Perceptual Benefit and Functional Outcomes for Children Using Sequential Bilateral Cochlear Implants

Validation of the Chinese Version of the Speech, Spatial, and Qualities of Hearing Scale for Parents and Children

OBJECTIVES

To translate and validate the Chinese version of the Speech, Spatial, and Qualities of Hearing Scale (SSQ) for children with hearing impairment (C-SSQ-C) and for their parents (C-SSQ-P).

DESIGN

We translated the SSQ for children into Chinese and verified its readability and comprehensibility. A total of 105 participants with moderate-to-profound hearing loss (HL) and 54 with normal hearing were enrolled in the validation process. The participants with HL were fitted with bilateral hearing aids, bimodal hearing, or bilateral cochlear implants. The C-SSQ-P was administered to the parents of participants aged 3 to 6.9 years, and the C-SSQ-C was administered to participants aged 7 to 18 years. The internal consistency, test-retest reliability, and validity were evaluated for both questionnaires.

RESULTS

Both C-SSQ-P and C-SSQ-C demonstrated high internal consistency (Cronbach's α >0.8) and good validity (generalized linear model revealed significant negative relationships between the C-SSQ-P subscales with aided better-hearing threshold [β = -0.08 to -0.12, p ≤ 0.001] and between the C-SSQ-C subscales with worse-hearing threshold [β = -0.13 to -0.14, p < 0.001]). Among the children with HL, the participants with bilateral cochlear implants had demonstrated better performance than those with bimodal hearing and bilateral hearing aids, as evidenced by the highest mean scores in three subscales.

CONCLUSIONS

Both C-SSQ-P and C-SSQ-C are reliable and valid for assessing HL in children and adolescents. The C-SSQ-P is applicable in evaluating young children aged 3 to 6.9 years after a 7-day observation period, while the C-SSQ-C is appropriate for children and adolescents aged 7 to 18 years.

Cochlear Implantation Outcomes in Pediatric Unilateral Hearing Loss: Impact of Device Use and Direct Input

OBJECTIVE

To investigate the impact of daily cochlear implant (CI) use on speech perception outcomes among children with unilateral hearing loss (UHL).

STUDY DESIGN

Multi-institutional retrospective case series of pediatric patients with UHL who underwent CI between 2018 to 2022.

SETTING

Three tertiary children's hospitals.

METHODS

Demographics were obtained including duration of deafness and age at CI. Best consonant-nucleus-consonant (CNC) word scores and data logs describing hours of CI usage were assessed postimplantation. Use of direct audio input (DAI) during rehabilitation was recorded.

RESULTS

Twenty-seven children were included, with a mean age at CI of 7.8 years. Mean datalogging time was 7.8 ± 3.0 hours/day. 40.7% of children utilized daily DAI. The mean CNC score using the best score during the study period was 34.9%. There was no significant correlation between hours of CI usage and CNC score. There was a significant improvement in CNC score associated with whether the child used DAI during rehabilitation (CNC 50.91% [yes] vs 23.81% [no]), which remained significant when adjusting for age at CI, duration of deafness, and data log hours.

CONCLUSION

Unlike children with bilateral hearing loss and CI, children with UHL and CI demonstrate no significant correlation between hours of daily CI usage and CNC scores. However, children who used DAI during postoperative rehabilitation achieved significantly higher CNC scores than those who did not. This suggests that rehabilitation focused on isolated listening with the implanted ear maybe critical in optimizing outcomes with CI in UHL patients.

Long-Term Outcome of Cochlear Implantation in Children With Congenital, Perilingual, and Postlingual Single-Sided Deafness

OBJECTIVES

We investigated the long-term outcomes of children with single-sided deafness (SSD) after cochlear implant (CI) surgery, during and after rehabilitation, and compared the results of children with congenital, perilingual, and postlingual SSD. We evaluated the impact of SSD at age at onset and duration of deafness on their performance.

DESIGN

Thirty-six children with SSD treated with CI participated in the study: 20 had congenital, seven perilingual (defined: >0 to 4 years), and nine had postlingual deafness (defined as >4 years of age). Their outcome with CI were measured on both subjective and objective scales: duration of device use, speech intelligibility in noise and in quiet, bilateral hearing and localization ability, quality of life and hearing, presence and loudness of tinnitus, and hearing ability of the better hearing ear.

RESULTS

After a mean follow-up time of 4.75 years, 32 of the 36 children used their CI on a regular basis. The remaining four children were nonusers. These children had congenital SSD and were older than three years at the time of CI surgery. Overall, for congenital/perilingual and postlingual SSD, speech intelligibility in noise and the Speech, Spatial and Qualities of Hearing Scale (SSQ) speech subscore were significantly improved, as were their subjective and objective localization ability and hearing-related quality of life. Children with postlingual SSD benefited from the CI with regard to speech intelligibility, SSQ speech/spatial/total score, and localization error, and children with congenital SSD showed better results with a short duration of deafness of less than 3 years compared with those with a longer deafness period.

CONCLUSIONS

Cochlear implantation is a successful treatment for children with congenital/perilingual or postlingual SSD. Results largely differed with respect to the onset and duration of deafness, and better outcomes were achieved by children with postlingual SSD and with a short duration of deafness. Our data also confirmed that children with congenital SSD should be implanted with a CI within three years of age.

A new tool for the assessment of speech understanding and spatial hearing difficulties in children: the Kid-SSQ questionnaire

PURPOSE

To develop and validate a new questionnaire, the Kid-SSQ, for the rapid screening of hearing abilities in children with hearing impairment, aged 7-17 years.

METHODS

The questionnaire was constructed from two existing, validated versions of the 'Speech, Spatial and Qualities of Hearing' - (SSQ) questionnaire (pediatric form and adult short-form). The 12 selected items included auditory aspects from three subscales: speech perception, spatial hearing, and qualities of hearing. This new short form was then validated in 154 children with cochlear implants (100 bilaterally, and 54 unilaterally implanted children). Construct validity was assessed by testing relationships between Kid-SSQ scores and objective clinical parameters (e.g., age at test, pure-tone audiometry-PTA threshold, speech reception threshold-SRT, duration of binaural experience).

RESULTS

Completion time was acceptable for use with children (less than 10 min) and the non-response rate was less than 1%. Good internal consistency was obtained (Cronbach's α = 0.78), with a stable internal structure corresponding to the 3 intended subscales. External validity showed the specificity of each subscale: speech subscale scores were significantly predicted (r = 0.32, p < 0.001) by both 2 kHz PTA threshold (β = 0.33, p < 0.001) and SRT (β = - 0.23, p < 0.001). Children with more binaural experience showed significantly higher scores on the spatial subscale than children with less binaural experience (F(1,98) = 5.1, p < 0.03) and the qualities of hearing subscale scores significantly depended on both age and SRT (r = 0.32, p < 0.001).

CONCLUSIONS

The Kid-SSQ questionnaire is a robust and clinically useful questionnaire for self-assessment of difficulties in various auditory domains.

