INTRODUCTIONMost patients with hearing loss, including severe loss, benefit from the use of hearing aids (HA) (1). In cases where the severity of the deficiency renders HA incapable of providing appropriate acoustic information, it is believed that a cochlear implant (CI) produces the best results in the rehabilitation of children with hearing loss, since they require sufficient cochlear reserve for sound detection (1).
Cochlear implants directly stimulate the cochlear nerve fibers and enable better perception and discrimination of speech, sounds of the environment, and alerts (2). Patients can acquire auditory performance comparable with that of individuals with mild/moderate hearing loss; however, the performance and evolution depend on age and the duration of deafness (1,2). Previously, some authors supported the idea that better speech perception would be achieved only by children who received CI at young ages, which has been contradicted in the last few years, when good results were obtained in children with prelingual deafness undergoing implantation at older ages (3).
In recent years, many studies were published comparing the hearing results obtained in patients with severe to profound hearing loss that used HA or CI (1). The aim of this study was to evaluate, by using as reference articles available from the worldwide literature, whether CI confer superior benefits than HA do in patients with prelingual deafness.
LITERATURE REVIEWThis study was a systematic review of the medical literature following a search made in June 2010 that included articles in Portuguese, English, and Spanish from the last 10 years. The search for relevant references was made through the SciELO, Cochrane, MEDLINE, and LILACS-BIREME databases. We selected papers that presented A or B strengths of evidence addressing the comparison between HA or CI in the pediatric population with prelingual deafness. The following mesh terms (keywords and delimiters) and their corresponding translations and varying combinations were used: cochlear implants/cochlear implantation; hearing aid; therapy; prognosis; comparative study.
Of the 2169 articles retrieved, 12 proved relevant to the theme and presented B strength of evidence (11 demonstrated 2b strength of evidence (2-12) and one, 2c (1)). We did not find papers with A strength of evidence. Among the study designs analyzed in the review, 7 were prospective cohorts (2-4,7,9-11) and 5 were transversal studies (1,5,6,8,12) (Table 1).
Children that present sufficient hearing to permit HA use develop a characteristically vocal pre-verbal style of conversation and hearing, may acquire good understanding, and use spoken language. Tait and Lutman (4) investigated pre-verbal conversation in 27 children that used CI or HA through videotape recordings and their subsequent analysis. They affirmed that the CI appeared to promote similar development of pre-verbal behavior in children with profound deafness that was not produced with regular HA. Thus, it could be possible that children implanted at too young an age may continue to develop age-appropriate understanding of speech and intelligible speech.
Through the Gestel-Nijmegen test of speech perception applied in 64 children, VERMEULEN et al. (5) observed that CI users obtained better results than those with HA did.
VAN DEN BORNE et al. (2) analyzed the capacity to detect daily sounds that were measured on a scale of 1-4 points. The scale was applied before the patients received the CI and at 6, 12, 24, and 36 months after the devices were introduced. In the same period, there was improvement in the obtained score by 3.5 and 1.9 points in CI recipients and HA users, respectively. In the same study, the authors reported on speech perception by means of the Scales of Early Communication Skills for Hearing-Impaired Children that evaluate speech and language development in deaf children aged 2-9 years. In these scales, HA users obtained better scores than those with CI, but the authors discussed whether its use and sensibility were adequate.
OSBERGER et al. (6) evaluated 30 children above 5 years old. Speech perception was measured with 3 tests (Early Speech Perception (ESP), Glendonald Auditory Screening Procedure (GASP), and Phonetically Balanced Kindergarten Test (PB-Ktest)) before CI implantation and HA use and at 3 and 6 months after the introduction of each device. All results revealed better responses for the CI group.
In the prospective cohort study performed by TOMBLIN et al. in 1999 (7), the authors reported measures of speech production using the Index of Productive Syntax (IPSyn) to analyze children recounting stories. The results revealed an average difference of total scores of 19.6 in 5 years in favor of CI. However, the results may have been influenced by biases: the group of implanted patients had the advantage of repeated exposure to the test. Analysis of regression showed that when age was included, time of CI use was the main factor of the IPSyn score.
