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Objectives: Evidence continues to emerge of associations between cochlear implant (CI) outcomes and cognitive functions in postlingually deafened adults. While there are multiple factors that appear to affect these associations, the impact of speech recognition background testing conditions (i.e., in quiet versus noise) has not been systematically explored. The two aims of this study were to (1) identify associations between speech recognition following cochlear implantation and performance on cognitive tasks, and to (2) investigate the impact of speech testing in quiet versus noise on these associations. Ultimately, we want to understand the conditions that impact this complex relationship between CI outcomes and cognition., Design: A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed on published literature evaluating the relation between outcomes of cochlear implantation and cognition. The current review evaluates 39 papers that reported associations between over 30 cognitive assessments and speech recognition tests in adult patients with CIs. Six cognitive domains were evaluated: Global Cognition, Inhibition-Concentration, Memory and Learning, Controlled Fluency, Verbal Fluency, and Visuospatial Organization. Meta-analysis was conducted on three cognitive assessments among 12 studies to evaluate relations with speech recognition outcomes. Subgroup analyses were performed to identify whether speech recognition testing in quiet versus in background noise impacted its association with cognitive performance., Results: Significant associations between cognition and speech recognition in a background of quiet or noise were found in 69% of studies. Tests of Global Cognition and Inhibition-Concentration skills resulted in the highest overall frequency of significant associations with speech recognition (45% and 57%, respectively). Despite the modest proportion of significant associations reported, pooling effect sizes across samples through meta-analysis revealed a moderate positive correlation between tests of Global Cognition ( r = +0.37, p < 0.01) as well as Verbal Fluency ( r = +0.44, p < 0.01) and postoperative speech recognition skills. Tests of Memory and Learning are most frequently utilized in the setting of CI (in 26 of 39 included studies), yet meta-analysis revealed nonsignificant associations with speech recognition performance in a background of quiet ( r = +0.30, p = 0.18), and noise ( r = -0.06, p = 0.78)., Conclusions: Background conditions of speech recognition testing may influence the relation between speech recognition outcomes and cognition. The magnitude of this effect of testing conditions on this relationship appears to vary depending on the cognitive construct being assessed. Overall, Global Cognition and Inhibition-Concentration skills are potentially useful in explaining speech recognition skills following cochlear implantation. Future work should continue to evaluate these relations to appropriately unify cognitive testing opportunities in the setting of cochlear implantation., Competing Interests: A.C.M. has received research grant funding from Cochlear Americas for an investigator-initiated project. A.C.M. has been a paid consultant for Cochlear Americas and Advanced Bionics. A.C.M. is Chief Medical Officer and is on the Board of Directors for Otologic Technologies. The other authors have no conflicts of interest to declare., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the minimal clinically important difference (MCID) values for cochlear implant-related speech recognition scores, which have not been previously reported., Study Design: Retrospective cohort., Setting: Tertiary referral center., Patients: Eight hundred sixty-three adult patients who underwent cochlear implantation between 2009 and 2022., Main Outcome Measures: MCID values for consonant-nucleus-consonant (CNC) word scores and AzBio sentences in quiet and noise scores using distribution-based methods (half-standard deviation, standard error of measurement, Cohen's d, and minimum detectable change)., Results: In this cohort, the mean preoperative CNC word score was 13.9% (SD, 15.6). The mean preoperative AzBio sentences in quiet score was 19.1% (SD, 22.1), and the mean preoperative AzBio sentences in noise score was 13.0% (SD, 12.0). The average MCID values of several distribution-based methods for CNC, AzBio in quiet, and AzBio in noise were 7.4%, 9.0%, and 4.9%, respectively. Anchor-based approaches with the Speech, Spatial, and Qualities of hearing patient-reported measure did not have strong classification accuracy across CNC or AzBio in quiet and noise scores (ROC areas under-the-curve ≤0.69), highlighting weak associations between improvements in speech recognition scores and subjective hearing-related abilities., Conclusions: Our estimation of MCID values for CNC and AzBio in quiet and noise allows for enhanced patient counseling and clinical interpretation of past, current, and future research studies assessing cochlear implant outcomes., Competing Interests: Conflicts of interest: A.C.M. serves as CMO and on Board of Directors for Otologic Technologies and has received grant support from Cochlear Americas. M.H.F. is an advisor for Endotheia, Inc. K.O.T. has served as an advisory board member for GlaxoSmithKline. D.S.H. is a consultant for Advanced Bionics, Cochlear Americas, MED-EL GmbH, Stryker, Synthes, Grace Medical, and Oticon. R.H.G. is a consultant for Advanced Bionics, Akouos, Cochlear Americas, Sony, and Skylar Bio., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: To compare speech recognition and quality of life outcomes between bilateral sequentially and simultaneously implanted adult cochlear implant (CI) recipients who initially qualify for a CI in both ears., Study Design: Retrospective chart review., Setting: Tertiary referral center., Methods: Retrospective chart review identified adults who underwent bilateral CI, either simultaneously or sequentially, at a high-volume center between 2012 and 2022. Sequentially implanted patients were only included if the second ear qualified for CI in quiet (defined as best-aided AzBio quiet testing <60%), at time of initial CI evaluation., Results: Of 112 bilateral CI patients who qualified in both ears at initial evaluation, 95 underwent sequential implantation and 17 simultaneous. Age, duration, and etiology of hearing loss, and CI usage were similar between groups. Preoperatively, the sequential group had lower pure-tone average (PTA) in the 1st ear than the simultaneously implanted group (P = <.001) but, no difference in 2nd ear PTA (P = .657). Preoperative speech recognition scores were significantly higher for the sequential group; however, this was not true for postoperative scores. There was no difference in the proportion of patients showing significant CI-only or bilateral performance improvement between the groups. Both groups demonstrated similar benefit in quality of life measures., Conclusion: Our findings indicate both simultaneous and sequential cochlear implantation are effective in improving hearing performance and quality of life. Thus, bilateral versus simultaneous implantation should be discussed and tailored for each individual patient., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: To use machine learning and a battery of measures for preoperative prediction of speech recognition and quality of life (QOL) outcomes after cochlear implant (CI) surgery., Design: Demographic, audiologic, cognitive-linguistic, and QOL predictors were collected from 30 postlingually deaf adults before CI surgery. K-means clustering separated patients into groups. Reliable change index scores were computed for speech recognition and QOL from pre-CI to 6 months post-CI, and group differences were determined., Results: Clustering yielded three groups with differences in reliable change index for sentence recognition. One group demonstrated low baseline sentence recognition and only small improvements post-CI, suggesting a group "at risk" for limited benefits. This group showed lower pre-CI scores on verbal learning and memory and lack of musical training., Conclusions: Preoperative assessments can prognosticate CI recipients' postoperative performance and identify individuals at risk for experiencing poor sentence recognition outcomes, which may help guide counseling and rehabilitation., (Copyright © 2024 The Authors. Ear & Hearing is published on behalf of the American Auditory Society, by Wolters Kluwer Health, Inc.)

Objective: This study investigated the comparative performance of ear, nose, and throat (ENT) physicians in correctly detecting ear abnormalities when reviewing digital otoscopy imaging using 3 different visualization methods, including computer-assisted composite images called "SelectStitch," single video frame "Still" images, and video clips. The study also explored clinicians' diagnostic confidence levels and the time to make a diagnosis., Study Design: Clinician diagnostic reader study., Setting: Online diagnostic survey of ENT physicians., Methods: Nine ENT physicians reviewed digital otoscopy examinations from 86 ears with various diagnoses (normal, perforation, retraction, middle ear effusion, tympanosclerosis). Otoscopy examinations used artificial-intelligence (AI)-based computer-aided composite image generation from a video clip (SelectStitch), manually selected best still frame from a video clip (Still), or the entire video clip. Statistical analyses included comparisons of ability to detect correct diagnosis, confidence levels, and diagnosis times., Results: The ENT physicians' ability to detect ear abnormalities (33.2%-68.7%) varied depending on the pathologies. SelectStitch and Still images were not statistically different in detecting abnormalities (P > .50), but both were different from Video (P < .01). However, the performance improvement observed with Videos came at the cost of significantly longer time to determining the diagnosis. The level of confidence in the diagnosis was positively associated with correct diagnoses, but varied by particular pathology., Conclusion: This study explores the potential of computer-assisted techniques like SelectStitch in enhancing otoscopic diagnoses and time-saving, which could benefit telemedicine settings. Comparable performance between computer-generated and manually selected images suggests the potential of AI algorithms for otoscopy applications., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Introduction: Cochlear implants (CIs) provide access to sound and help mitigate the negative effects of hearing loss. As a field, we are successfully implanting more adults with greater amounts of residual hearing than ever before. Despite this, utilization remains low, which is thought to arise from barriers that are both intrinsic and extrinsic. A considerable body of literature has been published in the last 5 years on barriers to adult CI uptake, and understanding these barriers is critical to improving access and utilization. This scoping review aims to summarize the existing literature and provide a guide to understanding barriers to adult CI uptake., Methods: Inclusion criteria were limited to peer-reviewed articles involving adults, written in English, and accessible with a university library subscription. A cutoff of 20 years was used to limit the search. Barriers uncovered in this review were categorized into an ecological framework., Results: The initial search revealed 2,315 items after duplicates were removed. One hundred thirty-one articles were reviewed under full-text, and 68 articles met the inclusion criteria., Discussion: Race, ethnicity, and reimbursement are policy and structural barriers. Public awareness and education are societal barriers. Referral and geographical challenges are forms of organizational barriers. Living context and professional support are interpersonal barriers. At the individual level, sound quality, uncertainty of outcome, surgery, loss of residual hearing, and irreversibility are all barriers to CI uptake. By organizing barriers into an ecological framework, targeted interventions can be used to overcome such barriers., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc.)