Comparison of response properties of the electrically stimulated auditory nerve reported in human listeners and in animal models

Cochlear implants (CIs) provide acoustic information to implanted patients by electrically stimulating nearby auditory nerve fibers (ANFs) which then transmit the information to higher-level neural structures for further processing and interpretation. Computational models that simulate ANF responses to CI stimuli enable the exploration of the mechanisms underlying CI performance beyond the capacity of in vivo experimentation alone. However, all ANF models developed to date utilize to some extent anatomical/morphometric data, biophysical properties and/or physiological data measured in non-human animal models. This review compares response properties of the electrically stimulated auditory nerve (AN) in human listeners and different mammalian models. Properties of AN responses to single pulse stimulation, paired-pulse stimulation, and pulse-train stimulation are presented. While some AN response properties are similar between human listeners and animal models (e.g., increased AN sensitivity to single pulse stimuli with long interphase gaps), there are some significant differences. For example, the AN of most animal models is typically more sensitive to cathodic stimulation while the AN of human listeners is generally more sensitive to anodic stimulation. Additionally, there are substantial differences in the speed of recovery from neural adaptation between animal models and human listeners. Therefore, results from animal models cannot be simply translated to human listeners. Recognizing the differences in responses of the AN to electrical stimulation between humans and other mammals is an important step for creating ANF models that are more applicable to various human CI patient populations.

A Modified Pediatric Ranked Order Speech Perception Score to Assess Speech Recognition Development in Children With Cochlear Implants

PURPOSE

Characterizing and comparing speech recognition development in children with cochlear implants (CIs) is challenging because of variations in test type. This retrospective cohort study modified the Pediatric Ranked Order Speech Perception (PROSPER) scoring system to (a) longitudinally analyze the speech perception of children with CIs and (b) examine the role of age at CI activation, listening mode (i.e., unilateral or bilateral implantation), and interimplant interval.

METHOD

Postimplantation speech recognition scores from 31 children with prelingual, severe-to-profound hearing loss who received CIs were analyzed (12 with unilateral CI [UniCI], 13 with sequential bilateral CIs [SEQ BiCIs], and six with simultaneous BiCIs). Data were extracted from the Massachusetts Eye and Ear Audiology database. A version of the PROSPER score was modified to integrate the varying test types by mapping raw scores from different tests into a single score. The PROSPER scores were used to construct speech recognition growth curves of the implanted ears, which were characterized by the slope of the growth phase, the time from activation to the plateau onset, and the score at the plateau.

RESULTS

While speech recognition improved considerably for children following implantation, the growth rates and scores at the plateau were highly variable. In first implanted ears, later implantation was associated with poorer scores at the plateau (β = -0.15, p = .01), but not growth rate. The first implanted ears of children with BiCIs had better scores at the plateau than those with UniCI (β = 0.59, p = .02). Shorter interimplant intervals in children with SEQ BiCIs promoted faster speech recognition growth of the first implanted ears.

CONCLUSION

The modified PROSPER score could be used clinically to track speech recognition development in children with CIs, to assess influencing factors, and to assist in developing and evaluating patient-specific intervention strategies.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20113538.

Benefit of sequential bilateral cochlear implantation in children between 5 to 18 years old: A prospective cohort study

Objective

To determine the benefit of sequential cochlear implantation after a long inter-implantation interval in children with bilateral deafness receiving their second implant between 5 and 18 years of age.

Study design

Prospective cohort-study.

Setting

Tertiary multicenter.

Patients

85 children with bilateral deafness and unilateral implantation receiving a contralateral cochlear implant at the age of 5 to 18 years.

Method

The primary outcomes were speech recognition in quiet and noise (CVC) scores. The secondary outcomes were language outcomes and subjective hearing abilities, all measured before and 12 months after sequential bilateral cochlear implantation. Medians of the paired data were compared using the Wilcoxon signed-rank test. Univariable linear regression analyses was used to analyze associations between variables and performance outcomes.

Results

A significant benefit was found for speech recognition in quiet (96% [89–98] vs 91% [85–96]; p < 0.01) and noise (65% [57–75] vs 54% [47–71]; p = 0.01) in the bilateral CI condition compared to unilateral (n = 75, excluded 10 non-users). No benefit was seen for language outcomes. The subjective sound quality score was statistically significant higher in bilateral compared to the unilateral CI condition. Pre-operative residual hearing level in the ear of the second implant, the inter-implant interval and age at time of second implantation was not significantly associated with performance scores.

Conclusion

After 12 months of use, sequential bilateral cochlear implantation showed improved speech perception in quiet and noise and improved subjective sound quality outcomes in children despite a great inter-implantation interval (median of 8 years [range 1–16 years]).

Cochlear Implantation in Young Mandarin-Speaking Children: One Year After First Fitting

INTRODUCTION

Bilateral cochlear implantation has been shown to be beneficial in terms of sound localization and speech recognition in children with congenital deafness. However, little is known about the benefits of bilateral cochlear implantationin children who communicate in a tonal language such as Mandarin. This study aims to investigate the auditory perception and speech intelligibility of Mandarin-speaking children 1 year after first fitting.

MATERIALS AND METHODS

Twenty-nine children aged between 11.5 and 17.9 months with severe-to-profound bilateral sensorineural hearing loss were recruited; 10 were unilaterally implanted and 19 were bilaterally implanted. A test battery was used to monitor improvements during the first year of cochlear implant use.

RESULTS

Bilaterally implanted children scored better in the spatial domain of the Speech, Spatial and Qualities of hearing scale for Parents (SSQ-P) in comparison to unilaterally implanted children. Significant improvements were observed in auditory performance and speech intelligibility at 6 and 12 months after first fitting for both groups of children.

DISCUSSION

Young children that speak a tonal language, such as Mandarin, can obtain significant improvements in hearing and speech abilities within the first year of cochlear implant use. Furthermore, bilateral implantation provides users with better spatial hearing in comparison to unilateral implantation.

French adaptation and validation of the Speech, Spatial and Qualities of Hearing scale for Parents (SSQ-P) and for Children (SSQ-Ch)

OBJECTIVES

Hearing loss can seriously impact children's daily life. This study aims to translate and validate the French versions of the hearing performance questionnaires, SSQ-Parent (for 5-18 years old children), and SSQ-Children (for 11-18 years old children).

DESIGN

This controlled prospective trial was conducted between April and October 2020. The forward-backward translation method was used, and a test-retest procedure was carried out on a case and a control population. Cases had at least 30 dBHL hearing loss.

STUDY SAMPLE

54 cases (mean age 10.4 years old) and 32 controls (mean age 12.5 years old) answered the SSQ-Parent. 35 cases (mean age 13.1 years old) and 35 controls (mean age 14.3 years old) answered the SSQ-Children.

RESULTS

Spearman's correlation coefficients between global scores of the test and re-test were 0.91 (p < 0.001) for SSQ-Parent, and 0.89 (p < 0.001) for SSQ-Children. Both tests were discriminant (respectively, global score 57.8 vs 92 p < 0.001, 61.2 vs 92.6 p < 0.001), and internally consistent (Cronbach's alpha 0.94 and 0.97). Items-global score correlation was satisfactory. ROC curves showed high area under curve for the SSQ-Children (0.990), and SSQ-Parent (0.988).

