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Tuesday, June 30, 2015
Mobile a key ingredient in a Millennial's kitchen
There is one ingredient that is more important than most for Millennials who enter the kitchen to prepare a meal - mobile. According to a new study from Think With Google in association with mcgarrybowen and Kraft Foods more than half of Millennials head into the kitchen to cook armed with a mobile device. >>
Expert: The benefits to early EMV conversion
EMV isn't going away, and yet many physical and online retailers are loathe to convert their existing systems to the new. In just a few months the point will be moot and there will be new regulations that require EMV; one expert weighs in on the benefits retailers could see from conversion. >>
Top 3 tips to reduce customer churn
Reaching consumers has never been simpler than with online and social media efforts, but engaging those same consumers so that they become loyal buyers has never been harder. One expert offers his top 3 tips to reduce customer churn. >>
Report: Mobile costs, downloads down
The mobile space has ups and downs just like the rest of the online world. That is the word from Fiksu's new mobile report which shows both downloads and mobile marketing costs decreased in May. >>
Latest Facebook workforce diversity report disappoints
The latest information on diversity within Facebook's workforce is disappointing with white males continuing to make up the vast majority. >>
Study highlights differences in email behavior based on age, gender
A recent study of email use between age and gender reveals that the differences in the way men and women communicate verbally appear to be inherent in the way they use email. >>
How beacons can fail and how to prevent that failure
In store beacons can give shoppers access to coupons and discounts, offer product information or even pricing options. But, if they don't work correctly, beacons can do damage to your brand. Her are three common issues with beacons and how retailers can overcome the obstacles. >>
The triggers retailers must ID to increase revenue
By now we all know that when a consumer abandons a cart, savvy retailers will send a quick email to remind them of the items. But a cart abandonment email is only one trigger of many that retailers can tap into to increase revenue and deepen customer engagement. >>
367% rise in mobile video viewing since Q1 2013
As mobile becomes ever more an integral part of daily life, so does mobile video. According to a study from Ooyala, mobile views have doubled over the past year and now account for two-fifths of all video viewing. >>
Demandware: Mobile orders up 59% in Q1 2015
Demandware's Q1 2015 Shopping Index highlights the increasing role of mobile in driving orders and that the duration of digital shopping visits is falling. >>
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Enlarge Cover
Ballantine Books | Aug 24, 2011
| 176 Pages
Ballantine Books
| Sep 29, 1998
| 176 Pages
| 5-1/2 x 8-1/2
Ballantine Books
| Aug 24, 2011
| 176 Pages
Grace the Cat is not at all like me, as she is forever bent on mischief. But because I am an older and wiser cat, she looks to me for counsel, and so I have allowed Grace to prevail upon me to set down the story of my life as a housecat in the human world. . . .As the irrepressible Foudini M. Cat regales us with his adventures, an exciting story unfolds. After his valiant but frail mother leaves him in search for food and never returns, the starving kitten is taken, hissing and spitting, to a frightening room with cages and men in white coats. Facing the specter of eternal sleep, the homeless cat is adopted by a woman he later calls "Warm." ("All cats like to make up strange names for things.")From here Foudini enchants us with splendid tales of his unlikely but ultimately poignant friendship with Sam the Dog; their trips between Cold House in the city and Mouse House in the country; his mystical experiences with famous felines of the past; his near-death in a raging river that leads to a profound act of sacrifice; and his introduction to a silly young thing named Grace, which evolves into something completely unexpected.
"I came into the world like everything else that is born, willy-nilly." So the wise old housecat Foudini begins the delightful story of his life. It is the tale of his orphaned kittenhood; of how he was rescued, cowering and spitting and hissing, from a damp city basement and lured into the lives of the couple he came to call Warm and Pest ("All cats like to make up strange names for things" ). It is the story of how Warm and Pest became "his people" ("Human beings must be excellent mousers; they have such patience" ); of how he learned to tolerate and then to love "his" dog, Sam; and of his adventures at Cold House in the city and Mouse House in the country (he prefers Mouse House, for obvious reasons). With feline equanimity, he tells how he was saved from a racing, swollen river; of how he lost the most unlikely and dearest friend he had; and of how he gained a cat family of his own. And he regales us with news of the ghost cats who visit him in his dreams–the cats of Cleopatra and Freud among them–bringing him their ancient cat wisdom, which Foudini tries, none too successfully at first, to impart to Grace, the sleek and beautiful gray country cat new to the household. As Foudini sees it, Grace is desperately in need of his guidance, but being young and willful, she has other things on her mind . . . Yet even Grace comes to understand that Foudini M. Cat is well worth listening to. Warm and witty–and possessed of a surprisingly sophisticated narrative manner–Foudini is a cat with truly irrepressible, and irresistible, feline flair.From the Hardcover edition.
Susan Fromberg Schaeffer was born in Brooklyn and educated at the University of Chicago, where she received her Ph.D. in 1966. In addition to The Autobiography of Foudini M. Cat, she is the author of ten other novels and five… More about Susan Fromberg Schaeffer
Visit other sites on the Penguin Random House Network

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Ellen Carolyn Model
Courtney QuinnModel Female West Palm Beach, Florida, US
My Website: https://www.facebook.com/courtneyquinnmodelMy MM URL: http://www.modelmayhem.com/courtneyquinn
Mayhem # 878261
About Me
Experienced model based in West Palm Beach, FL. Willing to do TFP shoots if the project is beneficial to me.
Represented by Posche Models in Florida.
I don't log onto this site too often, so if you are interested in working together, my Facebook page is the best way to reach me: https://www.facebook.com/courtneyquinnmodel
You can find many more photos on my Instagram: @courtneyquinn
Published Work:
Ellements Magazine - May 2015
Visions Hair Salon in Wellington
Visions Salon website - http://vhsalon.com/featured_item/undone/
The House of Perna website - www.thehouseofperna.com
Cosmetic Solutions website - http://www.naturalskincare.com/
Vero Beach-Portfolio Magazine - March/April 2015
Daily Mail UK - Feb 2015 - http://www.dailymail.co.uk/femail/artic … tfits.html
Sun Sentinel - Jan 2015 - http://www.sun-sentinel.com/business/co … story.html
Ikon Magainze - November 2014
Ellen Carolyn Model
Betsy Lavin Model
Melinda Williams Model
Montana Pritchard Photo Photographer
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f the norm Photographer
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I'm passionate about practicing yoga, hiking up a variety of mountains, bouldering/rock climbing, camping, cooking for my friends, music, craft beer, traveling and discovering new people, places and experiences.
I'm looking for a woman who is strong but not afraid to be vulnerable. Someone I can adore and who adores me and is not afraid to show it. Simple, classy, elegant and a little rough around the edges. She should glow in a summer dress and be perfectly at home in jeans and a t-shirt too. You don't have to be Miss REI, but you shouldn't be afraid to get your boots dirty either. Be sweet, laugh out loud and not afraid of a future together.


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Related Searches: Wireless Printer, wireless portable printer, wireless printer new, wireless laser printer
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Canon PIXMA MG5522 Inkjet Wireless All-in-One Photo Printer:Canon PIXMA Wireless All-in-One Printer, MG5522 Key Features:Canon Inkjet All-in-One Printer Print Speed Black: Up to 12 ipm; Color: Up to 8 ipm1 month ago on ebay.com
can even share your home and work printers with anyone you choose1 month ago on ebay.com


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15672Re: started treatment today---Anne
Expand Messages
- Mar 3, 2005I did do the blood tests regular at the beginning of all of this, but
never saw the doc. I have been on Epogen almost the whole time for
anemia, and I have been off and on Neupogen for low white count. I
have had absolutely no problem with depression and only slight
nausea. I have lost a lot of my hair (no bald spots, but very thin)
and I have lost about 35 pounds (huge grin).
