Asymmetric Hearing During

Development: The Aural Preference

Syndrome and Treatment Options
Karen Gordon, PhDa,b, Yael Henkin, PhDc,d, Andrej Kral, MD, PhDe,f,g

Deafness affects ∼2 in 1000 children and is one of the most common abstract
congenital impairments. Permanent hearing loss can be treated by fitting
hearing aids. More severe to profound deafness is an indication for cochlear
implantation. Although newborn hearing screening programs have increased a
Archie’s Cochlear Implant Laboratory, The Hospital for Sick
the identification of asymmetric hearing loss, parents and caregivers of Children, Department of Otolaryngology–Head and Neck
Surgery, bUniversity of Toronto, Toronto, Canada; cHearing,
children with single-sided deafness are often hesitant to pursue therapy for Speech, and Language Center, Sheba Medical Center, Tel
the deaf ear. Delayed intervention has consequences for recovery of hearing. It Hashomer, dDepartment of Communication Disorders,
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv,
has long been reported that asymmetric hearing loss/single-sided deafness Israel; and eCluster of Excellence Hearing4all, Institute of
compromises speech and language development and educational outcomes AudioNeuroTechnology, Hannover, Germany; fDepartment of
Experimental Otology, ENT Clinics, School of Medicine,
in children. Recent studies in animal models of deafness and in children Hannover Medical University, Hannover, Germany; and
consistently show evidence of an “aural preference syndrome” in which single- g
School of Behavioral and Brain Sciences, The University of
sided deafness in early childhood reorganizes the developing auditory Texas at Dallas, Dallas, Texas

pathways toward the hearing ear, with weaker central representation of the Drs Gordon, Henkin, and Kral co-proposed the article
deaf ear. Delayed therapy consequently compromises benefit for the deaf ear, to the editorial office, cowrote the manuscript, and
revised the manuscript; and all authors approved the
with slow rates of improvement measured over time. Therefore, asymmetric final manuscript as submitted.
hearing needs early identification and intervention. Providing early effective
www.pediatrics.org/cgi/doi/10.1542/peds.2014-3520
stimulation in both ears through appropriate fitting of auditory prostheses,
DOI: 10.1542/peds.2014-3520
including hearing aids and cochlear implants, within a sensitive period in
development has a cardinal role for securing the function of the impaired Accepted for publication Feb 9, 2015

ear and for restoring binaural/spatial hearing. The impacts of asymmetric Address correspondence to Karen Gordon,
Department of Otolaryngology–Head and Neck
hearing loss on the developing auditory system and on spoken language Surgery, Archie’s Cochlear Implant Laboratory, The
development have often been underestimated. Thus, the traditional minimalist Hospital for Sick Children, Room 6D08, 555
approach to clinical management aimed at 1 functional ear should be modified University Ave, Toronto, ON, Canada M5G 1X8. E-mail:
[email protected]
on the basis of current evidence.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2015 by the American Academy of
Deafness is one of the most common clinical implications. Screening Pediatrics
congenital impairments.1,2 Newborn programs will also miss children who
FINANCIAL DISCLOSURE: The authors have indicated
hearing screening programs, acquire deafness in 1 ear from
they have no financial relationships relevant to this
implemented in many countries, have infection, trauma, or worsening of article to disclose.
decreased the age at diagnosis of preexisting hearing loss.3–6 Acquired
FUNDING: Dr Kral has been supported by the
hearing loss. When hearing loss occurs unilateral deafness can go unidentified Deutsche Forschungsgemeinschaft (Cluster of
in only 1 ear, the screening result until educational, social, or other Excellence Hearing4all). Dr Gordon’s work has been
may be overlooked or dismissed as impairments push families and supported by the Canadian Institutes of Health
unimportant, particularly when caregivers to seek medical consult. Research and the SickKids Foundation, including the
Bastable-Potts Clinician-Scientist Award in Hearing
hearing in the opposite ear is normal Because the prevalence of permanent
Impairment. Dr Henkin’s work has been supported
(unilateral or single-sided deafness). unilateral hearing loss in neonates is by the Shauder grant, Sackler Faculty of Medicine,
The consequence will be a failure to reported to vary from 0.45 to 2.7 in Tel Aviv University, Israel.
intervene until long after major 10007,8 and estimates in school-aged POTENTIAL CONFLICT OF INTEREST: The authors have
developmental effects have set in, children range from 30 to 56 in indicated they have no potential conflicts of interest
which causes significant negative 1000,9,10 awareness of medical to disclose.