CONCLUSION

The SSQ-Parent and SSQ-Children revealed excellent statistical properties, and can be used for the evaluation of hearing performance of children.

An Adaptation and Validation Study of the Speech, Spatial, and Qualities of Hearing Scale (SSQ) in Italian Normal-Hearing Children

This study aimed to translate and adapt the English version of the Speech, Spatial, and Qualities of Hearing Scale (SSQ) for children and for parents into the Italian language; validate SSQ for hearing children and their parents; and evaluate the discriminant validity of the instrument. A group of 102 normal-hearing Italian children, aged between 9 and 16 years, and their parents were included in this study. A group of 31 parents of normal-hearing Italian children aged between 6 and 8 years was also included. A group of 57 hearing-impaired Italian children aged between 9 and 16 years, and their parents were also included, as well as a group of 30 parents of hearing-impaired Italian children aged between 6 and 8 years. Cronbach’s alpha in the SSQ for parents was 0.92; it was 0.95 in the SSQ for children. Guttmann’s split-half coefficient in SSQ for children for both λ4 and λ6 was 0.98; in SSQ for parents in λ4 was 0.96 and λ6 was 0.95. These data provide evidence for the discriminant validity of the SSQ scale (p-value < 0.001). Italian SSQ scales for children and for parents are now available.

Cortical imbalance following delayed restoration of bilateral hearing in deaf adolescents

Unilateral auditory deprivation in early childhood can lead to cortical strengthening of inputs from the stimulated side, yet the impact of this on bilateral processing when inputs are later restored beyond an early sensitive period is unknown. To address this, we conducted a longitudinal study with 13 bilaterally profoundly deaf adolescents who received unilateral access to sound via a cochlear implant (CI) in their right ear in early childhood before receiving bilateral access to sound a decade later via a second CI in their left ear. Auditory‐evoked cortical responses to unilateral and bilateral stimulation were measured repeatedly using electroencephalogram from 1 week to 14 months after activation of their second CI. Early cortical responses from the newly implanted ear and bilateral stimulation were atypically lateralized to the left ipsilateral auditory cortex. Duration of unilateral deafness predicted an unexpectedly stronger representation of inputs from the newly implanted, compared to the first implanted ear, in left auditory cortex. Significant initial reductions in responses were observed, yet a left‐hemisphere bias and unequal weighting of inputs favoring the long‐term deaf ear did not converge to a balanced state observed in the binaurally developed system. Bilateral response enhancement was significantly reduced in left auditory cortex suggesting deficits in ipsilateral response inhibition of new, dominant, inputs during bilateral processing. These findings paradoxically demonstrate the adaptive capacity of the adolescent auditory system beyond an early sensitive period for bilateral input, as well as restrictions on its potential to fully reverse cortical imbalances driven by long‐term unilateral deafness.

Long-Term Language Development in Children With Early Simultaneous Bilateral Cochlear Implants

Objectives:

This longitudinal study followed the language development of children who received the combination of early (5 to 18 months) and simultaneous bilateral cochlear implants (CIs) throughout the first 6 years after implantation. It examined the trajectories of their language development and identified factors associated with language outcomes.

Design:

Participants were 21 Norwegian children who received bilateral CIs between the ages of 5 and 18 mo and 21 children with normal hearing (NH) who were matched to the children with CIs on age, sex, and maternal education. The language skills of these two groups were compared at 10 time points (3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months after implantation) using parent reports and standardized measures of general language skills, vocabulary, and grammar. In addition, assessments were made of the effects of age at CI activation, speech recognition abilities, and mothers’ education on language outcomes 6 years after implantation.

Results:

During the first 4 years after implantation, the gap in general expressive and receptive language abilities between children with CIs and children with NH gradually closed. While at the initial five to six assessments (3 to 36 months after implantation), significant differences between children with CIs and children with NH were observed; at 4 years after implantation, there were no longer any significant group differences in general language skills and most children with CIs achieved scores within 1 SD of the tests’ normative means. From 2 to 3 years after implantation onward, expressive vocabulary and receptive grammar skills of children with CIs were similar to those of the reference group. However, from 4 years after implantation until the end of the observation period, 6 years after implantation, expressive grammar skills of children with CIs were lower than those of children with NH. In addition, a gap in receptive vocabulary appeared and grew increasingly larger from 4 to 6 years postimplantation. At the final assessment, the children with CIs had an average receptive vocabulary score around 1 SD below the normative mean. Regression analysis indicated that the children’s language outcomes at 6 years after implantation were related to their speech recognition skills, age at CI activation, and maternal education.

Conclusions:

In the first 4 years after implantation, the language performance of children with CIs became increasingly similar to that of their NH peers. However, between 4 and 6 years after implantation, there were indications of challenges with certain aspects of language, specifically receptive vocabulary and expressive grammar. Because these challenges first appeared after the 4-year assessment, the findings underline the importance of long-term language intervention to increase the chances of a continued language development comparable to that of NH peers. They also indicate that there is a need for comprehensive longitudinal studies of the language development of children with CIs beyond 4 years after implantation.

Cochlear Implantation in Children With Single-Sided Deafness: A Systematic Review and Meta-analysis

Importance

In 2019, the US Food and Drug Administration approved cochlear implantation for children with single-sided deafness (SSD). The absence of robust clinical data specific to pediatric patients to guide shared decision-making and to identify potential advantages is a challenge in family counseling.

Objective

To evaluate the audiological and patient-reported outcomes in children who underwent cochlear implantation for SSD and to assess the association between time of implantation, subjective outcomes, and cochlear implant device use rates.

Data Source

MEDLINE, Embase, Scopus, Cochrane, and PubMed were searched for English-language articles that were published in a peer-reviewed journal from database inception to February 18, 2020.

Study Selection

Inclusion criteria were designed to capture studies that evaluated pediatric patients (1) younger than 18 years, (2) with a diagnosis of SSD for which they underwent a cochlear implantation, and (3) with at least 1 outcome of interest measured numerically: speech perception, sound localization, device use, and patient-reported outcomes. Of the 526 articles reviewed, 12 (2.3%) met the selection criteria.

Data Extraction and Synthesis

The Meta-analyses Of Observational Studies in Epidemiology (MOOSE) reporting guidelines were followed. Data were pooled using fixed-effect and random-effect models. The following information was obtained from each article: study characteristics, patient characteristics, hearing loss and intervention characteristics, and outcomes.

Main Outcomes and Measures

Outcomes were (1) postoperative changes in speech perception (in quiet was measured as a proportion of correct responses, and in noise was measured as decibel signal to noise ratio for speech reception threshold) and sound localization (measured in degree of localization error), (2) patient-reported audiological outcomes (measured by the speech, spatial, and qualities of hearing scale), and (3) device use rates among children who received cochlear implantation for SSD.

