Pre- and Postoperative Binaural Unmasking for Bimodal Cochlear Implant Listeners

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Cochlear implants (CIs) are increasingly recommended to individuals with residual bilateral acoustic hearing. Although new hearing-preserving electrode designs and surgical approaches show great promise, CI recipients are still at risk to lose acoustic hearing in the implanted ear, which could prevent the ability to take advantage of binaural unmasking to aid speech recognition in noise. This study examined the tradeoff between the benefits of a CI for speech understanding in noise and the potential loss of binaural unmasking for CI recipients with some bilateral preoperative acoustic hearing.


Binaural unmasking is difficult to evaluate in CI candidates because speech perception in noise is generally too poor to measure reliably in the range of signal to noise ratios (SNRs) where binaural intelligibility level differences (BILDs) are typically observed (<5 dB). Thus, a test of audiovisual speech perception in noise was employed to increase performance to measureable levels. BILDs were measured preoperatively for 11 CI candidates and at least 5 months post-activation for 10 of these individuals (1 individual elected not to receive a CI). Audiovisual sentences were presented in speech-shaped masking noise between −10 and +15 dB SNR. The noise was always correlated between the ears, while the speech signal was either correlated (N0S0) or inversely correlated (N0Sπ). Stimuli were delivered via headphones to the unaided ear(s) and, where applicable, via auxiliary input to the CI speech processor. A z test evaluated performance differences between the N0S0 and N0Sπ conditions for each listener pre- and postoperatively. For listeners showing a significant difference, the magnitude of the BILD was characterized as the difference in SNRs required to achieve 50% correct performance. One listener who underwent hearing-preservation surgery received additional postoperative tests, which presented sound directly to both ears and to the CI speech processor.


Five of 11 listeners showed a significant preoperative BILD (range: 2.0 to 7.3 dB). Only 2 of these 5 showed a significant postoperative BILD, but the mean BILD was smaller (1.3 dB) than that observed preoperatively (3.1 dB). Despite the fact that some listeners lost the preoperative binaural benefit, 9 out of 10 listeners tested postoperatively had performance equal to or better than their best pre-CI performance. The listener who retained functional acoustic hearing in the implanted ear also demonstrated a preserved acoustic BILD postoperatively.


Approximately half of the CI candidates in this study demonstrated preoperative binaural hearing benefits for audiovisual speech perception in noise. Most of these listeners lost their acoustic hearing in the implanted ear after surgery (using nonhearing-preservation techniques), and therefore lost access to this binaural benefit. In all but one case, any loss of binaural benefit was compensated for or exceeded by an improvement in speech perception with the CI. Evidence of a preoperative BILD suggests that certain CI candidates might further benefit from hearing-preservation surgery to retain acoustic binaural unmasking, as demonstrated for the listener who underwent hearing-preservation surgery. This test of binaural audiovisual speech perception in noise could serve as a diagnostic tool to identify CI candidates who are most likely to receive functional benefits from their bilateral acoustic hearing.

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