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PEDIATRICS Volume 136, number 1, July 2015 STATE-OF-THE-ART REVIEW ARTICLE
professionals, and especially of difficult to distinguish from the development of speech, language,
pediatricians, to this hearing disorder original sound. Other situations are and cognition are well recognized
is of crucial importance. challenging because .1 sound source in children with unilateral
Asymmetric hearing loss can also is present. Many people could be deafness,21–28 with reports of
be established in children who have speaking at a time such as in a typical increased effects for right-eared
profound hearing loss in both ears cocktail party13,14. For children, impairments.19,29,30 A recent large-
by treating only 1 side. Since the common complex listening cohort study indicated lower mean
appearance of cochlear implants (CIs) environments include classrooms, vocabulary, verbal IQ, full-scale IQ,
in clinical medicine, this therapy for playgrounds, and school hallways and oral language scores in children
profound deafness has become very where they spend much of their daily with unilateral hearing loss compared
effective.11 Of the .100 000 children life. These can be more spatially with normal-hearing sibling
who presently use CIs worldwide,11 dynamic than the “cocktail party” controls.20 These children have high
the majority have bilateral deafness example because both the listener risks of educational problems,
but are only implanted in 1 ear12; and his/her peers tend to be on the including repeating at least 1 grade
they are, in effect, children with move. and/or receiving individualized
asymmetric hearing loss. educational assistance.31–36
Hearing from 2 ears (binaural) allows
Moreover, behavioral problems are
In this State-of-the-Art Review, we precise localization of sound sources.
more prevalent.37 Individuals with
present evidence from basic and Time and level differences between
asymmetric hearing loss perceive
applied neuroscience, audiology, and the ears are initially detected and
themselves to have significant
otology that points to the existence evaluated in the auditory brainstem
handicaps38 and exhibit reduced
of an impairment of the central and midbrain.13 The listener uses quality-of-life scores compared with
representation of the poorer hearing these cues to separate and distinguish normal-hearing peers.39 Importantly,
ear if developmental asymmetric between sound sources in space, these issues are not captured by
hearing is left untreated for years. thereby improving the signal-to-noise a typical clinical hearing test
First, we review the current state of ratio for complex sounds (binaural (audiogram), which measures
the problem as viewed in the clinic. unmasking) and separating original sensitivity to sound in a quiet
Next, we consider the background sounds from their reflections situation.
from well-controlled animal models, (precedence effect).15 Additional
in which investigations have ranged benefits of binaural hearing are that
from defined areas of the brain to the ear closer to the sound source AUDITORY PROSTHESES PRESENTLY
individual neurons. A review of can receive up to 20 dB louder input USED TO AID ASYMMETRIC HEARING
evidence from human brain imaging than the other ear, providing an LOSS
and behavioral studies complement advantage for speech comprehension To date, treatment approaches for
the picture by highlighting effects (better ear or head shadow effect) unilateral hearing loss range from
of single-sided hearing in children. and an improvement in hearing “watchful waiting” to hearing
The combined data support our sensitivity by ∼3 to 10 dB, which rehabilitation by means of a variety of
contention that a preference for 1 ear provides increased accessibility hearing devices, as shown in Fig 1,
is established biologically, to sound (binaural summation/ depending on the child’s age, degree
functionally, and subjectively from redundancy effect or diotic benefit). and type of hearing loss, and listening
asymmetric hearing in early Although the pinna (outer ear) can environment. These devices include
development. This “aural preference provide some localization ability from the following: a CI (Fig 1A), a hearing
syndrome” requires rapid diagnosis 1 ear alone by using spectral aid (Fig 1B), a bone-anchored hearing
and intervention. cues,16,17 it is less precise than with aid (BAHA) (Fig 1C), and a personal
binaural hearing and works best if the assistive listening device (Fig 1D).
CURRENT STATE OF THE PROBLEM sound is broadband (containing many
The most common auditory
frequencies) and is familiar to the
One ear alone carries only limited prosthetic is the hearing aid, which
listener.
information regarding locations of primarily amplifies sound so that it
sound sources. Without this Without normal binaural hearing, is audible to the impaired ear
information, hearing is degraded in individuals with asymmetric hearing (Fig 1B). Although fitting a hearing
adverse listening conditions. Some loss have impaired sound localization aid to the ear with hearing loss
rooms pose particular problems abilities, particularly in the hemifield has the potential of providing
because acoustic sound waves easily of the impaired ear,18 and bilateral stimulation, evidence for
bounce between the walls, floor, and compromised speech understanding effectiveness is limited to small
ceiling, adding reflections that are in noise.19,20 Deficits in the groups40 and is predominantly based

