Cochlear implants in children younger than 6 months

Day-case otology: Special attention to the pediatric cochlear implantation procedure

OBJECTIVE

Assess the feasibility of cochlear implantation as day-surgery in children and identify variables influencing admission, readmission, and unplanned postoperative consultation.

METHODS

This retrospective observational monocentric study was conducted according to the STROBE recommendations. Between January 2017 and July 2022, all medical records of children who underwent cochlear implantation were analyzed. Eligible children were admitted for the first time to the pediatric day-surgery unit. Exclusion criteria were children planned for inpatient procedure, bilateralization or explantation-reimplantation. Sex assigned at birth, analgesic medication, anesthesia and complications were related to categorical variables. Age, duration of anesthesia, length of stay and ASA score were related to continuous variables.

RESULTS

We included 66 children from a total of 106. Mean age was 53 months [SD: 46 months, range 8-184 months]. Successful day-surgery management was observed in 86% of cases. In 14% of cases, children were admitted to the pediatric ENT unit for the following reasons: late awakening in 6%, non-controlled pain in 4.5%, postoperative nausea and vomiting in 3.5% of cases. Univariate analysis did not observe any factor promoting success of day-surgery regarding anesthetic agents. Age was not statistically significant as a factor of ambulatory failure. Time spent in the operating room was not a determining factor (p = 0.559). None of the children were rehospitalized. Early unplanned consultations were observed in 3% of cases for vertex edema in 1 case and uncomplicated otorrhea in 1 case.

CONCLUSION

This study adds to the knowledge on pediatric cochlear implantation and suggests that this procedure is suitable for day-surgery at any age.

Spectral Resolution and Speech Perception in Cochlear Implanted School-Aged Children

OBJECTIVE

Cochlear implantation of prelingually deaf infants provides auditory input sufficient to develop spoken language; however, outcomes remain variable. Inability to participate in speech perception testing limits testing device efficacy in young listeners. In postlingually implanted adults (aCI), speech perception correlates with spectral resolution an ability that relies independently on frequency resolution (FR) and spectral modulation sensitivity (SMS). The correlation of spectral resolution to speech perception is unknown in prelingually implanted children (cCI). In this study, FR and SMS were measured using a spectral ripple discrimination (SRD) task and were correlated with vowel and consonant identification. It was hypothesized that prelingually deaf cCI would show immature SMS relative to postlingually deaf aCI and that FR would correlate with speech identification.

STUDY DESIGN

Cross-sectional study.

SETTING

In-person, booth testing.

METHODS

SRD was used to determine the highest spectral ripple density perceived at various modulation depths. FR and SMS were derived from spectral modulation transfer functions. Vowel and consonant identification was measured; SRD performance and speech identification were analyzed for correlation.

RESULTS

Fifteen prelingually implanted cCI and 13 postlingually implanted aCI were included. FR and SMS were similar between cCI and aCI. Better FR was associated with better speech identification for most measures.

CONCLUSION

Prelingually implanted cCI demonstrated adult-like FR and SMS; additionally, FR correlated with speech identification. FR may be a measure of CI efficacy in young listeners.

Psychometric properties of the Arabic version of the meaningful use of speech scale (Arabic MUSS)

PURPOSE

To examine the construct, discriminative, and predictive validity, and the test-retest reliability of the Arabic Meaningful Use of Speech Scale (MUSS).

METHODS

Parents of 102 children with cochlear implantation (CI) with a matching control group of 102 children with normal hearing completed the Arabic-MUSS scale. A random subsample of 30 parents was interviewed after two weeks to examine the test-retest reliability.

RESULTS

the construct validity of the Arabic-MUSS was established by exploratory factor analysis that yielded a unidimensional scale and explained a total of 92.48% of the variance in the total score of the Arabic-MUSS. The internal consistency of the scale was excellent with Cronbach's alpha = 0.975. The Arabic-MUSS discriminative validity was supported by the significant difference between the total score of children with CI and children with normal hearing (p < 0.0001). The Arabic-MUSS has a moderate predictive validity as demonstrated by the moderate correlation between the total score and the time since cochlear implantation (p < 0.001). The Arabic-MUSS has excellent test-retest reliability.

CONCLUSION

The Arabic-MUSS is a valid and reliable measure that can be used to guide plans for auditory rehabilitation and monitor the progress of children with cochlear implantation over time.IMPLICATIONS FOR REHABILITATIONThe Arabic-Meaningful Use of Speech Scale is a valid and reliable parent-report assessment.The Arabic-Meaningful Use of Speech Scale evaluates functional speech in children with cochlear implantation.Clinicians can use the Arabic- Meaningful Use of Speech Scale to plan and monitor the progress of auditory rehabilitation programs.

Evaluation of Parental Perspectives and Concerns about Pediatric Cochlear Implantation: A Social Media Analysis

OBJECTIVE

Parents often experience uncertainty during decision-making for their child's cochlear implantation (CI) surgery, and online forums provide insight on parental opinions that might not be expressed in clinic. This study aims to evaluate parental perspectives and concerns about pediatric CI using social media analysis.

STUDY DESIGN

Qualitative study.

SETTING

Three online forums involving parental posts about pediatric CI.

INTERVENTION/METHODS

Forums were queried using keywords (e.g., "cochlear implant") to gather all U.S. parent-initiated posts about pediatric CI from 2006 to 2021. Thematic content analysis was performed to classify posts by overarching domain, themes, and subthemes. Posts were reviewed for thematic synthesis and double coded. Descriptive statistics were calculated for each theme by unique users.

RESULTS

A total of 79 posts by 41 unique users were analyzed. Themes relating to decision for CI included facilitators, inhibitors, resources, and feelings. Parents posted about lack of benefit from hearing aids promoting decision for CI and high cost as an inhibitor. Some expressed concern about making a major decision for a minor. Parents often mentioned their child's healthcare providers and social media as resources.

CONCLUSION

Through social media posts, parental priorities and concerns for decision-making of CI surgery were identified. Findings may guide discussions between physicians and parents and facilitate shared decision-making about CI.

Production of Tone 2 in disyllabic words in Mandarin Chinese speaking children aged 3-5 with a cochlear implant and a contralateral hearing aid

To investigate Mandarin Tone 2 production of disyllabic words of prelingually deafened children with a cochlear implant (CI) and a contralateral hearing aid (HA) and to evaluate the relationship between their demographic variables and tone-production ability. Thirty prelingually Mandarin-speaking preschoolers with CI+HA and 30 age-matched normal-hearing (NH) children participated in the study. Fourteen disyllabic words were recorded from each child. A total of 840 tokens (14 × 60) were then used in tone-perception tests in which four speech therapists participated. The production of T2-related disyllabic words of the bimodal group was significantly worse than that of the NH group, as reflected in the overall accuracy (88.57% ± 16.31% vs 99.29% ± 21.79%, p < 0.05), the accuracy of T1+T2 (93.33% vs 100%), the accuracy of T2+T1 (66.67 ± 37.91% vs 98.33 ± 9.13%), and the accuracy of T2+T4 (78.33 ± 33.95% vs 100%). In addition, the bimodal group showed significantly inferior production accuracy of T2+T1 than T2+T2 and T3+T2, p < 0.05. Both bimodal age and implantation age were significantly negatively correlated with the overall production accuracy, p < 0.05. For the error patterns, bimodal participants experienced more errors when T2 was in the first position of the tone combination, and T2 was most likely to be mispronounced as T1 and T3. Bimodal patients aged 3-5 have T2-related disyllabic lexical tone production defects, and their performances are related to tone combination, implantation age, and bimodal age.

