2015 HSC Section 1 Book of Articles

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HANG ET AL. / EAR & HEARING, VOL. 36, NO. 1, 8–13
clinical decision-making could be used to help guide families
towards an accelerated track to CI.
Based on the results of the present study, we have instituted
a number of new programmatic changes to reduce the age at
implantation among children with NR dABRs. First, we have
become more proactive in the management of otitis media, con-
sidering early tympanostomy tube placement rather than watch-
ful waiting among children with middle ear effusion present at
the time of dABR. More importantly, CI surgery can be dis-
cussed with many families at the time of NR dABR or shortly
thereafter. While this may be as early at 2–3 months of age, it
allows families to begin setting expectations and allows clini-
cians to plan their diagnostic testing and therapeutic interven-
tions accordingly. While we remain flexible in our ability to
change the plan based on unexpected progress with amplifica-
tion or other extenuating circumstances, this proactive planning
aligns the family and team expectations.
The rationale behind confirming ABR results with behav-
ioral testing is to identify children who have greater degrees of
residual hearing than those predicted by the ABR. Presumably,
some of these children could benefit from amplification, thereby
obviating the need for a CI. The results of this study did identify
children with NR ABRs who have significant residual hearing
on behavioral testing. Some children had low frequency thresh-
olds as good as 40–60 dB HL at 250 and 500 Hz, respectively.
However, all of these children ultimately went on to receive a
CI because of poor progress with their hearing aids or progres-
sive loss of residual hearing. Previous studies have suggested
that hearing aid trials do not significantly change clinical out-
come after implantation but can substantially delay fitting of CI
(Govaerts et al. 2002; Colletti et al. 2005). Based on the results
of the present study and others, further consideration must be
given to the value of the hearing aid trial amongst children with
NR ABRs. It does not suggest that there is no benefit to fit-
ting amplification in infants in a timely and appropriate manner.
Stimulation of the auditory system, even when it does not afford
normal development of spoken language, promotes the devel-
opment of communication skills. Therefore, all infants with NR
ABRs should still be fitted with hearing aids as early as possible
and usage should be encouraged throughout the CI process. The
length of the hearing aid trial, however, should not be extended
beyond the time it takes to resolve other considerations for suc-
cessful cochlear implantation. These may include the acquisi-
tion of medical information, other medical treatments, and
appropriate counseling and habilitative planning.
Eleven patients in the study were lost to follow-up and did
not have corresponding behavioral audiometric data. It is pos-
sible but unlikely that these patients did not return for follow-up
because there was significant residual hearing that obviated fur-
ther CI evaluation. The severity of the hearing impairment and
the importance of proper follow-up must be stressed at the time
of the NR ABR so as to ensure continued hearing evaluation
and not delay appropriate intervention.
In conclusion, bilateral NR ABRs using multifrequency
stimuli are highly predictive of progression to CI. This infor-
mation can be used to counsel families and align services
toward the goal of implantation at or before 1 year of age.
Watchful waiting of middle ear effusions, long hearing aid tri-
als in anticipation of appropriate speech and language develop-
ment, and unclear messaging regarding parental expectations
should be avoided in the setting of a NR ABR. Importantly,
great care should be taken to insure that ABR testing protocols
are of the highest quality in an effort to utilize this information
appropriately.
ACKNOWLEDGMENTS
The authors declare no conflict of interest.
Address for correspondence: Craig A. Buchman, MD, Department of
Otolaryngology-Head and Neck Surgery, University of North Carolina at
Chapel Hill, G190 Physician’s Office Building, 170 Manning Drive, Chapel
Hill, NC 27599, USA. E-mail:
Received September 22, 2013; accepted May 2, 2014.
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