The influence of a vestibular dysfunction on the motor development of hearing-impaired children

Evaluation of the Effects of Optokinetic Stimuli and Dual-Task Performance on Vestibulo-Ocular Reflex Function in Children With Attention Deficit and Hyperactivity Disorder

OBJECTIVES

This study investigated the effects of optokinetic stimuli and dual-task performance on vestibulo-ocular reflex (VOR) function. The study primarily focused on understanding the effects of attention deficit and hyperactivity disorder (ADHD) and its subtypes.

STUDY DESIGN

A case-control study.

SETTING

Tertiary medical centre.

METHODS

Thirty-eight children diagnosed with ADHD and 40 typically developing (TD) children aged 8-18 were included in the study. According to their diagnostic reports, children diagnosed with ADHD were also examined in three subtypes: predominantly inattentive (ADHD-PI), predominantly hyperactive-impulsive (ADHD-HI) and the combined type. Functional head impulse test (fHIT) was applied to all participants in three conditions-with no additional stimulus, optokinetic stimulation and dual-task. Correct responses (CR) were determined for each group, and the conditions were compared. For the dual-task test performance, children were given a counting task.

RESULTS

The findings of the study are significant. The CR values obtained from the fHIT tests applied under three different conditions were lower in the ADHD group compared to the control group. CR values for all fHIT conditions and all semicircular canals were lower in the ADHD-PI subtype and higher in the ADHD-HI subtype compared to other subgroups.

CONCLUSION

This study has significant practical implications underscoring its relevance. fHIT, when applied with different protocols, can provide valuable information about the vestibular and cognitive states of children with ADHD. These results are particularly significant as the diagnosis of ADHD often relies on subjective interpretations, and fHIT offers a more objective and reliable method of evaluation.

Postural Sway Velocity of Deaf Children with and without Vestibular Dysfunction

BACKGROUND

Sensory information obtained from the visual, somatosensory, and vestibular systems is responsible for regulating postural control, and if damage occurs in one or more of these sensory systems, postural control may be altered.

OBJECTIVE

To evaluate and compare the postural sway velocity between children with normal hearing and with sensorineural hearing loss (SNHL), matched by sex and age group, and to compare the postural sway velocity between children with normal hearing and with SNHL, with and without vestibular dysfunction.

METHODS

Cross-sectional study that evaluated 130 children (65 with normal hearing and 65 with SNHL), of both sexes and aged between 7 and 11 years, from public schools of the city of Caruaru, Pernambuco state, Brazil. The postural sway velocity of the center of pressure (COP) was assessed by a force platform, in two directions, anteroposterior (AP) and mediolateral (ML)), in three positions, namely bipedal support with feet together and parallel (parallel feet (PF)), bipedal support with one foot in front of the other (tandem foot (TF)), and single-leg support (one foot (OF)), evaluated with the eyes open and closed.

RESULTS

Children with SNHL demonstrated greater postural sway velocity compared to children with normal hearing in all the positions evaluated, with significant differences in the AP direction, with the eyes open (PF: p = 0.001; TF: p = 0.000; OF: p = 0.003) and closed (PF: p = 0.050; TF: p = 0.005). The same occurred in the ML direction, with the eyes open (PF: p = 0.001; TF: p = 0.000; OF: p = 0.001) and closed (PF: p = 0.002; TF: p = 0.000). The same occurred in relation to vestibular function, where the children with SNHL with an associated vestibular dysfunction demonstrated greater postural sway velocity compared to children with normal hearing in all the positions evaluated, demonstrating significant differences in the AP direction, with the eyes open (TF: p = 0.001; OF: p = 0.029) and eyes closed (PF: p = 0.036; TF: p = 0.033). The same occurred in the ML direction, with the eyes open (TF: p = 0.000) and with the eyes closed (PF: p = 0.008; TF: p = 0.009).

CONCLUSIONS

Children with SNHL demonstrated greater instability of postural control than children with normal hearing in all the directions assessed. Children with SNHL and an associated vestibular dysfunction demonstrated the greatest instability of postural control in this study.

Vestibular assessment in children with sensorineural hearing loss: diagnostic accuracy and proposal for a diagnostic algorithm

Introduction

Vestibular assessment in children with sensorineural hearing loss (SNHL) is critical for early vestibular rehabilitation therapy to promote (motor) development or guide decision making towards cochlear implantation (timing of surgery and laterality). It can be challenging from a clinical viewpoint to decide which vestibular tests should be performed for a pediatric patient. The aim of this study was to evaluate the diagnostic accuracy of several clinically available vestibular tests in children with SNHL, and to provide recommendations for the implementation of vestibular testing of children in clinical practice, to screen for vestibular hypofunction (VH).

Methods

A two-center retrospective chart review was conducted. Eighty-six patients between the age of 0 and 18 years were included in this study with SNHL. Vestibular tests included video headimpulse test (VHIT), caloric test (performed at the age of four or higher), rotatory chair and cervical vestibular evoked myogenic potential (cVEMP). A combination of the clinical assessment and (combinations of) vestibular test outcomes determined the diagnosis. The diagnostic quality of tests and combination of tests was assessed by diagnostic accuracy, sensitivity and specificity.

Results

VH was diagnosed in 44% of the patients. The VHIT and caloric test showed the highest diagnostic accuracy compared to the rotatory chair and cVEMP. All combinations of VHIT, caloric test and cVEMP showed improvement of the diagnostic accuracy compared to the respective tests when performed singularly. All combinations of tests showed a relatively similar diagnostic accuracy, with the VHIT combined with the caloric test scoring the highest. Adding a third test did not substantially improve the diagnostic accuracy.

Discussion

Vestibular testing is feasible and VH is highly prevalent in children with SNHL. A proposed diagnostic algorithm recommends starting with VHIT, followed by cVEMP for children under the age of four, and caloric testing for older children if VH is not confirmed with the first test. Performing a third test is redundant as the diagnostic accuracy does not improve substantially. However, challenges remain, including the lack of a gold standard and the subjective nature of the diagnosis, highlighting the need for standardized testing and increased understanding of VH in this population.

Effects of proprioception and core stability training on gait parameters of deaf adolescents: a randomized controlled trial

The current study aimed to explore the effects of proprioception versus core stability training over 8 weeks on the gait parameters of deaf adolescents. A total of 20 deaf adolescents were randomized into two groups: one group receiving proprioception training (PT, n = 10), another group receiving core stability training (CST, n = 10), and eleven typically developing adolescents assigned into the control group (CON; n = 11). Gait was recorded by two digital cameras; then, using the Kinovea software, the parameters of gait included: gait velocity, cadence, stride length, stride time, stance time, and swing time were calculated in terms of percentages of the walking cycle. After 8 weeks of PT, no significant differences were observed for all gait parameters between PT and control groups (p > 0.05). Also, after 8 weeks of CST, no significant differences were observed in gait velocity and cadence between the CST and control groups (p > 0.05). However, after 8 weeks of CST, stride length (p = 0.02) was higher in the control group; Stride time (p = 0.03), stance time (p = 0.04) and swing time (p = 0.04) were higher in the CST group. Moreover, after 8 weeks of PT, values showed significant improvements in all gait parameters (p = 0.001). Also, after 8 weeks of CST, values showed significant improvements in gait velocity and cadence (p = 0.001), but no significant differences were observed in other gait parameters (p > 0.05). The findings of this study indicated that PT improved all gait parameters, whereas CST improved gait velocity and cadence. The results of the present study also demonstrated that PT had a greater effect on gait parameters of deaf adolescents compared with CST. It seems that PT induces more training effects than CTS for enhancing gait parameters of deaf adolescents.Trial registration: Clinical trial registry number: IRCT20170312033029N2. URL: https://en.irct.ir/trial/25584 .

Vestibular Follow-up Program for Congenital Cytomegalovirus Based on 6 Years of Longitudinal Data Collection

OBJECTIVES

Congenital cytomegalovirus (cCMV), the leading nongenetic cause of pediatric sensorineural hearing loss, can also affect vestibular function. Literature findings suggest clinical presentation of vestibular loss in cCMV to be as variable as the hearing loss. Still, probably due to the considerable additional burden it entails for both patients and diagnostic centers, longitudinal vestibular follow-up in cCMV is not well-established in clinical practice. Therefore, this study aims to propose an evidence-based vestibular follow-up program with proper balance between its feasibility and sensitivity.

DESIGN

In this longitudinal cohort study, 185 cCMV-patients (mean age 3.2 years, SD 1.6 years, range 0.5-6.7 years) were included. Vestibular follow-up data were obtained through lateral video head impulse test (vHIT) and cervical vestibular evoked myogenic potential (cVEMP) evaluations around the ages of 6 months, 1 year, and 2 years. Around 3 and 4.5 years of age, data from vertical vHIT and ocular vestibular evoked myogenic potentials (oVEMP) were also collected.

