Originalien
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DOI 10.1007/s00106-016-0297-5
© Springer Medizin Verlag Berlin 2017
Redaktion
W. Baumgartner, Wien
P. K. Plinkert, Heidelberg
M. Ptok, Hannover
C. Sittel, Stuttgart
N. Stasche, Kaiserslautern
B. Wollenberg, Lübeck
Introduction
Despite near-normal hearing levels in
one ear and the ability to understand
speech in quiet conditions, people with
single-sided deafness experience signifi-
cant impairment in many everyday situ-
ations. This becomes especially apparent
when speech signals reach the deaf ear in
the presence of background noise. Im-
paired hearing can lead to fatigue due
to the additional effort required to hear
and may influence psychosocial factors
such as self-esteem, self-confidence and
the feeling of security [3, 31]. Moreover,
the ability to localize sound is consider-
ably limited in patients with single-sided
deafness since binaural hearing is a pre-
requisite to spatial hearing ability [9, 14,
32].
Patients with single-sided deafness
can be rehabilitated with conventional
Contralateral Routing of Signals (CROS)
or BiCROS hearing aids, bone conduc-
tion devices (BCI) or cochlear implants
(CI).
Conventional (Bi)CROS hearing aids
conduct the acoustic signals either wire-
lessly or via cable and BCI via bone to
the inner ear of the better-hearing side.
Since the deaf ear is not rehabilitated
in using these therapy options, restora-
tion of binaural hearing is not possible.
Single-sided deafness (SSD) with near-
normal hearing on the contralateral side
is the extreme condition in asymmetric
The German version of this article can be found
under doi: 10.1007/s00106-016-0294-8.
S. Arndt · R. Laszig · A. Aschendorff · F. Hassepass · R. Beck · T. Wesarg
Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Freiburg,
Freiburg, Germany
Cochlear implant treatment of
patients with single-sided
deafness or asymmetric hearing
loss
hearing loss (AHL). In the case of asym-
metrical hearing loss, the better-hearing
ear also has hearing loss, up to a mod-
erate degree, and the difference between
the two ears is sufficiently large to fulfill
the criterion for asymmetry [7, 10].
Therapy of patients with single-sided
deafness with a CI was first described
in 2008 by Van de Heyning [26]. The
primary intention of the authors was
not, however, the rehabilitation of sin-
gle-sided deafness, but to treat intractable
tinnitus. The patients not only reported
a reduction or even total suppression of
their tinnitus, but also improved speech
comprehension in background noise and
improved localisation ability. As a con-
sequence, other researchers adopted CI
treatment as a therapy option for SSD pa-
tients and also reported successful out-
comes [1, 2, 5, 15, 26, 27]. To date,
only case series with smaller groups of
patients have been published, leaving re-
imbursement agencies still in doubt con-
cerning the success of this therapy option
[8, 13, 18, 25]. Similarly, with limited ev-
idence from earlier studies, treatment of
patients presenting with postlingual-ac-
quired deafness of long duration also re-
mained in question with the consequence
that duration of deafness was restricted
to a maximum of 10 years and cohorts
reported in studies are still small [14,
23]. With 28 SSD patients, the publica-
tion by Távora-Vieira et al. reports on the
largestpatientpopulationwithsignificant
improvement in speech comprehension
in background noise after CI treatment
[24]. To date, very few studies report
outcomes from comparison of the avail-
able treatment options in patients with
single-sided deafness, and the number
of subjects involved is relatively small [1,
2].
The comparative prospective study re-
ported here represents a single-centre
study of the clinical use of unilateral elec-
trical stimulation via a CI in a large group
of patients presenting with single-sided
deafness and their long-term outcomes.
The study also demonstrates for the first
time comparison of hearing treatment
options and outcomes, including BCI and
(Bi)CROS hearing aids in smaller sub-
groups of hearing impaired patients.
Materials and methods
The prospective clinical study presented
in this manuscript was conducted in com-
pliance with the Guidelines of the Dec-
laration of Helsinki (Washington, 2002)
and ISO 14155 governing clinical investi-
gation (“Clinical Testing of Medical Prod-
ucts in Humans – Good Clinical Prac-
tice”: Parts 1 and 2) and was approved by
the Ethics Commission of the University
of Freiburg.
A total of 85 adult patients (age >
18 years) with single-sided, postlingual-
acquired deafness, who had undergone
CI surgery since 2008 in our clinic, had
at least one year of experience with the
CI and fulfilled the audiometric inclu-
sion criteria, described below, were in-
cluded in the assessment. In addition,
subjectively inadequate hearing rehabil-
itation with conventional hearing aids
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 Originalien

Fig. 1 8 a Means and extremes of pure tone thresholds via air conduction in the better and poorer ears for 45 SSD patients.
b Means and extremes of pure tone thresholds via air conduction in the better and poorer ears for 40 AHL patients.AHL asym-
metric hearing loss, SSD single-sided deafness

was also an inclusion criterion. Eleven
patients reported in 2011 in this jour-
nal were also included [12]. The patients
were assigned to two groups with respect
to pure tone audiometric hearing levels
measured in the better-hearing ear. Pa-
tients with hearing loss ≤30 dB in the
frequencies 125, 250, 500, 1000, 2000,
3000 and 4000 Hz (up to 4 kHz) were
assigned to the group “single-sided deaf-
ness” (SSD). This SSD criterion applied to
45 patients of the collective cited above.
