Early identification and cochlear implantation: critical factors for spoken language development

A systematic review of altered resting-state networks in early deafness and implications for cochlear implantation outcomes

Auditory deprivation following congenital/pre-lingual deafness (C/PD) can drastically affect brain development and its functional organisation. This systematic review intends to extend current knowledge of the impact of C/PD and deafness duration on brain resting-state networks (RSNs), review changes in RSNs and spoken language outcomes post-cochlear implant (CI) and draw conclusions for future research. The systematic literature search followed the PRISMA guideline. Two independent reviewers searched four electronic databases using combined keywords: 'auditory deprivation', 'congenital/prelingual deafness', 'resting-state functional connectivity' (RSFC), 'resting-state fMRI' and 'cochlear implant'. Seventeen studies (16 cross-sectional and one longitudinal) met the inclusion criteria. Using the Crowe Critical Appraisal Tool, the publications' quality was rated between 65.0% and 92.5% (mean: 84.10%), ≥80% in 13 out of 17 studies. A few studies were deficient in sampling and/or ethical considerations. According to the findings, early auditory deprivation results in enhanced RSFC between the auditory network and brain networks involved in non-verbal communication, and high levels of spontaneous neural activity in the auditory cortex before CI are evidence of occupied auditory cortical areas with other sensory modalities (cross-modal plasticity) and sub-optimal CI outcomes. Overall, current evidence supports the idea that moreover intramodal and cross-modal plasticity, the entire brain adaptation following auditory deprivation contributes to spoken language development and compensatory behaviours.

Long Term Impact of Age at Implantation on Quality-of-Life Outcomes in Cochlear Implant Recipient Children

Cochlear implantation (CI) is used in management of children with bilateral severe to profound sensorineural hearing loss (SNHL). Recently, due to technological advancements, more and more infants and toddlers are undertaking the CI. The age at implantation may have an impact on CI outcomes. The primary aim of this study was to determine the long-term impact of 'age at implantation' on Health Related Quality of Life (HRQoL) outcome post-CI. In this prospective study at a tertiary care centre, we evaluated 50 CI recipient children from 2011 to 2018. Group A consisted of 35 (70%) children who received CI at less than or equal to 5 years of age and Group B with 15 (30%) children who underwent CI at more than 5 years of age. Following CI, all children received auditory-verbal therapy and thereafter we evaluated their long-term HRQoL outcomes at 5 years post-CI. Children were assessed by Nijmegen Cochlear Implant Questionnaire (NCIQ) and Children with cochlear implants: parental perspectives-questionnaire (CCIPPQ). There were significantly improved HRQoL outcomes (with an increase of 11.7% in mean NCIQ and 11.4% in mean CCIPPQ scores) at 5 years post-CI in CI recipients of age group '5 years or less' as compared to those who underwent CI at 'more than 5 years' age [P value < 0.05 for both the mean NCIQ scores and mean CCIPPQ scores respectively]. However, for children with 'more than 5 years' age at implantation, mean NCIQ and CCIPPQ scores were still more than 80% of maximum achievable NCIQ and CCIPPQ scores. In this study, CI recipient children who were implanted at less than or equal to 5 years of age were found to have significantly improved HRQoL outcomes at 5 years post-CI. Hence, it seems desirable to provide CI at an early age. However, even in children who received CI at more than 5 years of age, there was a substantial enhancement in HRQoL outcomes and CI was still effective in these children. Hence, knowledge of 'age at implantation' may provide reasonable assistance in predicting the HRQoL outcomes and optimal counseling of parents and families of CI candidates.

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.

Is Early Cochlear Implantation Leads to Better Speech and Language Outcomes?

A cochlear implant is an electronic sensory system that converts mechanical energy into coded electrical signals that directly activate the auditory nerve fibers. Present review article investigates the findings of previous research papers which have assessed speech and language outcome in children who underwent early cochlear implantation. Several databases, including PubMed, Google, Google Scholar, and Medline, were investigated for research papers on the speech and language outcomes of children who had early-life implants. According to previous research, early detection and intervention of hearing loss are critical for the growth of speech and language skills. The effect of early detection of hearing loss and early cochlear implantation on a child's overall speech-language and auditory growth is highlighted in this article.

Language Outcomes in Cochlear Implanted Children with White Matter Disturbances

Introduction:

The present study reviews our experience with children with white matter disturbances and the benefits they get from rehabilitation post cochlear implantation.

Materials and Methods:

It is a retrospective cohort study of 7 cochlear implanted children with white matter disturbances. Preoperatively all the subjects had undergone a complete Audiological test battery for confirmation of hearing thresholds. Post assessment, a digital hearing aid trial was followed by three months’ therapy. Unilateral cochlear implant surgery and monitored auditory-verbal therapy sessions were the next line of treatment for at least one year. The therapist regularly monitored hearing and communication outcomes on an Auditory verbal ongoing scale, revised CAP, MAIS, word, and sentence discrimination scores.

Results:

The age range of Implantation was between 48 to 60 months. 5 out of 7 participants showed remarkable improvement with regular therapy. Their Meaningful Auditory Integration Scale (MAIS) scores were greater than 35 indicating good auditory integration and Categories of Auditory Performance (CAP) revealed scores of even 9 and higher indicating good telephone conversation. Speech Intelligibility Rating (SIR) showed a rating of 4 meaning thereby that an unfamiliar Listener could understand Speech without additional cues. However, all of them reported difficulty perceiving speech in noisy environments. Two cochlear implantees needed speech reading cues in conjunction with the audition.

Conclusion:

Our experience with cochlear Implantation in children with white matter abnormalities has been positive and satisfactory. The presence of white matter abnormalities on MRI should not be a contraindication for Implantation. Successful outcomes can be expected with regular and dedicated auditory-verbal therapy sessions.

Irony Comprehension in Children With Cochlear Implants: The Role of Language Competence, Theory of Mind, and Prosody Recognition

Purpose Aims of this research were (a) to investigate higher order linguistic and cognitive skills of Italian children with cochlear implants (CIs); (b) to correlate them with the comprehension of irony, which has never been systematically studied in this population; and (c) to identify the factors that facilitate the development of this competence. Method We tested 28 Italian children with CI (mean chronological age = 101 [SD = 25.60] months, age range: 60-144 months), and two control groups of normal-hearing (NH) peers matched for chronological age and for hearing age, on a series of tests assessing their cognitive abilities (nonverbal intelligence and theory of mind), linguistic skills (morphosyntax and prosody recognition), and irony comprehension. Results Despite having grammatical abilities in line with the group of NH children matched for hearing age, children with CI lag behind both groups of NH peers on the recognition of emotions through prosody and on the comprehension of ironic stories, even if these two abilities were not related. Conclusions This is the first study that targeted irony comprehension in children with CI, and we found that this competence, which is crucial for maintaining good social relationships with peers, is impaired in this population. In line with other studies, we found a correlation between this ability and advanced theory of mind skills, but at the same time, a deeper investigation is needed, to account for the high variability of performance in children with CI.