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142 GORDON et al
 head so that sound can be transferred
to both cochleae through vibration
of the skull rather than via the
external and middle ear.
An option that should be considered
for unilateral severe-to-profound
hearing loss is a CI (Fig 1A), as
performed in adults whose single-
sided deafness was accompanied by
intractable tinnitus.45,46 The use of
CIs in individuals with single-sided
deafness is supported by significant
improvements in speech
understanding in noise, localization
ability, and subjective hearing
benefits in adults (meta-analysis47).
Preliminary data on 3 children (aged
4, 10, and 11 years old) with
noncongenital unilateral hearing loss
after cochlear implantation provide
evidence for binaural benefits.48
An alternate solution is to send sound
FIGURE 1 from the ear with severe-to-profound
Auditory prostheses worn by children. A, CIs are indicated for ears with severe-to-profound deaf- hearing loss to the better hearing
ness. Candidacy for cochlear implantation in children involves a comprehensive assessment of the ear by contralateral routing of signal
child, including radiologic assessment of the cochlea and auditory nerve, medical suitability for
surgery, confirmation that hearing aids do not provide adequate benefit, realistic expectations of (CROS) hearing aids.49 BAHAs have
the child/family, and enrollment in an appropriate educational/therapy program.12 The external also been provided on the side of the
equipment is shown. The ear-worn piece includes a microphone to pick up sound and a sound impaired ear as an alternative to
processor that analyzes the sound for frequency and intensity over time. This information is sent to
CROS hearing aids. Sounds from the
the internal equipment through FM signals via the round transmitting coil, which sits on the child’s
head. It stays in place with a magnet that is attracted to another magnet in the internal device. The impaired side are converted by the
internal device delivers electrical pulses to stimulate the auditory nerve. B, A hearing aid is shown BAHA into skull vibrations that
as worn on a child’s ear. Sounds are picked up by a microphone and amplified by gains specific to the stimulate the opposite, better
child’s hearing loss. The amplified sounds are sent via a tube into an earmold (here in blue) to the
child’s ear. For high-gain hearing aids, the earmold must seal sounds in the ear to avoid feedback
functioning cochlea. The use of
(whistling caused by a leak of amplified sounds back into the hearing aid microphone). C, A BAHA is BAHAs in children with profound
shown. The internal device vibrates the skull to stimulate fluid movement in the cochleae. Acoustic unilateral hearing loss remains
sound is picked up by a microphone on the external equipment and sent to the internal device through controversial, despite better speech
a direct connection (percutaneous abutment) or magnetic connection as in the device shown. The
device can also be secured by a soft band of elastic placed around the head. D, Two parts of an FM understanding in background noise50
system are shown. The equipment shown on the desk contains a microphone to be worn by speaker and significant improvements in
(ie, a teacher) attached to a transmitter. The sound is transmitted by FM signal to a receiver worn by quality of life.51 It is important to
the child in his better hearing ear (enlarged insert). The sound is sent to the ear via a tube connected remember that any therapeutic
to an earmold. Little amplification is required, and thus the earmold is not sealed and allows other
sounds to enter the ear. approach that bypasses the impaired
ear, such as the CROS aid and BAHA,
will leave it untreated.
on subjective reports of school-aged reluctance to fit a hearing aid in the
children, parents, and teachers presence of a normal-hearing ear, and There are other assistive listening
(reviewed in refs 40 and 41). restricted benefit in cases of severe- devices to help the child with
The reality is that the initial to-profound hearing loss in which asymmetric hearing loss. Frequency
recommendation for hearing aid high levels of gain may actually modulated (FM) technology has long
amplification is rare41–43 and that stimulate the better hearing ear been effectively used for increasing
adherence to hearing aid usage is through bone conduction. In the case the signal-to-noise ratio in individuals
poor.39,41–44 Underlying these of maximum unilateral conductive with hearing impairments to hear
findings are the following: hearing loss due to microtia/atresia, from a distance, in noise, and in
considerable uncertainty regarding a BAHA can be fitted on the affected reverberant environments.52 FM
clinical recommendations for side (Fig 1C). A BAHA contains systems transmit the input from
intervention in such cases, parents’ a sound processor coupled to the a microphone worn by a speaker,

