European Archives of Oto-Rhino-Laryngology

https://doi.org/10.1007/s00405-019-05737-6

OTOLOGY

Cochlear implantation in adults with single‑sided deafness: generic

and disease‑specific long‑term quality of life
Franz Muigg1,2   · Harald R. Bliem2 · Heike Kühn3 · Josef Seebacher1 · Bernhard Holzner4 · Viktor W. Weichbold1

Received: 13 August 2019 / Accepted: 16 November 2019

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose  To determine the 2-year outcome of health-related quality of life (HRQoL) in adults who received a cochlear implant
(CI) for single-sided deafness (SSD).
Methods  Twenty adults (mean age at implantation: 47 ± 11 years) with SSD (PTA worse ear: 113 dB HL, PTA better ear:
14 dB HL) were administered the Nijmegen Cochlear Implant Questionnaire (NCIQ), and the Health Utility Index 3 (HUI
3). Questionnaire administration occurred before cochlear implantation and 3, 6, 12, and 24 months after implant activation.
Results  Of the 20 patients, 2 discontinued CI use within the observation period due to poor benefit. The NCIQ total score
of the sample increased significantly over time (p = 0.003). The largest increase occurred within the first 3 months of CI
use. Also, the HUI 3 multi-attribute utility score increased significantly (p = 0.03). The post-treatment increase of this score
(+ 0.11 points) indicated that the gain in HRQoL was clinically relevant. Patients with a duration of deafness > 10 years had
in all measures an equal HRQoL improvement than had patients with a duration of deafness < 10 years.
Conclusion  Cochlear implantation led to significant improvement of hearing-specific and generic HRQoL in our patients.
The improvement was seen after 3 or 6 months but did not increase further at later intervals. Patients with long-lasting SSD
may be at higher risk of discontinuing CI use. However, if they adapt to the CI, they can experience an equal increase of
HRQoL as patients with a short duration of SSD.

Keywords  Single-sided deafness · Cochlear implant · Health-related quality of life · Duration of deafness

Introduction social problems due to their limited hearing abilities [6].

The latter suggests that SSD may negatively affect hearing-
Single-sided deafness (SSD) is a condition where a person related quality of life (HRQoL) of afflicted persons.
has normal hearing in one ear and severe-to-profound hear- The prevalence of SSD in adults is not well established.
ing loss in the other ear. Persons with SSD typically perform In the UK, the annual incidence of acquired SSD in adults
poorly in tasks that require binaural hearing, such as sound was estimated to range from 12 to 27 per 100,000 [7]. A
source localisation or speech recognition in noise [1–5]. In recent study estimated that about 7% of adult Americans
addition, these persons may experience psychological and have unilateral hearing loss; in 1.5% of them, the hearing
loss is moderate or worse [8]. According to this finding, the
prevalence rate of SSD may lie at 0.1–0.5%, when “SSD”
* Franz Muigg
franz.muigg@tirol‑kliniken.at is restricted to cases with severe-to-profound hearing loss
(> 80 dB HL).
1
Department for Hearing Speech and Voice Disorders, Treatment options for SSD include contralateral-routing-
Medical University of Innsbruck, Anichstraße 35, of-signal (CROS) devices, bone-anchored hearing devices,
6020 Innsbruck, Austria
and cochlear implants (CI). Cochlear implantation is cur-
2
Department of Psychology, University of Innsbruck, rently not considered a standard treatment for SSD but gains
Innsbruck, Austria
more and more interest, because it has several advantages
3
Comprehensive Hearing Center, ENT University Clinic, over its alternatives. The first advantage is that it facilitates
Würzburg, Germany
restoration of binaural hearing. In consequence, most SSD
4
University Hospital of Psychiatry I, Medical University patients supplied with a CI show improved performance in
of Innsbruck, Innsbruck, Austria

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 European Archives of Oto-Rhino-Laryngology