RESULTS

At birth, 55.1% (102/185) of patients were asymptomatic and 44.9% (83/185) were symptomatic. The mean duration of follow-up for all patients was 20.8 (SD 16.3) months (mean number of follow-up assessments: 3.2, SD 1.5). Vestibular loss occurred at some point during follow-up in 16.8% (31/185) of all patients. Six percent (10/164) of patients with normal vestibular function at first assessment developed delayed-onset vestibular loss; 80.0% (8/10) of these within the first 2 years of life. Vestibular deterioration was reported both in patients who had been treated with postnatal antiviral therapy and untreated patients. At final evaluation, both the semicircular and the otolith system were impaired in the majority of vestibular-impaired ears (29/36, 80.6%). Dysfunctions limited to the semicircular system or the otolith system were reported in 4 (4/36, 11.1%) and 3 (3/36, 8.3%) ears, respectively. The occurrence of vestibular loss was highest in patients with first trimester seroconversion (16/59, 27.1%) or with an unknown timing of seroconversion (13/71, 18.3%), patients with sensorineural hearing loss (16/31, 51.6%), and patients with periventricular cysts on magnetic resonance imaging (MRI) (7/11, 63.6%).

CONCLUSIONS

Longitudinal vestibular follow-up, most intensively during the first 2 years of life, is recommended in cCMV-patients with vestibular risk factors (first trimester or unknown timing of seroconversion; sensorineural hearing loss; periventricular cysts on MRI). If those risk factors can be ruled out, a single evaluation early in life (around 6 months of age) might be sufficient. Both semicircular and otolith system evaluation should be part of the follow-up program, as partial losses were reported.

Developing a serious game for gaze stability rehabilitation in children with vestibular hypofunction

BACKGROUND

Children with vestibular hypofunction (VH) may have gaze instability, balance disorders, and delayed postural-motor development. Gaze stabilization exercises (GSE) are designed to improve dynamic visual acuity (DVA). We aimed to assess the acceptability of a serious game prototype called Kid Gaze Rehab (KGR) designed to implement GSE training in children with VH, combined with traditional vestibular rehabilitation. Effects on DVA and motor performance were also analyzed.

METHODS

Twelve children (6 to 9 years old) were included. Sessions were held at the hospital twice a week, for 5 weeks. An adapted French version of The Child Simulator Sickness Questionnaire (SSQ) and the Face Scale Pain-Revised (FPS-R) were used to assess pain in the cervical region and undesirable side effects after each session. Vestibular and motor function parameters (active and passive DVA and Movement Assessment Battery for Children-Second Edition, MABC-2) were assessed before and after the training.

RESULTS

All children included completed the 10 sessions. The FPS-R visual analog scale and SSQ showed good cervical tolerance and no oculomotor or vegetative adverse effects nor spatial disorientation. After training, active DVA scores were significantly improved for the right, left, and up directions (p < 0.05). Passive DVA scores were significantly improved for the left and down directions (p < 0.01 and p < 0.05, respectively). MABC-2 scores were improved in the balance and ball skill sections (p < 0.05).

CONCLUSION

An innovative pediatric training method, the use of a dedicated serious game for gaze stabilization was well-tolerated as a complement to conventional vestibular rehabilitation in children with VH. Moreover, both DVA and motor performance were found to improve in the study sample. Although replication studies are still needed, serious game-based training in children with VH could represent a promising rehabilitation approach for years to come.

TRIAL REGISTRATION

The study was conducted in accordance with the Declaration of Helsinki and approved by an Institutional Review Board (local ethics committee, CPP Sud-Est IV, ID 2013-799). The study protocol was registered on ClinicalTrials.gov (NCT04353115).

Subtle alterations of vestibulomotor functioning in conductive hearing loss

Introduction

Conductive hearing loss (CHL) attenuates the ability to transmit air conducted sounds to the ear. In humans, severe hearing loss is often accompanied by alterations to other neural systems, such as the vestibular system; however, the inter-relations are not well understood. The overall goal of this study was to assess vestibular-related functioning proxies in a rat CHL model.

Methods

Male Sprague-Dawley rats (N=134, 250g, 2months old) were used in a CHL model which produced a >20dB threshold shift induced by tympanic membrane puncture. Auditory brainstem response (ABRs) recordings were used to determine threshold depth at different times before and after CHL. ABR threshold depths were assessed both manually and by an automated ABR machine learning algorithm. Vestibular-related functioning proxy assessment was performed using the rotarod, balance beam, elevator vertical motion (EVM) and Ferris-wheel rotation (FWR) assays.

Results

The Pre-CHL (control) threshold depth was 27.92dB±11.58dB compared to the Post-CHL threshold depth of 50.69dB±13.98dB (mean±SD) across the frequencies tested. The automated ABR machine learning algorithm determined the following threshold depths: Pre-CHL=24.3dB, Post-CHL same day=56dB, Post-CHL 7 days=41.16dB, and Post-CHL 1 month=32.5dB across the frequencies assessed (1, 2, 4, 8, 16, and 32kHz). Rotarod assessment of motor function was not significantly different between pre and post-CHL (~1week) rats for time duration (sec) or speed (RPM), albeit the former had a small effect size difference. Balance beam time to transverse was significantly longer for post-CHL rats, likely indicating a change in motor coordination. Further, failure to cross was only noted for CHL rats. The defection count was significantly reduced for CHL rats compared to control rats following FWR, but not EVM. The total distance traveled during open-field examination after EVM was significantly different between control and CHL rats, but not for FWR. The EVM is associated with linear acceleration (acting in the vertical plane: up-down) stimulating the saccule, while the FWR is associated with angular acceleration (centrifugal rotation about a circular axis) stimulating both otolith organs and semicircular canals; therefore, the difference in results could reflect the specific vestibular-organ functional role.

Discussion

Less movement (EVM) and increase time to transverse (balance beam) may be associated with anxiety and alterations to defecation patterns (FWR) may result from autonomic disturbances due to the impact of hearing loss. In this regard, vestibulomotor deficits resulting in changes in balance and motion could be attributed to comodulation of auditory and vestibular functioning. Future studies should manipulate vestibular functioning directly in rats with CHL.

Use of Virtual Reality-Based Games to Improve Balance and Gait of Children and Adolescents with Sensorineural Hearing Loss: A Systematic Review and Meta-Analysis

BACKGROUND

Children and adolescents with sensorineural hearing loss (SNHL) often experience motor skill disturbances, particularly in balance and gait, due to potential vestibular dysfunctions resulting from inner ear damage. Consequently, several studies have proposed the use of virtual reality-based games as a technological resource for therapeutic purposes, aiming to improve the balance and gait of this population.

OBJECTIVE

The objective of this systematic review is to evaluate the quality of evidence derived from randomized or quasi-randomized controlled trials that employed virtual reality-based games to enhance the balance and/or gait of children and adolescents with SNHL.

METHODS

A comprehensive search was conducted across nine databases, encompassing articles published in any language until 1 July 2023. The following inclusion criteria were applied: randomized or quasi-randomized controlled trials involving volunteers from both groups with a clinical diagnosis of bilateral SNHL, aged 6-19 years, devoid of physical, cognitive, or neurological deficits other than vestibular dysfunction, and utilizing virtual reality-based games as an intervention to improve balance and/or gait outcomes.

RESULTS

Initially, a total of 5984 articles were identified through the searches. Following the removal of duplicates and screening of titles and abstracts, eight studies remained for full reading, out of which three trials met the eligibility criteria for this systematic review. The included trials exhibited a very low quality of evidence concerning the balance outcome, and none of the trials evaluated gait. The meta-analysis did not reveal significant differences in balance improvement between the use of traditional balance exercises and virtual reality-based games for adolescents with SNHL (effect size: -0.48; [CI: -1.54 to 0.57]; p = 0.37; I² = 0%).

CONCLUSION

Virtual reality-based games show promise as a potential technology to be included among the therapeutic options for rehabilitating the balance of children and adolescents with SNHL. However, given the methodological limitations of the trials and the overall low quality of evidence currently available on this topic, caution should be exercised when interpreting the results of the trials analyzed in this systematic review.

Pediatric Vestibular Assessment: Clinical Framework

OBJECTIVES

Although vestibular deficits can have severe repercussions on the early motor development in children, vestibular assessment in young children has not yet been routinely integrated in clinical practice and clear diagnostic criteria to detect early vestibular deficits are lacking. In young children, specific adjustments of the test protocol are needed, and normative data are age-dependent as the vestibular pathways mature through childhood. Therefore, this study aims to demonstrate the feasibility of an extensive age-dependent vestibular test battery, to provide pediatric normative data with the concurrent age trends, and to offer a clinical framework for pediatric vestibular testing.

DESIGN

This normative study included 133 healthy children below the age of 4 years (mean: 22 mo, standard deviation: 12.3 mo, range: 5-47 mo) without history of hearing loss or vestibular symptoms. Children were divided into four age categories: 38 children younger than 1 year old, 37 one-year olds, 33 two-year olds, and 25 three-year olds. Children younger than 3 years of age were examined with the video Head Impulse Test (vHIT) of the horizontal semicircular canals, cervical vestibular evoked myogenic potentials (cVEMP) with bone conduction stimuli, and the rotatory test at 0.16, 0.04, and 0.01 Hz. In 3-year old children, the vHIT of the vertical semicircular canals and ocular vestibular evoked myogenic potentials (oVEMP) using a minishaker were added to the protocol.

