Auditory performance and language skills in children with auditory brainstem implants and cochlear implants

Abstract

Purpose
This study aims to evaluate school-age language skills and auditory performance in different listening situations in children with cochlear implants and auditory brainstem implants.

Method
The study included 60 children between the ages of 5 and 9 years with cochlear implants (CI) and auditory brainstem implants (ABI). The volunteer children were divided into two groups: bimodal CI-ABI and bilateral CI users. Test of Language Development: Primary (TOLD-P:4), which assesses components of language such as phonology, morphology, syntax and semantics, was used to evaluate school-age language skills. Children’s Auditory Performance Scale (CHAPS) was used to measure their listening performance in quiet, noisy, multi-stimulus environments and their auditory attention and memory skills in daily life. The correlations between language and auditory performance were analyzed and compared between the two groups.

Results
Children with ABI showed poorer performance in school-age language skills and auditory performance in different listening environments (p < 0.05). Significant correlations were between school-age language skills and auditory performance (p < 0.05).

Conclusion
Improved auditory performance is crucial for the development of school-age language skills. To improve auditory performance in children with ABI in different listening environments, assistive listening devices, acoustic environmental arrangements, informative activities, etc., should be used.

Full text

Vol.:(0123456789)
European Archives of Oto-Rhino-Laryngology (2024) 281:4153–4159
https://doi.org/10.1007/s00405-024-08594-0
OTOLOGY
Auditory performance andlanguage skills inchildren withauditory
brainstem implants andcochlear implants
NuriyeYıldırımGökay1 · BeyzaDemirtaş2· MerveÖzbalBatuk2· EsraYücel2· GoncaSennaroğlu2
Received: 2 January 2024 / Accepted: 1 March 2024 / Published online: 4 April 2024
© The Author(s) 2024
Abstract
Purpose This study aims to evaluate school-age language skills and auditory performance in different listening situations
in children with cochlear implants and auditory brainstem implants.
Method The study included 60 children between the ages of 5 and 9years with cochlear implants (CI) and auditory brain-
stem implants (ABI). The volunteer children were divided into two groups: bimodal CI-ABI and bilateral CI users. Test of
Language Development: Primary (TOLD-P:4), which assesses components of language such as phonology, morphology,
syntax and semantics, was used to evaluate school-age language skills. Children’s Auditory Performance Scale (CHAPS)
was used to measure their listening performance in quiet, noisy, multi-stimulus environments and their auditory attention
and memory skills in daily life. The correlations between language and auditory performance were analyzed and compared
between the two groups.
Results Children with ABI showed poorer performance in school-age language skills and auditory performance in different
listening environments (p < 0.05). Significant correlations were between school-age language skills and auditory performance
(p < 0.05).
Conclusion Improved auditory performance is crucial for the development of school-age language skills. To improve auditory
performance in children with ABI in different listening environments, assistive listening devices, acoustic environmental
arrangements, informative activities, etc., should be used.
Keywords Auditory brainstem implants· Cochlear implants· Children· Auditory performance· Language
Introduction
A pre-lingual severe and profound hearing loss has a nega-
tive impact on language and learning development [5].
Cochlear implants (CI) improve auditory performance and
language skills in children with severe to profound sensori-
neural hearing loss [22]. However, CI is limited in auditory
rehabilitation in cases of anatomical malformations in the
inner ear and/or auditory nerve. Auditory brainstem implan-
tation (ABI) is the preferred option in cases in which coch-
lear implantation is contraindicated due to these malforma-
tions [16, 17, 19]. Auditory brainstem implants help provide
a sense of hearing by placing them in the cochlear nuclei in
the brainstem without connecting to the inner ear [21].