Objective: To examine current practices and opinions of cochlear implant (CI) providers with respect to post-implantation auditory training., Methods: A survey was submitted to the American Cochlear Implant Alliance membership that reviewed current practice and opinions with respect to post-implantation auditory training for adult CI recipients., Main Outcome Measures: Review of respondent practice, center volume, role on CI team, and current usage and opinions surrounding auditory training, including resources used and schedule of use., Results: Most (79 %) of the 79 CI providers surveyed reported working at academic centers, 34 % at high-volume centers (>150 CIs/year), and 38 % were surgeons. Nearly all (99 %) respondents recommend auditory training for new adult CI recipients. Just over half (52 %) provide auditory training resources to the patient in the form of a broad list of patient-directed exercises from which a patient could select. A specific training resource, generally a computer-based auditory training program (e.g., AngelSound™), is recommended to patients by 30 % of the respondents. Regarding timing of rehabilitation, median preferred start time was 0 months (interquartile range [IQR] 0-1) post-activation. Sessions were preferably performed for a median of 3 h per week (IQR 2-4) and continued for a median of 12 months (IQR 6-12). Recommendations for auditory training were fairly consistent between surgeon and non-surgeon providers and by center volume. Non-surgeons more often had specific recommendations on training resources, benefits of music, and training condition (e.g., contralateral ear plugged)., Conclusions: Despite a lack of clinical guidelines for adult post-implantation auditory training, a cross-sectional survey of providers' current practices and opinions demonstrates that these services are widely recommended and regarded as valuable. Training is almost universally patient-directed and believed to be most beneficial if started soon after activation. Interestingly, specific recommendations for which training approaches to use are not common, suggesting a gap in provider knowledge of which resources are most efficacious., Competing Interests: Declaration of competing interest JRD receives research support from Cochlear Americas and Advanced Bionics. TNT receives research support from Cochlear Americas. ACM has served as paid consultant for Cochlear Americas and Advanced Bionics, and serves as CMO and on Board of Directors for Otologic Technologies. MLC receives research support from Cochlear Americas, Advanced Bionics, and MED-EL., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective(s): Despite undergoing thorough cochlear implant (CI) candidacy evaluation and counseling, some patients ultimately elect against implantation. This study sought to identify patient-related and socioeconomic factors predicting CI deferral., Methods: A retrospective study of adult (≥18 years old) CI candidates presenting between 2007 and 2021 at a tertiary academic CI center was performed. The primary outcome was device implantation. Data collected included age, gender, hearing status, race, zip code of residence, median family income (MFI), distance traveled from the CI center, marital status, employment status, and insurance status. Multivariable binary logistic regression was performed to identify predictors of implantation., Results: A total of 200 patients qualifying for CI were included, encompassing 77 adults deferring surgery (CI-deferred) and 123 consecutive adults electing for surgery (CI-pursued). Age, gender, hearing status, insurance type, employment status, distance from the implant center, and MFI were comparable between the groups (p > 0.05). Compared to CI-pursued patients, CI-deferred patients were more likely to be non-Caucasian (24.7% vs. 9.8%, p = 0.015) and unmarried (55.8% vs. 38.2%, p = 0.015). On multivariable logistic regression, older age (OR 0.981, 0.964-0.998, p = 0.027), African American race (OR 0.227, 0.071-0.726, p = 0.012), and unmarried status (OR 0.505, 0.273-0.935, p = 0.030) were independent predictors of implant deferral., Conclusion: This study demonstrates that increasing age at evaluation, African American race, and unmarried status are predictors for deferring CI surgery despite being implant candidates. These patients may benefit from increased outreach in the form of counseling, education, and social support prior to undergoing CI surgery., Level of Evidence: 3 - retrospective study with internal control group Laryngoscope, 134:2857-2863, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To assess patient factors, audiometric performance, and patient-reported outcomes in cochlear implant (CI) patients who would not have qualified with in-quiet testing alone., Study Design: Retrospective chart review., Setting: Tertiary referral center., Methods: Adult CI recipients implanted between 2012 and 2022 were identified. Patients with preoperative AzBio Quiet > 60% in the implanted ear, requiring multitalker babble to qualify, comprised the in-noise qualifying (NQ) group. NQ postoperative performance was compared with the in-quiet qualifying (QQ) group using CNC, AzBio Quiet, and AzBio +5 dB signal-to-noise ratio. Speech, Spatial and Qualities of Hearing Scale (SSQ), Cochlear Implant Quality of Life scale (CIQOL-10), and daily device usage were also compared between the groups., Results: The QQ group (n = 771) and NQ group (n = 67) were similar in age and hearing loss duration. NQ had higher average preoperative and postoperative speech recognition scores. A larger proportion of QQ saw significant improvement in CNC and AzBio Quiet scores in the CI-only listening condition (eg, CI-only AzBio Quiet: 88% QQ vs 51% NQ, P < .001). Improvement in CI-only AzBio +5 dB and in all open set testing in the best-aided binaural listening condition was similar between groups (eg, Binaural AzBio Quiet 73% QQ vs 59% NQ, P = .345). Postoperative SSQ ratings, CIQOL scores, and device usage were also equivalent between both groups., Conclusion: Patients who require in-noise testing to meet CI candidacy demonstrate similar improvements in best-aided speech perception and patient-reported outcomes as in-QQ, supporting the use of in-noise testing to determine CI qualification for borderline CI candidates., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: Adults with hearing loss (HL) demonstrate greater benefits of adding visual cues to auditory cues (i.e., "visual enhancement" [VE]) during recognition of speech presented in a combined audiovisual (AV) fashion when compared with normal-hearing peers. For patients with moderate-to-profound sensorineural HL who receive cochlear implants (CIs), it is unclear whether the restoration of audibility results in a decrease in the VE provided by visual cues during AV speech recognition. Moreover, it is unclear whether increased VE during the experience of HL before CI is beneficial or maladaptive to ultimate speech recognition abilities after implantation. It is conceivable that greater VE before implantation contributes to the enormous variability in speech recognition outcomes demonstrated among patients with CIs. This study took a longitudinal approach to test two hypotheses: (H1) Adult listeners with HL who receive CIs would demonstrate a decrease in VE after implantation; and (H2) The magnitude of pre-CI VE would predict post-CI auditory-only speech recognition abilities 6 months after implantation, with the direction of that relation supporting a beneficial, redundant, or maladaptive effect on outcomes., Design: Data were collected from 30 adults at two time points: immediately before CI surgery and 6 months after device activation. Pre-CI speech recognition performance was measured in auditory-only (A-only), visual-only, and combined AV fashion for City University of New York (CUNY) sentences. Scores of VE during AV sentence recognition were computed. At 6 months after CI activation, participants were again tested on CUNY sentence recognition in the same conditions as pre-CI. H1 was tested by comparing post- versus pre-CI VE scores. At 6 months of CI use, additional open-set speech recognition measures were also obtained in the A-only condition, including isolated words, words in meaningful AzBio sentences, and words in AzBio sentences in multitalker babble. To test H2, correlation analyses were performed to assess the relation between post-CI A-only speech recognition scores and pre-CI VE scores., Results: Inconsistent with H1, after CI, participants did not demonstrate a significant decrease in VE scores. Consistent with H2, preoperative VE scores positively predicted postoperative scores of A-only sentence recognition for both sentences in quiet and in babble (rho = 0.40 to 0.45, p < 0.05), supporting a beneficial effect of pre-CI VE on post-CI auditory outcomes. Pre-CI VE was not significantly related to post-CI isolated word recognition. The raw pre-CI CUNY AV scores also predicted post-CI A-only speech recognition scores to a similar degree as VE scores., Conclusions: After implantation, CI users do not demonstrate a decrease in VE from before surgery. The degree of VE during AV speech recognition before CI positively predicts A-only sentence recognition outcomes after implantation, suggesting the potential value of AV testing of CI patients preoperatively to help predict and set expectations for postoperative outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Evaluate listening effort (LE) in unilateral, bilateral, and bimodal cochlear implant (CI) users. Establish an easy-to-implement task of LE that could be useful for clinical decision making., Study Design: Prospective cohort study., Setting: Tertiary neurotology center., Methods: The Sentence Final Word Identification and Recall Task, an established measure of LE, was modified to include challenging listening conditions (multitalker babble, gender, and emotional variation; test), in addition to single-talker sentences (control). Participants listened to lists of sentences in each condition and recalled the last word of each sentence. LE was quantified by percentage of words correctly recalled and was compared across conditions, across CI groups, and within subjects (best aided vs monaural)., Results: A total of 24 adults between the ages of 37 and 82 years enrolled, including 4 unilateral CI users (CI), 10 bilateral CI users (CICI), and 10 bimodal CI users (CIHA). Task condition impacted LE (P < .001), but hearing configuration and listener group did not (P = .90). Working memory capacity and contralateral hearing contributed to individual performance., Conclusion: This study adds to the growing body of literature on LE in challenging listening conditions for CI users and demonstrates feasibility of a simple behavioral task that could be implemented clinically to assess LE. This study also highlights the potential benefits of bimodal hearing and individual hearing and cognitive factors in understanding individual differences in performance, which will be evaluated through further research., (© 2023 The Authors. Otolaryngology–Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: Performing pediatric otoscopy can be difficult secondary to patient compliance, which potentiates misdiagnosis and inaccurate treatment of acute otitis media. This study used a convenience sample to assess the feasibility of using a video otoscope for the examination of tympanic membranes in children presenting to a pediatric emergency department., Methods: We obtained otoscopic videos using the JEDMED Horus + HD Video Otoscope. Participants were randomized to video or standard otoscopy, and a physician completed their bilateral ear examinations. In the video group, physicians reviewed otoscope videos with the patient's caregiver. The caregiver and physician completed separate surveys using a 5-point Likert Scale regarding perceptions of the otoscopic examination. A second physician reviewed each otoscopic video., Results: We enrolled 213 participants in 2 groups (standard otoscopy, n = 94; video otoscopy, n = 119). We used Wilcoxon rank sum, Fisher exact test, and descriptive statistics to compare results across groups. For physicians, there were no statistically significant differences between groups with ease of device use, quality of otoscopic view, or diagnosis. There was moderate agreement between physician video otoscopic view satisfaction and slight agreement between physician video otologic diagnosis. Estimates of length of time to complete the ear examinations were longer more often for the video otoscope compared with standard for both caregivers (OR, 2.00; 95% confidence interval, 1.10-3.70; P = 0.02) and physicians (OR, 3.08; 95% confidence interval, 1.67-5.78; P < 0.01). There were no statistically significant differences between video and standard otoscopy with regard to caregiver perception of comfort, cooperation, satisfaction, or diagnosis understanding., Conclusions: Caregivers perceive that video otoscopy and standard otoscopy are comparable in comfort, cooperation, examination satisfaction, and diagnosis understanding. Physicians made a wider range of more subtle diagnoses with the video otoscope. However, examination length of time may limit the JEDMED Horus + HD Video Otoscope's feasibility in a busy pediatric emergency department., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: There is significant variability in speech recognition outcomes in adults who receive cochlear implants (CIs). Little is known regarding cognitive influences on very early CI performance, during which significant neural plasticity occurs., Methods: Prospective study of 15 postlingually deafened adult CI candidates tested preoperatively with a battery of cognitive assessments. The mini-mental state exam (MMSE), forward digit span, Stroop measure of inhibition-concentration, and test of word reading efficiency were utilized to assess cognition. consonant-nucleus-consonant words, AZBio sentences in quiet, and AZBio sentences in noise (+10 dB SNR) were utilized to assess speech recognition at 1- and 3-months of CI use., Results: Performance in all speech measures at 1-month was moderately correlated with preoperative MMSE, but these correlations were not strongly correlated after correcting for multiple comparisons. There were large correlations of forward digit span with 1-month AzBio quiet ( P ≤ 0.001, rho = 0.762) and AzBio noise ( P ≤ 0.001, rho = 0.860), both of which were strong after correction. At 3 months, forward digit span was strongly predictive of AzBio noise ( P ≤ 0.001, rho = 0.786), which was strongly correlated after correction. Changes in speech recognition scores were not correlated with preoperative cognitive test scores., Conclusions: Working memory capacity significantly predicted early CI sentence recognition performance in our small cohort, while other cognitive functions assessed did not. These results differ from prior studies predicting longer-term outcomes. Findings and further studies may lead to better preoperative counseling and help identify patients who require closer evaluation to ensure optimal CI performance., Competing Interests: A.C.M. and T.N.T. have received grant funding support from Cochlear Americas for unrelated investigator-initiated research studies. A.C.M. has served as a paid consultant for Cochlear Americas and Advanced Bionics and is CMO and on the Board of Directors for Otologic Technologies. The other author has no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc.)

