Flexible Electrode Array Research Articles

Systematic Literature Review of Hearing Preservation Rates in Cochlear Implantation Associated With Medium- and Longer-Length Flexible Lateral Wall Electrode Arrays.

BackgroundThe last two decades have demonstrated that preoperative functional acoustic hearing (residual hearing) can be preserved during cochlear implant (CI) surgery. However, the relationship between the electrode array length and postoperative hearing preservation (HP) with lateral wall flexible electrode variants is still under debate.Aims/ObjectivesThis is a systematic literature review that aims to analyze the HP rates of patients with residual hearing for medium-length and longer-length lateral wall electrodes.MethodA systematic literature review methodology was applied following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendations to evaluate the HP rates of medium-length and longer-length lateral wall electrodes from one CI manufacturer (medium length FLEX 24, longer length FLEX 28 and FLEX SOFT, MED-EL, Innsbruck, Austria). A search using search engine PubMed (https://www.ncbi.nlm.nih.gov/pubmed/) was performed using the search terms “hearing preservation” or “residual hearing” and “cochlear implant” in “All fields.” Articles published only in English between January 01, 2009 and December 31, 2020 were included in the search.ResultsThe HP rate was similar between medium-length (93.4%–93.5%) and longer (92.1%–86.8%) electrodes at 4 months (p = 0.689) and 12 months (p = 0.219). In the medium-length electrode group, patients under the age of 45 years had better HP than patients above the age of 45 years.ConclusionsBoth medium-length and longer electrode arrays showed high hearing preservation rates. Considering the hearing deterioration over time, implanting a longer electrode at primary surgery should be considered, thus preventing the need for future reimplantation.

Battery-free and wireless tag for in situ sensing of urinary albumin/creatinine ratio (ACR) for the assessment of albuminuria

Random urine albumin-to-creatinine ratio (ACR) is highly correlated with 24-hour urine albumin, which is of great significance for the diagnosis of nephropathy, diabetes, hyperglycemia, and hypertension. In this study, we developed a battery-free, wireless, and flexible electrochemical tag for in situ quantification of urinary ACR. A flexible circuit electrochemical board is integrated with chronoamperometry (CA) and differential pulse voltammetry (DPV) for the detection of creatinine and albumin, respectively. Near field communication (NFC) module is applied for wireless power obtaining and data transmission. A disposable screen-printed flexible electrode array connected with the circuit board, including a non-enzymatic sensor for creatinine detection and an electrochemical immunosensor was applied for albumin detection. Within the effective working distance (1 ~ 2 cm), ACR sensing platform could be powered wirelessly by the NFC-enabled smartphone via electromagnetic coupling, performing real-time urine ACR detection and data transmission. The tag showed high consistency with clinical laboratory methods to several synthetic urine samples. This platform provides a rapid and convenient method for the detection of urinary biochemical substance, such as ACR, which has a broad prospect in mobile health and point-of-care testing (POCT).

Distributed implantation of a flexible microelectrode array for neural recording

Flexible multichannel electrode arrays (fMEAs) with multiple filaments can be flexibly implanted in various patterns. It is necessary to develop a method for implanting the fMEA in different locations and at various depths based on the recording demands. This study proposed a strategy for reducing the microelectrode volume with integrated packaging. An implantation system was developed specifically for semiautomatic distributed implantation. The feasibility and convenience of the fMEA and implantation platform were verified in rodents. The acute and chronic recording results provied the effectiveness of the packaging and implantation methods. These methods could provide a novel strategy for developing fMEAs with more filaments and recording sites to measure functional interactions across multiple brain regions.

Muscle-Specific High-Density Electromyography Arrays for Hand Gesture Classification.