Yes, God has blessed me through this.
--- In email@example.com, AVansi7465@a... wrote:
> Tammie,
> You should be having labs done at least every two weeks........Gee
it's a
> good thing your not anemic, etc.
> Thank God you've weathered this okay.
> Anne
- << Previous post in topic Next post in topic >>


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USC Annenberg students were greeted by alumni at Viacom to kick off the inaugural Maymester program in New York City.
Read more
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USC Annenberg is now home to a newsroom that fully embraces the concept of media convergence. Here students are able to collaborate across media channels, produce quality news and communicate across multiple platforms.
Watch video
The Host and Editorial Director of the TED Radio Hour, Guy Raz, talks about the Third Space Project initiative created by the Annenberg School of Communications and Journalism at the University of Southern California.
Watch video
The 2014-2015 academic year was full of exciting news and momentous events. Explore the year at USC Annenberg in an interactive timeline.
View timeline
The USC Annenberg School for Communication and Journalism is an innovative, full-service school housed in a deeply networked university located in the heart of Los Angeles – the most diverse and global city in the United States and a celebrated center for media, entertainment and so much more.
Who We Are
The undergraduate degree programs at USC Annenberg emphasize hands-on experience in communication, journalism and public relations.
Public Relations
An evolving business environment means that today's professionals must be equipped to think on their feet with the right combination of intellectual knowledge and practical expertise. Are you prepared?
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We prepare our students for careers in academia, as well as in other endeavors that benefit from analytic and research skills and knowledge of communication processes and institutions. Rooted in the tradition of communication theory with an interdisciplinary focus, our Ph.D. program is one of the top programs in the country.
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At USC Annenberg you are part of a remarkable community, of faculty, students and staff who are curious, driven and passionate just like you. Numerous research centers, media outlets, student organizations, professional and international programs are sources of endless opportunity.
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Petri, Michala: 50th Birthday Concert With Kremerata Baltica - Albinoni, T. / Chen, Yi / Mozart, W.A. / Rota, N. / Vassiliev, A. / Vivaldi, A.
by Various Artists
Released: Apr 2009
Label: OUR Recordings
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40 years of experience
Video profile
40 years of experience
Video profile
11301 Wilshire Blvd
Los Angeles, CA 90073 Phone number & directions
11301 Wilshire Blvd
Los Angeles, CA 90073 Phone number & directions
License & Identifications
A medical license is required for a doctor to practice medicine in a particular state. Requirements vary by state but most require, at a minimum, post-graduate training in the doctor's specific specialty. An NPI number is a national identifier unique to an individual health care provider and is managed by the Center for Medicare & Medicaid Services (CMS).
Learn more about Dr. Stephen Marder:
View the full profile to get information on:
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Patient Reviews
Have you visited Dr. Marder? Share your experience.
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Specialties & Research
Dr. Stephen Marder, MD is board certified in Psychiatry.
- He has special expertise in 18 areas:
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Basal Ganglia Diseases
- Bipolar Disorder / Manic Depressive Disorder
- Cognition Disorders
- Depression
- Depressive Disorder
- Drug Abuse (Substance-Related Addiction Disorders)
- Drug-Induced Dyskinesia
- Insomnia
- Memory Disorders
- Mental Disorders
- Mood Disorders
- Psychomotor Agitation
- Psychopharmacology
- Psychotic Disorders
- Schizophrenia
- Sleep Disorders
- Weight Gain
Education & Awards
Dr. Marder graduated from State University of New York at Buffalo. He has 5 awards.
Dr. Marder has 8 hospital affiliations:
- UCLA Medical Center
- Santa Monica - UCLA Medical Center
- English
Home > Find a Psychiatrist > CA > Los Angeles Psychiatrists > Dr. Stephen Marder, MD
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- Additional Information
- Dr. Stephen Robert Marder MD is a male Psychiatrist, has 40 years of experience and practices in Psychiatry.
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- Dr. Stephen Marder has 2 office locations.
Dr. Stephen Marder practices Psychiatry near Los Angeles, CA.
See Los Angeles Psychiatrists.


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Xbox One
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1970 Chevrolet Chevelle SS 454 LS6 450hp, recent frame off restoration new wiring thru out black cherry paint silver stripes M22 4-speed transmission car... More
1965 Chevelle Malibu two door hardtop,just out of lengthy storage,needing a little bit of help,but the original 230 six runs whisper quiet,and is mated... More
JUST COMPLETES A SHOW QUALITY BODY OFF FRAME RESTORATION. UNDERSIDE IS DETAILED LIKE A MODEL CAR. FLOORS ARE PRIMERED & CLEAR COATED FRAME &... More
ONE VERY FUSSY OWNER FOR THE LAST 31 YEARS. THIS CAR HAS BEEN VERY CAREFULLY OWNED, LIKE A FAMILY MEMBER. ONE OF ONLY 3,321... More
BODY OFF FRAME RESTORED, #S MATCHING MOTOR, TRANS, REAR & COLOR. THIS CAR IS DETAILED TOP TO BOTTOM. CLEAN BLACK PAINTED FLOORS & FRAME.... More
BODY OFF FRAME SHOW QUALITY RESTORATION WITH GROUND POUNDING 468 BIG BLOCK ENGINE. ENTIRE DRIVETRAIN REBUILT WITH MANY PERFORMANCE UPGRADES. HAS NEW AIR CONDITIONING... More
1970 Chevrolet Chevelle Malibu 2 Door Sport Coupe If you are interested in this vehicle or have any questions, please contact Diane at 541-597-4904 White with black... More
One of only 3,307 '67 SS396 convertibles built! Fitted with power steering, power disc brakes, power top, console, buckets, bumper guards, Fisher seatbelts, AM/FM... More
True factory (U code) Super Sport, beautiful Cranberry red paint, black SS striping, black vinyl interior, matching numbers 402 ci engine, matching numbers Muncie... More
1966 Chevrolet Chevelle SS 396, Matching Numbers. This is the one you have been waiting for folks!Authentic, Fully Restored, Powerfully Optioned, CollectibleChevrolet described the... More
1969 Chevrolet Chevelle SS 396, Vin-136379G341592 Equipped with Bucket Seats, Horseshoe Shifter, Power Steering, Power Brakes, Front Disc Brakes, Rear Drum Brakes, Tinted Windshield, 15... More
Chevrolet Chevelle Malibu SS 1964 in very good condition Rare, fully original, real Super Sport Chevrolet Chevelle Malibu from 1964. Car is matching numbers 327... More
Ground up restoration. Garage kept. Custom leather seats. Awesome sound system. Has a strong 355 in it. Comes with the orig 350. Also have... More
Fully GM documented Rare Canadian (Oshawa, Ontario) built 1966 Chevrolet Chevelle CONVERTIBLE. This car had a total FRAME OFF restoration few years ago. MOSTLY... More
A recipient of a high dollar restoration with a 427ci V8 engine and a 4-speed manual transmission. It features air conditioning and 17" Boyd... More


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Kukla's Korner Hockey
Backup Woes In Vancouver
by Paul on 11/24/06 at 11:47 AM ET
Comments (0)
The Canucks were handed more than just an ugly 6-0 loss here Thursday night. They also have another one of those seemingly never-ending backup goalie controversies on their hands.... "It's too bad," Sabourin said. "I played good the last game I went down with Manitoba. I felt ready but a couple of tips and it's a different game. Maybe if they don't tip those in it's a tight game and you never know what is going to happen." His NHL record as a starter is now 0-6 and his goals-against average is well above the 4.0 mark. Now Sabourin must wait and wonder when, or if, he will get another start with the Canucks.more
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About Kukla's Korner Hockey
Paul Kukla founded Kukla's Korner in 2005 and the site has since become the must-read site on the 'net for all the latest happenings around the NHL.