Objective: Explore the effects of hearing loss on social life and identify residual social life deficits that remain after cochlear implantation., Study Design: Retrospective review of prospectively obtained data., Setting: Tertiary care adult neurotology center., Patients: Adults between the ages of 35 and 83 years were included with either normal hearing (NH) or a cochlear implant (CI)., Interventions: CI and non-CI-specific quality-of-life (QOL) surveys focused on social and overall QOL., Main Outcome Measures: (1) The difference in QOL survey responses between NH and CI participants. (2) The relationship between CI-specific global and social QOL responses and non-CI-specific social QOL responses in CI users., Results: A total of 51 participants were included: 31 CI users and 20 NH participants. Of the social QOL questionnaires, CI users reported significantly poorer scores on Self-Efficacy in Social Interactions than NH peers ( p = 0.049). Both Self-Efficacy in Social Interactions scores and Social Isolation Questionnaire scores were significantly correlated with the CI-specific social domain of QOL ( r = 0.64 and -0.58, respectively). Only the Self-Efficacy in Social Interactions scores had a moderate association with global CI QOL ( r = 0.47)., Conclusions: CI users self-report similar social life outcomes as their NH peers with the exception of poorer self-efficacy in social situations. Moreover, self-efficacy in social interactions and social isolation were associated with social QOL in CI users, and self-efficacy in social interactions was associated with broader CI-related QOL. Findings support the relevance of individuals' perception of social life to their overall QOL with a CI., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: to review evidence on the efficacy of auditory training in adult cochlear implant recipients. Data Sources: PRISMA guidelines for a systematic review of the literature were followed. PubMed, Scopus, and CINAHL databases were queried on 29 June 2023 for terms involving cochlear implantation and auditory training. Studies were limited to the English language and adult patient populations. Study Selection: Three authors independently reviewed publications for inclusion in the review based on a priori inclusion and exclusion criteria. Inclusion criteria encompassed adult cochlear implant populations, an analysis of clinician- or patient-directed auditory training, and an analysis of one or more measures of speech recognition and/or patient-reported outcome. Exclusion criteria included studies with only pediatric implant populations, music or localization training in isolation, and single-sample case studies. Data Extraction: The data were collected regarding study design, patient population, auditory training modality, auditory training timing, speech outcomes, and data on the durability of outcomes. A quality assessment of the literature was performed using a quality metric adapted from the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group guidelines. Data Synthesis and Meta-Analysis: Data were qualitatively summarized for 23 studies. All but four studies demonstrated significant improvement in at least one measured or patient-reported outcome measure with training. For 11 studies with sufficient data reporting, pre-intervention and post-intervention pooled means of different outcome measures were compared for 132 patients using meta-analysis. Patient-direct training was associated with significant improvement in vowel-phoneme recognition and speech recognition in noise ( p < 0.05 and p < 0.001, respectively), and clinician-directed training showed significant improvement in sentence recognition in noise ( p < 0.001). Conclusions: The literature on auditory training for adult cochlear implant recipients is limited and heterogeneous, including a small number of studies with limited levels of evidence and external validity. However, the current evidence suggests that auditory training can improve speech recognition in adult cochlear implant recipients.

