title: A clinical study of electrophysiological correlates of behavioural comfort levels in cochlear implantees.
abstract: OBJECTIVE
  Indications for cochlear implantation have expanded today to include very young children and those with syndromes/multiple handicaps. Programming the implant based on behavioural responses may be tedious for audiologists in such cases, wherein matching an effective Measurable Auditory Percept (MAP) and appropriate MAP becomes the key issue in the habilitation program. In 'Difficult to MAP' scenarios, objective measures become paramount to predict optimal current levels to be set in the MAP. We aimed to (a) study the trends in multi-modal electrophysiological tests and behavioural responses sequentially over the first year of implant use; (b) generate normative data from the above; (c) correlate the multi-modal electrophysiological thresholds levels with behavioural comfort levels; and (d) create predictive formulae for deriving optimal comfort levels (if unknown), using linear and multiple regression analysis.
  
  
  METHODS
  This prospective study included 10 profoundly hearing impaired children aged between 2 and 7 years with normal inner ear anatomy and no additional handicaps. They received the Advanced Bionics HiRes 90 K Implant with Harmony Speech processor and used HiRes-P with Fidelity 120 strategy. They underwent, impedance telemetry, neural response imaging, electrically evoked stapedial response telemetry (ESRT), and electrically evoked auditory brainstem response (EABR) tests at 1, 4, 8, and 12 months of implant use, in conjunction with behavioural mapping. Trends in electrophysiological and behavioural responses were analyzed using paired t-test. By Karl Pearson's correlation method, electrode-wise correlations were derived for neural response imaging (NRI) thresholds versus most comfortable level (M-levels) and offset based (apical, mid-array, and basal array) correlations for EABR and ESRT thresholds versus M-levels were calculated over time. These were used to derive predictive formulae by linear and multiple regression analysis. Such statistically predicted M-levels were compared with the behaviourally recorded M-levels among the cohort, using Cronbach's alpha reliability test method for confirming the efficacy of this method.
  
  
  RESULTS
  NRI, ESRT, and EABR thresholds showed statistically significant positive correlations with behavioural M-levels, which improved with implant use over time. These correlations were used to derive predicted M-levels using regression analysis. On an average, predicted M-levels were found to be statistically reliable and they were a fair match to the actual behavioural M-levels. When applied in clinical practice, the predicted values were found to be useful for programming members of the study group. However, individuals showed considerable deviations in behavioural M-levels, above and below the electrophysiologically predicted values, due to various factors. While the current method appears helpful as a reference to predict initial maps in 'difficult to Map' subjects, it is recommended that behavioural measures are mandatory to further optimize the maps for these individuals.
  
  
  CONCLUSIONS
  The study explores the trends, correlations and individual variabilities that occur between electrophysiological tests and behavioural responses, recorded over time among a cohort of cochlear implantees. The statistical method shown may be used as a guideline to predict optimal behavioural levels in difficult situations among future implantees, bearing in mind that optimal M-levels for individuals can vary from predicted values. In 'Difficult to MAP' scenarios, following a protocol of sequential behavioural programming, in conjunction with electrophysiological correlates will provide the best outcomes.
authors.forename: S
authors.initials: S
authors.lastname: Raghunandhan
authors.forename: A
authors.initials: A
authors.lastname: Ravikumar
authors.forename: Mohan
authors.initials: M
authors.lastname: Kameswaran
authors.forename: Kalyani
authors.initials: K
authors.lastname: Mandke
authors.forename: R
authors.initials: R
authors.lastname: Ranjith
mesh_terms: D001309:Auditory Threshold / Q000502:physiology; D001519:Behavior; D002648:Child; D002675:Child, Preschool; D019929:Cochlear Implantation; D003054:Cochlear Implants; D003638:Deafness / Q000503:physiopathology / Q000628:therapy*; D055724:Electrophysiological Phenomena; D016057:Evoked Potentials, Auditory, Brain Stem; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D013686:Telemetry
keywords: Clinical unit; Cochlear implant; Evoked compound action potential; Impedance telemetry; electrically evoked auditory brainstem response; electrically evoked stapedial response telemetry; measurable auditory percept; most comfortable level; neural response imaging