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Email Paul anytime at firstname.lastname@example.com


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Little Monkey (vector)
This great custom product in pink from our department Men and Bib category can be printed just for you in the size and style you like. The design Little Monkey (vector) was created by Offendmenow and uploaded to Spreadshirt for you to have printed on a Bib. Next to a host of other great customized designs, you can find this Little Monkey (vector) design in Spreadshirt's Baby category. If you are interested in topics like Evil or Hear no evil see no evil speak no evil, then you'll love Little Monkey (vector) designs by Offendmenow. Spreadshirt also offers a huge selection of custom t-shirts, hoodies and accessories for the category Baby as well as top Japanese clothing. Offendmenow's designs have already impressed many of our customers, so we are sure that we've got right stuff for you! Spreadshirt is your destination for great designs of all kinds – whether it's Evil, Hear no evil see no evil speak no evil or Japanese. We are sure that you will find something nice in our shop, there are many amazing custom Baby t-shirts, hoodies, or accessories for you to find! Tags: Design ID: 11160572
I hope you like the designs most are vector images.
Running, Drawing Comics
Happy Last Day T-Shirts Designed by teacher t-shirts
Nah Rosa Parks Quote T-Shirts Designed by The Shirt Yurt
Great Dads Get Promoted to Grandpa T-Shirts Designed by myfamily
WTF WHERE'S THE FIREBALL T-Shirts Designed by jimbosports
Black Lives Matter Designed by forhuman
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The Women of NPR Designed by Micah Fitzerman-Blue
Narwhal Rainbow Stormtrooper Designed by racoon
This organic cotton baby bib will keep your baby's clothing clean (for a few minutes, at least). The two snap closure makes this one easy-on and easy-off. This is an easy choice for any baby gift — no sizing necessary!
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Gunmetal Black Ep 01
episode 14.24 / 5.00 4,718 Views
Lucina's First Day
A look at the first day of Lucina in Super Smash4.24 / 5.00 15,061 Views
BATMAN v SUPERMAN final showdown
SPOILERS!!4.17 / 5.00 13,852 Views
The way that he threw the beer is that.He use his sholders to throw it at Salad Fingers
oddly funny
Isn't it odd how Milford couldn't catch the beer (due to his lacking arms) but he was still able to throw it at Salad Fingers? xD
They funniest thing i ever seen
So random i love it
BADASS!!!lol jk but still pretty funny
10 stars for making me laugh when i was young
i watched this when i was a kid and thought it was pretty funny
sorta the jackass funny


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Cortez Connects With A New Website
By Tom Yoder
The City of Cortez has built a new website to gather feedback from citizens on how the city should plan for future projects and growth. KSJD's Tom Yoder talks with Kirsten Sackett, Director of Planning and Building for the City of Cortez, and Rocky Moss, Project Coordinator for Cortez Heart and Soul, about cortezconnects.com and how it will create a new platform to interact and create meaningful dialog with city planners and other community leaders. Check out the new website at http://www.cortezconnects.com/
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Glendale Newswire
Comprehensive Real-Time News Feed for Glendale, CA.
Results 1 - 6 of 6 for "u:panarmenian.net" in Glendale, CA
Talin Arsenian elected Glendale Teachers Association president w/Photo
PanARMENIAN.Net - Glendale Unified School District math teacher Talin Arsenian was elected president of the Glendale Teachers Association earlier this month. She will assume the leadership post of the Glendale teachers' union on July 1, Asbarez reports. Comment?
Glendale to host Life100 art exhibition w/Photo
PanARMENIAN.Net - The Life100 art exhibition, to be held at the Brand Library Art Galleries in Glendale, California, March 14 May 1, will uplift, inspire and empower visitors by showcasing over 30 master Armenian artists and 20 contemporary Armenian artists from Los Angeles, whose stories represent the impact of the Armenian Genocide from over 15 countries, Asbarez reports. The exhibition and related programming is conceived and curated by the Life100 Organizing Committee in coordination with the City of Glendale Library, Arts and Culture Department and the United Armenian Council for the Commemoration of the Armenian Genocide/LA. Comment?
AGCC-WUSA announces Armenian Genocide commemoration events w/Photo
PanARMENIAN.Net - The Armenian Genocide Centennial Committee of the Western United States during a press conference it hosted on Wednesday, Jan 14, announced five major events its body is organizing in Los Angeles to commemorate the 100th anniversary of the Armenian Genocide and published a list of events that will take place throughout the Western United States. According to Asbarez, during a press conference held at Phoenicia Restaurant, Co-Chairs Garo Ghazarian, Esq., and Taline Yacoubian, Esq., announced the committee's active preparations to commemorate the souls of the 1.5 million massacred Armenians and to duly honor the lives of both Genocide survivors and heroes who facilitated the sacred mission of rescue and relief. Comment?
Master plan for Armenian American Museum under development w/Photo
PanARMENIAN.Net - An internationally recognized firm specializing in planning services for museums and cultural centers started work on developing the master plan for the Armenian American Museum in Glendale, California. The Armenian Genocide Centennial Committee of Western U.S. leadership participated in a workshop this week conducted by Lord Cultural Resources consultants to define the vision for the Museum and formulate the guiding principles for the master plan phase of the project. Comment?
Process for selection of Armenian American Museum architect starts w/Photo
PanARMENIAN.Net - The Armenian Genocide Centennial Committee of the Western U.S. on Wednesday, Dec 10, announced its process for the selection of an architect for the Armenian American Museum proposed for construction in Glendale, California. AGCC's Screening Committee will review the responses to the request for qualifications and invite up to 5 architects or their firms to submit proposals with design concepts. Comment?
Serj Tankian talks Genocide, musical tastes, future plans w/Photo
PanARMENIAN.Net - The frontman of a popular Armenian-American metal band System of A Down shared his views on the problem of genocides, musical tastes and plans for the future in a conversation with ROCK FM radio station. "The Armenian Genocide is an important issue, which should be given more attention to prevent the possibility of such tragedies in future. Comment?
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ENGELHARDT: Larry Mattingly goes from 'worst wrestler' to Hall of Fame wrestling coach
Will join Ralph Weinzapfel, Greg Schaefer, Welch family at induction ceremony in February
Larry Mattingly has no problems telling anyone and everyone that he may have been the worst wrestler in Memorial High School history, losing all nine of his matches in the 167-pound division his freshman year, all by pin in the first period. So much for his wrestling career.
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This case study describes a 45 year old female with bilateral, profound sensorineural hearing loss due to Meniere's disease. She received her first cochlear implant in the right ear in 2008 and the second cochlear implant in the left ear in 2010. The case study examines the enhancement to speech recognition, particularly in noise, provided by bilateral cochlear implants.
Speech recognition tests were administered prior to obtaining the second implant and at a number of test intervals following activation of the second device. Speech recognition in quiet and noise as well as localization abilities were assessed in several conditions to determine bilateral benefit and performance differences between ears. The results of the speech recognition testing indicated a substantial improvement in the patient's ability to understand speech in noise and her ability to localize sound when using bilateral cochlear implants compared to using a unilateral implant or an implant and a hearing aid. In addition, the patient reported considerable improvement in her ability to communicate in daily life when using bilateral implants versus a unilateral implant.