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PEDIATRICS Volume 136, number 1, July 2015 143
typically a teacher, to a receiver timing cues,63 the latter cues are not in the auditory cortices for the
coupled to the open, good ear. detected either by children implanted contralateral ear.90–92 As shown in
Advantages of FM technology in sequentially64 or by adults whose Fig 2A, electrodes placed in the
improving word recognition have deafness was present at birth.63 primary auditory cortex of a hearing
been reported.49 Disadvantages of Nonetheless, both adults and children cat reveal larger and faster responses
FM systems include the hardware benefit from using bilateral over to contralateral than ipsilateral ear
required for both speaker and unilateral implants due to the stimulation.92 The wiring pattern of
listener and the presentation of reduction in the head shadow effect the afferent auditory system can
binaural cues to only 1 ear, precluding and binaural summation.65–67 explain this finding, in part, because
their analysis and use. Reducing the interimplant delay in the majority of fibers cross
children appears to improve sound contralaterally at the brainstem.
localization68,69 and speech Congenital deafness changes this
ASYMMETRIC HEARING LOSS IN EARLY perception in noise,70,71 providing normal pattern; in bilateral deafness,
DEVELOPMENT evidence for the importance of the normal contralateral aural
Clinical studies show that the use of bilateral input during early auditory preference was reduced.92 (Fig 2B).
a congenitally deaf ear may be limited development. In unilateral deafness, on the other
later in life even when the other ear hand, both cortical hemispheres
has early access to sound. In children showed larger and faster responses
who are bilaterally implanted in PHYSIOLOGY AND PATHOPHYSIOLOGY from the hearing ear (Fig 2 B and
sequential procedures, outcomes of OF UNILATERAL HEARING
D90,91). In this sense, congenital
speech perception using the second- The mammalian brain is immature at single-sided deafness promotes an
implant ear are significantly poorer birth and can be manipulated by abnormal aural preference in which
than the outcomes with the first changes to the input it receives the representation of the better-
implanted ear.53–55 The difference in during development. The human hearing ear is “stronger” (more
performance increases as the delay auditory system continues to develop extensively represented in the
between implantation lengthens,56–58 after birth, with auditory areas of the auditory system) and the other ear is
and gains are particularly slow in cerebral cortex requiring more than “weaker” (less well represented in the
children who receive the second a decade of life to reach maturity.72,73 auditory system). The early onset
implant after puberty.55 Similarly, The circuitry for binaural processing of unilateral hearing thus puts the
patients with unilateral atresia is inborn and functional soon after deaf ear into a significant
exhibited a postoperative dichotic ear hearing onset,74,75 but is sensitive to disadvantage for competition for
advantage in the nonatretic ear that manipulation of hearing,75–77 with cortical resources. These effects
was adjustable before, but not after, sometimes lifelong consequences decreased with increasing age
puberty.59 If the single-sided deafness (reviewed in refs 13 and 78). of onset of single-sided hearing,
occurs during adulthood, asymmetric signaling an early sensitive
performance after treating the deaf Evidence for an Aural Preference period for unilaterally driven
ear is not prominent.45,60,61 In a large Syndrome reorganization.90,91 Importantly, the
study involving 2251 individuals with When unilateral deafness occurs in responses for the deaf ear were not
postlingual deafness, the implanted early development, the hearing ear completely eliminated in the feline
ear was not a predictive factor for becomes overrepresented in the brain;91 this finding significantly
outcomes62: results were similar auditory system.79–81 Novel auditory differs from effects of monocular
whether the ear with longer or shorter projections from the hearing ear are deprivation in which projections from
duration of deafness was implanted. formed when experimental lesions the sighted eye extensively take over
This outcome difference between are induced in animals near birth but neurons originally responsive to the
sequential bilateral implantation in do not occur in adult animals.81–86 deprived eye or both eyes.93 In the
adults and children provides evidence Moderate unilateral hearing loss case of unilateral deafness, even some
for a developmentally sensitive period leads to similar, although less (although substantially weakened)
for reorganization promoted by extensive, reorganization.77,87–89 The extraction of binaural cues was
asymmetric hearing. consequences for the opposite deaf preserved at the cellular level,75,94
Long periods of asymmetric hearing ear remained unexplored until CIs suggesting that the reorganized aural
in development also affect measures entered the scene. In congenitally preference is not permanent and can
of binaural hearing after bilateral deaf white cats, CI stimulation potentially be reversed. This is why
implantation. Whereas adults who revealed that complete (binaural) the term “aural dominance,” originally
became deaf after childhood perceive deafness reduces what has been proposed for aural cortical
changes in both interaural level and termed the normal “aural preference” representation in the auditory