Dexterous hand motion is critical for object manipulation. Electrophysiological studies of the hand are key to understanding its underlying mechanisms. High-density electromyography (HD-EMG) provides spatio-temporal information about the underlying electrical activity of muscles, which can be used in neurophysiological research, rehabilitation and control applications. However, existing EMG electrodes platforms are not muscle-specific, which makes the assessment of intrinsic hand muscles difficult. Muscle-specific flexible HD-EMG electrode arrays were developed to capture intrinsic hand muscle myoelectric activity during manipulation tasks. The arrays consist of 60 individual electrodes targeting 10 intrinsic hand muscles. Myoelectric activity was displayed as spatio-temporal amplitude maps to visualize muscle activation. Time-domain and temporal-spatial HD-EMG features were extracted to train cubic support vector machine machine-learning classifiers to classify the intended user motion. Experimental data was collected from 5 subjects performing a range of 10 common hand motions. Spatio-temporal EMG maps showed distinct activation areas correlated to the muscles recruited during each movement. The thenar muscle fiber conduction velocity (CV) was estimated to be at 4.7±0.3 m/s for all subjects. Hand motions were successfully classified and average accuracy for all subjects was directly related to spatial resolution based on the number of channels used as inputs; ranging from 74±4% when using only 5 channels and up to 92±2% when using 41 channels. Temporal-spatial features were shown to provide increased motion-specific accuracy when similar muscles were recruited for different gestures. Muscle-specific electrodes were capable of accurately recording HD-EMG signals from intrinsic hand muscles and accurately predicting motion. The muscle-specific electrode arrays could improve electrophysiological research studies using EMG decomposition techniques to assess motor unit activity and in applications involving the analysis of dexterous hand motions.

A Braille Reading System Based on Electrotactile Display With Flexible Electrode Array

Due to visual impairment and lack of social attention, the reading problem of the blind has not been well resolved. Many existing Braille reading devices still have many problems and are not accepted by the public. This paper developed a portable Braille reading system based on electrotactile display technology. The proposed system is composed of a six-channel electrotactile stimulator, a flexible electrode array for Braille display and a graphical user interface (GUI) for monitoring and control. Based on the flexibility of the system, two Braille reading strategies have been designed: spatial mode and sequential mode. The system was preliminary tested by six sighted subjects. The results showed that subjects were able to recognize Braille characters with more than 80% accuracy within less than 10 seconds for the initial use. Compared to existing Braille reading systems, this system is portable, wearable and flexible in control.

Photosensitive-Stamp-Inspired Scalable Fabrication Strategy of Wearable Sensing Arrays for Noninvasive Real-Time Sweat Analysis.

Wearable sweat sensing is essential to the development of personalized health monitoring in a noninvasive manner with molecular-level insight. Hence, there is an increasing demand for convenient, facile, and efficient fabrication of wearable sensing arrays. Inspired by a photosensitive stamp (PS), we present herein a simple, low-cost, and eco-friendly vacuum filtration-transfer printing method (termed PS-VFTP) for the scalable preparation of single-walled carbon nanotube (SWCNT) based flexible electrode arrays. This method can economically yield customized flexible SWCNT arrays with praiseworthy performance, such as high reproducibility, precision, uniformity, conductivity, and mechanical stability. In addition, the flexible SWCNT arrays can be easily functionalized into high-performance electrochemical sensors for the simultaneous monitoring of sweat metabolites (glucose, lactate) and electrolytes (Na+, K+). The integration of wearable sensing arrays with a signal acquisition and processing circuit system in the intelligent wearable sensors empowers them to realize noninvasive, real-time, and in situ sweat analysis during exercise. More meaningfully, such a PS-VFTP strategy can be easily expanded to the economical manufacturing of other flexible electronic devices.

333 First FDA Cleared Thin Film Electrode for Intracranial Recording and Monitoring of Brain Activity – Device Testing and Initial Clinical Use

INTRODUCTION: Subdural strip and grid (SDG) electrodes are routinely used for pre-surgical evaluation of patients with drug resistant epilepsy (DRE). Although these electrodes have been in the US market since their first FDA clearance in 1985, their fabrication, materials and properties have hardly changed. They are made of silicone, are thick (>0.5 mm), manufactured by hand, and do not optimally conform to brain convolutions. Technological solutions that overcome these limitations are needed. METHODS: Thin film electrode (0.08 mm) arrays were manufactured from polyimide with platinum contacts (multiple configurations, 3 mm contact diameter, spaced 10 mm apart). Electrochemical and electrical testing include electrolyte interface impedance, cyclic voltammetry and other impedance and isolation tests, according to the International Electrotechnical Commission 60601 for proving device safety and performance. Biocompatibility was tested using standard methods according to International Organization for Standardization 10993. Post-market data were collected employing a user feedback questionnaire using a rating scale (1 to 5, with 5 being the highest). RESULTS: Thin film electrodes passed all electrochemical, electrical and biocompatibility testing required for FDA clearance (obtained Nov 2019). Electrodes (n = 19) were used in clinical practice between Nov 23, 2020 and May 3, 2021 in the epilepsy monitoring units and for intraoperative monitoring (IOM) for recording brain activity in (a) DRE patients undergoing evaluation for potential surgical resection, and (b) patients undergoing tumor resection. Users (neurosurgeons; n = 6) provided ratings between 4 and 5 regarding the properties (thickness, flexibility, weight), features (ease of placement, conformability to the brain areas) and performance (qualitative signal recording quality) of the electrodes during surgical implantation. CONCLUSION: This is the first thin film electrode technology FDA cleared for use in clinical practice. The properties of these thin, flexible polyimide electrode arrays may overcome many limitations of the existing technology. Initial clinical use indicated that the technology is feasible for surgical implantation with greater flexibility compared to silicone based cortical electrodes.