This case suggests that cochlear implantation is a viable option for patients who have lost their hearing to Meniere's disease even when a number of medical treatments and surgical interventions have been performed to control vertigo. In the case presented, bilateral cochlear implantation was necessary for this patient to communicate successfully at home and at work.
Effective communication is necessary for adults to maintain employment, raise a family and enjoy life. Cochlear implantation improves the face-to-face communication of nearly all postlinguistically deafened adults and allows most to regain use of the telephone. For a young working mother, communication is of utmost importance; however, with debilitating vertigo due to Meniere's disease, effective communication may be secondary to functioning in daily life. The physical symptoms of Meniere's disease, vertigo, fluctuating hearing loss, and tinnitus, can be incapacitating and can lead to depression and anxiety (Anderson and Harris, 2001). The prevalence of Meniere's disease in the United States is estimated to be 190 per 100,000 with a higher prevalence for women and older adults (Harris and Alexander, 2010). For patients whose vertigo is not controlled through diet, vestibular rehabilitation, and/or medication, a number of surgical options exist; however, a risk of decreased hearing may come with surgical treatment (Lustig et al, 2003; Colletti et al, 2007).
Bilateral severe-to-profound hearing loss secondary to bilateral Meniere's disease is relatively rare, but should it occur, cochlear implantation is a viable option (Lustig et al, 2003). Lustig et al (2003) examined the speech recognition abilities of a group of nine cochlear implant (CI) recipients with Meniere's disease; seven of the nine patients had bilateral Meniere's disease. All study patients were implanted unilaterally in the poorer hearing ear, and all had significant improvement in open-set speech recognition scores at six months post initial activation of the CI compared to pre-operative scores with the exception of one patient whose device failed. The speech recognition abilities of the Meniere's group were compared to a group of postlingual CI recipients without Meniere's disease. No significant difference in scores was found between the two groups except for the CID sentence test (Davis and Silverman, 1978) presented in quiet for which the Meniere's group scored significantly higher. The results indicate that cochlear implantation is an option for patients with severe-to-profound hearing loss secondary to Meniere's disease.
The case study presented in this paper concerns a young woman diagnosed with bilateral Meniere's disease that resulted in profound hearing loss, bilaterally. The multiple procedures used to manage her dizziness will be discussed. Hearing rehabilitation included sequential, bilateral cochlear implantation. The results presented illustrate the advantages of bilateral CI use compared to unilateral CI use including improved speech understanding in noise, improved localization skills, and enhanced sound quality.
The patient was first seen at Washington University in St. Louis School of Medicine (WUSM) Department of Otolaryngology in 2007 at the age of 42. She reported having her first episode of dizziness, and fluctuating hearing loss in the right ear in 2000. Several months after this first attack, she began experiencing episodic vertigo lasting several minutes to several hours. After suffering with vertigo and fluctuating hearing loss for a year, she had a right endolymphatic shunt decompression operation performed at another center. The patient reported that the surgery along with medication provided some relief from the dizziness for several years. In 2004, the episodic vertigo began again and became worse during her pregnancy that same year. By 2006, she reported having severe vertigo two to three times per day. She was breast-feeding at that time and was unable to take medication. She stopped breast-feeding in early 2007 and began taking a number of medications daily which decreased the severity of her dizziness; however, she reported having mini episodes of vertigo daily and major episodes at least three times a month.
The patient obtained a hearing aid for the right ear in 2000 when she was first identified with hearing loss in that ear. She was identified with hearing loss in the left ear during a school hearing screening when she was eight years old. The hearing in the left ear had been stable until 2003 when she noticed a decrease in hearing, and at that time, obtained a hearing aid. The etiology of the hearing loss in the left ear was reported to be genetic as her father also had hearing loss as a child. She reported experiencing tinnitus in the right ear in 2000 when her Meniere's symptoms began, and then shortly after, she noticed tinnitus in her left ear as well. The tinnitus was masked by use of the hearing aids and was not bothersome. Her hearing loss in the right ear progressively worsened since being diagnosed with Meniere's disease. The hearing in the left ear also continued to deteriorate. A hearing test performed at WUSM in 2007 revealed a severe-to-profound sensorineural hearing loss in the both ears with 32% and 36% word recognition scores (WRS) on the NU-6 word test (Tillman and Carhart, 1966) for the right and left ears, respectively. Even though the patient had very poor hearing, her main concern was eliminating her vertigo.
After seeing an otologist/neurotologist (JGN) at WUSM, a sensorineural hearing loss was confirmed in the left ear and active cochleo-vestibular Meniere's disease was confirmed in the right ear. All blood work was normal and an MRI revealed no abnormalities. Binocular video-oculography results revealed intact central ocular motor function. Bithermal caloric responses were strong and symmetric. Computerized Dynamic Posturography revealed low scores on the Sensory Organization Test (SOT) and one fall on SOT 6. This is not consistent with a known pattern but suggests a visual preference which was consistent with the patient's reported history. It was recommended that the patient continue her low-salt diet, begin vestibular exercises, and slowly decrease her medications. The patient, however, continued to have multiple episodes of vertigo daily and reported that she was about to lose her job due to absences related to the Meniere's symptoms.
Over the course of the next several months, the patient had a number of intratympanic gentamicin injections, an endolymphatic sac operation (revision) with shunt and finally a vestibular nerve section in the right ear. One month after the vestibular nerve section, the patient reported that she had not had a vertiginous attack since the surgery although she reported feeling unbalanced. In addition, she reported that four days after surgery she could no longer hear sound when using her right hearing aid. The vestibular nerve section specimen was reviewed by the otologist/neurotologist and only vestibular nerve was found. An audiogram revealed a profound hearing loss in the right ear and a 0% WRS. No change in hearing was seen for the left ear. She was referred to the Adult CI Program at WUSM and began the pre-operative process to obtain an implant for the right ear. The patient continued to report no dizziness since the vestibular nerve section. A hearing test prior to CI surgery indicated slight improvement in hearing for the right ear (severe-to-profound loss, 8% WRS). In April 2008, she was implanted in the right ear with the Nucleus Freedom CI system.
The patient wore the Freedom speech processor on the right ear and a Starkey Destiny 400 behind-the-ear hearing aid (HA) on the left ear and reported doing well in most communication situations. Speech recognition results will be discussed later in this paper. In October 2008, the patient described having mini attacks of vertigo and one major attack which lasted two to three hours. She also reported that her hearing in her left ear was different and somewhat distorted. A hearing test in November 2008 revealed a decrease in hearing for the left ear. The dizziness continued and the patient stated that she could not live through dizziness like she had experienced in the past; therefore, a tympanostomy grommet tube was placed in the left tympanic membrane, and the patient received four injections of dexamethasone through the tube over a one month period. An improvement in the dizziness was reported with only minor attacks of dizziness since the injections. An infection around the tube in January 2009 precipitated its removal. The patient continued to report minor vertiginous episodes daily with a major episode occurring every three to four days. In deference to the patient's request, a left endolymphatic sac operation with shunt was performed in March 2009 after which her vertiginous episodes markedly improved, but the hearing in her left ear decreased to a profound sensorineural loss. Her hearing did not recover, and she discontinued the use of the hearing aid in that ear.
