Loud in the morning..??

This came up on a Facebook group..
 People with CI experiencing loud noise when turning on the CI in the morning, after a long period of inactivity.

Lotte never had this problem.. (See this post from 2007.. Jeezz.. has it been that long....)

But for those who have this experience.. Here is a possible explanation..
Not that I really understand... out of my league. 

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(From.. http://www.ncbi.nlm.nih.gov/pubmed/23533184)

J Biomed Mater Res A. 2013 Mar 27. doi: 10.1002/jbm.a.34719. [Epub ahead of print]

Dexamethasone released from cochlear implant coatings combined with a protein repellent hydrogel layer inhibits fibroblast proliferation.

Wrzeszcz A, Dittrich B, Haamann D, Aliuos P, Klee D, Nolte I, Lenarz T, Reuter G.

Source

Department of Otolaryngology, Hannover Medical School, 30625, Hannover, Germany.

Abstract

The insertion of cochlear implants into the inner ear often causes inflammation and fibrosis inside the scala tympani and thus growth of fibrous tissue on the implant surface. This deposition leads to the loss of function in both electrical and laser-based implants. The design of this study was to realize fibroblast growth inhibition by dexamethasone (Dex) released from the base material of the implant [polydimethylsiloxane (PDMS)]. To prevent cell and protein adhesion, the PDMS was coated with a hydrogel layer [star-shaped polyethylene glycol prepolymer (sPEG)]. Drug release rates were studied over 3 months, and surface characterization was performed. It was observed that the hydrogel slightly smoothened the surface roughened by the Dex crystals. The hydrogel coating reduced and prolonged the release of the drug over several months. Unmodified, sPEG-coated, Dex-loaded, and Dex/sPEG-equipped PDMS filaments were cocultivated in vitro with fluorescent fibroblasts, analyzed by fluorescent microscopy, and quantified by cell counting. Compared to the unmodified PDMS, cell growth on all modified filaments was averagely 95% ±standard deviation (SD) less, while cell growth on the bottom of the culture dishes containing Dex-loaded filaments was reduced by 70% ±SD. Both, Dex and sPEG prevented direct cell growth on the filament surfaces, while drug delivery was maintained for the duration of several months. © 2013 Wiley Periodicals, Inc. J Biomed Mater Res Part A, 2013.

Copyright © 2013 Wiley Periodicals, Inc.

Milestones, Mountain-ranges and views

Milestones....
They happen all the time, and like I have said on the blog.. sometimes they fly by, and sometimes they stand up in your face... (well, I said something to that effect..)

Last Thursday was the yearly checkup for Lotte. A great day out since we (actually, this was the first time I couldn't be there..) have to fly to Oslo, then take a train & tram to the hospital where the center for the check-up is located. One of Lotte's teachers joined Lotte and her mum.

This time, for the first time, it was Lotte who was in charge. She has grown so much lately, that my wife had no problem just sitting back and let Lotte do all the talking. And the specialists were excellent at directing everything to Lotte.
It must have been a wonderful day for Lotte because she was 100% focused the hole time. While adjusting the settings on the CI/BTE's, when finding the noises that she doesn't like (flushing the toilet) and trying to do something with that, she got it, and gave excellent feedback.. While doing speech tests in noisy environments and while doing comprehension tests. she did great. Her teacher was very impressed with Lotte..
But it's a great day out. She loves to go there and thrives on the attention, but this time, at the same time she realises the importance of the day.

In all, this day marks a beginning of Lotte taking over the "CI business" from us. She can accurately give feedback about how and what she hears. She understands the tests they are doing. She understands that there are different programs on her BTE she can use, because she was mentally there when they made them.
Of course life goes back to normal for her as soon as she was back at school, and she won't be playing with the different proframs, but she knows they are there.
Also, with one of her teachers being there, there is someone at school that will recognise difficult situations and can tell Lotte to switch to another program.. or, she might identify that Lotte forgot to switch back to the default setting.

Anyway.. It's a huge milestone. It didn't fly by. We didn't bump into it. It was like the mountain range in the distance that we finally reached.. We knew it was there, and were cruising along towards it. Now, having reached it, we can enjoy the view forward, and back...
It's a great view...

(btw.. Lotes mom promised to post an account of the day as well.... so stay tuned..)

HINT (Hearing In Noise test)

Here's Lotte's test result plotted in an example graph. 

