Otology & Neurotology
00:00Y00 Ó 2007, Otology & Neurotology, Inc.
1YYear Postactivation Results for Sequentially
Implanted Bilateral Cochlear Implant Users
*Jace Wolfe, †Stan Baker, *Teresa Caraway, *Heather Kasulis, *Andrea Mears,
*Joanna Smith, ‡Leva Swim, and †Mark Wood
*Hearts for Hearing, ÞOtologic Medical Clinic at the Hough Ear Institute, and þINTEGRIS Health Decision
Support Services, Oklahoma City, Oklahoma, U.S.A.
Objective: Evaluate speech recognition in quiet and in noise for
a group of 12 children, all of whom underwent sequential bilat-
eral cochlear implantation at various ages (range, 1 yr, 8 mo to 9
yr, 6 mo at time of second implant).
Study Design: Retrospective.
Setting: Outpatient cochlear implant clinic.
Patients: Children who underwent sequential bilateral cochlear
implantation.
Intervention: Rehabilitative.
Main Outcome Measures: Speech recognition in quiet was
evaluated for each ear separately using single-word speech
recognition assessments (Multisyllabic Lexical Neighborhood
Test and Early Speech Perception Test) via recorded presenta-
tion. Speech recognition in noise was assessed for each ear
separately and in the bilateral condition by obtaining a spondee
recognition threshold in the presence of speech-weighted noise
presented at 45 dB hearing level. The primary outcome measure
for speech recognition in noise assessment was the signal-to-
noise ratio for 50% performance, which was calculated by deter-
mining the difference between the presentation level of the
noise and the presentation level at which the speech recognition
threshold was obtained. The results of these assessments were
contrasted between children receiving their second cochlear
implant before 4 years of age and children receiving their sec-
ond cochlear implant after 4 years of age.
Results: A statistically significant difference for speech recog-
nition scores in quiet was obtained between the early-
The advantages of bilateral hearing are well known.
Specifically, research has demonstrated that bilateral
hearing allows for improved detection of low-level
sounds (1), improved localization (2), improved speech
recognition in noise (3Y5), and optimal access for
sounds originating from either side of the head. Further-
Address correspondence and reprint requests to Jace Wolfe, Ph.D.,
Hearts for Hearing, One Corporate Plaza, 3525 NW 56th St, Oklahoma
City, OK 73112; E-mail: Jace.wolfe@heartsforhearing.org
Copyright @ 2007 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
implanted ear and the late-implanted ears for children receiv-
ing their second cochlear implant after 4 years of age. There
was not a statistically significant difference in speech recogni-
tion scores in quiet between the early-implanted and late-
implanted ears of children receiving their second cochlear
before 4 years of age. Both groups of children possessed better
speech recognition scores in noise (statistically significant at
an > = 0.05) in the bilateral condition relative to either uni-
lateral condition. However, there was not a statistically signif-
icant relationship between speech recognition performance in
noise and the duration of deafness of the later implanted ear.
Conclusion: Bilateral cochlear implantation allowed for better
speech recognition in noise relative to unilateral performance
for a group of 12 children who underwent sequential bilateral
cochlear implantation at various ages. There was not a statis-
tically significant relationship between speech recognition in
noise benefit, which was defined as the difference in perfor-
mance between the first implanted ear and the bilateral condi-
tion and the age at which the second implant was received.
Children receiving bilateral cochlear implants younger than
4 years of age achieved better speech recognition in quiet
performance for the later implanted ear as compared with chil-
dren receiving their second cochlear implant after 4 year of
age. Key Words: Auditory-verbal therapyVBilateral cochlear
implantsVCochlear implantsVImplantationV Pediatric
cochlearVSpeech recognition assessment.
Otol Neurotol 00:00Y00, 2007.
more, studies have shown that children with unilateral
hearing loss, and presumably impaired binaural hearing,
experience substantial academic difficulty, with the like-
lihood of failing a grade being as much as 10 times
higher than typically hearing children (6Y9). In addition,
patients who have bilateral hearing loss but use only one
hearing aid may experience a reduction in their speech
recognition abilities of the unaided ear secondary to
auditory deprivation for that ear (10,11). In recognition
of the benefits of binaural hearing and the limitations of
2 J. WOLFE ET AL.
monaural hearing aid fittings, bilateral hearing aid fit-
tings are the standard of care for patients with bilateral
hearing loss (12,13).
Although unilateral cochlear implantation has been
more common than bilateral cochlear implantation, a
number of reports have shown that the advantages of
binaural hearing such as improved speech recognition
in noise and improved localization abilities are available
to adults using two cochlear implants (14Y21). However,
a paucity of studies exists, examining outcomes for chil-
dren using two cochlear implants (19,22Y24). The fol-
lowing discussion offers a summary of recent findings of
bilateral cochlear implant outcomes.
Litovsky et al. (19) initially reported on localization
abilities for three children assessed after 3 months of
bilateral cochlear implant use, and at that time, no
improvement was observed in localization abilities in
the bilateral condition. In a follow-up study, however,