OSBERGER et al. (8) studied the speech perception of 58 pre- and post-implant patients through 5 tests (PB-Ktest, GASP, ESP, Mr. Potato Head Task, and regular phrases test). All patients obtained gains in all tests after more than 18 months, with an average difference of scores between pre- and post-implant testing of 19.9 for the regular phrases test to 56.5 for the ESP. All evaluations favored CI (p < 0.0001).
In 1999, SVIRSKY and MEYER (9) applied the PB-Ktest in 297 children using CI or HA. In the children, aged between 6 and 12 years, the average score of the CI-implanted group improved by 6.3% in 18 months, that in children aged below 6 years was in 6.5 in 12 months. However, the authors reported insufficient information to calculate the difference in the scores for the HA group.
MILDNER et al. (1) used a transverse study to compare children using CI and those using HA. They found an average gain in visual understanding and in words orally presented of 82.8% and 60.4% in the CI and HA users, respectively (difference of 22.4%, p < 0.01).
IBERTSSON et al. (10) investigated the discrimination of words in 3 groups of 13 individuals with hearing loss. The children with CI obtained an average of 38.5%, that of HA users was 79.5%, and that of children with specific language impairment was 61%.
In 2009, MOST et al. (3) studied 3 groups of patients: CI users, HA patients with severe hearing loss, and HA users with profound hearing loss. They demonstrated that the performance in the CI users significantly overcame that of the patients who used HA due to profound hearing loss. The CI users achieved similar results to that of the HA users with severe hearing loss in phonemes perception and in low-intensity audio-visual sentence perception.
MOST and AVINER (11) studied the perception of emotion in CI patients implanted at early and advanced ages, in patients using HA, and in teenagers with normal hearing. The stimulus was visual, hearing, and combined hearing-visual. The results revealed that the teenagers with normal hearing achieved the best hearing identification. Both groups of hearing-loss patients revealed comparable perception of emotions through the visual and hearing-visual stimulus. The advantage of CI over HA was not evident and the correlation between the ages of implantation was insignificant. Although the age of implantation did not demonstrate a statistical difference, the authors themselves discussed the fact that the youngest age for the CI surgery in their study was 2.6 years, and that the results may have been different if the procedure had been performed earlier.
In 2010, BAUDONCK et al. (12) compared the intelligibility between children with normal hearing and those with hearing loss rehabilitated through CI or HA. The HA group produced more replacements (p = 0.021), omissions (p = 0.009), and above all, more mistakes in total (p = 0.005). Distortions were the most common type of error in both hearing-impaired groups: 62% in CI and 52% in HA. In children with HA, the comparative number of omissions was greater than that in the children with CI (p = 0.024). The early implant children presented a better performance in different phonetic and phonological characteristics in comparison to the children using HA, similar to the performance of normal-hearing children.
DISCUSSIONResearch development in the areas of audiology and deafness diagnosis and treatment has extensively contributed to the advance of knowledge in this multidisciplinary field of action.
The present systematic review of the subject has revealed a wide range of material comparing the results obtained for CI or HA users, which mostly included the acquisition and perception of speech. On the other hand, only 1.8% of the studies presented relevant strength of evidence in a time when evidence-based medicine has become increasingly crucial, mainly so that conduct is standardized.
In general, the results of these studies demonstrated the unquestionable benefits of CI in linguistic development, perception of environmental sound, speech, the process of learning, and in emotional and social areas.
Our main critique of the articles is of a methodological nature, since many measures of analysis were found for pre- and post-operatory hearing outcomes (scales and tests), rendering it difficult to compare the results of each author. However, some important tests were not mentioned, such as the Meaningful Use of Speech Scales and the Meaningful Auditory Integration Scale, and interview scripts used with the patient's parents, which would have provided information related to the frequency with which the children exhibited significant oral language behavior day by day.
Since 1990, the Food and Drug Administration approved the implementation of CI in children aged 2 years and up, and an increasing number of children have received CI. The CI has been established as the technological device with the greatest effectiveness for treatment of severe to profound sensorineural deafness currently available.