The patient reported to her CI audiologist that she struggled to understand speech at home and at work since she had been using the CI without the HA. At home she needed to communicate with her husband, her teenager, and her three year old. Her work environment included a large office with a number of people and office equipment. She was expected to use the telephone. She reported that speech sounded distorted and that her understanding in any type of background noise was very poor. An evaluation of her speech recognition scores with the CI revealed no change in performance since discontinuing the use of the HA and substantial open-set speech recognition. The possibility of a CI in the left ear was discussed.
In June 2009, the patient discontinued her medications due to dry mouth and was taking meclizine for dizziness only as needed. She saw the otologist/neurotologist several months later and reported mini episodes of vertigo daily, mainly in the mornings. At that time, she was given a prescription for valium. By March 2010, the patient was considering cochlear implantation for her left ear. She believed that the valium had helped to control her dizziness but continued to report great difficulty communicating especially at work where the background noise was detrimental to her speech understanding. In May 2010, two years after her first CI, the Nucleus 512 CI device was implanted in her left ear. Table 1 provides a general time line of the patient's symptoms and treatments. [TABLE 1]
After the first CI (right), the patient participated in a longitudinal study examining monosyllabic word recognition over time (Skinner et al, 2007a). Figure 1 shows her consonant-vowel nucleus-consonant (CNC) monosyllabic word scores (Peterson and Lehiste, 1962), using the right CI only, at 12 test intervals from two weeks to two years post initial activation. [FIGURE 1] At two weeks, her word score was 44% and by six months, 87%. Her score, then, reached a plateau and was maintained at that level through the two year test interval. With a score of 87% on CNC words, the patient would be considered a "star performer". She was scoring well above the average score of 62% for a group of 110 postlinguistically deafened adult CI users who participated in the same longitudinal study (Finley et al, 2010). The patient reported that she was pleased with her communication abilities when wearing the CI and HA together; however, about a year after cochlear implantation, she stopped wearing the HA due to a decrease in hearing. When using the CI only, she was no longer satisfied with her ability to communicate in daily life. As can be seen in Figure 1, her CI performance at one year was stable and above average for CNC words. Her difficulties understanding with just the CI were not related to a decrease in performance with the implant. The patient reported that she was comfortable with the CI during face-to-face communication in quiet environments, but when listening in background noise, she found herself struggling to understand. In fact, it was noted at her CI evaluations that her scores in noise were considerably lower than her scores in quiet. At her one year CI evaluation, her score on the TIMIT sentences (Lamil et al, 1986) presented in the sound-field at 60 dB SPL in quiet using the implant only (no lip-reading) was 76%. When the TIMIT sentences were presented at the same level in four-talker babble (Auditec of St. Louis; +8 signal-to-noise [SNR]), she scored 34% using the CI only, a decrease of 42% from listening in quiet to listening in noise. The TIMIT sentences are difficult due to the composition of the talkers, using both male and female speakers, different regional dialects, and varied speaking rates. Furthermore, the language is complex. For example, "His name became synonymous with cold-blooded cruelty" and "Vietnamese cuisine is exquisite" are two TIMIT sentences. Because of the variability of the talkers and complexity of the sentences, the TIMIT sentences are thought to be more representative of real-life listening. It appeared that, indeed, the patient did fairly well with the CI listening in quiet (76%) but as reported, much poorer in noise (34%). Difficulty understanding speech in noise is a common report by CI users (Donaldson et al, 2009). Additionally, research has shown that CI users have a significant decrease in sentence scores at SNRs that would not affect those with normal hearing (Spahr et al, 2007). Because of the communication difficulties she encountered in daily life, the patient expressed a strong interest in obtaining a second CI.
As mentioned above, two years after obtaining the Nucleus Freedom CI for the right ear, the patient was implanted with the Nucleus 512 CI in the left ear. She was programmed using the Advanced Combination Encoder (ACE; Skinner et al, 2002) speech processing strategy (pulse width = 25-μs/phase, monopolar stimulation) and 1800 pulses per second /channel (pps/ch) stimulation rate in the first implanted ear. At the initial activation of the second implant, a speech processor program or map was created using similar parameters to those used with the first CI (ACE strategy, 1800 pps/ch stimulation rate). The patient was familiar with the procedures used to program the speech processor. No programming issues were encountered and the maps created appeared typical. The patient scored 100% when simple sentences were presented live voice using the second CI only. Three days after initial activation of the second CI, the patient reported having a "full blown" vertiginous attack that lasted all day. She had not reported having an attack of vertigo since her left endolymphatic sac operation with shunt was performed several months prior to the second CI surgery. For the next month, the patient reported feeling unsteady to the point of having to remove the second CI speech processor every couple of days to recover.
The patient wore the first CI speech processor at a volume setting of 9 (range: 1–9) and sensitivity setting of 12 (range: 1–20), but in order to prevent feeling unsteady, the patient wore the second CI speech processor at a softer level, volume of 4 and sensitivity of 10. She reported that the first CI was louder than the second CI; however, she noted an improvement in speech understanding when the two were worn together. Furthermore, her CNC word score using the second CI only was 75% at her one month evaluation. Five weeks post-initial activation of the second CI, the patient could consistently wear both processors but still needed to keep the volume and sensitivity of the second CI speech processor at lower settings. In an attempt to equalize loudness between the two ears without causing further dizziness, the stimulation rate of the second CI was changed from 1800 pps/ch to 500 pps/ch. The stimulation rate used with the first CI remained at 1800 pps/ch. After using the 500 pps/ch map for two weeks, the patient reported that the unsteadiness was not occurring as frequently and that she was able to increase the volume to 5. She reported that the 500 pps/ch map sounded louder than the previous 1800 pps/ch map; moreover, she appreciated the longer battery life that the 500 pps/ch map provided. She stated that when she first used the 500 pps/ch map with the second CI and the 1800 pps/ch map with the first CI, there was a difference in sound quality between the ears. After several weeks of continued use, she no longer noticed a difference in sound quality when wearing both the right and left speech processors together. Table 2 shows the speech processor parameters that are currently used by the patient for each ear. [TABLE 2]
Figure 2 shows the placement of the electrode array within the cochlea for the first and second CI. [FIGURE 2] CT scans were obtained both pre-operatively and post-operatively to create these images using a technique described by Skinner et al, 2007b. The rectangular black and white marks within the cochlea represent the 22 electrodes of the Nucleus internal device (Nucleus Freedom with Contour Advance Electrode, first CI; Nucleus CI512 cochlear implant with Contour Advance Electrode, second CI). Ideally, all electrodes should be in scala tympani. The 3D reconstruction of the CT scans, which is based on a cochlear atlas model (Teymouri et al, 2010), indicate that for the first CI (right), thirteen electrodes are located in scala tympani, and nine electrodes are involved in a transition from scala tympani through scala media to scala vestibuli with the two most apical electrodes in scala vestibuli. All electrodes remain in scala tympani for the second CI (left). Note that the electrodes are closer to the modiolar wall of the cochlea for the second CI compared to first CI; consequently, electrodes may be in closer proximity to spiral ganglion cells with the second CI compared to the first CI.