Studies have demonstrated that auditory perception and
language skills improve in children with CI and ABI [2, 18,
20]. A study revealed that the word recognition scores were
80% in a quiet environment and 45% in a noisy environment
approximately 10years after implantation. Similarly, 60%
* Nuriye Yıldırım Gökay
nuriye.yildirim94@gmail.com
Beyza Demirtaş
beyzademirtasodyoloji9008@gmail.com
Merve Özbal Batuk
merveozbal@gmail.com
Esra Yücel
esyucel@yahoo.com
Gonca Sennaroğlu
gsennar@yahoo.com
1 Department ofAudiology, Faculty ofHealthy Science, Gazi
University, Emek, 06900Ankara, Turkey
2 Department ofAudiology, Faculty ofHealth Sciences,
Hacettepe University, Ankara, Turkey
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4154 European Archives of Oto-Rhino-Laryngology (2024) 281:4153–4159
of children with cochlear implants can make a phone call
to a familiar speaker but continue to have problems with
complex language structures such as syntax, semantics, and
pragmatics. A systematic review of the change of speech
perception with cochlear implantation showed that children
experienced a sharp improvement in early speech perception
in 1year after implantation. Children who are younger than
18months benefit from CI in terms of speech recognition
faster [3, 10, 14, 27]. On the other hand, ABI develops spo-
ken language in children, but this happens slowly and gradu-
ally. A study comparing language characteristics between
ABI and CI users showed that language development the
ability to recognize two-syllable words and sentences are
worse in children with ABI.
Language and communication skills in children with
ABI develop in postoperative 12months [15]. So, it has
been shown that hearing loss can affect the quality of life
by affecting speech and language development. The chil-
dren with hearing loss have lower scores on quality of life
than other children. Also, children with hearing loss have
a higher risk of impaired language development and social
life. Although it is promising that children with HL show
similar levels of self-esteem and mental health as children
with normal hearing, HL can negatively affect the quality of
life of these children in various aspects (for example, per-
sonal relationships with other people and environmental/
situational factors that challenge them). Noisy environments,
distorted and/or distant auditory signals and hearing loss
require children to use explicit processing mechanisms and
high cognitive resources.
There are a limited number of studies that include func-
tional assessment of hearing quality and daily life hearing
performance in children using CI and ABI [1, 7, 10, 14].
According to these studies, although patients are unhappy
with their ABI in some communication skills, overall, their
quality of life improves over time. A study revealed that
ABIs are suitable for children with cochlear anomalies to
provide auditory input and benefit all developmental areas
[2]. It has been found that children using ABI perform
poorly compared to their peers using CI in terms of cogni-
tive and language skills and daily life hearing performance
[27]. To the authors’ best knowledge, there are no studies
investigating language skills with the “Children’s Audi-
tory Performance Scale (CHAPS)” in children with ABI in
the same study. The CHAPS is generally addressed in the
evaluation of central auditory processing disorder and valid-
ity–reliability studies [3, 4, 9, 23].
The current study aims to evaluate language skills and
auditory performance in quiet-noisy environments in daily
life and listening situations requiring auditory attention and
auditory memory for children with CI and ABI. For this
purpose, it is assumed that it will shed light on these berms
of examining daily life listening performance and language
skills in children with ABI, especially in a significant sample
size.
Materials andmethods
This study was approved by The University Clinical
Research Ethics Committee with GO23/601 decision num-
ber. All informed consent forms were obtained from all chil-
dren and their parents.
Participants
Children included in this study consisted of patients who
applied to the University Department of Audiology. The
volunteer children aged 5 to 9years were divided into two
groups: those using bilateral CI (n = 30) and those using
bimodal CI-ABI (n = 30). An experienced radiologist and
otologist diagnosed inner ear malformations using high-res-
olution computed tomography using axial sections. Audi-
tory brainstem implantation is applied on children who have
contraindications to cochlear implants due to inner ear and/
or auditory nerve malformations. The children whose hear-
ing loss diagnosis age and hearing aid starting age were
less than 1year, who had their first auditory implantation
surgery before the age of 2, and who had regular use for at
least 1year after the activation of the auditory implant were
included. Bilateral cochlear implanted children underwent
simultaneous bilateral implantation surgery. For bimodal
CI-ABI users, the time between two surgeries is, at most
2years. Children with bilateral CI have no inner ear and/or
auditory nerve anomalies. All participants receive regular
auditory rehabilitation. In the evaluation of candidates for
auditory implantation, additional disabilities in the fields of
child psychiatry, developmental pediatrics, neurology, etc.,
are routinely examined before surgery by experts in the field.
As a result, children diagnosed with additional deficiency in
these areas or syndromic hearing losses were excluded from
the study. The average free-field hearing thresholds of all
children with bilateral auditory implants are approximately
25 to 45dB HL at 500, 1000, and 2000Hz. None of the
children use FM systems or other assistive listening devices.