CMV-induced Hearing Loss

Congenital cytomegalovirus (cCMV) infection is the most common fetal viral infection and contributes to about 25% of childhood hearing loss by the age of 4 years. It is the leading nongenetic cause of sensorineural hearing loss (SNHL). Infants born to seroimmune mothers are not completely protected from SNHL, although the severity of their hearing loss may be milder than that seen in those whose mothers had a primary infection. Both direct cytopathic effects and localized inflammatory responses contribute to the pathogenesis of cytomegalovirus (CMV)-induced hearing loss. Hearing loss may be delayed onset, progressive or fluctuating in nature, and therefore, a significant proportion will be missed by universal newborn hearing screening (NHS) and warrants close monitoring of hearing function at least until 5-6 years of age. A multidisciplinary approach is required for the management of hearing loss. These children may need assistive hearing devices or cochlear implantation depending on the severity of their hearing loss. In addition, early intervention services such as speech or occupational therapy could help better communication, language, and social skill outcomes. Preventive measures to decrease intrauterine CMV transmission that have been evaluated include personal protective measures, passive immunoprophylaxis and valacyclovir treatment during pregnancy in mothers with primary CMV infection. Several vaccine candidates are currently in testing and one candidate vaccine in phase 3 trials. Until a CMV vaccine becomes available, behavioral and educational interventions may be the most effective strategy to prevent maternal CMV infection.

Patient-centered empirical research on ethically relevant psychosocial and cultural aspects of cochlear, glaucoma and cardiovascular implants - a scoping review

BACKGROUND

The significance of medical implants goes beyond technical functioning and reaches into everyday life, with consequences for individuals as well as society. Ethical aspects associated with the everyday use of implants are relevant for individuals' lifeworlds and need to be considered in implant care and in the course of technical developments.

METHODS

This scoping review aimed to provide a synthesis of the existing evidence regarding ethically relevant psychosocial and cultural aspects in cochlear, glaucoma and cardiovascular implants in patient-centered empirical research. Systematic literature searches were conducted in EBSCOhost, Philpapers, PsycNET, Pubmed, Web of Science and BELIT databases. Eligible studies were articles in German or English language published since 2000 dealing with ethically relevant aspects of cochlear, glaucoma and passive cardiovascular implants based on empirical findings from the perspective of (prospective) implant-wearers and their significant others. Following a descriptive-analytical approach, a data extraction form was developed and relevant data were extracted accordingly. We combined a basic numerical analysis of study characteristics with a thematically organized narrative synthesis of the data.

RESULTS

Sixty-nine studies were included in the present analysis. Fifty were in the field of cochlear implants, sixteen in the field of passive cardiovascular implants and three in the field of glaucoma implants. Implant-related aspects were mainly found in connection with autonomy, freedom, identity, participation and justice, whereas little to no data was found with regards to ethical principles of privacy, safety or sustainability.

CONCLUSIONS

Empirical research on ethical aspects of implant use in everyday life is highly relevant, but marked by ambiguity and unclarity in the operationalization of ethical terms and contextualization. A transparent orientation framework for the exploration and acknowledgment of ethical aspects in "lived experiences" may contribute to the improvement of individual care, healthcare programs and research quality in this area. Ethics-sensitive care requires creating awareness for cultural and identity-related issues, promoting health literacy to strengthen patient autonomy as well as adjusting healthcare programs accordingly. More consideration needs to be given to sustainability issues in implant development and care according to an approach of ethics-by-design.

Auditory Outcomes in Children Who Undergo Cochlear Implantation Before 12 Months of Age: A Systematic Review

OBJECTIVE

To systematically review the literature to determine auditory outcomes of cochlear implantation in children ≤12 months old.

DATA SOURCE

PubMed, EMBASE, Medline, CINAHL, Cochrane, Scopus, and Web of Science databases were searched from inception to 9/1/2021 using PRISMA guidelines.

REVIEW METHODS

Studies analyzing auditory outcomes after cochlear implantation (CI) in children ≤12 months of age were included. Non-English studies and case reports were excluded. Outcome measures included functional and objective auditory results. Two independent reviewers evaluated each abstract and article. Heterogeneity and bias across studies were evaluated.

RESULTS

Of 305 articles identified, 17 met inclusion criteria. There were 642 children ages 2 to 12 months at CI. The most common etiologies of hearing loss were congenital CMV, meningitis, idiopathic hearing loss, and GJB2 mutations and other genetic causes. All studies concluded that early CI was safe. Overall, outcomes improved following early CI: IT-MAIS (9 studies), LittlEARS (4 studies), PTA (3 studies), CAP (3 studies), GASP (3 studies), and LNT (3 studies). Nine studies compared outcomes to an older implantation group (>12 months); of these (n = 450 early CI, n = 1189 late CI), 8 studies showed earlier CI achieved comparable or better auditory outcomes than later implantation, whereas 1 study (n = 120) concluded no differences in speech perception improvement.

CONCLUSION

Auditory outcomes were overall improved in children ≤12 months old undergoing CI. Studies that compared early to late CI demonstrated similar or better auditory outcomes in early implantation group. Given the comparable safety profile and critical time period of speech and language acquisition, earlier CI should be considered for infants with hearing loss.

Patient Preferences for Long-Term Implant Care in Cochlear, Glaucoma and Cardiovascular Diseases

In the process of developing and implementing innovative implant technologies the consideration of patient preferences can be beneficial for patients, doctors and developers. Nevertheless, in existing literature, there is still scarce knowledge of patients' perspectives on long-term implant care. In this study, three discrete choice experiments (DCEs) were conducted in the context of cochlear implants (CI, n = 92), glaucoma implants (GI, n = 21) and cardiovascular implants (CVI, n = 23), examining the relative importance of attributes of long-term implant care from the patients' perspective. The participants chose between differently shaped options for implant-related care. The attributes of these care options were generated and selected based on previous literature reviews, group discussions and a diary study with patients. The choice data were analyzed via binary logit regression. In CI-DCE, the technological compatibility of the implant with newer implant models, accessories or devices from other manufacturers was highly valued by participants, whereas in GI-DCE the (in)dependency on glaucoma medication post-implantation had the greatest influence on participants' choice behavior. In CVI-DCE, the attribute with the highest relative importance related to the means of securing long-term treatment success. In all three DCE, shared decision making was relatively important for participants. Our results emphasized the importance of an adequate transfer of technological advancements in implant care for promoting patient benefits, such as the availability of comprehensible, understandable, high-quality information about current developments. Similarly, promoting technological health literacy and further pushing the technological compatibility, durability and safety of implants are directions for future implant development in accordance with patients' preferences. Therefore, the participation of implant wearers in the development process is encouraged.

Cochlear implants: the effects of age on outcomes

INTRODUCTION

Cochlear implants (CIs) provide access to sound for children and adults who do not receive adequate benefit from hearing aids. Age at implantation is known to affect outcomes across the lifespan.

AREAS COVERED

The effects of age on CI outcomes are examined for infants, children, adolescents, and older adults. A variety of outcome measures are considered, including speech perception, language, cognition, and quality of life measures.

