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 Table of Contents  
Year : 2017  |  Volume : 23  |  Issue : 3  |  Page : 185-188

Speech language development after cochlear implants in prelingual children according to the age of implantation

Department of Otorhinolaryngology, Head and Neck Surgery, University of Campinas – UNICAMP, Campinas, SP, Brazil

Date of Web Publication31-Aug-2017

Correspondence Address:
Henrique Furlan Pauna
Faculdade de Ciências Médicas – UNICAMP, Rua: Tessália Vieira de Camargo, nº126, CEP: 13083-887, Campinas, SP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_50_17

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Objectives: The purpose of this article is to evaluate the results regarding speech development of implanted children according to the age of implantation. Materials and Methods: This is a retrospective study with all implanted children at a tertiary hospital from 2003 to 2010. Children were grouped according to the age of the activation of the cochlear implant (CI), gender, and etiology. The degree of oral communication and the speech development using the MacArthur-Bates scale were evaluated. Results: Fifty-six children were included, 23 of them were activated before 3 years of age and 33 between 3 and 6 years. The average time of CIs use was 66 months with no significant difference between groups. Oral communication and the MacArthur-Bates Communicative Development Inventories were significantly better in children activated before 3 years (P = 0.018). Conclusion: The oral communication and speech development of children implanted before 3 years of age were significantly better than children implanted after 3 years of age.

Keywords: Age of implantation, children, cochlear implants, development speech

How to cite this article:
Guimarães AC, Pauna HF, Curi SB, Silva VR, Duarte AS, Castilho AM. Speech language development after cochlear implants in prelingual children according to the age of implantation. Indian J Otol 2017;23:185-8

How to cite this URL:
Guimarães AC, Pauna HF, Curi SB, Silva VR, Duarte AS, Castilho AM. Speech language development after cochlear implants in prelingual children according to the age of implantation. Indian J Otol [serial online] 2017 [cited 2019 Jul 21];23:185-8. Available from: http://www.indianjotol.org/text.asp?2017/23/3/185/213870

  Introduction Top

Cochlear implants (CIs) have improved life quality of children and adults worldwide,[1],[2] making auditory rehabilitation possible to deaf people due to the transformation of acoustic energy into electric stimuli.[3] It is considered the ideal treatment of children with profound bilateral hearing loss.[4]

The age of implantation is a factor truly related to auditory results, and children who received their implants in an earlier age have better audiological results and oral speech acquisition.[5],[6],[7] Deaf children implanted before 2 years of age had better results of the learning of spoken language than those ones implanted later.[8]

There are many studies showing that, in general, better audiological results are achieved when early implantation is done. However, comparisons between specific age groups are still scarce. Because there is little evidence in the literature, the results of this study may help to develop public health politics focusing an earlier implantation.


This study aims to evaluate the level of speech language development obtained from severe-to-profound, congenital or acquired, deaf children implanted in different ages.

  Materials and Methods Top

This is a transversal retrospective study, where all the data related to implanted children in a teaching hospital in Southeast of Brazil, from October 2003 to May 2010. All patients were first fitted with bilateral hearing aids, during a 3-month period, at least. However, with no benefits and with no language acquisition. Children were divided in different groups according to their age at the moment of the CI activation. First group, named “Group A,” was composed by children who had their CI activated up to 3 years of age (36 months); second group, “Group B,” had their CI activated between 3 and 6 years of age (37–72 months). We decided to compare both groups since only a few studies had evaluated such ages after implantation.

All the data related to the age of implantation, etiology of their hearing loss, side of implantation, gender, auditory tests before implantation, length of use of the CI, and oral communication skills that were acquired after the implantation. We also used the MacArthur-Bates Communicative Development Inventories for language evaluation, in Portuguese. All implanted children were included in this study; therefore, no exclusion criteria were used. We also included only unilateral implanted children because bilateral CI is not yet covered by the Brazilian Public Health System.

The MacArthur-Bates Communicative Development Inventories are widely used for parental reports, and provide a cost-efficient, reliable and valid means for assessing early language skills. It was first developed for English language, but now it is adapted to more than 60 languages.[9]

In addition, oral communication skills were defined according to a subjective evaluation performed by a single Audiologist (SBC), as follow: “poor” (no comprehension of speech, no auditory attention); “good” (understanding of speech with no need of visual clues, but eventually need to use lip reading. Use of short sentences and eventually incomplete); and “excellent” (understanding of speech with no need of visual clues, use of oral communication with proper use of connective terms).