speech-in-noise tests and sound localization, when compared c. How rapidly does the improvement in HRQoL occur
to the unaided situation or to rehabilitation options such as after implantation with CI?
CROS and bone conduction devices [9–16]. The second
advantage of cochlear implantation in SSD is that it may The outcome of cochlear implantation in SSD is not only
reduce tinnitus severity and tinnitus distress [11, 14, 17–19]. of clinical interest, but also of economic interest. The cost-
Third, cochlear implantation in SSD also has positive effects effectiveness of CI in SSD is still a difficult topic to assess
on HRQoL. A number of studies have reported significant for authorities due to limited research and lack of utility
improvement of HRQoL in SSD patients after cochlear data published from this population. For this purpose, we
implantation. For instance, Härkönen et al. [20] adminis- decided to address the above questions with two different
tered the Glasgow Benefit Inventory (GBI) to seven SSD instruments: with an instrument that measures disease-spe-
patients before cochlear implantation and 6 months after CI cific HRQoL and an instrument that provides generic utility-
activation. They found that the GBI total score significantly based measures of HRQoL. Generic utility-based measures
increased between the two time-points. Similarly, Dillon have the potential to influence resource allocation decisions
et al. [21] administered the Abbreviated Profile of Hearing in health care policy making when considered in an eco-
Aid Benefit (APHAB), the Speech, Spatial and Qualities of nomic evaluation [28].
Hearing Scale (SSQ), and the Tinnitus Handicap Inventory
(THI) to 20 patients with SSD who received a CI. After
12 months of CI use, significant improvement was found
with all three questionnaires; in some cases, the improve- Method
ment was seen already at 1 month after CI activation. Finke
et al. [22] interviewed 19 SSD patients with a semi-struc- Study design
tured questionnaire to explore their experiences after coch-
lear implantation. Analysis of patient responses indicated The study was conducted as a retrospective analysis of ques-
that a major part of the sample had experienced a substantial tionnaire data obtained routinely within the CI program
change of HRQoL after CI activation. The patients were implemented at the University Clinic in Innsbruck and at
also administered the International Outcome Inventory for the University Clinic in Würzburg. Approval from the local
Hearing Aids (IOI-HA), and it was found that the scores of institutional Ethics Committees for conducting the study
the IOI-HA subscale “HRQoL” had significantly risen after was received. Within the CI program, two different HRQoL
the treatment. Positive effects of cochlear implantation on questionnaires (see below for description) were adminis-
HRQoL of SSD patients were also reported from Rösli et al. tered to the patients at the following five time-points: before
[23], Skarzinsky et al. [24] and Häußler et al. [25]. cochlear implantation and 3, 6, 12 and 24 months after CI
Mixed results, on the other side, were reported by Louza activation.
et al. [26]. These authors administered 4 questionnaires to
a sample of 10 SSD patients: the SSQ, the APHAB, the
Nijmegen Cochlear Implant Questionnaire (NCIQ) and the Sample
EuroQoL-5-Dimensions-3-Levels (EQ-5D-3L). The latter
is a tool for assessment of generic HRQoL, while the NCIQ The study sample consisted of 20 adults (12 males, 8
is a tool for assessment of hearing-specific HRQoL in CI females) who received a CI for unilateral hearing loss in
patients [27]. When the data were analysed 1 year after coch- 1 of the above named clinics. The patients were implanted
lear implantation, none of these four measures indicated a between September 2015 and December 2016 (study onset),
significant improvement of the sample’s total score. Only and were followed over a period of 2 years for data collec-
a few subscales of the NCIQ and the SSQ showed a sig- tion. Only SSD patients were included in the study who met
nificant increase. Based on these findings, the authors con- the following criteria:
cluded that not all SSD patients might benefit from cochlear
implantation. • aged 18 years or older,
The goal of our study was to assess long-term outcome of • for the first time implanted with a CI (no previous CI),
HRQoL in patients who received a CI for SSD. In particular, • hearing in the worse (implanted) ear: > 80 dB HL (i.e., at
our study addressed the following questions: least severe hearing loss, measured as pure-tone average
[PTA] over frequencies 0.5, 1, 2 and 4 kHz),
a. What is the outcome of HRQoL in SSD patients after • hearing in the better ear: ≤ 30 dB HL PTA (i.e., at worst
2 years of CI use? mild hearing loss),
b. How does HRQoL in SSD develop over time after
implantation with CI?

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European Archives of Oto-Rhino-Laryngology