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Early pediatric Cochlear implantation: An update

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

The Limits of "Communication Mode" as a Construct

Questions about communication mode (a.k.a. "communication options" or "communication opportunities") remain among the most controversial issues in the many fields that are concerned with the development and well-being of children (and adults) who are d/Deaf or hard of hearing. In this manuscript, we argue that a large part of the reason that this debate persists is due to limitations of the construct itself. We focus on what we term "the crucial question": namely, what kind of experience with linguistic input during infancy and toddlerhood is most likely to result in mastery of at least one language (spoken or signed) by school entry. We argue that the construct of communication mode-as currently construed-actively prevents the discovery of compelling answers to that question. To substantiate our argument, we present a review of a relevant subset of the recent empirical literature and document the prevalence of our concerns. We conclude by articulating the desiderata of an alternative construct that, if appropriately measured, would have the potential to yield answers to what we identify as "the crucial question."

Communication Mode and Speech and Language Outcomes of Young Cochlear Implant Recipients: A Comparison of Auditory-Verbal, Oral Communication, and Total Communication

OBJECTIVE

To evaluate the effect of communication mode on the spoken language outcomes of children who received a cochlear implant.

STUDY DESIGN

Retrospective analysis of postoperative speech and language and reading scores for children who received a cochlear implant and used three different modes of communication: auditory-verbal (AV) (n = 39), oral communication (OC) (n = 107), and total communication (TC) (n = 57).

SETTING

A single tertiary cochlear implant clinic.

PATIENTS

All children received their cochlear implant before the age of 5 years, had no known cochlear anomaly or cognitive delay that would affect their outcome with the CI, and had established consistent use of their respective communication methodology.

INTERVENTION

Rehabilitation varied depending on the selected communication methodology. Data were collected during routine postoperative speech and language evaluations.

MAIN OUTCOME MEASURES

Receptive and expressive language, reading comprehension, and speech intelligibility scores obtained up to 7 years post-activation of a cochlear implant.

RESULTS

All groups showed improvements over time. Linear mixed model analyses indicated scores obtained by children in the AV group were significantly higher than mean scores obtained by children in the other groups on most test measures at most post-implant intervals. Significantly greater numbers of children in the AV group obtained standard scores within normal limits than children in the OC and TC groups.

CONCLUSIONS

These findings support the use of the auditory-verbal communication approach to facilitate development of age-appropriate speech and language and literacy skills in profoundly deaf children.

Effects of Age at Cochlear Implantation on Auditory Outcomes in Cochlear Implant Recipient Children

Cochlear implantation (CI) is used for rehabilitation of children with bilateral severe to profound sensorineural hearing loss. Recently, treatment of such children has been influenced by diagnostic technological advances. Infants and toddlers are now increasingly included for CI. The primary aim of this study was to determine the effects of 'age at CI' on CI outcome. The primary aim of this study was to determine the effects of 'age at CI' on CI outcome. In this prospective study at a tertiary care centre, we evaluated 50 cochlear implanted children from October 2011 to March 2013. The case group consists of 15 (30%) children who underwent CI at more than 5 years of age and control group consisted of 35 (70%) children who underwent CI at less than or equal to 5 years age. All patients received auditory and speech rehabilitation and we evaluated their auditory perception outcomes 1 year post CI, the children were assessed by categories of auditory performance (CAP) and meaningful auditory integration scale (MAIS) tests. There were significantly improved mean auditory perception outcomes (increase of 12.29% in CAP, and 14.05% in MAIS scores) at 1 year post CI in CI recipients of age group '5 years or less' in comparison to those who underwent CI at 'more than 5 years of age'. However, children of 'more than 5 years' age at CI, mean CAP and MAIS scores were still more than 80% of maximum achievable CAP and MAIS scores. In this study, CI recipient children who were implanted at less than or equal to 5 years of age were found to have significantly improved auditory perception outcome at 1 year post CI. Hence, it appears preferable to provide CI early. However, even in children who underwent CI at more than 5 years of age, there was substantial improvement in auditory perception outcomes and CI was still helpful in these children. Hence, knowledge of 'age at CI' can provide reasonable help in predicting the auditory perception outcome and optimal counselling of families of CI candidates.

The power of language: Functional brain network topology of deaf and hearing in relation to sign language experience

Prolonged auditory sensory deprivation leads to brain reorganization. This is indicated by functional enhancement in remaining sensory systems and known as cross-modal plasticity. In this study we investigated differences in functional brain network topology between deaf and hearing individuals. We also studied altered functional network responses between deaf and hearing individuals with a recording paradigm containing an eyes-closed and eyes-open condition. Electroencephalography activity was recorded in a group of sign language-trained deaf (N = 71) and hearing people (N = 122) living in rural Africa. Functional brain networks were constructed from the functional connectivity between fourteen electrodes distributed over the scalp. Functional connectivity was quantified with the phase lag index based on bandpass filtered epochs of brain signal. We studied the functional connectivity between the auditory, somatosensory and visual cortex and performed whole-brain minimum spanning tree analysis to capture network backbone characteristics. Functional connectivity between different regions involved in sensory information processing tended to be stronger in deaf people during the eyes-closed condition in both the alpha and beta frequency band. Furthermore, we found differences in functional backbone topology between deaf and hearing individuals. The backbone topology altered during transition from the eyes-closed to eyes-open condition irrespective of deafness, but was more pronounced in deaf individuals. The transition of backbone strength was different between individuals with congenital, pre-lingual or post-lingual deafness. Functional backbone characteristics correlated with the experience of sign language. Overall, our study revealed more insights in functional network reorganization caused by auditory deprivation and cross-modal plasticity. It further supports the idea of a brain plasticity potential in deaf and hearing people. The association between network organization and acquired sign language experience reflects the ability of ongoing brain adaptation in people with hearing disabilities.

An Analysis of Safety and Adverse Events Following Cochlear Implantation in Children Under 12 Months of Age

OBJECTIVE

To determine perioperative morbidity of children ≤12 months undergoing cochlear implantation (CI).

STUDY DESIGN

Retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Pediatric Database (ACS-NSQIP-P).

SETTING

General acute care children's hospitals, children's hospitals within larger hospitals, specialty children's hospitals, and general acute care hospitals with a pediatric wing.

PATIENTS

Children who underwent CI were queried using the ACS-NSQIP-P from 2012 to 2015.

INTERVENTION

Cochlear implantation.

