Determining cochlear implant candidacy in children with residual hearing: A scoping review

OBJECTIVES

The purpose of this review was to summarize what is known about criteria, assessments, and recommendations for evaluating cochlear implant (CI) candidacy in children with residual hearing.

METHODS

Peer-reviewed studies were identified through a systematic search in five electronic databases. Articles were screened and assessed for eligibility. From the eligible studies, data were extracted to summarize and present a narrative synthesis of the findings.

RESULTS

A total of seven articles (two reviews and five primary studies) were included in the final analysis. Hearing levels better than the moderately severe to severe range (65-90 dB HL) tend to be supported as audiological candidacy criteria for pediatric CI. Recommendations for candidacy consideration based on audiologic thresholds range from 65 to 80 dB Hl pure-tone average as the lower boundary. Our review did not identify any specific assessment protocols. However, additional decision-making considerations related to borderline hearing loss configurations and assessment tools (the Speech Intelligibility Index and the Pediatric Minimum Speech Test Battery) were identified. Supplementary assessment considerations were also reported.

CONCLUSION

There is limited information regarding specific assessment protocols for children with residual hearing. The literature is primarily focused on guidelines related to audiologic criteria, although it is widely recommended that other areas of functioning should also be considered. Most recommendations appear to be based on expert opinion, clinical expertise, and evidence from overall pediatric CI outcomes rather than empirical evidence targeting children with residual hearing. There is an ongoing need for research to further develop protocols and tools that can assist clinicians and families in making cochlear implantation decisions for children with residual hearing.

Hearing Thresholds, Speech Recognition, and Audibility as Indicators for Modifying Intervention in Children With Hearing Aids

OBJECTIVES

The purpose of this study was to determine if traditional audiologic measures (e.g., pure-tone average, speech recognition) and audibility-based measures predict risk for spoken language delay in children who are hard of hearing (CHH) who use hearing aids (HAs). Audibility-based measures included the Speech Intelligibility Index (SII), HA use, and auditory dosage, a measure of auditory access that weighs each child's unaided and aided audibility by the average hours of HA use per day. The authors also sought to estimate values of these measures at which CHH would be at greater risk for delayed outcomes compared with a group of children with typical hearing (CTH) matched for age and socioeconomic status, potentially signaling a need to make changes to a child's hearing technology or intervention plan.

DESIGN

The authors compared spoken language outcomes of 182 CHH and 78 CTH and evaluated relationships between language and audiologic measures (e.g., aided SII) in CHH using generalized additive models. They used these models to identify values associated with falling below CTH (by > 1.5 SDs from the mean) on language assessments, putting CHH at risk for language delay.

RESULTS

Risk for language delay was associated with aided speech recognition in noise performance (<59% phonemes correct, 95% confidence interval [55%, 62%]), aided Speech Intelligibility Index (SII < 0.61, 95% confidence internal [.53,.68]), and auditory dosage (dosage < 6.0, 95% confidence internal [5.3, 6.7]) in CHH. The level of speech recognition in quiet, unaided pure-tone average, and unaided SII that placed children at risk for language delay could not be determined due to imprecise estimates with broad confidence intervals.

CONCLUSIONS

Results support using aided SII, aided speech recognition in noise measures, and auditory dosage as tools to facilitate clinical decision-making, such as deciding whether changes to a child's hearing technology are warranted. Values identified in this article can complement other metrics (e.g., unaided hearing thresholds, aided speech recognition testing, language assessment) when considering changes to intervention, such as adding language supports, making HA adjustments, or referring for cochlear implant candidacy evaluation.

Cochlear Implant Decision Making for Children With Residual Hearing: Perspectives of Practitioners

PURPOSE

Cochlear implants (CIs) are increasingly considered for children with residual hearing who benefit from hearing aids (HAs). However, the decision-making process for families of these children and for practitioners is particularly challenging because there is no clear audiological cut point for CI candidacy. This study aimed to understand Canadian practitioners' perspectives of the CI decision-making process and how they guide families of children with residual hearing.

METHOD

Semistructured interviews were conducted with a total of 17 practitioners through four focus groups and one individual interview. Interviews were transcribed verbatim, and a thematic analysis was carried out.

RESULTS

Data were organized into five broad domains: candidacy issues for children with residual hearing, practitioners' roles in decision support, additional considerations affecting decision making, factors facilitating decision making, and practitioners' needs.

CONCLUSIONS

This study found that practitioners' confidence in determining candidacy and supporting parents has increased due to their experiences with positive outcomes for these children. Practitioners indicated that there was a need for more research to guide the decision-making process.

