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Tot 10

Counting Down the ‘Tot 10’ Highlights of 2013

Smith, Joanna T. MS; Wolfe, Jace PhD

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doi: 10.1097/01.HJ.0000444133.71020.52
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Although the number 13 is often associated with bad luck and misfortune, the pediatric hearing healthcare field enjoyed many successes in 2013. This month's column celebrates some of the year's top advances.


Rene Gifford, PhD, and colleagues at Vanderbilt University released preliminary results from their work exploring the use of high-resolution 3-D CT scans to evaluate the position of cochlear implant (CI) electrode arrays and improve our ability to optimally program implant processors (IEEE Trans Neural Syst Rehabil Eng 2013;21[5]:820-829

Joanna T. Smith, MS

In short, this work can precisely identify the location of the electrode array—even pinpointing in which scala it resides and the distance from the electrode to the modiolus—and determine which electrodes possess a higher likelihood of undesirable interactions.

Jace Wolfe, PhD

By disabling electrodes that do not interact well together, the Vanderbilt team has observed substantial improvement in speech understanding and spectral resolution.

Although this work is in the earliest stages and has been conducted in adults, it potentially holds particular ramifications for young children who cannot report on the signal they receive from their implant.


We have long known that children with minimal and mild hearing loss are at risk for delays in language, academic, and social development. However, our field has been poorly equipped with tools to determine how to manage these children.

Marlene Bagatto, AuD, PhD, and Anne Marie Tharpe, PhD, have developed an excellent preliminary protocol to guide clinicians in the decision-making process for the care of children with lesser degrees of hearing loss.

Be on the lookout this year for more information on how we can use this protocol in our practices.


The cochlear implant world took a big step forward in the past year. Two major manufacturers commercially released in the United States cochlear implant sound processors whose technology surpasses that of the preceding CI generation by an order of magnitude.

Pediatric cochlear implant recipients are now able to enjoy wireless streaming, adaptive processing, digital noise reduction, interaural processing, etc.


Last year, the Joint Committee on Infant Hearing (JCIH) released a supplement to its 2007 position statement.

Quite a bit has changed over the past six years. Prior to 2007, one of our most pressing challenges was ensuring that infants universally received hearing screenings during the first month of life.

As a field, we have made amazing progress in that area, and we are now tackling the bigger challenges associated with providing adequate and timely care for children who do not pass the hearing screening.

The 2013 JCIH supplement addresses the obstacles we currently face and provides goals that will facilitate success.


The year 2013 also saw a big advance in our understanding of how we currently manage the care of children with moderate hearing loss.

The amazing teams at Boys Town National Research Hospital, the University of Iowa, and the University of North Carolina are beginning to crank out publications describing the findings of the multicenter Outcomes of Children with Hearing Loss study, funded by the National Institutes of Health–National Institute on Deafness and Other Communication Disorders (NIH–NIDCD). Their work holds many clinically relevant lessons.

For instance, analysis has suggested that these children tend to experience relatively poor outcomes when their aided Speech Intelligibility Index (SII) for conversational-level speech is lower than 0.65.

Also, we have learned that many of these children are using hearing aids with outputs that do not meet pediatric prescriptive targets (Ear Hear 2013;34[6]:701-710

With that in mind, it is not surprising to discover that the speech and language skills of many of these children lag behind those of their normal hearing counterparts.


Exciting progress was seen over the past year in the development and commercial provision of cochlear implant electrode arrays designed to minimize trauma to the cochlea and enhance the likelihood of preserving low-frequency residual hearing.

Researchers at the University of Iowa have begun to explore the use of these technologies in children. This work has considerable ramifications, as an atraumatic electrode may improve the possibility that children with cochlear implants benefit from inner-ear therapies developed years from now.

Also, hearing-preservation electrodes will likely provide better speech, language, and auditory outcomes for children who have considerable low-frequency hearing after CI surgery.


The provision of tele-hearing healthcare showed a marked increase over the past year. For example, clinicians in Canada have demonstrated the feasibility of conducting remote auditory brainstem response (ABR) assessment, and St. Joseph Institute for the Deaf has led a multicenter study examining the benefits and limitations of providing auditory verbal therapy via the Internet to children with hearing loss.

In addition, Anu Sharma, PhD, and Jim Grigsby, PhD, are coprincipal investigators on a U01 grant from the NIDCD to conduct a Phase 2 clinical trial on the Effectiveness of Therapy via Telemedicine Following Cochlear Implants.

Finally, manufacturers of hearing aids and cochlear implants are actively examining the utility of remote programming for these hearing technologies.


Digital, adaptive, wireless remote-microphone radio-frequency (RF) technology was released commercially in 2013. Research has shown that these systems provide better speech recognition in noise than their analog FM predecessors (HJ July 2013, pp. 24-26

Also, digital RF systems remove the burden of managing transmission channels—a welcome relief to pediatric audiologists around the world—and their transmission range is typically greater.

Adaptive digital radio frequency technologies should be considered essential for all children who have a hearing aid or cochlear implant.


The American Academy of Audiology (AAA) last published a protocol for fitting amplification in children a decade ago. Needless to say, hearing aids and our knowledge of fitting them in children are a tad different now.

The AAA Task Force on Pediatric Amplification did an excellent job updating the guideline, equipping pediatric audiologists with the contemporary knowledge required to fit modern hearing aids for children.


We are cheating a little bit with the entry in the number one spot.

The UK National Health Service (NHS) Newborn Hearing Screening Program published a guideline for ABR assessment in infants and young children in 2007. The latest revision,d.b2I of the document was released in 2013.

Although a good portion of the existing document was published six years ago, we still feel compelled to recognize the update as the most significant highlight in pediatric hearing healthcare for 2013.

For far too long, our field has been in need of a detailed publication describing not only how auditory brainstem response assessment should be conducted, but also how ABR waveforms should be analyzed. This document fills that void.

The guideline's protocol for ABR analysis is particularly relevant because, when the clinician follows it as indicated, the potential for making a significant mistake in auditory brainstem response assessment is virtually eliminated.

That wraps up our Tot 10 highlights in pediatric hearing healthcare for 2013. Here's hoping 2014 is filled with the same level of success and productivity.

© 2014 by Lippincott Williams & Wilkins, Inc.