Litovsky et al. (22) evaluated localization performance
for a group of children with early-onset deafness and
greater than 3 months of experience with bilateral
cochlear implants, and they reported that the minimum
audible angle [MAA] threshold for a group of nine
pediatric bilateral cochlear implant users was signifi-
cantly better in the bilateral condition as compared
with the unilateral condition. In the bilateral condition,
the mean MAA threshold for the group of children with
bilateral cochlear implants was less than 20 degrees, a
significantly lower MAA than that of 70 degrees
obtained with unilateral cochlear implant use (22).
Litovsky et al. (22) noted additional findings of inter-
est in the study of localization abilities of pediatric bilat-
eral cochlear implant users. First, localization abilities
frequently improved throughout the first year of bilateral
cochlear implant use, suggesting that an extended period
of bilateral cochlear implant use is required to facilitate
the development of localization abilities. In addition,
improvement in localization was observed for several
children who had congenital deafness and did not
receive their second cochlear implant until as late as
12 years of age. As such, the period during which the
plasticity of the human binaural auditory system can
adapt to bilateral signals to yield an improvement in
localization abilities may extend into the second decade
of life and is longer than critical period of speech and
language development, which is typically thought to be
during the first 3 years of life (25).
There is a paucity of reports describing speech recog-
nition in noise performance for a group of children using
bilateral cochlear implants (19,23,24). Litovsky et al.
(19) reported on speech recognition in noise findings
for three children that had used bilateral cochlear
implants for 3 months and noted that two of those chil-
dren achieved better speech recognition in noise in the
bilateral condition as compared with monaural use.
There was no difference in speech perception between
the binaural and monaural conditions for the third child.
In an extension of that study, Litovsky et al. (23) eval-
uated speech recognition in noise for a group of children
Otology & Neurotology, Vol. 00, No. 0, 2007
Copyright @ 2007 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
using bilateral cochlear implants and concluded that
speech recognition in noise was significantly better in
the bilateral condition relative to the best unilateral con-
dition. In contrast, Schafer and Thibodeau (24) did not
find a difference in mean speech recognition in noise
performance between the bilateral and unilateral condi-
tions for a group of children with bilateral cochlear
implants. For both studies, speech recognition in noise
was assessed for some participants who had less than 6
months of experience with their second cochlear implant.
As previously stated, Litovsky et al. (22) noted that up to a
year of bilateral experience may be necessary to develop
localization abilities, so it is reasonable to presume that
similar experience may be necessary to develop speech
recognition in noise performance. Consequently, the
aforementioned studies may have found better speech
recognition in noise performance in the bilateral condi-
tion if measures were made after a longer period of bilat-
eral cochlear implant use.
Additionally, neither study examined speech recogni-
tion performance in quiet and noise as a function of the
duration of deafness at which the children received their
cochlear implants. Both studies included some children
that received their first cochlear implant later than 3
years of age and several children that received their
second cochlear implant much later than 3 years of
age (with most subjects receiving their second cochlear
implant between 6 and 10 years of age). As stated ear-
lier, the critical period of speech, language, and auditory
development is thought to be during the first 3 years of
life, and research has demonstrated that cochlear
implant outcomes are frequently poorer when implanta-
tion is provided at a later age (26Y30). Furthermore,
Sharma et al. (29) demonstrated that the central auditory
nervous system may be less receptive to auditory stimuli
if adequate auditory stimulation is not provided by as
early as 4 years of age. As such, it is possible that dura-
tion of deafness may impact benefit of bilateral cochlear
implantation, and children receiving a second cochlear
implant after 4 years of age may exhibit a poorer adjust-
ment to bilateral implantation.
The primary intent of this article is to report the
results of speech recognition assessment in quiet and
in noise for a group of 12 children who underwent
sequential bilateral cochlear implantation at various
ages and who have at least 1 year of bilateral cochlear
implant use. Speech recognition is compared between
two groups, one that received a second cochlear implant
with a duration of deafness of less than 4 years for the
second ear, and another group with children that
received their second cochlear implant with a duration
of deafness greater than 4 years for the later implanted
ear. Both groups received their first cochlear implant no
later than 3 years of age. This information is important
because it has yet to be reported in association with a
peer-reviewed journal and is valuable to health profes-
sionals seeking to provide optimal, evidenced-based
intervention to maximize auditory outcomes for patients
with severe to profound hearing loss.
 1-YEAR RESULTS FOR BILATERAL COCHLEAR IMPLANT USERS 3