Children’s Auditory Performance Scale (CHAPS)
The CHAPS is a 36-item questionnaire that compares a
child’s listening behavior with other children of similar
age and background in six different domains: listening in
noisy, quiet, ideal, multiple-input conditions, and listen-
ing activities that require auditory memory/sequencing
and auditory attention span. Each item is scored using a
seven-point scale from + 1 to 5 (+ 1 = less difficulty than
other children, 0 = same amount of problem, 1 = slightly
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4155European Archives of Oto-Rhino-Laryngology (2024) 281:4153–4159
more difficulty, 2 = more difficulty, 3 = important signifi-
cantly more difficulty, 4 = significantly more difficulty,
and 5 = unable to function at all). There are seven items
each assessing listening in noise and quiet, three assessing
listening in ideal and multiple-input conditions, and eight
items each for listening that requires auditory memory/
sequence and attention span. The items in the subsections
include questions such as “when asked a question, when
given simple commands, when given more than one com-
mand, when with several children, when listening in a
room with visual stimuli, etc.”. As mentioned above, these
are asked to be scored according to the degree of diffi-
culty of auditory performance. The “average part score”
for each part was calculated by dividing the total score of
the items in each part by the number of items in the part.
The “average total score” was calculated by dividing the
total score by 36. In this study, not the average scores, but
the total score of each section and the scale’s total score
were analyzed statistically. The studies with the CHAPS
in different languages are examined, it is emphasized that
the current scale is a safe and appropriate tool for meas-
uring hearing performance [3, 4, 9, 23]. Based on that
there are no studies evaluating children with ABI and CI.
According to the authors’ best knowledge, it aims to make
a unique contribution to the literature.
Test ofLanguage Development: Primary (TOLD‑P:4)
The TOLD-P:4 test was used for the general assessment
of children’s school-age language skills. This test is a
standard test whose validity and reliability have been
studied and is used in many studies and clinical applica-
tions [12, 24, 26, 28]. This test includes six basic skills:
showing the picture of the spoken word, explaining the
relationship between two words, describing a word,
showing the picture of the spoken sentence, repeating
the spoken sentence, and completing the morphemes in
a sentence. The sum of the scores of these tests reveals
the verbal language score. In this test, 1 point is given for
each correct answer.
Statistical analysis
All statistical analyzes were implemented by SPSS Statistics
v.23.0. The normal distribution of the data was examined
using histogram graphs and analytical methods. The descrip-
tive statistics were presented as mean and standard deviation
for normally distributed data, and as median and range for
non-normally distributed data. The comparisons between
groups with bilateral CI and bimodal CI-ABI were evalu-
ated by independent samples t test or Mann–Whitney U test.
The relationship between TOLD-P:4 and CHAPS scores was
examined by correlation analysis. Statistical significance was
set at p < 0.05.
Results
A total of 60 volunteer children and their families,
30 (16 girls, 14 boys) with CI and 30 (15 boys, 15
girls) with ABI, were included in the study. The mean
age was 90.40 ± 9.01 months in the CI group and
91.87 ± 7.77months in the ABI group. The age at onset of
hearing loss was 5.07 ± 1.34months in the CI group and
4.43 ± 1.25months in the ABI group. The duration of coch-
lear implant use was 19.00 ± 3.41months in the CI group
and 20.23 ± 3.87months in the ABI group. The etiologies of
hearing loss were generally idiopathic. The educational level
of the children’s families was predominantly high school and
university. There were no statistically significant differences
between the ABI and CI groups in terms of age of hearing
loss, age of first implantation, age of starting hearing aid use,
and duration of implant use. See Tables1 and 2 for detailed
information on demographic information.
The CHAPS total scores were 56.30 ± 12.80 in the ABI
group and 35.80 ± 11.58 in the CI group. According to listen-
ing performance in noisy environments, children with ABI
had 11.43 ± 4.46 points and children with CI had 8.66 ± 3.39
points. The statistically significant differences were found
between children with ABI and CI in terms of CHAPS total
score and auditory attention and auditory memory skills in
quiet and noisy listening conditions (see Table3). According
Table 1 Demographic
information I Groups p
ABI CI
Mean Standard
deviation
Mean Standard
deviation
Age (months) 91.87 7.77 90.40 9.01 0.502
Onset age of hearing loss (months) 4.43 1.25 5.07 1.34 0.063
Onset age of hearing aid usage (months) 5.50 0.86 5.40 1.13 0.196
Age of cochlear implantation (months) 20.23 3.87 19.00 3.41 0.253
Duration of cochlear implant (months) 71.03 7.40 71.80 9.89 0.702
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4156 European Archives of Oto-Rhino-Laryngology (2024) 281:4153–4159
to the instructions of the CHAPS, the higher the score, the
more difficult the child had. The children with ABI showed
poorer performance in listening situations in daily life and
skills requiring auditory memory-attention.