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144 GORDON et al
FIGURE 2
Summary of the results of cortical responsiveness from binaural hearing, binaurally congenitally deaf, and single-sided hearing cats, obtained by
microelectrode mappings (.100 recording positions) of cortical local field potentials in the primary auditory cortex (field A1) evoked by CI stimulation.
Shown are maximum positive amplitudes as a function of recording position. A, In a hearing control, similar to acoustic stimulation, electrical stimulation
at the contralateral ear results in larger responses and shorter latencies (color denotes onset latency) compared with ipsilateral stimulation.
Consequently, there is an aural preference for the contralateral ear. B, In a single-sided hearing cat if the hearing ear is the ipsilateral ear, the aural
preference reverses: ipsilateral responses become larger and appear earlier (color). C, Summary of the binaural cats. Normal-hearing cats show
a contralateral aural preference. In binaurally deaf cats, the contralateral aural preference is weakened but not reversed. D, In unilaterally hearing cats,
aural preference reverses at the ipsilateral hemisphere to the hearing ear and stronger responses are observed for the hearing ear in both
hemispheres. Rudimentary responsiveness for the deaf ear is, however, preserved. Thus, a “stronger” and a “weaker” ear effect results. Data and figures
were modified from refs 91 and 90, respectively.

cortex,95 was softened to “aural compared with the left ear.103,104,108 auditory brainstem, the first point of
preference.”91 More extensive effects, including binaural integration in the ascending
Supporting evidence for recruitment of additional cortical pathways, is already affected.
a developmental change toward areas/networks, were observed in Brainstem responses rapidly change
abnormal cortical aural preference is children with unilateral hearing over the first year of unilateral CI use
available in humans with asymmetric loss,109–113 in line with the increasing in children with early-onset
hearing who did not receive effects found in younger cats90,91 deafness.118,119 When the opposite
treatment. Various imaging and the language, cognitive, and (second) ear was implanted after this
techniques have been used, including educational challenges these children period (.1.5 years), the brainstem
electroencephalography and are reported to have (discussed in responses from this ear remained
functional MRI. A number of studies “Current State of the Problem” abnormally prolonged despite up to 3
documented a stronger than normal section above). years of bilateral implant use
representation of the hearing ear at Further support for abnormal aural (Fig 3120,121). By contrast, bilateral
the cortex ipsilateral to the hearing preference comes from children who implantation with minimal or no
ear in adult onset of single-sided receive bilateral CIs sequentially. delay in early development promoted
deafness.96–101 This change resulted Although expected cortical symmetric maturation of the
in a more symmetric activation of electrophysiologic responses were responses for both ears.120 Cortical
both auditory cortices from the measured from the first implanted responses of sequentially implanted
hearing ear.101–107 The differences ear, responses from the second, later- children revealed a reduction in
from normal were larger when the implanted ear remained normal contralateral aural preference,
loss occurred in the right ear abnormal.114–117 The developing consistent with the animal studies