RESULTS

The horizontal vHIT appeared to be the most feasible test across age categories, except for children younger than 1-year old in which the success rate was the highest for the cVEMP. Success rates of the rotatory test varied the most across age categories. Age trends were found for the vHIT as the mean vestibulo-ocular reflex (VOR) gain increased significantly with age (r = 0.446, p < 0.001). Concerning the cVEMP, a significant increase with age was found for latency P1 (r = 0.420, p < 0.001), rectified interpeak amplitude P1-N1 (r = 0.574, p < 0.001), and averaged electromyographic (EMG) activity (r = 0.430, p < 0.001), whereas age trends for the latency N1 were less pronounced (r = 0.264, p = 0.004). Overall, the response parameters of the rotatory test did not show significant age effects ( p > 0.01), except for the phase at 0.01 Hz (r = 0.578, p < 0.001). Based on the reported success rates and age-dependent normative vestibular data, straightforward cutoff criteria were proposed (vHIT VOR gain < 0.7, cVEMP rectified interpeak amplitude < 1.3, oVEMP interpeak amplitude < 10 µV) with accompanying clinical recommendations to diagnose early vestibular impairment.

CONCLUSIONS

In this large cohort of typically developing children below the age of 4 years, the vHIT and cVEMP were the most feasible vestibular tests. Moreover, the age-dependent normative vestibular data could specify age trends in this group of young children. Finally, based on the current results and clinical experience of more than ten years at the Ghent University Hospital (Belgium), a clinical framework to diagnose early vestibular deficits in young patients is proposed.

Vestibular Infant Screening-Flanders: What is the Most Appropriate Vestibular Screening Tool in Hearing-Impaired Children?

OBJECTIVES

As children with sensorineural hearing loss have an increased risk for vestibular impairment, the Vestibular Infant Screening-Flanders project implemented a vestibular screening by means of cervical vestibular evoked myogenic potentials (cVEMP) at the age of 6 months for each child with hearing loss in Flanders (Belgium). Given that vestibular deficits can affect the child's development, this vestibular screening should allow early detection and intervention. However, less is currently known about which screening tool would be the most ideal and how vestibular impairment can evolve. Therefore, this study aimed to determine the most appropriate tool to screen for vestibular deficits, to assess the necessity of vestibular follow-up, and to set clinical guidelines for vestibular screening in children with hearing loss.

DESIGN

In total, 71 children with congenital or early-onset sensorineural hearing loss were enrolled (mean age at first appointment = 6.7 months). Follow-up was provided at 6 months, 1, 2, and 3 years of age. Below three years of age, the video Head Impulse Test (vHIT) of the horizontal semicircular canals (SCC), the cVEMP, and the rotatory test at 0.16, 0.04, and 0.01 Hz were applied. At 3 years of age, the vHIT of the vertical SCC and ocular vestibular evoked myogenic potentials (oVEMP) were added. To evaluate early motor development, the Alberta Infant Motor Scale (AIMS) results at 6 months and 1-year old were included.

RESULTS

At 6 months of age, the highest success rate was obtained with the cVEMP (90.0%) compared to the vHIT (70.0%) and the rotatory test (34.3-72.9%). Overall, vestibular deficits were found in 20.0% of the children, consisting of 13.9% with both SCC and otolith deficits (bilateral: 9.3%, unilateral: 4.6%), and 6.1% with unilateral isolated SCC (4.6%) or otolith (1.5%) deficits. Thus, vestibular deficits would not have been detected in 4.6% of the children by only using the cVEMP, whereas 1.5% would have been missed when only using the vHIT. Although vestibular deficits were more frequently found in severe to profound hearing loss (28.6%), characteristics of vestibular function were highly dependent on the underlying etiology. The AIMS results showed significantly weaker early motor development in children with bilateral vestibular deficits ( p = 0.001), but could not differentiate children with bilateral normal vestibular function from those with unilateral vestibular deficits ( p > 0.05). Progressive or delayed-onset vestibular dysfunction was only found in a few cases (age range: 12-36 months), in which the hearing loss was mainly caused by congenital cytomegalovirus (cCMV).

CONCLUSIONS

The cVEMP is the most feasible screening tool to assess vestibular function in 6-months-old children with hearing loss. Although the majority of children with vestibular deficits are detected with the cVEMP, the vHIT seems even more sensitive as isolated SCC deficits are associated with specific etiologies of hearing loss. As a result, the cVEMP is an appropriate vestibular screening tool, which is advised at least in severe to profound hearing loss, but certain etiologies require the addition of the vHIT (i.e., cCMV, meningitis, cochleovestibular anomalies with or without syndromic hearing loss).

Vestibular Loss in Children Affected by LVAS and IP2 Malformation and Operated with Cochlear Implant

This is a single center cohort study regarding the prevalence of vestibular loss in hearing impaired children affected by large vestibular aqueduct syndrome (LVAS) with incomplete cochlear partition malformation type II (IP2), fitted with cochlear implant (CI). Twenty-seven children received CI operations at 0.4-13 years on one or both ears and tested for vestibular loss with head impulse test, video head impulse test, mini ice-water test and cervical VEMP. Vestibular loss was found in 19% of operated ears and in 13.9% of non-operated ears. The difference was not statistically significant and was not significantly modified by age at implantation, age at testing, sex, presence of SLC26A4 gene mutation or bilaterality. However, the presence of anatomic anomalies at the level of the vestibulum or semicircular canals was significantly associated with a higher incidence of vestibular loss in CI operated children but not in those non-operated. No other factors, such as the surgical access, the electrode type, the presence of Gusher perioperatively, or post-operative vertigo modified significantly the prevalence of vestibular loss. In conclusion, LVAS/IP2 appears to be the major determinant of vestibular loss in these children, with a less obvious impact of CI, excluding the cases with vestibulum/canal anomalies: this group might have a higher risk for vestibular loss after CI surgery.

The global prevalence of vestibular dysfunction in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Vestibular dysfunction has been extensively studied amongst the older population. Recently, conditions and management of vestibular dysfunction among children and adolescent has gained attention. Yet, a lack of awareness and expertise in managing children and adolescents with vestibular dysfunction has led to a delay in diagnosis as well as a trifling prevalence rate.

AIM

To conduct a systematic review and meta-analyses to estimate the overall pooled prevalence of vestibular dysfunction in children and adolescents.

METHODS

PubMed, Scopus, and Web of Science databases were searched to identify studies published until 29 April 2022. We used a random-effects model to estimate the pooled prevalence with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic and Cochran's Q test. The robustness of the pooled estimates was checked by different subgroups and sensitivity analyses.

RESULTS

We identified 1811 studies, of which 39 studies (n = 323,663) were included in the meta-analysis. Overall, the pooled prevalence of children and adolescents with VD was 30.4% [95% CI 28.5-32.3%]. The age of the participants ranged from 1 to 19 years. Participants of the included 39 studies were from 15 countries. Among the studies, 34 were cross-sectional, and five were case-control designed. There were discrepancies found in the studies with objective (higher prevalence) versus subjective (lower prevalence) evaluations.

CONCLUSION

The prevalence of VD among children and adolescents was found to be 30.4% based on high-quality evidence. Due to the subjective assessment of most studies pooled in the analysis, the results should be interpreted cautiously until future comparative studies with objective assessments are carried out.

The significance of right ear auditory processing to balance

Although the association between balance and hearing thresholds at different frequencies in the right/left ear is crucial, it has received scant empirical attention. Balance is widely ignored when evaluating hearing in adults. This study examined the relative contribution of left versus right ear hearing at different frequencies to balance, and the mediating role of suprathreshold speech perception on age-balance associations. Pure tone hearing thresholds (500-4000 Hz), suprathreshold speech perception, balance, and risk of falling were evaluated in 295 adults. The results indicate that the right ear contributes more to balance than the left ear. This might imply dominance of the left hemisphere in processing hearing cues for balance. Frequencies within the speech range (500/1000/2000 Hz) were correlated with balance and mediated the interaction between age and balance. These results should be considered when tailoring hearing and balance rehabilitation programs.

Vestibular function in children with cochlear implant: Impact and evaluation

Over the last 30 years, cochlear implant (CI) has been dedicated to improving the rehabilitation of hearing impairments. However, CI has shown potential detrimental effects on vestibular function. For children, due to atypical symptoms and difficulty in cooperating with vestibular function tests, systematic and objective assessments of vestibular function with CI have been conducted sparsely. This review focuses on the impact of vestibular function in children with CI and summarized the evaluation of vestibular function in children. In addition, some recommended strategies are summarized and proposed.