• adequate speech–language skills (i.e., capable of follow- considered to cover the full range of abilities/disabilities rel-
ing all oral and written communication at clinical exami- evant to the human health status: Vision, Hearing, Speech,
nations and counselling without the help of others). Ambulation (i.e. mobility), Dexterity, Emotion, Cognition,
and Pain. The HUI 3 scoring system provides utility scores
The demographic and clinical data of the sample, includ- on a generic scale between values 1.00 (= perfect health)
ing causes for the deafness, are shown in Table 1. Of the 20 and 0.00 (= dead). Utility scores can be computed for each
patients, 11 had a duration of deafness longer than 10 years, of the eight attributes (single-attribute utility score [SAUS])
and 9 had a duration of deafness less than 10 years. These and for the general health-state (multi-attribute utility score
patients were assigned to two groups: long-duration SSD [MAUS]). Further information about the HUI 3 is summa-
and short-/medium-duration SSD, and the two groups were rized and reviewed in Horsman et al. [29].
considered separately in the statistical analysis. All the
patients were implanted with a MED-EL SYNCHRONY CI Statistical analysis
with a MEDEL electrode (either FLEX28 or FLEXSOFT),
and received a MED-EL SONNET speech processor. The NCIQ total score, SAUS and MAUS were each entered
in a repeated-measures ANOVA which included two fac-
Questionnaires tors: “Change over Time” (with the five measurement inter-
vals as levels) and “Duration of Deafness” (with two levels:
Two questionnaires were used to assess HRQoL in the sam- “more than 10 years” and “less than 10 years”). Sphericity
ple: the Nijmegen Cochlear Implant Questionnaire (NCIQ) assumption was tested with the Mauchly test and, if violated,
and the Health Utility Index 3 (HUI 3). Greenhouser–Geisser correction was applied to degrees of
The NCIQ [27] has been developed for assessment of freedom. Alpha-error level was set at 5%. Post hoc com-
hearing-specific HRQoL in CI patients. It consists of 60 parisons between the measurement intervals were performed
items covering 6 domains of hearing-specific HRQoL: with the paired-sample t test at a Bonferroni-adjusted alpha-
Basic Sound Perception (BSP), Advanced Sound Perception error level (α’ = 5% / 10 = 0.5%).
(ASP), Speech Production (SP), Self-Esteem (SE), Social Apart from significance, changes of the SAUS and the
interaction (SI), and Activity (Act). Responses to the items MAUS were also interpreted in view of their clinical rel-
are given on a five-step scale with the values 0/25/50/75/100. evance. It has been proposed to consider a difference of 0.05
Internal consistency (Cronbach’s alpha) of the six domains points or more between mean utility scores as clinically
has been reported in the range 0.73 < α < 0.89; retest reli- important [28]. This proposal has been based on the results
ability has been reported in the range 0.64 < r < 0.85 [26]. of studies, which compared the mean scores of patients with
The HUI 3 [29, 30] is a questionnaire for measuring certain clinical conditions (e.g. schizophrenia) to sex- and
generic and attribute-specific HRQoL and producing util- ethnicity-adjusted HUI population norms. Thereby, differ-
ity scores. It includes eight attributes (domains) which are ences as low as 0.03–0.05 points were found to indicate a
significant difference [29–32].
Table 1  Demographic and clinical data of SSD patients

Sample size (N) 20

Results
Male: female (N) 12: 8
Mean age at implantation (years) 46.7 ± 11.0
Missing data and drop‑outs
Mean hearing loss in the worse ear (PTA dB HL) 113.0 ± 19.6
Mean hearing loss in the better ear (PTA dB HL) 14.4 ± 9.6
Of the 20 persons included in the sample, 14 (70%) arrived
Causes of unilateral hearing loss
at the study endpoint (i.e. 24 months after implant activa-
 Sudden hearing loss (N) 6
tion). Six patients did not finish the study; the reasons for
 Congenital or early acquired (N) 5
their dropout were:
 Trauma (N) 3
 Cholesteatoma (N) 3
• change of residence (1);
 Meningitis (N) 1
• incapacity to fill out the questionnaires due to exacer-
 Otosclerosis (N) 1
bated vision problems (1);
 Measles (N) 1
• failure to return the questionnaires (2);
Duration of deafness
• discontinuation of CI use (2).
 More than 10 years (N) 11
 Between 3 and 10 years (N) 4
Of the six patients who dropped out of the study, four
 Between 1 and 3 years (N) 5
continued to use their CI throughout the observation period.

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 European Archives of Oto-Rhino-Laryngology

Their dropout was unrelated to dissatisfaction with the CI. 100

Two patients (10% of the sample), however, discontinued 90

80
using the CI within the observation period. The reasons
70
for the discontinuation were that they had either problems 60
in adapting to the CI or they did not experience the ben- 50
efit they had expected. The time-points of dropout were 40
very different: the first patient terminated CI use at about 30

