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Cochlear Implants in Children: Ethics and Choices

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Another issue related to implant surgery that is of concern to parents is the question of which ear to implant. Not only must parents decide what type of implant to get for their child, they must frequently decide where to put it. In a few cases, the cochlear implant surgeon made the decision about which ear to implant, but in most of the families we discussed this with it was the parents who made the final choice.

Deciding which ear to implant is still far from an exact science, and the parents we talked with described a variety of reasons why they decided to have the implant surgery on one ear or the other. Many parents said they decided to implant their child’s “worst” ear (in terms of decibel loss) so that, if the implant did not work as expected, then the “best” ear would be available for later implantation (or for continued hearing aid use). In recent years, it appears that parents and implant centers have been more willing to implant the “better” ear since the likelihood of implant success, at least to some extent, has increased, and because it may be desirable to implant the ear that has a better history (or memory) of auditory stimulation.

In some cases, major or minor medical reasons governed the choice. For example, in one family, meningitis led to more ossification of the cochlea in one ear, which necessitated implantation in the other ear, whereas in another family a pre-existing scar near one ear made it appealing to have the surgeon “use” the same scar for the implant surgery. In another family, X-rays of the cochlea in both ears revealed that the facial nerve was too close to the cochlea in one ear, and the surgeon wanted to avoid possible complications in that ear. A minor skull fracture on one side of the head resulting from a fall led to implant surgery on the opposite side of the head for a child in one family, and, in another, it was determined that, on one side, the mastoid bone in the skull was not thick enough to support the internal transmitter.

Although medical problems and issues were important for some of the families, much of the time they were not the major factors in determining which ear received the implant. Rather, social factors, including concerns about expected speech and language development, frequently entered into the picture.

A few parents said that they decided to have the implant on the right ear because they thought this might facilitate language and speech development, which is centered in the left hemisphere of the brain. Others decided on the right ear because of athletic concerns (such as a child batting right-handed in baseball or softball and having the implant on the right ear, away from the pitcher), or because it was thought that, in the future, if their child were to be driving a car, an implant on the right ear would be more practical for hearing other people in the vehicle. Another parent decided to have an implant on her child’s right ear for a very practical reason: I usually am using my right hand and carrying [my son] around on my left and I thought that his right ear is going to be most available to me. 

Cochlear implant centers now sometimes perform a promontory stimulation test to determine if implantation in one ear might be more desirable than the other. In this test, an electrode is inserted through the eardrum onto the promontory of the cochlea. Then, tests are performed to determine how the auditory nerve responds to an electrical signal. Presumably, if the response is significantly better in one ear, this might be an important reason to do the implant in that ear. But, there is still no one, single, overriding criterion that is used for determining which ear to implant, and parents and surgeons continue to use a combination of aesthetic, practical, and medical reasons when making the decision.