EXPERT OPINION/COMMENTARY

For those meeting candidacy criteria, CIs are beneficial at any age. In general, younger age is related to greater benefit when considering pre-lingual deafness. Other factors such as additional disabilities, may mitigate this effect. Post-lingually deafened adults demonstrate similar benefit regardless of age, though the oldest individuals (80+) may see smaller degrees of improvement from preoperative scores. Benefit can be measured in many ways, and the areas of greatest benefit may vary based on age: young children appear to see the greatest effects of age at implantation on language measures, whereas scores on cognitive measures appear to be most impacted for the oldest population. Future research should consider implantation at extreme ages (5-9 months or > 90 years), unconventional measures of CI benefit including qualitative assessments, and longitudinal designs.

Preoperative factors influencing the rate and speed of available communication ability in prelingual paediatric cochlear implantation recipients

BACKGROUND

Few studies have assessed factors influencing the rate and speed of good outcomes in cochlear implantation (CI) children.

OBJECTIVE

To analyse the factors influencing the rate and speed of available communication in CI children.

MATERIAL AND METHODS

The study involved 316 children. The categories of auditory performance (CAP) and speech intelligibility rating (SIR) were used to evaluate outcomes. Multivariable proportional Cox regression models were established to analyse the effect of preoperative factors.

RESULTS

Five variables were entered into the three multivariable models of CAP ≥6, SIR ≥4 and concurrent CAP ≥6 and SIR ≥4. Older age at implantation was a significant poor factor in the three models with estimated hazard ratios (HRs) of .541, .629, and .554, respectively. Another negative factor was poor parental literacy for the three outcomes (HR .639, .638, and .542, respectively). More than 3 months of rehabilitation from institutes had a positive effect on CAP ≥6 and concurrent CAP ≥6 and SIR ≥4 (HR 1.626 and 1.667, respectively).

CONCLUSIONS AND SIGNIFICANCE

Older age at implantation and poor parental literacy were negative factors. Receiving regular rehabilitation from institutes pre-CI could help the children gain available communication ability earlier on.

Simultaneous Bilateral Cochlear Implantation in Very Young Children Improves Adaptability and Social Skills: A Prospective Cohort Study

OBJECTIVES

To investigate the value of using the Gesell Development Diagnosis Scale (GDDS) to predict developmental outcomes in very young children who undergo simultaneous bilateral cochlear implantation.

DESIGN

In this prospective cohort study, a repeated-measures investigation was conducted in a tertiary referral hospital. A total of 62 children receiving simultaneous bilateral cochlear implantations were enrolled from April 2017 to August 2018. They were divided into 2 groups depending on the operative age: "Infants" group (6 to 12 months, N = 38) or "Children" group (12 to 36 months, N = 24). Data on the surgical outcomes, auditory development, speech production, and developmental indicators were collected until 2 years after the initial fitting. The primary outcome measure was the GDDS, a neuropsychological development examination. Secondary outcomes included the following: complication rate, aided pure-tone average, Infant-Toddler Meaningful Auditory Integration Scale, Categories of Auditory Performance-II, Meaningful Use of Speech Scale, Speech Intelligibility Rating, and the LittlEARS Auditory Questionnaire.

RESULTS

The mean ages at implantation in infants and children groups were 9.2 ± 1.17 and 16.6 ± 3.60 months, respectively. Significant differences were found in the social skills ( p = 0.001) and adaptability ( p = 0.031) domains of GDDS. The younger the age of bilateral cochlear implants surgery, the higher developmental quotient of language, social skills, and adaptability the child could achieve after 2 years. The complication rates in the infants and children groups were 0% versus 2.1% ( p = 0.57). There was no surgical complication in the infants group. In the children group, 1 case with enlarged vestibular aqueduct and Mondini malformation had a receiver-implant misplacement on the right side (2%, 1/48). In the two groups, auditory performance and speech production had improved similarly. In the infants group, social skills developmental quotient at baseline had a significant positive relationship with Meaningful Use of Speech Scale after 2 years.

CONCLUSIONS

Simultaneous bilateral cochlear implantation in younger children improves adaptability and social skills. GDDS is a sensitive tool of evaluating short-term effect of bilateral cochlear implants in neuropsychological development and constitutes a reliable predictor of speech production for the very younger pediatric cochlear implant users.

The feasibility of cochlear implantation in early infancy

OBJECTIVES

To determine the key image anatomical parameters that are relevant to cochlear implantation (CI) using temporal bone high-resolution computed tomography (HRCT) scans and to identify age group differences in order to provide image anatomical support for early CI.

METHODS

The data of 346 temporal bone HRCTs of 173 children from 5 months to 18 years of age were retrospectively selected and reviewed. Parameters of the human temporal bone that are relevant to CI key surgical steps include mastoid thickness (MT), the facial recess width (FRW), and an angle representing the round window visibility. All measurements are performed on axial images.

RESULTS

There was no significant difference in the above morphological values by gender (p > 0,05). Two-sided FRW was not significantly different (p > 0,05), but MT and angle A were significantly different (p < 0,001). FRW and angle were independent of age (p > 0,05). However, MT had been found to exhibit postnatal development. The linear function of MT were calculated as y = 2463 × group(s) + 20,574 (p < 0,001).

CONCLUSIONS

Based on preoperative imaging analysis at different ages, middle ear development was stable at 5 months of age, allowing early CI in infancy with severe to severe hearing loss at this age. These data must be considered exploratory and more extensive clinical studies are needed.

Spectrotemporal Modulation Discrimination in Infants With Normal Hearing

OBJECTIVES

Spectral resolution correlates with speech understanding in post-lingually deafened adults with cochlear implants (CIs) and is proposed as a non-linguistic measure of device efficacy in implanted infants. However, spectral resolution develops gradually through adolescence regardless of hearing status. Spectral resolution relies on two different factors that mature at markedly different rates: Resolution of ripple peaks (frequency resolution) matures during infancy whereas sensitivity to across-spectrum intensity modulation (spectral modulation sensitivity) matures by age 12. Investigation of spectral resolution as a clinical measure for implanted infants requires understanding how each factor develops and constrains speech understanding with a CI. This study addresses the limitations of the present literature. First, the paucity of relevant data requires replication and generalization across measures of spectral resolution. Second, criticism that previously used measures of spectral resolution may reflect non-spectral cues needs to be addressed. Third, rigorous behavioral measurement of spectral resolution in individual infants is limited by attrition. To address these limitations, we measured discrimination of spectrally modulated, or rippled, sounds at two modulation depths in normal hearing (NH) infants and adults. Non-spectral cues were limited by constructing stimuli with spectral envelopes that change in phase across time. Pilot testing suggested that dynamic spectral envelope stimuli appeared to hold infants' attention and lengthen habituation time relative to previously used static ripple stimuli. A post-hoc condition was added to ensure that the stimulus noise carrier was not obscuring age differences in spectral resolution. The degree of improvement in discrimination at higher ripple depth represents spectral frequency resolution independent of the overall threshold. It was hypothesized that adults would have better thresholds than infants but both groups would show similar effects of modulation depth.

DESIGN

Participants were 53 6- to 7-month-old infants and 23 adults with NH with no risk factors for hearing loss who passed bilateral otoacoustic emissions screening. Stimuli were created from complexes with 33- or 100-tones per octave, amplitude-modulated across frequency and time with constant 5 Hz envelope phase-drift and spectral ripple density from 1 to 20 ripples per octave (RPO). An observer-based, single-interval procedure measured the highest RPO (1 to 19) a listener could discriminate from a 20 RPO stimulus. Age-group and stimulus pure-tone complex were between-subjects variables whereas modulation depth (10 or 20 dB) was within-subjects. Linear-mixed model analysis was used to test for the significance of the main effects and interactions.