12 months after implant activation, and the second one at 20

about 20 months after implant activation. Both patients had 10

0
long-term SSD (> 10 years duration). Total BSP ASP SP SE SI Act

pre-op 3 months 6 months 12 months 24 months

Hearing‑specific HRQoL (NCIQ)
Fig. 1  Mean NCIQ scores (total score and domain-specific scores)
Repeated-measures ANOVA of NCIQ total scores revealed at time-points pre-operatively (each first bar of the domains) and 3,
significance of the factor “Change over Time” (F = 6.6, 6, 12 and 24 months after implant activation (subsequent bars in this
order). Error bars represent SD. BSP basic sound perception, ASP
p = 0.003), but not of “Duration of Deafness” (F = 1.4, advanced sound perception, SP speech production, SE self-esteem, SI
p = 0.26) and also not of the interaction between the two fac- social interaction, Act activities, Total total score
tors. This result indicates that NCIQ scores of SSD patients
changed significantly after cochlear implantation, but that
duration of deafness had no impact on the scores. Post hoc good keeping with the statistical finding that, after 3 months
comparisons of measurement time-points showed that the of CI use, no significant changes of the NCIQ total score
pre-operative score differed significantly from all post-oper- occurred any more.
ative ones (with all p‘s < 0.005), but post-operative scores
did not differ significantly from each other. Generic HRQoL (HUI 3)
Because duration of deafness was shown not to affect
NCIQ total scores, the scores of the two patient groups were Generic HRQoL measured with the HUI 3 is indicated by
pooled and are presented together in Table 2 and Fig. 1. the multi-attribute utility score (MAUS) as an indicator of
Table 2 provides the NCIQ total mean scores (last line) and the general health status. In addition, the single-attribute
also all domain-specific mean scores (lines above). The latter utility score (SAUS) of the eight health attributes Vision,
were not statistically compared to avoid excess of statistical Hearing, Speech, Ambulation, Dexterity, Emotion, Cogni-
testing. Figure 1 gives an illustration of the time course of tion, and Pain can be considered as indicators of the func-
the total mean score and the domain-specific mean scores tional state of these health domains. Both the MAUS and the
as a series of bars. From Fig. 1, it is easy to recognize that SAUS of the eight attributes found in our sample are shown
the NCIQ total score (most-left series of bars) increased in Table 3, and their course over time is illustrated in Fig. 2.
between time-points pre-operative and 3  months after As shown in Fig.  2, all single-attribute utility scores
implant activation, and then remained more or less stable (SAUS)—except for Hearing—lay more or less between
at all subsequent time-points. This visual impression is in 0.90 and 1.00, which indicates that our sample consisted of
patients with, in essence, good health. The lowered scores
on the attribute Vision were due to one patient with seri-
Table 2  Mean scores and standard deviations (in brackets) of the
NCIQ ous vision problems, and the lowered scores on the attribute
Pain are likely due to the fact, that chronic pain is frequent
Domain Pre-opera- 3 months 6 months 12 months 24 months
in older persons. On the attribute Hearing, however, the
tive
SAUS took a different course. It started from a low pre-
BSP 64 (17) 71 (14) 68 (16) 75 (12) 75 (12) operative level (0.58) and subsequently increased up to 0.80
ASP 66 (14) 74 (16) 73 (16) 77 (13) 75 (14) at 6 months after implant activation. After this increase, it
SP 82 (17) 86 (12) 79 (17) 82 (15) 82 (14) decreased again to 0.72 at 24 months after implant activa-
SE 48 (12) 60 (14) 61 (15) 62 (10) 61 (13) tion. Despite the decrease in the second half of the observa-
SI 50 (13) 64 (14) 68 (14) 67 (13) 65 (14) tion period, the SAUS of Hearing had an overall gain of
Act 52 (17) 64 (16) 67 (12) 67 (15) 64 (14) (0.72 – 0.58) = 0.14 between time-points pre-operative and
Total 60 (12) 70 (12) 69 (13) 72 (10) 70 (11) 24 months after CI activation.
Repeated-measures ANOVA of the SAUS of Hearing,
BSP  basic sound perception, ASP advanced sound perception, SP
speech production, SE self-esteem, SI  social interaction, Act activi- including the two factors “Change over Time” and “Duration
ties, Total total score. of Deafness” yielded significance for the first one (F = 3.6,

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European Archives of Oto-Rhino-Laryngology

Table 3  HUI 3 findings: Attribute pre-operative 3 months 6 months 12 months 24 months

single-attribute utility scores of
the eight attributes and multi- Vision 0.89 (0.25) 0.89 (0.25) 0.90 (0.24) 0.90 (0.24) 0.86 (0.27)
attribute utility score (MAUS)
Hearing 0.58 (0.32) 0.69 (0.30) 0.80 (0.16) 0.78 (0.17) 0.72 (0.13)
Speech 0.94 (0.11) 0.93 (0.13) 0.93 (0.12) 0.96 (0.07) 0.97 (0.06)
Ambulation 0.95 (0.09) 0.94 (0.11) 0.95 (0.16) 0.98 (0.08) 0.97 (0.06)
Dexterity 0.99 (0.04) 0.99 (0.04) 0.98 (0.04) 0.99 (0.03) 0.98 (0.04)
Emotion 0.94 (0.04) 0.92 (0.16) 0.97 (0.04) 0.95 (0.07) 0.96 (0.08)
Cognition 0.96 (0.07) 0.96 (0.06) 0.94 (0.07) 0.94 (0.07) 0.95 (0.07)
Pain 0.87 (0.16) 0.85 (0.24) 0.91 (0.13) 0.89 (0.14) 0.85 (0.18)
MAUS 0.57 (0.18) 0.61 (0.27) 0.72 (0.17) 0.71 (0.18) 0.68 (0.20)

