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Chen YW, Lin PH, Fang TY, Wu CC, Wang PC, Wang H, Ko Y. Health Utilities of Bilateral Severe-to-Profound Hearing Loss with Assistive Devices. Healthcare (Basel) 2023; 11:healthcare11111649. [PMID: 37297789 DOI: 10.3390/healthcare11111649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Hearing loss is a common sensory disorder in newborns. Early intervention with assistive devices benefits children's auditory and speech performance. This study aimed to measure the health utilities of children with bilateral severe-to-profound hearing impairment with different assistive devices. The descriptions of four hypothetical health states were developed, and their utility values were obtained from healthcare professionals via the visual analogue scale (VAS) and time trade-off (TTO) methods. Thirty-seven healthcare professionals completed the TTO interview and were included in the analysis. The mean utility scores obtained via VAS were 0.31 for no assistive devices, 0.41 for bilateral hearing aids, 0.63 for bimodal hearing, and 0.82 for bilateral cochlear implants. As for the utility scores obtained via TTO, mean values were 0.60, 0.69, 0.81, and 0.90, respectively. None of the four groups had the same VAS- or TTO-elicited utility (p < 0.001). The post hoc test results showed that the difference was significant between any two groups (all p < 0.05). In conclusion, this study elicited health utility of bilateral hearing impairment with different assistive devices using the VAS and TTO methods. The utility values obtained provide critical data for future cost-utility analysis and health technology assessment.
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Affiliation(s)
- Yi-Wen Chen
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
| | - Pei-Hsuan Lin
- Department of Otolaryngology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Te-Yung Fang
- Department of Otolaryngology, Cathay General Hospital, Taipei 10630, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City 24205, Taiwan
| | - Chen-Chi Wu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei 100225, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu 30261, Taiwan
- Hearing and Speech Center, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Pa-Chun Wang
- Department of Otolaryngology, Cathay General Hospital, Taipei 10630, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei City 24205, Taiwan
| | - Han Wang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Yu Ko
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
- Research Center for Pharmacoeconomics, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
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Nagaraj S, Singhal P, Singh ASP, Sharma S, Sharma AK, Jat KS, Agarwal S, Harshvardhan R, Sharma MP. A Comparative Study of Surgical Outcomes in Children with Cochlear Implantation Using Posterior Tympanotomy & Modified Veria Technique. Indian J Otolaryngol Head Neck Surg 2023; 75:255-260. [PMID: 37206821 PMCID: PMC10188718 DOI: 10.1007/s12070-022-03399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose: To compare the two common approaches of cochlear implantations i.e., mastoidectomy with posterior tympanotomy approach (MPTA) and modified veria technique and to know whether veria technique and its later modifications are as efficacious as the classic approach in terms of duration of procedure, gain in hearing and acquisition and incidence of complications if any. Methods: A prospective comparative study was undertaken at a tertiary care teaching institute. 30 children were selected and randomised into 2 groups who then underwent surgery from the same surgeon after proper evaluation but with 2 different approaches. Their outcomes were then observed and compared in terms of surgical technique and complications and hearing outcomes. Results: 30 children were operated with 15 in each group. In the study, patients under Group A (MPTA) had mean surgical duration of 139.67 ± 16.53 min while Group B (modified Veria) had of 84.67 ± 11.72 min, which was statistically significant (p < 0.05). 1 patient in Group A suffered House Brackman grade 4 facial nerve injury that recovered over 3 months and another had discolouration of the skin flap. No complications were observed in group B. During follow-up CAP and SIR scores were compared and were found to be statistically non-significant between the 2 groups (p value > 0.05), but the paired differences within each group showed statistical significance (P value- <0.001). Conclusion: Veria Technique (and its later modifications) for cochlear implantation is a simple, safe and easy procedure, which is as efficacious as MPTA with added benefits of consuming lesser surgical duration. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-022-03399-1.