Purpose: Tests measuring speech comprehension and listening effort for cochlear implant (CI) users may reflect important aspects of real-world speech communication. In this study, we describe the development of a multiple-talker, English-language sentence verification task (SVT) for use in adult CI users to measure speech comprehension and listening effort. We also examine whether talker differences affect speech comprehension and listening effort., Method: Thirteen experienced adult CI users participated in the study and underwent testing using a newly developed multiple-talker SVT. Participants were sequentially presented with audio recordings of unique sentences spoken in English by six different talkers. Participants classified each sentence as either true or false. Accuracy of classification and the response time (RT) for correct responses were used as measures of comprehension and listening effort, respectively. The effect of talker on the results was further analyzed., Results: All 13 participants successfully completed the SVT. The mean verification accuracy for participants was 87.2% ± 8.8%. The mean RT for correct responses across participants was 1,050 ms ± 391 ms. When stratified by talker, verification accuracy ranged from 83.7% to 95.2% and mean RTs across participant ranged from 786 ms to 1,254 ms. Talker did not have a significant effect on sentence classification accuracy, but it did have a significant effect on RTs ( p < .001)., Conclusions: The SVT is an easily implemented test that can assess speech comprehension and listening effort simultaneously. CI users may experience increased effort for comprehending certain talkers' speech, despite showing similar levels of comprehension accuracy., Supplemental Material: https://doi.org/10.23641/asha.24126630.

Objective: Hearing loss has a detrimental impact on cognitive function. However, there is a lack of consensus on the impact of cochlear implants on cognition. This review systematically evaluates whether cochlear implants in adult patients lead to cognitive improvements and investigates the relations of cognition with speech recognition outcomes., Data Sources: A literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies evaluating cognition and cochlear implant outcomes in postlingual, adult patients from January 1996 to December 2021 were included. Of 2510 total references, 52 studies were included in qualitative analysis and 11 in meta-analyses., Review Methods: Proportions were extracted from studies of (1) the significant impacts of cochlear implantation on 6 cognitive domains and (2) associations between cognition and speech recognition outcomes. Meta-analyses were performed using random effects models on mean differences between pre- and postoperative performance on 4 cognitive assessments., Results: Only half of the outcomes reported suggested cochlear implantation had a significant impact on cognition (50.8%), with the highest proportion in assessments of memory & learning and inhibition-concentration. Meta-analyses revealed significant improvements in global cognition and inhibition-concentration. Finally, 40.4% of associations between cognition and speech recognition outcomes were significant., Conclusion: Findings relating to cochlear implantation and cognition vary depending on the cognitive domain assessed and the study goal. Nonetheless, assessments of memory & learning, global cognition, and inhibition-concentration may represent tools to assess cognitive benefit after implantation and help explain variability in speech recognition outcomes. Enhanced selectivity in assessments of cognition is needed for clinical applicability., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: Otitis media (OM) is a model disease for developing, validating, and implementing artificial intelligence (AI) techniques. We aim to review the state of the art applications of AI used to diagnose OM in pediatric and adult populations., Data Sources: Several comprehensive databases were searched to identify all articles that applied AI technologies to diagnose OM., Review Methods: Relevant articles from January 2010 through May 2021 were identified by title and abstract. Articles were excluded if they did not discuss AI in conjunction with diagnosing OM. References of included studies and relevant review articles were cross-referenced to identify any additional studies., Conclusion: Title and abstract screening resulted in full-text retrieval of 40 articles that met initial screening parameters. Of this total, secondary review articles (n = 7) and commentary-based articles (n = 2) were removed, as were articles that did not specifically discuss AI and OM diagnosis (n = 5), leaving 25 articles for review. Applications of AI technologies specific to diagnosing OM included machine learning and natural language processing (n = 23) and prototype approaches (n = 2)., Implications for Practice: This review emphasizes the utility of AI techniques to automate and aid in diagnosing OM. Although these techniques are still in the development and testing stages, AI has the potential to improve the practice of otolaryngologists and primary care clinicians by increasing the efficiency and accuracy of diagnoses., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objectives: Existing cochlear implant (CI) outcomes research demonstrates a high degree of variability in device effectiveness among experienced CI users. Increasing evidence suggests that verbal learning and memory (VL&M) may have an influence on speech recognition with CIs. This study examined the relations in CI users between visual measures of VL&M and speech recognition in a series of models that also incorporated spectro-temporal discrimination. Predictions were that (1) speech recognition would be associated with VL&M abilities and (2) VL&M would contribute to speech recognition outcomes above and beyond spectro-temporal discrimination in multivariable models of speech recognition., Methods: This cross-sectional study included 30 adult postlingually deaf experienced CI users who completed a nonauditory visual version of the California Verbal Learning Test-Second Edition (v-CVLT-II) to assess VL&M, and the Spectral-Temporally Modulated Ripple Test (SMRT), an auditory measure of spectro-temporal processing. Participants also completed a battery of word and sentence recognition tasks., Results: CI users showed significant correlations between some v-CVLT-II measures (short-delay free- and cued-recall, retroactive interference, and "subjective" organizational recall strategies) and speech recognition measures. Performance on the SMRT was correlated with all speech recognition measures. Hierarchical multivariable linear regression analyses showed that SMRT performance accounted for a significant degree of speech recognition outcome variance. Moreover, for all speech recognition measures, VL&M scores contributed independently in addition to SMRT., Conclusion: Measures of spectro-temporal discrimination and VL&M were associated with speech recognition in CI users. After accounting for spectro-temporal discrimination, VL&M contributed independently to performance on measures of speech recognition for words and sentences produced by single and multiple talkers., Level of Evidence: 3 Laryngoscope, 133:661-669, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: When listening to speech under adverse conditions, older adults, even with "age-normal" hearing, face challenges that may lead to poorer speech recognition than their younger peers. Older listeners generally demonstrate poorer suprathreshold auditory processing along with aging-related declines in neurocognitive functioning that may impair their ability to compensate using "top-down" cognitive-linguistic functions. This study explored top-down processing in older and younger adult listeners, specifically the use of semantic context during noise-vocoded sentence recognition., Method: Eighty-four adults with age-normal hearing (45 young normal-hearing [YNH] and 39 older normal-hearing [ONH] adults) participated. Participants were tested for recognition accuracy for two sets of noise-vocoded sentence materials: one that was semantically meaningful and the other that was syntactically appropriate but semantically anomalous. Participants were also tested for hearing ability and for neurocognitive functioning to assess working memory capacity, speed of lexical access, inhibitory control, and nonverbal fluid reasoning, as well as vocabulary knowledge., Results: The ONH and YNH listeners made use of semantic context to a similar extent. Nonverbal reasoning predicted recognition of both meaningful and anomalous sentences, whereas pure-tone average contributed additionally to anomalous sentence recognition. None of the hearing, neurocognitive, or language measures significantly predicted the amount of context gain, computed as the difference score between meaningful and anomalous sentence recognition. However, exploratory cluster analyses demonstrated four listener profiles and suggested that individuals may vary in the strategies used to recognize speech under adverse listening conditions., Conclusions: Older and younger listeners made use of sentence context to similar degrees. Nonverbal reasoning was found to be a contributor to noise-vocoded sentence recognition. However, different listeners may approach the problem of recognizing meaningful speech under adverse conditions using different strategies based on their hearing, neurocognitive, and language profiles. These findings provide support for the complexity of bottom-up and top-down interactions during speech recognition under adverse listening conditions.

Objective: To investigate the electrophysiology of the cochlear summating potential (SP) in patients with Meniere's disease (MD). Although long considered a purely hair cell potential, recent studies show a neural contribution to the SP. Patients with MD have an enhanced SP compared to those without the disease. Consequently, this study was to determine if the enhancement of the SP was in whole or part due to neural dysfunction., Design: Study participants included 41 adults with MD and 53 subjects with auditory neuropathy spectrum disorder (ANSD), undergoing surgery where the round window was accessible. ANSD is a condition with known neural dysfunction, and thus represents a control group for the study. The ANSD subjects and 17 of the MD subjects were undergoing cochlear implantation (CI) surgery; the remaining MD subjects were undergoing either endolymphatic sac decompression or labyrinthectomy to alleviate the symptoms of MD. Electrocochleography was recorded from the round window using high intensity (90 dB nHL) tone bursts. The SP and compound action potential (CAP) were measured to high frequencies (> = 2 kHz) and the SP, cochlear microphonic (CM) and auditory nerve neurophonic (ANN) to low frequencies. Linear mixed models were used to assess differences between MD and ANSD subjects., Results: Across frequencies, the MD subjects had smaller alternating current (AC) response than the ANSD subjects ( F = 31.6 1 , 534 , p < 0.001), but the SP magnitudes were larger ( F = 94.3 1 , 534 , p < 0.001). For frequencies less than 4 kHz the SP magnitude in the MD group was significantly correlated with the magnitude of the CM ( p 's < 0.001) but not in the ANSD group ( p 's > 0.05). Finally, the relative proportions of both ANN and CAP were greater in MD compared to ANSD subjects. The shapes of the waveforms in the MD subjects showed the presence of multiple components contributing to the SP, including outer and inner hair cells and neural activity., Conclusion: The results support the view that the increased negative polarity SP in MD subjects is due to a change in the operating point of hair cells rather than a loss of neural contribution. The steady-state SP to tones in human subjects is a mixture of different sources with different polarities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Riggs, Fontenot, Hiss, Varadarajan, Moberly, Adunka and Fitzpatrick.)

