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Original articles
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https://doi.org/10.1007/s00106-019-0705-8
© Springer Medizin Verlag GmbH, ein Teil von
Springer Nature 2019
Introduction
Single-sided deafness (SSD) is an ex-
treme case with functional deafness in
the poorer ear and regular hearing in the
healthy ear. Acquired SSD is a challenge
for these patients because they lose their
binaural hearing and the ability to localize
sound sources, which has consequences
for their daily lives and their commu-
nicative skills [7, 12, 20, 21, 25]. For
a long time, SSD has been treated with
contralateral routing of signal (CROS)
or bone-conduction devices which can
provide some acoustic clues and improve
hearing-related quality of life, but the lo-
calization of sound sources and speech-
in-noise hearing abilities are limited as
shown in earlier studies [27, 34]. There-
fore in 2016, Van de Heyning et al. [35]
published a testing framework for the in-
vestigation of speech perception, local-
ization hearing, tinnitus handicap and
a comparison with biCROS and bone-
anchored hearing devices in SSD and
asymmetric hearing loss (AHL) patients.
The testing framework is supposed to be
administered in several cochlear implant
(CI) centers around the world to harmo-
The German version of this article can be
found under https://doi.org/10.1007/s00106-
019-0706-7.
S. M. Häußler1 · S. Knopke1 · S. Dudka1 · S. Gräbel1 · M. C. Ketterer2 · R.-D. Battmer3 ·
A. Ernst3 · H. Olze1
1
Department of Otorhinolaryngology, Head and Neck Surgery, Charité—University Medical Center Berlin,
Campus Virchow-Klinikum, Berlin, Germany
2
Department of Otorhinolaryngology, Medical Center, Faculty of Medicine, University of Freiburg,
Freiburg, Germany
3
Department of Otorhinolaryngology, Unfallkrankenhaus Berlin, Berlin, Germany
Improvement in tinnitus distress,
health-related quality of life and
psychological comorbidities by
cochlear implantation in single-
sided deaf patients
nize the data concerning these special
patient groups.
There are already some studies that
have shown the benefit of CI for SSD
patients. They gain a profound improve-
ment in spatial hearing, a reduction in
tinnitus distress and a long-term subjec-
tive benefit [3, 14].
Before CI was introduced as a reha-
bilitation strategy in SSD, hearing-assis-
tive devices had frequently been used.
Gardell et al. [11] reported that 70% of
the bone-anchored hearing aid (BAHA)
users with SSD appreciated and actively
used the system despite the fact that the
Abbreviated Profile of Hearing Aid Ben-
efit (APHAB) results clearly showed that
“the device (is) . . . insufficiently helpful
in challenging listening situations”.
In a direct comparison of CI recip-
ients with SSD who had prior osseoin-
tegrated devices, the sound localization
and patient satisfaction were shown to be
superior with CI [9]. Apart from these
audiological results, CI in SSD was as-
sociated with a greater improvement in
hearing-related quality of life compared
to hearing-assistive devices as shown in
a systematic review [21].
This effect is well known from bi-
laterally implanted patients with respect
to their quality of life and psychological
well-being [29]. Recently, we have shown
that in addition to improved hearing abil-
ity and speech understanding, bilaterally
deaf patients report tinnitus suppression,
stress reduction, and an increase in their
health-related quality of life following CI.
In addition, a significant inverse correla-
tion was found between tinnitus-related
distress and health-related quality of life
(HRQoL). Furthermore, anxiety and de-
pression symptoms decreased and coping
strategies improved in these patients after
CI.
Therefore, the aim of this study was
to evaluate the levels of tinnitus, psycho-
logical comorbidities, coping strategies
and HRQoL in patients with SSD be-
fore and after implantation. In addition,
we aimed to characterize the association
between tinnitus impairment and audio-
logical parameters measured in the situ-
ation before and after CI using validated
questionnaires.
Patients and methods
The study was performed at the Depart-
ments of Otorhinolaryngology of Char-
ité-Universitätsmedizin Berlin and Un-
fallkrankenhaus Berlin (UKB) over a pe-
riod of 3 years (2011–2014). Twenty adult
patients with acquired unilateral deafness
were enrolled in the study, which was
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Original articles

Table 1 Validated questionnaires applied in this study approved by the local Ethics Committee
Nijmegen The NCIQ is a validated tool designed to determine the health-related qual- (appl. no.: EA2/030/13).
Cochlear Implant ity of life of implanted patients. There are six subdomains: The major inclusion criteria were an
Questionnaire 1: basic sound perception, intact auditory nerve and an open cochlea
(NCIQ) 2: advanced sound perception,
suitable for implantation. Further inclu-
3: speech production,
4: self-esteem, sion criteria were
5: activity, 4 Hearing on the better ear limited to
6: social interactions. pure-tone average
The score ranges from 0 (very bad) to 100 (optimal) j with a maximum 30 dB hearing
SF-36 The non-disease specific, generic 36-item Short Form Survey (SF-36) consists level (HL) in air conduction
of 36 items with 8 subcategories. The scores are coded and transformed into j a minimum word score of 80% in
a scale that ranges from 0 to 100 (0: worst self-perceived health and 100:
best self-perceived health). The subdomains are summarized in a physical
the Freiburg word test
summary score and a mental summary score j at 70 dB sound pressure level (SPL).