Patients with audiometric hearing loss
in the better-hearing ear of ≤60 dB to
4 kHz and >30 dB in at least one fre-
quency up to 4 kHz were assigned to the
“asymmetric hearing loss” (AHL) group.
Forty patients were assigned accordingly
to this group. In both subgroups, the
asymmetry criterion was set at an inter-
aural difference of ≥30 dB between the
PTA4 (pure tone average: mean of air-
conduction threshold at the frequencies
0.5, 1, 2 and 4 kHz) in the poorer ear and
the PTA4 of the better ear. In both the
SSD and the AHL groups, only patients
who presented with a mean air-conduc-
tion hearing loss of more than 80 dB for
the frequencies 0.1, 1, 2 and 4 kHz in the
poorer ear were included. The audio-
metric data of the two patient groups are
shown in . Fig. 1 and the demographic
data in . Table 1. We described the pre-
operative diagnostic measures in detail
in our article published in 2011 [2].

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Prior to determining candidacy for
CI surgery, an evaluation test phase was
conducted with a conventional CROS (in
SSD patients) or BiCROS hearing aid
(in AHL patients) and a bone-conduc-
tion implant (on a Softband or test rod).
The indication for bone-anchored hear-
ing systems is recommended by the re-
spective manufacturers for single-sided
deaf patients with a maximum hearing
loss of20 dB inthe better-hearing ear. Ac-
cording to manufacturers’ information,
these systems were indicated as a therapy
option only in our SSD patients. Due
to repeated demands from reimburse-
ment agencies to submit evidence with
BCI testing, the same evaluation protocol
was performed in the present study for
all AHL patients, who consented to the
additional test phase. Speech compre-
hension in background noise and sound
localisation ability were evaluated and
recorded for all patients, preoperatively
monaurally (i. e. in SSD patients without
hearing aid and in AHL patients with
hearing aid on the better-hearing ear as
available), and with the specific test de-
vice after optimization of the settings.
Additionally both evaluations were per-
formed post implant for the CI group in
the CI condition 12 months after initial
switch-on. The adjustments of the CI
speech processors and the test devices
((Bi)CROS hearing aids and BCI audio
processors) were made at our clinic us-
ing uniform procedures, independent of
the audiologist, based on recommenda-
tions by the manufacturer of the hearing
system. Optimisation of the settings was
made based onvarious hearing testresults
obtained with the hearing systems, such
as hearing threshold and speech com-
prehension, as well as feedback from the
patients. After the initial CI switch-on,
a series of 3-day rehabilitation sessions
were scheduled in our CI centre every
3 months, with appropriate technical ad-
justments, speech training, hearing exer-
cises and recommendations for hearing
training at home provided. AHL patients
were tested 12 months after initial CI fit-
ting in the bilateral condition with CI and
the individually adjusted hearing aid in
the better ear.
For audiological tests in noise, the
adaptive Oldenburger Sentence Test
(Satztest, OlSa) was used to determine
the speech reception threshold (SRT),
a fixed noise level of 65 dB SPL and
a starting speech level of 65 dB SPL
were applied [29, 30]. The SRT was de-
termined in 3 presentation conditions:
S0°N0°, S + 45°N – 45° and S – 45°N +
45°. Considering the patient’s better and
poorer ear, these conditions were indi-
vidually assigned with the presentation
configurations S0N0 (speech and noise
from the front), SnhNssd (speech from
the hearing side/noise from the deaf
side) and SssdNnh (speech from the
deaf side/noise from the hearing side)
[2].
Examination of localisation was made
with seven loudspeakers, arranged at an
angle interval of 30° in a semicircle at
the height of the patient’s head. The OlSa
sentences were used as stimuli for mea-
surement of localisation ability. Each lo-
calisation test consisted of 70 sentences
at sound levels of 59, 62, 65, 68 and 71 dB
SPL and a mean sound level of 65 dB SPL,
presented in random sequence from one
of the 7 loudspeakers.
For each patient and each condition,
the localisation ability was measured as
the angle error in degrees, that is, as the
mean angle distance between the presen-
tation loudspeaker and the loudspeaker
identified by the patient. The angle error
corresponding to chance correct identi-
fication of localisation for our study set-
up was 68.6° [1].