RESULTS

All adults and 94% of infants provided ripple density thresholds at both modulation depths. The upper range of threshold approached 17 RPO with the 100-tones/octave carrier and 20 dB depth condition. As expected, mean threshold was significantly better with the 100-tones/octave compared with the 33-tones/octave complex, better in adults than in infants, and better at 20 dB than 10 dB modulation depth. None of the interactions reached significance, suggesting that the effect of modulation depth on the threshold was not different for infants or adults.

CONCLUSIONS

Spectral ripple discrimination can be measured in infants with minimal listener attrition using dynamic ripple stimuli. Results are consistent with previous findings that spectral resolution is immature in infancy due to immature spectral modulation sensitivity rather than frequency resolution.

Translation, adaptation, and validation of the Arabic version of the meaningful auditory integration scale

OBJECTIVES

The main objectives of this study were to translate and adapt the infant-toddler meaningful integration scale (IT-MAIS) into Arabic and to establish the psychometric properties of the translated scale in children with a cochlear implant.

METHODS

The translation and cross-cultural adaptation of this questionnaire were completed in multiple steps and following standard translation protocols. In total, twenty-eight parents of young cochlear implant recipients completed IT-MAIS. Data were collected postoperatively and at 3-, 6-, 9-, and 12-month post-device activation. Data were examined for the validity and reliability of the scale. The internal consistency and reliability of the scale were analyzed using Cronbach α, split-half reliability, and the corrected item-total correlation coefficients.

RESULTS

Findings demonstrated that the scale exhibited good face and content validity, suggesting that the scale is a one-dimensional measure. Additionally, the reliability analysis for the scale indicated high reliability and correlation among test items. IT-MAIS scores consistently improved over time for all participants and this improvement. correlated negatively with the duration of deafness.

CONCLUSION

Current findings indicated that the translated Arabic version of the IT-MAIS scale could serve as a valid instrument for assessing the development of auditory skills in Arabic-speaking children with cochlear implants.

Task force Guideline of Brazilian Society of Otology - hearing loss in children - Part II - Treatment

OBJECTIVES

To provide an overview of the main evidence-based recommendations for the diagnosis of hearing loss in children and adolescents aged 0-18 years.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on childhood hearing loss were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) treatment of sensorineural hearing loss: individual hearing aids, bilateral cochlear implants, cochlear implants in young children, unilateral hearing loss, and auditory neuropathy spectrum disorder; and (2) treatment of conductive/mixed hearing loss: external/middle ear malformations, ventilation tube insertion, and tympanoplasty in children.

CONCLUSIONS

In children with hearing loss, in addition to speech therapy, Hearing AIDS (HAs) or implantable systems may be indicated. Even in children with profound hearing loss, both the use of HAs and behavioral assessments while using the device are important.

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.

A Retrospective Evaluation to Assess Reliability of Electrophysiological Methods for Diagnosis of Hearing Loss in Infants

Background: An electrophysiological investigation with auditory brainstem response (ABR), round window electrocochleography (RW-ECoG), and electrical-ABR (E-ABR) was performed in children with suspected hearing loss with the purpose of early diagnosis and treatment. The effectiveness of the electrophysiological measures as diagnostic tools was assessed in this study. Methods: In this retrospective case series with chart review, 790 children below 3 years of age with suspected profound hearing loss were tested with impedance audiometry and underwent electrophysiological investigation (ABR, RW-ECoG, and E-ABR). All implanted cases underwent pure-tone audiometry (PTA) of the non-implanted ear at least 5 years after surgery for a long-term assessment of the reliability of the protocol. Results: Two hundred and fourteen children showed bilateral severe-to-profound hearing loss. In 56 children with either ABR thresholds between 70 and 90 dB nHL or no response, RW-ECoG showed thresholds below 70 dB nHL. In the 21 infants with bilateral profound sensorineural hearing loss receiving a unilateral cochlear implant, no statistically significant differences were found in auditory thresholds in the non-implanted ear between electrophysiological measures and PTA at the last follow-up (p > 0.05). Eight implanted children showed residual hearing below 2000 Hz worse than 100 dB nHL and 2 children showed pantonal residual hearing worse than 100 dB nHL (p > 0.05). Conclusion: The audiological evaluation of infants with a comprehensive protocol is highly reliable. RW-ECoG provided a better definition of hearing thresholds, while E-ABR added useful information in cases of auditory nerve deficiency.

Two Bonebridge bone conduction hearing implant generations: audiological benefit and quality of hearing in children

PURPOSE

The study aimed to evaluate audiological benefits, quality of hearing and safety of two Bonebridge generation: BCI601 and BCI602 (MED-EL, Innsbruck, Austria) in children.

METHODS

Twelve children were implanted: five BCI601 and seven BCI602 comprising of ten conductive hearing loss, and two single sided deaf SSD subjects. Audiological outcomes tested were sound field audiometry, functional gain, speech recognition threshold (SRT50), speech recognition in noise (SPRINT) and localisation abilities. Subjective measures were Speech, Spatial and Qualities of Hearing Scale (SSQ12).

RESULTS

The mean FG with the BCI601 was 25.0 dB and with the BCI602 28.0 dB. The benefit in SRT50 was 23.2 dB and 33.8 dB, respectively. The mean benefit in SPRINT was 15% and 6.7% and the localisation ability improved from 33.3° to 16° and from 26.2° to 17.6°, respectively. The two SSD subjects reported a FG of 17 dB, a benefit in SRT50 of 22.5 and a benefit in SPRINT of 20%. Subjective outcomes improved significantly and even exceeded the values of their age-and sex matched normal hearing peers. One revision was reported: a retroauricular emphysema above the implant occurred 12 months post-OP, it was resolved operatively with the implant still being functional.

CONCLUSION

The pediatric cohort reports significant audiological benefit, even exceeding that of the age- and sex matched control. The combination of the high safety and audiological benefit makes the Bonebridge a comfortable and effective option in hearing rehabilitation in children.

American Cochlear Implant Alliance Task Force Guidelines for Determining Cochlear Implant Candidacy in Children

This article summarizes the available evidence on pediatric cochlear implantation to provide current guidelines for clinical protocols and candidacy recommendations in the United States. Candidacy determination involves specification of audiologic and medical criteria per guidelines of the Food and Drug Administration. However, recommendations for a cochlear implant evaluation also should maintain flexibility and consider a child’s skill progression (i.e., month-for-month progress in speech, language, and auditory development) and quality of life with appropriately fit hearing aids. Moreover, evidence supports medical and clinical decisions based on other factors, including (a) ear-specific performance, which affords inclusion of children with asymmetric hearing loss and single-sided deafness as implant candidates; (b) ear-specific residual hearing, which influences surgical technique and device selection to optimize hearing; and (c) early intervention to minimize negative long-term effects on communication and quality of life related to delayed identification of implant candidacy, later age at implantation, and/or limited commitment to an audiologic rehabilitation program. These evidence-based guidelines for current clinical protocols in determining pediatric cochlear implant candidacy encourage a team-based approach focused on the whole child and the family system.

Speech production in Mandarin-speaking children with cochlear implants: a systematic review

OBJECTIVE

This study aimed to systematically review and critically appraise the literature describing the phonetic characteristics and accuracy of the consonants, vowels and tones produced by Mandarin-speaking children with cochlear implants (CIs).

DESIGN

The protocol in this review was designed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. EBSCOhost, PubMed, Scopus, PsycINFO, ProQuest Central databases were searched for relevant articles which met the inclusion criteria.

STUDY SAMPLE

A total of 18 journal papers were included in this review.