Tinnitus Question- The TQ includes 52 items and assesses the grade of tinnitus-related distress 4 Postlingual deafness on the poorer
naire (TQ) on four severity levels: ear
– low (1–30 points), j with speech perception of ≤40%
– moderate (31–46 points), using the Freiburg monosyllable
– severe (47–59 points) or test
– very severe (60–84 points).
j at 65 dB SPL.
There are 6 subcategories. 4 Preoperative testing with a CROS
– E: emotional distress,
hearing aid
– C: cognitive distress,
– E + C: combined psychological distress, j with insufficient benefit.
– I: Intrusiveness,
– A: auditory perceptual difficulties, Retrospectively, there were 4 patients
– SI: sleeping disturbances, who postoperatively had a pure-tone
– SO: somatic complaints
threshold of 30–45 dB at one frequency
and a total score (0–84) in the better hearing ear.
Perceived Stress To determine the level of stress perceived by the patients, we used the PSQ. Before surgery, all patients gave their
Questionnaire It comprises 30 items measuring four subscales: informed, written consent to participate
(PSQ) – worries,
in the study.
– tension,
– joy, The patients were asked to complete
– demands. all the questionnaires in the Charité test
The subscale “joy” is recoded in the total score. The split-half reliability is in battery (. Table 1) before and after im-
the range from 0.80–0.88 plantation. Twenty patients (7 male and
COPE (Brief-COPE) Coping strategies were evaluated by the Brief-COPE questionnaire (COPE), 13 female) completed the surveys. The
which comprises 28 questions with 14 subcategories. The subcategories are mean age at the time of implantation was
summarized in 4 domains: 56.9 ± 17.3 years (range 21.0–80.0 years).
– evasive coping (EC), The mean duration of deafness before
– seeking support (SS),
implantation was 4.8 ± 7.7 years (range
– focus on positive (FP), and
– active coping (AC) 0.3–26.9 years). The meantime post-CI at
General Depres- Depressive symptoms were measured by the General Depression Scale
the moment of completing the question-
sion Scale (ADS) (ADS), which includes 20 items. The total score ranges between 0 and 60, naire was 1.5 ± 0.9 years (range 0.6–3.2).
whereby the cut-off value for depressive symptoms is 23 All patients received a multichannel im-
Generalized Anx- The GAD-7 is a screening instrument that is used to assess the severity of plant and a postoperative x-ray was taken
iety Disorder generalized anxiety disorders on a 7-point scale to verify successful intracochlear elec-
(GAD-7) trode insertion. The most commonly
Oldenburg Inven- The OI evaluates subjective hearing ability and includes a total score in used type was the CI24RE (Cochlear, Syd-
tory (OI) 3 categories: ney Australia; n = 9), followed by a CI512
– hearing in quiet,
(Cochlear, Sydney Australia; n = 7) and
– hearing with background noise and
– localization Concerto (MED-EL, Innsbruck, Austria;
n = 4).

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 Abstract
HNO https://doi.org/10.1007/s00106-019-0705-8
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019
S. M. Häußler · S. Knopke · S. Dudka · S. Gräbel · M. C. Ketterer · R.-D. Battmer · A. Ernst · H. Olze
Improvement in tinnitus distress, health-related quality of life and psychological comorbidities by
cochlear implantation in single-sided deaf patients
Abstract
Background. Patients with single-sided
deafness (SSD) lack the ability localize sound
sources and have difficulty with speech-in-
noise hearing. In addition, there is a high
prevalence of tinnitus distress. These problems
may result in reduced health-related quality of
life (HRQoL) and psychological comorbidities.
This study aimed to investigate the influence
of treatment with a cochlear implant (CI)
on HRQoL, tinnitus distress, psychological
comorbidities, and audiological parameters in
SSD patients.
Methods. This retrospective study included
20 patients with postlingually acquired SSD
(13 women, 7 men, mean age 57.0 years).
Data on HRQoL were collected with the
Nijmegen Cochlear Implant Questionnaire
Nijmegen Cochlear Implant
Questionnaire
The Nijmegen Cochlear Implant Ques-
tionnaire (NCIQ) is a disease-spe-
cific, validated questionnaire measuring
HRQoL, which was designed by Hin-
derink et al. and published in 2000
[17]. The NCIQ was translated into
German by native German and English
speakers using forward–backward trans-
lation. The NCIQ covers three general
domains with six specified subdomains
(. Table 1). Since its validation, the
NCIQ has been used as a standard test
to evaluate HRQoL in patients with
cochlear implants.
Medical Outcomes Study 36 Short
Form Health Survey
The Medical Outcomes Study36-Item Short
Form Health Survey (SF 36) is a nondis-
ease-specific, generic HRQoL instru-
ment [16]. A physical component sum-
mary score and a mental component
summary score can be computed using
the standardized scoring system.
(NCIQ) and the Medical Outcome Study Short
Form 36 Survey (SF-36). Tinnitus distress was
assessed with the Tinnitus Questionnaire (TQ),
psychological comorbidities were evaluated
with validated questionnaires, and speech
perception and hearing ability were measured
with validated speech tests.