Understanding of sentences grows with age as understanding/vocabulary grows, hence the rising line up to 12-13 years of age. Lotte's score 14 months ago is also plotted (Age 7½ - November 2010) and last results (Age 9½ - Feb 2012) The improvement is clear. Also that she is still catching up.. Whether the gap is due to actual hearing, or understanding..r both?? The future will tell....

The official graphs look like this: (Coloured area on the right is Normal hearing adults)

Here one can see on the left how Lotte scores close to perfect without noise. (from 69% 14 months ago) and how (on the right) she improved from her 2010 results in noisy environment

In writing (Norwegian):

Translation:

Lotte was wearing bilateral CI when she was tested with one-syllable words and HINT sentenses.

One-syllable words HIST: 40 of 44 = 88%

HINT sentenses:

I silence: 98%

In noise from the front: STN= 5.7 dB with v=2,0dB and STN= 3.3dB with v= 2,0dB 

In noise from right: STN= 2.2 dB with v=1.5dB

In noise from left: STN= -0.2 dB with v=2,2dB 

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From the www..

What is the HINT test?
The Hearing in Noise Test (HINT) measures a person’s ability to hear speech in quiet and in noise.
During the test, the patient uses both ears together (binaural hearing) to repeat sentences. Binaural hearing ability is essential for communication in noisy settings and for other aspects of functional hearing, such as sound localization and recognition of environmental sounds. In this test, the patient is required to repeat sentences both in a quiet environment and with competing noise being presented from different directions.

What is involved in taking this test? 
The HINT battery consists of four test conditions. For each test, speech is located directly in front of the subject at 0° azimuth, and all sound sources are one meter from the center of the subject’s head. For each of the four conditions, the subject is required to listen to a sentence and repeat it. The four test conditions are:
(1) sentences with no competing noise,
(2) sentences with competing noise presented directly in front of the patient,
(3) noise presented at 90° to the right of the patient, and
(4) noise presented at 90° to the left of the patient.

In all conditions, the competing noise is presented at a steady loudness of 65dB(A). The loudness of the sentences presented is varied throughout the test, depending on whether the patient repeats it correctly or not.

How is the HINT test scored? 
The tester scores each sentence repeated as either correct or incorrect. All words in the sentence must be repeated correctly. At the end of the test, a signal-to-noise ratio (SNR) is generated for each test condition. A signal-to-noise ratio equals how loud the sentences needed to be turned up above the noise floor so that the patient could repeat them correctly 50% of the time. For example, an SNR of 5dB indicates that the sentences had to be presented at 70dB (or 5dB above the 65dB noise floor) in order to be repeated correctly 50% of the time. The higher the SNR, the more difficulty the patient has hearing in noise. The HINT test is scored as a “pass” or “fail” in each condition and the cut-off criteria are based on the scores from a group of more than 50 subjects with normal hearing. These scores were provided by House Ear Institute who developed the HINT test. HINT test results show three things:
Subject’s signal to noise ratio threshold (e.g. 5dB)
Subject’s threshold as a percentile in reference to the normal distribution of the data (e.g. 95th %ile)
Subject’s maximum percent change in intelligibility. This is the predicted maximum difference in intelligibility in reference to the mean normal performance (e.g. the subject’s predicted intelligibility is 23% poorer than normal hearing intelligibility)

Good basic info regarding Bi-lateral CI....

From a thesis by Carol A. Sammeth, Ph.D, CCC-A

Please be careful that the statements selected are representative of the paper's overall conclusions.  Also, the part posted is only a piece of a longer work. (Full pdf here..)
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BRIEF REVIEW OF BENEFITS OF TWO-EARED INPUT


The Psychoacoustic Literature
There is a fairly voluminous literature in psychoacoustics (hearing science) illustrating the benefits in normal hearing persons of having two-eared rather than one-eared input. When hearing loss disrupts the ability of the brain to process binaural inputs, whether due to large differences in the degree of loss between the ears, or a failure to provide amplification or a cochlear implant to one impaired ear, these benefits can be severely degraded or lost. There are three primary effects ascribed to binaural listening: the head shadow effect, the binaural summation effect, and the binaural squelch effect (e.g. Durlach & Colburn, 1978), producing benefits that range from improved speech recognition in noise, to the ability to localize the direction of a sound, to more “natural” perception. The following briefly describes the key benefits of binaural functioning.