Results

Twelve observational studies that evaluated 119 children (mean [SD] age, 6.6 [4.0] years) with SSD who received a cochlear implant were included. Most children showed clinically meaningful improvement in speech perception in noise (39 of 49 children [79.6%]) and in quiet (34 of 42 children [81.0%]). Long duration of deafness (>4 years in congenital SSD and >7 years in perilingual SSD) was the most commonly proposed reason for lack of improvement. Sound localization as measured by degrees of error from true location (mean difference [MD], -24.78°; 95% CI, -34.16° to -15.40°; I2 = 10%) improved statistically significantly after cochlear implantation. Patients with acquired SSD and shorter duration of deafness compared with those with congenital SSD reported greater improvements in speech (MD, 2.27; 95% CI, 1.89-2.65 vs 1.58; 95% CI, 1.00-2.16) and spatial (MD, 2.95; 95% CI, 2.66-3.24 vs 1.68; 95% CI, 0.96-2.39) hearing qualities. The duration of deafness among device nonusers was statistically significantly longer than the duration of deafness among regular device users (median difference, 6.84; 95% CI, 4.02-9.58).

Conclusions and Relevance

This systematic review and meta-analysis found that cochlear implantation for children with SSD was associated with clinically meaningful improvements in audiological and patient-reported outcomes; shorter duration of deafness may lead to better outcomes. These findings can guide future research efforts, refine cochlear implantation candidacy criteria, and aid in family counseling and shared decision-making.

Long-term results of cochlear implantation in children with congenital single-sided deafness

Purpose

The purpose of this retrospective study was to investigate the outcome and critical age of cochlear implantation in congenital single-sided deafness (SSD).

Methods

11 children with congenital SSD were implanted with a cochlear implant (CI). Auditory performance was measured through the results of speech discrimination, subjective assessment by the Categories of auditory performance (CAP) score, the Speech, Spatial and Qualities scale questionnaire (SSQ) and the German version of the IOI-HA [Internationales Inventar zur Evaluation von Hörgeräten (IIEH, version for CI)].

Results

Long-term follow-up [median: 3 years and 5 months (3;5 years)] revealed that nine children use their CI (> 8 h/day) and two became nonusers. In children aged below 3;2 years at surgery, there was a substantial long-term increase in speech discrimination and subjective benefit. Children over 4;4 years of age at CI surgery improved partially in audiological/subjective measurements. Among children above 5 years, the SSQ score did not improve despite further slight improvement in speech discrimination long-term.

Conclusion

Our data suggest a critical age for CI surgery below 3 years in children with congenital SSD for successful hearing rehabilitation. It is mandatory to identify children with SSD as early as bilaterally deaf children.

Auditory Attention and Spatial Unmasking in Children With Cochlear Implants

The ability to attend to target speech in background noise is an important skill, particularly for children who spend many hours in noisy environments. Intelligibility improves as a result of spatial or binaural unmasking in the free-field for normal-hearing children; however, children who use bilateral cochlear implants (BiCIs) demonstrate little benefit in similar situations. It was hypothesized that poor auditory attention abilities might explain the lack of unmasking observed in children with BiCIs. Target and interferer speech stimuli were presented to either or both ears of BiCI participants via their clinical processors. Speech reception thresholds remained low when the target and interferer were in opposite ears, but they did not show binaural unmasking when the interferer was presented to both ears and the target only to one ear. These results demonstrate that, in the most extreme cases of stimulus separation, children with BiCIs can ignore an interferer and attend to target speech, but there is weak or absent binaural unmasking. It appears that children with BiCIs mostly experience poor encoding of binaural cues rather than deficits in ability to selectively attend to target speech.

Hearing and speech benefits of cochlear implantation in children: A review of the literature

Cochlear implantation is a safe and reliable treatment for children with severe to profound hearing loss. The primary benefit of these medical devices in children is the acquisition of hearing, which promotes development of spoken language. The present paper reviews published literature demonstrating predictive effects of a number of factors on acquisition of hearing development and speech recognition. Of the many variables that contribute to an individual child's development after implantation, age at implantation, the presence of medical comorbidities, social determinants of health, and the provision of bilateral versus unilateral hearing are those that can vary widely and have consistently shown clear impacts. Specifically, age of implantation is crucial to reduce effects of deafness on the developing auditory system and capture the remarkable plasticity of early development. Language development after cochlear implantation requires therapy emphasizing hearing and oral communication, education, and other support which can be influenced by known social determinants of health; specifically, outcomes in children decline with reductions in socioeconomic status and levels of parental education. Medical co-morbidities also slow rates of progress after cochlear implantation. On the other hand, benefits of implantation increase in children who are provided with access to hearing from both ears. In sum, cochlear implants promote development of hearing in children and the best outcomes are achieved by providing early access to sound in both ears. These benefits can be limited by known social determinants of health which restrict access to needed support and medical comorbidities which add further complexity in care and outcome.

Listening in Noise Remains a Significant Challenge for Cochlear Implant Users: Evidence from Early Deafened and Those with Progressive Hearing Loss Compared to Peers with Normal Hearing

Cochlear implants (CIs) are the state-of-the-art therapy for individuals with severe to profound hearing loss, providing them with good functional hearing. Nevertheless, speech understanding in background noise remains a significant challenge. The purposes of this study were to: (1) conduct a novel within-study comparison of speech-in-noise performance across ages in different populations of CI and normal hearing (NH) listeners using an adaptive sentence-in-noise test, and (2) examine the relative contribution of sensory information and cognitive–linguistic factors to performance. Forty CI users (mean age 20 years) were divided into “early-implanted” <4 years (n = 16) and “late-implanted” >6 years (n = 11), all prelingually deafened, and “progressively deafened” (n = 13). The control group comprised 136 NH subjects (80 children, 56 adults). Testing included the Hebrew Matrix test, word recognition in quiet, and linguistic and cognitive tests. Results show poorer performance in noise for CI users across populations and ages compared to NH peers, and age at implantation and word recognition in quiet were found to be contributing factors. For those recognizing 50% or more of the words in quiet (n = 27), non-verbal intelligence and receptive vocabulary explained 63% of the variance in noise. This information helps delineate the relative contribution of top-down and bottom-up skills for speech recognition in noise and can help set expectations in CI counseling.

Critical Factors for Binaural Hearing in Children with Bilateral Sequential Cochlear Implantation: First Implant Performance and Inter-Implant Interval

Objectives: This study evaluated the influence of the performance of the first cochlear implant (CI-1) on the second implant (CI-2) and the significance of inter-implant intervals in children with sequential cochlear implantation. Method: Thirty-four patients were included for speech perception outcome and 38 patients were included for subjective hearing satisfaction in daily life in this study. The patients were classified into 3 groups according to inter-implant interval: group I, <4 years; group II, 4–7 years; group III, >7 years. Open-set speech perception scores before and at 3, 6, 12, and 24 months after the second implantation was compared among the CI-1, CI-2, and bilateral CI conditions. Subjective hearing benefits in daily life were measured using a questionnaire of Speech, Spatial, and Qualities of Hearing Scale (SSQ) for parents of children with impaired hearing, and device use and preference were evaluated (by phone interview.) Results: The speech perception of children using the CI-2 only improved quickly within 3 months postoperatively and were similar to those using the CI-1 only. The results of monosyllabic and disyllabic word tests using CI-2 at 3 months after second implantation were not significantly different from those in patients using the CI-1 only. In the sentence test, the scores using the CI-2 only were not significantly different from those using the first implant only at 6 months after second implantation. SSQ scores were similar among groups and the worst score in each section was shown from the questions about performance under noisy conditions in each section. Device usage habits showed that 17 (44.7%) and 16 (42.1%) patients preferred bilateral and the CI-1, respectively. Only 5 (13.2%) patients wanted the CI-2 rather than the CI-1. While group I and II showed a prominent positive attitude to bilateral use, group III, for which the inter-implant interval was 7 years or more, showed a definite preference for the CI-1 (p < 0.01). Conclusions: Functional binaural benefits were achieved in patients who were good performers with the CI-1 after the second implantation irrespective of the inter-implant interval. Sequential CI should be strongly recommended for patients with unilateral CI showing a good performance.