Results. Postoperatively, the mean total
NCIQ score (p < 0.0001) and four subscores
improved significantly, as did tinnitus distress
(p < 0.05). Anxiety symptoms (Generalized
Anxiety Disorder questionnaire, GAD-7)
decreased significantly after CI. Speech
perception improved significantly, particularly
“hearing with background noise” (p < 0.05,
Oldenburg Inventory, OI) and “localization”
(p < 0.001, OI), as well as the Oldenburg
Tinnitus Questionnaire
The Tinnitus Questionnaire (QT) of
Goebel and Hiller [13] is a well-val-
idated questionnaire and is used to
evaluate tinnitus distress. There are four
tinnitus severity levels determined by
the total score: low (0–30), moderate
(31–46), severe (47–59), or very severe
(60–84).
Perceived Stress Questionnaire
To determine the level of stress perceived
by the patients, we used the Perceived
Stress Questionnaire (PSQ). According
to Fliege et al. [10, 26], the cut-off score
for a low level of perceived stress is 0.45
using the PSQ.
Brief-COPE Questionnaire
The Brief-COPE questionnaire (COPE)
[8] evaluates coping strategies, which are
summarized in four domains: evasive
coping (EC), seeking support (SS), focus
on positive (FP), and active coping (AC).
Sentence Test (OlSa) scores for with vs. without
CI when speech was presented from the SSD
side and noise was presented from the normal
hearing side (SSSDNNH; p < 0.005).
Conclusion. CI in SSD patients is a powerful
procedure to improve HRQoL, reduce
tinnitus distress, and improve psychological
comorbidities. Additionally, it is beneficial for
hearing improvement, particularly in noise
and for directional hearing.
Keywords
Cochlear implant · Unilateral hearing loss ·
Correction of hearing impairment · Anxiety ·
Speech perception
General depression scale
Depression can be a primary disorder
or comorbidity. Hearing handicap and
chronic tinnitus can be associated with
depressive symptoms such as anxiety or
emotions such as helplessness. For our
study, we have chosen the long version of
the general depression scale (Allgemeine
Depressions Skala, ADS) by Hautzinger
and Bailer (1993) [15]. The total score
ranges between 0 and 60 and scores
greater than 23 indicate a depressive
pathology.
Generalized Anxiety Disorder
Questionnaire
The Generalized Anxiety Disorder Ques-
tionnaire (GAD-7) [32] was designed
as a screening instrument for gener-
alized anxiety disorders and to assess
their severity, and it has high reliabil-
ity and validity in clinical practice and
research [32]. The 7-item scale asks
patients whether and how often, during
the 2 weeks before the examination, they
were bothered by the 7 core symptoms of
generalized anxiety disorder. Response
options are “not at all” (0 points), “sev-
eral days” (1 point), “more than half
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 Original articles
Fig. 1 8 Preoperative and postoperative Nijmegen Cochlear Implant Questionnaire (NCIQ) scores.
Asterisks indicate significant changes. NCIQ 1 Basic sound perception, NCIQ 2 Advanced sound percep-
tion, NCIQ 3 Speech production, NCIQ 4 Self-esteem, NCIQ 5 Activity limitations, NCIQ6 Social interac-
tions
the days” (2 points), and “nearly every
day” (3 points). The total score ranges
between 0 and 21 with the GAD-7 score
ranges of 5–9 (mild), 10–14 (moderate)
and 15–21 (severe) anxiety symptom
levels [22].
Speech perception
Data on speech perception (monosylla-
ble and sentence tests) were obtained to
compare performance for the unaided
and the CI-aided conditions. For each
patient, the measures were assessed be-
fore and after implantation. Postopera-
tively, hearing was tested at 1.5 ± 0.9 years
(range 0.6–3.2 years) after surgery.
Pure Tone Audiometry/Freiburg
monosyllable test
Preoperatively, the Pure Tone Average
(PTA) and the Freiburg monosyllable test
were recorded. After CI, speech percep-
tion was measured using the Freiburg
monosyllable test in a quiet environment
(65 dB SPL).
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Oldenburg sentence test
Speech perception in noise was evaluated
after surgery using the Oldenburg sen-
tence test (OLSA) [24]. The background
noise was presented to subjects at 65 dB
SPL, and the speech level of each sentence
was adjusted depending on the response
to each test item, to obtain the signal-to-
noise ratio (SNR) at which the percent-
age correct word score is 50% (critical
SNR).
Three presentation set-ups S0°N0°/
S–45°N + 45°/S + 45°N–45° were used
for testing speech perception in back-
ground noise. On the hearing-impaired
ear, these presentation set-ups were the
configurations S0N0 (speech and noise
from the front), SNHNSSD (speech from
the normal hearing side/noise from the
deaf side), and SSSDNNH (speech from the
deaf side/noise from the normal hearing
side).
Oldenburg Inventory
The Oldenburg Inventory (OI) was used
to quantitatively evaluate the subjective
hearing after CI [18]. The OI that was
used contains 12 closed questions on
different hearing situations. The re-
sponse choices (“always”, “often”, “rare”,
“sometimes” and “never”) are evaluated
by scores from 1 to 5. The test result is
obtained by adding the scores in each
domain (hearing in quiet, hearing with
background noise and localization).