The standardized Speech, Spatial and
Quality of Hearing Scale (SSQ question-
naire, Version 3.1.2) [11] was used for
the subjective assessment of therapy with
a CI. The questionnaire consists of three
sections, in which the patient’s subjective
assessments of speech comprehension,
spatial hearing and quality of hearing are
rated for each of the 50 questions with
a score between 0 and 10. A higher score
corresponds to better subjective rating of
the condition in question. The subjective
assessment with the SSQ questionnaire
was recorded at the first preimplant ap-
pointment and 1 year after the initial CI
fitting.
Individual CI use by the patient was
recorded in hours/day at each fitting ses-
sion.
Abstract
HNO DOI 10.1007/s00106-016-0297-5
© Springer Medizin Verlag Berlin 2017
S. Arndt · R. Laszig · A. Aschendorff ·
F. Hassepass · R. Beck · T. Wesarg
Cochlear implant treatment of
patients with single-sided
deafness or asymmetric
hearing loss
Abstract
Background. The rehabilitation of patients
with single-sided deafness (SSD) or
asymmetric hearing loss can be achieved
with conventional (Bi)CROS hearing aids
((Bi)CROS-HA, (Bi)CROS), bone conduction
devices (BCI) or with cochlear implants (CI).
Unfortunately, only small case series have
been published on the treatment outcomes
in SSD patients after CI surgery and there are
only a few comparative studies evaluating
rehabilitation outcomes.
Objective. The aim of this study was to
provide evidence of successful treatment
of SSD and asymmetric hearing loss with
a CI compared to the untreated, monaural
hearing condition and the therapy options
of BCI and (Bi)CROS in a large number of
patients.
Materials and methods. In a single-centre
study, 45 patients with SSD and 40 patients
with asymmetric hearing loss were treated
with a CI after careful evaluation for CI
candidacy. Monaural speech comprehension
in noise and localisation ability were
examined with (Bi)CROS-HA and BCI devices
(on a test rod) both preoperatively and at
12 months after CI switch-on. At the same
intervals, subjective evaluation of hearing
ability was conducted using the Speech,
Spatial and Qualities of Hearing Scale (SSQ).
Results and discussion. This report presents
the first evidence of successful binaural
rehabilitation with CI in a relatively large
patient cohort and the advantages over
(Bi)CROS and BCI in smaller subgroups, thus
confirming the indication for CI treatment.
Moreover, patients with long-term acquired
deafness (>10 years) show a benefit from the
CI comparable to that observed in patients
with shorter-term deafness.
Keywords
Rehabilitation · Hearing aids · Implantable
neurostimulators · Bone conduction ·
Unilateral hearing loss
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 Originalien
Table 1 Demographic data for 45 SSD patients and 40 AHL patients
Female
Male
Age at implantation (years): median (min–max)
Duration of deafness (months): median (min–max)
Duration of deafness ≥120 months (min–max)
Implant
Cochlear
CI24RE(CA); CI512; CI422
MED-EL
CONCERTO FLEX 28;
SYNCHRONY FLEX 28
Advanced Bionics
HiRes90k HiFocus MS
AHL asymmetric hearing loss, SSD single-sided deafness
Statistical analysis
Data analysis was made using the
statistics program Gnu R Version 3.3.0
(R Foundation for Statistical Comput-
ing, Vienna, Austria). For each of the
two patient groups (AHL and SSD), the
various hearing/treatment conditions
(preoperative untreated, preoperative
with (Bi)CROS-HA, preoperative with
BCI and postoperative with CI after
12 months) were compared with respect
to each of the measured audiomet-
ric and subjective parameters (speech
comprehension threshold in three pre-
sentation conditions, three SSQ scores)
using ANOVA. Tukey’s Honest Signif-
icant Difference test was used for the
post hoc analysis. The Wilcoxon sign
rank test with Holm’s correction for
multiple testing was applied for both
patient groups for comparison of the
various hearing/treatment conditions
with respect to localisation ability. In
both groups (SSD und AHL), the benefit
obtained by CI treatment compared to
the untreated condition was calculated
with respect to the speech comprehen-
sion threshold in the three conditions,
the localisation ability and the three SSQ
scores for patients with shorter duration
of deafness and for patients with longer
duration of deafness. All comparisons
were based on a significance level of
0.05. The package “pwr”, Version 1.1-
3 by Champely et al. was used to cal-
culate the power effect (https://github.
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SSD patients AHL patients
n = 27 n = 18
n = 18 n = 22
45.3 (22.5–68.3) 53.7 (21.8–71.2)
18 (1–408) 40 (4–480)
n = 4 (120–408) n = 11 (120–480)
16; 13; 8 12; 9; 10
7 5
1 1
– 3
com/heliosdrm/pwr). The assumptions
made here, especially for estimation of
the power effect, are based upon Cohen
[6].
Results
Due to the ceiling effect in sentence scores
observed when using the Hochmair–
Schulz–Moser (HSM) sentence test,
assessments after 2011 included the
Oldenburger Sentence Test (OlSa) for
testing speech comprehension in noise
instead of the HSM. As a result, speech
recognition data are available for only
20/45 SSD patients and 17/40 AHL pa-
tients for comparison test results for the
monaural preoperative condition with
the (Bi)CROS hearing aid, BCI and the
12 months post implant CI. The com-
parison of the monaural preoperative
condition with the CI at 12 months after
the initial fitting is shown for all patients.