Nondestructive inspection of packaged microcircuits by aperture-type terahertz near-field imaging

A scanning aperture-type terahertz near-field imaging system is developed to perform precise nondestructive testing on packaged aluminum etched antenna arrays, and surface imaging of a flexible gold electrode array, to obtain subsurface imaging and surface imaging. The resolution of subsurface imaging is 110 and 500 μm when the packaging (polyethylene terephthalate) thickness is 50 and 200 μm respectively, and the surface imaging resolution is 6 μm at 0.11 THz. An adaptive threshold segmentation algorithm of Hilbert scan combined with wavelet transform were employed to successfully suppress the noise of the imaging results due to the change of near-field distance. We also proposed a derivative filtering extremum threshold segmentation algorithm to effectively suppress severely uneven threshold distribution of the packaged aluminum etched antenna arrays.

Integrated solid-state wearable sweat sensor system for sodium and potassium ion concentration detection

PurposeDesign, fabricate and evaluate all-solid-state wearable sensor systems that can monitor ion concentrations in human sweat to provide real time health analysis and disease diagnosis capabilities.Design/methodology/approachA human health monitoring system includes disposable customized flexible electrode array and a compact signal transmission-processing electronic unit.FindingsPatterned rGO (reduced-graphene oxide) layers can replace traditional metal electrodes for the fabrication of free-standing all solid film sensors to provide improved flexibility, sensitivity, selectivity, and stability in ion concentration monitoring. Electrochemical measurements show the open circuit potential of current selective electrodes exhibit near Nernst responses versus Na+ and K+ ion concentration in sweat. These signals show great stability during a typical measurement period of 3 weeks. Sensor performances evaluated through real time measurements on human subjects show strong correlations between subject activity and sweating levels, confirming high degree of robustness, sensitivity, reliability and practicality of current sensor systems.Originality/valueIn improving flexibility, stability and interfacial coherency of chemical sensor arrays, rGO films have been the developed as a high-performance alternative to conventional electrode with significant cost and processing complexity reduction. rGO supported solid state electrode arrays have been found to have linear potential response versus ion concentration, suitable for electrochemical sensing applications. Current sweat sensor system has a high degree of integration, including electrode arrays, signal processing circuits, and data visualization interfaces.

Chronic co-implantation of ultraflexible neural electrodes and a cranial window.

.Significance: Electrophysiological recording and optical imaging are two prevalent neurotechnologies with complementary strengths, the combined application of which can significantly improve our capacity in deciphering neural circuits. Flexible electrode arrays can support longitudinal optical imaging in the same brain region, but their mechanical flexibility makes surgical preparation challenging. Here, we provide a step-by-step protocol by which an ultraflexible nanoelectronic thread is co-implanted with a cranial window in a single surgery to enable chronic, dual-modal measurements.Aim: The method uses -thick polymer neural electrodes which conform to the site of implantation. The mechanical flexibility of the probe allows bending without breaking and enables long-lasting electrophysiological recordings of single-unit activities and concurrent, high-resolution optical imaging through the cranial window.Approach: The protocol describes methods and procedures to co-implant an ultraflexible electrode array and a glass cranial window in the mouse neocortex. The implantation strategy includes temporary attachment of flexible electrodes to a retractable tungsten-microwire insertion shuttle, craniotomy, stereotaxic insertion of the electrode array, skull fixation of the cranial window and electrode, and installation of a head plate.Results: The resultant implant allows simultaneous interrogation of brain activity both electrophysiologically and optically for several months. Importantly, a variety of optical imaging modalities, including wide-field fluorescent imaging, two-photon microscopy, and functional optical imaging, can be readily applied to the specific brain region where ultraflexible electrodes record from.Conclusions: The protocol describes a method for co-implantation of ultraflexible neural electrodes and a cranial window for chronic, multimodal measurements of brain activity in mice. Device preparation and surgical implantation are described in detail to guide the adaptation of these methods for other flexible neural implants and cranial windows.