RESULTS

The results revealed that Mandarin-speaking children with CIs perform consistently more poorly in their production of consonants, in particular on fricatives, have a smaller and less well-defined vowel space, and exhibit greater difficulties in tone realisation, notably T2 and T3, when compared to their normal-hearing (NH) peers. The results from acoustic and accuracy analyses are negatively correlated with CI implantation age, but largely positively correlated with hearing age.

CONCLUSIONS

Findings of this review highlight the factors that influence consonant, vowel and tone production in Mandarin-speaking children with CIs, thereby providing critical information for clinicians and researchers working with this population.

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.

Children with hearing impairment and early cochlear implant: A pragmatic assessment

Extensive research has demonstrated the benefits of cochlear implants (CI) in contributing to improve the linguistic skills of children with hearing impairment; however, few studies have focused on the development of pragmatic ability and its relationship with age of implantation. Pragmatics is the ability to use language in different contexts and its development has crucial implications, e.g., social inclusion and professional attainments. In this study, we conducted a comprehensive assessment of pragmatic ability using the Language Pragmatic Abilities (APL Medea), a battery composed by five different tasks: Comprehension of Metaphors, Implicit meaning, Comics, Situations and Colors Game (a perspective taking task). Eighteen children with early CI, belonging to 3 different age groups (6; 11-7; 11, 8; 0-8; 11 and 9; 0-9; 11 years-old), and twenty-four children with typical development (Control Group) participated to the study. We also investigated how the precocity of CI, i.e., age of first implantation, may affect the pragmatic development. Globally, children with CI obtained lower scores in the APL Medea battery than typically hearing children. However, focusing on the Medea tasks separately, children with CIs differed from their hearing peers only in Comics and Colors Game tasks. Finally, age of implantation was a moderate but significant predictor of pragmatic performance.

Frühe Prädiktoren der Sprachentwicklung von Kindern mit permanenter Hörstörung

Zusammenfassung. Theoretischer Hintergrund: Sprachentwicklungsverläufe bei Kindern mit Hörstörungen zeigen eine hohe und überwiegend ungeklärte Varianz. Fragestellung und Methode: Unsere Übersichtsarbeit präsentiert aktuelle Evidenz zu frühen Prädiktoren der Sprachentwicklung. Ergebnisse und Diskussion: Trotz deutlicher positiver Trends erreicht nur jedes zweite Kind ein Sprachentwicklungsniveau im Normbereich. Der Literaturüberblick ergibt signifikante kindbezogene und familiäre Prädiktoren mit eher geringer Beeinflussbarkeit. Als hoch prädiktiv für sprachliche Ergebnisse und zudem der Intervention zugänglich erweisen sich die frühe Erkennung und technische Versorgung mit Hörgeräten oder -implantaten und Aufnahme in die Frühförderung, konsistente Hörtechnikverwendung und/oder früher Zugang zur Gebärdensprache. Zudem zeigt sich die Qualität der täglichen Eltern-Kind-Interaktion als hocheffektiv für die Sprachentwicklung. Schlussfolgerung: Es bestätigt sich die Wirksamkeit aktueller Best Practice früher Erkennung, Versorgung und familienzentrierter Frühförderung.

JT, Waltzman SB. Cochlear Implantation in Infants: Evidence of Safety

The aim of this study was to investigate surgical, anesthetic, and device-related complications associated with cochlear implantation (CI) in children younger than 1 year of age. This was a multicenter, retrospective chart review of all children with severe-to-profound sensorineural hearing loss who underwent cochlear implantation with a Cochlear Nucleus Implant System before 1 year of age. Endpoints included perioperative course, major and minor surgical, anesthetic and device-related complications, and 30-day readmission rates. One hundred thirty-six infants (242 ears) met criteria. The mean age at implantation was 9.4 months (standard deviation 1.8). Six-month follow-up was reported in all patients. There were no major anesthetic or device-related complications. Adverse events were reported in 34 of implanted ears (14%; 7 major, 27 minor). Sixteen adverse events occurred ≤30 days of surgery, and 18 occurred >30 days of surgery. The 30-day readmission rate was 1.5%. The rate of adverse events did not correlate with preexisting medical comorbidities or duration under anesthesia. There was no significant difference detected in complication rate for patients younger than 9 months of age versus those 9 to 11 months of age. This study demonstrates the safety of CI surgery in infants and supports reducing the indication for cochlear implantation to younger than 1 year of age for children with bilateral, profound sensorineural hearing loss obtaining a Cochlear Nucleus Implant System.

Evolving Criteria for Adult and Pediatric Cochlear Implantation

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

Safety and Effectiveness of Cochlear Implantation of Young Children, Including Those With Complicating Conditions

OBJECTIVE

Determine safety and effectiveness of cochlear implantation of children under age 37 months, including below age 12 months.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care children's medical center.

PATIENTS

219 children implanted before age 37 mos; 39 implanted below age 12 mos and 180 ages 12-36 mos. Mean age CI = 20.9 mos overall; 9.4 mos (5.9-11.8) and 23.4 mos (12.1-36.8) for the two age groups, respectively. All but two ≤12 mos (94.9%) received bilateral implants as did 70.5% of older group. Mean follow-up = 5.8 yrs; age last follow-up = 7.5 yrs, with no difference between groups.

INTERVENTIONS

Cochlear implantation.

MAIN OUTCOME MEASURES

Surgical and anesthesia complications, measurable open-set speech discrimination, primary communication mode(s).

RESULTS

Few surgical complications occurred, with no difference by age group. No major anesthetic morbidity occurred, with no critical events requiring intervention in the younger group while 4 older children experienced desaturations or bradycardia/hypotension. Children implanted under 12 mos developed open-set earlier (3.3 yrs vs 4.3 yrs, p ≤ 0.001) and were more likely to develop oral-only communication (88.2% vs 48.8%, p ≤ 0.001). A significant decline in rate of oral-only communication was present if implanted over 24 months, especially when comparing children with and without additional conditions associated with language delay (8.3% and 35%, respectively).

CONCLUSIONS

Implantation of children under 37 months of age can be done safely, including those below age 12 mos. Implantation below 12 mos is positively associated with earlier open-set ability and oral-only communication. Children implanted after age 24 months were much less likely to use oral communication exclusively, especially those with complex medical history or additional conditions associated with language delay.

Long-term Outcomes in Down Syndrome Children After Cochlear Implantation: Particular Issues and Considerations

OBJECTIVE

The aim of the study was to analyze the long-term outcomes after cochlear implantation in deaf children with Down syndrome (DS) regarding age at the first implantation and refer the results to preoperative radiological findings as well as postoperative auditory and speech performance. Additionally, the influence of the age at implantation and duration of CI use on postoperative hearing and language skills were closely analyzed in children with DS.

STUDY DESIGN

Retrospective analysis.

SETTING

Referral center (Cochlear Implant Center).

MATERIALS AND METHODS

Nine children with Down syndrome were compared with 220 pediatric patients without additional mental disorders or genetic mutations. Patients were divided into four categories depending on the age of the first implantation: CAT1 (0-3 yr), CAT2 (4-5 yr), CAT3 (6-7 yr), and CAT4 (8-17 yr). The auditory performance was assessed with the meaningful auditory integration scales (MAIS) and categories of auditory performance (CAP) scales. The speech and language development were further evaluated with meaningful use of speech scale (MUSS) and speech intelligibility rating (SIR). The postoperative speech skills were analyzed and compared between the study group and the reference group by using nonparametric statistical tests. Anatomic abnormalities of the inner ear were examined using magnetic resonance imaging (MRI) and high-resolution computed tomography of the temporal bones (HRCT).

