Saudi Journal of Otorhinolaryngology Head and Neck Surgery

: 2022  |  Volume : 24  |  Issue : 2  |  Page : 78--81

Changes of cochlear implant programming in cochlear implant user with middle ear disease

Shahad Saeed Bamhair 
 King Abdullah Ear Specialist Center, Riyadh, Saudi Arabia

Correspondence Address:
Aud. Shahad Saeed Bamhair
King Abdullah Ear Specialist Center, Riyadh
Saudi Arabia


We present a cochlear implant (CI) adult with active middle ear disease (MED). A 55-year-old Saudi female had sudden hearing loss (HL) since she was 18 years old (sensorineural HL). The patient developed MED after a period of CI programming stabilization that negatively affected the CI function. This case study clarifies these adverse effects on subjective hearing and objective CI measures (impedance and electrical compound action potential). Reprogramming the CI is recommended during the active MED and monitoring the middle ear status for cochlear-implanted children when noticing changes of objective CI measures accompanied with decreased overall performance.

How to cite this article:
Bamhair SS. Changes of cochlear implant programming in cochlear implant user with middle ear disease.Saudi J Otorhinolaryngol Head Neck Surg 2022;24:78-81

How to cite this URL:
Bamhair SS. Changes of cochlear implant programming in cochlear implant user with middle ear disease. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Jan 30 ];24:78-81
Available from:

Full Text


The middle ear (ME) is an air-filled space behind the eardrum that contains tiny vibrating bones of the ear called ossicles. The ME is located within the temporal bone and communicates anteriorly with the epipharynx via the Eustachian tube. In the opposite direction, it connects backward with the mastoid cavity through a recess, the tympanic antrum (Luers and Hüttenbrink, 2016)[1].

There are three ME functions: transmission of acoustic vibrations from the tympanic membrane (TM) to the cochlea, impedance matching between the air in the external auditory meatus, and the labyrinthine fluid protection of the inner ear through the acoustic reflex (Ayerbe et al.,1999).[2]

ME function can be affected by many infections leading to decreased hearing, ear pain, and drainage of fluid from the ear that include: otitis media with effusion (OME) is characterized by an accumulation of mucus behind the TM within the ME without other symptoms such as fever or otalgia and resolves within 3 months without treatment. Acute otitis media (AOM) is acute ME inflammation and middle ear effusion (MEE) within the ME space, usually presenting with symptoms consistent with infection, such as fever and otalgia. Chronic suppurative otitis media usually occurs as a complication of constant AOM and is specified by persistent ear discharge through a hole in the TM perforation (Shirai and Preciado, 2019).[3]

There is some evidence that MED and ME inflammation could affect the CI function due to CI device failure (Simmons, 2015).[4] This case study describes a unilaterally implanted patient infected and developed OME and its effects on the CI performance, effects on subjective hearing, and effects on objective measures.

 Case Report

A 55-year-old Saudi female had sudden hearing loss (HL) and tinnitus since she was 18 years old.

The etiology of her HL is unknown. She has no family history of HL and negative history of ototoxic drug exposure, otological trauma or surgery, and no significant occupational noise exposure.

She depended on lip reading for communication after HL. In the auditory assessment, a pure-tone audiogram showed bilateral profound sensorineural HL (SNHL). Tympanogram showed bilateral type A, and oto acoustic emissions were absent bilaterally. Radiological and preoperative computed tomographic scan was normal. The patient used bilateral (Phonak-Naida Q50UP) behind the ear. However, she used it irregularly with limited benefits.

The CI committee accepted the patient for bilateral CI. However, she chooses to be implanted in the right ear only. The patient underwent cochlear implantation of the HiRes Ultra Advanced Bionics device with a High Focus Mid-Scala electrode in the right ear.

The operation went smoothly; a 3 cm postauricular incision was done. The patient obtained full insertion of electrodes through the round window. The surgical technique used, and the patient had an uneventful recovery. Intraoperative measurements were unremarkable [Figure 1]. Postoperative X-ray was showing complete insertion.{Figure 1}

The patient's performance was improving with time in terms of overall hearing [Figure 2]. Her speech understanding was not improving fast as she depended on lip reading before implantation. Her speech recognition threshold (SRT) was 25 dB HL and word recognition score (WRS) was 33% at 65 dB. There were no significant changes in impedances, electrical compound action potentials (ECAP), or stimulation levels for the first 8 months.{Figure 2}

After 9 months of implantation, the patient presented to our clinic complaining of otalgia and decreased speech understanding, and she described the sound as “not clear and noisy.” She started to experience these symptoms 1 day after flight traveling to a rainy and cold area as per the patient report. There was no ear discharge, no facial weakness, or dizziness.

Aided audiometry showed a significant decrease in all frequencies comparing to the last visit before MED [Figure 3]. Speech tests were too hard for the patient to perform as the speech understanding was worse with WRS = 0% at 65 dB HL. Type C pattern tympanogram was attained on the right side with average volume [Figure 4].{Figure 3}{Figure 4}

In terms of objective measures, the patient's impedance shifted to significantly higher levels at all electrodes [Figure 5], and there were no ECAP responses at all electrodes [Figure 6].{Figure 5}{Figure 6}

The patient was referred to an otologist for diagnosis and treatment.