Graphene Microelectrodes for Real-Time Impedance Spectroscopy of Neural Cells.

Understanding the changes in the electrochemical properties of neural cells upon exposure to stress factors imparts vital information about the conditions prior to their death. This study presents a graphene-based biosensor for real-time monitoring of N27 rat dopaminergic neural cells which characterizes cell adhesion and cytotoxicity factors through impedance spectroscopy. The aim was to monitor the growth of the entire cell network via a nonmetallic flexible electrode array. Therefore, a water-based graphene solution was formulized as a conductive ink, 3D-printed into a flexible substrate through an electrohydrodynamic approach, resulting in electrodes with a conductivity of 6750 s/m. The presented high-throughput method enabled microscale monitoring of the entire cell network via the design of PDMS-based growth channels. The electrical resistance of the cell network was measured continuously along with their network density, constituting a mean density of 1890 cell/mm2 at full cell confluency. The results demonstrate the applicability of the impedance-based sensing of the cell network for rapid screening of the cytotoxic elements, and the real-time effect of UV exposure on dopaminergic neural cells was reported as an immediate application of the device.

Flexible Tongue Electrode Array System for In Vivo Mapping of Electrical Signals of Taste Sensation.

Tongue is a unique organ that senses tastes, and the scientific puzzle about whether electricity can evoke taste sensations and how the sensations have been distributed on the tongue has not been solved. Investigations on tongue stimulation by electricity might benefit the developments of techniques for clinical neuromodulation, tissue activation, and a brain-tongue-machine interface. To solve the scientific puzzle of whether electrical stimulation induces taste-related sensations, a portable flexible tongue electrode array system (FTEAS) was developed, which can synchronously provide electrical stimulation and signal mapping at each zone of the tongue. Utilizing the FTEAS to perform tests on the rat tongue in vivo, specific electrical signals were observed to be evoked by chemical and electrical stimulations. The features and distributions of the electric signals evoked during the rat tongue tests were systematically studied and comprehensively analyzed. The results show that an appropriate electrical stimulation can induce multiple sensations simultaneously, while the distribution of each sensation was not significantly distinguished among different zones of the tongue, and at the same time, this taste-related electrical signal can be recorded by the FTEAS. This work establishes a promising platform to solve the scientific puzzle of how sensations are activated chemically and electrically on the tongue and may provide advanced noninvasive oral-electrotherapy and a brain-tongue-machine interface.

Comparison of gold and PEDOT:PSS contacts for high-resolution gastric electrical mapping using flexible printed circuit arrays.

Motility of the stomach is governed by an electrophysiological event termed gastric slow waves. High-resolution (HR) bioelectrical mapping involves placing array of electrodes over the surface of the stomach to record gastric slow waves. Conductive polymer materials have recently been applied to great effect in cardiology and neurophysiology due to its compliant and biocompatible properties. The aim of this study was to quantify the performance of poly(3,4-ethylenedioxythiophene) doped with poly(styrenesulfonate) (PEDOT:PSS) deposited on a flexible print circuit electrode array for gastric slow wave HR mapping. The Au electrodes were coated with PEDOT:PSS at 1 V and different levels of charges (0.3-1.2 mC). HR mapping alongside standard Au electrodes was performed in three anesthetized pigs. Overall, the PEDOT:PSS electrodes detected both antegrade and retrograde slow wave propagations, with comparable frequency, velocity and signal-to-noise ratio to the Au electrodes. Differences between the two electrodes were noted in terms of amplitude and downstroke gradient. The findings of this study will inform designs of future stretchable and implantable HR mapping electrode arrays for gastrointestinal recording and stimulation therapies.