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Affiliation(s)
- Sushmitha Nagaraj
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Pawan Singhal
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
- 78-A, Lipi clinics, 302018 Vishnupuri, Durgapura, Jaipur, Rajsthan India
| | - Amreen SP Singh
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Shivam Sharma
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Anjani Kumar Sharma
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Kailash Singh Jat
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Shubham Agarwal
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Rekha Harshvardhan
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
| | - Man Prakash Sharma
- Department of Otorhinolaryngology and Head Neck Surgery, S.M.S Medical College and Hospital, 302004 Jaipur, Rajasthan India
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Köse B, Karaman-Demirel A, Çiprut A. Psychoacoustic abilities in pediatric cochlear implant recipients: The relation with short-term memory and working memory capacity. Int J Pediatr Otorhinolaryngol 2022; 162:111307. [PMID: 36116181 DOI: 10.1016/j.ijporl.2022.111307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to investigate school-age children with cochlear implants (CIs) and their typically developing peers in terms of auditory short-term memory (ASTM), auditory working memory (AWM), visuospatial short-term memory (VSTM), visuospatial working memory (VWM), spectral resolution and monosyllabic word recognition in noise. METHODS Twenty-three prelingually deaf CI users and twenty-three typically developing (TD) peers aged 7-10 years participated. Twelve children with CI were earlier-implanted (i.e., age at implantation ≤24 months). Children with CIs were compared to typically developing peers and correlations between cognitive and psychoacoustic abilities were computed separately for the groups. Besides, regression analyses were conducted to develop models that could predict SMRT (spectral-temporally modulated ripple test) and speech recognition scores. RESULTS The AWM scores of the later-implanted group were significantly lower than both earlier-implanted and TD groups. ASTM scores of TD children were significantly higher than both earlier-implanted and later-implanted participants. There was no statistically significant difference between groups in terms of VSTM and VWM. AWM performance was positively correlated with ASTM, SMRT scores, and speech recognition under noisy conditions for pediatric CI recipients. The AWM was a statistically significant predictor of the SMRT score and the SMRT score was an indicator of speech recognition score under 0 dB SNR condition. CONCLUSION Most of children using CI are at risk for clinically remarkable deficits across cognitive abilities such as AWM and ASTM. While evaluating cognitive and psychoacoustic abilities in the clinic routine, it should be kept in mind that they can be influenced by each other.
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Affiliation(s)
- Büşra Köse
- Department of Audiology, School of Medicine, Marmara University, Istanbul, Turkey; Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey.
| | - Ayşenur Karaman-Demirel
- Department of Audiology, School of Medicine, Marmara University, Istanbul, Turkey; Vocational School of Health Services, Okan University, Istanbul, Turkey
| | - Ayça Çiprut
- Department of Audiology, School of Medicine, Marmara University, Istanbul, Turkey
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Bradfield OM. Hearing Parents' Voices: Parental Refusal of Cochlear Implants and the Zone of Parental Discretion. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:143-150. [PMID: 34918184 PMCID: PMC9007755 DOI: 10.1007/s11673-021-10154-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/14/2021] [Indexed: 05/24/2023]
Abstract
It has been forty years since the first multi-channel cochlear implant was used in Australia. While heralded in the hearing world as one of the greatest inventions in modern medicine, not everyone reflects on this achievement with enthusiasm. For many people in the Deaf community, they see the cochlear implant as a tool that reinforces a social construct that pathologizes deafness and removes Deaf identity. In this paper, I set out the main arguments for and against cochlear implantation. While I conclude that, on balance, cochlear implants improve the well-being and broaden the open futures of deaf children, this does not justify mandating implants in circumstances where parents refuse them because this may compound unintended harms when society interferes in the parent-child relationship. For this reason, I argue that parental refusal of cochlear implantation falls within Gillam's concept of the zone of parental discretion.
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Affiliation(s)
- Owen M Bradfield
- Law & Public Health Unit, Centre for Health Policy, Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Australia.
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Badr A, Shabana Y, Mokbel K, Elsharabasy A, Ghonim M, Sanna M. Atraumatic Scala Tympani Cochleostomy; Resolution of the Dilemma. J Int Adv Otol 2019; 14:190-196. [PMID: 30100542 DOI: 10.5152/iao.2018.4974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES While an accurate placement in cochleostomy is critical to ensure appropriate insertion of the cochlear implant (CI) electrode into the scala tympani (ST), the choice of preferred cochleostomy sites widely varied among experienced surgeons. We present a novel technique for precise yet readily applicable localization of the optimum site for performing ST cochleostomy. MATERIAL AND METHODS Twenty fresh frozen temporal bones were dissected using the mastoidectomy-posterior tympanotomy approach. Based on the facial nerve and the margins of the round window membrane (RWM), the cochleostomy site was chosen to insert the electrode into the ST while preserving the surrounding intracochlear structures. RESULTS There is a limited safe area suitable for the ST implantation in the area inferior and anterior to the RWM. There is a higher risk of scala vestibuli (SV) insertion anterior to that area. Posterior to that area, the cochlear aqueduct (CA) and inferior cochlear vein (ICV) are liable for the injury. CONCLUSION For atraumatic CI, precise and easy localization of the site of cochleostomy play a pivotal role in preserving intracochlear structures. Accurate setting of the vertical and horizontal orientations is mandatory before choosing the site of cochleostomy. The facial nerve and the margins of the RWM offer a very helpful clue for such localization; meanwhile, it is readily identifiable in the surgical field.