Head Shadow Effect
When speech and noise come from different directions (i.e. are spatially separated, as typically occurs in the real world), there is always a more favorable signal-to-noise ratio (SNR) at one ear than at the other because of the head shadow effect and different sound distances to the ears. The head shadow effect is primarily seen in frequencies higher than 1500 Hz (e.g. Shaw, 1974), with the amount of attenuation of sounds from the opposite side of the head dependent on frequency but ranging from about 7 dB in the speech range up to 20 dB or more at the highest frequencies. If both ears are participatory, the ear with the most favorable SNR is always available so that the patient can selectively attend to this ear. This is compared to the unfavorable situation where only the ear with the poorer SNR is functional. Persons with unilateral hearing loss can become very frustrated when people are talking on both sides of them because they must constantly turn their “good ear” to whomever they want to hear best at the time, and then they miss sounds on the deaf ear side.

As will be shown later in this paper, a primary benefit of bilateral cochlear implants appears to be related to the beneficial aspects of hearing from both sides, and always having the ear with the more favorable SNR available. This is generally tested with speech from a frontal speaker and noise from a side speaker - - when the second ear is added that is contralateral to (opposite side of) the noise source, performance benefit comes primarily from the head shadow effect. Note, however, that there is discrepancy across the published studies in how to quantify the head shadow effect, with some researchers merely examining differences in scores with sound ipsilateral versus contralateral to a unilateral ear under test, and others comparing the score for listening with bilateral inputs to that for unilateral listening with the noise presented ipsilateral to the ear under test.

Binaural Summation & Redundancy
Sounds that are presented to both ears rather than just one are perceived as louder due to binaural summation of the information received at each ear. In fact, the threshold of hearing is known to improve by about 3 dB for binaural versus monaural presentation to normal ears, resulting in a doubling of perceptual loudness and improved sensitivity to fine differences in the intensity and frequency domains. This latter effect is sometimes referred to as binaural redundancy, and it is believed that it may translate into improved speech perception scores. When listening to speech with only one ear in a difficult listening situation or with one ear with greater sensorineural hearing impairment than the other, there is a loss of the redundancy in cues across the ears that may reduce performance.

The benefit of the binaural redundancy aspect of bilateral inputs is typically tested by presenting speech alone or having speech and noise emanate from the same loudspeaker frontally - - when the second ear is added, benefit is possible through redundancies or overlaps in representation at the two ears. In a normal hearing ear, this effect produces about a 1 to 2 dB improvement in SNR (Bronkhorst & Plomp, 1988). At this time, there is only limited evidence for true binaural redundancy effects on speech perception results in the
bilateral cochlear implant literature reviewed herein. This effect is probably not stronger either because such subtle cues are not able to be utilized by ears that have severe to profound hearing loss, or simply because the signal processing available in today’s cochlear implants (with two implants processing independently) does not adequately maintain these interaural cues.

Binaural loudness summation has been shown to occur, however, and is a potential confounding factor in comparing across studies. While most researchers have adjusted the loudness of the implant processing for binaural presentation versus monaural presentation (and made sure loudness is reasonably balanced across the ears), some have not. In a clinical bilateral implant fitting, it would generally be presumed that loudness would be adjusted so that the patient’s overall loudness comfort level is reasonable, and thus any purely binaural summation effects would be reduced or negated for bilateral listening compared to a previous unilateral implant.

Binaural Squelch/Unmasking
A person with only one functioning ear can usually understand conversation well when listening in a quiet environment, as long as the sounds of speech are made loud enough. However, even a normal hearing person who is listening in high levels of background noise can find speech understanding to be difficult in an adverse listening situation (consider, for example, competing conversations with multiple persons seated at a long table in a very high noise level restaurant). This occurs partly because of direct masking and partly because of upward spread of masking on the basilar membrane of the cochlea (whereby low-frequency sounds have a greater impact on reducing perception of higher-frequency sounds than vice versa). Speech recognition in such noisy environments is even harder for a person with sensorineural hearing loss both because of the inherent distortion and loss of normal nonlinearities introduced by cochlear damage, and because these patients show even greater amounts of upward spread of masking effects than do normal ears.

Fortunately, the auditory nervous system is wired to help in noisy situations as long as there is functional input from both ears - - that is, the auditory system and brain can combine information from both ears so that there is a better central representation than would be had with only information from one ear (e.g. Zurek, 1993). This effect, commonly referred to as binaural squelch (but also sometimes called binaural unmasking), results from the brainstem nuclei processing timing, amplitude, and spectral differences between the ears to provide a clearer separation of the speech and noise signals. The squelch effect takes advantage of the spatial separation of the signal source and the noise source(s) and the differences in time and intensity that these create at each ear. This is generally tested with speech from a front speaker and noise from a side speaker - - when the second ear is added that is ipsilateral to (same side as) the noise source, any benefit comes from the binaural squelch effect. There is some limited evidence of improved speech understanding in noise in bilateral cochlear implant patients due to binaural squelch effects, although the effect is not seen across all bilateral implant users or studies, and is not as large as the head shadow effect.

