of outcomes using other technologies such as hearing aids. This study will present data on direct and indirect benefits for hearing-impaired children using Nucleus cochlear implant systems, and compare this data with benefits shown for similarly hearing impaired children using hearing aids. The significance of these results to cost-effective delivery of services will be discussed.
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ItemEvaluation of direct and indirect benefits in the selection of cochlear implant candidates [Abstract]( 1998)The value of cochlear implants as an established clinical option for profoundly hearing-impaired adults and children has been supported by significant research results over a number of years which clearly established the benefits available (U.S. National Institutes of Health Consensus Statement 1995). Benefit has traditionally been considered as the impact of the cochlear implant procedure on hearing, and in the case of children, on the use of that hearing to develop speech and language. However, as a result of continuing research, improvements have been realised both in hardware and speech processing. As a direct consequence of these improvements, the mean open-set implant-alone speech perception scores for implanted adults have continued to increase. In response to the increased mean scores shown by adult cochlear implant users in quiet, perception tests in background noise are now being used as a direct measure of the potential benefits of cochlear implants available to severely-to-profoundly hearing-impaired candidates. In addition, consideration in candidature should also be given to indirect benefits, such as reduction in the stress. of listening and lipreading, improved performance at work, enhanced opportunity to maintain or in children to develop speech which is understandable to the general community, and the social effects of reducing the isolating effects of profound deafness. Measurement of indirect benefit can be combined with a costing study, enabling evaluation of the implant procedure from a cost-utility standpoint, and comparison of outcomes using other technologies such as hearing aids. The use of new approaches to candidature, including new measures of direct and indirect benefit is reported using data from the Melbourne cochlear implant program.