Extended genetic diagnostics for children with profound sensorineural hearing loss by implementing massive parallel sequencing. Diagnostic outcome, family experience and clinical implementation

OBJECTIVES

The aim of this study was to investigate genetic outcomes, analyze the family experience, and describe the process of implementing genetic sequencing for children with profound sensorineural hearing loss (SNHL) at a tertial audiological center in southern Sweden.

DESIGN

This is a prospective pilot study including eleven children with profound bilateral SNHL who underwent cochlear implant surgery. Genetic diagnostic investigation was performed with whole exome sequencing (WES) complemented with XON-array to identify copy number variants, using a manually curated gene panel incorporating 179 genes associated with non-syndromic and syndromic SNHL. Mitochondrial DNA (mtDNA) from blood was examined separately. A patient reported experience measures (PREM) questionnaire was used to evaluate parental experience. We also describe here the process of implementing WES in an audiology department.

RESULTS

Six female and five male children (mean 3.4 years, SD 3.5 years), with profound bilateral SNHL were included. Genetic variants of interest were found in six subjects (55%), where three (27%) could be classified as pathogenic or likely pathogenic. Among the six cases, one child was found to have a homozygous pathogenic variant in MYO7A and two children had homozygous likely pathogenic variants in SLC26A4 and PCDH15, respectively. One was carrying a compound heterozygote frameshift variant of uncertain significance (VUS) on one allele and in trans, a likely pathogenic deletion on the other allele in PCDH15. Two subjects had homozygous VUS in PCDH15 and ADGRV1, respectively. In five of the cases the variants were in genes associated with Usher syndrome. For one of the likely pathogenic variants, the finding was related to Pendred syndrome. No mtDNA variants related to SNHL were found. The PREM questionnaire revealed that the families had difficulty in fully understanding the results of the genetic analysis. However, the parents of all eleven (100%) subjects still recommended that other families with children with SNHL should undergo genetic testing. Specifically addressed referrals for prompt complementary clinical examination and more individualized care were possible, based on the genetic results. Close clinical collaboration between different specialists, including physicians of audiology, audiologists, clinical geneticists, ophthalmologists, pediatricians, otoneurologists, physiotherapists and hearing habilitation teams was initiated during the implementation of the new regime. For all professionals involved, a better knowledge of the diversity of the genetic background of hearing loss was achieved.

CONCLUSIONS

Whole exome sequencing and XON-array using a panel of genes associated with SNHL had a high diagnostic yield, added value to the families, and provided guidance for further examinations and habilitation for the child. Great care should be taken to thoroughly inform parents about the genetic test result. Collaborations between departments were intensified and knowledge of hearing genomics was increased among the staff.

Three Years of Vestibular Infant Screening in Infants With Sensorineural Hearing Loss

OBJECTIVES

Although vestibular deficits are more prevalent in hearing-impaired children and can affect their development on many levels, a pediatric vestibular assessment is still uncommon in clinical practice. Since early detection may allow for timely intervention, this pioneer project has implemented a basic vestibular screening test for each six-month-old hearing-impaired infant in Flanders, Belgium. This study aims to report the vestibular screening results over a period of three years and to define the most important risk factors for abnormal vestibular screening results.

METHODS

Cervical Vestibular Evoked Myogenic Potentials with bone-conduction were used as a vestibular screening tool in all reference centers affiliated to the Universal Newborn Hearing Screening Program in Flanders. From June 2018 until June 2021, 254 infants (mean age: 7.4 months, standard deviation: 2.4 months) with sensorineural hearing loss were included.

RESULTS

Overall, abnormal vestibular screening results were found in 13.8% (35 of 254) of the infants. The most important group at risk for abnormal vestibular screening results were infants with unilateral or bilateral severe to profound sensorineural hearing loss (20.8%, 32 of 154) (P < .001, odds ratio = 9.16). Moreover, abnormal vestibular screening results were more prevalent in infants with hearing loss caused by meningitis (66.7%, 2 of 3), syndromes (28.6%, 8 of 28), congenital cytomegalovirus infection (20.0%, 8 of 40), and cochleovestibular anomalies (19.2%, 5 of 26).

CONCLUSIONS

The vestibular screening results in infants with sensorineural hearing loss indicate the highest risk for vestibular deficits in severe to profound hearing loss, and certain underlying etiologies of hearing loss, such as meningitis, syndromes, congenital cytomegalovirus, and cochleovestibular anomalies.

Impaired body-centered sensorimotor transformations in congenitally deaf people

Congenital deafness modifies an individual’s daily interaction with the environment and alters the fundamental perception of the external world. How congenital deafness shapes the interface between the internal and external worlds remains poorly understood. To interact efficiently with the external world, visuospatial representations of external target objects need to be effectively transformed into sensorimotor representations with reference to the body. Here, we tested the hypothesis that egocentric body-centred sensorimotor transformation is impaired in congenital deafness. Consistent with this hypothesis, we found that congenital deafness induced impairments in egocentric judgements, associating the external objects with the internal body. These impairments were due to deficient body-centred sensorimotor transformation per se, rather than the reduced fidelity of the visuospatial representations of the egocentric positions. At the neural level, we first replicated the previously well-documented critical involvement of the frontoparietal network in egocentric processing, in both congenitally deaf participants and hearing controls. However, both the strength of neural activity and the intra-network connectivity within the frontoparietal network alone could not account for egocentric performance variance. Instead, the inter-network connectivity between the task-positive frontoparietal network and the task-negative default-mode network was significantly correlated with egocentric performance: the more cross-talking between them, the worse the egocentric judgement. Accordingly, the impaired egocentric performance in the deaf group was related to increased inter-network connectivity between the frontoparietal network and the default-mode network and decreased intra-network connectivity within the default-mode network. The altered neural network dynamics in congenital deafness were observed for both evoked neural activity during egocentric processing and intrinsic neural activity during rest. Our findings thus not only demonstrate the optimal network configurations between the task-positive and -negative neural networks underlying coherent body-centred sensorimotor transformations but also unravel a critical cause (i.e. impaired body-centred sensorimotor transformation) of a variety of hitherto unexplained difficulties in sensory-guided movements the deaf population experiences in their daily life.

Using Functional Outcomes to Predict Vestibular Loss in Children

OBJECTIVE

The purpose of this study was to determine: (1) the relationship between vestibular loss severity and functional performance, (2) which functional performance outcomes best predict vestibular loss, and (3) which vestibular rate sensors (canals vs. otoliths) provide the most weighting during different functional measures.

STUDY DESIGN

Prospective.

SETTING

Tertiary referral center.

PATIENTS

Fifty-seven children with normal hearing (mean age: 12.3 years, 32 males) and 55 children with cochlear implants (mean age 12.8 years, 29 males).

INTERVENTION

Diagnostic.

MAIN OUTCOME MEASURES

Video head impulse test, cervical vestibular evoked myogenic potential (cVEMP), ocular VEMP (oVEMP), single leg stance, Standing Balance Test, active and passive dynamic visual acuity, and the balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2).

RESULTS

Performance worsened as vestibular loss severity worsened for all functional outcomes except the standing balance test conditions 1 and 2. The best outcomes for classifying children with vestibular loss were the single leg stance (cut-off criterion: 5 seconds; sensitivity and specificity of 88% and 86%) and the BOT-2 balance subtest (cut-off criterion of 27.5 points; sensitivity and specificity of 88% and 88%). Average horizontal canal vHIT gain was a significant predictor of all functional outcomes while neither corrected cVEMP amplitude nor oVEMP amplitude predicted performance.

CONCLUSION

Functional performance declines as vestibular loss severity worsens. Single leg stance is fast and efficient for predicting vestibular loss in school age children. Average horizontal canal vHIT best predicts functional performance; if using a tiered approach, horizontal canal vHIT should be completed first.

Effect of cochlear implantation on vestibular function in children: A scoping review

OBJECTIVE

To provide a scoping review of the available literature for determining objectively the effect of cochlear implantation on vestibular function in children.

METHODS

A literature search was performed and the following criteria were applied: vestibular tests that were performed on subjects within the range of 0-18 years old before and after cochlear implantation. The papers conducted at least one of the following tests: (video) head impulse test, caloric test, cervical and ocular vestibular evoked myogenic potentials or rotatory chair test. Included papers underwent quality assessment and this was graded by risk of bias and directness of evidence.

RESULTS

Fourteen articles met the selection criteria. The included studies showed that cochlear implantation leads to a decrease in vestibular function in a proportion of the patient population. This loss of vestibular function can be permanent, but (partial) restoration over the course of months to years is possible. The pooling of data determined that the articles varied on multiple factors, such as time of testing pre- and post-operatively, age of implantation, etiologies of hearing loss, used surgical techniques, type of implants and the applied protocols to determine altered responses within vestibular tests. The overall quality of the included literature was deemed as high risk of bias and medium to low level of directness of evidence. Therefore, the data was considered not feasible for systematic analysis.