PDMS-Parylene Hybrid, Flexible Micro-ECoG Electrode Array for Spatiotemporal Mapping of Epileptic Electrophysiological Activity from Multicortical Brain Regions.

Epilepsy detection and focus location are urgent issues that need to be solved in epilepsy research. A cortex conformable and fine spatial accuracy electrocorticogram (ECoG) sensor array, especially for real-time detection of multicortical functional regions and delineating epileptic focus remains a challenge. Here, we fabricated a polydimethylsiloxane (PDMS)-parylene hybrid, flexible micro-ECoG electrode array. The multiwalled carbon nanotubes (MWCNTs)/poly(3,4-ethylenedioxythiophene):poly(styrene sulfonate) (PEDOT:PSS) nanocomposite-modified electrode interface significantly improved the sensing performance with low impedance (20.68 ± 6.65 kΩ), stable phase offset, and high sensitivity. The electrophysiological activities of multicortical brain regions (somatosensory cortex, parietal association cortex, and visual cortex) were simultaneously monitored during normal and epileptic statuses. The epileptic ECoG activities spread spatiotemporally from the starting point toward the adjacent cortex. Significant variations of the waveform, power, and frequency band were observed. The ECoG potential (123 ± 23 μV) at normal status was prominently up to 417 ± 87 μV at the spike wave stage. Besides, the power for epileptic activity (11.049 ± 4.513 μW) was 10 times higher than that (1.092 ± 0.369 μW) for normal activity. In addition, the theta frequency band was found to be a characteristic frequency band of epileptic signals. These joint analysis results of multicortical regions indicated that the active micron-scale region on the parietal association cortex was more likely to be the epileptogenic focus. Cortical mapping with high spatial detail provides the accurate delineation of lesions. The flexible micro-ECoG electrode array is a powerful tool for constructing a spatiotemporal map of the cortex. It provides a technical platform for epileptic focus location, biomedical diagnosis, and brain-computer interaction.

Graphene-electrode array for brain map remodeling of the cortical surface

Cortical maps, which are indicative of cognitive status, are shaped by the organism’s experience. Previous mapping tools, such as penetrating electrodes and imaging techniques, are limited in their ability to be used to assess high-resolution brain maps largely owing to their invasiveness and poor spatiotemporal resolution, respectively. In this study, we developed a flexible graphene-based multichannel electrode array for electrocorticography (ECoG) recording, which enabled us to assess cortical maps in a time- and labor-efficient manner. The flexible electrode array, formed by chemical vapor deposition (CVD)-grown graphene, provided low impedance and electrical noise because a good interface between the graphene and brain tissue was created, which improved the detectability of neural signals. Furthermore, cortical map remodeling was induced upon electrical stimulation at the cortical surface through a subset of graphene spots. This result demonstrated the macroscale plasticity of cortical maps, suggesting perceptual enhancement via electrical rehabilitation at the cortical surface.

Temperature Gradient‐Driven Multilevel and Grayscale Patterning of Tosylate‐Doped Poly(3,4‐Ethylenedioxythiophene) Films for Flexible and Functional Electronics

AbstractFlexible conducting polymers are an integral part of emerging flexible and functional electronics such as rollables, photovoltaics, and wearables. Patterning the polymers into various surface morphologies is essential to fabricating such devices. Introduced here is an approach of realizing the pattern by polymerizing a precursor solution into the shape of the desired pattern on substrate. Selective temperature activation of the monomer precursor containing an inhibitor leads to the formation of the polymer only on the area of the desired pattern, thereby accomplishing the pattern formation. Even multilevel and graduated patterns, not readily realizable with the conventional lithography, can be formed autonomously. Flexible electrode arrays, a foldable supercapacitor, and an electrochromic device are fabricated to demonstrate the utility of the patterning approach and to showcase development of prototype devices quickly and inexpensively.

A flexible electrode array for determining regions of motor function activated by epidural spinal cord stimulation in rats with spinal cord injury.