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Affiliation(s)
- Ahmad Badr
- Department of ENT, Head and Neck Surgery, Mansoura University School of Medicine, Mansoura City, Egypt
| | - Yousef Shabana
- Department of ENT, Head and Neck Surgery, Mansoura University School of Medicine, Mansoura City, Egypt
| | - Khaled Mokbel
- Department of ENT, Head and Neck Surgery, Mansoura University School of Medicine, Mansoura City, Egypt
| | - Ayman Elsharabasy
- Department of ENT, Head and Neck Surgery, Mansoura University School of Medicine, Mansoura City, Egypt
| | - Mohamed Ghonim
- Department of ENT, Head and Neck Surgery, Mansoura University School of Medicine, Mansoura City, Egypt
| | - Mario Sanna
- Department of Otology and Skull Base Surgery, Gruppo Otologico, Piacenza, Rome, Italy
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Mapping of Paediatric Cochlear Implant Using Neural Response Threshold (NRT) and Behavioural Observation Audiometry (BOA). Indian J Otolaryngol Head Neck Surg 2019; 71:42-47. [DOI: 10.1007/s12070-018-1524-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/27/2018] [Indexed: 11/25/2022] Open
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Yiğit E, Edizer DT, Durna YM, Altay MA, Yiğit Ö. Satisfaction with Life among Mothers of Pediatric Cochlear Implant Candidates: The Impact of Implant Operation and Sociodemographic Factors. J Int Adv Otol 2018; 14:202-207. [PMID: 30100548 DOI: 10.5152/iao.2018.5531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To evaluate the satisfaction with life among mothers of pediatric cochlear implant candidates regarding implant surgery and sociodemographic factors. MATERIALS AND METHODS Mothers of 160 pediatric patients with profound sensorineural hearing loss who underwent unilateral cochlear implant surgery were included. A questionnaire form with items on sociodemographic-familial characteristics and Satisfaction with Life Scale (SWLS) was employed via face-to-face interview method before and 12 months after the implant surgery. RESULTS The SWLS scores significantly improved after the implant surgery [from 19.1 (7.0) to 28.9 (4.0), p<0.000]. Being unemployed vs. employed [17.9 (6.9) vs. 24.0 (5.3), p=0.000], having another child with hearing disability [13.5 (5.7) vs. 19.7 (6.9), p=0.001], younger (12-24 months) vs. older (>24 months) age of the child at the time of implant surgery [7.1 (0.4) vs. 19.7 (6.6), p=0.001], absence vs. presence of regular follow-up visits [13.0 (0.0) vs. 19.4 (7.1), p=0.002], and presence vs. absence of change in social life after the diagnosis of disease [17.3 (6.5) vs. 20.9 (7.1), p=0.001] were associated with significantly lower SWLS scores among mothers. SWLS scores were positively correlated with patient's age at the time of implant surgery (r=0.206, p=0.009), whereas negatively correlated with the number of household members (r=-0.406, p=0.000) and number of children (r=-0.310, p=0.000). CONCLUSION In conclusion, our findings revealed the association of cochlear implantation with a significant increase in mother's life satisfaction, despite the unemployment, presence of another child with hearing disability, and crowded household. Our findings emphasize on the consideration of family systems with special attention to mother's emotional experiences and occupational competence in the intervention programs.
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Affiliation(s)
- Enes Yiğit
- Department of Otolaryngology Head and Neck Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Deniz Tuna Edizer
- Department of Otolaryngology Head and Neck Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yusuf Muhammed Durna
- Department of Otolaryngology Head and Neck Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Mengühan Araz Altay
- Clinic of Child and Adolescent Psychiatry, Edirne Sultan I. Murat State Hospital, Edirne, Turkey
| | - Özgür Yiğit
- Department of Otolaryngology Head and Neck Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
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9
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Daneshi A, Mirsalehi M, Hashemi SB, Ajalloueyan M, Rajati M, Ghasemi MM, Emamdjomeh H, Asghari A, Mohammadi S, Mohseni M, Mohebbi S, Farhadi M. Cochlear implantation in children with auditory neuropathy spectrum disorder: A multicenter study on auditory performance and speech production outcomes. Int J Pediatr Otorhinolaryngol 2018; 108:12-16. [PMID: 29605339 DOI: 10.1016/j.ijporl.2018.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To evaluate the auditory performance and speech production outcome in children with auditory neuropathy spectrum disorder (ANSD). The effect of age on the outcomes of the surgery at the time of implantation was also evaluated. METHODS Cochlear implantation was performed in 136 children with bilateral severe-to- profound hearing loss due to ANSD, at four tertiary academic centers. The patients were divided into two groups based on the age at the time of implantation; Group I: Children ≤24 months, and Group II: subjects >24 months. The categories of auditory performance (CAP) and speech intelligibility rating (SIR) scores were evaluated after the first and second years of implantation. The differences between the CAP and SIR scores in the two groups were assessed. RESULTS The median CAP scores improved significantly after the cochlear implantation in all the patients (p value < 0.001). The improvement in the CAP scores during the first year in Group II was greater than Group I (p value: 0.007), but the improvement in CAP scores tended to be significantly higher in patients who were implanted at ≤24 months (p value < 0.001). There was no significant difference between two groups in SIR scores at first-year and second-year follow-ups. The evaluation of the SIR improvement revealed significantly higher values for Group I during the second-year follow-up (p value: 0.003). CONCLUSION The auditory performance and speech production skills of the children with ANSD improved significantly after cochlear implantation, and this improvement was affected by age at the time of implantation.
