European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S1–S3

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Original article

ECAP analysis in cochlear implant patients as a function of patient’s

age and electrode-design
F. Christov ∗ , P. Munder , L. Berg , H. Bagus , S. Lang , D. Arweiler-Harbeck
Department for head and neck surgery, Universitätsklinikum, Essen, Germany

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Electric compound action potentials (ECAPs) provide information about the nerve’s and
Cochlear device’s function in and after cochlear implantation. In general, lower ECAP values are expected to gen-
Implant erate better results. Aim was an analysis of ECAPs in the course of time as a function of the patient’s age
ECAP
and electrode design.
NRT
Patients and methods: Between 2008 and 2013, 168 patients of eight defined age groups were included
CI
Electrode into the investigation. NRTs were measured intraoperatively, after 6 and after 12 months.
Array Results: The intraoperative mean value of ECAP was 174.14 CL (current level) and decreased after
Perimodiolar 6 months to 156.38 CL. Highest ECAPs were achieved intraoperatively in the clusters “younger than
Hearing loss 18 months” (181.04 CL) and “older than 80 years” (190.45 CL). CI 422 showed apparently higher ECAP
Threshold thresholds (182.69) during surgery than CI 24 RE (171.47) and CI 512 (170.64).
Conclusion: ECAPs are a well-established method to get information about the CI’s and nerve’s function
during and after surgery. After initial higher values NRTs decrease after 6 months and remain stable
in the following controls. Very young and older patients tend to have higher thresholds than middle-
aged groups. Perimodiolar electrodes are significantly attached to lower values because there is a closer
nerve–electrode interaction.
© 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction operation and can help postoperatively to adjust the cochlear

Electric compound action potentials (ECAPs) are determined as
a matter of routine in cochlear implant patients. There is little com-
prehensive knowledge of the influence of age or electrode type
on these potentials. ECAPs provide information on the nerve’s and
device’s function in and after cochlear implantation. Corresponding
to wave I of the Auditory Brainstem Response (ABR), the potentials
appear with a latency of 0.2 ms. In general, lower ECAP values are
expected to create better results because they are generated by
lower stimuli. ECAPs are scaled in current level (CL) by using the
NRT-System (Neural Response Telemetry). There are two different
ways to obtain NRTs:
• vNRTs (visual) represent the lowest stimulation level at which
the initial potential is visible;
• tNRTs are the predicted NRT-thresholds based on a linear regres-
sion [1]. tNRTs are measured automatically during and after
∗ Corresponding author. Tel.: +49 17 68 24 96 28 5.
E-mail address: florian.christov@uk-essen.de (F. Christov).
implant.
In order to optimize the individual hearing result, an additional
setting is provided. Within Mapping (MAPs), it is possible to iden-
tify the hearing threshold (T-level) as well as a comfortable hearing
volume (C-level). Nevertheless, it is not recommended to use NRTs
as single setting for CI-adjustment [1]. In the literature, NRTs mea-
sured intraoperatively are reported to show higher levels than
those in the postoperative controls [2]. Further influence factors
such as patient’s age are discussed contrary [3,4]. The outcome of
NRT values also depends substantially on the electrode type as far
as length, shape and diameter is concerned [5]. The aim of the fol-
lowing study was an analysis of tNRTs with respect of patient’s age
and electrode design in the course of time.
2. Patients and methods
A retrospective study of intra- and postoperative tNRTs at the
hospital’s Cochlear Implant Centre was realized. One hundred and
sixty-eight CI-patients of eight defined age groups (Fig. 1) oper-
ated between 2008 and 2013 were included into the investigation.
Auto-tNRTs of all 22 electrodes were measured intraoperatively