MAIN OUTCOME MEASURES

Risk factors analyzed include age, prematurity, and presence of congenital disorders. Outcomes analyzed include operative time, length of stay, general surgical complications, readmissions, and related reoperations.

RESULTS

Over the database accrual period, the percentage of children ≤12 months at the time of surgery increased from 2012 to 2015 (6.08-7.78%, p = 0.0752). Total operative time, length of stay (≥1 d), and readmissions for those ≤12 months were significantly greater compared with those >12 months at the time of surgery (p < 0.001, p = 0.0037, and p < 0.0001, respectively). There were no statistically significant differences in general surgical complications (i.e., superficial incisional surgical site infections, organ/space surgical site infections, and/or unplanned reoperations) in cases ≤12 months. Complications specific to CI such as facial nerve paralysis, cerebrospinal fluid leak, and mastoiditis were not recorded in the ACS-NSQIP-P.

CONCLUSION

Infants had no more general surgical complications in the immediate postoperative period compared with older children, although total operative time, length of stay, and readmissions were found to be significantly greater in frequency.

Pediatric Cochlear Implantation: Why Do Children Receive Implants Late?

OBJECTIVES

Early cochlear implantation has been widely promoted for children who derive inadequate benefit from conventional acoustic amplification. Universal newborn hearing screening has led to earlier identification and intervention, including cochlear implantation in much of the world. The purpose of this study was to examine age and time to cochlear implantation and to understand the factors that affected late cochlear implantation in children who received cochlear implants.

DESIGN

In this population-based study, data were examined for all children who underwent cochlear implant surgery in one region of Canada from 2002 to 2013. Clinical characteristics were collected prospectively as part of a larger project examining outcomes from newborn hearing screening. For this study, audiologic details including age and severity of hearing loss at diagnosis, age at cochlear implant candidacy, and age at cochlear implantation were documented. Additional detailed medical chart information was extracted to identify the factors associated with late implantation for children who received cochlear implants more than 12 months after confirmation of hearing loss.

RESULTS

The median age of diagnosis of permanent hearing loss for 187 children was 12.6 (interquartile range: 5.5, 21.7) months, and the age of cochlear implantation over the 12-year period was highly variable with a median age of 36.2 (interquartile range: 21.4, 71.3) months. A total of 118 (63.1%) received their first implant more than 12 months after confirmation of hearing loss. Detailed analysis of clinical profiles for these 118 children revealed that late implantation could be accounted for primarily by progressive hearing loss (52.5%), complex medical conditions (16.9%), family indecision (9.3%), geographical location (5.9%), and other miscellaneous known (6.8%) and unknown factors (8.5%).

CONCLUSIONS

This study confirms that despite the trend toward earlier implantation, a substantial number of children can be expected to receive their first cochlear implant well beyond their first birthday because they do not meet audiologic criteria of severe to profound hearing loss for cochlear implantation at the time of identification of permanent hearing loss. This study underscores the importance of carefully monitoring all children with permanent hearing loss to ensure that optimal intervention including cochlear implantation occurs in a timely manner.

Are Auditory Steady-State Responses Useful to Evaluate Severe-to-Profound Hearing Loss in Children?

Objective. To evaluate Auditory Steady-State Responses (ASSR) at high intensities in pediatric cochlear implant candidates and to compare the results to behavioral tests responses. Methods. This prospective study evaluated 42 children with suspected severe-to-profound hearing loss, aged from 3 to 72 months. All had absent ABR and OAE responses. ASSR were evoked using binaural single frequency stimuli at 110 dB HL with a 10 dB down-seeking procedure. ASSR and behavioral test results were compared. Results. Forty-two subjects completed both ASSR and behavioral evaluation. Eleven children (26.2%) had bilateral responses. Four (9.5%) showed unilateral responses in at least two frequencies, all confirmed by behavioral results. Overall 61 ASSR responses were obtained, most (37.7%) in 500 Hz. Mean thresholds were between 101.3 and 104.2 dB HL. Among 27 subjects with absent ASSR, fifteen had no behavioral responses. Seven subjects showed behavioral responses with absent ASSR responses. No spurious ASSR responses were observed at 100 or 110 dB HL. Conclusion. ASSR is a valuable tool to detect residual hearing. No false-positive ASSR results were observed among 42 children, but in seven cases with absent ASSR, the test underestimated residual hearing as compared to the behavioral responses.

Facilitating Vocabulary Acquisition of Children With Cochlear Implants Using Electronic Storybooks

The present intervention study explored the word learning of 18 children with cochlear implants in response to E-book instruction. Capitalizing on the multimedia options available in electronic storybooks, the intervention incorporated videos and definitions to provide a vocabulary intervention that includes evidence-based teaching strategies. The extent of the children's word learning was assessed using three assessment tasks: receptive pointing, expressively labeling, and word defining. Children demonstrated greater immediate expressive labeling gains and definition generation gains for words taught in the treatment condition compared to those in the comparison condition. In addition, the children's performance on delayed posttest vocabulary assessments indicated better retention across the expressive vocabulary task for words taught within the treatment condition as compared to the comparison condition. Findings suggest that children with cochlear implants with functional speech perception can benefit from an oral-only multimedia-enhanced intensive vocabulary instruction.

Are auditory steady-state responses a good tool prior to pediatric cochlear implantation?

INTRODUCTION

ASSR allow frequency-specific evaluation in intensities up to 120dB HL and detection of residual hearing in patients with severe-to-profound hearing loss.

AIM

to compare ASSR thresholds and behavioral test results in children with suspected severe-to-profound hearing loss.

METHODS

Cross sectional study to compare ASSR and behavioral responses (VRA or audiometry) in 63 pediatric cochlear implant candidates (126 ears) aged between 6 and 72 months. We included children with normal otomicroscopy, absent responses to click-ABR and otoaccoustic emissions. We excluded children with inner ear malformations, auditory neuropathy spectrum disorder or who did not complete VRA or achieve EEG noise<30nV during the ASSR test. Air-conduction ASSR stimuli were continuous sinusoidal tones presented at 0.5, 1, 2 and 4kHz starting at 110dB HL. Behavioral thresholds were acquired with warble tones presented at 0.5, 1, 2 and 4kHz in each ear through insert or head phones at maximum presentation level of 120dB HL.