Statistical analyses
The changes in patient scores were tested
for significance using the nonparametric
Wilcoxon matched pairs test because the
data were not distributed normally (Kol-
mogorov–Smirnov test). The relation-
ship between hearing ability and scores
from the questionnaires was tested using
Spearman’s correlation test. The results
in the text are shown as mean ± standard
deviation in the text. Plots show the
mean ± standard error of the mean. Sig-
nificance was set at p < 0.05. Statisti-
cal analysis was performed and graphs
were constructed using SPSS software
(SPSS Statistics for Windows, Version
24.0., IBM Corp., Armonk, NY, USA).
Results
This retrospective study was conducted
at the Departments of Otorhinolaryn-
gology of Unfallkrankenhaus Berlin and
Charité—Universitätsmedizin Berlin,
Germany.
We included 20 postlingually deaf-
ened patients (13 women, 7 men) in this
study who were implanted with a mul-
tichannel cochlear implant by Cochlear
(n = 16) or MED-EL (n = 4). Surgery was
performed between 2010 and 2012. The
mean age of the patients was 57.0 ± 17.3
(range 21.5–80.6) years. Mean duration
of deafness was 4.8 ± 7.7 (range 0.3–26.9)
years (. Table 2).
The postoperative evaluation was con-
ducted 1.5 ± 0.9 (range 0.5–3.3) years af-
ter surgery.
 Table 2 General patient characteristics Decreased tinnitus-related distress
Characteristic Number
Patients (n) 20 Seventeen of 20 patients (85%) reported
– Male 7
tinnitus before implantation. After im-
plantation, for the implant on situation,
– Female 13
tinnitus decreased in 12 patients, 3 of
Patient age, mean ± SD (range), years 57.0 ± 17.3 (22–81)
them reported complete disappearance
Duration of deafness, mean ± SD (range), years 4.8 ± 7.7 (0.3–26.9) of tinnitus. However, 4 patients had an
Speech perception: Freiburg Monosyllable Test preoperatively, mean ± SD 2.7 ± 6.4 (0–20) increase in tinnitus distress and 1 patient
(range), %
reported no change. In the 3 patients
SD standard deviation who were tinnitus-free before surgery,
implantation did not induce tinnitus
Table 3 Patients characteristics (. Table 3).
Pa- Age Sex Duration Freiburg Freiburg TQ TQ Daily
The mean total score preoperatively
tient of deaf- monosyllable monosyllable total total wearing with the TQ was 25.2 ± 18.7 (range 1–61)
ness test preop test postop preop postop time (h) and this improved significantly after CI
(years) (%) (%) and with the implant turned on to a mean
1 71.0 m 1.1 0 65 41 47 16 score of 17.3 ± 18.1 (range 0–54). There
2 44.6 m 0.4 0 70 8 10 9 was also a statistically significant im-
3 80.6 f 2.9 0 35 32 0 15 provement in the subdomains Emotional
4 55.2 f 1.9 20 60 10 0 10 distress (TFE), Intrusiveness (TFI) and
Auditory perceptual difficulties (TFA)
5 59.4 f 4.8 0 15 25 32 10
(. Fig. 2).
6 70.3 m 3.0 0 20 16 19 6
Tinnitus severity was not correlated
7 64.2 m 25.3 0 70 0 0 16 with duration of deafness or patients’ age.
8 58.1 f 1.9 15 30 22 14 16 Furthermore, no correlations were found
9 62.1 f 4.1 0 68 56 6 8 between tinnitus-related distress and au-
10 63.5 m 2.0 0 45 0 0 16 ditory performance measured with the
11 57.1 m 1.1 0 60 24 12 12 Freiburg monosyllable testand the OLSA.
12 38.0 f 2.2 0 65 33 13 14 In contrast, the grade of tinnitus-
13 67.8 m 1.1 0 48 1 1 12 related distress measured with TQ cor-
14 24.6 f 0.3 0 25 61 54 16
related negatively with HRQoL in all
subdomains apart from the TQ subdo-
15 72.7 f 0.5 0 50 0 0 6
mains Sleeping disturbances and Somatic
16 50.0 f 1.3 0 85 55 53 6
complaints and the NCIQ subdomain
17 77.2 f 0.8 18 60 19 14 8 Advanced sound perception (. Tables 4
18 72.4 f 1.6 0 65 14 10 8 and 5).