METHODS those children, the monosyllabic version of the Central

Speech recognition in quiet and in the presence of inter-
fering noise was assessed at various intervals throughout the
first year of bilateral cochlear implant use for 12 children
who underwent sequential bilateral cochlear implantation.
Table 1 includes demographic information for all 12 chil-
dren. ll children included in this evaluation were prelin-
gually deafened and underwent activation of their first
cochlear implant at or before 3 years of age. Each child has
participated in intensive auditory-verbal therapy. The children
received limited to no benefit from hearing aid use in the
ear opposite their first implanted ear as evidenced by poor
aided speech recognition scores and an unfavorable anecdo-
tal report from the children, the children’s parents, and/or
the children’s auditory-verbal therapist. The age at which
the second cochlear implant was activated varied widely
among the 12 children, with a range from 22 months to
9.5 years of age. None of the children possessed otologic
characteristics (or any other attribute for that matter) that
would suggest one ear to have a more favorable prognosis
for postimplant performance than the opposite ear.
Open-set speech recognition in quiet was assessed with
the Multisyllabic Lexical Neighborhood Test (MLNT) pre-
sented at 50 dB hearing level (HL) in recorded format from
a loudspeaker positioned directly in front of the subjects at
a distance of 1 m. Two lists of 12 items each were pre-
sented for each condition. Open-set speech recognition
could not be assessed for five of the youngest patients
because their speech production made it difficult to score
responses or they would not participate in the task. For
Institute for the Deaf (CID) Early Speech Perception
(ESP) test was used to assess closed-set speech recognition.
Each item of the monosyllabic ESP test was presented twice
(for a total of 24 items) at 50 dB HL via recorded format,
and the subjects pointed to the picture that corresponded to
the word that was presented. Speech recognition in quiet
was evaluated for each ear separately for each child.
Speech recognition in noise was evaluated by obtaining a
speech recognition threshold in the presence of steady-state,
speech-weighted noise. The noise signal was presented at
45 dB HL from a loudspeaker located at 180 degrees in
the horizontal azimuth (i.e., 1 m directly behind the child),
and the level of the speech signal, which was presented via
monitored live voice (all speech recognition testing for
each patient was conducted by author J.W.) at 0 degree
in the horizontal azimuth (1 m directly in front of the
child), was adaptively varied to analyze the speech-to-
noise ratio at which the child could correctly identify the
target stimuli with 50% accuracy (SNR-50). The speech
signal was initially presented at 50 dB HL and decreased
in 5-dB steps until an incorrect response was obtained, at
which point, the presentation level was varied adaptively
(up in 1-dB steps after each incorrect response and down
in 2-dB steps after each correct response). The speech
recognition in noise threshold was deemed as the presenta-
tion level (decibel hearing level) at which the children
correctly identified spondee stimuli at a rate of 50% correct
(8 presentations were administered at the level specified as
threshold). The SNR-50 was defined as the difference in
decibels between the presentation level of the noise signal