In brackets: standard deviations of scores

1.10 90
1.00 80
0.90 70

0.80 60

0.70 50

0.60 40

0.50
30
20
0.40
10
0.30
0
0.20
pre-operave 3 months 6 months 12 months 24 months
0.10
short/medium duraon of SSD long duraon of SSD
0.00

Fig. 3  NCIQ total mean scores at time-points pre-operatively and

3, 6, 12 and 24  months after implant activation with a duration of
pre-op 3 months 6 months 12 months 24 months
SSD < 10 years (bright bars) and a duration of SSD > 10 years (dark
bars). Error bars represent SD
Fig. 2  HUI 3 findings over time: multi-attribute utility score (MAUS)
and single-attribute utility scores of the eight single attributes shown
as series of bars. Each series represents the time-points pre-opera- implant activation. Considering again the above-named cri-
tively, 3, 6, 12, and 24 months after implant activation (in this order).
terion for clinical relevance (i.e. a gain of at least 0.05), then
Error bars represent SD
a clinically relevant improvement of the MAUS was seen
after 6 months of CI use.
p = 0.03), but not for the second one (F = 0.19; p = 0.75). No When entering the MAUS into a repeated-measures
significant interaction between the two factors was found. ANOVA with the two factors “Change over time” and
This result indicates that only time after cochlear implan- “Duration of Deafness”, again only the first one was sig-
tation, but not duration of deafness, had an impact on the nificant (F = 2.9 p = 0.03), while Duration of Deafness and
SAUS of Hearing. Pairwise comparisons of the pre-oper- the interaction between the two factors were not significant.
ative and post-operative scores showed significance only Pairwise comparisons of the pre-operative and post-opera-
for the difference between the pre-operative score and the tive scores showed significant differences between the pre-
6 months’ score at the Bonferroni-adjusted alpha-error level operative and the 6-month scores, and also between the pre-
(α = 0.005), but not for any other differences. Taking into operative and the 12-month scores at a Bonferroni-adjusted
account that changes of utility scores are also interpreted in alpha-error level (α = 0.005). The other differences were not
terms of clinical importance (indicated by a gain of at least significant.
0.05), then all post-treatment utility scores of the attribute
Hearing showed a clinically relevant improvement compared Impact of duration of deafness on the results
to their pre-treatment values.
The HUI 3 multi-attribute utility score (MAUS) showed In an effort to analyse the effect of duration of SSD on post-
a course over time that equalled that of the single attribute operative HRQoL gain, two groups of SSD patients were
Hearing. It started from a similar level (0.57), increased up formed: patients with SSD lasting > 10 years (long duration,
to above 0.70 at 6 months and at 12 months after implant LD, N = 11) and patients with SSD lasting < 10 years (short
activation, and then decreased to 0.68 at 24 months after or medium duration, SMD; N = 9). Data of the two groups

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1.00 to a worse outcome of the SAUS of Hearing, in comparison

0.90
to a short duration of deafness.
0.80
0.70
Figure  5 depicts the MAUS values of LD and SMD
0.60 patients. It is striking that SMD patients had lower values
0.50 than have LD patients at all measurement intervals. How-
0.40 ever, the difference was not shown significant with the
0.30
repeated-measures ANOVA (reported above). The failure
0.20
0.10
to detect significance may be due to the small size of the
0.00
subsamples (N = 11 and 9, resp.). The observed difference
pre-operave 3 months 6 months 12 months 24 months is partly in line with the findings of the SAUS of Hearing
short/medium duraon of SSD long duraon of SSD (where SMD patients also had lower values at all post-opera-
tive time-points), but the differences between the two groups
Fig. 4  Single-attribute utility score (SAUS) of Hearing of patients can hardly be attributed to the SAUS of Hearing alone. We
with a duration of SSD < 10  years (bright bars) and a duration of
are unable to explain it. Perhaps, the SMD subsample for-
SSD > 10 years (dark bars). Error bars represent SD
tuitously had a lower level of generic HRQoL than the LD
subsample. When applying the relevance criterion (≥ 0.05)
1.00 to the observed differences, a relevant improvement of the
0.90
MAUS was seen in LD patients already after 3 months of
0.80
0.70
CI use (+ 0.07), and in SMD patients after 12 months of CI
0.60 use (+ 0.12). After 24 months, both patient groups had an
0.50 increase of + 0.11, compared to their pre-operative value.
0.40
This indicates that, despite different levels, LD and SMD
0.30
0.20
patients had similar gains of generic HRQoL.
0.10
0.00
pre-operave 3 months 6 months 12 months 24 months
Discussion
short/medium duraon of SSD long duraon of SSD