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Affiliation(s)
- Ahmad Daneshi
- ENT and Head & Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - Marjan Mirsalehi
- ENT and Head & Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - Seyed Basir Hashemi
- Department of Otorhinolaryngology, Khalili Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mohammad Ajalloueyan
- Department of Otorhinolaryngology, Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Mohsen Rajati
- Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Mohammad Mahdi Ghasemi
- Sinus and Surgical Endoscopic Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Hesamaldin Emamdjomeh
- ENT and Head & Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - Alimohamad Asghari
- Skull Base Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Shabahang Mohammadi
- Department of Otorhinolaryngology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Mohseni
- ENT and Head & Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - Saleh Mohebbi
- ENT and Head & Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - Mohammad Farhadi
- ENT and Head & Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran.
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Abstract
OBJECTIVE Identify variables associated with paediatric access to cochlear implants (CIs). DESIGN Part 1. Trends over time for age at CI surgery (N = 802) and age at hearing aid (HA) fitting (n = 487) were examined with regard to periods before, during, and after newborn hearing screening (NHS). Part 2. Demographic factors were explored for 417 children implanted under 3 years of age. Part 3. Pre-implant steps for the first 20 children to receive CIs under 12 months were examined. RESULTS Part 1. Age at HA fitting and CI surgery reduced over time, and were associated with NHS implementation. Part 2. For children implanted under 3 years, earlier age at HA fitting and higher family socio-economic status were associated with earlier CI. Progressive hearing loss was associated with later CIs. Children with a Connexin 26 diagnosis received CIs earlier than children with a premature / low birth weight history. Part 3. The longest pre-CI steps were Step 1: Birth to diagnosis/identification of hearing loss (mean 16.43 weeks), and Step 11: MRI scans to implant surgery (mean 15.05 weeks) for the first 20 infants with CIs under 12 months. CONCLUSION NHS implementation was associated with reductions in age at device intervention in this cohort.
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Affiliation(s)
- Shani Dettman
- a The University of Melbourne, Department of Audiology and Speech Pathology , Parkville, Victoria , Australia ;,b The Royal Victorian Eye and Ear Hospital , East Melbourne, Victoria , Australia ;,c The HEARing CRC , Carlton, Victoria , Australia
| | - Dawn Choo
- a The University of Melbourne, Department of Audiology and Speech Pathology , Parkville, Victoria , Australia ;,b The Royal Victorian Eye and Ear Hospital , East Melbourne, Victoria , Australia ;,c The HEARing CRC , Carlton, Victoria , Australia
| | - Richard Dowell
- a The University of Melbourne, Department of Audiology and Speech Pathology , Parkville, Victoria , Australia ;,b The Royal Victorian Eye and Ear Hospital , East Melbourne, Victoria , Australia ;,c The HEARing CRC , Carlton, Victoria , Australia
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Kocdor P, Iseli CE, Teagle HF, Woodard J, Park L, Zdanski CJ, Brown KD, Adunka OF, Buchman CA. The effect of interdevice interval on speech perception performance among bilateral, pediatric cochlear implant recipients. Laryngoscope 2016; 126:2389-94. [DOI: 10.1002/lary.26012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 02/09/2016] [Accepted: 03/09/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Pelin Kocdor
- Department of Otolaryngology Head and Neck Surgery; University of North Carolina at Chapel Hill; Chapel Hill North Carolina U.S.A
| | - Claire E. Iseli
- Department of Otolaryngology Head and Neck Surgery; The Royal Victorian Eye and Ear Hospital; Melbourne Australia
| | - Holly F. Teagle
- Department of Otolaryngology Head and Neck Surgery; University of North Carolina at Chapel Hill; Chapel Hill North Carolina U.S.A
| | - Jennifer Woodard
- Department of Otolaryngology Head and Neck Surgery; University of North Carolina at Chapel Hill; Chapel Hill North Carolina U.S.A
| | - Lisa Park
- Department of Otolaryngology Head and Neck Surgery; University of North Carolina at Chapel Hill; Chapel Hill North Carolina U.S.A
| | - Carlton J. Zdanski
- Department of Otolaryngology Head and Neck Surgery; University of North Carolina at Chapel Hill; Chapel Hill North Carolina U.S.A
| | - Kevin D. Brown
- Department of Otolaryngology Head and Neck Surgery; University of North Carolina at Chapel Hill; Chapel Hill North Carolina U.S.A
| | - Oliver F. Adunka
- Department of Otolaryngology Head and Neck Surgery; The Ohio State University; Columbus Ohio U.S.A
| | - Craig A. Buchman
- Department of Otolaryngology; Washington University in St. Louis; St Louis Missouri U.S.A
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Iseli C, Buchman CA. Management of Children with Severe, Severe-profound, and Profound Sensorineural Hearing Loss. Otolaryngol Clin North Am 2015; 48:995-1010. [DOI: 10.1016/j.otc.2015.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Ramos D, Jorge JX, Teixeira A, Ribeiro C, Paiva A. Desenvolvimento da linguagem em crianças com implante coclear: terá o gênero alguma influência? REVISTA CEFAC 2015. [DOI: 10.1590/1982-021620155214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVO:avaliar a influencia do gênero no desenvolvimento da linguagem de crianças com surdez severa a profunda neurossensorial, após implante coclear.MÉTODOS:foram estudadas 30 crianças, 12 do gênero feminino e 18 do masculino, entre os 8 anos e 1 mês e os 10 anos com surdez severa a profunda neurossensorial bilateral congênita com implante coclear. Avaliaram-se as estruturas linguísticas semântica, morfossintaxe e fonologia. Utilizou-se o instrumento de avaliação: Grelha de Observação da Linguagem - nível escolar.RESULTADOS:a idade auditiva média foi de 72 meses no gênero feminino e 72.7 meses no masculino. As pontuações obtidas nos três níveis linguisticos foram estatisticamente semelhantes, quando comparados os gêneros. Nas provas de cada estrutura linguística também não se verificaram diferenças estatisticamente significantes.CONCLUSÕES:o gênero não influenciou o desenvolvimento da linguagem oral nas crianças utilizadoras de implante coclear, nas três estruturas linguísticas estudadas.