Cochlear Implants or Hearing Aids: Speech Perception, Language, and Executive Function Outcomes

OBJECTIVES

We aimed to determine whether children with severe hearing loss (HL) who use hearing aids (HAs) may experience added value in the perception of speech, language development, and executive function (EF) compared to children who are hard of hearing (HH) or children who are deaf and who use cochlear implants (CIs) and would benefit from CIs over HAs. The results contribute to the ongoing debate concerning CI criteria. We addressed the following research question to achieve this aim: Do children who are HH or deaf with CIs perform better than children with severe HL with HAs with respect to auditory speech perception, and receptive vocabulary and/or EF?

DESIGN

We compared two groups of children with severe HL, profound HL or deafness, with CIs or HAs, matched for gender, test age (range, 8 to 15 years), socioeconomic status, and nonverbal intelligence quotient. Forty-three children had CIs (pure-tone average at 2000 and 4000 Hz >85 dB HL), and 27 children had HAs (mean pure-tone average: 69 dB HL). We measured speech perception at the conversational level (65 dB SPL) and the soft speech perception level (45 dB SPL). We established receptive vocabulary using the Peabody Picture Vocabulary Test-III-NL. We tested EF using the Delis Kaplan Executive Function System battery and the Dutch Rey Auditory Verbal Learning Test. We employed the Mann-Whitney U test to compare data between the CI and HA groups. We used Chi-square goodness of fit tests to contrast the CI and HA group distributions with the norm data of children who are typically developing (TD). We harnessed Kendall's Tau-b to investigate relationships between the study variables.

RESULTS

Both groups of children, with CIs and Has, obtained ceiling scores for perception of speech on a conversational level. However, the HA group exhibited significantly lower perception on a soft speech level scores (68 %) than the CI group (87%). No difference was present between the receptive vocabulary distributions of the CI and HA groups. The median receptive vocabulary standard scores for both groups were well within the normal range (CI group: 93; HA group: 96). In addition, we did not find any difference in EF between the CI and HA groups. For planning and verbal memory, the distributions of observed scores for children with CIs were different from the expected distributions of children who are TD. In both groups, a large proportion of children obtained below-average scores for planning (CI: 44%; HA: 33%) and for long-term verbal memory (CI: 44%; HA: 35%). In the HA group, perception at a soft speech level was associated with receptive vocabulary and planning. In the CI group, we did not find any associations.

CONCLUSIONS

Both groups of children with severe and profound HL with HAs exhibit less favorable auditory perception on the soft speech level, but not at a conversational level, compared to children who are HH or deaf with CIs. Both groups, children with CIs and HAs, only exhibit more problems in planning and verbal memory than the norm groups of children who are TD. The results indicate that to obtain age-appropriate levels of receptive vocabulary and EF, the perception at the soft speech level is a necessary but not sufficient prerequisite.

Hearing loss patterns in enlarged vestibular aqueduct syndrome: Do fluctuations have clinical significance?

OBJECTIVES

To reveal hearing loss patterns in patients with enlarged vestibular aqueduct (EVA) syndrome according to demographic and clinical characteristics.

METHODS

A retrospective, longitudinal study design was utilized to identify patients with EVA. Ears of patients were categorized into one of four cohorts: progressive fluctuating, progressive non-fluctuating, stable fluctuating, and stable non-fluctuating patterns. Pairwise and group comparisons were performed with non-parametric tests to assess vestibular aqueduct (VA) morphology, clinical, and demographic variables between hearing loss pattern cohorts. Rates of hearing loss in the subgroups were determined utilizing a mixed linear effects model.

RESULTS

44 patients (25 female, 19 male, median diagnosis age: 8.06 years) met inclusion criteria. 16 individuals demonstrated unilateral EVA and 29 had bilateral EVA, resulting in 74 total ears with EVA. Amongst the four cohorts, differences in operculum widths amongst groups were statistically significant (p = 0.049) while VA midpoint widths were not (p = 0.522). Progressive hearing loss ears without fluctuations demonstrated a 3.20 dB per year (p < 0.001) progression while progressive hearing loss ears with fluctuations reported a rate of 3.52 dB loss per year (p < 0.001).

CONCLUSION

Hearing fluctuations occur similarly in EVA patients with stable and progressive hearing loss. With the exception of increased rates of hearing loss progression for fluctuating progressive hearing loss patients, vestibular aqueduct morphology, demographic, and clinical characteristics commonly reported are likely not strong predictors for whether patients will or will not experience fluctuating patterns of hearing loss.