Hypotheses: 1) Scores of reading efficiency (the Test of Word Reading Efficiency, second edition) obtained in adults before cochlear implant surgery will be predictive of speech recognition outcomes 6 months after surgery; and 2) Cochlear implantation will lead to improvements in language processing as measured through reading efficiency from preimplantation to postimplantation., Background: Adult cochlear implant (CI) users display remarkable variability in speech recognition outcomes. "Top-down" processing-the use of cognitive resources to make sense of degraded speech-contributes to speech recognition abilities in CI users. One area that has received little attention is the efficiency of lexical and phonological processing. In this study, a visual measure of word and nonword reading efficiency-relying on lexical and phonological processing, respectively-was investigated for its ability to predict CI speech recognition outcomes, as well as to identify any improvements after implantation., Methods: Twenty-four postlingually deaf adult CI candidates were tested on the Test of Word Reading Efficiency, Second Edition preoperatively and again 6 months post-CI. Six-month post-CI speech recognition measures were also assessed across a battery of word and sentence recognition., Results: Preoperative nonword reading scores were moderately predictive of sentence recognition outcomes, but real word reading scores were not; word recognition scores were not predicted by either. No 6-month post-CI improvement was demonstrated in either word or nonword reading efficiency., Conclusion: Phonological processing as measured by the Test of Word Reading Efficiency, Second Edition nonword reading predicts to a moderate degree 6-month sentence recognition outcomes in adult CI users. Reading efficiency did not improve after implantation, although this could be because of the relatively short duration of CI use., (Copyright © 2022, Otology & Neurotology, Inc.)

Introduction: Real-world speech communication involves interacting with many talkers with diverse voices and accents. Many adults with cochlear implants (CIs) demonstrate poor talker discrimination, which may contribute to real-world communication difficulties. However, the factors contributing to talker discrimination ability, and how discrimination ability relates to speech recognition outcomes in adult CI users are still unknown. The current study investigated talker discrimination ability in adult CI users, and the contributions of age, auditory sensitivity, and neurocognitive skills. In addition, the relation between talker discrimination ability and multiple-talker sentence recognition was explored., Methods: Fourteen post-lingually deaf adult CI users (3 female, 11 male) with ≥1 year of CI use completed a talker discrimination task. Participants listened to two monosyllabic English words, produced by the same talker or by two different talkers, and indicated if the words were produced by the same or different talkers. Nine female and nine male native English talkers were paired, resulting in same- and different-talker pairs as well as same-gender and mixed-gender pairs. Participants also completed measures of spectro-temporal processing, neurocognitive skills, and multiple-talker sentence recognition., Results: CI users showed poor same-gender talker discrimination, but relatively good mixed-gender talker discrimination. Older age and weaker neurocognitive skills, in particular inhibitory control, were associated with less accurate mixed-gender talker discrimination. Same-gender discrimination was significantly related to multiple-talker sentence recognition accuracy., Conclusion: Adult CI users demonstrate overall poor talker discrimination ability. Individual differences in mixed-gender discrimination ability were related to age and neurocognitive skills, suggesting that these factors contribute to the ability to make use of available, degraded talker characteristics. Same-gender talker discrimination was associated with multiple-talker sentence recognition, suggesting that access to subtle talker-specific cues may be important for speech recognition in challenging listening conditions., Competing Interests: Declaration of Competing Interest A.C.M. received grant funding support from Cochlear Americas for an unrelated investigator-initiated research study. A.C.M. serves as a paid consultant for Cochlear Americas and Advanced Bionics and is CMO and on Board of Directors for Otologic Technologies., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Histologic reports of temporal bones of ears with vestibular schwannomas (VSs) have indicated findings of endolymphatic hydrops (ELH) in some cases. The main goal of this investigation was to test ears with VSs to determine if they exhibit electrophysiological characteristics similar to those of ears expected to experience ELH., Design: Fifty-three subjects with surgically confirmed VS aged ≥18 and with normal middle ear status were included in this study. In addition, a second group of adult subjects (n = 24) undergoing labyrinthectomy (n = 6) or endolymphatic sac decompression and shunt (ELS) placement (n = 18) for poorly controlled vestibular symptoms associated with Meniere's disease (MD) participated in this research. Intraoperative electrocochleography (ECochG) from the round window was performed using tone burst stimuli. Audiometric testing and word recognition scores (WRS) were performed preoperatively. ECochG amplitudes, cochlear microphonic/auditory nerve neurophonic (ANN) in the form of the "ongoing" response and summation potential, were analyzed and compared between the two groups of subjects. In addition, to evaluate any effect of auditory nerve function, the auditory nerve score was calculated for each subject. Pure-tone averages were obtained using the average air conduction thresholds at 0.5, 1, and 2 kHz while WRS was assessed using Northwestern University Auditory Test No. 6 word lists., Results: In the VS group the average pure-tone averages and WRS were 59.6 dB HL and 44.8%, respectively, while in the MD group they were 52.3 dB HL and 73.8%. ECochG findings in both groups revealed a reduced trend in amplitude of the ongoing response with increased stimulus frequency. The summation potential amplitudes of subjects with VS were found to be less negative than the MD subjects for nearly all test frequencies. Finally, the VS group exhibited poorer amounts of auditory nerve function compared to the MD group., Conclusions: The current findings suggest cochlear pathology (e.g., hair cell loss) in both groups but do not support the hypothesis that VSs cause ELH., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This study examined the performance of a group of adult cochlear implant (CI) candidates (CIC) on visual tasks of verbal learning and memory. Preoperative verbal learning and memory abilities of the CIC group were compared with a group of older normal-hearing (ONH) control participants. Relations between preoperative verbal learning and memory measures and speech recognition outcomes after 6 mo of CI use were also investigated for a subgroup of the CICs., Design: A group of 80 older adult participants completed a visually presented multitrial free recall task. Measures of word recall, repetition learning, and the use of self-generated organizational strategies were collected from a group of 49 CICs, before cochlear implantation, and a group of 31 ONH controls. Speech recognition outcomes were also collected from a subgroup of 32 of the CIC participants who returned for testing 6 mo after CI activation., Results: CICs demonstrated poorer verbal learning performance compared with the group of ONH control participants. Among the preoperative verbal learning and memory measures, repetition learning slope and measures of self-generated organizational clustering strategies were the strongest predictors of post-CI speech recognition outcomes., Conclusions: Older adult CI candidates present with verbal learning and memory deficits compared with older adults without hearing loss, even on visual tasks that are independent from the direct effects of audibility. Preoperative verbal learning and memory processes reflecting repetition learning and self-generated organizational strategies in free recall were associated with speech recognition outcomes 6 months after implantation. The pattern of results suggests that visual measures of verbal learning may be a useful predictor of outcomes in postlingual adult CICs., Competing Interests: The authors declare no conflicts of interest. All authors contributed to the conceptualization and completion of this research project. A.C.M. supervised the data collection; C.R. and D.B.P. wrote the initial draft of the article; A.C.M., E.L., and W.G.K. provided edits and revisions. All authors discussed the results and implications and commented on the article in various stages of preparation., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

When listening to degraded speech, such as speech delivered by a cochlear implant (CI), listeners make use of top-down linguistic knowledge to facilitate speech recognition. Lexical knowledge supports speech recognition and enhances the perceived clarity of speech. Yet, the extent to which lexical knowledge can be used to effectively compensate for degraded input may depend on the degree of degradation and the listener's age. The current study investigated lexical effects in the compensation for speech that was degraded via noise-vocoding in younger and older listeners. In an online experiment, younger and older normal-hearing (NH) listeners rated the clarity of noise-vocoded sentences on a scale from 1 ("very unclear") to 7 ("completely clear"). Lexical information was provided by matching text primes and the lexical content of the target utterance. Half of the sentences were preceded by a matching text prime, while half were preceded by a non-matching prime. Each sentence also consisted of three key words of high or low lexical frequency and neighborhood density. Sentences were processed to simulate CI hearing, using an eight-channel noise vocoder with varying filter slopes. Results showed that lexical information impacted the perceived clarity of noise-vocoded speech. Noise-vocoded speech was perceived as clearer when preceded by a matching prime, and when sentences included key words with high lexical frequency and low neighborhood density. However, the strength of the lexical effects depended on the level of degradation. Matching text primes had a greater impact for speech with poorer spectral resolution, but lexical content had a smaller impact for speech with poorer spectral resolution. Finally, lexical information appeared to benefit both younger and older listeners. Findings demonstrate that lexical knowledge can be employed by younger and older listeners in cognitive compensation during the processing of noise-vocoded speech. However, lexical content may not be as reliable when the signal is highly degraded. Clinical implications are that for adult CI users, lexical knowledge might be used to compensate for the degraded speech signal, regardless of age, but some CI users may be hindered by a relatively poor signal., Competing Interests: AM and TT have received grant funding support from Cochlear Americas for unrelated investigator-initiated research studies. AM has served as a paid consultant for Cochlear Americas and Advanced Bionics and is CMO and on Board of Directors for Otologic Technologies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Tamati, Sevich, Clausing and Moberly.)