TABLE 1. Demographic information for 12 children with prelingual deafness and at least 1 year of bilateral cochlear implant use
(listed in order of duration of deafness at the time in which the second cochlear implant was received)
Subject Age at first CI Age at second CI Duration of deafness at Duration of deafness at Make/model of Make/model of
no. Patient (yr;mo) (yr;mo) first CI (yr;mo) second CI (yr;mo) first CI second CI
1 P.M. 1;0 2;10 1;0 1;10 Advanced Advanced
Bionics/90K Bionics/90K
2 B.H. 1;0 2;0 1;0 2;0 Cochlear Cochlear
Corporation/ Corporation/
N24 Freedom
3 K.G. 1;1 2;3 1;1 2;3 Advanced Advanced
Bionics/90K Bionics/90K
4 B.L. 1;1 2;6 1;1 2;6 Advanced Advanced
Bionics/90K Bionics/90K
5 L.Z. 1;1 2;9 1;1 2;9 Cochlear Cochlear
Corporation/ Corporation/
N24 N24
6 F.H. 1;7 3;0 1;7 3;0 Cochlear Cochlear
Corporation/ Corporation/
N24 Freedom
7 K.P. 2;5 4;1 1;0 3;0 Cochlear Cochlear
Corporation/ Corporation/
N24 N24
8 M.N. 1;1 3;9 1;1 3;9 Cochlear Cochlear
Corporation/ Corporation/
N24 N24
9 P.H. 1;1 4;11 1;1 4;11 Advanced Advanced
Bionics/C1 Bionics/90K
10 R.M. 1;6 6;0 1;6 6;0 Advanced Advanced
Bionics/C1 Bionics/90K
11 M.G. 2;2 8;1 2;2 8;1 Advanced Advanced
Bionics/C1 Bionics/90K
12 S.Y. 3;0 9;6 3;0 9;6 Advanced Advanced
Bionics/C1 Bionics/90K

Otology & Neurotology, Vol. 00, No. 0, 2007

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4 J. WOLFE ET AL.

TABLE 2. Speech recognition scores obtained at 1-year Figure 2 possesses mean scores for the MLNT test
postactivation of the second cochlear implant for 12 children obtained with both the early implanted ear and the
that sequentially received bilateral cochlear implants later implanted ear after 1 year of activation of the sec-
Speech Speech ond implant for two groups: prelingually deafened chil-
recognition recognition SNR- SNR- dren who received their second cochlear implant with
in quiet, in quiet, 50 50 less than 4 years’ duration of deafness for the later
first ear second ear (dB), (dB), SNR-50
Subject (test/% (test/% first second (dB),
implanted ear (A) and prelingually deafened children
no. Patient correct) correct) ear ear binaural who received their second cochlear implant with greater
than 4 years’ duration of deafness for the later implanted
1 PM ESP/100 ESP/100 j4 j4 j10 ear (B). Speech recognition scores obtained for the sec-
2 BH ESP/100 ESP/100 j10 j10 j16
3 KG ESP/92 ESP/92 j6 j2 j11 ond ear with hearing aid use before the receipt of a
4 BL MLNT/100 MLNT/100 j6 j6 j12 cochlear implant are also provided in Figure 2. Student’s
5 LZ ESP/100 ESP/100 0 0 j6 t test was used to compare the differences between
6 FH ESP/100 ESP/100 j4 j6 j10 speech recognition scores for the two groups. There
7 KP MLNT/100 MLNT/100 j10 j5 j18
8 MN MLNT/100 MLNT/100 j9 j8 j14
was not a statistically significant difference between
9 PH MLNT/100 MLNT/50 j6 3 j15 speech recognition scores of the two groups for the
10 RM MLNT/100 MLNT/58 j5 j2 j11 first implanted ear ( p = 0.21), but the mean speech
11 MG MLNT/100 MLNT/50 j2 7 j7 recognition in quiet score for the second implanted ear
12 SY MLNT/92 MLNT/8 j7 7 j11 of the group with a duration of deafness of less than
4 years was significantly higher than the mean speech
recognition in quiet score of the group with a duration of
and the speech recognition in noise threshold (noise signal deafness of greater than 4 years ( p = 0.007). For both
level (45 dB HL) j speech recognition in noise threshold). groups, speech recognition in quiet for the later
The spondee stimuli were presented in random fashion implanted ear was significantly better than speech
from the Spondee version of the CID ESP test, and the recognition in quiet performance obtained with a hear-
children’s responses consisted of pointing to pictures that
ing aid before implantation ( p G 0.001).
corresponded to the word that was presented. Speech recog-
nition in noise was assessed for each ear separately and in Figure 3 shows the difference between speech recog-
the bilateral condition. nition scores obtained for the first and second implanted
ear for the two groups: Group A, which included chil-
dren who received their second cochlear implant with
RESULTS less than 4 years’ duration of deafness, and Group B,
which included children who received their second
Table 2 provides speech recognition scores for all 12 cochlear implant with greater than 4 years’ duration of
patients. Figure 1 possesses mean open-set speech deafness. The MLNT open-set speech recognition test
recognition scores for the MLNT test in quiet for 7 of was used to assess speech perception for seven of the
the 12 children while they used only the later implanted children, whereas the monosyllabic version of the CID
cochlear implant 1 year after the activation of the chil- ESP closed-set test was used to evaluate speech percep-
dren’s second cochlear implant. Linear regression and tion for five of the children in Group A because they
correlation analysis indicated a statistically significant were not developmentally mature enough to accurately
inverse relationship between duration of deafness for participate in open-set speech recognition assessment.
the second ear to be implanted and speech recognition Student’s t test was used to analyze the mean difference
score obtained in quiet when using only the later of speech perception between ears for the two groups
implanted ear (r = 0.86, p = 0.002). and indicated that a statistically significant difference