RESULTS

Behavioral thresholds were obtained in 36.7% (185/504) of all frequencies in all subjects, 9% in intensities >110dB HL. Among 504 ASSR measurements, 53 thresholds were obtained (10.5%). Overall 89.5% of the tested frequencies did not show any response at 110dB HL. Most responses were at 500Hz. Mean differences between behavioral and ASSR thresholds varied from 0.09 to 8.94dB. Twenty-seven comparisons of behavioral and ASSR thresholds were obtained: 12 at 0.5kHz, 9 at 1kHz, 5 at 2kHz and 1 at 4kHz. Absent responses were observed in both tests in 38.1% at 0.5kHz, 52.4% at 1kHz, 74.6% at 2kHz and 81.0% at 4kHz. Specificity was>90% at 1, 2 and 4kHz. In ears with no behavioral response at 120dB HL all ASSR thresholds were in the profound hearing loss range, 90% of them were ≥110dB HL.

CONCLUSION

Among 63 pediatric CI candidates, absent responses to high-intensity ASSR was the major finding (specificity>90%) predicting behavioral thresholds in the profound hearing loss range. These findings can be helpful to confirm the decision for cochlear implantation.

Cochlear Implant Outcomes and Genetic Mutations in Children with Ear and Brain Anomalies

Background. Specific clinical conditions could compromise cochlear implantation outcomes and drastically reduce the chance of an acceptable development of perceptual and linguistic capabilities. These conditions should certainly include the presence of inner ear malformations or brain abnormalities. The aims of this work were to study the diagnostic value of high resolution computed tomography (HRCT) and magnetic resonance imaging (MRI) in children with sensorineural hearing loss who were candidates for cochlear implants and to analyse the anatomic abnormalities of the ear and brain in patients who underwent cochlear implantation. We also analysed the effects of ear malformations and brain anomalies on the CI outcomes, speculating on their potential role in the management of language developmental disorders. Methods. The present study is a retrospective observational review of cochlear implant outcomes among hearing-impaired children who presented ear and/or brain anomalies at neuroimaging investigations with MRI and HRCT. Furthermore, genetic results from molecular genetic investigations (GJB2/GJB6 and, additionally, in selected cases, SLC26A4 or mitochondrial-DNA mutations) on this study group were herein described. Longitudinal and cross-sectional analysis was conducted using statistical tests. Results. Between January 1, 1996 and April 1, 2012, at the ENT-Audiology Department of the University Hospital of Ferrara, 620 cochlear implantations were performed. There were 426 implanted children at the time of the present study (who were <18 years). Among these, 143 patients (64 females and 79 males) presented ear and/or brain anomalies/lesions/malformations at neuroimaging investigations with MRI and HRCT. The age of the main study group (143 implanted children) ranged from 9 months and 16 years (average = 4.4; median = 3.0). Conclusions. Good outcomes with cochlear implants are possible in patients who present with inner ear or brain abnormalities, even if central nervous system anomalies represent a negative prognostic factor that is made worse by the concomitant presence of cochlear malformations. Common cavity and stenosis of the internal auditory canal (less than 2 mm) are negative prognostic factors even if brain lesions are absent.

Cochlear implants in children implanted in Jordan: A parental overview

OBJECTIVE

Exploring the perspective of parents on the cochlear implant process in Jordan.

METHODS

Sixty parents of deaf children were surveyed on the information gathering process prior to cochlear implant surgery, and their implant outcome expectations post-surgery. Whether child or parent characteristics may impact parents' post-surgical expectations was explored.

RESULTS

Although parents used a variety of information sources when considering a cochlear implant, the ear, nose and throat doctor comprised their major source of information (60%). Parents received a range of information prior to cochlear implant but agreed (93.3%) on the need for a multidisciplinary team approach. Post-surgically, parents' expected major developments in the areas of spoken language (97%), and auditory skills (100%). Receiving education in mainstream schools (92%) was expected too. Parents perceived the cochlear implant decision as the best decision they can make for their child (98.3%). A significant correlation was found between parents contentment with the cochlear implant decision and expecting developments in the area of reading and writing (r=0.7). Child's age at implantation and age at hearing loss diagnosis significantly affected parents' post-implant outcome expectations (p<0.05).

CONCLUSION

Despite the general satisfaction from the information quantity and quality prior to cochlear implant, parents agree on the need for a comprehensive multidisciplinary team approach during the different stages of the cochlear implant process. Parents' education about cochlear implants prior to the surgery can affect their post-surgical outcome expectations. The parental perspective presented in this study can help professionals develop better understanding of parents' needs and expectations and henceforth improve their services and support during the different stages of the cochlear implant process.

Cross-modal activation of auditory regions during visuo-spatial working memory in early deafness

Early deafness can reshape deprived auditory regions to enable the processing of signals from the remaining intact sensory modalities. Cross-modal activation has been observed in auditory regions during non-auditory tasks in early deaf subjects. In hearing subjects, visual working memory can evoke activation of the visual cortex, which further contributes to behavioural performance. In early deaf subjects, however, whether and how auditory regions participate in visual working memory remains unclear. We hypothesized that auditory regions may be involved in visual working memory processing and activation of auditory regions may contribute to the superior behavioural performance of early deaf subjects. In this study, 41 early deaf subjects (22 females and 19 males, age range: 20-26 years, age of onset of deafness < 2 years) and 40 age- and gender-matched hearing controls underwent functional magnetic resonance imaging during a visuo-spatial delayed recognition task that consisted of encoding, maintenance and recognition stages. The early deaf subjects exhibited faster reaction times on the spatial working memory task than did the hearing controls. Compared with hearing controls, deaf subjects exhibited increased activation in the superior temporal gyrus bilaterally during the recognition stage. This increased activation amplitude predicted faster and more accurate working memory performance in deaf subjects. Deaf subjects also had increased activation in the superior temporal gyrus bilaterally during the maintenance stage and in the right superior temporal gyrus during the encoding stage. These increased activation amplitude also predicted faster reaction times on the spatial working memory task in deaf subjects. These findings suggest that cross-modal plasticity occurs in auditory association areas in early deaf subjects. These areas are involved in visuo-spatial working memory. Furthermore, amplitudes of cross-modal activation during the maintenance stage were positively correlated with the age of onset of hearing aid use and were negatively correlated with the percentage of lifetime hearing aid use in deaf subjects. These findings suggest that earlier and longer hearing aid use may inhibit cross-modal reorganization in early deaf subjects. Granger causality analysis revealed that, compared to the hearing controls, the deaf subjects had an enhanced net causal flow from the frontal eye field to the superior temporal gyrus. These findings indicate that a top-down mechanism may better account for the cross-modal activation of auditory regions in early deaf subjects.See MacSweeney and Cardin (doi:10/1093/awv197) for a scientific commentary on this article.