Introduction: Talker-specific adaptation facilitates speech recognition in normal-hearing listeners. This study examined talker adaptation in adult cochlear implant (CI) users. Three hypotheses were tested: (1) high-performing adult CI users show improved word recognition following exposure to a talker ("talker adaptation"), particularly for lexically hard words, (2) individual performance is determined by auditory sensitivity and neurocognitive skills, and (3) individual performance relates to real-world functioning., Methods: Fifteen high-performing, post-lingually deaf adult CI users completed a word recognition task consisting of 6 single-talker blocks (3 female/3 male native English speakers); words were lexically "easy" and "hard." Recognition accuracy was assessed "early" and "late" (first vs. last 10 trials); adaptation was assessed as the difference between late and early accuracy. Participants also completed measures of spectral-temporal processing and neurocognitive skills, as well as real-world measures of multiple-talker sentence recognition and quality of life (QoL)., Results: CI users showed limited talker adaptation overall, but performance improved for lexically hard words. Stronger spectral-temporal processing and neurocognitive skills were weakly to moderately associated with more accurate word recognition and greater talker adaptation for hard words. Finally, word recognition accuracy for hard words was moderately related to multiple-talker sentence recognition and QoL., Conclusion: Findings demonstrate a limited talker adaptation benefit for recognition of hard words in adult CI users. Both auditory sensitivity and neurocognitive skills contribute to performance, suggesting additional benefit from adaptation for individuals with stronger skills. Finally, processing differences related to talker adaptation and lexical difficulty may be relevant to real-world functioning., (© 2021 S. Karger AG, Basel.)

Hypotheses: Significant variability persists in speech recognition outcomes in adults with cochlear implants (CIs). Sensory ("bottom-up") and cognitive-linguistic ("top-down") processes help explain this variability. However, the interactions of these bottom-up and top-down factors remain unclear. One hypothesis was tested: top-down processes would contribute differentially to speech recognition, depending on the fidelity of bottom-up input., Background: Bottom-up spectro-temporal processing, assessed using a Spectral-Temporally Modulated Ripple Test (SMRT), is associated with CI speech recognition outcomes. Similarly, top-down cognitive-linguistic skills relate to outcomes, including working memory capacity, inhibition-concentration, speed of lexical access, and nonverbal reasoning., Methods: Fifty-one adult CI users were tested for word and sentence recognition, along with performance on the SMRT and a battery of cognitive-linguistic tests. The group was divided into "low-," "intermediate-," and "high-SMRT" groups, based on SMRT scores. Separate correlation analyses were performed for each subgroup between a composite score of cognitive-linguistic processing and speech recognition., Results: Associations of top-down composite scores with speech recognition were not significant for the low-SMRT group. In contrast, these associations were significant and of medium effect size (Spearman's rho = 0.44-0.46) for two sentence types for the intermediate-SMRT group. For the high-SMRT group, top-down scores were associated with both word and sentence recognition, with medium to large effect sizes (Spearman's rho = 0.45-0.58)., Conclusions: Top-down processes contribute differentially to speech recognition in CI users based on the quality of bottom-up input. Findings have clinical implications for individualized treatment approaches relying on bottom-up device programming or top-down rehabilitation approaches., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objectives: Cochlear implantation (CI) is a well-established treatment for sensorineural hearing loss. Due in part to a lack of referral guidelines, CI technology remains underutilized, and many patients who could benefit from CI may not be referred for evaluation. This study aimed to develop a model for predicting CI candidacy using routine audiometric measures, with the goal of providing guidance to clinicians regarding when to refer a patient for CI evaluation., Methods: Unaided three-frequency pure tone average (PTA), unaided speech discrimination score (SDS), and best-aided sentence recognition testing with AZBio sentence lists were collected from 252 subjects undergoing CIE. Candidacy was defined by meeting traditional (AZBio score ≤ 60%), or Medicare criteria (≤40%). A logistic regression model was developed to predict candidacy. Confusion matrices were plotted to determine the sensitivity and specificity at various probability thresholds., Results: Logistic regression models were capable of predicting probability of candidacy for traditional criteria ( P  < .001) and Medicare criteria ( P  < .001). PTA and SDS were significant predictors ( P  < .001). Using a probability cutoff of .5, the models yielded a sensitivity rate of 91% and 78% for traditional and Medicare criteria, respectively., Conclusion: Probability of CI candidacy may be determined using a novel screening tool for referral. This tool supports individualized counseling, serves as a proof of concept for candidacy prediction, and could be modified based on an institution's philosophy regarding an acceptable false positive rate of referral., Level of Evidence: 4., Competing Interests: C. R. and A. C. M. have received grant support from Cochlear Americas for an unrelated investigator‐initiated research project. C. R., K. V., and A. C. M. serve as paid consultants for Cochlear Americas and Advanced Bionics. A. C. M. serves as CMO and on the Board of Otologic Technologies., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: Recent models theorize that neurocognitive resources are deployed differently during speech recognition depending on task demands, such as the severity of degradation of the signal or modality (auditory vs. audiovisual [AV]). This concept is particularly relevant to the adult cochlear implant (CI) population, considering the large amount of variability among CI users in their spectro-temporal processing abilities. However, disentangling the effects of individual differences in spectro-temporal processing and neurocognitive skills on speech recognition in clinical populations of adult CI users is challenging. Thus, this study investigated the relationship between neurocognitive functions and recognition of spectrally degraded speech in a group of young adult normal-hearing (NH) listeners., Purpose: The aim of this study was to manipulate the degree of spectral degradation and modality of speech presented to young adult NH listeners to determine whether deployment of neurocognitive skills would be affected., Research Design: Correlational study design., Study Sample: Twenty-one NH college students., Data Collection and Analysis: Participants listened to sentences in three spectral-degradation conditions: no degradation (clear sentences); moderate degradation (8-channel noise-vocoded); and high degradation (4-channel noise-vocoded). Thirty sentences were presented in an auditory-only (A-only) modality and an AV fashion. Visual assessments from The National Institute of Health Toolbox Cognitive Battery were completed to evaluate working memory, inhibition-concentration, cognitive flexibility, and processing speed. Analyses of variance compared speech recognition performance among spectral degradation condition and modality. Bivariate correlation analyses were performed among speech recognition performance and the neurocognitive skills in the various test conditions., Results: Main effects on sentence recognition were found for degree of degradation ( p  = < 0.001) and modality ( p  = < 0.001). Inhibition-concentration skills moderately correlated ( r  = 0.45, p  = 0.02) with recognition scores for sentences that were moderately degraded in the A-only condition. No correlations were found among neurocognitive scores and AV speech recognition scores., Conclusions: Inhibition-concentration skills are deployed differentially during sentence recognition, depending on the level of signal degradation. Additional studies will be required to study these relations in actual clinical populations such as adult CI users., Competing Interests: Aaron C. Moberly has served as a paid consultant for Cochlear Americas and Advanced Bionics. Moberly has received unrelated investigator-initiated research funding from Cochlear Americas. He is Chief Medical Officer and on the Board for Otologic Technologies. The other authors report no conflict of interest., (American Academy of Audiology. This article is published by Thieme.)