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PEDIATRICS Volume 136, number 1, July 2015 145
(Fig 4122). Importantly, this abnormal sided deafness will lead to a biased school-aged,21,129 long after many of
asymmetry was not found in children input to higher-order cortical areas the changes reviewed above have
who received bilateral implants and cognition. Behaviorally, it is likely already occurred. The increased age/
with ,1.5 years of interimplant delay further aggravated by subjective duration of deafness will thus limit
(short delay or simultaneous bilateral factors such as an attentional bias the potential benefits of hearing aids,
implantation). Protection against toward the better-represented ear. In as already reported,130 or of CIs.
aural preference to 1 ear thus this context, the aim of treating Treatment is thus important and
requires bilateral input during asymmetric hearing loss is to prevent cannot be delayed.
development. this reorganization. Despite the increased representation
The change in aural preference from of the hearing ear in the brain, the
the contralateral ear to preference for IMPORTANT FACTORS FOR A NEW representation of the deaf ear does
the hearing ear in both cats and TREATMENT OF ASYMMETRIC HEARING not vanish completely (Fig 2).
children91,122 may reflect differential LOSS Moreover, residual sensitivity for
reorganization of inhibition and Single-sided hearing, due to binaural cues persists in cochlear-
excitation in both hemispheres, reorganization toward the hearing implanted humans,120 in
ie, hemisphere-specific ear, likely protects from hearing and experimental animals with
reorganizations.84–86,90,123 Because language deficits associated with the asymmetric hearing,77,87 and in
of the earlier development of completely deaf brain (reviewed in congenital deafness.75,94 Thus, even
inhibitory synapses,124,125 there is refs 126 and 127), including in the worst condition (early onset,
a shorter sensitive period for the immature cortical circuits, cross- long duration of single-sided
change in aural preference at the modal reorganization, and reduced deafness), there is some hope for
hemisphere ipsilateral to the hearing plasticity (reviewed in refs 78 and stimulating hearing in the deaf ear
ear91 and a longer sensitive period 128). Initial acquisition of speech and and establishing binaural hearing,
for the hemisphere contralateral to language by children with single- with demonstrable benefits already
the hearing ear.90 In other words, sided deafness has made the hearing realized.64–66,68–70,131–134 On the
single-sided deafness leads to an loss difficult to identify in the absence other hand, these skills remain
asymmetric brain that shows distinct of neonatal hearing screening abnormal, reflecting persistent
adaptations at the 2 hemispheres,90 programs and has also fueled reorganization after single-sided
which both result in boosting arguments against treatment. Yet, by hearing. Without focused training,
responses from the hearing ear. the time challenges in spatial hearing 3 to 4 years of bilateral implant use
Stronger representation of the and listening in noise have been was not sufficient to reduce the
hearing ear in developmental single- found, these children often are preference of the first-implanted ear

FIGURE 3
A, EABR wave eV evoked by the CI-1 (right implant) and CI-2 (left implant) are at similar latencies to the BD in a child receiving both implants
simultaneously. B, A period of unilateral CI use before bilateral cochlear implantation reduces wave eV latency evoked by CI-1 and the response from
CI-2 remains delayed despite 2 years of bilateral CI use. The BD is delayed relative to the CI-1–evoked wave eV. C, CI-2–evoked wave eVs are
significantly prolonged relative to CI-1 when the period of unilateral CI use exceeds 2 years. Plots were reprinted from ref 120, Fig 3. BD, binaural
difference component; EABR, electrically evoked auditory brainstem response; eII, the second wave of the EABR; eIII, the third wave of the EABR; eV, the
fifth wave of the EABR.

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146 GORDON et al
FIGURE 4
A–D, Schematic representations of the strength of pathways from each ear (right ear in red, left ear in blue) to the contralateral and ipsilateral auditory
cortices are shown. E, Mean (SE) dipoles measured in the left (blue) and right (red) auditory cortices.122 Contralateral activity is normally stronger than
ipsilateral activity. Bilateral pathways are essentially symmetric in children receiving bilateral input in early development (normal-hearing, simultaneous
bilateral implants, short delay between implants). Unilateral right implant use strengthens pathways to both contralateral and ipsilateral auditory
cortices, increasing dipoles in the left auditory cortex and reversing aural preference to the first implanted right ear. Data from ref 122. CI-1, first implant;
CI-2, second implant.