Cortical development and neuroplasticity in Auditory Neuropathy Spectrum Disorder

Cortical development is dependent to a large extent on stimulus-driven input. Auditory Neuropathy Spectrum Disorder (ANSD) is a recently described form of hearing impairment where neural dys-synchrony is the predominant characteristic. Children with ANSD provide a unique platform to examine the effects of asynchronous and degraded afferent stimulation on cortical auditory neuroplasticity and behavioral processing of sound. In this review, we describe patterns of auditory cortical maturation in children with ANSD. The disruption of cortical maturation that leads to these various patterns includes high levels of intra-individual cortical variability and deficits in cortical phase synchronization of oscillatory neural responses. These neurodevelopmental changes, which are constrained by sensitive periods for central auditory maturation, are correlated with behavioral outcomes for children with ANSD. Overall, we hypothesize that patterns of cortical development in children with ANSD appear to be markers of the severity of the underlying neural dys-synchrony, providing prognostic indicators of success of clinical intervention with amplification and/or electrical stimulation. This article is part of a Special Issue entitled <Auditory Synaptology>.

Factors influencing speech and language outcomes of children with early identified severe/profound hearing loss: Clinician-identified facilitators and barriers

PURPOSE

Early identification of severe/profound childhood hearing loss (HL) gives these children access to hearing devices and early intervention to facilitate improved speech and language outcomes. Predicting which infants will go on to achieve such outcomes remains difficult. This study describes clinician identified malleable and non-malleable factors that may influence speech and language outcomes for children with severe/profound HL.

METHOD

Semi-structured interviews were conducted with six experienced auditory verbal clinicians. A collective case study design was implemented. The interviews were transcribed and coded into themes using constant comparative analysis.

RESULT

Clinicians identified that, for children with severe/profound HL, early identification, early amplification and commencing auditory-verbal intervention under 6 months of age may facilitate child progress. Possible barriers were living in rural/remote areas, the clinicians' lack of experience and confidence in providing intervention for infants under age 6-months and belonging to a family with a culturally and linguistically diverse (CALD) background.

CONCLUSION

The results indicate that multiple factors need to be considered by clinicians working with children with HL and their families to determine how each child functions within their own environment and personal contexts, consistent with the International Classification of Functioning, Disability and Health (ICF) framework. Such an approach is likely to empower clinicians to carefully balance potential barriers to, and facilitators of, optimal speech and language outcomes for all children with HL.

Pediatric Cochlear Implantation-Why the Delay

The aim of the study was to evaluate the factors that act as barriers and delay the process of cochlear implantation in children with congenital profound sensorineural hearing loss. This is a cross sectional observational study in which 154 children with profound sensorineural deafness attending ENT outdoor from Jan 2013 to June 2014 at Sri Aurobindo Institute of Medical College and PG Institute, Indore, were included in the study. Information was taken from the parents of the candidates regarding the reasons for the delay in reporting, the delay in intervention and a detailed history was also taken to evaluate the possible reason for the hearing loss with the help of open ended questions. The most common cause for the delay in reporting was lack of information about the availability of technique and procedure for cochlear implant. Financial constrain was the most common cause for the delay in getting the cochlear implant surgery.

Assessment of early auditory development of very young Finnish children with LittlEARS(®) Auditory Questionnaire and McArthur Communicative Developmental Inventories

OBJECTIVES

We analysed the Finnish version of the LittlEARS(®) Auditory Questionnaire as a method for assessing very young children's early auditory, pre-verbal and emerging verbal development. We also examined whether any background factors exist that influence the results and thus the usability of this method. To determine its potential in assessment, the Finnish version of the LittlEARS(®) Auditory Questionnaire was analysed in relation to the Finnish McArthur Communicative Developmental Inventories. The latter is currently the method most commonly used together with parental interviews. However, this method is neither designed for infants younger than 8 months nor is its main emphasis on auditory development. Thus, we investigated whether the Finnish version of LittlEARS(®) Auditory Questionnaire could supplement the Finnish McArthur Communicative Developmental Inventories and thereby help in detecting children with hearing impairments.

METHODS

Normative data were collected for Finnish children with normal hearing (N=318) using the LittlEARS(®) Auditory Questionnaire and an abridged version of the Finnish McArthur Communicative Developmental Inventories. In addition, background information was collected with a questionnaire designed for this study. The results of these questionnaires were analysed in relation to each other.

RESULTS

Statistical analysis showed that the results gained with the Finnish version of LittlEARS(®) Auditory Questionnaire and the abridged version of the Finnish McArthur Communicative Developmental Inventories are closely related. However, the LittlEARS(®) Auditory Questionnaire manages to capture the earlier and subtler changes that occur in infancy, therefore making a good continuum with McArthur Communicative Developmental Inventories. Also, most background factors, such as parents' educational level, did not affect the results significantly, rendering the LittlEARS(®) Auditory Questionnaire a valuable method for assessment of early auditory development in very young children.

CONCLUSIONS

The Finnish version of the LittlEARS(®) Auditory Questionnaire is a reliable assessment tool with no confounding background factors. It enables evaluation of the early auditory development in even the youngest of children.

Auditory neuropathy spectrum disorder: a review

PURPOSE

Auditory neuropathy spectrum disorder, or ANSD, can be a confusing diagnosis to physicians, clinicians, those diagnosed, and parents of children diagnosed with the condition. The purpose of this review is to provide the reader with an understanding of the disorder, the limitations in current tools to determine site(s) of lesion, and management techniques.

METHOD

This article is a review of what is known about ANSD. It includes descriptions of assessment tools, causes of ANSD, and patient management techniques.

CONCLUSIONS

This review is a guide to audiologists, speech-language pathologists, and early interventionists who work with individuals diagnosed with ANSD and/or their families. It highlights the need for more precise tools to describe the disorder in order to facilitate decisions about interventions and lead to better predictions of outcome.

Knowledge, experience and practice of SLTs regarding (re)habilitation in deaf children with cochlear implants

OBJECTIVES

To assess the knowledge, experience and practices of speech and language therapists (SLTs) in Greece regarding children with cochlear implants.

METHODS

A special designed questionnaire was originally completed electronically by 313 SLTs via surveymonkey platform.

RESULTS

From the 313 respondents 35% had worked with implanted children, 37% received course training and 44% had participated in post-graduate seminars. Although 96% believe that there are differences in the management of these children, almost 47% of the participants did not have adequate knowledge on the candidacy criteria for implantation and 70% regarding the available technology for implanted children. Knowledge and skills on CI were better for those SLTs who worked with hearing-impairment. Diverse practice models were noted. Interestingly, more than 87% of the participants advocated toward further training and supervision in the field, even the ones who had less than extensive knowledge in working with CI. As for practice, a lack of organizational interdisciplinary structure became evident.

CONCLUSIONS

There is a growing need for well organized professional training and team networks for SLTs in order for them to further improve their knowledge and service delivery to implanted children.