19 29.0 f 26.9 0 10 2 0 14 There was a statistically significant
20 21.5 f 12.0 0 20 10 9 12 correlation between the preoperative
TQ Tinnitus Questionnaire, m male, f female scores of the TQ (subdomains Auditory
perceptual difficulties and TQ Total)
and the SF36 psychological subdomain
Better health-related quality of life Improved general quality of life (p < 0.05). Preoperatively, there were fur-
ther correlations between psychological
Cochlear implantation resulted in a sta- Following cochlear implantation, the comorbidities and TQ scores (p < 0.05)
tistically significant increase in the health subscale vitality of the SF-36 increased as follows:
related quality of life (HRQoL), as mea- from 55.5 ± 22.7 before CI to 64.0 ± 19.3 4 TQ (subdomains Sleeping distur-
sured by the NCIQ (. Fig. 1). The mean after CI (p < 0.05). However, the scores bance and Somatic complaints) and
total score of this study population for all other domains remained un- the GAD-7 score for generalized
was 63.3 ± 13.8 before CI surgery and changed. anxiety,
increased to 73.8 ± 10.7 after implanta- There were no correlations between 4 TQ (subdomains Intrusiveness and
tion (p < 0.0001). Also, the individual duration of deafness or patients’ age and Somatic complaints) and the ADS-L
scores from subdomains measuring basic the NCIQ and SF-36 scores following CI. score for depressive symptoms,
(NCIQ1) and advanced sound percep- 4 TQ (subdomain Intrusiveness) and
tion (NCIQ2), self-esteem (NCIQ4) and the PSQ (Tension and Total).
activity (NCIQ5) improved significantly.

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 Original articles
Fig. 2 8 Preoperative and postoperative Tinnitus Questionnaire (TQ) scores. Asterisks indicate signif-
icant changes. TFE Emotional distress, TFC Cognitive distress, TFEC combined psychological distress,
TFI Intrusiveness, TFA Auditory perceptual difficulties, TFSI Sleeping disturbances, TFSO Somatic com-
plaints
Low stress level
Using the Perceived Stress Questionnaire
(PSQ), perceived stress scores were low
before (0.31 ± 0.23) and after (0.29 ± 0.22)
CI and there was no significant change.
There were also no significant changes
concerning coping strategies (COPE
questionnaire).
Decrease in anxiety symptoms
Anxiety symptoms (GAD-7 scores) de-
creased significantly from 5.2 ± 4.0 to
3.8 ± 3.9 (p < 0.05).
Psychological comorbidities did not
correlate with the duration of deafness
or patients’ age.
Improved auditory performance
Preoperatively, the mean percentage
score in the Freiburg monosyllable test
at 65 dB SPL was 2.7 ± 6.5% (range
0.0–20.0%; . Table 6). Postoperatively,
the mean percentage score improved
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significantly to 48.3 ± 22.5% (range
10.0–85.0%; p < 0.001).
Measured with the Oldenburg sen-
tence test (OLSA), speech perception for
the configuration SSSDNNH (speech from
the deaf side/noise from the normal
hearing side) with the CI (mean score:
–1.8 dB) significantly improved com-
pared to the unaided situation (mean
score: 0.43 dB; p < 0.005). Thus, the
mean advantage from the head shadow
effect was 2.2 dB. There were no statis-
tically significant differences in speech
perception for the presentation config-
uration S0N0 (speech and noise from
the front, unaided mean score: –3.7 dB,
aided mean score: –4.0 dB; summation
effect 0.3 dB) and SNHNSSD (speech from
the normal hearing side/noise from the
deaf side, unaided mean score: –11.9 dB,
aided mean score: –11.6; squelch effect
–0.3 dB).
There were improvements in the sub-
jective assessment of auditory ability
measured with the OI after implanta-
tion: hearing in noise’ (p < 0.05) and
sound localization (p < 0.001).
There were no correlations between
duration of deafness or age and auditory
performance after CI.
Discussion
In the present study, we have demon-
strated that cochlear implantation in
SSD patients improves anxiety and re-
duces tinnitus-related distress. In ad-
dition, HRQoL improved after surgery,
especially in regard to social and psy-
chological aspects of life. Moreover
their speech perception in background
noise and sound localization improved
significantly.
A negative aspect of this study is the
retrospective study design, which can
cause a recall bias. Therefore a prospec-
tive evaluation is in progress. Another
negative aspect is the point in time
of the postoperative evaluation, which
is heterogeneous (1.5 ± 0.9 years, range
0.6–3.2, post-CI). But as the meantime of
the postoperative follow-up is 1.5 years,
the hearing rehabilitation program has
been finished by then by most of our
patients and therefore presumably many
of them have reached their best hearing
level. For the prospective evaluation we
plan to do a follow-up at a standardized
point of time.
Positive aspects of this study are
the usage of reliable and well-evaluated
questionnaires as well as audiometry and
the representative number of patients.
The positive outcome for the patients
included in this study is confirmed by
their daily usage of the CI with a mean
time of 11.5 ± 3.7 h.
Health-related quality of life
This study demonstrates that CI of SSD
patients results in a significant increase
in HRQoL, positively affecting not only
sound perception but also the social and
psychological aspects. In addition, SSD
patients reported increased vitality, as
measured by the generic QoL question-
naire SF-36. The results of this study
corroborate previous results obtained in
CI studies with bilaterally deaf patients.