Note that binaural summation and squelch are signs of the ability of the auditory nervous system to integrate, fuse, and use information from the two ears. In contrast, the head shadow effect merely results from the physical attenuation of sound across the head and does not require central nervous system integration - - This does not negate the fact, however, that the head shadow effect is a substantial factor in everyday performance for those listeners with unilateral versus bilateral devices.

Localization
Finally, perhaps the most well-known practical binaural benefit is the ability to localize (i.e. determine the direction that a sound is coming from). This function is dependent on auditory Bimodal Devices and Bilateral CIs, page 9 system perception of interaural (between ear) differences in time, intensity, and phase (e.g. Yost & Dye, 1997). Localization ability can be a safety consideration. For example, when crossing a busy street, it is important to know the direction that a car is coming from. Persons with significant unilateral hearing impairment can also attest to the frustration of hearing their name spoken but not knowing which direction to turn in order to find the person calling them.

Research to date has focused on localization of sound sources in the horizontal azimuth, but keep in mind that it is also possible for a listener to differentiate sound sources in the vertical plane (by elevation) and in terms of the distance from the listener. It is well known that interaural timing differences provide the information necessary to locate the direction of low frequency sounds - - specifically, those less than about 1500 Hz. For sounds that are higher in frequency, the main cue for horizontal plane localization is the interaural intensity difference that occurs because of the head shadow effect. In addition, head and pinna shadow effects,
pinna filtering effects, and torso absorption properties can all contribute to spectral differences that can be particularly helpful in determining elevation of a sound. For a listener with only one functional ear, there are very few cues to assist in sound localization although some rudimentary localization ability can still exist. The literature on bilateral cochlear implants provides significant and substantial evidence that localization abilities are enhanced with the use of both ears versus just one.

Update.... 3 years with sound...!!

Lotte is moving on fast, catching up every day.
Lately her sentences became longer, more clear. Discovered rhymes, and more and more singing. Putting on CD's by herself (as in her own choice) with songs and/or stories..
Also writing new words is getting more and more her attention. She can write all the names she knows, but that's just remembering the order of the characters. Now she starts to figure out how to write words she hears.
It's a great adventure.!!

She had her yearly checkup in Oslo where they checked her equipment and tested her for hearing, sound discrimination, sentences etc. Everything was excellent.!!
In order not to waist time (and attention from Lotte), they skipped most of the easy tests in order to move on quickly.
She's at 92% on the scale of hearing / understanding. Whatever it means, and however it is calculated, it shows she's doing great.
In a way, we know, but it's nice to get it "officially"..... (why is that so important.?)

She is using longer sentenses, understanding more and more of the world.
More able to explain her wishes, and, recently, more able to explain what happened during the day, or previous day.

Some days ago, we had friends visiting us that we hadn't seen for almost a year, and when these kind of visits happen, people are amazed about how well they can understand her now, compared to a year ago. For us, it's a confirmation that she improves. Sometimes, improvements are so slow (like with any child growing up) that we don't notice, and it takes "outsiders" to give a sort of reality-check.

Eerste Activation - Dag 2

Opnieuw de intensiteit opgeschroefd in twee keer vandaag. Na vanochtend geen reactie, maar vanmiddag kwamen er eindelijk een knipper-reflex bij harde geluidjes.
Jij amuseerde je kostelijk, absoluut niet onder de indruk of geschrokken. Een paar keer dat je verwonderd keek, en wat bedachtzaam.
Wat gebeurt er toch allemaal? Aan het einde van de middag ben je vreselijkmoe, wat timide en teruggetrokken.
Een aantal malen gedurende de dag kom je naar ons toe wanneer het spoeltje heeft losgelaten. We moeten je helpen om het weer terug te plaatsen. Dit is heel goed!!
Betekend dit dat je verschil merkt wanneer het geluid verdwijnt?
Volgens Ole moet je nu je eigen stem kunnen horen.
Vlak voor je gaat slapen: Knijp-Nijntje achter je rug geeft een reactie. Je draait je om en je ogen zoeken Nijntje..Wanneer je blik valt op Nijntje, zien we een tevreden glimlach.