Our study applied two different types of HRQoL ques-

Fig. 5  Multi-attribute utility score (MAUS) of patients with a dura-
tion of SSD < 10 years (bright bars) and a duration of SSD > 10 years tionnaires: a disease-specific one (NCIQ) and a generic
(dark bars). Error bars represent SD one (HUI 3). Findings with both questionnaires showed a
significant improvement of HRQoL in SSD patients after
cochlear implantation. In addition, findings with question-
were analysed separately and results are presented in Fig. 3 naires showed that hearing-related HRQoL (NCIQ und
(NCIQ), Fig. 4 (SAUS) and Fig. 5 (MAUS). SAUS) improved very rapidly: a significant increase was
Figure 3 shows that the NCIQ total scores of LD and seen already after 3 or 6 months of implant use. This rapid
SMD patients were very similar, at the pre-operative time- increase indicates that our patients had little problems with
point and at all post-operative time-points. Also, the post- adapting to the new hearing sensation provided by the CI.
operative increases of the scores were equal in both groups: As a result, they were able to experience the benefits of the
LD and SDM patients experienced equal improvement of CI within a short time. As for the long-term course and out-
hearing-specific HRQoL after cochlear implantation. This come of HRQoL, however, the findings obtained in the two
finding is in line with the results of the repeated-measures questionnaires must be considered separately.
ANOVA (reported above) which indicated that NCIQ scores
of the two groups are not significantly different. Hearing‑specific HRQoL: NCIQ scores
Figure 4 shows the SAUS of Hearing of LD and SMD
patients. Remarkably, LD patients started at a lower level The NCIQ total score did not change further after 3 months
than did SMD patients, but had higher post-operative gains of CI use: the raised level of HRQoL measured at this time-
(and scores). This finding suggests that patients with a long point remained stable for the rest of the observation time.
duration of deafness experienced even more improvement A similar picture was obtained when the domain-specific
of hearing-related HRQoL than patients with less duration scores of the NCIQ were eyed (see Fig.  1). The largest
of deafness. However, this conclusion is uncertain, as the increase was always seen between intervals pre-operative
results of the repeated-measures ANOVA (reported above) and 3  months, while the changes at later intervals were
did not indicate significant difference between the two much smaller. Domain-specific scores more or less reflect
groups. At any rate, a long duration of deafness did not lead the course over time of the NCIQ total score, indicating

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European Archives of Oto-Rhino-Laryngology