The statistically significant differences were found
between the groups in all TOLD-P:4 subtests and verbal lan-
guage scores in school-age language skills in children with
ABI and CI (p < 0.001). Accordingly, while the TOLD-P:4
verbal language score of children with ABI is 67.30 ± 6.13,
it is 77.30 ± 5.90 in children with CI.
The correlation analyses were conducted between chil-
dren’s school-age language scores and the CHAPS scores.
Accordingly, there are strong, statistically significant nega-
tive correlations between the CHAPS auditory attention
and auditory memory scores and TOLD-P:4 verbal lan-
guage scores (see Table4). According to the CHAPS scor-
ing guideline, there is a negative relationship between the
TOLD-P:4 score because a higher CHAPS score indicates
poorer performance.
A very strong negative, statistically significant correla-
tion was detected between the CHAPS total score and the
TOLD-P:4 verbal language score (r = − 0.851, p < 0.001).
Similarly, moderate statistically significant correlations were
found between auditory performance in the CHAPS quiet
and noisy listening conditions and TOLD-P:4 verbal lan-
guage score (see Table5).
Additionally, Fig.1 shows the negative and strong rela-
tionship between the TOLD-P:4 verbal language score and
the CHAPS total score.
Discussion
This study investigated auditory performance and language
skills in routine listening conditions, such as quiet, ideal,
noisy, long-distance, etc., in children with bimodal (CI-ABI)
and bilateral cochlear implants. It has been determined that
there is a significant relationship between school-age lan-
guage skills and hearing quality in children with auditory
implants. The daily life auditory performance and school-
age language skills were found to be poorer in children with
auditory brainstem implants.
There are active and changing listening environments
in daily life. Children with auditory implants struggle to
maintain joint attention, use selective attention skills toward
the target sound source, and focus on changing conditions.
This can be predicted from the scores given to the ques-
tions about listening environments in the subsections of
the CHAPS scale used in the current study. Thanks to the
CHAPS subsections detailed in the method section, attention
and memory performances underlying routine skills such as
maintaining a conversation, executing multiple commands,
and answering questions can be assessed. The present study
assumes a unique contribution to the literature in terms of
investigating auditory performance in quiet, noisy, ideal,
Table 2 Demographic information II
Groups
ABI CI
Count Count
Gender
Girl 15 16
Boy 15 14
Etiology of hearing loss
İdiopathic 16 16
Other reason 14 14
Modality of cochlear implantation
Bilateral simultaneously cochlear implant 0 30
Bimodal cochlear implant and auditory brain-
stem implant
30 0
Family education level
Primary school 0 0
High school 14 20
University 16 10
Table 3 The scores of total
CHAPS and sections
*There is a statistically significant difference
Groups NMean Std. deviation p
CHAPS total ABI 30 56.30 12.80 < 0.001*
CI 30 35.80 11.58
CHAPS attention ABI 30 16.10 6.58 < 0.001*
CI 30 9.76 3.21
CHAPS memory ABI 30 19.06 7.02 < 0.001*
CI 30 12.63 5.51
CHAPS noisy environments ABI 30 11.43 4.46 0.009*
CI 30 8.66 3.39
CHAPS silent environments ABI 30 5.90 2.83 0.003*
CI 30 3.93 1.92
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4157European Archives of Oto-Rhino-Laryngology (2024) 281:4153–4159
multi-stimulus environments and environments requiring
auditory attention-memory [1, 7, 10, 14]. Similar to other
studies assessing hearing quality of life and daily life hearing
performance, this study also showed that children with the
ABI were poorer [1, 14, 27]. Possible reasons for this find-
ing may be the lack of auditory stimuli in the preoperative
period in children with ABI, different tonotopic organiza-
tion of the ABI placement site, inability to reach optimum
hearing thresholds due to postoperative fitting and follow-up
difficulties, and differences in the experience of special-
ists [2, 17, 21, 30, 31]. On the other hand, in children with
indications for ABI, such as auditory nerve and inner ear
anomalies, auditory rehabilitation with ABI has been found
to significantly improve children’s quality of life and daily
life hearing performance [1, 7].