in the auditory cortices of children as adolescents suggest that there are 2. asymmetric speech understanding
implanted sequentially with a long continued difficulties in processing in each ear that is resistant to
delay.122 Although these children input from the second-treated ear. treatment (ie, persisting after
learned to detect large changes in Overall, the data indicate that an early compensation of the initial asym-
binaural timing cues after long period of monaural hearing as brief as metry); and
periods of bilateral implant 1.5 years has long-lasting 3. deficits in binaural hearing, in-
experience, they continued to judge consequences. cluding sound localization, re-
input as coming from the side of their sistant to therapy of the weaker
first implant more often than children ear.
receiving bilateral implants RECOMMENDATIONS FOR
simultaneously.134 Furthermore, IDENTIFICATION AND TREATMENT OF Awareness of the problem is
ASYMMETRIC HEARING LOSS important. On the basis of recent
although speech perception was
gained in the weaker ear, the progress Combining the available evidence, evidence, a more aggressive approach
was slow and did not match the we propose the existence of an to treating asymmetric hearing loss in
stronger ear even after 5 to 9 years of “aural preference syndrome,” children appears to be justified, with
implant use.58 Poor speech characterized by a combination of the following objectives:
perception55 together with absent following factors: 1. early identification of hearing loss
cortical binaural interaction135 in 1. asymmetric hearing during that is more pronounced in 1 ear
children receiving the second implant development; than the other;

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PEDIATRICS Volume 136, number 1, July 2015 147
2. a reduction in asymmetric hearing hearing (CI in 1 ear and a hearing aid
by providing appropriate auditory in the other) provides benefits over
ABBREVIATIONS
prostheses* in each ear with unilateral listening132,136–142 but BAHA: bone-anchored hearing aid
limited delay; and may not necessarily avoid or CI: cochlear implant
3. provision of auditory-based reverse asymmetric aural CROS: contralateral routing of
training to limit possible effects preference or provide accurate signal
of “aural preference” for the binaural cues. FM: frequency modulation
stronger hearing ear. The potential for reversing the
preference for the stronger ear
exists. After developmentally mild REFERENCES
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recognized and more aggressively 2008;72(4):475–482
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that presently concentrate on
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do not own a car made in this millennium, and were looking for a reliable all-wheel
drive car that was safe in the snow. We were fairly open-minded about what we
wanted, so we looked at many different cars from diverse manufacturers. We also
got lots of interesting advice from friends and family. My daughter scoffed when I
told her I wanted a specific car in red, retorting that the particular model was clearly
not sporty, was designed for old men like me, and that I should stick with a basic color.
For a brief time, my wife decided that she wanted a white car because it would send
a message (or at least until I told her that white is the most common color of new cars
sold in the US and the world). It seems that what type of car one purchases and even
the color can say a lot about the buyer.
As reported in The New York Times (Real Estate: April 9, 2015), wealthy car drivers
have very particular buying preferences which vary by zip code. For example, in
Beverly Hills, luxury car buyers prefer Mercedes, while in the San Francisco Bay area
they prefer the Tesla Model S, and in New York City they prefer the BMW X5. Surveys
completed by more than 300,000 car buyers, between September 2013 and August
2014, showed that car choice correlates with a myriad of personal characteristics
and interests. It turns out that bridge and poker are popular pursuits among
Mercedes-Benz S Class buyers, while New York BMW X5 buyers enjoy bowling more
than those who buy other luxury brand cars.
I certainly do not plan to fill out a survey after we finally purchase a car, but if I do,
I am pretty sure that the most important reason that we purchased the car is because
my wife liked it the most.
Noted by WVR, MD

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PEDIATRICS Volume 136, number 1, July 2015 153
Asymmetric Hearing During Development: The Aural Preference Syndrome and
Treatment Options
Karen Gordon, Yael Henkin and Andrej Kral
Pediatrics 2015;136;141
DOI: 10.1542/peds.2014-3520 originally published online June 8, 2015;

Updated Information & including high resolution figures, can be found at:
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orders_sub
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Asymmetric Hearing During Development: The Aural Preference Syndrome and
Treatment Options
Karen Gordon, Yael Henkin and Andrej Kral
Pediatrics 2015;136;141
DOI: 10.1542/peds.2014-3520 originally published online June 8, 2015;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/136/1/141

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