FIG. 1. Multisyllabic Lexical Neighborhood Test scores obtained for the later implanted ear at 1-year postactivation of the second
cochlear implant (scores are plotted in percent correct as a function of duration of deafness [in yr, mo] for the second ear at time of
implantation for that ear).

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 1-YEAR RESULTS FOR BILATERAL COCHLEAR IMPLANT USERS 5

FIG. 2. Mean MLNT scores for the first implanted ear (first ear) and second implanted ear (second ear) for two groups of children who
underwent sequential bilateral cochlear implantation: Group A (n = 3) possessed less than 4 years’ duration of deafness at the time in
which they received the second cochlear implant, and Group B (n = 4) possessed greater than 4 years’ duration of deafness at the time in
which they received the second cochlear implant.

existed for the two groups (p G 0.001). Finally, Figure 4
shows open-set speech recognition scores for the later
implanted ear of nine children for whom speech percep-
tion testing was assessed at additional intervals through-
out the first year of bilateral cochlear implant use.
Speech recognition in noise was assessed for 12 chil-
dren with 1 year of bilateral cochlear implant experience,
and mean results are provided in Figure 5. Bilateral ben-
efit in noise was defined as the difference in the SNR-50
between assessment conducted while the children used
only the first implanted ear and that obtained when they
used both cochlear implants simultaneously. Speech
recognition in noise was significantly better in the
binaural condition for the group of 12 children as com-
pared with performance when using only the earlier
implanted ear (p G 0.001). Bilateral benefit scores as a
function of duration of deafness at the time the second
cochlear implant was received are provided in Figure 6.
Linear regression and correlation analysis did not indicate
a statistically significant relationship between duration of
deafness for the later implanted ear and bilateral benefit in
noise (r = 0.11, p G 0.29). Mean bilateral benefit in noise is
shown in Figure 7 for two groups: Group A, which
included children who received their second cochlear
implant with less than 4 years’ duration of deafness, and
Group B, which included children who received their sec-
ond cochlear implant with greater than 4 years’ duration
of deafness. Student’s t test was used to analyze the mean
difference in bilateral benefit between the two groups and
indicated that a statistically significant difference did not
exist between the two groups (p = 1).
DISCUSSION
Advantages of Bilateral Cochlear Implantation
for Children
The results of this study indicate that children are able
to understand speech better in the presence of competing
noise with the use of bilateral cochlear implants relative
to their performance with one cochlear implant. The
degree of bilateral benefit was comparable to that
reported for adult bilateral cochlear implant recipients
in previous reports (16,21). A 6-dB mean improvement
in the SNR-50 was observed for the 12 children that
participated in this study. Research has shown that
each 1-dB improvement in the SNR may result in as
much as an increase of 5 to 10 percentage points in
speech recognition performance (31). As such, an
improvement of 30 to 60 percentage points in speech
recognition may potentially be achieved when listening
in noisy environments.
All children exhibited bilateral benefit in noise
regardless of the duration of deafness that existed for
the later implanted ear, and at 1-year postactivation of
the second cochlear implant, there was not a statistically
significant difference in bilateral benefit in noise
between children receiving their second cochlear
implant before 4 years of age and those receiving their

FIG. 3. Mean difference in speech recognition scores between the first and second ear for 12 children 1 year after the activation of their
second cochlear implant.