Epidural stimulation of the spinal cord is a promising technique for the recovery of motor function after spinal cord injury. The key challenges within the reconstruction of motor function for paralyzed limbs are the precise control of sites and parameters of stimulation. To activate lower-limb muscles precisely by epidural spinal cord stimulation, we proposed a high-density, flexible electrode array. We determined the regions of motor function that were activated upon epidural stimulation of the spinal cord in a rat model with complete spinal cord, which was established by a transection method. For evaluating the effect of stimulation, the evoked potentials were recorded from bilateral lower-limb muscles, including the vastus lateralis, semitendinosus, tibialis anterior, and medial gastrocnemius. To determine the appropriate stimulation sites and parameters of the lower muscles, the stimulation characteristics were studied within the regions in which motor function was activated upon spinal cord stimulation. In the vastus lateralis and medial gastrocnemius, these regions were symmetrically located at the lateral site of L1 and the medial site of L2 vertebrae segment, respectively. The tibialis anterior and semitendinosus only responded to stimulation simultaneously with other muscles. The minimum and maximum stimulation threshold currents of the vastus lateralis were higher than those of the medial gastrocnemius. Our results demonstrate the ability to identify specific stimulation sites of lower muscles using a high-density and flexible array. They also provide a reference for selecting the appropriate conditions for implantable stimulation for animal models of spinal cord injury. This study was approved by the Animal Research Committee of Southeast University, China (approval No. 20190720001) on July 20, 2019.

Transparent and Flexible Electrocorticography Electrode Arrays Based on Silver Nanowire Networks for Neural Recordings

Transparent and Flexible Electrocorticography Electrode Arrays Based on Silver Nanowire Networks for Neural Recordings

The Effect of Ultra-slow Velocities on Insertion Forces: A Study Using a Highly Flexible Straight Electrode Array.

The present study sought to 1) characterize insertion forces resulting from a flexible straight electrode array (EA) inserted at slow and ultra-slow insertion velocities, and 2) evaluate if ultra-slow velocities decrease insertion forces independent of other variables. Low insertion forces are desirable in cochlear implant (CI) surgery to reduce trauma and preserve hearing. Recently, ultra-slow insertion velocities (lower than manually feasible) have been shown to produce significantly lower insertion forces using other EAs. Five flexible straight EAs were used to record insertion forces into an inelastic artificial scala tympani model. Eleven trial recordings were performed for each EA at five predetermined automated, continuous insertion velocities ranging from 0.03 to 1.6 mm/s. An ultra-slow insertion velocity of 0.03 mm/s resulted in a median insertion force of 0.010 N at 20 mm of insertion depth, and 0.026 N at 24.3 mm-the final insertion depth. These forces represent only 24 to 29% of those measured using 1.6 mm/s. After controlling for insertion depth of the EA into the artificial scala tympani model and trial insertion number, decreasing the insertion velocity from 0.4 to 0.03 mm/s resulted in a 50% decrease in the insertion forces. Using the tested EA ultra-slow velocities can decrease insertion forces, independent of variables like insertion depth. Our results suggest ultra-slow velocities can reduce insertion forces at least 60%, compared with humanly feasible continuous velocities (≥0.9 mm/s).

Initial Hearing Preservation Is Correlated With Cochlear Duct Length in Fully-inserted Long Flexible Lateral Wall Arrays.

To characterize the relationship between cochlear duct length (CDL) and initial hearing preservation among cochlear implant recipients of a fully inserted 31.5 mm flexible lateral wall electrode array. Retrospective review. Tertiary academic referral center. Adult cochlear implant recipients who presented preoperatively with unaided hearing detection thresholds of ≤ 65 dB HL at 125 Hz and underwent cochlear implantation with a 31.5 mm flexible lateral wall array. Cochlear implantation with a hearing preservation surgical approach. Computed tomography was reviewed to determine CDL. Hearing preservation was characterized by the shift in low-frequency pure-tone average (LFPTA; 125, 250, and 500 Hz), and shift in individual unaided hearing detection thresholds at 125, 250, and 500 Hz. Nineteen patients met the criteria for inclusion. The mean CDL was 34.2 mm (range: 30.8-36.5 mm). Recipients experienced a mean LFPTA shift of 27.6 dB HL (range: 10-50 dB HL). Significant, negative correlations were observed between CDL and smaller threshold shifts at individual frequencies and LFPTA (p ≤ 0.048). A longer CDL is associated with greater likelihood of preserving low-frequency hearing with long arrays. Low-frequency hearing preservation is feasible with fully inserted long flexible arrays within the initial months after cochlear implantation. Preoperative measurement of CDL may facilitate a more individualized approach in array selection to permit optimal cochlear coverage while enhancing hearing preservation outcomes.