Bilateral implantation resulted in an in-
 Table 4 Correlation between tinnitus distress and health-related quality of life (HRQoL) before Health Utilities Index 3 (HUI3), which is
cochlear implantation (CI) a measure of general health status. They
NCIQ 1 NCIQ 2 NCIQ 3 NCIQ 4 NCIQ 5 NCIQ 6 NCIQ reported a significant postoperative in-
total crease in the total score compared to the
TQ E Correlation –0.057 –0.300 –0.178 0.749 –0.657 –0.534 –0.683 pre-implant condition with either con-
Coefficient tralateral routing of signals (CROS) or
Significance 0.038* 0.243 0.494 0.001 0.004 0.027 0.003 bone conduction device (BCD).
n 17 17 17 17 17 17 17
TQ C Correlation –0.543 –0.301 –0.216 –0.654 –0.621 –0.422 –0.672 Tinnitus
Coefficient
Significance 0.024* 0.240 0.405 0.004 0.008 0.092 0.003 The initial intention of CI in SSD patients
n 17 17 17 17 17 17 17 was not the restoration of hearing but the
TQ EC Correlation –0.567 –0.382 –0.231 –0.778 –0.716 –0.597 –0.760 treatment of tinnitus. Van de Heyning
Coefficient et al. [36], Vermeire and Van de Heyning
Significance 0.018* 0.130 0.372 0.000** 0.001** 0.011* 0.000** [37] and, in Germany, Arndt et al. [2]
n 17 17 17 17 17 17 17 published the first studies about cochlear
TQ I Correlation –0.640 –0.463 –0.678 –0.674 –0.562 –0.608 –0.825
implantation as an option to treat tinnitus
Coefficient in SSD. In 2012, Arts et al. [4] reviewed
Significance 0.006** 0.061 0.003** 0.003** 0.019* 0.010** 0.000** the literature on cochlear implantation in
patients with SSD to investigate the effect
n 17 17 17 17 17 17 17
on tinnitus suppression. In our present
TQ A Correlation –0.463 –0.301 –0.261 –0.837 –0.622 –0.607 –0.710
Coefficient
work, 70% of patients reported a decrease
in tinnitus. These results are in line with
Significance 0.061 0.240 0.311 0.000** 0.008** 0.010** 0.001**
all the other studies on this topic, which
n 17 17 17 17 17 17 17
also affirm that the majority of implanted
TQ SI Correlation –0.519 –0.028 –0.048 –0.309 –0.331 –0.251 –0.365 SSD patients profit from this treatment
coefficient
by a reduction of tinnitus.
Significance 0.033 0.915 0.855 0.228 0.195 0.332 0.150
Several subjective scales were used to
n 17 17 17 17 17 17 17 assess tinnitus distress or tinnitus loud-
TQ SO Correlation –0.278 0.284 –0.220 –0.225 0.048 0.048 –0.154 ness and the studies included monitored
Coefficient tinnitus at different time points before
Significance 0.279 0.269 0.396 0.386 0.856 0.854 0.554 and after cochlear implantation. To date,
n 17 17 17 17 17 17 17 very few studies have used tinnitus-spe-
TQ Correlation –0.610 –0.296 –0.342 –0.766 –0.654 –0.562 –0.765 cific, validated questionnaires such as the
total Coefficient Tinnitus Questionnaire (TQ) or the Tin-
Significance 0.009** 0.250 0.179 0.000** 0.004** 0.019* 0.000** nitus Reaction Questionnaire (TRQ) to
n 17 17 17 17 17 17 17 evaluate the effects of cochlear implanta-
Subscales of Nijmegen Cochlear Implantation Questionnaire (NCIQ): 1: basic sound perception; tion on tinnitus distress [31, 36]. Távora-
2: advanced sound perception; 3: speech production; 4: self-esteem; 5: activity; and 6: social Vieira et al. [33] reported a reduction of
interactions tinnitus varying from 77 to 100%, using
Subscales of Tinnitus Questionnaire (TQ): E emotional distress; C cognitive distress E + C combined the TRQ. In their study, Van de Heyning
psychological distress, I intrusiveness, A auditory perception difficulties, SI sleep disturbances,
SO somatic complaints et al. [36] included 21 patients with severe
Spearman correlation, *p ≤ 0.05, **p ≤ 0.01 unilateral tinnitus affecting the deafened
side. One and two years after unilateral
cochlear implantation, a significant de-
crease in NCIQ score from 39.0 to 65.4 studies. In other studies, a diverse range crease in tinnitus loudness and tinnitus-
after the first implantation and finally, of questionnaires was used to determine related distress was noted. In the study
71.3 points after the second implanta- changes in the quality of life following by Punte et al. [31], 26 SSD patients with
tion. The HRQoL score measured after CI. One of these questionnaires is the severe tinnitus were included and there
bilateral implantation of bilaterally deaf Speech, Spatial, and Qualities of Hear- was a continuous decrease in the TQ
patients is therefore comparable with that ing (SSQ), which is divided into three score from 60 preoperatively to 49 one
of SSD patients after single-sided implan- subsections: speech, spatial, and quality month after CI surgery, and to 39.4 after
tation (total NCIQ score 73.8 ± 10.7) [29]. of hearing. The greatest improvement 6 months.