When creating a CI speech processor program or map for the Nucleus device, two levels need to be set for each of the active electrodes, a minimum and a maximum electrical stimulation level. For the Nucleus device, the minimum electrical stimulation levels are commonly referred to as T-levels and maximum electrical stimulation levels are commonly referred to as C- levels. T-levels and C-levels are set based on the each patient's perception of loudness. The technique used to set T- and C-levels can vary between CI centers, but in general, T-levels are set at a percept of "very soft", and C-levels are set at a percept of "loud but comfortable". Both levels can be adjusted to allow soft speech and sound to be audible and conversational speech comfortably loud in daily life. T- and C-levels are different for each patient and can vary between ears as well as across the array within a single ear for the same patient. The T- and C-levels used in the patient's map for each ear (1800 pps/ch stimulation rate) were averaged across electrodes. For the first CI, averaged T- and C-levels were 178 and 209 (range: 1–255) current levels1, respectively. For the second CI, averaged T- and C-levels were 85 and 128 current levels, respectively. This is a substantial difference in T- and C-levels between ears when using the same stimulation rate and may be related to the difference in the placement of the electrode arrays within the cochlea for the two implants.
Prior to the second CI surgery, the patient agreed to participate in a longitudinal study evaluating performance after sequential, bilateral cochlear implantation. Subjects in this study are tested before the second CI surgery (pre-operatively) and at one, three, six, nine, twelve, fifteen and eighteen months post-initial activation of the second CI (post-operatively). Pre-operative testing is carried out with the patient using a CI in one ear and a HA in the other ear. Post-operative testing is completed with the patient using an implant in each ear. Prior to speech recognition testing, each patient's external equipment is checked and frequency modulated (FM) tone, sound-field threshold levels from 250–6000 Hz are obtained. If a patient reports changes in speech understanding or sound-field threshold levels are inconsistent with those previously obtained, a check of the map is performed with reprogramming as necessary. Testing through six months has been completed for this patient. FM tone, sound-field threshold levels obtained at the six-month test interval are shown in Figure 3 for each ear.[FIGURE 3] The patient's sound-field threshold levels with each CI are ≤ 20 dB HL across the frequency range ensuring the audibility of soft speech and sound (Holden et al, 2007, Davidson et al, 2009).
The test materials used to evaluate speech recognition performance for this study are difficult. Many of the tests are presented in noise or at soft presentation levels in order to replicate difficult listening situations that CI users encounter in daily life. Since the patient reported experiencing difficulty understanding speech in noise when using her first CI alone, the test results will predominately focus on her performance in noise. Two lists of each test were presented in a pseudo-randomized order at each test interval. All testing was performed in the sound-field. The majority of tests were performed with the patient seated at 0° azimuth approximately 1.5 meters from a loudspeaker. For the R-SPACE™ test environment (Revit et al, 2002; 2007) and the localization test (Potts et al, 2009), the loudspeaker configuration was different and will be described below.
Figure 4 shows CNC monosyllabic word scores for each ear separately at each study test interval (Pre-operatively: CI and HA; Post-operatively: first CI and second CI). [FIGURE 4] Pre-operatively, the patient scored 91% with the first CI and 0% with the HA. Post-operatively, scores with the second CI progress quickly and are higher than scores with the first CI at the three and six month test intervals.
The next several figures show results for each test interval in three conditions. Pre-operative scores are shown with the patient using the first CI only, the HA only, and then both together (bilateral condition). It is important to remember that at the pre-operative test interval, the patient had been using the first CI (right) for approximately two years. Post-operative scores are shown for the first and second CI separately and bilaterally. Scores for TIMIT sentences presented at 60 dB SPL in noise (four-talker babble, +8 dB SNR) are shown in Figure 5. [FIGURE 5] Note the improvement in the bilateral scores from the pre-operative to the six-month test interval. In addition, the patient's scores in noise are higher with the second CI than with the first CI at all test intervals. It is interesting to note an improvement in the noise score with the first CI at the six-month test interval compared to the pre-operative and three-month test intervals. At the six-month test interval, the patient had been using the first CI for approximately 2.5 years.
The Bamford-Kowal-Bench Speech in Noise Test (BKB-SIN; Killion et al, 2004) is a sentence test in noise where the SNR varies throughout the test. The first sentence is presented at an SNR of +21 dB, and for each consecutive sentence, the SNR decreases by 3 dB. An SNR-50 score is obtained; that is, an SNR for which the subject can correctly repeat the key words within the sentences 50% of the time. The BKB-SIN was presented with the speech and noise (four-talker babble) coming from the same loudspeaker located in front of the patient. In addition, the noise was presented through a loudspeaker located 90° to the left of the patient as well as 90° to the right of patient with the speech always presented through the front speaker. Scores obtained when speech and noise were presented through the front speaker are shown in Figure 6 for the pre-operative, three and six-month test intervals. [FIGURE 6] The score is an SNR; therefore, a lower number represents a decrease in SNR and a better result. In other words, a low SNR means that the listener can understand speech in a greater amount of noise. Recall that pre-operatively, scores were obtained with the first CI, a HA, and both together (bilaterally), whereas post-operatively, scores were obtained with each CI separately and both together (bilaterally). The patient could not do the task when using the HA only. The scores improved considerably, especially in the bilateral condition, by the six-month test interval. At each postoperative test interval, the SNR is lower with the second CI than with the first CI. Again, note the improvement in SNR with the first CI at the three-month and six-month test interval following implantation of the second ear.
Figure 7 illustrates the benefits of bilateral cochlear implantation when noise was presented to the sides of the patient. [FIGURE 7] The left side of Figure 7 shows the SNR obtained when noise was presented 90° to the right of the patient. Pre-operatively, the patient was listening with the first CI (right) only and with the first CI and HA. Post-operatively, the patient was listening with the first CI only and with both implants. The right side of Figure 7 reveals the SNR obtained when noise was presented 90° to the left of the patient. Pre-operatively, the patient was listening with the HA in the left ear and then with the HA and first CI together. Post-operatively, the patient was listening with the second CI (left) only and with both implants. A substantial decrease in SNR was seen in the bilateral condition from the pre-operative to the six-month test interval regardless of the direction of the noise. When the noise was presented on the right side, an improvement in SNR of 12 dB was obtained by the addition of the second CI (left). When noise was presented to the left of the patient, an improvement in SNR of 9 dB was obtained when using two implants. When the noise was presented to the left, the SNR with the second implant (left) was lower, at each post-operative test interval, than the SNR with the first implant (right) when noise was presented to the right.
The R-SPACE™ test environment is shown in Figure 8. [FIGURE 8] The patient was seated in the center of eight loudspeakers through which restaurant noise was presented. The speech stimuli were paired HINT sentence (Nilsson et al, 1994) lists presented from the loudspeaker directly in front of the patient. The noise was fixed at 60 dB SPL and the sentence presentation level was varied depending upon the patient's response. An adaptive procedure in which the sentence presentation level was decreased for each correct response and increased for each incorrect response was utilized. For sentences 1–4, a 4 dB step size was used and then for sentences 5–20, a 2 dB step size was used. An SNR at which the patient could correctly repeat 50% of the sentences was determined by averaging sentence presentation levels for sentences 5–20 and a calculated presentation level for sentence 21. Figure 9 shows the considerable decrease (improvement) in SNR from the pre-operative to the six-month test interval for all three listening conditions. [FIGURE 9] A +6 dB SNR was obtained in the pre-operative bilateral test condition (HA and CI), whereas a -2 dB SNR was obtained in the bilateral test condition (both CIs) at six months. Note that for each post-operative test interval, a lower SNR is obtained with the second CI than with the first CI. Additionally, note the improvement in SNR, with the first CI at both the three-month and six-month test intervals compared to the pre-operative SNR.