Objectives: Patient-specific surgical simulation allows presurgical planning through three-dimensional (3D) visualization and virtual rehearsal. Virtual reality simulation for otologic surgery can be based on high-resolution cone-beam computed tomography (CBCT). This study aimed to evaluate clinicians' experience with patient-specific simulation of mastoid surgery., Methods: Prospective, multi-institutional study. Preoperative temporal bone CBCT scans of patients undergoing cochlear implantation (CI) were retrospectively obtained. Automated processing and segmentation routines were used. Otologic surgeons performed a complete mastoidectomy with facial recess approach on the patient-specific virtual cases in the institution's temporal bone simulator. Participants completed surveys regarding the perceived accuracy and utility of the simulation., Results: Twenty-two clinical CBCTs were obtained. Four attending otologic surgeons and 5 otolaryngology trainees enrolled in the study. The mean number of simulations completed by each participant was 16.5 (range 3-22). "Overall experience" and "usefulness for presurgical planning" were rated as "good," "very good," or "excellent" in 84.6% and 71.6% of the simulations, respectively. In 10.7% of simulations, the surgeon reported to have gained a significantly greater understanding of the patient's anatomy compared to standard imaging. Participants were able to better appreciate subtle anatomic findings after using the simulator for 60.4% of cases. Variable CBCT acquisition quality was the most reported limitation., Conclusion: Patient-specific simulation using preoperative CBCT is feasible and may provide valuable insights prior to otologic surgery. Establishing a CBCT acquisition protocol that allows for consistent segmentation will be essential for reliable surgical simulation., Level of Evidence: 3 Laryngoscope, 131:1855-1862, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Background Standards for auditory rehabilitation are currently lacking for adults who receive cochlear implants. Speech recognition outcomes are highly variable, and many adults with cochlear implants present with suboptimal performance. Functional real-life communication abilities are not routinely measured clinically and are not strongly linked to performance on traditional measures of speech recognition. In fact, even individuals with relatively good speech recognition outcomes often present with persistent communication difficulties. In contrast to pediatric cochlear implant users, speech-language pathologists are not routinely involved in the rehabilitation of adults who receive cochlear implants. Purpose The purpose of this article is to describe the value of including a speech-language pathologist in a comprehensive approach to auditory rehabilitation for adults with cochlear implants. Method The theoretical and clinical foundations of incorporating a speech-language pathologist into an adult auditory rehabilitation program are discussed. A description of the skills and potential roles of the speech-language pathologist for providing adult cochlear implant rehabilitation services is presented, along with potential barriers to implementation. Conclusion Person-centered management of postlingually deafened adults with cochlear implants can be augmented by a more complete approach utilizing the skill set of a speech-language pathologist. Supplemental Material https://doi.org/10.23641/asha.14669652.

Hypotheses: Adult cochlear implant candidates would self-report their executive functioning abilities as poorer than normal-hearing peers. These executive function abilities would correlate with laboratory-based cognitive tests. Lastly, executive functioning (EF) abilities would be associated with hearing-related quality of life., Background: Executive function refers to cognitive abilities involved in behavioral regulation during goal-directed activity. Pediatric and adult users have demonstrated delays and deficits in executive function skills compared with normal-hearing peers. This study aimed to compare self-report executive function in adult cochlear implant candidates and normal-hearing peers and to relate executive function skills to laboratory-based cognitive testing and hearing-related quality of life., Methods: Twenty-four postlingually deaf adult cochlear implant candidates were enrolled, along with 42 normal-hearing age-matched peers. Participants completed self-reports of executive function using the Behavior Rating Inventory of Executive Function- Adult (BRIEF-A). Participants were also tested using laboratory-based cognitive measures, as well as assessment of hearing-related quality of life on the Nijmegen Cochlear Implant Questionnaire. Groups were compared on BRIEF-A scores, and relations between BRIEF-A and lab-based cognitive measures as well as Nijmegen Cochlear Implant Questionnaire scores were examined., Results: Self-report executive function on the BRIEF-A was not significantly different between groups. Consistent relations of self-report executive function and nonverbal reasoning were identified. Strong relations were not found between self-report executive function and hearing-related quality of life., Conclusions: Executive function as measured by BRIEF-A demonstrates some relation with a laboratory-based metric of nonverbal reasoning, but not other cognitive measures. Hearing-impaired individuals did not report poorer EF than normal-hearing controls. EF additionally did not correlate with quality of life. Our findings provide preliminary, partial validation of the BRIEF-A instrument in the preoperative evaluation of adult cochlear implant candidates., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objectives/hypothesis: With the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video., Study Design: Diagnostic survey analysis., Methods: Five Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image., Results: There were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate., Conclusions: Equal to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training., Level of Evidence: 3 Laryngoscope, 131:E1668-E1676, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Purpose The aims of this study were (a) to longitudinally assess environmental sound recognition (ESR) before and after cochlear implantation in a sample of postlingually deafened adults and (b) to assess the extent to which spectro-temporal processing abilities influence ESR with cochlear implants (CIs). Method In a longitudinal cohort study, 20 postlingually deafened adults were tested with hearing aids on the Familiar Environmental Sound Test-Identification and AzBio sentences in quiet pre-CI and 6 months post-CI. A subset of 11 participants were also tested 12 months post-CI. Pre-CI spectro-temporal processing was assessed using the Spectral-temporally Modulated Ripple Test. Results Average ESR accuracy pre-CI ( M = 63.60%) was not significantly different from ESR accuracy at 6 months ( M = 65.40%) or 12 months ( M = 69.09%) post-CI. In 11 participants (55%), however, ESR improved following implantation by 10.91 percentage points, on average. Pre-CI ESR correlated moderately and significantly with pre-CI and 12-month post-CI AzBio scores, with a trend toward significance for AzBio performance at 6 months. Pre-CI spectro-temporal processing was moderately associated with ESR at 6 and 12 months post-CI but not with speech recognition post-CI. Conclusions The present findings failed to demonstrate an overall significant improvement in ESR following implantation. Nevertheless, more than half of our sample showed some degree of improvement in ESR. Several environmental sounds were poorly identified both before and after implantation. Spectro-temporal processing ability prior to implantation appears to predict postimplantation performance for ESR. These findings indicate the need for greater attention to ESR following cochlear implantation and for developing individualized targets for ESR rehabilitation. Supplemental Material https://doi.org/10.23641/asha.13876745.

Purpose Cognitive screening tools to identify patients at risk for cognitive deficits are frequently used by clinicians who work with aging populations in hearing health care. Although some studies show improvements in performance on cognitive screening exams when hearing loss intervention is provided in the form of a hearing aid or cochlear implant (CI), it is worth examining whether these improvements are attributable to increased auditory access to test items. This study aimed to examine whether performance and pass rate on a cognitive screening measure, the Montréal Cognitive Assessment (MoCA), improve as a result of CI, whether improved performance on auditory-based test items drives changes in MoCA performance, and whether postoperative MoCA performance relates to post-CI speech perception ability. Method Data were collected in adult CI candidates pre-implantation and 6 months postimplantation to examine the effect of intervention on MoCA performance. Participants were 77 CI users between the ages of 55 and 85 years. Participants completed the MoCA, administered audiovisually, and speech perception testing with monosyllabic (CNC) words at both intervals. Results Compared to 31 participants pre-operatively, 45 participants passed the MoCA postoperatively, which was a significant difference in pass rate. An improvement in MoCA scores could be attributed primarily to improvement in the "Delayed Recall" test domain, which was auditory based. Post-CI MoCA performance was related to post-CI CNC speech perception performance. Conclusions Improved performance and pass rates were demonstrated on the traditional MoCA test of cognitive screening from before to 6 months after CI. Improvements could primarily be attributed to better performance on a delayed recall task dependent on auditory access, and post-CI MoCA scores were related to post-CI speech perception abilities. Further studies are needed to investigate the application of cognitive screening tools in patients receiving hearing loss interventions, and these interventions' impact on patients' real-world functioning.

Purpose The Cochlear Implant Skills Review (CISR) was developed as a measure of cochlear implant (CI) users' skills and knowledge regarding device use. This study aimed to determine intra- and interrater reliability and agreement and establish construct validity for the CISR. Method In this study, the CISR was developed and administered to a cohort of 30 adult CI users. Participants included new CI users with less than 1 year of CI experience and experienced CI users with greater than 1 year of CI experience. The CISR administration required participants to demonstrate skills using the various features of their CI processors. Intra- and interrater reliability were assessed using intraclass correlation coefficients, agreement was assessed using Cohen's kappa, and construct validity was assessed by relating CISR performance to duration of CI use. Results Overall reliability for the entire instrument was 92.7%. Inter- and intrarater agreement were generally substantial or higher. Duration of CI use was a significant predictor of CISR performance. Conclusions The CISR is a reliable and valid assessment measure of device skills and knowledge for adult CI users. Clinicians can use this tool to evaluate areas of needed instruction and counseling and to assess users' skills over time.