Categories of Auditory Performance and Speech Intelligibility Ratings in Prelingually Deaf Children With Bilateral Implantation

Purpose The aim of the current study was to review all pediatric cases with congenital deafness who underwent bilateral implantation in our center. Specifically, auditory performance and speech intelligibility ratings were compared across children based on their mode of bilateral stimulation (simultaneous or sequential implantation). Method A retrospective chart review design was used in this study. A total of 46 congenitally deaf children were included. Children ranged in age between 2 and 8 years, with a mean of 3 years 7 months. Participants were divided into 2 groups: those who received their bilateral implant simultaneously and those who received them sequentially. Categories of Auditory Performance (CAP; Archbold, Lutman, & Marshall, 1995 ) scores and Speech Intelligibility Rating (SIR; M. C. Allen, Nikolopoulos, & O'Donoghue, 1998 ) scores were used to measure their performance. Results Children scored an average of 4.1 (±1.6) on the CAP Scale and 1.6 (±1) on the SIR Scale. Results showed that children who received their implants simultaneously scored relatively higher on the CAP Scale than those with sequential implants. However, there were no differences between the 2 groups in SIR scores. These 2 outcome measures were not correlated with age at implantation. Conclusion The current study demonstrated that simultaneous implantation could potentially improve audiologic outcome.

Speech Detection in Noise for Young Bilaterally Implanted Children: Is There Evidence of Binaural Benefit Over the Shadowed Ear Alone?

OBJECTIVES

To measure binaural benefit over the shadowed ear alone for young bilateral cochlear implant (CI) users. It was hypothesized that children who received bilateral CIs at a young age (<4 years), and had significant bilateral experience, would demonstrate lower detection thresholds for speech sounds in background noise in the bilateral CI over the unilateral CI condition when the added CI was ipsilateral to the noise source.

DESIGN

Children receiving bilateral CIs at the Eye and Ear Hospital Clinic in Melbourne were invited to participate in a wider research project evaluating outcomes; those participating in the wider project who were bilaterally implanted by 4 years and were approximately 2 years postoperative were included in the present study. For 20 participants, detection signal to noise ratios (SNRs) were measured for speech presented from in front and noise from 90° in at least 3 of 4 device/noise conditions, namely left CI/noise right and right CI/noise left, plus bilateral CIs/noise right and bilateral CIs/noise left.

RESULTS

As some participants could only complete testing in 3 conditions within the 1 test block, the unilateral versus bilateral comparison was performed for 1 CI (i.e., 1 noise direction) for 15 participants and for both CIs (i.e., noise left and noise right) for 5 participants. Group analysis indicated no significant difference in detection SNR between the unilateral and bilateral CI conditions when adding the left CI or right CI (for the overall group) or when adding the first or second CI (for the 15 participants with sequential bilateral CIs). Separate analyses indicated no significant difference in detection SNR between the unilateral and bilateral CI conditions for the majority of individuals; this occurred irrespective of whether the analysis indicated that the CI added in the bilateral condition was poorer-performing, better-performing, or not significantly different compared with the other CI. Four individuals demonstrated a significant improvement in the bilateral condition when the CI added in the bilateral condition was a better-performing (n = 1), poorer-performing (n = 2), or not significantly different CI (n = 1). There was no relationship between the detection SNR difference between each CI and the detection SNR difference between the unilateral and bilateral conditions.

CONCLUSIONS

The hypothesis of a lower detection SNR in the bilateral condition was not supported by the group results or by the results for the majority of individuals. For the 4 participants who did demonstrate benefit over the shadowed ear alone, that benefit cannot be separated from the potential benefit gained as a result of the CI added in the bilateral condition being the better-performing CI for 1 of the 4. Variation in outcomes could not be related to demographic factors for this group, which was relatively homogeneous for age at bilateral CI and experience; an older, more experienced group may demonstrate greater binaural benefit in these conditions. These results can be used during counseling for families regarding postoperative expectations for young children, especially in the first 2 years.

Perceived improvements and challenges following sequential bilateral cochlear implantation in children and adults

OBJECTIVE

Semi-structured interviews were conducted with sequentially implanted bilateral cochlear-implant (biCI) recipients to examine functional aspects of communication that are affected by listening with one versus two CIs.

DESIGN

Participants were 15 adult biCI recipients and parents of 30 children (categorized into three groups by age) with biCIs. All CI users had sequential placement of biCIs with at least six months' experience with the first CI before activation of the second device, and at least three months' experience with both CIs prior to the interview. The parent/paediatric and adult interviews were all conducted by the same examiner. Electronic transcripts of the interview responses were coded for perceived changes or lack thereof in 23 behaviours following biCI. Extent of reported benefit was quantified for each subject within and across these behaviours and at the group level as a function of age.

RESULTS

Most adults and parents of children reported multiple functional changes following biCI use, and changes often translated to enhanced social communication. Nearly all participants were consistent users of biCIs, and were satisfied with their perceived gains in communicating in everyday settings. Most reported ongoing challenges listening in noisy settings. Although many reports on children paralleled those of adults, developmental differences were apparent. Thirteen percent of adults and twenty percent of parents of children in each of the respective groups reported low levels of change.

CONCLUSIONS

Results suggest that many biCI users experience meaningful functional benefits that may be underestimated by traditional outcome measures. We suggest the need to expand measurement approaches to better quantify the nature of these benefits.

Sequential pediatric bilateral cochlear implantation: The effect of time interval between implants

OBJECTIVE

To examine speech intelligibility in children subjected to sequential bilateral cochlear implants (CI) surgery and to assess the influence of the inter-stage interval duration.

INTRODUCTION

Binaural hearing recovery can have additional benefits, especially in speech and language development in patients with congenital profound sensorineural hearing loss; so recently there has been an increase in the number of children receiving bilateral CI.

METHODS

Twenty-seven children who underwent sequential bilateral cochlear implant (SBCI) with a short (1-3 yrs), medium (4-6 yrs) and long (7-12 yrs) range interval between both implantations, respectively, were evaluated. All patients underwent periodic speech perception test in quiet and noise after second implant activation in three conditions: with the first or second implant alone and with both implants. Results were examined according to the inter-stage interval.

RESULTS

Speech intelligibility in noise was significantly better under bilateral conditions than either ear alone, in all three groups. Small improvements were seen in quiet, especially in the third group (6-12 yrs).