In addition to difficulties understanding speech in noise, many unilateral CI users report difficulty localizing sound. To evaluate localization skills, testing was performed pre-operatively using the CI and HA and post-operatively using both implants. The test environment consisted of a 140° loudspeaker array with 15 loudspeakers, 10° apart. Figure 10 is a schematic of the test configuration. [FIGURE 10] The localization task required the patient to state the perceived location of the stimulus (i.e. loudspeaker number 1–15). The patient faced the front (0° azimuth) prior to initiation of each trial, but was permitted to turn her head (i.e., turn toward the loudspeaker from which the word was perceived) during the trial. An equal number of words were presented from each of 10 selected positions; five of the visible loudspeakers were inactive (+/−60°, +/−40° and 0°), but the patient was not aware of this. The words were presented at a roving level of 60 dB SPL (±3 dB SPL). The scores are presented in terms of degree of RMS error. The RMS error is the mean deviation of the patient's response from the actual location of the presentation, and it is not related to the direction of the deviation (Potts et al, 2009). Pre-operatively, the patient obtained an RMS error of 59°, and at the six-month test interval, an RMS error of 26° degrees was obtained. An RMS error of 0° represents 100% accurate localization; therefore, the patient's localization ability improved using two implants compared to using a HA and CI.
Even though this patient was scoring near 90% on the CNC word test with her first implant, she stated that she struggled to communicate in daily life when using only one CI. The results of the testing described above revealed that this patient obtains considerable benefit from bilateral cochlear implantation; however, these speech tests were all performed in a sound booth. No matter how difficult and varied the testing, the multitude of listening environments encountered in daily life can not be replicated in a sound booth. To better understand the benefits of bilateral implantation in different listening environments in daily life, the Speech, Spatial and Qualities of Hearing Scale (SSQ; Gatehouse and Noble, 2004) was given at each test session. The test consists of three scales. The Speech scale questions the patient's abilities to understand speech in a variety of difficult listening situations. A question from the Speech scale is a follows: "You are talking with one other person and there is a TV on in the same room. Without turning the TV down, can you follow what the person you're talking to says?" The Spatial scale concerns spatial hearing or the ability to tell the direction and judge the distance of the sound. A question from the Spatial scale is as follows: "You are outside. A dog barks loudly. Can you tell immediately where it is without having to look?" The Sound Qualities scale of the SSQ questions a patient's ability to segregate sounds. That is, can a patient recognize each of two sounds that are going on at once, for example water running and a radio playing? Additionally, this third scale examines the "naturalness" and "clarity" of sound and determines the amount of effort the patient exerts to listen ("Do you have to put in a lot of effort to hear what is being said in conversations with others?"). For each item on the SSQ, the patient provides a rating on a continuum from 0–10 with a higher number indicating greater ability. The patient was able to see her ratings from the previous test interval while completing each SSQ. Figure 11 indicates the average rating across items for each of the three scales. [FIGURE 11] An improvement from the pre-operative test interval, where the patient was using one CI, to the six-month test interval (bilateral CIs) was seen for all scales with the greatest improvement seen for the Spatial scale.
Fortunately, the procedures used to treat this patient's Meniere's disease successfully alleviated her symptoms. She reported experiencing vertigo several days after the initial activation of the second CI and continued to report imbalance for the next five weeks. Since that time, she reports no dizziness or imbalance. She is able to work full time as well as take care of her family; furthermore, she is satisfied with her ability to communicate at work and at home when using both implants.
Prior to the profound hearing loss in her left ear, the patient was able to use the first CI and a HA to successfully communicate in daily life. When she was no longer able to use the HA, she reported struggling to communicate in all but quiet, face-to-face listening situations. The patient's report is consistent with the literature describing the importance of symmetric hearing. Individuals with asymmetric hearing have more difficulty localizing sound, segregating sounds and understanding speech in noise than individuals with symmetric hearing (Firszt et al, 2008). Even though the patient did not have complete symmetric hearing with the CI and HA, she was able to make use of the input from both devices to understand speech in a variety of listening situations encountered in her daily life. The loss of the use of the HA, creating greater asymmetry between the ears, proved detrimental to speech understanding in difficult listening environments. The addition of the second CI restored symmetric hearing. The test results reported here reveal substantial improvement in the patient's speech understanding in noise and in her localization abilities when using bilateral implants compared to using only one implant or an implant and a HA.
The patient's performance with each implant is excellent with scores of 90% and 98% on the CNC word test with the first and second implants, respectively. Her above average performance is consistent with the findings of Lustig et al (2003). These researchers described significant improvement in speech recognition for a group of nine CI recipients diagnosed with Meniere's disease. Five of these patients had undergone surgical procedures (endolymphatic shunt and vestibular nerve section) to control vertigo yet had significant open-set speech recognition with the CI. None of the study patients were experiencing vertigo at the time of CI surgery and only one of the nine patients had post-operative vertigo which resolved within several months of surgery. The dizziness was not related to electrical stimulation. Fina et al, (2003) performed a retrospective study examining the incidence of dizziness after cochlear implantation for a group of 75 patients. The researchers found that only one patient experienced vertigo due to electrical stimulation; however, for this patient, the implant was placed in the vestibule due to complete ossification of the cochlea. The results of the study did indicate, however, a higher probability of post-operative dizziness for patients with pre-operative diagnosis of Meniere's disease. The positive outcomes shown in the study by Lustig et al (2003) as well as the positive outcome for our patient demonstrates that cochlear implantation is a viable option for patients with bilateral Meniere's disease and bilateral cochlear implantation should be considered. Patients should be counseled on the possibility of post-operative dizziness.
As described above, the patient is doing well with each implant; however, it is interesting to note the rapid progress made in speech recognition with the second implant (left ear) even with the reported long-term hearing loss (identified at age eight), dizziness and unsteadiness presumably caused by electrical stimulation of that ear. Moreover, the patient's speech recognition in noise is better when using the second CI compared to the first CI (right ear). A possible explanation for the rapid progress and better noise scores with the second CI may be the placement of the electrode array within the cochlea with regard to scalar placement and proximity to the modiolar wall. Skinner et al (2007a, b) and Finley et al (2008) reported that higher monosyllabic word recognition scores are correlated with scala tympani placement of the electrode array. For this subject, all electrodes remained in scala tympani with the placement of the second CI, whereas the nine apical-most electrodes transitioned from scala tympani to scala vestibuli during placement of the first CI perhaps damaging cochlear tissues and possibly increasing cross turn stimulation for these electrodes (Finley et al, 2008). The patient did not report aberrant percepts for any electrodes while programming the first CI, and we have found no correlation between aberrant percepts and scala vestibuli placement in our patient population. The electrode array of the second CI is closer to the modiolar wall of the cochlea than the electrode array of the first CI (see Figure 2) which places the electrodes of the second CI nearer spiral ganglion cells and may explain the lower minimum and maximum electrical stimulation levels across electrodes for this device. Closer wrapping of the array around the modiolar wall has also been observed to correlate with better speech recognition (Finley et al, 2010).
A number of procedures were performed to alleviate the patient's dizziness including endolymphatic sac surgery with shunt (right and left ears), intratympanic gentamicin injections (right), intratympanic dexamethasone injections (left) and vestibular nerve section (right). It may be the case that the procedures used caused greater trauma to the peripheral auditory system in the right ear than in the left ear; though, the audiograms for both ears were similar prior to CI surgery. Intratympanic gentamicin injections and vestibular nerve section were used to control the patient's dizziness in the right ear. Both have been shown to cause hearing loss with intratympanic gentamicin injections causing greater degree of hearing loss than vestibular nerve section (Colletti et al, 2007). After a middle fossa complete vestibular nerve section in the right ear, this patient was relieved of the severe episodic vertigo and maintained hearing but did have a considerable reduction in thresholds and in the word recognition score. Later, the patient had a right CI. Intratympanic dexamethasone was used in the left ear to control dizziness. Yilmaz et al (2005) treated 26 patients with intratympanic dexamethasone injections to alleviate tinnitus and found no differences in patient's pure tone averages before or after the injections. Additionally, the study found that outer hair cell function, measured via transient-evoked otoacoustic emission testing, was not affected by dexamethasone treatments. No deterioration in hearing was documented after intratympanic dexamethasone injections for our patient; however, her dizziness continued after treatment. An endolymphatic sac operation with shunt was then performed after which a significant decrease in hearing was documented. The patient obtained a second CI in the left ear about a year after this decrease in hearing. Her vertigo was under control at the time of the second CI surgery.