http://dx.doi.org/10.1016/j.anorl.2016.04.015
1879-7296/© 2016 Elsevier Masson SAS. All rights reserved.
S2 F. Christov et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S1–S3
Fig. 1. Mean NRTs of all patients and electrodes at three points of time.
at closed operative site as well as 6- and 12 months after surgery.
Using SPSS 22, the analysis of variance (ANOVA) and statistically
significance were calculated as well as a t-test. Significant results
were defined for P < 0.05. This study was performed in accordance
with the Declaration of Helsinki and was approved by the local
ethics committee.
3. Results
In all, 168 patients tNRTs were reproducible and the average
values of all patients and all electrodes at three points of time
were analysed. The intraoperative mean value was quite high
174.14 CL (current level) and decreased after 6 months significantly
(P = 0.000) down to 156.38 CL, followed by a slightly not significant
increase (P = 0.351) after 12 months (157.79 CL). Fig. 2 pictures the
mean tNRTs of all patients and electrodes at three points of time.
The collective was splitted into eight age groups. The data
of the very young ones and patients older than 60 years
showed a tendency towards higher values. Highest tNRTs were
achieved intraoperatively in the clusters “younger than 18 months”
(181.04 CL) and “older than 80 years” (190.45 CL). The middle age
groups seem to have lower thresholds but the results weren’t sig-
nificant (P = 0.305). The mean NRTs in eight age groups at three
points of time are demonstrated in Fig. 2. The thesis was ver-
ified in another classification. The cohort was divided in three
groups (0–1.5 years, 1.5–18 years, > 18 years) and the analysis of
mean tNRTs also showed lower values for patients between 1.5
and 18 years.
Regarding the electrode design three subgroups were classified:
CI 512, CI 24RE and CI 422, even though CI 512 and CI 24RE use the
same array type. CI 422 showed apparently higher ECAP thresholds
during surgery than the other two groups (182.69 CL intraoper-
ative and 168.49 CL after 12 months). The results were indicated
statistically significant showing the P-values P = 0.035 and P = 0.045.
The 6 month-value was higher (159.42 CL) too, but not significantly
(P = 0.219 CL). Table 1 shows the mean NRTs depending on electrode
design at three points of time.
4. Discussion
In the present study, the intra- and postoperative tNRTs were
compared. At first view, the results showed a decrease of ini-
tially high tNRT values intraoperatively to lower thresholds after
6 months. Chen et al. showed a significant diminishing of the results
already after 24 hours [2]. He claimed the phenomenon is caused by
an almost immediate restoration of neuronal sensitivity and inter-
action between matrix and electrodes. Potentially, the measured
tNRTs would show a similar performance being determined at an
earlier point of time after fitting. However, there is no information
whether Chen at al. evaluated the intraoperative tNRTs in an open
or already closed surgical setting [2]. In our experience, tNRTs as
well as the impedances are likely higher in an open operative site
than determined after suturing. tNRTs in this survey were exclu-
sively measured in a closed operative setting, however there could
still be seen an additional decrease after 6 months.
Potts et al. stated that vNRTs are more reliable than tNRTs [1].
They traced the thesis back to the way of determining each value.
While tNRTs are predicted values based on a linear regression of
several NRT thresholds vNRTs are the first potential measured after
the lowest stimulation. In their investigation, the mean vNRT was
10 current levels higher than the tNRT value. In the present study,
tNRTs seemed to be reliable and showed the same chronological
sequence in every patient and electrode. However, a rule regarding
vNRTs cannot be established as they were not analysed for this
study.
Carvalho et al. revealed no differences between children and
adults for NRTs [4]. In this study, an analysis between age and tNRTs
showed a tendency of higher values in children less than 1.5 years
and users older than 60 years. It is assumed that newborns still
have a developing auditory pathway while senior patients might
partially have an already degenerating one. Potentially in the by
Carvalho et al. described infants group, there was an accumulation
towards older kids and the effect was not as apparent. However, the
last named results showed an obvious tendency but were not sig-
nificant. Another opinion about the correlation of NRTs and age was
published by Brown et al. They claimed higher ECAPs for pediatric
cochlear implant users than for postlingually deafened adults and
argued that children might have different current fields and a con-
secutive enhanced formation of fibrous tissue which alleviates the
contact between electrode and nerve [3]. Hughes et al. published
in their study the same phenomenon with regard to the impedance
values [6]. Referring to infants younger than 18 months, we agree
with these results and the explanation of the potential origin. Potts
et al. also found a significant correlation between tNRTs and age and
justified the thesis with a loss of spiral ganglion cells beginning in
the basal parts of the cochlear with increasing age [1].
Contour advanced electrodes (CI 24 RE and CI 512) are charac-
terized by a perimodiolar location in the cochlea. Our investigations
ascertained lower NRTs for these cochlear implant types compared
to the slim straight array of the CI 422. The closer electrode–nerve
contact in contour advanced electrodes causes a better redirection
of the stimulus and consequently lower thresholds. This assertion
is supported by the study of Telmesani et al. [7]. In another survey,
Saunders et al. showed that thresholds and comfort levels were sig-
nificant lower in contour advanced than in straight electrodes [5].
Potts et al. joined the opinion confirming that slim straight elec-
trodes have significantly higher tNRTs [1]. In opposition to that,
Polak et al. as well as Hughes et al. did not find significant differ-
ences between both electrode designs [8,9]. The different results
might be due to the obviously smaller patient cohort. Polak evalu-
ated 30 and Hughes only 10 cases, while in the present investigation
168 patients were analysed.
Apart from that, there are many other factors which are consid-
erable for the outcome of tNRT thresholds. There is an important
impact of the cause and duration of deafness. A slowly progredient
hearing loss might result in different tNRT values compared to a
sudden hearing loss or congenital deafness. Likewise, there is a dis-
tinction between long-term and short-term hearing loss. Moreover
tNRTs of a drug-induced deafness might differ from a hearing loss
caused by genetical or postinflammatory origin.
 F. Christov et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 133S (2016) S1–S3
Fig. 2. Mean NRTs in different age groups at three points of time.
Table 1
Mean tNRTs of different electrode arrays at three specific points of time.
CI device type n Intra op
CI24RE 51 171.47
CI422 46 182.69
CI512 71 170.64
The influence of different insertion methods and electrode loca-
tion will be subject of upcoming studies. Practical experience shows
a difference between round-window insertion and cochleostomy-
approach. Furthermore tNRTs generated in the basal parts of the
electrode array lead to different values compared to the medial
or apical section. Reasons for this could be seen in the variable
electrode–nerve interaction or distinct features of hair cells and
the hearing nerve.
Another upcoming research subject is the dependency of tNRT
thresholds on postoperative hearing outcome. The aim of this item
is to answer the question whether the objective measured tNRT
results can predict postoperative speech perception. Consequently,
the presented results would suggest that the hearing outcome pro-
vided by perimodiolar electrodes might be better than with thinner
straight arrays (in case it directly depends on a low ECAP level).
Considering the fact that the thinner electrode (CI 422) so far has
been supposed to grant not only a better hearing preservation but
also a better hearing outcome it is a challenging task to answer this
question by further investigations.
5. Conclusion
ECAPs are a well-established method to get information about
the cochlear implants’ and nerve’s function during and after
surgery. After initial higher values, NRTs decrease after 6 months
and remain stable in the following controls. Very young and older
patients tend to have higher thresholds than middle-aged groups.
Perimodiolar electrodes are attached significantly to lower values
due to a closer nerve–electrode interaction.
S3
6 months 12 months Average NRT
153.17 156.15 160.26
159.42 163.38 168.49
156.65 155.32 160.87
Disclosure of interest
The authors declare that they have no competing interest.
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