CONCLUSION

Benefits of second implant in the early-implanted children and after a short inter-implant delay are more evident. However our study support that, even after a long period of deafness and despite a prolonged inter-stage interval, sequential bilateral cochlear implantation should be considered.

LEVEL OF EVIDENCE

Level 4.

A Longitudinal Study in Children With Sequential Bilateral Cochlear Implants: Time Course for the Second Implanted Ear and Bilateral Performance

PURPOSE

Whether, and if so when, a second-ear cochlear implant should be provided to older, unilaterally implanted children is an ongoing clinical question. This study evaluated rate of speech recognition progress for the second implanted ear and with bilateral cochlear implants in older sequentially implanted children and evaluated localization abilities.

METHOD

A prospective longitudinal study included 24 bilaterally implanted children (mean ear surgeries at 5.11 and 14.25 years). Test intervals were every 3-6 months through 24 months postbilateral. Test conditions were each ear and bilaterally for speech recognition and localization.

RESULTS

Overall, the rate of progress for the second implanted ear was gradual. Improvements in quiet continued through the second year of bilateral use. Improvements in noise were more modest and leveled off during the second year. On all measures, results from the second ear were poorer than the first. Bilateral scores were better than either ear alone for all measures except sentences in quiet and localization.

CONCLUSIONS

Older sequentially implanted children with several years between surgeries may obtain speech understanding in the second implanted ear; however, performance may be limited and rate of progress gradual. Continued contralateral ear hearing aid use and reduced time between surgeries may enhance outcomes.

Speech Recognition and Parent Ratings From Auditory Development Questionnaires in Children Who Are Hard of Hearing

OBJECTIVES

Progress has been made in recent years in the provision of amplification and early intervention for children who are hard of hearing. However, children who use hearing aids (HAs) may have inconsistent access to their auditory environment due to limitations in speech audibility through their HAs or limited HA use. The effects of variability in children's auditory experience on parent-reported auditory skills questionnaires and on speech recognition in quiet and in noise were examined for a large group of children who were followed as part of the Outcomes of Children with Hearing Loss study.

DESIGN

Parent ratings on auditory development questionnaires and children's speech recognition were assessed for 306 children who are hard of hearing. Children ranged in age from 12 months to 9 years. Three questionnaires involving parent ratings of auditory skill development and behavior were used, including the LittlEARS Auditory Questionnaire, Parents Evaluation of Oral/Aural Performance in Children rating scale, and an adaptation of the Speech, Spatial, and Qualities of Hearing scale. Speech recognition in quiet was assessed using the Open- and Closed-Set Test, Early Speech Perception test, Lexical Neighborhood Test, and Phonetically Balanced Kindergarten word lists. Speech recognition in noise was assessed using the Computer-Assisted Speech Perception Assessment. Children who are hard of hearing were compared with peers with normal hearing matched for age, maternal educational level, and nonverbal intelligence. The effects of aided audibility, HA use, and language ability on parent responses to auditory development questionnaires and on children's speech recognition were also examined.

RESULTS

Children who are hard of hearing had poorer performance than peers with normal hearing on parent ratings of auditory skills and had poorer speech recognition. Significant individual variability among children who are hard of hearing was observed. Children with greater aided audibility through their HAs, more hours of HA use, and better language abilities generally had higher parent ratings of auditory skills and better speech-recognition abilities in quiet and in noise than peers with less audibility, more limited HA use, or poorer language abilities. In addition to the auditory and language factors that were predictive for speech recognition in quiet, phonological working memory was also a positive predictor for word recognition abilities in noise.

CONCLUSIONS

Children who are hard of hearing continue to experience delays in auditory skill development and speech-recognition abilities compared with peers with normal hearing. However, significant improvements in these domains have occurred in comparison to similar data reported before the adoption of universal newborn hearing screening and early intervention programs for children who are hard of hearing. Increasing the audibility of speech has a direct positive effect on auditory skill development and speech-recognition abilities and also may enhance these skills by improving language abilities in children who are hard of hearing. Greater number of hours of HA use also had a significant positive impact on parent ratings of auditory skills and children's speech recognition.

What Is the International Classification of Functioning, Disability and Health and Why Is It Relevant to Audiology?

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is widely used in disability and health sectors as a framework to describe the far-reaching effects of a range of health conditions on individuals. This biopsychosocial framework can be used to describe the experience of an individual in the components of body functions, body structures, and activities and participation, and it considers the influence of contextual factors (environmental and personal) on these components. Application of the ICF in audiology allows the use of a common language between health care professionals in both clinical and research settings. Furthermore, the ICF is promoted as a means of facilitating patient-centered care. In this article, the relevance and application of the ICF to audiology is described, along with clinical examples of its application in the assessment and management of children and adults with hearing loss. Importantly, the skills necessary for clinicians to apply the ICF effectively are discussed.

Adaptation of the speech, spatial, and qualities of hearing scale for use with children, parents, and teachers

Subjective assessment of hearing ability in everyday life complements more objective forms of evaluation. A broad evaluation of the additional benefit provided to children by a second bilateral cochlear implant required such an assessment. As no paediatric tool provided detailed evaluation of performance in the areas of daily listening in which benefit was likely to be demonstrated, an adult questionnaire was adapted. Items of the Speech, Spatial and Qualities of Hearing Scale (SSQ) focused mainly, although not exclusively, on hearing functions requiring the binaural system. The adapted child, parent, and teacher versions of the SSQ retained the structure of rating listening performance in everyday scenarios across the domains of speech perception, spatial hearing, and other qualities of hearing. Modifications were minimized, although deletion of some items and wording changes were required, and some subdomains could not be included. Observation periods were introduced so that parents and teachers observe performance prior to providing ratings. The suggested minimum age is 11 years for the child version and 5 years for the parent and teacher versions. Instructions indicate interview-style administration in which interpretation of the described listening scenarios can be clarified and use of the ruler-style response format demonstrated. Researchers applying the SSQ for parents have reported higher performance ratings for bilateral over unilateral cochlear implants, particularly in the spatial hearing domain. Further research should provide evidence for the target age range, compare child and parent responses, and evaluate modifications for use with younger children.

Cochlear implantation in children with single-sided deafness: does aetiology and duration of deafness matter?

For adult patients with single-sided deafness (SSD), treatment with a cochlear implant (CI) is well established as an acceptable and beneficial hearing rehabilitation method administered routinely in clinical practice. In contrast, for children with SSD, CI has been applied less often to date, with the rationale to decide either on a case-by-case basis or under the realm of clinical research. The aim of our clinical study was to evaluate the longitudinal benefits of CI for a group of children diagnosed with SSD and to compare their outcomes with respect to patient characteristics. Evaluating a pool of paediatric SSD patients presenting for possible CI surgery revealed that the primary aetiology of deafness was congenital cochlear nerve deficiency. A subgroup of children meeting the CI candidacy criteria for the affected ear (the majority with acquired hearing loss) were enrolled in the study. Preliminary group results suggest substantial improvements in speech comprehension in noise and in the ability to localise sound, which was demonstrated through objective and subjective assessments after CI treatment for the group, with results varying from patient to patient. Our study shows a trend towards superior outcomes for children with acquired hearing loss and a shorter duration of hearing loss compared to congenitally deafened children who had a longer duration of SSD. This indicates an interactive influence of the age at onset, aetiology and duration of deafness upon the restoration of binaural integration and the overall benefits of sound stimulation to two ears after CI treatment. Continued longitudinal investigation of these children and further studies in larger groups may provide more guidance on the optimal timing of treatment for paediatric patients with acquired and congenital SSD.