CONCLUSION

This review implicates that vestibular function is either unaffected or shows short-term or permanent deterioration after cochlear implantation in children. However, the heterogeneity of the available literature indicates the importance of standardized testing to improve our knowledge of the effect of cochlear implantation on the vestibular function and subsequent developmental consequences for the concerned children.

Deaf Individuals Who Report Having Good Balance Function Present with Significant Vestibular Deficits

BACKGROUND

 Vestibular and/or balance deficits are well documented in deaf individuals. In the adult population, poor vestibular and/or balance function can lead to activity limitations and increased risk of falling. An effective case history by health care providers to probe for potential balance concerns is necessary for appropriate referral; however, patients may not consistently report vestibular and balance symptoms. Currently, there is little information available as to how deaf individuals report these symptoms and how their reported balance ability relates to measures of balance and vestibular functions.

PURPOSE

 The aim of the current study was to evaluate self-perceived balance ability in participants who self-identify as either deaf or hearing, and compare these results to measures of balance and vestibular functions.

RESEARCH DESIGN

 This is a prospective, between-group design.

STUDY SAMPLE

 Data from 57 adults between the ages of 18 to 29 years who self-reported as deaf (39) or hearing (18) were evaluated. Participants completed the activities-specific balance confidence (ABC) scale, a brief case history, self-report rating of balance (SRRB), the Modified Clinical Test of Sensory Integration of Balance (mCTSIB), along with both ocular vestibular-evoked myogenic potentials (oVEMPs) and cervical vestibular-evoked myogenic potentials (cVEMPs). Only participants with SRRBs of good or excellent were included in the inferential analyses.

RESULTS

 Proportions of participants rating their balance ability as either good or excellent were similar between both groups, as were the results on the ABC scale. Statistical analyses revealed significant associations between the groups on both oVEMPs and cVEMPs. No significant differences were observed on sway velocities in any of the mCTSIB conditions; however, more than one-third of deaf participants had mCTSIB Condition 4-on foam, eyes closed-scores above 2 standard deviations of the hearing group.

CONCLUSION

 Deaf participants self-report similar ratings of balance ability as hearing participants despite significant differences in vestibular function. A relatively large subset of deaf participants had increased sway velocity on balance function testing that required increased reliance on vestibular cues. A thorough discussion of balance and vestibular symptoms should be completed when a patient who self-identifies as deaf is seen by a health care provider so that appropriate screenings or referrals can be completed as necessary.

Vestibular Evaluation and Management of Children with Sensorineural Hearing Loss

Vestibular dysfunction is the most common comorbidity associated with childhood sensorineural hearing loss. Early identification of vestibular dysfunction enables early intervention to mitigate its impact of motor, behavioral, and neurocognitive deficits of developing children. Screening for vestibular impairment can be achieved in the busy clinical setting.

Peripheral Vestibular Dysfunction Is a Common Occurrence in Children With Non-syndromic and Syndromic Genetic Hearing Loss

Hearing loss (HL) is the most common sensory deficit in humans and is frequently accompanied by peripheral vestibular loss (PVL). While often overlooked, PVL is an important sensory dysfunction that may impair development of motor milestones in children and can have a significant negative impact on quality of life. In addition, many animal and in vitro models of deafness use vestibular hair cells as a proxy to study cochlear hair cells. The extent of vestibular end organ dysfunction associated with genetic pediatric hearing loss is not well-understood. We studied children with a known genetic cause of hearing loss who underwent routine preoperative vestibular testing prior to cochlear implantation between June 2014 and July 2020. Vestibular testing included videonystagmography, rotary chair, video head impulse testing, and/or vestibular evoked myogenic potentials. Etiology of HL was determined through history, physical examination, imaging, laboratory testing, and/or genetic testing. Forty-four children (21 female/23 male) met inclusion criteria; 24 had genetic non-syndromic and 20 had genetic syndromic forms of HL. Mean age at the time of testing was 2.8 ± 3.8 years (range 7 months-17 years). The most common cause of non-syndromic HL was due to mutations in GJB2 (n = 13) followed by MYO15A (3), MYO6 (2), POU3F4 (2), TMPRSS3 (1), CDH23 (1), TMC1 (1), and ESRRB (1). The most common forms of syndromic HL were Usher syndrome (4) and Waardenburg (4), followed by SCID/reticular dysgenesis (3), CHARGE (2), CAPOS (1), Coffin-Siris (1), Jervell and Lange-Nielsen (1), Noonan (1), peroxisome biogenesis disorder (1), Perrault (1), and Trisomy 21 (1). Overall, 23 patients (52%) had PVL. A larger proportion of children with syndromic forms of HL had PVL (12/20, 60%) compared with children with genetic non-syndromic HL (11/24, 46%), though without statistical significant (p = 0.3). The occurrence of PVL varied by affected gene. In conclusion, PVL is a common finding in children with syndromic and non-syndromic genetic HL undergoing vestibular evaluation prior to cochlear implantation. Improved understanding of the molecular physiology of vestibular hair cell dysfunction is important for clinical care as well as research involving vestibular hair cells in model organisms and in vitro models.

Cervical Vestibular-Evoked Myogenic Potentials and Balance Testing in Children with Down Syndrome

Introduction  Vestibular otolith function plays a major role in balance control. Objective  To investigate the saccular and balance functions of children with Down syndrome (DS). Methods  In total, 15 children with DS aged between 9 and 11 years were included. An age- and gender-matched control group (CG) composed of 15 normal participants was also included. The subjects with DS had trisomy 21, without hearing or organic problems, and they had independence in stance. The saccular function among the children with DS and among the controls was tested using air-conduction cervical vestibular-evoked myogenic potentials (cVEMPs). In addition, the static and dynamic balance statuses were evaluated using the following assessments; the Pediatric Balance Scale (PBS), the modified Clinical Test of Sensory Interaction on Balance (mCTSIB), the Romberg test, and the Timed Up and Go (TUG) test. Results  In the present study, the results of the saccular function test showed that there was a significant difference between children with and without DS ( p  < 0.05). The DS subjects had significantly earlier N1 latancy and lower amplitude of the cVEMPs (< 70 μV) compared with the control subjects. The static-dynamic balance ability was statistically and significantly different in children with DS compared with the controls ( p  < 0.05). Conclusion  These results revealed that saccular function seems to be affected in DS subjects. The dysfunction in static and dynamic balance abilities of the children with DS may be attributed to vestibular dysfunction as well as low gross motor skills. This knowledge should be taken into account when assessing motor performance in those subjects. Additional larger studies testing other dimensions of the vestibular system in children with DS are needed.

Repercussions of the Degrees of Hearing Loss and Vestibular Dysfunction on the Static Balance of Children With Sensorineural Hearing Loss

OBJECTIVE

The purpose of this study was to assess the static balance of children with sensorineural hearing loss (SNHL) according to the degrees of SNHL and the function of the vestibular system.

METHODS

This cross-sectional study was conducted in public schools located in Caruaru, Pernambuco state, Brazil, with 130 children (65 with normal hearing and 65 with SNHL as documented by air and bone conduction audiometry) of both sexes between 7 and 11 years old. Static balance was assessed by a stabilometric analysis using a force platform consisting of the circular area of center-of-pressure displacement of the children evaluated in 3 positions: bipedal support with feet together and parallel (PF), tandem feet (TF), and 1 foot (OF), carried out under 2 sensory conditions each, with eyes open and eyes closed. After balance assessments, the children with SNHL received examinations of auditory and vestibular functions-through audiometry and computerized vectoelectronystagmography, respectively-to compose the groups according to degrees of SNHL and vestibular function.

RESULTS

The children with severe and profound SNHL demonstrated more static balance instabilities than the children with normal hearing in 5 positions assessed with eyes open (PF, TF, and OF) and eyes closed (PF and TF). The same phenomenon occurred in children with SNHL and associated vestibular dysfunction in all of the positions assessed with eyes open and eyes closed (PF, TF, and OF).

CONCLUSION

The larger the degree of SNHL, the greater the balance instability of the children. The children with SNHL and associated vestibular dysfunction showed the highest balance instabilities in this study.

IMPACT

Children with larger degrees of SNHL and associated vestibular dysfunction might require prolonged periods to rehabilitate their balance.

A Systematic Review on the Association Between Vestibular Dysfunction and Balance Performance in Children With Hearing Loss

OBJECTIVES

The objective of this study was to understand the functional impact of vestibular dysfunction on balance control in children with hearing loss. The vestibular system is an important contributor to maintaining balance. In adults, vestibular dysfunction is known to lead to unsteadiness and falls. Considerably less is known about the effects of vestibular dysfunction in children with hearing loss.

DESIGN

We conducted a systematic review in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included articles on children with hearing loss who underwent vestibular and balance testing. The Downs and Black checklist was used to assess the risk of bias.

RESULTS

A total of 20 articles were included in this systematic review, of which, 17 reported an association between vestibular dysfunction and balance abnormalities in children with hearing loss. Bias (as measured by the Downs and Black Checklist) was a concern, as most studies were nonblinded cohort studies or case series selected through convenience sampling.