Universal newborn hearing screening with automated auditory brainstem response (AABR) in Hungary: 5-year experience in diagnostics and influence on the early intervention

PURPOSE

In 2015 a new regulation and guidelines for the universal newborn hearing screening by AABR measurement have been implemented in Hungary. The aim of our study was to analyse (1) the past 5 years of data from our diagnostic centre about the incidence and types of congenital hearing losses, and (2) the first experiences with the National Newborn Hearing Screening Registry, started in 2019, and (3) the influence of the screening on the pediatric cochlear implant program.

METHODS

1269 children referred to our diagnostic centre between 2017 and 2021 were investigated. A third AABR measurement and full audiological evaluation were performed. Furthermore, one-year period data of the screening registry, and the number of implanted children at or under the age of 3 were analysed using the national databases.

RESULTS

Altogether 276 newborns (22% of the referred cases after the two-stage screening) had hearing loss, 134 (49%) out of them was conductive origin, almost twice frequent in male as in female. Permanent sensorineural hearing impairment was found in 142 (51%), 58 (40%) of them had bilateral, severe to profound hearing loss, occurring more frequently in male as in female. The national digital registration of the screening data within 12 months concerned 68%. The number of early cochlear implantation in one year increased from 1 to 23 children in the past 15 years.

CONCLUSION

A third AABR after the two-stage screening increased the efficiency and filtered the 78% false-positive cases. The audiological diagnostics verified and typed the hearing losses ensuring the early intervention.

Bimodal Fitting and Bilateral Cochlear Implants in Children With Significant Residual Hearing: The Impact of Asymmetry in Spatial Release of Masking on Localization

Purpose This study aimed to gain more insight into the primary auditory abilities of children with significant residual hearing in order to improve decision making when choosing between bimodal fitting or sequential bilateral cochlear implantation. Method Sound localization abilities, spatial release of masking, and fundamental frequency perception were tested. Nine children with bimodal fitting and seven children with sequential bilateral cochlear implants were included in the study. As a reference, 15 children with normal hearing and two children with simultaneous bilateral cochlear implants were included. Results On all outcome measures, the implanted children performed worse than the normal hearing children. For high-frequency localization, children with sequential bilateral cochlear implants performed significantly better than children with bimodal fitting. Compared to children with normal hearing, the left-right asymmetry in spatial release of masking was significant. When the implant was hindered by noise, bimodally fitted children obtained significantly lower spatial release of masking compared to when the hearing aid was hindered by noise. Overall, the larger the left-right asymmetry in spatial release of masking, the poorer the localization skills. No significant differences were found in fundamental frequency perception between the implant groups. Conclusions The data hint to an advantage of bilateral implantation over bimodal fitting. The extent of asymmetry in spatial release of masking is a promising tool for decision making when choosing whether to continue with the hearing aid or to provide a second cochlear implant in children with significant residual hearing.

A Scoping Review of Studies Comparing Outcomes for Children With Severe Hearing Loss Using Hearing Aids to Children With Cochlear Implants

OBJECTIVES

Clinical practice regarding children's candidature for cochlear implantation varies internationally, albeit with a recent global trend toward implanting children with more residual hearing than in the past. The provision of either hearing aids or cochlear implants can influence a wide range of children's outcomes. However, guidance on eligibility and suitability for implantation is often based on a small number of studies and a limited range of speech perception measures. No recent reviews have catalogued what is known about comparative outcomes for children with severe hearing-loss using hearing aids to children using cochlear implants. This article describes the findings of a scoping review that addressed the question "What research has been conducted comparing cochlear implant outcomes to outcomes in children using hearing aids with severe hearing-loss in the better-hearing ear?" The first objective was to catalogue the characteristics of studies pertinent to these children's candidature for cochlear implantation, to inform families, clinicians, researchers, and policy-makers. The second objective was to identify gaps in the evidence base, to inform future research projects and identify opportunities for evidence synthesis.

DESIGN

We included studies comparing separate groups of children using hearing aids to those using cochlear implants and also repeated measures studies comparing outcomes of children with severe hearing loss before and after cochlear implantation. We included any outcomes that might feasibly be influenced by the provision of hearing aids or cochlear implants. We searched the electronic databases Medline, PubMed, and CINAHL, for peer-reviewed journal articles with full-texts written in English, published from July 2007 to October 2019. The scoping methodology followed the approach recommended by the Joanna Briggs Institute regarding study selection, data extraction, and data presentation.

RESULTS

Twenty-one eligible studies were identified, conducted across 11 countries. The majority of children studied had either congenital or prelingual hearing loss, with typical cognitive function, experience of spoken language, and most implanted children used one implant. Speech and language development and speech perception were the most frequently assessed outcomes. However, some aspects of these outcomes were sparsely represented including voice, communication and pragmatic skills, and speech perception in complex background noise. Two studies compared literacy, two sound localization, one quality of life, and one psychosocial outcomes. None compared educational attainment, listening fatigue, balance, tinnitus, or music perception.