Mous

Eerste Activation - Dag 1

Vandaag was je vroeg wakker, 06:16 uur. Dan duurt het lang als je moet wachten tot 10:00 uur. Eenmaal in de wachtkamer wilde je niet mee toen ze ons kwamen halen.
Je herkent het ziekenhuis, je bent hier eerder geweest en toen gebeurden er dingen die je niet zo leuk vond.
Op mamma's arm ga je huilend mee naar binnen. Dit verdwijnt echter snel wanneer er fantastisch speelgoed te voorschijn komt.
De electroden worden gecontroleerd en alles werkt goed. Als Ole begint met geluidspulsen ben je absoluut niet onder de indruk. Er heerst wat onenigheid tussen jou en ons over het feit dat je de magneetjes moet laten zittenop je hoofd.
De geluidspulsen zijn heel zwak om je niet te laten schrikken; op deze manier "sluipen" ze je hoofd binnen. Voor ons wat minder spectaculair dan we verwacht hadden, maar het feit dat je het niet oncomfortabel vindt is heel positief , wordt ons verzekerd.
Tussen nu en donderdag wordt het geluid heel langzaam opgevoerd.

Na ruim een uur geef je aan heel moe te worden, dan is het pauze voor de lunch.
NA een uurtje slapen zijn we weer terug bij Ole, en gaat het volume weer omhoog..

NB: je maakt nog veel dezelfde geluiden als voorheen, met dezelfde intensiteit. Dat betekend naar alle waarschijnlijkheid dat je je eigen stem niet hoort.

Audiograaf: Ole
Audiopedagoog: Tove

Eerste Activation - Vooravond

Aan de vooravond van Lottes "aankoppeling".
Wij wachten af in spanning, niet wetende wat te verwachten morgen. Mijn verwachtingen zijn ongewild toch wel heel hoog. Ongewild, want ik ben bang voor de teleurstelling.
Hoe ga je reageren, Lotte? Wat hangt er boven jouw hoofd? Zalig onwetend ben je vrolijk en "praatziek" als altijd.
Morgen zit er ineens iets in jouw hoofd. Wat doet dat met jouw? Blijf je dezelfde Lotte of brengt dit een verandering teweeg, en zo ja, in welk opzicht.?

Marieke

2004-09 (September ) - Testing

Fortunately, in october after all the tests confirming she was a good candidate.

Marieke took Lotte the first time to the Rikshospital in Oslo, where the CI-team arranged her to be checked. I joined the second time.
In addition we agreed to have a gene-test to see if there is any reason for Lotte to be deaf (Later, nothing was found..)

More info to be added.

2004-06 (June)

In June 2004 tests started to see if she was a candidate. And she was a good one.... Finally

2003-11 (November) CI procedure starts

In November 2003 the docter was "kind enough" to apply for a Cochlear Implant. A year lost! This could have been done when that child was diagnosed in the first time. Waiting lists were quite long at the time.
Had Lotte benefitted from the HA's then the application could have been stopped.

2003-07 (July) - ABR test

The official test was in july/august - an Auditory Brainstem Response (ABR) -test.

Not completely sure how to interpret the graphs..

(Below Lottes test)

  

But there the message was "profound deaf"....
Appearently / Strangely, the audiogram curve was opposite the "normal" curve for hearing loss.

Hearing aids (HA's) were fitted and programmed...

We don't recall her ever to have responded to sound, so she must have been deaf from birth. (Information regarding this can be found for example here.)

__________________________________________

ABR –Medische bevestiging

Voor de ABR moest Lotte onder narkose. Ze was te klein om zelf stil te zitten.
Ik ben met haar naar binnen gegaan in de operatiekamer zodat ze bij mij in slaap kon vallen.

Terwijl Lotte uit lag te slapen kregen wij het bericht van de arts. Die gaf aan dat ze een gehoorverlies had van 90% tot 95%. En dit van de specialist die na de eerste testen had gezegd – „maar ze hoort toch“ – Een bewijs van de belabberde kwaliteit van het test-systeem van het ziekenhuis.

Direct daarna hebben we gebarentaal-boekjes gekocht and zijn we ermee begonnen.

Het eerste woord dat we hebben opgezocht was „spaghetti“ en „pan“ want dat was de maaltijd.

  

First apointment with GP and "Specialist"

Making all these hard sounds, we decided to do some realt tests when she was sleeping.....
Nothing.... absolutely nothing....

Appointment with the doctor, with excellent help from some friends...

In february she got a hearingtest in the hospital which she passed without problems. The test was done by handheld items. Alarmclock, bel... No wonder she passed.... if you put something that makes sound on her left side, she'll look to the left... There's nothing wrong with her eyes!!