Four SSD and 11 AHL patients had been
deaf for more than 10 years.
Monoaural vs. binaural speech
comprehension
Comparison of monaural vs. binaural
speech comprehension (SC) in noise
and the localisation ability of all SSD
and AHL patients. A detectable power
effect of 0.34 (AHL) and 0.32 (SSD)
was calculated assuming the usual error
values (α = 0.05 and β = 0.15) and the
group size of 40 (AHL) and 45 (SSD).
This corresponds to the estimated mean
effect power using the Cohen method.
The results of speech comprehension
in the OlSa and the localisation abil-
ity of the 45 SSD and 40 AHL patients
in the preoperative monaural condition
and after 12 months of CI experience
in the 3 presentation configurations are
shown in . Fig. 2. Significant improve-
ments in speech comprehension could
be confirmed in both groups after 12-
month experience with the CI in the
configuration SssdNnh compared to the
preoperative condition (SSD group: p <
0.001, AHL group: p < 0.001). For the
constellation S0N0, there was significant
improvement in the SSD group, but only
a trend towards improvement in the AHL
group (SSD group: p < 0.01; AHL group:
p = 0.062). There was no difference in
speech comprehension in the SSD group
in the condition SnhNssd (p = 0.559),
whereas the AHL group profited signifi-
cantly (p < 0.05). With the CI, the patients
achieved significantly better localisation
ability compared to the preoperative con-
dition 12 months after initial fitting (SSD
group: p < 0.001; AHL group: p < 0.001).
Comparison of (Bi)CROS—BCI—CI
Comparison of monaural SC vs. SC with
(Bi)CROS and BCI vs. SC with CI in noise
and the localisation ability of SSD and
AHL patients (17/40 AHL, 20/45 SSD).
A detectable power effect of 0.44 (AHL)
or 0.40 (SSD) was calculated assuming
the usual error values (α = 0.05 and β =
0.15) and the group size of 17 (AHL)
and 20 (SSD). This corresponds to a high
power effect using the Cohen method.
The results of speech comprehension
and the localisation ability of 20 SSD
and 17 AHL patients in the monaural
condition and in the treated condition
with the 3 various therapy options are
presented in . Fig. 3.
SSD group
The SSD group consisted of 20 people.
The binaural SC with CI in the config-
uration SssdNnh was significantly supe-
rior to the monaural condition and to
the SC with either BCI or CROS (CI vs.
monaural and CI vs. BCI: p < 0.001; CI
vs. CROS: p = 0.0018). Moreover, with

the CROS-HA, significantly better SRT
could be demonstrated compared to the
monaural condition (p = 0.004). The re-
sults with the BCI showed no significantly
improved values in this condition com-
pared to the monaural condition (p =
0.062) or in the comparison CROS vs.
BCI (p = 0.755).
In the configuration S0N0, there was
significant improvement in SRT with the
CI compared to the monaural condition
and to CROS (CI vs. monaural: p =
0.0024347 → p < 0.01 and CI vs. CROS:
p = 0.0010357 → p < 0.01). No significant
improvement was seen in the comparison
of CI and BCI (p = 0.084) or in compari-
Fig. 2 9 Whisker box
plots of speech compre-
hension thresholds in
noise assessed with the
OlSa for 3 presentation
configurations in the hear-
ing conditions monaural
preoperative and post
implant binaural with CI
at 12 months after initial
CI fitting (a SSD patients
(n = 45); b AHL patients
(n = 40)). c Whisker box
plots of the angle error for
48 SSD and 40 AHL patients
in monaural preoperative
and postimplant with CI
at 12 months after initial
CI fitting. AHL asymmetric
hearing loss; CI cochlear
implant; OlSa Oldenburg
sentence test; SSD sin-
gle-sided deafness; S0N0
speech and noise from the
front; SnhNssd speech from
the hearing side/noise
from the deaf side; SssdNnh
speech from the deaf side/
noise from the hearing side
son of BCI with the monaural condition
(p = 0.584).
In the easiest test configuration for
single-sided deaf patients (SnhNssd), sig-
nificantly better SRT was demonstrated
with the CI compared to the CROS and
BCI (CI vs. BCI: p = 0.0160; CI vs.
CROS: p < 0.001). The SRT values did
not differ significantly between the CI and
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monaural hearing conditions (p = 0.461).
The SRT with BCI was significantly bet-
ter than with CROS (p = 0.0084). In
the monaural condition, there was sig-
nificant improvement in SRT compared
to the CROS (p < 0.001) but no signifi-
cantly better SRT compared to the BCI
(p = 0.389).