Quantification of speech-in-noise and sound localisation abilities in children with unilateral hearing loss and comparison to normal hearing peers

The study objective was to quantify abilities of children with unilateral hearing loss (UHL) on measures that address known deficits for this population, i.e. speech understanding in quiet and noise, and sound localisation. Noise conditions varied by noise type and source location. Parent reports of real-world abilities were also obtained. Performance was compared to gender- and age-matched normal hearing (NH) peers. UHL performance was poorer and more varied compared to NH peers. Among the findings, age correlated with localisation ability for UHL but not NH participants. Low-frequency hearing in the better ear of UHL children was associated with performance in noise; however, there was no relation for NH children. Considerable variability was evident in the outcomes of children with UHL and needs to be understood as future treatment options are considered.

Bilateral versus unilateral cochlear implants in children: a study of spoken language outcomes

Objectives:

Although it has been established that bilateral cochlear implants (CIs) offer additional speech perception and localization benefits to many children with severe to profound hearing loss, whether these improved perceptual abilities facilitate significantly better language development has not yet been clearly established. The aims of this study were to compare language abilities of children having unilateral and bilateral CIs to quantify the rate of any improvement in language attributable to bilateral CIs and to document other predictors of language development in children with CIs.

Design:

The receptive vocabulary and language development of 91 children was assessed when they were aged either 5 or 8 years old by using the Peabody Picture Vocabulary Test (fourth edition), and either the Preschool Language Scales (fourth edition) or the Clinical Evaluation of Language Fundamentals (fourth edition), respectively. Cognitive ability, parent involvement in children’s intervention or education programs, and family reading habits were also evaluated. Language outcomes were examined by using linear regression analyses. The influence of elements of parenting style, child characteristics, and family background as predictors of outcomes were examined.

Results:

Children using bilateral CIs achieved significantly better vocabulary outcomes and significantly higher scores on the Core and Expressive Language subscales of the Clinical Evaluation of Language Fundamentals (fourth edition) than did comparable children with unilateral CIs. Scores on the Preschool Language Scales (fourth edition) did not differ significantly between children with unilateral and bilateral CIs. Bilateral CI use was found to predict significantly faster rates of vocabulary and language development than unilateral CI use; the magnitude of this effect was moderated by child age at activation of the bilateral CI. In terms of parenting style, high levels of parental involvement, low amounts of screen time, and more time spent by adults reading to children facilitated significantly better vocabulary and language outcomes. In terms of child characteristics, higher cognitive ability and female sex were predictive of significantly better language outcomes. When family background factors were examined, having tertiary-educated primary caregivers and a family history of hearing loss were significantly predictive of better outcomes. Birth order was also found to have a significant negative effect on both vocabulary and language outcomes, with each older sibling predicting a 5 to 10% decrease in scores.

Conclusions:

Children with bilateral CIs achieved significantly better vocabulary outcomes, and 8-year-old children with bilateral CIs had significantly better language outcomes than did children with unilateral CIs. These improvements were moderated by children’s ages at both first and second CIs. The outcomes were also significantly predicted by a number of factors related to parenting, child characteristics, and family background. Fifty-one percent of the variance in vocabulary outcomes and between 59 to 69% of the variance in language outcomes was predicted by the regression models.

The study compared language abilities of children with unilateral and bilateral cochlear implants (CIs), quantified the rate of language development attributable to bilateral CIs and documented predictors of language development. Children with bilateral CIs achieved significantly better vocabulary outcomes, and 8-year-old children with bilateral CIs had significantly better language outcomes. Improvements were moderated by children’s ages at both first and second CIs. Outcomes were significantly predicted by a number of factors related to parenting, child characteristics, and family background. Fifty-one percent of the variance in vocabulary outcomes and between 59 to 69% of the variance in language outcomes was predicted by the regression models.

Supplemental Digital Content is available in the text.

Binaural fusion and listening effort in children who use bilateral cochlear implants: a psychoacoustic and pupillometric study

Bilateral cochlear implants aim to provide hearing to both ears for children who are deaf and promote binaural/spatial hearing. Benefits are limited by mismatched devices and unilaterally-driven development which could compromise the normal integration of left and right ear input. We thus asked whether children hear a fused image (ie. 1 vs 2 sounds) from their bilateral implants and if this “binaural fusion” reduces listening effort. Binaural fusion was assessed by asking 25 deaf children with cochlear implants and 24 peers with normal hearing whether they heard one or two sounds when listening to bilaterally presented acoustic click-trains/electric pulses (250 Hz trains of 36 ms presented at 1 Hz). Reaction times and pupillary changes were recorded simultaneously to measure listening effort. Bilaterally implanted children heard one image of bilateral input less frequently than normal hearing peers, particularly when intensity levels on each side were balanced. Binaural fusion declined as brainstem asymmetries increased and age at implantation decreased. Children implanted later had access to acoustic input prior to implantation due to progressive deterioration of hearing. Increases in both pupil diameter and reaction time occurred as perception of binaural fusion decreased. Results indicate that, without binaural level cues, children have difficulty fusing input from their bilateral implants to perceive one sound which costs them increased listening effort. Brainstem asymmetries exacerbate this issue. By contrast, later implantation, reflecting longer access to bilateral acoustic hearing, may have supported development of auditory pathways underlying binaural fusion. Improved integration of bilateral cochlear implant signals for children is required to improve their binaural hearing.

A factor analysis of the SSQ (Speech, Spatial, and Qualities of Hearing Scale)

OBJECTIVE

The speech, spatial, and qualities of hearing questionnaire (SSQ) is a self-report test of auditory disability. The 49 items ask how well a listener would do in many complex listening situations illustrative of real life. The scores on the items are often combined into the three main sections or into 10 pragmatic subscales. We report here a factor analysis of the SSQ that we conducted to further investigate its statistical properties and to determine its structure.

DESIGN

Statistical factor analysis of questionnaire data, using parallel analysis to determine the number of factors to retain, oblique rotation of factors, and a bootstrap method to estimate the confidence intervals.

STUDY SAMPLE

1220 people who have attended MRC IHR over the last decade.

RESULTS

We found three clear factors, essentially corresponding to the three main sections of the SSQ. They are termed "speech understanding", "spatial perception", and "clarity, separation, and identification". Thirty-five of the SSQ questions were included in the three factors. There was partial evidence for a fourth factor, "effort and concentration", representing two more questions.

CONCLUSIONS

These results aid in the interpretation and application of the SSQ and indicate potential methods for generating average scores.