The children who cannot fully receive the auditory
stimulus may appear in various ways, such as being more
easily distracted, out of context, unable to focus on the
target speaker, etc. [6, 13]. This results in more difficul-
ties in developing and using verbal language. In the pre-
sent study, children who had limited exposure to auditory
stimuli during the critical period of 0–2years of life [29],
despite being implanted at a relatively early age, may have
performed poorly on the TOLD-P:4 school-age language test
for this reason. On the other hand, the lower language scores
of children using ABI may be due to the preoperative and
postoperative follow-up and rehabilitation difficulties of the
ABI process, less audibility in the preoperative period, and
the failure of postoperative fitting sessions to achieve good
hearing thresholds [18, 21, 27, 31].
The correlations between school-age language skills and
auditory performances in various listening environments are
consistent with the study hypotheses. Thus, children with
limited auditory access, who do not receive sufficient audi-
tory input in routine listening environments, may develop
limited verbal language. Also, there are several studies eval-
uating hearing performance and language skills in ABI users
[1, 7, 14, 27]. The present findings are consistent with these
studies. Although children with ABI show limited develop-
ment compared to their peers with CI, they offer significant
progress in language and communication skills thanks to
ABI [8, 11, 25].
To the best of the authors’ knowledge, the CHAPS scale,
which assesses skills requiring auditory attention and audi-
tory memory in silence, noise, and multi-stimulus environ-
ments, has not been applied in children with ABI. In addi-
tion, another unique aspect of the study is the comparison
Table 4 Correlations I
**Correlation is significant at the 0.01 level (2-tailed). r Pearson cor-
relation
TOLD:P-4 verbal
language
CHAPS attention CHAPS memory
TOLD:P-4 verbal language
r1− 0.695** − 0.640**
p< 0.001 < 0.001
N40 40 40
CHAPS attention
r− 0.695** 1 0.601**
p< 0.001 < 0.001
N40 60 60
CHAPS memory
r− 0.640** 0.601** 1
p< 0.001 < 0.001
N40 60 60
Table 5 Correlations II
**Correlation is significant at the 0.01 level (2-tailed). r Pearson cor-
relation
TOLD:P-4
verbal lan-
guage
CHAPS total CHAPS noisy
environments
CHAPS silent
environments
TOLD:P-4 verbal language
r1− 0.851** − 0.508** − 0.534**
p< 0.001 0.001 < 0.001
N40 40 40 40
CHAPS total
r− 0.851** 1 0.603** 0.579**
p< 0.001 < 0.001 < 0.001
N40 60 60 60
CHAPS noisy environments
r− 0.508** 0.603** 1 0.773**
p0.001 < 0.001 < 0.001
N40 60 60 60
CHAPS silent environments
r− 0.534** 0.579** 0.773** 1
p< 0.001 < 0.001 < 0.001
N40 60 60 60
Fig. 1 The scatter graph of correlation
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4158 European Archives of Oto-Rhino-Laryngology (2024) 281:4153–4159
of the auditory performance in different conditions with
school-age language skills. The study’s strengths include
the homogeneity of the children in terms of age at implanta-
tion, age at diagnosis of hearing loss, age at onset of hearing
aid use, etc., and the inclusion of a relatively large sample.
On the other hand, future studies with methods that include
cognitive tests and high-level auditory processing tests are
needed.
Conclusion
In the present study, children with bimodal CI-ABI per-
formed poorly in terms of language skills and auditory skills
in different listening environments compared to their peers
with bilateral CI. Access to auditory stimuli and improved
auditory performance are crucial for improved school-age
language skills. It may be helpful to recommend using
assistive listening devices to improve auditory performance
in children with ABI. Similarly, acoustic modifications at
school, home, and other listening environments can improve
auditory performance. Additionally, informative activities
about children with ABI and their auditory performance
should be organized for families and teachers. Moreover, it
is recommended to be more attentive in the diagnosis and
follow-up of children with ABIs, to consult experienced spe-
cialists, and to work as a multidisciplinary team.
Funding Open access funding provided by the Scientific and Techno-
logical Research Council of Türkiye (TÜBİTAK). No.
Data availability The current study’s data are kept secure and confi-
dential with the first author. The data can be shared when necessary.
Declarations
Conflict of interest The authors would like to declare that there is no
conflict of interest.
Ethical approval The study had been approved by the University Ethics
Commission with decision number GO23/601.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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