CONCLUSIONS

This scoping review provides a summary of the literature regarding comparative outcomes of children with severe hearing-loss using acoustic hearing aids and children using cochlear implants. Notable gaps in knowledge that could be addressed in future research includes children's quality of life, educational attainment, and complex listening and language outcomes, such as word and sentence understanding in background noise, spatial listening, communication and pragmatic skills. Clinician awareness of this sparse evidence base is important when making management decisions for children with more residual hearing than traditional implant candidates. This review also provides direction for researchers wishing to strengthen the evidence base upon which clinical decisions can be made.

Pediatric Bilateral Sensorineural Hearing Loss: Minimum Test Battery and Referral Criteria for Cochlear Implant Candidacy Evaluation

Among the various cochlear implant systems approved by the Food and Drug Administration, current labeling for pediatric usage encompasses (1) bilateral profound bilateral sensorineural hearing loss in children aged 9 to 24 months and bilateral severe to profound sensorineural hearing loss in children older than 2 years; (2) use of appropriately fitted hearing aids for 3 months (this can be waived if there is evidence of ossification); and (3) demonstration of limited progress with auditory, speech, and language development. Pediatric guidelines require children to have significantly worse speech understanding before qualifying for cochlear implantation. The early years of life have been shown to be critical for speech and language development, and auditory deprivation is especially detrimental during this crucial time.Level of evidence: 2.

Assessment of speech perception in deaf or hard of hearing children who received auditory-verbal therapy with hearing aids or cochlear implants

OBJECTIVES

To reframe the criteria for pediatric cochlear implants (CIs) in Japan, we investigated monosyllabic and word speech perception at the time of school entry in deaf or hard of hearing (D/HH) children who underwent auditory-verbal therapy (AVT) with hearing aids (HAs) or CIs in early childhood.

METHODS

D/HH children who started AVT at Fujimidai Auditory Center for Hearing-Impaired Children before the age of 1 year and who underwent auditory assessment in the previous year of schooling (at the age of 5 or 6) from 2010 to 2020 were enrolled in this study. The results of hearing level tests with or without amplification and monosyllabic and word speech discrimination were assessed.

RESULTS

The children with profound hearing impairment (>90 dB HL) had worse speech perception than children with CIs. The children with severe hearing impairment (>70-90 dB HL) did not show any significant differences in speech perception compared with the children with CIs. The children with HAs with a wearing threshold <40 dB HL did not show any significant differences in speech perception from the children with CIs.

CONCLUSION

D/HH children with audiologic thresholds greater than 90 dB HL or aided thresholds greater than 40 dB HL should be considered for CIs to ensure development of appropriate listening and spoken language.

Clinical characteristics and outcomes of children with cochlear implants who had preoperative residual hearing

OBJECTIVE

Cochlear implants (CI) candidacy criteria have expanded to include children with more residual hearing. This study explored the clinical profiles and outcomes of children with CIs who had preoperative residual hearing in at least one ear.

DESIGN

A retrospective chart review was conducted to collect clinical characteristics and speech perception data. Pre- and post-CI auditory and speech perception data were analysed using a modified version of the Pediatric Ranked Order Speech Perception (PROSPER) score.

STUDY SAMPLE

This study included all children with residual hearing who received CIs in one Canadian paediatric centre from 1992 to 2018.

RESULTS

A total of 100 of 389 (25.7%) children with CIs had residual hearing (median 77.6 dB HL, better ear). The proportion of children with residual hearing increased from 1992 to 2018. Children who had auditory behaviour and speech perception tests (n = 83) showed higher modified PROSPER scores post-CI compared to pre-CI. Phonologically Balanced Kindergarten (PBK) test scores were available for 71 children post-CI; 81.7% (58/71) of children achieved > 80% on the PBK.

CONCLUSIONS

One in four children who received CIs had residual hearing, and most of them had severe hearing loss at pre-CI. These children showed a high level of speech perception with CIs.

Hearing Loss in Children: A Review

IMPORTANCE

Hearing loss in children is common and by age 18 years, affects nearly 1 of every 5 children. Without hearing rehabilitation, hearing loss can cause detrimental effects on speech, language, developmental, educational, and cognitive outcomes in children.