RESULTS

The mean follow-up time was 14.9 years (range, 13.1-18.3 yr). Patients with DS received a multichannel implant at a mean age of 75.3 months (SD 27.9; ranging from 21 to 127 mo) and 220 non-syndromic children from reference group at a mean age of 51.4 months (SD 34.2; ranging from 9 to 167 mo). The intraoperative neural response was present in all cases. The auditory and speech performance improved in each DS child. The postoperative mean CAP and SIR scores were 4.4 (SD 0.8) and 3.2 (SD 0.6), respectively. The average of scores in MUSS and MAIS/IT-MAIS scales was 59.8% (SD 0.1) and 76.9% (SD 0.1), respectively. Gathered data indicates that children with DS implanted with CI at a younger age (<6 years of age) benefited from the CI more than children implanted later in life, similarly in a control group. There were additional anomalies of the temporal bone, external, middle, or inner ear observed in 90% of DS children, basing on MRI or HRCT.

CONCLUSIONS

The early cochlear implantation in children with DS is a similarly useful method in treating severe to profound sensorineural hearing loss (SNHL) as in non-syndromic patients, although the development of speech skills present differently. Due to a higher prevalence of ear and temporal bone malformations, detailed diagnostic imaging should be taken into account before the CI qualification. Better postoperative outcomes may be achieved through comprehensive care from parents/guardians and speech therapists thanks to intensive and systematic rehabilitation.

Morphological Accuracy in the Speech of Bimodal Bilingual Children with CIs

Sign language use in the (re)habilitation of children with cochlear implants (CIs) remains a controversial issue. Concerns that signing impedes spoken language development are based on research comparing children exposed to spoken and signed language (bilinguals) to children exposed only to speech (monolinguals), although abundant research demonstrates that bilinguals and monolinguals differ in language development. We control for bilingualism effects by comparing bimodal bilingual (signing-speaking) children with CIs (BB-CI) to those with typical hearing (BB-TH). Each child had at least one Deaf parent and was exposed to ASL from birth. The BB-THs were exposed to English from birth by hearing family members, while the BB-CIs began English exposure after cochlear implantation around 22-months-of-age. Elicited speech samples were analyzed for accuracy of English grammatical morpheme production. Although there was a trend toward lower overall accuracy in the BB-CIs, this seemed driven by increased omission of the plural -s, suggesting an exaggerated role of perceptual salience in this group. Errors of commission were rare in both groups. Because both groups were bimodal bilinguals, trends toward group differences were likely caused by delayed exposure to spoken language or hearing through a CI, rather than sign language exposure.

Relationship Between Objective and Behavioral Audiology for Young Children Being Assessed for Cochlear Implantation: Implications for CI Candidacy Assessment

OBJECTIVE

This study aimed to evaluate the feasibility of making cochlear implant recommendations based on diagnostic ABR and ASSR results. The goal was to challenge the need for behavioral audiometry as part of the standard cochlear implant assessment battery for infants with profound hearing loss and to reduce the age at which cochlear implant recommendation was made.

STUDY DESIGN

A retrospective review of 123 patient files for children referred to the pediatric cochlear implant service before 3 years of age over a 3-year period was undertaken. Results for click-ABR, ASSR, and behavioral audiology at 500, 1k, 2k and 4k Hz, and tympanometry were collected and relationships were investigated for 64 children who met the inclusion criteria. Data were excluded for 59 children due to the presence of auditory neuropathy findings, middle ear pathology at the time of testing, if ASSR was not assessed at intensity levels >85 dB, and/or behavioral testing was judged to be unreliable by two experienced clinicians.

SETTING

Primary care pediatric cochlear implant program located within a hospital setting.

PATIENTS

Pediatric patients referred for cochlear implant evaluation before 3 years of age.

INTERVENTIONS(S)

Children were assessed using ABR, ASSR, and behavioral audiometry for identification and confirmation of hearing loss.

MAIN OUTCOME MEASURES(S)

Correlation between diagnostic click-ABR and ASSR thresholds and subsequently obtained behavioral hearing thresholds.

RESULTS

Results for objective measures (click-ABR and ASSR) were significantly correlated with behavioral results. The correlations, however, were poorer than expected with limited predictive value. For 6 of the 64 children click-ABR and/or ASSR suggested profound hearing loss and corresponding behavioral hearing threshold was found to be in the severe hearing loss range.

CONCLUSIONS

Findings of this study do not support making cochlear implant recommendations based on the findings of diagnostic click-ABR and ASSR alone. Investigating ways to reduce the average age children with severe-to-profound hearing loss receive a cochlear implant is a priority for the study institution. An alternate evaluation pathway for infants which incorporates a multifaceted assessment is warranted and will be the focus of future work at the study institution.

Cochlear Implantation for Children and Adults with Severe-to-Profound Hearing Loss

Cochlear implants (CIs) have proven to be a useful treatment option for individuals with severe-to-profound hearing loss by providing improved access to one's surrounding auditory environment. CIs differ from traditional acoustic amplification by providing information to the auditory system via electrical stimulation. Both postlingually deafened adults and prelingually deafened children can benefit from a CI; however, outcomes with a CI can vary. Numerous factors can impact performance outcomes with a CI. It is important for the audiologist to understand what factors might play a role and impact performance outcomes with a CI so that they can effectively counsel the recipient and their family, as well as establish appropriate and realistic expectations with a CI. This review article will discuss the CI candidacy process, CI programming and postoperative follow-up care, as well as considerations across the lifespan that may affect performance outcomes with a CI.

The maxillary nerve block for in-office hybrid balloon sinus dilation procedures: A preliminary study

Transitioning of rhinologic procedures from the operating room to the office setting in selected patients is a rising trend. An effective pain-control, patient-preparation protocol is essential, especially with advanced in-office rhinologic procedures such as hybrid balloon sinus dilation (BSD), in which other procedures such as ethmoidectomy, turbinate reduction, and other procedures are concomitantly performed. A regimen using oral sedation, topical tetracaine gel, topical tetracaine/epinephrine-soaked cottonoid packs, and intranasal local infiltrative anesthesia can vary significantly in effectiveness and be suboptimal at times (as determined by using treated patients as historical controls). A modification of this regimen was subsequently used, incorporating the maxillary nerve block, and qualitative differences were then assessed retrospectively between the two regimens. Twenty-five consecutive patients were retrospectively studied who underwent hybrid BSD procedures in the office setting using the maxillary nerve-block regimen modification. All patients underwent BSD of the sphenoid, frontal, and maxillary sinuses with anterior and partial posterior ethmoidectomies. Five patients also underwent septoplasty, and 18 patients underwent inferior turbinate reduction procedures. Twenty-four patients received oral sedation, and all patients received topical tetracaine/epinephrine-soaked cottonoid packs. The topical tetracaine gel was dropped after 5 patients because it was not felt to be needed anymore. No intranasal local infiltrative anesthesia was used. Several qualitative differences were observed after modifying the patient-preparation regimen incorporating the maxillary nerve block. The most important observation seen with this modification was a consistently reproducible, dense anesthesia coverage over the entire nasal cavity with good paranasal sinus coverage. This modification eliminated intranasal bleeding and swelling associated with intranasal local anesthetic injections. No complications were encountered. This preliminary study provides support for use and further evaluation of the maxillary nerve block for in-office rhinologic procedures. If the trend continues to rise in performing advanced in-office rhinologic procedures in selected patients, the maxillary nerve block may find a place in the patient-preparation protocol.