that cochlear implantation leads to a quick improvement of The only study with divergent findings is the one of
hearing-specific HRQoL which, however, does not further Louza et al. [26]. This study also used the NCIQ for HRQoL
increase at subsequent intervals. The only exception is the measurement, but did not find a significant improvement of
score of the domain Speech Production (SP), where no pro- the sample’s total score after 1 year of CI use. In a figure
gress was made. While on the other domains, the scores included in their article, Louza et al. illustrate the pre- and
from intervals pre-operative and 24 months differed, on post-implantation NCIQ scores (total score and domain-
average, by some 10 points, on this domain, the two scores specific scores) of their sample. Indeed, when looking at
were identical. This finding suggests that speech produc- the total score, no pre–post change is seen. However, when
tion after cochlear implantation did not at all change in our looking at the domain-specific scores, a different picture
sample. This is not surprising, because SSD patients already emerges. One finds that in five out of six domains, the score
have good Speech Production before cochlear implantation. had increased after cochlear implantation by 5–10 points.
Hence, further improvement may not be expected. Only in one domain (Advanced Sound Perception) had it
When trying to compare our NCIQ findings to those of decreased by about 5 points. Considering these changes, one
other studies, one finds that comparability is limited. The wonders why they are not reflected in the total score. If the
major problem is that most studies that assessed HRQoL in scores of five out of six domains increase, and only one score
SSD patients did not use the NCIQ, but questionnaires such slightly decreases, then also the total score is expected to
as the APHAB, the GBI, the SSQ12, or the IO-HA. With increase. As we miss background information about Louza
regard to these studies, we can only state that our findings et al.’s study, we are not in the position to comment further
are in line with theirs in so far as most of them found that on their findings.
HRQoL (however measured) significantly improved in SSD
patients after cochlear implantation. Among the few stud- Generic health‑related HRQoL: HUI 3
ies that used the NCIQ, Häußler et al. [25] reported find-
ings that compare very well to ours. Häußler et al. admin- The HUI 3 utility scores of our sample showed a different
istered the NCIQ to a sample of 20 patients with a similar time course than the NCIQ scores. Both the single-attribute
degree of unilateral HL (up to 45 dB HL in the better ear) utility score (SAUS) of Hearing and the multi-attribute util-
and with a similarly wide range of duration of deafness ity score (MAUS) increased up to 6 months after implant
(0.3–27 years). Administration of the NCIQ occurred pre- activation, with the largest gains between 3 and 6 months
operatively and, on average, 1.5 years after implant surgery after implant activation. At subsequent time-points, how-
(range 0.5–3.3 years). The mean total score of their sample ever, both decreased again. The factor “Change over Time”
increased significantly from 63 to 74 points (+ 11 points) was significant for either scores: the MAUS and the SAUS.
after implantation. This increase corresponds well to that Post hoc comparisons between pre-operative and post-
observed in our sample (+ 9 points), even though in our operative scores did not show significant differences in all
sample, the total mean score was a little lower at the start- cases. This finding was somewhat unexpected in view of the
ing point and at the endpoint of the study. Also, Rösli et al. strong increase of the utility scores. It could be related to
[23] reported NCIQ scores from SSD patients. Their sample the hypothesis, that the Bonferroni adjustment (which was
consisted of eight SSD patients with normal hearing in the applied in our study) may be too conservative when a larger
better ear (PTA average: 7 dB HL) and an average duration number of subtests are performed. Nevertheless, the overall
of deafness of 7 ± 11 years. The NCIQ was administered, on increase of the scores between the time-points pre-opera-
average, 7–8 months after implant activation. The patients tive and 24 months after implant activation was impressive
indicated that, post-operatively, the scores had significantly (SAUS + 0.14; MAUS: + 0.09). Considering that an increase
increased (by > 10 points) on all domains of the NCIQ, of 0.05 is rated as clinically relevant, our findings suggest
except for Speech Production. Accordingly, the NCIQ total that cochlear implantation in SSD may be highly effective
score was significantly raised (+ 13 points). However, the in improving also the patients’ generic HRQoL.
large gains observed in this study must be seen with caution. It is remarkable that in the second half of the observa-
Because the study had a retrospective design, where pre- tion period the SAUS and the MAUS decreased. A possible
operative scores were not assessed but post-operatively esti- explanation could be that the questions of the HUI 3, which
mated, its results could be affected by a recall bias. Another assess the single attribute Hearing, are focusing on speech
study that used the NCIQ for assessment of HRQoL in SSD perception. The patients’ satisfaction with speech percep-
patients is the one of Sladen et al. [33]. This study also found tion, however, may vary over time. In the first months after
significant improvement on all six domains of the NCIQ implant activation, many patients are pleased when they
after 6 months of CI use. Unfortunately, NCIQ scores of notice the quick progress they are making. When asked for
this study are reported in a manner that does not allow direct the quality of their speech perception, they may indicate
comparison to our findings. a high level as they relate it to their previous experiences

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 European Archives of Oto-Rhino-Laryngology

(without CI). After a year or so, however, the progress slows from the CI and that these benefits were comparable to those
down, and some patients may recognize that there are still experienced by patients with a short duration of deafness.
situations where they do not understand well. In reaction, The findings from our study support the view that
they may be frustrated, because their hopes were not ful- duration of deafness plays a complex role in SSD. On one
filled. When asked about the quality of their speech percep- hand, we observed that long-lasting deafness was a risk
tion, they now may indicate an only moderate level, as they factor for CI discontinuation. The two patients of our sam-
relate it to their previous hopes. This would explain why the ple, who discontinued CI use, had long-lasting deafness
utility scores of the HUI 3 declined a little after 1 year. In (> 10 years). Referring this number to the size of the sub-
contrast, NCIQ scores remained stable, because the ques- sample, it means that 18% of the patients with long-term
tions of the NCIQ cover a broader range of sound percep- deafness, but none of the patients with short-term deafness
tion, not only speech recognition in demanding situations. have become CI non-users.
On the other hand, the patients with long-term SSD who
continued using the CI experienced equal improvement of
Dropout rate HRQoL as the patients with short-term SSD. Either sub-
sample showed a significant post-implantation increase of
Our sample included 20 patients at study onset and 14 at HRQoL scores, with similar gains and a similar course
study end (24 months after implant activation). Hence, there over time. As for the generic HRQoL, it even appeared
was a loss of six patients corresponding to a 30% dropout that scores were higher in the subsample with long-lasting
rate. In four of the six patients (20%), the study dropout was deafness, but the interpretation of this finding is difficult.
not related to dissatisfaction with the CI (according to our At any rate, long-lasting deafness was not found to yield
information). Two patients, however, discontinued using the poorer HRQoL outcome after cochlear implantation in
CI during the study period (10% of the sample). The reasons SSD than short-lasting deafness.
for the discontinuation were that either they had problems Based on these observations, we conclude that the role
with adapting to the CI or that they did not experience the of long-term deafness for cochlear implantation in SSD
benefit expected from it. The latter point deserves special is indeed complex. Long-lasting deafness may require
attention as it could play a critical role for SSD patients’ stronger rehabilitative efforts to get the deaf ear reacti-
satisfaction with the CI. Because SSD patients have normal vated. Due to this, there is an enhanced risk that the patient
hearing in their intact ear, their expectations towards hear- becomes dissatisfied with the CI and discontinues using it.
ing with the implanted ear may be very high. Perhaps, they But in case the patient continues using the CI, long-term
hope to hear as well with it as with the intact ear. Finally, deafness is not a risk factor for poorer outcome of HRQoL.
they may be disappointed when they recognize that, despite In this regard, our findings add to those of other stud-
several months of auditory training, their hearing skills are ies that reported similar observations [37–39]. We hence
still below their expectations. Especially for patients with suggest that long-term SSD should not be considered a
long-lasting deafness, the reactivation of the deaf ear may contraindication against cochlear implantation. If patients
be a challenge [34]. Indeed, both patients of our sample who with long-term SSD adapt to the CI, they can draw sig-
discontinued CI use were unilaterally deaf since birth or nificant benefit from it and can obtain equal improvement
early childhood. Our findings are, therefore, supporting the as patients with short-term SSD. The important point is,
view that patients with long-lasting unilateral deafness are at however, that these patients are adapting to the CI—which
an enhanced risk of experiencing dissatisfaction with a CI. emphasizes the need for good rehabilitative support and
auditory training.
Outcome in patients with long‑lasting deafness