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Affiliation(s)
- Daniela Ramos
- Centro Hospitalar e Universitário de Coimbra, Portugal
| | | | | | | | - António Paiva
- Centro Hospitalar e Universitário de Coimbra, Portugal
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Pinyon JL, Tadros SF, Froud KE, Y Wong AC, Tompson IT, Crawford EN, Ko M, Morris R, Klugmann M, Housley GD. Close-field electroporation gene delivery using the cochlear implant electrode array enhances the bionic ear. Sci Transl Med 2015; 6:233ra54. [PMID: 24760189 DOI: 10.1126/scitranslmed.3008177] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The cochlear implant is the most successful bionic prosthesis and has transformed the lives of people with profound hearing loss. However, the performance of the "bionic ear" is still largely constrained by the neural interface itself. Current spread inherent to broad monopolar stimulation of the spiral ganglion neuron somata obviates the intrinsic tonotopic mapping of the cochlear nerve. We show in the guinea pig that neurotrophin gene therapy integrated into the cochlear implant improves its performance by stimulating spiral ganglion neurite regeneration. We used the cochlear implant electrode array for novel "close-field" electroporation to transduce mesenchymal cells lining the cochlear perilymphatic canals with a naked complementary DNA gene construct driving expression of brain-derived neurotrophic factor (BDNF) and a green fluorescent protein (GFP) reporter. The focusing of electric fields by particular cochlear implant electrode configurations led to surprisingly efficient gene delivery to adjacent mesenchymal cells. The resulting BDNF expression stimulated regeneration of spiral ganglion neurites, which had atrophied 2 weeks after ototoxic treatment, in a bilateral sensorineural deafness model. In this model, delivery of a control GFP-only vector failed to restore neuron structure, with atrophied neurons indistinguishable from unimplanted cochleae. With BDNF therapy, the regenerated spiral ganglion neurites extended close to the cochlear implant electrodes, with localized ectopic branching. This neural remodeling enabled bipolar stimulation via the cochlear implant array, with low stimulus thresholds and expanded dynamic range of the cochlear nerve, determined via electrically evoked auditory brainstem responses. This development may broadly improve neural interfaces and extend molecular medicine applications.
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Affiliation(s)
- Jeremy L Pinyon
- Translational Neuroscience Facility and Department of Physiology, School of Medical Sciences, University of New South Wales, UNSW Australia, Sydney, New South Wales 2052, Australia
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Vincenti V, Bacciu A, Guida M, Marra F, Bertoldi B, Bacciu S, Pasanisi E. Pediatric cochlear implantation: an update. Ital J Pediatr 2014; 40:72. [PMID: 25179127 PMCID: PMC4282008 DOI: 10.1186/s13052-014-0072-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 08/04/2014] [Indexed: 11/10/2022] Open
Abstract
Deafness in pediatric age can adversely impact language acquisition as well as educational and social-emotional development. Once diagnosed, hearing loss should be rehabilitated early; the goal is to provide the child with maximum access to the acoustic features of speech within a listening range that is safe and comfortable. In presence of severe to profound deafness, benefit from auditory amplification cannot be enough to allow a proper language development. Cochlear implants are partially implantable electronic devices designed to provide profoundly deafened patients with hearing sensitivity within the speech range. Since their introduction more than 30 years ago, cochlear implants have improved their performance to the extent that are now considered to be standard of care in the treatment of children with severe to profound deafness. Over the years patient candidacy has been expanded and the criteria for implantation continue to evolve within the paediatric population. The minimum age for implantation has progressively reduced; it has been recognized that implantation at a very early age (12-18 months) provides children with the best outcomes, taking advantage of sensitive periods of auditory development. Bilateral implantation offers a better sound localization, as well as a superior ability to understand speech in noisy environments than unilateral cochlear implant. Deafened children with special clinical situations, including inner ear malformation, cochlear nerve deficiency, cochlear ossification, and additional disabilities can be successfully treated, even thogh they require an individualized candidacy evaluation and a complex post-implantation rehabilitation. Benefits from cochlear implantation include not only better abilities to hear and to develop speech and language skills, but also improved academic attainment, improved quality of life, and better employment status. Cochlear implants permit deaf people to hear, but they have a long way to go before their performance being comparable to that of the intact human ear; researchers are looking for more sophisticated speech processing strategies as well as a more efficient coupling between the electrodes and the cochlear nerve with the goal of dramatically improving the quality of sound of the next generation of implants.