Sensitive and critical periods in visual sensory deprivation

While the demonstration of crossmodal plasticity is well established in congenital and early blind individuals, great debate still surrounds whether those who acquire blindness later in life can also benefit from such compensatory changes. No proper consensus has been reached despite the fact that a proper understanding of the developmental time course of these changes, and whether their occurrence is limited to—or within—specific time windows, is crucial to our understanding of the crossmodal phenomena. An extensive review of the literature reveals that while the majority of investigations to date have examined the crossmodal plasticity available to late blind individuals in quantitative terms, recent findings rather suggest that this reorganization also likely changes qualitatively compared to what is observed in early blindness. This obviously could have significant repercussions not only for the training and rehabilitation of blind individuals, but for the development of appropriate neuroprostheses designed to aid and potentially restore vision. Important parallels will also be drawn with the current state of research on deafness, which is particularly relevant given in the development of successful neuroprostheses (e.g., cochlear implants) for providing auditory input to the central nervous system otherwise aurally deafferented. Lastly, this paper will address important inconsistencies across the literature concerning the definition of distinct blind groups based on the age of blindness onset, and propose several alternatives to using such a categorization.

Communication development in children who receive a cochlear implant by 12 months of age

OBJECTIVE

Describe the long-term benefits of early cochlear implantation. Provide a comprehensive description of outcomes, including: language, speech production, and speech perception. Compare the communication outcomes for the early implanted children to those of normally hearing children and children who received a cochlear implant at a comparatively older age.

METHOD

Retrospective review of the communication development of 35 children implanted between 6 and 12 months of age and 85 children implanted between 13 and 24 months of age. Audiologic assessments included unaided and aided audiograms, auditory brainstem response (ABR), auditory steady state response (ASSR), and otoacoustic emissons (OAEs). Formal language, speech production, and speech perception measures were administered, preimplant and at 1, 2, 3, and 5 years postimplant.

RESULTS

The children who received their cochlear implant by 12 months of age demonstrated language growth rates equivalent to their normally hearing peers and achieved age appropriate receptive language scores 3 years postimplant. The children who received their cochlear implant between 13 and 24 months demonstrated a significant language delay at 3 years postimplant. Speech production development followed a similar pattern to that of normal-hearing children, although was delayed, for both groups of children. Mean open-set speech perception scores were comparable with previous reports for children and adults who use cochlear implants.

CONCLUSION

Children implanted by 12 months of age demonstrate better language development compared with children who receive their cochlear implant between 13 and 24 months. This supports the provision of a cochlear implant within the first year of life to enhance the likelihood that a child with severe-to-profound hearing impairment will commence elementary school with age-appropriate language skills.

Central auditory maturation and behavioral outcome in children with auditory neuropathy spectrum disorder who use cochlear implants

OBJECTIVE

We examined cortical auditory development and behavioral outcomes in children with ANSD fitted with cochlear implants (CI).

DESIGN

Cortical maturation, measured by P1 cortical auditory evoked potential (CAEP) latency, was regressed against scores on the infant toddler meaningful auditory integration scale (IT-MAIS). Implantation age was also considered in relation to CAEP findings.

STUDY SAMPLE

Cross-sectional and longitudinal samples of 24 and 11 children, respectively, with ANSD fitted with CIs.

RESULTS

P1 CAEP responses were present in all children after implantation, though previous findings suggest that only 50-75% of ANSD children with hearing aids show CAEP responses. P1 CAEP latency was significantly correlated with participants' IT-MAIS scores. Furthermore, more children implanted before age two years showed normal P1 latencies, while those implanted later mainly showed delayed latencies. Longitudinal analysis revealed that most children showed normal or improved cortical maturation after implantation.

CONCLUSION

Cochlear implantation resulted in measureable cortical auditory development for all children with ANSD. Children fitted with CIs under age two years were more likely to show age-appropriate CAEP responses within six months after implantation, suggesting a possible sensitive period for cortical auditory development in ANSD. That CAEP responses were correlated with behavioral outcome highlights their clinical decision-making utility.

A case study assessing the auditory and speech development of four children implanted with cochlear implants by the chronological age of 12 months

Children with severe hearing loss most likely receive the greatest benefit from a cochlear implant (CI) when implanted at less than 2 years of age. Children with a hearing loss may also benefit greater from binaural sensory stimulation. Four children who received their first CI under 12 months of age were included in this study. Effects on auditory development were determined using the German LittlEARS Auditory Questionnaire, closed- and open-set monosyllabic word tests, aided free-field, the Mainzer and Göttinger speech discrimination tests, Monosyllabic-Trochee-Polysyllabic (MTP), and Listening Progress Profile (LiP). Speech production and grammar development were evaluated using a German language speech development test (SETK), reception of grammar test (TROG-D) and active vocabulary test (AWST-R). The data showed that children implanted under 12 months of age reached open-set monosyllabic word discrimination at an age of 24 months. LiP results improved over time, and children recognized 100% of words in the MTP test after 12 months. All children performed as well as or better than their hearing peers in speech production and grammar development. SETK showed that the speech development of these children was in general age appropriate. The data suggests that early hearing loss intervention benefits speech and language development and supports the trend towards early cochlear implantation. Furthermore, the data emphasizes the potential benefits associated with bilateral implantation.

Listen up: children with early identified hearing loss achieve age-appropriate speech/language outcomes by 3 years-of-age

OBJECTIVES

Age-appropriate speech/language outcomes for children with early identified hearing loss are a possibility but not a certainty. Identification of children most likely to achieve optimal outcomes is complicated by the heterogeneity of the children involved in outcome research, who present with a range of malleable (e.g. age of identification and cochlear implantation, type of intervention, communication mode) and non-malleable (e.g. degree of hearing loss) factors. This study considered whether a homogenous cohort of early identified children (≤ 12 months), with all severities of hearing loss and no other concomitant diagnoses could not only significantly outperform a similarly homogenous cohort of children who were later identified (>12 months to <5 years), but also achieve and maintain age-appropriate speech/language outcomes by 3, 4 and 5 years of age.

METHODS

A mixed prospective/retrospective comparative study of a homogenous cohort of 45 early identified (≤ 12 months) and 49 late identified (> 12 months to < 5 years) children with hearing loss was conducted. The children all attended the same oral auditory-verbal early intervention programme. Speech/language assessments standardized on typically developing hearing children were conducted at 3, 4 and 5 years of age.

RESULTS

The early identified children significantly outperformed the late identified at all ages and for all severities of HL. By 3 years of age, 93% of all early identified participants scored within normal limits (WNL) for speech; 90% were WNL for understanding vocabulary; and 95% were WNL for receptive and expressive language. Progress was maintained and improved so that by 5 years of age, 96% were WNL for speech, with 100% WNL for language.