The present findings indicating that in quality of life was observed in the The mean preoperative TQ score in
CI is followed by a significant increase in “Speech” subsection [1, 2, 18, 36]. Arndt this study (25.2 ± 18.7) is much lower
HRQoL corroborates the results of other et al. [2] evaluated quality of life using the than the score of 58.5 ± 13.9 reported

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 Original articles

Table 5 Correlation between tinnitus distress and health-related quality of life (HRQoL) after [28] concluded that tinnitus distress also
cochlear implantation (CI) influences the hearing ability of the bet-
NCIQ 1 NCIQ 2 NCIQ 3 NCIQ 4 NCIQ 5 NCIQ 6 NCIQ ter hearing ear in patients with single-
total sided deafness.
TQ E Correlation –0.244 –0.490 –0.094 –0.122 –0.338 –0.415 –0.373 Knopke et al. [23] and Olze et al. [30]
Coefficient reported a lasting decrease in tinnitus-
Significance 0.346 0.046 * 0.721 0.641 0.185 0.98 0.141 related distress after CI in patients with
n 17 17 17 17 17 17 17 bilateral deafness.
TQ C Correlation –0.062 –0.378 –0.189 –0.090 –0.221 –0.230 –0.213
Coefficient Psychological comorbidities
Significance 0.812 0.135 0.467 0.731 0.393 0.374 0.413
n 17 17 17 17 17 17 17 Reports on the effect of CI on psy-
TQ EC Correlation –0.217 –0.493 –0.140 –0.134 –0.326 –0.355 –0.355 chological comorbidities and tinnitus-
Coefficient related distress are rare, even though the
Significance 0.402 0.044 0.591 0.608 0.202 0.162 0.162 measurement of HRQoL, distress fac-
n 17 17 17 17 17 17 17 tors, coping strategies and psychological
TQ I Correlation –0.254 –0.336 –0.053 –0.004 –0.256 –0.346 –0.266
comorbidities as well as tinnitus distress
Coefficient and tinnitus level and their correlations
Significance 0.326 0.187 0.839 0.989 0.304 0.174 0.301 appears to be a meaningful assessment
of the positive or negative effects of CI.
n 17 17 17 17 17 17 17
Using validated questionnaires, An-
TQ A Correlation –0.258 –0.357 –0.027 0.022 –0.214 –0.387 –0.282
Coefficient
dersson et al. [1] have retrospectively
examined cochlear implant users who
Significance 0.317 0.159 0.918 0.933 0.409 0.125 0.272
reported tinnitus post-CI. That study
n 17 17 17 17 17 17 17
demonstrated that, in 24.5% of patients,
TQ SI Correlation –0.053 –0.090 0.030 0.110 –0.014 –0.147 –0.043 tinnitus was related to hearing prob-
coefficient
lems, anxiety, and depression following
Significance 0.839 0.732 0.908 0.676 0.956 0.574 0.869
implantation. However, no preoperative
n 17 17 17 17 17 17 17 or disease-specific HRQoL data were
TQ SO Correlation –0.027 –0.036 0.155 0.155 0.006 –0.063 0.014 presented. To the best of our knowledge,
Coefficient no data are available for SSD patients
Significance 0.917 0.891 0.553 0.554 0.983 0.810 0.956 with regard to this topic.
n 17 17 17 17 17 17 17
TQ Correlation –0.246 –0.358 –0.057 –0.026 –0.278 –0.325 –0.292 Stress
total Coefficient
Significance 0.341 0.158 0.829 0.920 0.280 0.203 0.256 In contrast to bilaterally deaf patients,
n 17 17 17 17 17 17 17 only a few SSD patients have reported an
Subscales of Nijmegen Cochlear Implantation Questionnaire (NCIQ): 1: basic sound perception; elevated level of perceived stress and psy-
2: advanced sound perception; 3: speech production; 4: self-esteem; 5: activity; and 6: social chological comorbidities. In this study,
interactions the Perceived Stress Questionnaire (PSQ)
Subscales of Tinnitus Questionnaire (TQ): E emotional distress, C cognitive distress, E + C combined scores before CI (0.31 ± 0.23) were within
psychological distress, I intrusiveness, A auditory perception difficulties, SI sleep disturbances,
SO somatic complaints the range found in healthy adults as re-
Spearman correlation, *p ≤ 0.05, **p ≤ 0.01 ported by Fliege et al. [10]; following CI,
no further statistically significant reduc-
tion (0.29 ± 0.22) was seen. These results
by Van de Heyning et al. [36]. The sual analog scale, TQ, Tinnitus Handicap show that CI has not induced additional
reason for this discrepancy is that the Inventory, Tinnitus Diary), and the sam- stress in SSD patients during the hearing
inclusion criteria in the trial by van de ple sizes in other studies are small, the rehabilitation process. In a recently con-
Heyning et al. were single-sided deafness use of CI in SSD is generally associated ducted prospective study on this topic,
and a TQ score of more than 47 (tinnitus with suppression of tinnitus in the ma- we found an elevated stress level pre-
degree 3), whereas we did not set a thresh- jority of patients. Correlation analysis operatively. The prospective study is in
old on TQ score. In this study, the total revealed that the extent of tinnitus dis- progress.
TQ decreased significantly to a mean of tress after CI has a negative influence on
17.3 ± 18.1 following implantation. anxiety and HRQoL. Thus, tinnitus may
Although there are marked differences influence the outcome of cochlear im-
in the approaches to measure tinnitus (vi- plantation. In their study, Mertens et al.