Localisation ability was significantly
better at 12 months postimplant with the
CI than in the monaural condition or with
the BCI test device (CI vs. monaural p =
0.037; CI vs. BCI p = 0.029). There were
no statistically significant differences be-
tween outcomes for CI and CROS-HA
or the monaural and CROS or BCI con-
ditions.
AHL group
The AHL group consisted of 17 people.
In the most difficult test configuration
for single-sided deaf patients (SssdNnh),
binaural SC with the CI is superior to
monaural SC in the AHL patients (p =
0.0033). The SRT with the BiCROS was
found to be significantly better than the
monaural hearing condition (p = 0.0065).
The SRT in the other modalities showed
no significant differences.
Nosignificantdifferences inSRT could
be determined among the four hearing
conditions in the presentation of speech
and noise from the front (S0N0).
Consistent with results for the SSD pa-
tients, the SRT with the CI in the presen-
tation configuration SnhNssd was signif-
icantly better than that achieved in any of
the other conditions: SRT (CI vs. monau-
ral: p = 0.013, CI vs. BCI: p = 0.045, CI vs.
BiCROS: p < 0.001). No significant dif-
Fig. 3 9 Whisker box plots of speech compre-
hension scores in noise assessed with the OlSa
for 3 presentation configurations in the hearing
conditions: monaural, with (Bi)CROS-HA or BCI
and postimplant binaural with CI at 12 months
after initial CI fitting (a SSD patients (n = 20);
b AHL patients (n = 17)). c Whisker box plots
of the angle error for 21 SSD and 17 AHL pa-
tients in the hearing conditions: monaural, with
(Bi)CROS or BCI and postimplant binaural with
CI at 12 months after initial CI fitting.AHL asym-
metric hearing loss; CI cochlear implant; OlSa
Oldenburg sentence test; SSD single-sided deaf-
ness; (Bi)CROS (bilateral) contralateral routing
of signals; BCI bone conduction devices; S0N0
speechandnoise from the front; SnhNssdspeech
from the hearing side/noise from the deaf side;
SssdNnh speech from the deaf side/noise from
the hearing side
ferences were noted between SRT values
in the other test conditions.
The localisation ability with the CI
after 12 months was significantly better
than the monaural hearing condition and
in comparison with use of the BiCROS
(CI vs. monaural p = 0.009, CI vs. Bi-
CROS p = 0.039). No difference in locali-
sation ability was demonstrable between
CI and BCI, the monaural condition and
BiCROS or BCI or also between BiCROS
and BCI.
Benefit of CI in speech
comprehension
Comparison of benefit of the CI in
speech comprehension in noise and
sound localisation in AHL and SSD pa-
tients with shorter and longer duration
of deafness. The benefit measured with
the HSM Sentence Test in the individ-
ual loudspeaker configurations and the
change in localisation ability due to CI
treatment did not depend significantly
on the duration of deafness in the SSD
patients (SssdNnh: p = 0.0527; S0N0:
p = 0.0527; SnhNssd: p = 0.742; locali-
sation: p = 0.81). For the AHL patients,
significant influence of the duration of
deafness was observed only in the test
condition SssdNnh (p = 0.0173). No
influence of the duration of deafness
was found in the other test conditions
(S0N0: p = 0.1028, SnhNssd: p = 0.3712,
localisation: p = 0.43).
Speech discrimination of the SSD and
AHL patients in quiet. After 12 months
postimplant, the SSD group achieved
Freiburger monosyllabic word discrim-
ination scores in quiet of 48 ± 25%
(mean ± standard deviation) at a pre-
sentation level of 65 dB SPL. The AHL
group achieved comparable speech com-
prehension word scores of 41 ± 26%.
Device usage for SSD and AHL patients.
SSD patients wore the CI on average 9 h
per day (min. 3–max. 19 h). Device use
was comparable for the AHL patients, on
average 10 h per day (min. 4–max. 18 h).
Questionnaire survey
Subjective assessment of hearing abil-
ity—Speech, Spatial and Quality of
Hearing Scale (SSQ). Repeated subjective
measures via completed questionnaires
filled out preoperatively, representing the
monaural condition and at 12 months
postimplant CI, representing the bilateral
listening condition (i. e. everyday con-
dition) were available for analysis from
36 SSD patients and 13 AHL patients.
The results of the three subcategories of
the SSQ questionnaires for the patient
groups are shown in . Fig. 4.
SSD group
The SSD group consisted of 36 people.
Subjective assessment of speech compre-
hension with the CI postimplant showed,
on average, a significantly better result
than in the preoperative monaural con-
dition (p < 0.001). The patients also rated
spatial hearing ability with the CI as sig-
nificantly better (p < 0.001). No signifi-
cant difference was observed for subjec-
tive assessment of sound quality between
the monaural and binaural hearing con-
dition.
AHL group
The AHL group consisted of 13 people.
Both speech comprehension and spatial
hearing were rated by AHL patients as sig-
nificantly better in the binaural hearing
condition with the CI than in the preoper-
ative monaural condition (speech com-
prehension: p < 0.001; spatial hearing:
p < 0.001). No significant difference was
observed in assessment of sound quality.