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Affiliation(s)
- Vincenzo Vincenti
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
| | - Andrea Bacciu
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
| | - Maurizio Guida
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
| | - Francesca Marra
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
| | - Barbara Bertoldi
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
| | - Salvatore Bacciu
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
| | - Enrico Pasanisi
- Department of Clinical and Experimental Medicine, Unit of Audiology and Pediatric Otorhinolaryngology, University of Parma, Via Gramsci, 14 43126, Parma, Italy
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Evaluation of Auditory Cortical Development in the Early Stages of Post Cochlear Implantation Using Mismatch Negativity Measurement. Otol Neurotol 2014; 35:e7-14. [DOI: 10.1097/mao.0000000000000181] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Necula V, Cosgarea M, Necula SE. Health-related quality of life in cochlear implanted patients in Romania. Int J Pediatr Otorhinolaryngol 2013; 77:216-22. [PMID: 23228691 DOI: 10.1016/j.ijporl.2012.10.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 10/25/2012] [Accepted: 10/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Cochlear implantation is a well established treatment method in severe to profound hearing impaired people. Hearing devices do not cure hearing loss, but correct the disability, so it is important to assess the benefits not only on auditory-verbal performances but in terms of health-related quality of life. MATERIALS AND METHODS We evaluated the health-related quality of life in a cochlear implant group (84 patients), split into two subgroups, according to the age of implantation and compared with a hearing aided group (50 patients). We used the Nijmegen cochlear implant HRQoL questionnaire which was sent to the parents. In the study group, all patients had unilateral MedEl device and at least 6 months of experience with the speech processor. RESULTS Although there were differences between hearing aided and implanted children in all areas of quality of life, in the physical area, these differences were greater than those in the psychological and social domains. HRQoL was positively correlated with auditory performance, speech intelligibility and negatively correlated with implantation age. The correlation coefficient, R=0.78, indicates that between these three variables, implantation age, SIR and CAP and quality of life, there was a very good linear and direct proportional correlation. According to the determination coefficient (R(2) adjusted=0.59), 59.5% of quality of life's variation was explained by the variation of these three parameters. CONCLUSIONS Cochlear implant improves the auditory performance and speech production much more than hearing aids. Associated diseases have a negative effect on the evolution of cochlear implanted children but the cochlear implant may have an important impact on these children quality of life. It is well known that children implanted at a young age evolve better than older ones, but we should take into consideration that even older children can get good results, good performances if they are properly selected and well trained.
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Affiliation(s)
- Violeta Necula
- ENT Department, University of Medicine and Pharmacy Iuliu Haţieganu Cluj-Napoca, V Babeş 8, 400012 Cluj-Napoca, Romania.
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Melo TMD, Lara JD. Auditory and oral language abilities in children with cochlear implants: a case study. ACTA ACUST UNITED AC 2013; 24:390-4. [PMID: 23306692 DOI: 10.1590/s2179-64912012000400017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 07/23/2012] [Indexed: 11/22/2022]
Abstract
The cochlear implant (CI) represents the most important advance in the treatment of individuals with severe to profound bilateral hearing loss who do not benefit from hearing aids. Children who receive the CI during the critical period of neuroplasticity of the auditory system, when combined with speech therapy, have the chance to develop the auditory and linguistic skills similarly to their normal hearing peers. Two cases of implanted children are presented in this study, and one of them was not enrolled in a formal aurioral therapeutic program since the implantation surgery. At the moment of language and auditory assessment, the children were 2 years and 5 months old, and the CI had been used for 11 months. According to the results presented, it was observed that the child enrolled in rehabilitation program had better auditory and language performance when compared to the other child. Despite the remarkable benefits that the CI provides to children with hearing impairment, the device itself only provides the child with the audibility of environmental sounds and speech signal. For the auditory and language development to happen, it is necessary, among other factors, a speech-language intervention, with partnership between professionals and parents.
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Affiliation(s)
- Tatiana Mendes de Melo
- Speech-Language Pathology and Audiology, Universidade de Guarulhos, Guarulhos, SP, Brazil.