CONCLUSIONS

This study found that most children with all severities of hearing loss and no other concomitant diagnosed condition, who were early diagnosed; received amplification by 3 months; enrolled into AV intervention by 6 months and received a cochlear implant by 18 months if required, were able to "keep up with" rather than "catch up to" their typically hearing peers by 3 years of age on measures of speech and language, including children with profound hearing loss. By 5 years, all children achieved typical language development and 96% typical speech.

Cochlear implantation in multi-handicapped patients: the merf experience

Hearing loss is the most common form of sensory impairment in humans. When hearing impairment is present from birth or is acquired in early childhood, it can be devastating for normal development. Early childhood deafness also has implications for cognitive, emotional and social development. In the majority of cases of early childhood hearing impairment, deafness is an isolated disorder. However, in a substantial number of cases, early childhood hearing impairment is not isolated, but forms part of a genetic syndrome with associated handicaps, or is acquired through pre-, perior postnatal causes, possibly with associated deficits. This means that more demands are made on the child's family, the teachers and medical professionals to help these children cope with their rehabilitation, needs and demands. The presence of an additional handicap can pose special problems with regard to surgery, anesthesia or rehabilitation. Cochlear implantation is effective and aids in the effective rehabilitation of other additional handicaps. However, careful patient selection is required and thorough parental counseling regarding expectations must be given. In our Cochlear Implant Clinic a large proportion of implantees are in the paediatric age group. Of these, a few have had multiple disabilities in addition to their deafness. This paper attempts to share our experience in this extremely challenging and specialized field.

Determining early speech development in children with cochlear implants using the ELFRA-2 parental questionnaire

OBJECTIVES

Increased early identification of hearing loss has led to infants younger than 24 months of age being implanted with cochlear implants. The objective of this study was to assess early speech development in children implanted with a cochlear implant before 24 months of age using the German questionnaire Elternfragebogen für Risikokinder 2 (ELFRA-2), and to compare these results to normative data of the ELFRA-2 in order to determine any performance differences.

METHODS

Two groups of children were included in this study. The first group included 6 children with a mean age at implantation of 11 months (range: 8-14 months). These children were tested by their parents or caretakers with the ELFRA-2 at the chronological age of 24 months. The second group included 9 children with a mean age at implantation of 13 months (range: 6-20 months) who were tested with the ELFRA-2 after 24 months of cochlear implant use.

RESULTS

Comparison analyses of children tested with the ELFRA-2 demonstrated a statistically significant difference in all ELFRA-2 scales between children with cochlear implants (CIs) at the chronological age of 24 months and the norm group (productive vocabulary: p=0.002; syntax: p=0.003; and morphology: p<0.001), and no significant difference between children with CIs at 24 months of device use and the norm group in all scales (productive vocabulary: p=0.335; syntax: p=0.965; and morphology: p=0.304).

CONCLUSION

Children implanted before 24 months of age reach a speech production level after 24 months of device use that is comparable to that of their normal hearing peers.

Differences between electrically evoked compound action potential (ECAP) and behavioral measures in children with cochlear implants operated in the school age vs. operated in the first years of life

OBJECTIVE

The aim of this study was to identify the differences in the NRT measures, behavioral measures, and their relationship between the group of congenitally deaf children operated in the first years of life and the group of children operated in the school age.

METHODS

The study included 40 congenitally deaf children with cochlear implants divided into two groups. Group 1 was composed of 20 children (mean age at operation 2.3 years, range 1.4-4.6 years) and Group 2 was composed of 20 children (mean age at operation 11.3 years, range 7.0-17.1 years). The ECAP was recorded using the Nucleus 24 neural response telemetry (NRT) system. In each child, the responses were evoked by the apical, middle and basal electrodes. The analyzed parameters were: the ECAP threshold (T-NRT), N1P2 amplitude, N1 latency, slope of the amplitude growth function, response morphology, threshold (T-) level, maximum comfort (C-) level, dynamic range (DR), T-NRT as a percentage of the map DR, the correlation between the T-NRT and the T- and C-levels. The recordings of parameters were performed two years after implantations.

RESULTS

The T-NRT, DR, T-NRT as a percentage of the map DR and the correlation between T-NRT and C-levels were significantly different between both groups of children. There were no statistically significant differences between the groups with respect to the amplitude, latency, slope and morphology recorded using the same electrodes. However, intragroup differences regarding NRT measures and behavioral measures with respect to the position of stimulating electrode were more prominent in Group 2 than in the Group 1.

CONCLUSIONS

Results of this study have also found a great variability of NRT and MAP measures within and across patients in both groups of children, but it was still more pronounced in the group of school children. NRT profile across electrodes follows MAP profiles better in the Group 1 then in the Group 2. Overall findings of NRT and MAP measures are not consistent and unambiguous as we expected, but still suggest potential differences between results in children operated in first years of life, and those operated in school age.

Sensory rehabilitation in the plastic brain

The purpose of this review is to consider new sensory rehabilitation avenues in the context of the brain's remarkable ability to reorganize itself following sensory deprivation. Here, deafness and blindness are taken as two illustrative models. Mainly, two promising rehabilitative strategies based on opposing theoretical principles will be considered: sensory substitution and neuroprostheses. Sensory substitution makes use of the remaining intact senses to provide blind or deaf individuals with coded information of the lost sensory system. This technique thus benefits from added neural resources in the processing of the remaining senses resulting from crossmodal plasticity, which is thought to be coupled with behavioral enhancements in the intact senses. On the other hand, neuroprostheses represent an invasive approach aimed at stimulating the deprived sensory system directly in order to restore, at least partially, its functioning. This technique therefore relies on the neuronal integrity of the brain areas normally dedicated to the deprived sense and is rather hindered by the compensatory reorganization observed in the deprived cortex. Here, we stress that our understanding of the neuroplastic changes that occur in sensory-deprived individuals may help guide the design and the implementation of such rehabilitative methods.

Exploring factors that affect the age of cochlear implantation in children

OBJECTIVE

Early access to sound through early cochlear implantation has been widely advocated for children who do not derive sufficient benefit from acoustic amplification. Early identification through newborn hearing screening should lead to earlier intervention including earlier cochlear implantation when appropriate. Despite earlier diagnosis and the trend towards early implantation, many children are still implanted well into their preschool years. The purpose of this study was to examine the factors that affected late cochlear implantation in children with early onset permanent sensorineural hearing loss.

METHODS

Data were examined for 43 children with cochlear implants who were part of a group of 71 children with hearing loss enrolled in a Canadian outcomes study. Eighteen (41.9%) of the 43 children were identified through newborn screening and 25 (58.1%) through medical referral to audiology. Medical chart data were examined to determine age of hearing loss diagnosis, age at cochlear implant candidacy, and age at cochlear implantation. Detailed reviews were conducted to identify the factors that resulted in implantation more than 12 months after hearing loss confirmation.