Discussion
Since the first description by Van de
Heyning et al., many authors have shown
that hearing performance achieved with
a CI is superior to the monaural condi-
tioninpatients with single-sided deafness
who have undergone thorough preoper-
ative audiological diagnostics and patient
selection [1, 2, 5, 8, 13, 15, 17, 25–27].
Application of CI in patients with single-
sided deafness has not been limited to
patients with contralateral normal hear-
ing (single-sided deafness, SSD). Van de
Heyning et al. also described patients
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Fig. 4 8 Whiskerboxplots ofscores forsubcategories speech, spatial hearingandhearingqualityinthe SSQ assessmentscale;
a SSD patients (n = 36); b AHL patients (n = 13).AHL asymmetric hearing loss; CI cochlear implant; SSD single-sided deafness
within their cohorts who presented with
moderate deafness in the contralateral
ear [26]. In such cases the asymmetry
of the hearing loss configuration could
be offset for speech comprehension in
noise and spatial hearing by the use of
a hearing aid in the contralateral ear in
combination with a CI in the implanted
ear [7, 26, 27].
Speech comprehension
Of relevance for the success of treatment
of AHL patients is not the achievement of
identical scores with the CI compared to
that achieved for SSD patients, but rather
the comparison of performance with the
CI over monaural hearing. For this rea-
son, we divided our study patients into
two groups, SSD and AHL, even before
the indication for cochlear implantation
was clinically defined. For consistency
across the increasing number of publica-
tions on the topic of asymmetric hearing
loss, we suggested a clinical definition of
SSD and AHL at the AHL Symposium
in 2012 in Berlin, and later published in
2015 by Boyd [4, 28].
Given the relatively large number of
patients in both the SSD and AHL groups,
our results confirm significantly better
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speech comprehension in noise with the
CI after 12 months compared to pre-
operative monaural hearing. This result
was shown in the presentation configu-
ration SssdNnh in both groups. In the
S0N0 test configuration, the SSD group
demonstrated significantly better speech
comprehension and a trend for better re-
sults was observed in the AHL group. In
addition, the AHL group demonstrated
significant benefits from the CI in the test
configuration SnhNssd. Thus, a clear ad-
vantage with the CI over no treatment
can be demonstrated by these results in
both groups.
The lack of change in speech compre-
hension in the presentation configuration
SnhNssd in the SSD group is considered
a positive result. It shows that when noise
is presented to the CI-treated ear, it does
not impair speech comprehension in the
better-hearing ear. The results published
by Arndt et al. [1, 2] have now been con-
firmed in a considerably larger number
of patients. Contrary to the data pub-
lished in 2011, a significant advantage
can be demonstrated with the CI when
both speech and noise are presented from
the front. Távora-Viera et al. also report
a significantimprovementinspeechcom-
prehension in noise with a CI for this
presentation configuration [24]. Other
authors have also described the benefits
of CI, especially with respect to over-
coming the head shadow effect and in
the S0N0 condition [1, 2, 8, 13, 14, 18,
25–27].
Localisation ability
In the present study, the localisation abil-
ity also improved 12 months after CI
surgery with a reduction of the angle er-
ror of 13.5° for the AHL patients and 22.7°
for the SSD patients. This corresponds
to the consistent results in the literature,
which show significant improvement in
directional hearing with CI, but with con-
siderably smaller patient cohorts [1, 2, 5,
7, 13, 15, 33].
Thus, in SSD patients, it appears that
binaural integration of stimuli from the
electrically stimulated CI ear and from
the acoustically/physiologically stimu-
lated normal-hearing ear is possible and
very successful. However, evaluation of
binaural integration remains difficult.
The evidence for improved localisation
ability in single-sided deaf patients, as
well as the occurrence of the summa-
tion effect when using the CI, leads to
the assumption that, in these patients,
binaural processing of the peripheral
stimulation response of the acoustically
stimulated normal-hearing ear and the
deaf ear electrically stimulated by CI
takes place in the auditory brain stem.
Comparison with conventional
care
The indications for cochlear implanta-
tion in single-sided deafness also include
educating patients about the alternative
therapy options, their advantages and
disadvantages. We also tested the alter-
native treatment methods (conventional
treatment with (Bi)CROS-HA and with
BCI) to obtain the most reliable infor-
mation possible with respect to the re-
sults with these treatment alternatives.
The comparative results are compelling.
In the SSD group, the speech compre-
hension results with the CI in all three
presentation configurations were signif-
icantly superior to results obtained with
the CROS or with BCI. No essential dif-
ference could be determined in speech
comprehension in noise with the CROS-
HA versus the BCI. Significantly better
results with the BCI than with the CROS
could only be observed in the condition
SnhNssd. This result can be attributed
to the applied test method. In hearing
tests with the BCI, the BCI was used
on a Softband, simulating transcutaneous
coupling, which can yield a sound atten-
uation of up to 10–15 dB compared to
percutaneous coupling. This reduction
in transmission cannot be adequately off-
set by adjustments [12]. This means that
noise is damped in the SnhNssd condi-
tion and, thus, speech comprehension in
the better ear is less negatively influenced
by the BCI.