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6 J. WOLFE ET AL.
FIG. 4. Speech recognition in quiet scores obtained for the sec-
ond ear at several intervals throughout the first year of bilateral
use (n = 9) (scores provided in percent correct as a function of
duration of deafness [in yr, mo] for the second ear at time of
implantation for that ear).
second cochlear implant after 4 years of age. The find-
ing that children who receive a second cochlear implant
after a duration of deafness of greater than 4 years can
understand speech better in noise with two cochlear
implants relative to their performance with one is sig-
nificant. Benefit from bilateral cochlear implantation
may not be restricted to children with a short duration
of deafness. The period of development for central audi-
tory processing mechanisms responsible for hearing in
noise may be protracted as compared with the traditional
critical period of speech and language development,
which has long been considered to be approximately 3
years of age. As such, the exact Bcritical period^ to
access bilateral benefit in noise has yet to be analyzed.
Interestingly, the finding that bilateral benefit
observed for speech recognition was observed for chil-
dren with a duration of deafness extending from 2 to
almost 10 years is similar to the observation of Litovsky
et al. (22) that localization skills may improve with
bilateral implantation for children with a duration of
FIG. 5. Mean results for speech recognition in noise assess-
ment. The SNR_50 is provided for three conditions: (A) when
only the first cochlear implant is used; (B) when only the second
cochlear implant is used, and (C) when both cochlear implants
are used. Bilateral benefit is defined as the difference in SNR-50
between the first ear condition and the bilateral condition.
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FIG. 6. Bilateral benefit for speech recognition in noise (differ-
ence in SNR_50 between first ear condition and bilateral condi-
tion) as a function of the duration of deafness for the second
implanted ear at the time of implantation (scores provided in
SNR_50 as a function of duration of deafness [in yr, mo] of the
second ear at time of implantation for that ear) is provided.
deafness extending into the second decade of life.
Improved localization abilities and speech recognition
in noise have long been appreciated as benefits of bilat-
eral hearing. This study and the study of Litovsky et al.
(22) suggest that children have the potential to receive
substantial benefit from bilateral cochlear implantation
for both tasks, and the potential to benefit from bilateral
cochlear implantation on either task seems to be avail-
able for children that receive their second cochlear
implant as late as 10 years of age.
However, if a child is a good candidate for bilateral
cochlear implantation, there seems to be a potential
advantage in providing a cochlear implant for both
ears before 4 years of age to maximize the auditory
skill level of each ear. The results obtained for the
assessment of speech recognition in quiet suggest better
speech perception skills for children that receive their
second cochlear implant before 4 years of age. In fact,
the eight children that received their second cochlear
implant with a duration of deafness less than 4 years
possessed good speech recognition scores for the later
implanted ear, and the measures used in this study sug-
gested similar speech recognition capacity between the
first and second implanted ears. Children who received
their second cochlear implant with a duration of deaf-
ness of 5 to 8 years obtained much better open-set
speech recognition ability relative to their performance
with a hearing aid, but the speech perception capacity of
the later implanted ear was much poorer than that of the
first implanted ear. One child who received his second
cochlear implant at 9.5 years of age obtained very lim-
ited open-set speech recognition capacity after 1 year of
bilateral implant use. Additional studies should be con-
ducted to evaluate outcomes for the later implanted ear
of a larger group of children as a function of the duration
of deafness for that ear. In addition, assessment of
speech recognition should be conducted at intervals
that exceed 1-year postactivation of the second cochlear
 1-YEAR RESULTS FOR BILATERAL COCHLEAR IMPLANT USERS
FIG. 7. Bilateral benefit for speech recognition in noise (difference in SNR_50 between first ear condition and bilateral condition) for two
groups: Group A (n = 8) possessed less than 4 years’ duration of deafness at the time in which they received the second cochlear implant,
and Group B (n = 4) possessed greater than 4 years’ duration of deafness at the time in which they received the second cochlear implant.
implant because the possibility exists that performance
of the later implanted ear may continue to improve.
CONCLUSION
Bilateral cochlear implantation can allow for a signifi-
cant improvement in speech recognition in noise relative
to unilateral cochlear implantation. The improvement in
speech recognition in noise seems to be available for
children that receive their first cochlear implant before
3 years of age and a second cochlear implant as late as
10 years of age. This finding is similar to the finding of
Litovsky et al. (22) that showed improved localization
abilities for children receiving their first cochlear implant
at an early age and their second cochlear implant as late as
12 years of age.
Speech recognition in quiet was similar for the first
and second implanted ears of children who received
their second cochlear implant before a duration of deaf-
ness of 4 years. However, a large difference in speech
recognition in quiet occurred between the two ears of
children who received their second cochlear implant
after a duration of deafness of 4 years. As such, provid-
ing bilateral cochlear implantation at an early age may
potentially serve to enhance the speech recognition
capacity of each ear.
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