CONCLUSIONS

Research to date has predominantly found that children with concomitant hearing loss and vestibular impairment tend to perform more poorly on balance measures than either children with hearing loss and normal vestibular function or children with both normal-hearing and normal vestibular function. A standardized approach to assessing both vestibular function and balance would better characterize the impact of vestibular dysfunction in children with hearing loss at the population level.

Changes in Vestibular Function Following Pediatric Cochlear Implantation: a Prospective Study

OBJECTIVES

Given the close interconnection between the auditory and vestibular end organs, the increasingly broad application of (bilateral) cochlear implantation (CI) in children raises concern about its impact on the vestibular function. Unfortunately, literature on this matter is inconclusive and subject to several limitations. Therefore, this study aimed to elucidate the impact of pediatric CI on the vestibular function in a large sample of children, representative for the current CI population.

DESIGN

Fifty hearing-impaired children followed in the Ghent University Hospital were included in this prospective study. Twenty-seven patients underwent unilateral CI, and 23 were bilaterally implanted (9 sequentially, 14 simultaneously), adding up to 73 implanted ears. Children's median age at first implantation was 29 (range 8 to 194) months. Vestibular assessment was scheduled on average 2.8 months (SD: 3.6) before and 4.6 (SD: 4.0) months after implantation and consisted of video Head Impulse Testing of the lateral semicircular canals, rotatory testing (0.16, 0.04, and 0.01 Hz) and cervical vestibular evoked myogenic potential (cVEMP) testing with bone conduction stimulation. Caloric testing was added in children older than 3 years of age.

RESULTS

Overall, group analysis in our sample of 73 CI-ears did not reveal any significant impact on the vestibular function, except for a significantly shortened ipsilateral N1 latency of the cVEMP responses (p = 0.027) after CI. Complete ipsilateral loss of function after implantation was seen in 5% (3/54) of all CI-ears on the video head impulse testing, in 0% (0/10) on the caloric test and in 2% (1/52) on the cVEMP, notably all patients deafened by a congenital cytomegalovirus infection.

CONCLUSIONS

The impact of CI on the vestibular function in our dataset was limited. Therefore, the many advantages of simultaneous bilateral implantation may outweigh the risk for vestibular damage postoperatively. However, the impact on the vestibular function may be dependent on various factors (e.g., etiology of the hearing loss), and the clinical outcome is still difficult to predict. Vestibular assessment remains thus an important aspect in the pediatric CI population; first because the vestibular function should be considered in the decision-making process on (simultaneous or sequential bilateral) CI and second because it is essential to reveal a possible additional sensory deficit, allowing an opportunity for rehabilitation to improve the overall outcome of these children.

Neuropsychological profiles of children with vestibular loss

BACKGROUND

The impact of vestibular loss (VL) on cognition has been previously studied in experimental animal, human and adult patient studies showing links between VL, and cognitive impairments in space orientation, working memory, mental rotation and selective attention. However, few studies have been conducted on children with VL.

OBJECTIVE

We investigated for the first time, the impact of a VL on children's cognition.

METHODS

13 children with VL (10 years, 5 months) and 60 average-age matched controls performed a neuropsychological assessment consisting of visuospatial working memory, selective visual attention, mental rotation and space orientation tasks.

RESULTS

Children with VL recalled smaller sequences for both forward and backward memory subtasks (mean±SD = 6.3±1.9 and 5.3±2.6) than controls (8.2±2.3 and 7.3±2.0), have less accurate mental rotation scores (25.4±6 versus 30.8±5.1) and greater additional distance travelled in the maze task (96.4±66.6 versus 60.4±66.3); all corrected p-values <0.05. Selective visual attention measures do not show significant differences.

CONCLUSIONS

Children with VL show similar cognitive difficulties that adults with VL, in tasks involving dynamic cognitive processes (higher attentional load) that in tasks requiring static cognitive processes such as visual attention task.

Sport as a Factor in Improving Visual Spatial Cognitive Deficits in Patients with Hearing Loss and Chronic Vestibular Deficit

Hearing loss and chronic vestibular pathologies require brain adaptive mechanisms supported by a cross-modal cortical plasticity. They are often accompanied by cognitive deficits. Spatial memory is a cognitive process responsible for recording information about the spatial environment and spatial orientation. Visual-spatial working memory (VSWM) is a kind of short-term working memory that allows spatial information to be temporarily stored and manipulated. It can be conditioned by hearing loss and also well-compensated chronic vestibular deficit. Vestibular rehabilitation and hearing aid devices or training are able to improve the VSWM. We studied 119 subjects suffering from perinatal or congenital hearing loss, compared with 532 healthy subjects and 404 patients with well-compensated chronic vestibular deficit (CVF). VSWM was evaluated by the eCorsi test. The subjects suffering from chronic hearing loss and/or unilateral or bilateral vestibular deficit showed a VSWM less efficient than healthy people, but much better than those with CVF, suggesting a better multimodal adaptive strategy, probably favored by a cross-modal plasticity which also provides habitual use of lip reading. The sport activity cancels the difference with healthy subjects. It is therefore evident that patients with this type of deficit since childhood should be supported and advised on a sport activity or repeated vestibular stimulation.

The Visuo-Spatial Abilities Diagnosis (VSAD) test: Evaluating the potential cognitive difficulties of children with vestibular impairment through a new tablet-based computerized test battery

Recent data collected on adult patients with vestibular loss (VL) tend to demonstrate possible cognitive impairments in visuospatial working memory, mental rotation, selective attention, and space orientation. However, the neuropsychological profile of children with VL remains largely under-investigated in the scientific literature. Although previous research has shown that children with VL may experience some degree of delayed motor development, it is not yet clear if VL could also lead to specific delayed cognitive development. In this study, we will present the development and validation of a new tablet-based computerized test battery (VSAD) that evaluates visuospatial working memory, mental rotation, selective attention, and space orientation abilities. Thirteen children with VL and 54 average-age matched healthy children performed the VSAD and classical paper-and-pencil neuropsychological tasks twice within a 1-month interval. Our results demonstrated a good concurrent validity with strong correlations between the visuospatial working memory, mental rotation, and space orientation tests of the VSAD and classical tasks. Test-retest reliability was also supported through good intra-class coefficients. However, the test of selective attention showed no concurrent validity with the matched classical task. The discriminant validity of the VSAD was partially supported for visuospatial working memory and mental rotation performance accuracy. The VSAD shows good concurrent validity and reliability for measuring visuospatial working memory, mental rotation, and space orientation in children with VL. Future studies are needed to extend discriminant validity with other populations.

Vestibular status: A missing factor in our understanding of brain reorganization in deaf individuals

The brain of deaf people is definitely not just deaf, and we have to reconsider what we know about the impact of hearing loss on brain development in light of comorbid vestibular impairments.

Long-Term Lateral Semicircular Canal Function in Children with Cochlear Implants: Results of Video Head Impulse Test

In children with profound deafness, bilateral cochlear implant (CI) is an effective, established procedure. However, its safety on vestibular function has recently been debated. The goal of this study is to evaluate the long-term lateral semicircular canal high-frequency vestibulo-oculomotor reflex (LSC HF VOR) in children with CI by video head impulse testing (vHIT). This is a cross-sectional study assessing a cohort of children who received either a unilateral (12) or a bilateral (12) cochlear implant (CI), compared with a control group of 12 normal-hearing children. No significant LSC HF VOR gain difference was found between CI users and controls. In the unilaterally implanted group, the LSC HF VOR gain measured in the “CI-ON” condition was significantly higher than in the “CI-OFF” condition, both in the implanted and in the non-implanted ear. In the bilaterally implanted group, the difference between the two conditions was not significant. Our results do not show any impairment of LSC HF VOR function in children with CI compared to normal-hearing children in the long-term period. This suggests that both unilateral and simultaneous/sequential bilateral CI are procedures that do not impair HF LSC long-term function when analyzed by vHIT.

Vestibular Infant Screening (VIS)-Flanders: results after 1.5 years of vestibular screening in hearing-impaired children

Due to the close anatomical relationship between the auditory and vestibular end organs, hearing-impaired children have a higher risk for vestibular dysfunction, which can affect their (motor) development. Unfortunately, vestibular dysfunction often goes unnoticed, as vestibular assessment in these children is not standard of care nowadays. To timely detect vestibular dysfunction, the Vestibular Infant Screening–Flanders (VIS–Flanders) project has implemented a basic vestibular screening test for hearing-impaired infants in Flanders (Belgium) with a participation rate of 86.7% during the first year and a half. The cervical Vestibular Evoked Myogenic Potentials (cVEMP) test was applied as vestibular screening tool to map the occurrence of vestibular (mainly saccular) dysfunction in this population. At the age of 6 months, 184 infants were screened. No refers on vestibular screening were observed in infants with permanent conductive hearing loss. In infants with permanent sensorineural hearing loss, a cVEMP refer rate of 9.5% was observed. Failure was significantly more common in infants with severe-profound compared to those with mild-moderate sensorineural hearing loss (risk ratio = 9.8). Since this is the first regional study with a large sample size and successful participation rate, the VIS–Flanders project aims to set an example for other regions worldwide.