As expected, the localisation results
with the CI are significantly better com-
pared both to the monaural condition
and with the BCI. The literature con-
tains several discussions on this topic and
recognises that localisation of sounds is
only possible with binaural hearing [2,
9, 14, 17–21, 24, 31, 32].
Similarly positive results can be re-
ported for the AHL group in this study.
In the configuration SnhNssd, the re-
sults of speech comprehension with the
CI were significantly superior to both
the BiCROS and the BCI. No outstand-
ing advantage of either system, BiCROS
or BCI, over the other was apparent.
For localisation, significant advantages
of the CI were found compared to the
monaural condition and the BiCROS. On
the other hand, no difference could be
demonstrated between CI and BCI or
between BCI and BiCROS. In the pre-
sentation configuration SnhNssd, speech
comprehension with the (Bi)CROS-HA
and BCI test device is poorer than with
CI or a monaural condition since the
head shadow effect is circumvented. The
(Bi)CROS-HA and the BCI test device
each transmit noise largely undamped
(SSD) or even augmented (AHL) to the
contralateral hearing ear, thus worsen-
ing the signal–noise ratio of the speech
presented in noise to that ear.
Limitations
One weakness of these therapy-option
comparisons is the small number of pa-
tients resulting from the switch to speech
comprehension tests in noise undertaken
inourclinic. Since we were able toachieve
comparable results with the HSM test
in our study published in 2011, it can
be assumed that analogous results were
achieved in using the same test for the
patients in the current study [1].
In general, publications on the use of
(Bi)CROS hearing aids in single-sided
deaf patients report limited benefit and
low acceptance due to a number of factors
including social stigmatization, occlu-
sion of the good ear and poor tone quality
[16, 19, 20]. In an extensive survey arti-
cle, Peters et al. report on the available
comparison studies with (Bi)CROS hear-
ing aids and BCI in single-sided deafness.
In addition to very inhomogeneous re-
sults due to different study designs, no
general advantage could be demonstrated
for one type of device over the others.
The authors also found only improved
responsiveness from the deaf side asso-
ciated with overcoming the head shadow,
and no improvement in localisation abil-
ity due to the absence of bilateral input
[20].
Duration of deafness
In our pilot study, we initially limited the
indication criterion for CI treatment of
single-sided deaf patients to a duration of
deafness of maximum 10 years in order to
show that binaural rehabilitation with the
CI is possible and successful [2]. Single
case reports or case series had already
reported success in single-sided, long-
term deaf patients [15, 23]. The publi-
cation with the largest number of long-
term deaf patients (n = 5) with a duration
of deafness between 27 and 40 years was
published by Távora-Vieira et al. [23].
They were able to demonstrate both an
objective improvement in the hearing of
patients in three different speech–noise
configurations and a significant subjec-
tive improvement based on the SSQ cat-
egories. In addition to intensive modi-
fied rehabilitation programs, the patient’s
motivation was shown to be definitely de-
cisive in our study.
We also investigated the influence of
the duration of deafness on speech com-
prehension and localisation ability after
CI surgery. In the SSD patients, no in-
fluence of the duration of deafness could
be determined. In the AHL patients, the
analysis revealed a significant influence
of the duration of deafness in the pre-
sentation configuration SssdNnh. Our
results show that early CI treatment of
the near-deaf or deaf ear should thus be
the goal, especially in patients with hear-
ing loss on the contralateral side (AHL
patients). Moreover, the present posi-
tive results should motivate professionals
and the reimbursement agencies to pro-
vide a CI to patients, even those with ac-
quired, long-term deafness, if appropri-
ate pretherapy diagnostic outcomes are
positive [15, 23].
Subjective rating
Not only are the objective audiological
data important in demonstrating the suc-
cess of CI treatment in single-sided deaf
patients, but also a patient’s subjective
rating and device usage behaviour (wear
time/day). The SSQ questionnaire return
rate after 12 months experience with the
CI was 75% in the SSD group and 42.5%
in the AHL group.
HNO
 Originalien
The SSD patients rated their hearing
with the CI as significantly better than
in the preoperative condition in the cat-
egories of speech and spatial hearing but
not with respect to sound quality. Thus,
we obtained results analogous to those
published earlier by Vermeire et al. and
Arndt et al. [1, 2, 26]. Although the rat-
ing of hearing quality with the CI did not
differ from the rating at baseline, it does
emphasize that acoustic hearing with the
normal-hearing side and “electric” hear-
ing with the CI is possible without nega-
tive influence upon sound quality for bi-
lateral hearing [2]. In contrast, Távora-
Vieira et al. showed a significant im-
provement after CI rehabilitation in all
three categories, including sound quality
[23].