P1 cortical auditory evoked potential in children with unilateral or bilateral cochlear implants; implication for the timing of second cochlear implantation

OBJECTIVE

To examine maturation of the central auditory pathway, using P1 cortical auditory evoked potential (CAEP), in children who had received unilateral or bilateral cochlear implantation (CI).

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral hospital.

METHODS

Twenty children who had received CI due to congenital, or prelingual, deafness participated in the study. Participants had received the 1st implant at a mean age of 3.4 ± 0.7 years; 16 had also received a 2nd CI for the contralateral ear, at a mean age of 11.1 ± 2.1 years. P1 CAEP was recorded while using the 1st implant and, for those who received contralateral CI, within 2 weeks of switching on the 2nd implant. Relations between P1 latency and duration with the 1st implant, and between age at 1st CI and P1 latency, were investigated. Relations between P1 latency with the 1st and 2nd implants, and between the interstage interval and difference between P1 latencies with the 1st and 2nd implants, were also examined.

RESULTS

P1 CAEP with the 1st implant was present in 16 of the 20 children. Mean P1 latency was shorter in the early CI group compared with the late CI group, but this difference was not statistically significant (p = 0.154). There was a significant negative correlation between the duration with the 1st implant and P1 latency (r = - 0.783, p < 0.001). Among the 16 children with sequential bilateral CI, P1 CAEP with the 2nd implant was present in 10. There was a significant negative correlation between the duration with the 1st implant before receiving the 2nd implant and P1 latency with the 2nd implant (r = - 0.710, p = 0.021); there was also a significant positive correlation between P1 latency with the 1st and 2nd implants (r = 0.722, p = 0.018). There was not a significant correlation between interstage interval and the difference between the two P1 latencies (r = - 0.430, p = 0.248).

CONCLUSION

Longer cochlear implant use is associated with shorter P1 latency. Unilateral hearing with the 1st implant may positively affect P1 latency with the 2nd CI ear. These findings imply that increased auditory experience may influence central auditory pathway maturation and that the degree of central auditory pathway maturation before the 2nd CI, rather than the timing when the surgery is received, may influence 2nd CI outcome in children with sequential bilateral cochlear implants.

Language development in the pediatric cochlear implant patient

Objective

To access the long-term outcomes of children implanted during most sensitive period for language development.

Study design

Literature review.

Method

An initial PubMed search was carried out using the search terms language development and cochlear implant resulted in 1149 citations. A second search was carried out on the initial citations using the criterion of implantation in the period of birth to 24 months, which identified 386 articles. These were analyzed to determine those studies in which linguistic outcome was measured at least three or more years following implantation.

Results

Twenty-one reports published from 2004 to 2017 that met the criteria. The range of follow-up was from 3 years to an excess of 10 years. Four => 10-year follow-up reports were consistent in showing that the earlier the subject is implanted the better the outcome. Many, but not all, of these children did obtain age-appropriate language. There were 17 reports with follow-up from 3 to less than 10 years. In 7 of the 11 studies, the children's expressive language was reported to have reached an age level of less than 80%. The results for receptive language showed that 4 of the 11 studies found that the children achieved a receptive language age level of less than 80%. There were 8 studies which documented the effect of implantation before 12 months of age and between 12 and 24 months of age and they all found that the earlier the implantation, the better the outcome for language.

Conclusion

The cochlear implant is efficacious in the amelioration of receptive and expressive language deficits in most congenitally deafened children implanted before the age of one. The language outcomes for those implanted after the age of one decline as the age of implantation increases.

Level of Evidence

N/A.

Consonant and Vowel Identification in Cochlear Implant Users Measured by Nonsense Words: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this systematic review and meta-analysis was to establish a baseline of the vowel and consonant identification scores in prelingually and postlingually deaf users of multichannel cochlear implants (CIs) tested with consonant-vowel-consonant and vowel-consonant-vowel nonsense syllables.

METHOD

Six electronic databases were searched for peer-reviewed articles reporting consonant and vowel identification scores in CI users measured by nonsense words. Relevant studies were independently assessed and screened by 2 reviewers. Consonant and vowel identification scores were presented in forest plots and compared between studies in a meta-analysis.

RESULTS

Forty-seven articles with 50 studies, including 647 participants, thereof 581 postlingually deaf and 66 prelingually deaf, met the inclusion criteria of this study. The mean performance on vowel identification tasks for the postlingually deaf CI users was 76.8% (N = 5), which was higher than the mean performance for the prelingually deaf CI users (67.7%; N = 1). The mean performance on consonant identification tasks for the postlingually deaf CI users was higher (58.4%; N = 44) than for the prelingually deaf CI users (46.7%; N = 6). The most common consonant confusions were found between those with same manner of articulation (/k/ as /t/, /m/ as /n/, and /p/ as /t/).

CONCLUSIONS

The mean performance on consonant identification tasks for the prelingually and postlingually deaf CI users was found. There were no statistically significant differences between the scores for prelingually and postlingually deaf CI users. The consonants that were incorrectly identified were typically confused with other consonants with the same acoustic properties, namely, voicing, duration, nasality, and silent gaps. A univariate metaregression model, although not statistically significant, indicated that duration of implant use in postlingually deaf adults predict a substantial portion of their consonant identification ability. As there is no ceiling effect, a nonsense syllable identification test may be a useful addition to the standard test battery in audiology clinics when assessing the speech perception of CI users.

Medical and bioethical considerations in elective cochlear implant array removal

OBJECTIVE

Cochlear explantation for purely elective (e.g. psychological and emotional) reasons is not well studied. Herein, we aim to provide data and expert commentary about elective cochlear implant (CI) removal that may help to guide clinical decision-making and formulate guidelines related to CI explantation.

DATA SOURCES

We address these objectives via three approaches: case report of a patient who desired elective CI removal; review of literature and expert discussion by surgeon, audiologist, bioethicist, CI user and member of Deaf community.

REVIEW METHODS

A systematic review using three scientific online databases was performed. Included articles addressed the benefits and/or complications of cochlear implantation in young children, CI explantation with or without revision surgery and the ethical debate between the medical and Deaf communities on cochlear implantation and explantation.

CONCLUSIONS

The medical and audiological perspectives identify a host of risks related to implant removal without reimplantation, including risk from surgery, general anaesthesia, cochlear ossification and poor audiometric outcomes. The member of the deaf community and bioethicist argue that physicians need to guide the principles of beneficence, non-maleficence and patient autonomy. Taken together, patient desires should be seen as paramount, if the patient is otherwise fit for surgery and well informed.

IMPLICATIONS FOR PRACTICE

Similar to the case of device implantation, device explantation should be a multidisciplinary and collaborative decision with the patient and the family's desires at the centre. While every case is different, we offer a CI explantation discussion to assist in clinical decision-making, patient counselling and education.

Assessment of early language development in Turkish children with a cochlear implant using the TEDIL test

OBJECTIVES

To analyse language development of children with a cochlear implant (CI) in relation to length of CI use and age at implantation and to examine the suitability of the TEDIL as an assessment tool for measuring early language development in Turkish children.

METHODS

A total of 119 children implanted with a CI before 5 years of age were assessed acutely on sound field thresholds, speech recognition thresholds, open-set and closed-set monosyllabic word tests, the TEDIL, categories of auditory performance (CAP), and speech intelligibility rating (SIR). The outcome scores were analysed in relation to length of CI use (3, 4, and 5 years) and age at implantation (<24 months vs. >24 months). The TEDIL scores were compared to all other outcome measures.