RESULTS

The median age of diagnosis of hearing loss for all 43 children was 9.0 (IQR: 5.1, 15.8) months and a median of 9.1 (IQR: 5.6, 26.8) months elapsed between diagnosis and unilateral cochlear implantation. The median age at identification for the screened groups was 3.3 months (IQR: 1.4, 7.1) but age at implantation (median 15.8 months: IQR: 5.6, 37.1) was highly variable. Eighteen of 43 children (41.9%) received a cochlear implant more than 12 months after initial hearing loss diagnosis. For many children, diagnosis of hearing loss was not equivalent to the determination of cochlear implant candidacy. Detailed reviews of audiologic profiles and study data indicated that late implantation could be accounted for primarily by progressive hearing loss (11 children), complex medical conditions (4 children) and other miscellaneous factors (3 children).

CONCLUSIONS

This study suggests that a substantial number of children will continue to receive cochlear implants well beyond their first birthday primarily due to progressive hearing loss. In addition, other medical conditions may contribute to delayed decisions in pediatric cochlear implantation.

Language development in children after receiving bilateral cochlear implants between 5 and 18 months

OBJECTIVE

The objective of this study was to examine receptive and expressive language development in children who received simultaneous bilateral cochlear implants (CIs) between 5 and 18 months of age and to compare the results with language development in chronologically age-matched children with normal hearing.

METHODS

The study used a prospective, longitudinal matched-group design. Data were collected in a clinical setting at postoperative cochlear implant check-ups after 3, 6, 9, 12, 18, 24, 36, and 48 months of implant use. The sample included 42 children: 21 cochlear implant users and 21 with normal hearing, matched pairwise according to gender and chronological age. Communication assessments included the LittlEARS questionnaire, the Mullen Scale of Early Learning, and the Minnesota Child Development Inventory.

RESULTS

The cochlear implant users' hearing function according to LittlEARS was comparable to that of normal-hearing children within 9 months post-implantation. The mean scores after 9 and 12 months were 31 and 33, respectively in the prelingually deaf versus 31 and 34 in the normal-hearing children. The children's receptive and expressive language scores showed that after 12-48 months with cochlear implants, 81% had receptive language skills within the normative range and 57% had expressive language skills within the normative range. The number of children who scored within the normal range increased with increasing CI experience.

CONCLUSIONS

The present study showed that prelingually deaf children's ability to develop complex expressive and receptive spoken language after early bilateral implantation appears promising. The majority of the children developed language skills at a faster pace than their hearing ages would suggest and over time achieved expressive and receptive language skills within the normative range.

Accuracy of consonant-vowel syllables in young cochlear implant recipients and hearing children in the single-word period

PURPOSE

Attaining speech accuracy requires that children perceive and attach meanings to vocal output on the basis of production system capacities. Because auditory perception underlies speech accuracy, profiles for children with hearing loss (HL) differ from those of children with normal hearing (NH).

METHOD

To understand the impact of auditory history on emergence of speech capacities, the authors compared consonant-vowel (CV) syllable accuracy in early words in 4 NH children and 4 children with HL who received cochlear implantation (CI) before age 2 years. Participants were video-recorded monthly for 6 months following word onset. CV vocalizations were coded perceptually with broad phonetic transcription. Observed-to-expected ratios of CV productions and accuracy were tested with chi-square analysis. An ordered multinomial model tested level of accuracy, including both accuracy and error patterns.

RESULTS

Most frequently produced sequences were most accurately produced across group and time. NH children were more accurate overall than children with CI. Both groups improved accuracy over time by decreasing partially accurate productions (accurate consonant-inaccurate vowel). Both groups favored CV patterns with compatible place of articulation between consonant and vowel in absolute frequency and level of accuracy.

CONCLUSION

Differences in emergence of CV syllable accuracy arise from differences in auditory perception between the NH and CI groups.

The prelexical development in children implanted by 16 months compared with normal hearing children

OBJECTIVE

Few studies exist which document the early speech development of German-speaking children or German-speaking children who are deaf and using cochlear implants. The current study aims to: (1) document the pre-canonical and canonical speech development of German-speaking children who are deaf and receive cochlear implants by the age of 16 months and (2) compare these children's results with those of children with normal hearing.

DESIGN

This longitudinal study included 5 German-speaking children with normal hearing and 5 with sensorineural deafness. All children from the deaf group received hearing amplification before cochlear implantation, received their first implant by 16 months of age, and became bilateral implant users by 31 months of age. The pre-canonical and canonical vocalisations of each child were recorded on video- and audiotapes in a semi-standardised playing situation every 4 weeks over a span of 1 year. In the cochlear implant group, the recording started 4-5 days postoperatively (first implant); in the normal hearing group it began between the ages of 4 and 5 months. The video and audio recordings were analysed using EUDICO Linguistic Annotator version 2.4 (Nijmegen, The Netherlands) and International Phonetic Alphabet transcription.

RESULTS

Both groups showed individual patterns of babbling acquisition, though the groups' patterns of acquisition were similar when analysed for consonant manner and place. Some children started with plosives and others, with nasals, but all acquired fricatives and laterals next. Onset of canonical babbling for children in the cochlear implant group began 0-4 months after first fitting of the first device, while children from the normal hearing group demonstrated an onset of canonical babbling between 4 and 9 months of age.

CONCLUSION

Our results show that deaf children who receive cochlear implants at an early age are capable of reaching the canonical babbling milestone in a shorter time than children with normal hearing typically do and that their consonant phoneme acquisition follows a similar sequence to normal hearing peers'. These results are consistent with the literature indicating that early identification and intervention are important for allowing children with cochlear implants the opportunity to catch up to hearing peers.

Cochlear Implant Outcomes for Children With Auditory Neuropathy Spectrum Disorder

Cochlear implantation is currently the intervention option of choice for many children with auditory neuropathy spectrum disorder (ANSD) who are unable to obtain benefit from conventional amplification. The aim of this study was to review the speech perception and language outcomes for children with ANSD who had received a cochlear implant and highlight specific clinical considerations for working with this population of children with hearing impairment who are being considered for implantation. Finds for the group of 17 children with ANSD using cochlear implants were compared to previously reported outcomes for children with sensori-neural (SN) type hearing loss using cochlear implants.

Two children, identified with cochlear nerve deficiency pre-operatively, received no useful auditory percepts from their cochlear implant and discontinued device use. The remaining children demonstrated speech perception and language outcomes comparable to those observed for SN hearing loss peers using cochlear implants.

This paper highlights a number of considerations for clinicians to be aware of and the importance of careful counseling pre-operatively regarding the potential for less-than-optimal outcomes, particularly for those children identified with cochlear nerve deficiency.