The group of AHL patients likewise
rated CI treatment as significantly better
than at baseline in the categories speech
and spatial hearing, but no difference was
recorded for sound quality. Overall, the
reported scores were lower than those of
the SSD patients, both pre- and postop-
eratively. The improvement in quality of
life after CI surgery in 20 single-sided
deaf patients was recently described by
Rösli et al. They used questionnaires that
addressed the hearing handicap and the
increase in quality of life after CI surgery
[22].
CI daily use
All of the patients we have presented here
use the CI daily (3–19 h), which is also
proof of the success of this treatment.
The indication criteria for SSD and AHL
patients, the minimum requirements for
hearing tests and the recommended ques-
tionnaires were defined in a recently pub-
lished summary of a Round Table held
during the AHL Symposium in Toulouse
in 2014 [26]. It was pointed out that the
success of rehabilitation or the binaural
benefit can be demonstrated especially by
improved localisation ability. Moreover,
due to the lack of SSD-specific question-
naires, the SSQ Scale was recommended
for subjective rating of CI treatment and
the Health Utilities Index Mark 3 (HUI3)
for rating quality of life. Recording CI
wearing time is a very important crite-
HNO
rion that describes the benefit patients
receive from CI treatment.
Future
The present study is the first to verify in
a considerably large number of patients,
45 SSD and 40 AHL, the subjective lim-
itations experienced due to single-sided
hearing loss, the success of binaural re-
habilitation with CI treatment and, in
20 SSD and 17 AHL patients, the supe-
riority of CI treatment over alternative
therapies with(Bi)CROS hearing aids and
BCI. These findings thus confirm the in-
dications for CI intervention. Both the
audiometric data and the subjective re-
sults of the questionnaires and patient’s
device usage behaviour support this state-
ment. Moreover, based on our data, it can
now be demonstrated that the duration of
deafness in SSD patients has no negative
influence on the results after CI surgery.
Patients with additional hearing loss in
the better-hearing ear should receive CI
treatment for the deaf ear early on in
order to obtain the best possible benefit
from the CI for speech comprehension.
Practical conclusions
4 Cochlear implant treatment is a pos-
sibility for rehabilitation of binaural
hearing in adult patients with single-
sided deafness.
4 Cochlear implant treatment is sig-
nificantly superior to the alternative
therapy options (CROS-/BiCROS and
BCI) in speech comprehension in
noise and in sound localisation.
4 In adults with acquired deafness and
appropriate, supporting pretherapy
diagnostics, CI treatment is indicated
independent of the duration of
deafness.
Corresponding address
Prof. Dr. S. Arndt
Department of Otorhinolaryngology, Head
and Neck Surgery, University Medical Center
Freiburg
Killianstraße 5, 79106 Freiburg, Germany
susan.arndt@uniklinik-freiburg.de
Compliance with ethical
guidelines
Conflict of interest. S. Arndt received travelling
expenses from Advanced Bionics, Stäfa, Switzerland;
financial support for research and travelling expenses
from Cochlear Ltd, Australia; financial support for
research and travelling expenses from Med-El, Inns-
bruck, Austria and travelling expenses from Oticon,
Copenhagen, Denmark.
R. Laszig received financial support for research and
travelling expenses from Advanced Bionics, Stäfa,
Switzerland; financial support for research, travelling
expenses and consultancy fees from Cochlear Ltd,
Australia; travelling expenses from Oticon, Copen-
hagen, Denmark; financial support for research from
Med-El, Innsbruck, Austria; financial support for re-
search and travelling expenses from ARRIAG Munich,
Germany; travelling expenses from Otologics Boul-
der, USA; travelling expenses from Sonova Holding,
Stäfa, Switzerland; financial support for research from
TKIH, Freiburg, Germany; travelling expenses from the
General Secretary of the German HNO Society; con-
tract fees, consultancy fees and travelling costs from
Medupdate and fees from Springer Medicine EiC.
A. Aschendorff received travelling expenses, Medical
advisory board and financial support for research from
AdvancedBionics, Stäfa, Switzerland; financialsupport
for research and travelling expenses from Cochlear Ltd,
Australia; financial support for research and travelling
expenses from Med-El, Innsbruck, Austria; travelling
expenses and financial support for research from
Oticon, Copenhagen, Denmark.
F. Hassepass received travelling expenses from Ad-
vanced Bionics, Stäfa, Switzerland and Cochlear Ltd,
Australia.
R. Beck received travelling expenses from Cochlear Ltd,
Australia.
T. Wesarg received consultancy fees, financial support
for research and travelling expenses from Advanced
Bionics, Stäfa, Switzerland; consultancy fees, finan-
cial support for research and travelling expenses
from Med-El, Innsbruck, Austria; financial support
for research and travelling expenses from Phonak
Communications, Murten, Switzerland.
This article does not contain any studies with human
participants or animals performed by any of the au-
thors.
The supplement containing this article is not spon-
sored by industry.
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