Benefits and detriments of unilateral cochlear implant use on bilateral auditory development in children who are deaf

We have explored both the benefits and detriments of providing electrical input through a cochlear implant in one ear to the auditory system of young children. A cochlear implant delivers electrical pulses to stimulate the auditory nerve, providing children who are deaf with access to sound. The goals of implantation are to restrict reorganization of the deprived immature auditory brain and promote development of hearing and spoken language. It is clear that limiting the duration of deprivation is a key factor. Additional considerations are the onset, etiology, and use of residual hearing as each of these can have unique effects on auditory development in the pre-implant period. New findings show that many children receiving unilateral cochlear implants are developing mature-like brainstem and thalamo-cortical responses to sound with long term use despite these sources of variability; however, there remain considerable abnormalities in cortical function. The most apparent, determined by implanting the other ear and measuring responses to acute stimulation, is a loss of normal cortical response from the deprived ear. Recent data reveal that this can be avoided in children by early implantation of both ears simultaneously or with limited delay. We conclude that auditory development requires input early in development and from both ears.

Acquisition of tense marking in English-speaking children with cochlear implants: a longitudinal study

This study investigated the development of tense markers (e.g., past tense -ed) in children with cochlear implants (CIs) over a 3-year span. Nine children who received CIs before 30 months of age participated in this study at three, four, and five years postimplantation. Nine typical 3-, 4-, and 5-year- olds served as control groups. All children participated in a story-retell task. Percent correct of tense marking in the task was computed. Within the groups, percent correct of tense marking changed significantly in children with CIs and in typical children who had more hearing experience. Across the groups, children with CIs were significantly less accurate in tense marking than typical children at four and five years postimplantation. In addition, the performance of tense marking in children with CIs was correlated with their speech perception skills at earlier time points. Errors of tense marking tended to be omission rather than commission errors in typical children as well as in children with CIs. The findings suggested that despite the perceptual and processing constraints, children who received CIs may learn tense marking albeit with a delayed pattern.

Enduring advantages of early cochlear implantation for spoken language development

PURPOSE

In this article, the authors sought to determine whether the precise age of implantation (AOI) remains an important predictor of spoken language outcomes in later childhood for those who received a cochlear implant (CI) between 12 and 38 months of age. Relative advantages of receiving a bilateral CI after age 4.5 years, better pre-CI-aided hearing, and longer CI experience were also examined.

METHOD

Sixty children participated in a prospective longitudinal study of outcomes at 4.5 and 10.5 years of age. Twenty-nine children received a sequential second CI. Test scores were compared with normative samples of hearing age mates, and predictors of outcomes were identified.

RESULTS

Standard scores on language tests at 10.5 years of age remained significantly correlated with age of first cochlear implantation. Scores were not associated with receipt of a second, sequentially acquired CI. Significantly higher scores were achieved for vocabulary as compared with overall language, a finding not evident when the children were tested at younger ages.

CONCLUSION

Age-appropriate spoken language skills continued to be more likely with younger AOI, even after an average of 8.6 years of additional CI use. Receipt of a second implant between ages 4 and 10 years and longer duration of device use did not provide significant added benefit.

Functional performance among children with cochlear implants and additional disabilities

OBJECTIVE

To assess daily functional skills among young cochlear implant (CI) recipients with additional disabilities.

METHODS

Children with CI and developmental disabilities and a hearing control group containing similar ages and similar disabilities were enrolled in a cross-sectional study of language and functional skills. Daily functional skills were measured using the Pediatric Evaluation of Disability Inventory (PEDI), which provides standard and scaled scores in Self-Care, Mobility, and Social Functioning domains. Language was assessed using the Preschool Language Scales, 4th edition which provides standard scores and age equivalents.

RESULTS

Fourteen children with CIs and seven hearing controls were included in this analysis. Most children in this study (90.5%) had cognitive disabilities and 57% had motor disabilities. Compared with the hearing controls, children with CIs were less likely to have functional independence in any PEDI domain. Children with CI had significantly lower median social functioning standard scores compared with controls (17.3 vs. 27.5, P = 0.009). After controlling for nonverbal cognitive abilities and language level, the difference was no longer significant (19.1 vs. 24, P = 0.3). Among children with CI, age at implant and duration with device were not associated (P > 0.4) with PEDI scores.

DISCUSSION

Although children with CI and developmental disabilities had similar functional skills as hearing children with similar disabilities regarding the PEDI domains of Self-Care and Mobility, they had lower Social Function standard scores. This lower social functioning among children with implants may be related to lower language levels and possible language deficits seen in the CI group. Regular assessments of functional abilities coupled with language abilities are essential in providing every child with the opportunity for maximizing the potential for independence.

Functional benefits of sequential bilateral cochlear implantation in children with long inter-stage interval between two implants

OBJECTIVES

Older children are increasingly deriving binaural benefits from sequential bilateral cochlear implantation, and this procedure should be considered by experienced cochlear implant centers. This study aimed to identify the influence of a long inter-stage interval between two implants in older children. Speech perception and everyday listening performance were investigated and analyzed according to the length of the inter-stage interval.

STUDY DESIGN AND SETTINGS

Forty-two children who received sequential bilateral cochlear implantation participated in this study. Their average ages at the first and second implantation were 4.2 and 9.7 years, respectively. All subjects acquired excellent speech performance from their first implant, and the mean inter-stage interval was 5.5 years. Speech perception in quiet was assessed by formal speech measures, and postoperative performance using the second implant only was compared with the preoperative performance. Speech perception in noise test was administered using three noise directions with noise (+10 dB signal-to-noise ratio) from front and 90° to each side, and the change in performance using the first implant only and both implants were analyzed across the three noise directions. Subjects were divided into three groups according to their inter-stage interval (group I, 3-4.9 years; group II, 5-6.9 years; and group III, 7-9.9 years), and the test results were compared between the groups. Functional hearing benefits in daily life were measured by a questionnaire before and after bilateral cochlear implantation.

RESULTS

The speech perception abilities in quiet using the second implant only improved quickly and were similar to those using the first implant only within 1 year after the second implantation. The scores for the monosyllabic word test (phoneme: p=0.052; word: p=0.125) and common phrases sentence test (p=0.062) 6 month after the second implantation, and the Categories of Auditory Performance score (p=1.000) 1 year after the second implantation using the second implant only did not differ significantly from those using the first implant only. Speech perception was significantly better using both implants than using the first implant in all three noise conditions (speech and noise in front: p=0.004; speech in front and noise to the first implant: p=0.003; speech in front and noise to the second implant: p<0.001), and the effect of noise direction was negligibly small. No salient influence of inter-stage interval was observed in both quiet and noise tests. The second and third groups with longer inter-stage intervals (>5 years) achieved performance close to the level of the first group with a shorter interval. These subjects obtained significantly better functional hearing benefits in the everyday environment with bilateral implants compared with the first implant (p=0.018).

CONCLUSION

The subjects in this study showed rapid postoperative progression within 6 months after the second implantation, and more listening benefits in noise and daily life with bilateral implants. This group of older children, who were good performers with the first implant, developed auditory perceptual competence in the second ear and achieved functional binaural benefits with their two implants. Sequential bilateral cochlear implantation should be recommended to this group of older children despite a long inter-stage interval between two implants.