She was diagnosed with air babbles and fluids behind the TM, suggesting OME due to Eustachian tube dysfunction resulted from pressure changes when the patient was flying on a plane. The otologist recommended saline nasal spray and Valsalva maneuver.

Re-mapping was done, and there was an increase in both most comfort levels (M-levels) and threshold levels (T-levels) using tone bursts stimulus on each electrode as the patient needed more loudness level.

Follow-up was 1 week after the treatment and improvement of clinical symptoms. The patient-reported speech understanding improvement to be SRT= 30 dB HL and WRS= 40% was done at 65 dB HL without visual cues and aided audiometry improved at all frequencies [Figure 7]. Impedance level was decreased; ECAP showed again except for 15 and 16 electrodes. Electrodes 15 and 16 were deactivated before the MED episode due to increase impedance, no ECAP, and elevated T- and M-levels at these two electrodes with poor discrimination of/sh/and/s/sounds.{Figure 7}


This case study's findings showed the effects of MED on subjective hearing and objective CI measures. The subjective changes were manifested in decreased overall hearing level and speech understanding. Objective changes were significantly evident in impedance, ECAP, and the electrical stimulation levels (M- and T-levels).

Since the impedance is measured automatically, once the device is connected to the system (sound wave 3.2), the impedance was the first change observed. It is defined as measuring the resistance that tissues in the perilymph produce when a current–voltage is applied, as defined by (Alhabib et al., 2021).[5] As mentioned in the case, the impedance level was significantly higher during the MED episode than the first fitting impedance level. (Henkin et al., 2003)[6] reported that the impedance values stabilization occurs after 1 month of the fitting. Moreover, they explained the increase in impedance values after a period of stabilization could be a result of an inflammation in cochlear tissue due to the presence of otitis media. (Henkin et al., 2003)[6]

The ECAP as well was affected. The ECAP function is to assess the changes of auditory nerve responses and confirm the device function, and it works as an objective baseline to which subsequent measurements can be verified (Wolfe and Schafer, 2015)[7]. Tanamati et al and Telmesani[8],[9] agreed that the ECAP thresholds stabilized in the 3rd month after the fitting time, and there are no significant changes at later time points.

However, in our case, the ECAP of apical electrodes, mid electrodes, and basal electrodes was disappeared 10 months after fitting due to MED, which suggests physiological changes within the cochlear tissue. Further research to explore differences in ECAP thresholds and their relation to MED in CI systems is needed.

In addition to the impedance and ECAP measurement changes, the electrical stimulation levels were changed too. In Henkin et al.'s study, 2003, they suggested that the T-levels keep increasing and then stabilized after 3 months of visits. As for M-levels, the gradual increase goes on until 6 months, and then the stabilization occurs. On the contrary, in our case study, the patient's electrical thresholds (M- and T-levels) suddenly needed to be raised after a period of stabilization.


Results from this case study showed the association between MED and the changes in CI functions. Therefore, the audiologists should be keenly aware of the potential changes in impedance and ECAP – also, the need to adjust CI maps in cases of active MED. Careful monitoring of ME status for cochlear-implanted children should be taken, especially when noticing a sudden increase in impedance and ECAP changes accompanied by behavioral changes as they cannot express their symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Luers JC, Hüttenbrink KB. Surgical anatomy and pathology of the middle ear. J Anat 2016;228:338-53.
2Ayerbe I, Négrevergne M, Ucelay R, Sanchez Fernandez JM. Middle ear physiology. Rev Laryngol Otol Rhinol (Bord) 1999;120:291-9.
3Shirai N, Preciado D. Otitis media: What is new? In: Current Opinion in Otolaryngology and Head and Neck Surgery. Vol. 27. USA: Lippincott Williams and Wilkins; 2019. p. 495-8. Available from: [Last accessed on 2020 Dec 22].
4Simmons JL. Can Middle Ear Dysfunction Affect Cochlear Implant Function? Can Middle Ear Dysfunction Impact Cochlear Implant Function?; 2015. Available from:
5Alhabib SF, Abdelsamad Y, Yousef M, Alzhrani F, Hagr A. Effect of early activation of cochlear implant on electrode impedance in pediatric population. Int J Pediatr Otorhinolaryngol 2021;140:110543.
6Henkin Y, Kaplan-Neeman R, Muchnik C, Kronenberg J, Hildesheimer M. Changes over time in electrical stimulation levels and electrode impedance values in children using the Nucleus 24M cochlear implant. Int J Pediatr Otorhinolaryngol 2003;67:873-80.
7Wolfe J, Schafer E. Programming Cochlear Implants, 2015 (2nd ed.), plural publishing.
8Tanamati LF, Bevilacqua MC, Costa OA. Longitudinal evaluation of ECAP recorded in children with cochlear implants. Braz J Otorhinolaryngol 2009;75:90-6.
9Telmesani LM, Said NM. Electrically evoked compound action potential (ECAP) in cochlear implant children: Changes in auditory nerve response in first year of cochlear implant use. Int J Pediatr Otorhinolaryngol 2016;82:28-33.