HNO
 Table 6 Auditory results without and with cochlear implant (CI)
Results without CI
Freiburg Monosyllabic Test 2.73 ± 6.47
OLSA
S0N0 –3.68 ± 1.65
SNHNSSD –11.60 ± 2.08
SSSDNNH –1.76 ± 2.83
OI
Hearing in quiet 3.46 ± 0.93
Hearing in noise 2.46 ± 1.0
Directional hearing 1.95 ± 1.04
Total score 2.78 ± 0.88
OlSA Oldenburg sentence test, OI Oldenburg Inventory, S0N0 speech and noise from the front,
SNHNSSD speech from the normal hearing side/noise from the deaf side, SSSDNNH speech from the
deaf side/noise from the normal hearing side
*p ≤ 0.05
Anxiety
Preoperatively, depression and anxiety
scores in SSD patients were at a rela-
tively low level in this study, in contrast
to previous results in bilaterally deaf pa-
tients with elevated preoperative scores
for psychological comorbidities (stress,
depressive symptoms, anxiety).
Anxiety symptoms (GAD-7 scores)
decreased significantly from 5.2 ± 4.0
to 3.8 ± 3.9 post-implantation (p < 0.05).
On the one hand, SSD patients are not
as handicapped in daily life with re-
gard to hearing impairment, stress and
depressive symptoms as bilaterally deaf
patients and they are not recognized as
handicapped. On the other hand, SSD
patients are impaired, especially with
regard to directional hearing, hearing in
noise, HRQoL and anxiety compared to
normal hearing individuals.
These results might be influenced
by the retrospective study design and
thus by a recall bias. It is possible that
a prospective study design might re-
veal different preoperative scores with
regard to HRQoL, tinnitus and psycho-
logical comorbidities. Another notable
fact is the time range of postoperative
assessment (0.6–3.2 years postopera-
tively), which might have an effect on
the postoperative score.
Auditory performance
We noted the most significant improve-
ment in auditory performance when test-
Results with CI p-value
46.36 ± 22.79 0.0033*
–3.97 ± 1.47 0.1075
–11.9 ± 1.62 0.4769
0.43 ± 2.30 0.0020*
3.65 ± 1.16 0.1978
3.09 ± 1.01 0.0186*
3.26 ± 1.01 0.0002*
3.32 ± 1.10 0.1075
ing with the OLSA and presenting the
sound to the implanted side for the con-
figuration SSSDNNH (head shadow effect).
Our results generally corroborate those
of Arndt et al. [2] and Távora-Vieira
et al. [33], who both also demonstrated
that sound perception in noise improves
mainly in the SSSDNNH configuration.
Current studies report varying re-
sults of speech perception in noise after
cochlear implantation [5, 22]. However,
speech perception in noise can be mea-
sured using different methods, which
may affect the results. Vermeire and Van
de Heyning [37] found a positive effect
of CI in two subgroups. There was one
group with SSD, which gained significant
benefit from CI in the S0NSSD (speech
from front/noise from the SSD side)
configuration, and there was one group
with asymmetric hearing loss (hearing
aid on the contralateral side), which
experienced significant benefit in the
S0NSSD configuration and in the SSSDNNH
configuration.
Similar to our findings, Vermeire and
Van de Heyning [37] and Arndt et al. [2]
did not find significant differences when
using the S0N0 configuration. In contrast,
Jacob et al. [19] reported no changes in
signal-to-noise ratios between the CI-on
and CI-off conditions. Buechner et al.
[6] reported a significant improvement in
speech perception in noise in the SSSDNNH
configuration for three of five patients.
A further advantage of CI in SSD pa-
tients is the improvement they bring in
the ability to localize sound [22, 31].
In this study, the capability to localize
sound was evaluated using a subjective
assessment tool (OI). The scores for the
subscale “localization” increased signifi-
cantly compared to the status before CI.
Practical conclusion
4 Cochlear implantation (CI) in single-
sided deaf (SSD) patients is a powerful
intervention to improve HRQoL
including social and psychological
aspects.
4 This also reduces distress associated
with tinnitus and improves psycho-
logical comorbidities.
4 In addition, CI is beneficial for hearing
improvement, especially in noise, and
for directional hearing.
Corresponding address
S. M. Häußler, MD
Department of Otorhinolaryngology, Head and
Neck Surgery, Charité—University Medical
Center Berlin, Campus Virchow-Klinikum
Augustenburger Platz 1, 13353 Berlin, Germany
sophia-marie.haeussler@charite.de
Compliance with ethical
guidelines
Conflict of interest S. M. Häußler S. Knopke, S. Dudka,
S. Gräbel, M. C. Ketterer, R.-D. Battmer, A. Ernst and
H. Olze declare that they have no competing interests.
All procedures performed in studies involving hu-
man participants or on human tissue were in accor-
dance with the ethical standards of the institutional
and/or national research committee and with the
1975 Helsinki declaration and its later amendments or
comparable ethical standards. Informed consent was
obtained from all individual participants included in
the study.
The supplement containing this article is not spon-
sored by industry.
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