RESULTS

Scores significantly increased with CI experience. CAP and SIR were significantly higher in the younger implanted group. No significant difference was observed between the younger and older implanted group on the closed-set and open-set monosyllabic tests and the TEDIL. The TEDIL scores significantly correlated with CAP, SIR, and the closed-set and open-set word scores. The mean TEDIL standard score was close to average.

CONCLUSIONS

Performance of CI users improves with increased CI experience. CI users implanted <24 months tend to have better auditory skills and clearer speech than CI users implanted >24 months. CI users implanted between 24 months and 60 months tend to develop language similarly to CI users implanted <24 months. The TEDIL is a suitable tool for assessing early receptive and expressive language development in Turkish children.

Validation of a Cochlear Implant Patient-Specific Model of the Voltage Distribution in a Clinical Setting

Cochlear Implants (CIs) are medical implantable devices that can restore the sense of hearing in people with profound hearing loss. Clinical trials assessing speech intelligibility in CI users have found large intersubject variability. One possibility to explain the variability is the individual differences in the interface created between electrodes of the CI and the auditory nerve. In order to understand the variability, models of the voltage distribution of the electrically stimulated cochlea may be useful. With this purpose in mind, we developed a parametric model that can be adapted to each CI user based on landmarks from individual cone beam computed tomography (CBCT) scans of the cochlea before and after implantation. The conductivity values of each cochlea compartment as well as the weighting factors of different grounding modes have also been parameterized. Simulations were performed modeling the cochlea and electrode positions of 12 CI users. Three models were compared with different levels of detail: a homogeneous model (HM), a non-patient-specific model (NPSM), and a patient-specific model (PSM). The model simulations were compared with voltage distribution measurements obtained from the backward telemetry of the 12 CI users. Results show that the PSM produces the lowest error when predicting individual voltage distributions. Given a patient-specific geometry and electrode positions, we show an example on how to optimize the parameters of the model and how to couple it to an auditory nerve model. The model here presented may help to understand speech performance variability and support the development of new sound coding strategies for CIs.

Using Rasch Analysis to Examine the Item-Level Psychometrics of the Infant-Toddler Meaningful Auditory Integration Scales

The Infant-Toddler Meaningful Auditory Integration Scales (IT-MAIS; Zimmerman-Phillips et al. 2001) is a popular assessment designed to measure listening skills in children with hearing loss aged 0-3 years. For this study we analyzed the item-level psychometric properties of the IT-MAIS via Rasch analysis to gain further understanding about its validity and reliability. We chose to analyze the psychometric properties of the IT-MAIS because very little information exists regarding its development and validation, although it is widely used to assess listening skills in children with SNHL ages 0 to 3 years pre- and post-CI. Our results indicated that the IT-MAIS items demonstrated less than ideal psychometric properties and the IT-MAIS item order did not reflect the order in which children are expected to develop functional listening skills. Our findings suggest that there is a pressing need for further discussion among researchers and clinicians about 1) how the IT-MAIS is used, and 2) what other valid and reliable outcome measures could be used alongside, or in place of, the IT-MAIS to determine CI candidacy, establish treatment goals, or track progress in listening development in very young children with hearing loss.

A Systematic Review to Define the Speech and Language Benefit of Early (<12 Months) Pediatric Cochlear Implantation

Objective: This review aimed to evaluate the additional benefit of pediatric cochlear implantation before 12 months of age considering improved speech and language development and auditory performance. Materials and Methods: We conducted a search in PubMed, EMBASE and CINAHL databases and included studies comparing groups with different ages at implantation and assessing speech perception and speech production, receptive language and/or auditory performance. We included studies with a high directness of evidence (DoE). Results: We retrieved 3,360 articles. Ten studies with a high DoE were included. Four articles with medium DoE were discussed in addition. Six studies compared infants implanted before 12 months with children implanted between 12 and 24 months. Follow-up ranged from 6 months to 9 years. Cochlear implantation before the age of 2 years is beneficial according to one speech perception score (phonetically balanced kindergarten combined with consonant-nucleus-consonant) but not on Glendonald auditory screening procedure scores. Implantation before 12 months resulted in better speech production (diagnostic evaluation of articulation and phonology and infant-toddler meaningful auditory integration scale), auditory performance (Categories of Auditory Performance-II score) and receptive language scores (2 out of 5; Preschool Language Scale combined with oral and written language skills and Peabody Picture Vocabulary Test). Conclusions: The current best evidence lacks level 1 evidence studies and consists mainly of cohort studies with a moderate to high risk of bias. Included studies showed consistent evidence that cochlear implantation should be performed early in life, but evidence is inconsistent on all speech and language outcome measures regarding the additional benefit of implantation before the age of 12 months. Long-term follow-up studies are necessary to provide insight on additional benefits of early pediatric cochlear implantation.

Delayed-onset hearing loss in pediatric candidates for cochlear implantation

The objective of this study was to evaluate the clinical significance of delayed-onset hearing loss in children. Seventy-three children who underwent cochlear implantation (CI) were included. They were divided into a congenital hearing loss group (n = 50) and a delayed-onset hearing loss group (n = 23). The age at diagnosis of hearing loss, age at the beginning of auditory habilitation, the age at CI, and the postimplant speech perception abilities were compared between the two groups. Children in the congenital hearing loss group were confirmed to have hearing loss at a mean age of 0.3 years, and those in the delayed-onset hearing loss group were diagnosed with hearing loss at a mean age of 2.0 years. Auditory habilitation began at a mean age of 0.4 and 2.0 years, and CI was performed at a mean age of 1.4 and 2.6 years, respectively. Children in the congenital hearing loss group had better scores on speech perception tests than those in the delayed-onset hearing loss group, but the differences were not significant. About half of the children with delayed-onset hearing loss (57 %) had risk factors associated with delayed-onset hearing loss. A high prevalence of delayed-onset hearing loss was noted in the group of children who underwent CI. Risk factors for hearing loss were not found in 43 % of children with delayed-onset hearing loss. Universal screening for delayed-onset hearing loss needs to be performed during early childhood.

Results in cochlear implanted children before 5 years of age. a long term follow up

OBJECTIVE

To assess the hearing threshold and linguistic results of cochlear implanted children aged 10 months to 5 years, when they reached the age of 12. We studied the benefits of sequential bilateral implantation.

METHOD AND RESULTS

This is an observational, descriptive, transversal study comprising 57 cochlear implanted subjects. We performed a free field tonal audiometry at 65dB SPL, speech tests and sentences in quiet and noise (SNR+10) tests. The Objective and Criterial Language Battery (BLOC) was used to assess linguistic competence, in its screening version.

RESULTS

Children implanted under the age of 2 and with inter-implant period less than or equal to 4 years reached better statistically significant results in disyllabic and sentences with and without noise (p=0.006) tests and in the disyllabic test with noise (p=0.045) (the hardest speech test). This suggests the acquisition of binaurality, as opposed to children implanted after this age, with inter-implant period longer than 4 years, who do not reach the same performance levels.

RESULTS

of language development in the group implanted at ages 10 months to 2 years are better with respect to implanted children at ages 3-5 (<0.05) in both unilateral and bilateral implanted children in relation to the age of implantation.

CONCLUSION

Children with pre-lingual deafness implanted before the age of 2, when they are 12 years old obtain more benefits in their language development and in their linguistic competence than children implanted after this age. The audiology results are better in children implanted bilaterally under the age of 2.