Hypothesis: This study tested the hypotheses that 1) experienced adult cochlear implants (CI) users demonstrate poorer reading efficiency relative to normal-hearing controls, 2) reading efficiency reflects basic, underlying neurocognitive skills, and 3) reading efficiency relates to speech recognition outcomes in CI users., Background: Weak phonological processing skills have been associated with poor speech recognition outcomes in postlingually deaf adult CI users. Phonological processing can be captured in nonauditory measures of reading efficiency, which may have wide use in patients with hearing loss. This study examined reading efficiency in adults CI users, and its relation to speech recognition outcomes., Methods: Forty-eight experienced, postlingually deaf adult CI users (ECIs) and 43 older age-matched peers with age-normal hearing (ONHs) completed the Test of Word Reading Efficiency (TOWRE-2), which measures word and nonword reading efficiency. Participants also completed a battery of nonauditory neurocognitive measures and auditory sentence recognition tasks., Results: ECIs and ONHs did not differ in word (ECIs: M = 78.2, SD = 11.4; ONHs: M = 83.3, SD = 10.2) or nonword reading efficiency (ECIs: M = 42.0, SD = 11.2; ONHs: M = 43.7, SD = 10.3). For ECIs, both scores were related to untimed word reading with moderate to strong effect sizes (r = 0.43-0.69), but demonstrated differing relations with other nonauditory neurocognitive measures with weak to moderate effect sizes (word: r = 0.11-0.44; nonword: r = (-)0.15 to (-)0.42). Word reading efficiency was moderately related to sentence recognition outcomes in ECIs (r = 0.36-0.40)., Conclusion: Findings suggest that postlingually deaf adult CI users demonstrate neither impaired word nor nonword reading efficiency, and these measures reflect different underlying mechanisms involved in language processing. The relation between sentence recognition and word reading efficiency, a measure of lexical access speed, suggests that this measure may be useful for explaining outcome variability in adult CI users., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2020, Otology & Neurotology, Inc.)

Purpose This preliminary research examined (a) the perception of two common sources of indexical variability in speech-regional dialects and foreign accents, and (b) the relation between indexical processing and sentence recognition among prelingually deaf, long-term cochlear implant (CI) users and normal-hearing (NH) peers. Method Forty-three prelingually deaf adolescent and adult CI users and 44 NH peers completed a regional dialect categorization task, which consisted of identifying the region of origin of an unfamiliar talker from six dialect regions of the United States. They also completed an intelligibility rating task, which consisted of rating the intelligibility of short sentences produced by native and nonnative (foreign-accented) speakers of American English on a scale from 1 ( not intelligible at all ) to 7 ( very intelligible ). Individual performance was compared to demographic factors and sentence recognition scores. Results Both CI and NH groups demonstrated difficulty with regional dialect categorization, but NH listeners significantly outperformed the CI users. In the intelligibility rating task, both CI and NH listeners rated foreign-accented sentences as less intelligible than native sentences; however, CI users perceived smaller differences in intelligibility between native and foreign-accented sentences. Sensitivity to accent differences was related to sentence recognition accuracy in CI users. Conclusions Prelingually deaf, long-term CI users are sensitive to accent variability in speech, but less so than NH peers. Additionally, individual differences in CI users' sensitivity to indexical variability was related to sentence recognition abilities, suggesting a common source of difficulty in the perception and encoding of fine acoustic-phonetic details in speech.

Objectives: Intraoperative electrocochleography (ECochG) has provided insight regarding inner ear pathophysiology during neurotologic procedures. In this study, intraoperative ECochG findings are reported in patients who presented with episodic aural and vestibular symptoms during resection of posterior fossa neoplasms., Patients: Three patients with episodic vertigo who underwent resection of posterior fossa tumors., Intervention: Intraoperative ECochG was performed before and after tumor resection with the active electrode at the round window. Acoustic stimuli consisted of click and tone bursts presented in alternating polarity., Main Outcome Measure: ECochG responses including summation potential (SP), action potential (AP), and SP:AP ratio values to evaluate for endolymphatic hydrops., Results: All subjects presented with asymmetric sensorineural hearing loss (SNHL), episodic vertigo, and tinnitus. Subject 1 was a 63-year-old woman who underwent left translabyrinthine excision of an endolymphatic sac (ELS) tumor and demonstrated no measurable responses until fenestration of the lateral semicircular canal, suggesting severe hydrops relieved by labyrinthotomy. Subject 2 was a 44-year-old woman who underwent right ELS tumor resection and exhibited an elevated SP:AP ratio. Subject 3 was a 55-year-old woman who underwent right retrolabyrinthine resection of a meningioma and exhibited robust responses without hydrops., Conclusions: Endolymphatic hydrops secondary to mechanical obstruction by a posterior fossa neoplasm may be demonstrated using intraoperative ECochG. Immediate improvement of hydrops may not be demonstrated after tumor resection.

Objectives: Enormous variability in speech recognition outcomes persists in adults who receive cochlear implants (CIs), which leads to a barrier to progress in predicting outcomes before surgery, explaining "poor" outcomes, and determining how to provide tailored rehabilitation therapy for individual CI users. The primary goal of my research program over the past 9 years has been to extend our understanding of the contributions of "top-down" cognitive-linguistic skills to CI outcomes in adults, acknowledging that "bottom-up" sensory processes also contribute substantially. The main objective of this invited narrative review is to provide an overview of this work. A secondary objective is to provide career "guidance points" to budding surgeon-scientists in Otolaryngology., Methods: A narrative, chronological review covers work done by our group to explore top-down and bottom-up processing in adult CI outcomes. A set of ten guidance points is also provided to assist junior Otolaryngology surgeon-scientists., Results: Work in our lab has identified substantial contributions of cognitive skills (working memory, inhibition-concentration, speed of lexical access, nonverbal reasoning, verbal learning and memory) as well as linguistic abilities (acoustic cue-weighting, phonological sensitivity) to speech recognition outcomes in adults with CIs. These top-down skills interact with the quality of the bottom-up input., Conclusion: Although progress has been made in understanding speech recognition variability in adult CI users, future work is needed to predict CI outcomes before surgery, to identify particular patients' strengths and weaknesses, and to tailor rehabilitation approaches for individual CI users., Level of Evidence: 4., Competing Interests: Investigator‐initiated grant funding was provided by Cochlear Americas to complete an adult cochlear implant auditory rehabilitation study. ACM serves as a paid consultant for Cochlear Americas and Advanced Bionics, and owns stock and serves as CMO and on the Board for Otologic Technologies., (© 2020 The Author. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: To assess the benefits of bimodal listening (i.e., addition of contralateral hearing aid) for cochlear implant (CI) users on real-world tasks involving high-talker variability speech materials, environmental sounds, and self-reported quality of life (quality of hearing) in listeners' own best-aided conditions., Study Design: Cross-sectional study between groups., Setting: Outpatient hearing clinic., Patients: Fifty experienced adult CI users divided into groups based on normal daily listening conditions (i.e., best-aided conditions): unilateral CI (CI), unilateral CI with contralateral HA (bimodal listening; CIHA), or bilateral CI (CICI)., Intervention: Task-specific measures of speech recognition with low (Harvard Standard Sentences) and high (Perceptually Robust English Sentence Test Open-set corpus) talker variability, environmental sound recognition (Familiar Environmental Sounds Test-Identification), and hearing-related quality of life (Nijmegen Cochlear Implant Questionnaire)., Main Outcome Measures: Test group differences among CI, CIHA, and CICI conditions., Results: No group effect was observed for speech recognition with low or high-talker variability, or hearing-related quality of life. Bimodal listeners demonstrated a benefit in environmental sound recognition compared with unilateral CI listeners, with a trend of greater benefit than the bilateral CI group. There was also a visual trend for benefit on high-talker variability speech recognition., Conclusions: Findings provide evidence that bimodal listeners demonstrate stronger environmental sound recognition compared with unilateral CI listeners, and support the idea that there are additional advantages to bimodal listening after implantation other than speech recognition measures, which are at risk of being lost if considering bilateral implantation.

Purpose Cochlear implant (CI) performance varies considerably across individuals and across domains of auditory function, but clinical testing is typically restricted to speech intelligibility. The goals of this study were (a) to develop a basic auditory skills evaluation battery of tests for comprehensive assessment of ecologically relevant aspects of auditory perception and (b) to compare CI listeners' performance on the battery when tested in the laboratory by an audiologist or independently at home. Method The battery included 17 tests to evaluate (a) basic spectrotemporal processing, (b) processing of music and environmental sounds, and (c) speech perception in both quiet and background noise. The battery was administered online to three groups of adult listeners: two groups of postlingual CI listeners and a group of older normal-hearing (ONH) listeners of similar age. The ONH group and one CI group were tested in a laboratory by an audiologist, whereas the other CI group self-tested independently at home following online instructions. Results Results indicated a wide range in the performance of CI but not ONH listeners. Significant differences were not found between the two CI groups on any test, whereas on all but two tests, CI listeners' performance was lower than that of the ONH participants. Principal component analysis revealed that four components accounted for 82% of the variance in measured results, with component loading indicating that the test battery successfully captures differences across dimensions of auditory perception. Conclusions These results provide initial support for the use of the basic auditory skills evaluation battery for comprehensive online assessment of auditory skills in adult CI listeners.