Long-lasting auditory deprivation of an ear is a risk fac-

tor for a poorer outcome after cochlear implantation [35].
Conclusions
Adult SSD patients who have been deaf for many years, and
Cochlear implantation leads to significant improvement of
did not use a hearing aid in the deaf ear, could hence be at
health-related quality of life in patients with single-sided
risk for poorer benefit from the CI than are patients with a
deafness (SSD). Long-lasting SSD before cochlear implan-
short-lasting deafness. A few studies seem to corroborate
tation may be a risk factor for becoming a non-user as it
this hypothesis [34, 36], but others suggest that the role of
requires higher efforts for reactivating the deaf ear than
long-term deafness in SSD is more complex [37–39]. These
short-lasting SSD. However, if patients with long-lasting
studies found that also patients with a pre-operative duration
SSD have adapted to the CI, they may draw the same sig-
of deafness longer than 10 years obtained significant benefits
nificant benefit from the CI as patients with short-lasting

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European Archives of Oto-Rhino-Laryngology

SSD. In this regard, long-lasting SSD should not be con- longitudinal assessment of spatial hearing abilities and tinnitus
sidered a contra-indication for cochlear implantation. handicap. Otol Neurotol 35(9):1525–1532
12. Zeitler DM, Dorman MF, Natale SJ, Loiselle L, Yost WA,
Gifford RH (2015) Sound source localization and speech
Acknowledgements  The authors thank Dr. Anke Hirschfelder, Charité understanding in complex listening environments by single-
University Clinic Berlin, for providing a German version of the NCIQ. sided deaf listeners after cochlear implantation. Otol Neurotol
36(9):1467–1471
Compliance with ethical standards  13. Mertens G, Kleine Punte A, De Bodt M, Van de Heyning P (2015)
Binaural auditory outcomes in patients with postlingual profound
Conflict of interests This study did not receive funding in financial unilateral hearing loss: 3 years after cochlear implantation. Audiol
form. The MedEl Elektromedizinische Geräte GmbH supported the Neurootol 20(Suppl 1):67–72
study with licencing of the HUI 3 utility tool. 14. Blasco MA, Redleaf MI (2014) Cochlear implantation in uni-
lateral sudden deafness improves tinnitus and speech compre-
Ethical approval  This study was conducted according to the ethical hension: meta-analysis and systematic review. Otol Neurotol
standards of the 1964 Helsinki Declaration and its later amendments. 35(8):1426–1432
The study was approved by the Ethic Committees of the Medical Uni- 15. Tokita J, Dunn C, Hansen MR (2014) Cochlear implantation and
versity of Innsbruck, Austria, and the University of Würzburg, Ger- single sided deafness. Curr Opin Otolaryngol Head Neck Surg
many. 22(5):353–358
16. Vlastarakos PV, Nazos K, Tavoulari E-F, Nikolopoulos TP
Informed consent  Informed consent was not applicable in this study (2014) Cochlear implantation for single-sided deafness: the out-
because data were obtained during routine clinical procedures. comes. An evidence-based approach. Eur Arch Otorhinolaryngol
271:2119–2126
17. Holder JT, O’Connell B, Hedley-Williams A, Wanna G (2017)
Cochlear implantation for single-sided deafness and tinnitus sup-
pression. Am J Otolaryngol 38(2):226–229
18. Mertens G, De Bodt M, Van de Heyning P (2016) Cochlear
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