OBSERVATIONS

Consequences of hearing loss in children include worse outcomes in speech, language, education, social functioning, cognitive abilities, and quality of life. Hearing loss can be congenital, delayed onset, or acquired with possible etiologies including congenital infections, genetic causes including syndromic and nonsyndromic etiologies, and trauma, among others. Evaluation of hearing loss must be based on suspected diagnosis, type, laterality and degree of hearing loss, age of onset, and additional variables such as exposure to cranial irradiation. Hearing rehabilitation for children with hearing loss may include use of hearing aids, cochlear implants, bone anchored devices, or use of assistive devices such as frequency modulating systems.

CONCLUSIONS AND RELEVANCE

Hearing loss in children is common, and there has been substantial progress in diagnosis and management of these cases. Early identification of hearing loss and understanding its etiology can assist with prognosis and counseling of families. In addition, awareness of treatment strategies including the many hearing device options, cochlear implant, and assistive devices can help direct management of the patient to optimize outcomes.

Evolving Criteria for Adult and Pediatric Cochlear Implantation

The indications for cochlear implantation have gradually expanded as advancements in technology have evolved, resulting in improved audiologic outcomes for both adult and children. There remains a significant underutilization of cochlear implant technology in the United States, and recognition of the potential benefits of cochlear implantation for non-traditional indications is critical for encouraging the evolution of candidacy criteria. Adult cochlear implantation candidacy has progressed from patients with bilateral profound sensorineural hearing loss (SNHL) to include patients with greater degrees of residual hearing, single-sided deafness and asymmetric hearing, and atypical etiologies of hearing loss (eg, vestibular schwannoma, Ménière's disease, and otosclerosis). Indications for pediatric cochlear implantation have similarly evolved from children with bilateral severe to profound SNHL to implanting children at a younger age, including those with residual hearing, asymmetric hearing loss, inner ear malformations, as well as cochlear nerve deficiency. In this editorial, the literature investigating cochlear implantation for nontraditional indications is reviewed with an aim to use the best available evidence to encourage the evolution of candidacy criteria.

Prenatal findings, neonatal symptoms and neurodevelopmental outcome of congenital cytomegalovirus infection in a university hospital in Montreal, Quebec

Background Outcome of congenital cytomegalovirus (cCMV) infection in the absence of routine CMV screening and third-trimester scan in North America is scarcely documented. The aim of this study was to assess the severe outcomes related to cCMV according to the indication for screening. Methods This was a retrospective study of 84 mother-child pairs followed for cCMV between 2003 and 2017 at CHU Sainte-Justine in Montreal, Canada. Prenatal ultrasound, neonatal symptoms, neuroimaging and severe outcomes (cerebral palsy, severe cognitive impairment, bilateral hearing loss or neonatal death) were reviewed. Results Among 38 cases with abnormal prenatal ultrasound, 41.9% of live-born infants developed severe outcomes. Sixteen (42.1%) were detected in the third trimester. Among 16 cases diagnosed prenatally because of maternal history, all had normal prenatal ultrasound, and none developed severe outcomes. Among cases diagnosed postnatally because of neonatal symptoms, 25% developed severe outcomes. All infants who developed severe outcomes had moderate/severe neonatal symptoms. Conclusion Outcome of cCMV infection varies according to the reason for screening and timing of diagnosis. Any prenatal ultrasound anomaly might indicate a risk of severe outcome, and warrants a detailed ultrasound scan. However, late detection, or postnatal diagnosis, represented more than half of the cases, and awareness of this will help ensuring optimal management.

Special Populations in Implantable Auditory Devices: Pediatric

"Hearing loss in the pediatric population can have significant social and developmental implications. Early auditory rehabilitation by at least 6 months of age is imperative. Although traditional hearing aids are often a first-line treatment option, there is a wide array of implantable auditory devices available. This article describes the indications for such devices as they pertain to the pediatric population, including osseointegrated bone-conduction devices, middle ear implants, cochlear implants, and auditory brainstem implants."

A multilinguistic analysis of spelling among children with cochlear implants

This study examines the spelling of nine elementary school children with cochlear implants (CIs) who use spoken language, and compares their performance with children who have typical hearing and children who are hard of hearing (HH). Compared to children with typical hearing, children with CIs did not produce a significantly different percentage of misspelled words (p = 0.431, d = 0.38), but their spelling errors comprised significantly lower percentages of homophone substitutions (p = 0.019, r = 0.61) and legal vowel errors (p = 0.011, r = 0.61). Children with CIs and children who are HH did not produce a significantly different percentage of misspelled words (p = 0.521, d = 0.31) or a significantly different distribution of categorical spelling errors. Results suggest that children with CIs utilize similar linguistic strategies as their peers who are HH but different strategies than peers with typical hearing when attempting to spell unfamiliar words.