The benefits from CI in children under 6 years of age with bilateral severe to profound sensorineural deafness were not provided by HA use over a 3 month-period. In children aged 7-12 years, CI is indicated when there is bilateral severe to profound sensorineural hearing loss with open-set sentence recognition with HA use in both ears of 50% or less, and the presence of an established linguistic code.
FINAL COMMENTSEvaluation of the benefits received by hearing-impaired children through CI is of fundamental importance to conduct candidates through the procedure and familiarization orientation. After the analysis of strength of evidence and grade of scientific recommendation of the studies included in this systematic review, it was possible to conclude that there was consensus between the authors in that CI conferred greater benefits compared to conventional HA for the acquisition of linguistic and communicative skills in patients with prelingual deafness.
REFERENCES1. Mildner V, Sindija B, Zrinski KV. Speech perception of children with cochlear implants and children with traditional hearing aids. Clin Linguist Phon, 2006; 20:219-29.
2. Van den Borne S, Snik AF, Hoekstra CC, Vermeulen AM, van den Broek P, Brokx JP. Assessment of basal sound identification skills and communication abilities in profoundly deaf children fitted with hearing aids or a cochlear implant. Clin Otolaryngol Allied Sci, 1998; 23:455-61.
3. Most T, Rothem H, Luntz M. Auditory, visual, and auditory-visual speech perception by individuals with cochlear implants versus individuals with hearing aids. Am Ann Deaf, 2009; 154:284-92.
4. Tait M, Lutman ME. Comparison of early communicative behavior in young children with cochlear implants and with hearing aids. Ear Hear, 1994; 15:352-61.
5. Vermeulen AM, Snik AF, Brokx JP, van den Broek P, Geelen CP, Beijk CM. Comparison of speech perception performance in children using a cochlear implant with children using conventional hearing aids, based on the concept of "equivalent hearing loss". Scand Audiol Suppl, 1997; 47:55-7.
6. Osberger MJ, Fisher L, Zimmerman-Phillips S, Geier L, Barker MJ. Speech recognition performance of older children with cochlear implants. Am J Otol, 1998; 19:152-7.
7. Tomblin JB, Spencer L, Flock S, Tyler R, Gantz B. A comparison of language achievement in children with cochlear implants and children using hearing aids. J Speech Lang Hear Res, 1999; 42:497-511.
8. Svirsky MA, Meyer TA. Comparison of speech perception in pediatric clarion cochlear implant and hearing aid users. Ann Otol Rhinol Laryngol Suppl, 1999; 177:104-9.
9. Osberger MJ, Zimmerman-Phillips S, Barker M, Geier L. Clinical trial of the clarion cochlear implant in children. Ann Otol Rhinol Laryngol Suppl, 1999; 177:88-92.
10. Ibertsson T, Willstedt-Svensson U, Radeborg K, Sahlén B. A methodological contribution to the assessment of nonword repetition-a comparison between children with specific language impairment and hearing-impaired children with hearing aids or cochlear implants. Logoped Phoniatr Vocol, 2008; 33:168-78.
11. Most T, Aviner C. Auditory, visual, and auditory-visual perception of emotions by individuals with cochlear implants, hearing AIDS, and normal hearing. J Deaf Stud Deaf Educ, 2009; 14:449-64.
12. Baudonck N, Dhooge I, D'haeseleer E, Van Lierde K. A comparison of the consonant production between Dutch children using cochlear implants and children using hearing aids. Int J Pediatr Otorhinolaryngol, 2010; 74:416-21.
1) Neurotology Fellow - Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil.
2) Professor and Chairman - Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil.
3) Associate Doctor - Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil.
4) Associate Professor - Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil.
Institution: Departamento de Otorrinolaringologia - Hospital das Clínicas/Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. São Paulo / SP - Brazil. Mailing address: Aline Gomes Bittencourt - Departamento de Otorrinolaringologia do Hospital das Clínicas da Universidade de São Paulo - Avenida Professor Doutor Enéas de Carvalho Aguiar, 255 - 6 º andar / sala 6167 - Zip code: 05403-000 - São Paulo / SP - Brazil.
Article received in October 30, 2011. Article approved in February 11, 2012.
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