Vestibular function in adults with intellectual disabilities: feasibility and outcome of a vestibular screening protocol in Special Olympics athletes

OBJECTIVE

This study aimed to evaluate the feasibility of a well-adapted vestibular screening battery to objectively examine the (peripheral) vestibular function, and to explore the characteristics of potential vestibular deficits in the adult ID population.

DESIGN

Cross-sectional study design.

STUDY SAMPLE

Compared to an age- and gender-weighted control group, a heterogeneous group of forty-five adults with ID participated in the vestibular screening at the National Games of Special Olympics Belgium (2019), which consisted of a bone conduction cervical Vestibular Evoked Myogenic Potential (cVEMP) measurement and video Head Impulse Test (vHIT).

RESULTS

The screening battery appeared to be feasible in the majority of the participants (cVEMP: 92%; vHIT: 72%). Overall, the occurrence of abnormal cVEMP and vHIT responses was significantly higher in the ID group, with significantly lower corrected peak-to-peak cVEMP amplitudes (p < 0.001), lower vHIT gains (p < 0.001), and higher cVEMP and vHIT asymmetry ratios in the ID group (p = 0.008 and p < 0.001 resp.).

CONCLUSIONS

Vestibular assessment using the cVEMP and vHIT technique shows a promising feasibility in adults with ID. In addition, this study suggests that people with ID exhibit an increased prevalence of (peripheral) vestibular deficits relative to the general population.

Does the practice of sports or recreational activities improve the balance and gait of children and adolescents with sensorineural hearing loss? A systematic review

BACKGROUND

Balance and gait disorders have been observed in children and adolescents with sensorineural hearing loss (SNHL), justified by vestibular dysfunctions that these children may present, due to the injury to the inner ear. Therefore, some investigations have suggested that the practice of sports or recreational activities can improve the balance and gait of this population.

OBJECTIVE

Assess the evidence quality from randomized or quasi-randomized controlled trials that used sports or recreational activities as an intervention to improve the balance and /or gait of children and/or adolescents with SNHL.

METHODS

Systematic review that surveyed articles in nine databases, published up to January 10, 2019, in any language, using the following inclusion criteria: (1) Randomized or quasi-randomized controlled trials. (2) Participants from both groups with the clinical diagnosis of SNHL, aged 6-19 years old, without physical problems, cognitive or neurological deficits, except the vestibular dysfunction. (3) Using the practice of sports or recreational activities as an intervention, to improve the balance and/or gait outcomes.

RESULTS

4732 articles were identified in the searches, after the removal of the duplicates articles and the reading of the titles and their abstracts, remained 16 articles for reading in full, being 5 trials eligible for this systematic review. Of the five eligible trials, three used sports activities and two recreational activities as intervention and presented very low-quality evidence for balance and gait outcomes.

SIGNIFICANCE

Sports and recreational practices seem to represent promising modalities to improve the balance and gait of children and adolescents with SNHL. However, due to the methodological limitations of the trials and the low quality of the current evidence on the topic, the results of the trials should be interpreted with caution. Due to the low quality of evidence observed, we suggest that new trials be proposed on this topic, with greater methodological rigor, to provide high-quality evidence on the effectiveness of sports and recreational practices to improve the balance and gait of children and adolescents with SNHL.

How sacculo-collic function assessed by cervical vestibular evoked myogenic Potentials correlates with the quality of postural control in hearing impaired children?

OBJECTIVE

Functional integrity of vestibular end organs is essential for gaze stabilization, dynamic visual acuity, postural control and spatial orientation. Some authors hypothesized on the importance of saccules for postural control and motor development in children, including achievements such as standing up and walking. The purpose of this article was to observe how saccular dysfunction assessed by cervical Vestibular Evoked Myogenic Potentials (cVEMPs) correlates with the quality of postural control in non-syndromic deaf children.

METHOD

Seventy-six non-syndromic hearing-impaired children were retrospectively included. Sacculo-collic pathway was assessed with cVEMPs elicited in bone conduction. The response was quoted "normal" if a reproducible wave P13-N23 of at least 50μV in amplitude was present, if not, it was quoted "absent". The sample was divided in 3 groups depending on the presence of the sacculo-collic responses: normal bilateral group (Group 1), normal unilateral (Group 2) and absent bilaterally group (Group 3). Motor assessment was achieved with Movement Assessment Battery for Children, second edition (MABC-2). Postural control (PC) was assessed using the dynamic Balance Quest platform. The scores obtained with MABC-2, and the postural parameters recorded on the Balance Quest platform (sway of Centre of Pressure and spectral power index) were analyzed and compared throughout the groups.

RESULTS

Group 1 (normal bilateral) showed the best scores regarding motor abilities and postural stability within available normative data. Group 3 (absent bilateral) had the lowest motor and postural control skills. A good correlation between the scores obtained by MABC-2 motor test and dynamic posturography (Balance Quest) was observed.

CONCLUSIONS

The presence of at least one sacculo-collic response would predict satisfactory static and dynamic motor and postural control skills in non-syndromic hearing-impaired children. MABC-2 and Dynamic Posturography Balance Quest appears reliable and comparable tools for PC assessment in hearing impaired children. In the light of these results, it appears that in young children candidates for uni- or bilateral CI whose walking is not yet acquired, should receive a vestibular assessment before surgery to avoid the risk of bilateral sacculo-collic function impairment.

The Effect of Cochlear Implantation on Vestibular Evoked Myogenic Potential in Children

Objectives/Hypothesis

We conducted this study to assess the effects of unilateral cochlear implantation (CI) on otolith function by observing the changes in ocular vestibular evoked myogenic potential (oVEMP) and cervical vestibular evoked myogenic potential (cVEMP) in children.

Study Design: Prospective case series.

Methods

The oVEMP and cVEMP elicited by air‐conducted sound in 35 children were analyzed preoperatively and at 5 days, 1 month, and 2 months after surgery.

Results

Before CI, the response rates of oVEMPs and cVEMPs were 81.4% and 91.4%, respectively. In the implanted side, oVEMPs and cVEMPs were reduced by 37.1% and 68.6%, respectively, 5 days after CI. One month after CI, oVEMPs and cVEMPs were 34.6% and 72%, respectively, with the device switched off, and 50% and 73.1%, respectively, with the device switched on. Two months after CI, the oVEMPs and cVEMPs were 36% and 80%, respectively, when the implant was turned off, and 70.8% and 75%, respectively, when the implant was turned on.

Conclusions

The study confirmed the value of VEMP testing in the clinical setting and that absent VEMPs could indicate impairment of otolith function after CI.

Level of Evidence

4 Laryngoscope, 2020

Evolution of Cochlear implant mapping and vestibular function in a pediatric case of Labyrinthitis

Background

Vestibular symptoms such as vertigo and imbalance are known to occur in some cochlear implant patients during the immediate postoperative period; however, acute vertigo in implanted children occurring remotely from the postoperative period has not been previously well-described.

Case presentation

A three-year-old girl with a history of bilateral sequential cochlear implantation presented with acute labyrinthitis associated with sudden onset of vertigo, balance impairment, and decline in right cochlear implant function 2 years after her most recent implant surgery. We describe her audiological and vestibular testing results during both the acute phase and following medical management and recovery.

Conclusion

Acute labyrinthitis should be considered when sudden onset vertigo and/or imbalance presents in children with cochlear implants outside of the perioperative period. Such symptoms should prompt early assessment of cochlear implant function, so that the device can be reprogrammed accordingly.

Prevalence of Vestibular Dysfunction in Children With Neurological Disabilities: A Systematic Review

Background: In children with neurological or neurodevelopmental conditions, vestibular disorders may co-exist with the primary condition and further contribute to disability and restriction in functional independence and participation. Awareness of their existence may favor an early diagnosis and better treatment outcomes.

Objectives: To determine the prevalence of vestibular dysfunction in children and adolescents (3–21 years old) diagnosed with either cerebral palsy (CP), traumatic brain injury (TBI), sensorineural hearing loss (SNHL), or cochlear implantations (CI).

Methods: Four researchers systematically reviewed the literature from three databases (EMBASE, MEDLINE, CINAHL) until June 2018.

Results: Twenty-four studies were analyzed in this systematic review. A single, high-quality study reports a prevalence of 48.4% of spastic CP children having a saccular dysfunction. Three fair-quality studies report a prevalence of 14.6–81%, 21 days post-TBI. Twelve poor-to-high quality studies demonstrate a prevalence of 18.7–96.1% in children with SNHL. A prevalence range of 3–84% in children with CI is reported by nine fair-to-high quality studies.

Conclusion: Clinicians should be aware of the prevalence of vestibular dysfunction in these populations and implement appropriate assessments to improve treatment outcomes.

Vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with sensorineural hearing loss: A systematic review

BACKGROUND

Several studies have demonstrated that children with sensorineural hearing loss (SNHL) exhibit postural instabilities, as well as balance and gait disorders, due to the vestibular dysfunction that they are prone to display as a consequence of inner ear injury. Thus, some experiments have proposed vestibular rehabilitation exercises programs as a treatment to improve these motor skills in children with SNHL.

OBJECTIVE

Assess the evidence quality of the trials that used vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with SNHL.

METHODS

This is a systematic review that surveyed articles in nine databases, published up to July 4, 2019, in any language, using the following inclusion criteria: (1) Randomized or quasi-randomized controlled trials. (2) Participants of both groups with clinical diagnosis of SNHL, aged up to 12 years old, with no physical problems, cognitive or neurological impairments, except the vestibular dysfunction. (3) Using vestibular rehabilitation exercises programs to improve the following outcomes: postural control, balance and/or gait.

RESULTS

Six experiments, including 153 children, met the inclusion criteria of this systematic review. Two randomized controlled trials (45 children) on the postural control exhibited low evidence quality and four others; three randomized and controlled trials (90 children) on the balance and one quasi-randomized (18 children) on the gait demonstrated very low evidence quality, respectively.

CONCLUSION

There is promising evidence that vestibular rehabilitation exercises programs improve the postural control, balance and gait of children with SNHL. However, due to the methodological limitations of the trials and low quality of current evidence on this topic, the trials results analyzed by this systematic review should be interpreted with caution. Due to the low quality of evidence observed in this review, we suggest that new trials be proposed on this topic, with better methodological quality, to prove the effectiveness of vestibular rehabilitation exercises programs to improve the postural control, balance and gait of children with SNHL.

BalanCI: Head-Referenced Cochlear Implant Stimulation Improves Balance in Children with Bilateral Cochleovestibular Loss

INTRODUCTION

To determine the impact of a head-referenced cochlear implant (CI) stimulation system, BalanCI, on balance and postural control in children with bilateral cochleovestibular loss (BCVL) who use bilateral CI.

METHODS

Prospective, blinded case-control study. Balance and postural control testing occurred in two settings: (1) quiet clinical setting and (2) immersive realistic virtual environment (Challenging Environment Assessment Laboratory [CEAL], Toronto Rehabilitation Institute). Postural control was assessed in 16 and balance in 10 children with BCVL who use bilateral CI, along with 10 typically developing children. Children with neuromotor, cognitive, or visual deficits that would prevent them from performing the tests were excluded. Children wore the BalanCI, which is a head-mounted device that couples with their CIs through the audio port and provides head-referenced spatial information delivered via the intracochlear electrode array. Postural control was measured by center of pressure (COP) and time to fall using the WiiTM (Nintendo, WA, USA) Balance Board for feet and the BalanCI for head, during the administration of the Modified Clinical Test of Sensory Interaction in Balance (CTSIB-M). The COP of the head and feet were assessed for change by deviation, measured as root mean square around the COP (COP-RMS), rate of deviation (COP-RMS/duration), and rate of path length change from center (COP-velocity). Balance was assessed by the Bruininks-Oseretsky Test of Motor Proficiency 2, balance subtest (BOT-2), specifically, BOT-2 score as well as time to fall/fault.

RESULTS

In the virtual environment, children demonstrated more stable balance when using BalanCI as measured by an improvement in BOT-2 scores. In a quiet clinical setting, the use of BalanCI led to improved postural control as demonstrated by significant reductions in COP-RMS and COP-velocity. With the use of BalanCI, the number of falls/faults was significantly reduced and time to fall increased.

CONCLUSIONS

BalanCI is a simple and effective means of improving postural control and balance in children with BCVL who use bilateral CI. BalanCI could potentially improve the safety of these children, reduce the effort they expend maintaining balance and allow them to take part in more complex balance tasks where sensory information may be limited and/or noisy.

Vestibular Infant Screening - Flanders: The implementation of a standard vestibular screening protocol for hearing-impaired children in Flanders

OBJECTIVES

The Vestibular Infant Screening - Flanders (VIS-Flanders) project aims to implement and refine a vestibular screening protocol for all children with neonatal hearing loss in Flanders (Belgium) to limit the impact of a vestibular dysfunction on the motor, cognitive and psychosocial development of hearing-impaired children.

METHODS

Each child with a confirmed neonatal hearing loss in Flanders will undergo a vestibular screening at the age of 6 months in the reference centers involved in the neonatal hearing screening program. The cervical Vestibular Evoked Myogenic Potential (cVEMP) test will be used as a screening tool. The test is short, child-friendly, feasible at a young age and highly correlated with motor and balance performance. The results of an extensive follow-up protocol at the Ghent University Hospital will enable further refinement of the screening protocol.

RESULTS

Data collection in all reference centers has started since June 2018. This paper outlines the rationale for the screening and the set-up of this four-year project.

CONCLUSIONS

Current available literature strongly favors vestibular assessment in congenitally hearing-impaired children. A standard vestibular screening for these children should lead to early identification of vestibular deficits and subsequent prompt referral for further motor assessment and rehabilitation, in order to limit the impact of a vestibular dysfunction in developing children and improve their quality of life.

Cochlear Implants and Children with Vestibular Impairments

Sensorineural hearing loss (SNHL) in children occurs in 1 to 3% of live births and acquired hearing loss can additionally occur. This sensory deficit has far reaching consequences that have been shown to extend beyond speech and language development. Thankfully there are many therapeutic options that exist for these children with the aim of decreasing the morbidity of their hearing impairment. Of late, focus has shifted beyond speech and language outcomes to the overall performance of children with SNHL in real-world environments. To account for their residual deficits in such environments, clinicians must understand the extent of their sensory impairments. SNHL commonly coexists with other sensory deficits such as vestibular loss. Vestibular impairment is exceedingly common in children with SNHL with nearly half of children exhibiting vestibular end-organ dysfunction. These deficits naturally lead to impairments in balance and delay in motor milestones. However, this additional sensory deficit likely leads to further impairment in the performance of these children. This article focuses on the following: 1. Defining the coexistence of vestibular impairment in children with SNHL and cochlear implants. 2. Describing screening methods aimed at identifying vestibular dysfunction in children with SNHL. 3. Understanding the functional implications of this dual-sensory impairment. 4. Exploring possible rehabilitative strategies to minimize the impact of vestibular impairment in children with SNHL.

Balance performance of children and adolescents with sensorineural hearing loss: Repercussions of hearing loss degrees and etiological factors

INTRODUCTION

Some studies have demonstrated a parallelism between the extent of hearing loss and the frequency of vestibular dysfunction in children with sensorineural hearing loss (SNHL). Despite this, little is known about the repercussion of degrees of hearing loss and etiological factors on the balance performance in this children.

OBJECTIVE

Compare the balance performance between normal hearing (NH) children and those with SNHL, considering the sex and age range of the sample, and analyze balance performance according to the degrees of hearing loss and etiological factors in the latter group.

METHODS

Cross-sectional study that assessed 96 children (48 NH and 48 with SNHL), aged between 7 and 18 years old. The balance performance was assessed by the Brazilian version of the Pediatric Balance Scale, validated for Brazilian child population and the Mann-Whitney test used for statistical analysis.

RESULTS

The group with SNHL showed lower average balance performance compared to NH (p = 0.000). This was also observed when the children were grouped by sex: female and male (p = 0.001). The same difference occurred when the children were stratified by age group: 7-14 years old (p = 0.000). There were no differences between the balance performance of the groups according to the degrees of hearing loss (p = 0.236) and the children with prematurity or post-natal meningitis as an etiological factor demonstrated the worst balance performance.

CONCLUSION

The children with SNHL showed worse balance performance compared to NH of the same sex and age range between seven to fourteen years. There were no differences between balance performance and hearing loss degrees, and those children with prematurity or post-natal meningitis as an etiological factor demonstrated the worst balance performances.

Animal Models of Vestibular Evoked Myogenic Potentials: The Past, Present, and Future

Vestibular-evoked myogenic potentials (VEMPs) provide a simple and cost-effective means to assess the patency of vestibular reflexes. VEMP testing constitutes a core screening method in a clinical battery that probes vestibular function. The confidence one has in interpreting the results arising from VEMP testing is linked to a fundamental understanding of the underlying functional anatomy and physiology. In this review, we will summarize the key role that studies across a range of animal models have fulfilled in contributing to this understanding, covering key findings regarding the mechanisms of excitation in the sensory periphery, the processing of sensory information in central networks, and the distribution of reflexive output to the motor periphery. Although VEMPs are often touted for their simplicity, work in animals models have emphasized how vestibular reflexes operate within a broader behavioral and functional context, and as such vestibular reflexes are influenced by multisensory integration, governed by task demands, and follow principles of muscle recruitment. We will conclude with considerations of future questions, and the ways in which studies in current and emerging animal models can contribute to further use and refinement of this test for both basic and clinical research purposes.