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Hiraumi H, Yamamoto N, Sakamoto T, Yamaguchi S, Ito J. The effect of pre-operative developmental delays on the speech perception of children with cochlear implants. Auris Nasus Larynx 2012; 40:32-5. [PMID: 22727355 DOI: 10.1016/j.anl.2012.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 05/07/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the relationship between developmental delays and speech perception in pre-lingually deafened cochlear implant recipients. METHODS This study was a retrospective review of patient charts conducted at a tertiary referral center. Thirty-five pre-lingually deafened children underwent multichannel cochlear implantation and habilitation at the Kyoto University Hospital Department of Otolaryngology-Head and Neck Surgery. A pre-operative cognitive-adaptive developmental quotient was evaluated using the Kyoto scale of psychological development. Post-operative speech performance was evaluated with speech perception tests two years after cochlear implantation. We computed partial correlation coefficients (controlled for age at the time of implantation and the average pre-operative aided hearing level) between the cognitive-adaptive developmental quotient and speech performance. RESULTS A developmental delay in the cognitive-adaptive area was weakly correlated with speech perception (partial correlation coefficients for consonant-vowel syllables and phrases were 0.38 and 0.36, respectively). CONCLUSION A pre-operative developmental delay was only weakly associated with poor post-operative speech perception in pre-lingually deafened cochlear implant recipients.
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Affiliation(s)
- Harukazu Hiraumi
- Department of Otolaryngology-Head and Neck Surgery, Kyoto University, Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Japan.
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Changes in the hearing thresholds of infants who failed the newborn hearing screening test and in infants treated in the neonatal intensive care unit. Clin Exp Otorhinolaryngol 2012; 5 Suppl 1:S32-6. [PMID: 22701771 PMCID: PMC3369979 DOI: 10.3342/ceo.2012.5.s1.s32] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 01/26/2012] [Accepted: 02/10/2012] [Indexed: 11/18/2022] Open
Abstract
Objectives The aim of this study was to investigate changes in the hearing thresholds during the first year of life in infants who failed the newborn hearing screening (NHS) test and of infants treated in the neonatal intensive care unit (NICU). Methods From March 2007 to November 2010, 193 healthy infants who failed the NHS test and 51 infants who were treated in the NICU were referred for evaluation of hearing acuity. Their hearing was evaluated using impedance audiometry, auditory brainstem response (ABR), and otoacoustic emission before 6 months of age, and follow-up hearing tests were administered before 12 months of age. Changes in their hearing thresholds were then analyzed. Results Of the 193 healthy infants who failed the NHS test, 60 infants (31%) had normal hearing acuity, 126 infants (65%) had sensorineural hearing loss (SNHL, ABR threshold ≥40 dB) and 7 infants (4%) had auditory neuropathy (AN). On the follow-up hearing tests, which were conducted in 65 infants, 6 infants showed a hearing threshold deterioration of more than 20 dB, and 19 infants showed a hearing threshold improvement of more than 20 dB. Of the 51 infants who were treated in the NICU, 38 infants (75%) had normal hearing acuity, 12 infants (24%) had SNHL, and one infant (2%) had AN. In the follow-up hearing tests, which were performed in 13 infants, one infant with normal hearing progressed to severe hearing loss. Five infants who had SNHL showed a hearing threshold improvement of more than 20 dB, and 4 infants recovered to normal hearing. Conclusion The hearing thresholds of infants with congenital SNHL can change during the first year of life; therefore, the importance of administration of follow-up hearing tests is emphasized. Irreversible intervention such as cochlear implantation should be considered with great caution within the first year after birth.
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Capone FV, Torres DDA, Lima MADMTD. Neuropatia auditiva: alerta aos pediatras. REVISTA PAULISTA DE PEDIATRIA 2011. [DOI: 10.1590/s0103-05822011000400030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Alertar os pediatras sobre a neuropatia auditiva, doença descrita recentemente e ainda desconhecida por muitos médicos. Descrever seus fatores de risco, características clínicas e diagnósticas, com a finalidade de possibilitar uma intervenção terapêutica precoce e eficaz. FONTES DE DADOS: Realizada pesquisa nas bases de dados PubMed, Lilacs e SciELO utilizando os descritores "neuropatia auditiva" e "auditory neuropathy", entre os anos de 1996 e 2010. SÍNTESE DOS DADOS: A neuropatia auditiva, também conhecida como dessincronia auditiva, descrita em 1996, caracteriza-se clinicamente pela dificuldade na compreensão das palavras, mesmo em casos de perdas auditivas leves ou moderadas. Foi relacionada a diversas neuropatias generalizadas e fatores de risco neonatais, como internação em terapia intensiva, hiperbilirrubinemia, sepse e hipóxia. Após suspeita clínica, o diagnóstico é confirmado pela presença das emissões otoacústicas associada a um potencial evocado auditivo de tronco encefálico ausente ou alterado. Sua terapêutica permanece controversa, tendo como opções a protetização auditiva, o acompanhamento fonoterápico para habilitação ou reabilitação da linguagem e, em casos de insucesso, há relatos de resultados satisfatórios com o implante coclear. CONCLUSÕES: Enfatiza-se a importância do reconhecimento pelo pediatra da neuropatia auditiva, entidade ainda pouco citada na literatura latino-americana da especialidade.