As with all CI recipients, a number of factors contributed to this patient's speech recognition abilities, and we can only speculate as to why she has somewhat better performance with the second CI than with the first CI. It is noteworthy that a 20% improvement on TIMIT sentences in noise was seen for the first CI at the six-month test interval (see Figure 5). At this test interval, the patient had been using her first implant for approximately 2.5 years. Learning effects may have contributed to the improvement in scores; although learning effects were not evident prior to implantation of the second ear. For example, at her one year evaluation with the first CI, her score on TIMIT sentences in noise was 34% which is consistent with her scores at the pre-operative and three-month study test intervals (37% and 38%, respectively). Improvements in scores with the first CI after second-side implantation were also observed for the BKB-SIN and the R-SPACE™ measures (see Figures 6 and and9,9, respectively). Learning effects may have contributed to the improvement as these test measures were not used with the patient prior to this study. Then again, perhaps listening with two implants has helped improve her ability to understand speech in noise with the first implant. If speech cues are more salient in noise with bilateral input, the patient may have been able to learn to use these same cues to improve her understanding in noise in the unilateral condition. Furthermore, given the many crossed and uncrossed auditory pathway connections, conceivably strengthened bilateral projections could influence monaural connections and ultimately function.
Another contributor to the improvement in noise scores with the first CI may be related to the speech processor program or map used at the six-month test interval. The C-Levels on all electrodes with the first CI were high (209 current levels averaged across electrodes), and the patient used the maximum volume setting of 9. C-levels on a number of electrodes were reaching maximum voltage compliance levels allowed by the software. When maximum voltage compliance is reached, the implant is not able to deliver the required current level for electrodes that are at or above the compliance limit. This can result in the absence of loudness growth and distortion of sound (Cochlear™ Clinical Guidance Document). In an effort to equalize the loudness between the ears, the CI audiologist had the patient decrease the volume of the first CI speech processor after the three-month test interval. The patient continued to use the same map with the lower volume setting in daily life and was tested with this map and setting at the six-month test interval. It is suspected that the lower volume setting may have helped to improve her understanding of speech in noise by making sound less distorted. With the Nucleus device, lowering the volume decreases C-levels. Perhaps reaching maximum voltage compliance levels on a number of electrodes caused distortion that may have improved with a lower volume setting and consequently lower C-levels.
The difference in stimulation rates used with the first CI (1800 pps/ch) and second CI (500 pps/ch) is unusual. The majority of bilateral implant patients at WUSM are sequentially implanted and use the same stimulation rate for both implants. At WUSM, a number of stimulation rates are tried with each patient at programming sessions during the first six weeks after initial activation of the CI. After experience with a number of stimulation rates, the patients choose which rate they prefer. A stimulation rate of 1800 pps/ch was chosen by this patient with the first CI as providing the best speech understanding and sound quality in daily life. The same stimulation rate was then used at the initial activation of the second implant; however, the patient experienced dizziness that was controlled by keeping the volume and sensitivity at lower levels than what she felt was needed to provide equal loudness between the two implants. Lowering the stimulation rate to 500 pps/ch with the second CI allowed the patient to raise the volume from 4 to 5 and made speech and sound louder without dizziness. She quickly became accustomed to the sound quality with the two different rates. She declined to try a lower stimulation rate with the first CI reporting that she liked the sound quality when the two implants were worn together. The Nucleus device provides audiologists a number of programming parameters to manipulate in order to improve sound quality and speech understanding. These parameters can and should be utilized in order to maximize CI benefit for each patient.
The test results presented show that the patient is doing well on a number of difficult speech recognition measures presented in quiet and noise, especially in the bilateral condition, yet these tests can not completely replicate the difficult listening environments encountered in daily life. The patient's responses to the items on the SSQ provide a more realistic view of her perceived everyday communication abilities. As seen in Figure 11, there is an improvement from the pre-operative test interval to the six-month test interval in her averaged ratings across test items for each of the three scales; however, her average rating is only a five for the Speech scale. The Speech scale questions the patient's ability to understand in difficult listening environments. If the patient believed she was able to hear and understand perfectly in every situation on the SSQ, the average rating would be ten. The ratings for both the Spatial and Sound Qualities scales are higher but are still at an average rating of six. The SSQ data show that the patient's communication abilities have improved since being implanted bilaterally and continue to improve over time. It will be interesting to see if the perceived improvement in her communication abilities continues past six months or if it plateaus. Bilateral cochlear implantation has provided this patient with a substantial improvement in her speech understanding compared to unilateral cochlear implantation; however, the results of the SSQ clearly indicate that there are situations in which she has considerable difficulty. Research focusing on improving cochlear implant recipients' speech understanding in difficult listening situations is warranted.
This case study focused on a patient with bilateral, profound sensorineural hearing loss secondary to bilateral Meniere's disease. Her debilitating vertigo was controlled after a number of procedures on both the right and left ears including endolymphatic sac surgery with shunt (both ears), intratympanic gentamicin injections (right), intratympanic dexamethasone injections (left), and vestibular nerve section (right). To improve her hearing and speech understanding, the patient obtained a cochlear implant in her right ear and was able to continue to wear a hearing aid in the left ear. She reported to be satisfied with her communication abilities when wearing the CI and HA together. Her hearing deteriorated in the left ear after an endolymphatic sac operation, and she discontinued the use of the HA due to lack of benefit. She reported great difficulty communicating in daily life and especially in noisy environments when using the CI only. A second CI was implanted in her left ear two years after the first CI. Monosyllabic word scores of 90% and 98%, for the first and second implants, respectively, revealed above average speech recognition with each CI. Speech recognition testing in noise revealed a substantial improvement in scores when using two implants compared to scores using either implant alone. Her localization abilities improved when using bilateral implants compared to using a CI and a HA. In addition, the patient's responses to the SSQ indicated that bilateral cochlear implantation improved her ability to communicate in difficult listening situations, improved her localization of speech and sound, enhanced sound quality, and diminished the effort needed to understand speech in daily life. Bilateral cochlear implantation appears to be a viable option for patients with bilateral Meniere's disease whose dizziness has been controlled.
Appreciation is expressed to this patient for being so generous with her time and willing to share her experience with us. We would also like to acknowledge Chris Brenner for her assistance in designing the figures for this article and Tim Holden for creating the CT images and providing us with pertinent information. The adult bilateral research study was approved by the Human Research Protection Office at Washington University in St. Louis School of Medicine (#07–1037). This research was supported by Grant R01 DC009010 (JBF) from the National Institute on Deafness and Other Communication Disorders.
This research was supported by Grant R01DC009010 (JBF) from the National Institute on Deafness and Other Communication Disorders.
1Current level represents the amount of electrical current delivered to electrodes and is expressed in clinical programming units. For a more detailed description, see Cochlear™ Clinical Guidance Document (February, 2010) page 4.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's Canada Institute for Scientific and Technical Information in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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