Bilateral Cochlear Implants or Bimodal Hearing for Children with Bilateral Sensorineural Hearing Loss

This review describes speech perception and language outcomes for children using bimodal hearing (cochlear implant (CI) plus contralateral hearing aid) as compared to children with bilateral CIs and contrasts said findings with the adult literature. There is a lack of clinical evidence driving recommendations for bimodal versus bilateral CI candidacy and as such, clinicians are often unsure about when to recommend a second CI for children with residual acoustic hearing. Thus the goal of this review is to identify scientific information that may influence clinical decision making for pediatric CI candidates with residual acoustic hearing.

Bilateral CIs are considered standard of care for children with bilateral severe-to-profound sensorineural hearing loss. For children with aidable acoustic hearing-even in just the low frequencies-an early period of bimodal stimulation has been associated with significantly better speech perception, vocabulary, and language development. HA audibility, however, is generally poorer than that offered by a CI resulting in interaural asymmetry in speech perception, head shadow, as well as brainstem and cortical activity and development. Thus there is a need to optimize "two-eared" hearing while maximizing a child's potential with respect to hearing, speech, and language while ensuring that we limit asymmetrically driven auditory neuroplasticity. A recent large study of bimodal and bilateral CI users suggested that a period of bimodal stimulation was only beneficial for children with a better-ear pure tone average (PTA) ≤ 73 dB HL. This 73-dB-HL cutoff applied even to children who ultimately received bilateral CIs.

Though we do not yet have definitive guidelines for determining bimodal versus bilateral CI candidacy, there is increasing evidence that 1) bilateral CIs yield superior outcomes for children with bilateral severe-to-profound hearing loss and, 2) an early period of bimodal stimulation is beneficial for speech perception and language development, but only for children with better-ear PTA ≤ 73 dB HL. For children with residual acoustic hearing, even in just the low-frequency range, rapid sequential bilateral cochlear implantation following a trial period with bimodal stimulation will yield best outcomes for auditory, language, and academic development. Of course, there is also an increasing prevalence of cochlear implantation with acoustic hearing preservation allowing for combined electric and acoustic stimulation even following bilateral implantation.