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Landry TG, Wise AK, Fallon JB, Shepherd RK. Spiral ganglion neuron survival and function in the deafened cochlea following chronic neurotrophic treatment. Hear Res 2011; 282:303-13. [PMID: 21762764 PMCID: PMC3205216 DOI: 10.1016/j.heares.2011.06.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 12/26/2022]
Abstract
Cochlear implants electrically stimulate residual spiral ganglion neurons (SGNs) to provide auditory cues for the severe-profoundly deaf. However, SGNs gradually degenerate following cochlear hair cell loss, leaving fewer neurons available for stimulation. Providing an exogenous supply of neurotrophins (NTs) has been shown to prevent SGN degeneration, and when combined with chronic intracochlear electrical stimulation (ES) following a short period of deafness (5 days), may also promote the formation of new neurons. The present study assessed the histopathological response of guinea pig cochleae treated with NTs (brain-derived neurotrophic factor and neurotrophin-3) with and without ES over a four week period, initiated two weeks after deafening. Results were compared to both NT alone and artificial perilymph (AP) treated animals. AP/ES treated animals exhibited no evidence of SGN rescue compared with untreated deafened controls. In contrast, NT administration showed a significant SGN rescue effect in the lower and middle cochlear turns (two-way ANOVA, p < 0.05) compared with AP-treated control animals. ES in combination with NT did not enhance SGN survival compared with NT alone. SGN function was assessed by measuring electrically-evoked auditory brainstem response (EABR) thresholds. EABR thresholds following NT treatment were significantly lower than animals treated with AP (two-way ANOVA, p = 0.033). Finally, the potential for induced neurogenesis following the combined treatment was investigated using a marker of DNA synthesis. However, no evidence of neurogenesis was observed in the SGN population. The results indicate that chronic NT delivery to the cochlea may be beneficial to cochlear implant patients by increasing the number of viable SGNs and decreasing activation thresholds compared to chronic ES alone.
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Affiliation(s)
- Thomas G. Landry
- The Bionic Ear Institute, Daly Wing, St. Vincent’s Hospital, Fitzroy, Victoria, 3065, Australia
- The University of Melbourne, Parkville, Victoria, 3052, Australia
| | - Andrew K. Wise
- The Bionic Ear Institute, Daly Wing, St. Vincent’s Hospital, Fitzroy, Victoria, 3065, Australia
- The University of Melbourne, Parkville, Victoria, 3052, Australia
| | - James B. Fallon
- The Bionic Ear Institute, Daly Wing, St. Vincent’s Hospital, Fitzroy, Victoria, 3065, Australia
- The University of Melbourne, Parkville, Victoria, 3052, Australia
| | - Robert K. Shepherd
- The Bionic Ear Institute, Daly Wing, St. Vincent’s Hospital, Fitzroy, Victoria, 3065, Australia
- The University of Melbourne, Parkville, Victoria, 3052, Australia
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Moon IJ, Kim EY, Chu H, Chung WH, Cho YS, Hong SH. A new measurement tool for speech development based on Ling's stages of speech acquisition in pediatric cochlear implant recipients. Int J Pediatr Otorhinolaryngol 2011; 75:495-9. [PMID: 21295354 DOI: 10.1016/j.ijporl.2011.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/03/2011] [Accepted: 01/08/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVES With the rapid increase of pediatric cochlear implantation (CI), there exists a need for a standardized assessment tool regarding speech and communication skills in children with CI. However, the current testing tools are not appropriate for the longitudinal evaluation of young children after CI. The aims of this study were to describe a progressive testing tool developed for the evaluation of speech acquisition and production in young children who have undergone CI and to examine its validity. METHODS Sixty children younger than six years of age with CI participated in this study. A Korean version of Ling's stages (K-Ling) was developed based on the Ling speech teaching model to longitudinally assess phonologic and phonetic developments in young children after CI. The K-Ling, the Categories of Auditory Performance (CAP), and the Sequenced Language Scale for Infants (SELSI) were performed in the children with CI preoperatively and three, six, and 12 months postoperatively. Correlations among these three testing tools were analyzed. RESULTS Auditory, language, and speech skills assessed using the CAP, SELSI, and K-Ling improved continuously for 12 months in young children following CI. Strong correlations were obtained among K-Ling's level, CAP scores, and the equivalent age of SELSI; correlation indices ranged from 0.540 to 0.800. CONCLUSIONS The K-Ling was a valid evaluation tool regarding speech development in young children who are using CI and who are in the early stages of speech development. Longitudinal assessments of phonetic and phonologic developments may be attainable in young children using the K-Ling.
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Affiliation(s)
- Il Joon Moon
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 50 Irwon-dong, Gangnam-gu, 135-710 Seoul, Republic of Korea
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