Statistical analysis

For the data normally distributed, we used Chi-square test, Spearman Rank correlations, Pearson Correlations, and the independent t-test. The Mann–Whitney U-test was used for the data not normally distributed. We used the software Sigma XL for statistical analyses. Findings were considered statistically significant when P < 0.05.


This is a retrospective study with a chart review, so there was no informed consent form to be filled by any patient. The institutional review board approved this project.

  Results Top

The final group included in this study comprised of 56 medical charts, from 25 male patients, and from 31 female patients. Children underwent through cochlear implantation, and their ages during surgery ranged from 1 to 6 years of age. Group A, with 23 patients, and Group B with 33 patients [Table 1] and [Table 2].
Table 1: Descriptive analysis of the samples

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Table 2: Descriptive analysis of the age of implantation (months)

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According to the side of implantation, Group A had 13 children with their CI done on the right side, and 10 implanted on the left side. Group B, instead, had 17 children implanted on the right side, while 16 were implanted on the left side [Table 3].
Table 3: Descriptive analysis of groups and side of implantation

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Group A presented six cases of genetic deafness, six cases of infectious deafness, two cases related to ototoxic drugs use, and nine cases of unknown causes. Group B presented 3 cases of genetic deafness, 9 cases of infectious deafness, 1 case due to ototoxic drugs use, and 20 cases of unknown causes [Table 4].
Table 4: Analysis of groups according to their etiology of hearing loss

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The comparison between both groups, regarding the duration of use of CI, in months, is shown in [Table 5]. There was no statistical difference between the groups when one considers the duration of use of the device (P = 0.900).
Table 5: Duration of use of cochlear implant (months)

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Considering the oral communication skills, an important difference was observed. Group A had five children with oral communication considered as “poor,” nine considered “good,” and 10 considered “excellent,” while in Group B, 13 children had their oral communication skills considered “poor,” 15 considered “good,” and 5 considered “excellent.” Differences between the two groups were statistically significant (P = 0.041) [Table 6]. We also observed a statistically significant correlation when considering the age of the activation of the device with better oral communication skills (P = 0.024). Based on this observation, we may infer that the older is the patient when activating the device, the worse is the oral communication.
Table 6: Oral communication skills between groups

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Finally, the set of words based on the MacArthur-Bates Communicative Development test showed that Group A had the lowest score of 120 and highest of 725 (mean 581.66); and Group B showed the lowest score of 69 and highest of 725 (mean 447.0) (P = 0.018) [Table 7].
Table 7: MacArthur-Bates Communicative Development Test results between groups

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  Discussion Top

As a result of newborn hearing screening, and therefore, early auditory rehabilitation with CI, children with profound hearing impairment have access to sound (auditory signals and spoken language) at a very early age.[10] Despite the large use of CI to restore hearing in prelingual deaf children in the last 30 years, many studies have demonstrated that the late implantation (after the age of 6–7 years old) do not benefit as much as earlier implantation.[11] One plausible explanation is the absence of sound stimulation during the critical period of auditory plasticity.[11] Experimental studies showed that the destruction of the cochlea during the early phase of development in young animal models led to the establishment of new innervating patterns in the auditory pathway.[12],[13],[14],[15],[16]

In 1995, there were 12,000 implanted patients worldwide. In 2008, this number was 120,000 and reached the number of 200,000 implanted patients in 2010.[15] Main outcomes are very satisfactory, however, individual results vary considerably. This marked variability is partly explained by peripheral predictors (as the number of spiral ganglion cells, or the position of the electrode array); the duration of hearing loss (or sound deprivation); and the central nervous system. It is important to consider that cognitive factors, as well as motivation to use auditory information, also play an important role in the performance of CI.[16],[17]

As aforementioned, the age of implantation is a factor related to auditory results. Many studies have assessed and showed improvement among patients with prelingual hearing loss who underwent to cochlear implantation.[3],[18],[19],[20] Bosco et al.[20] demonstrated that CI improved speech perception among adults and adolescents – with positive impact in both groups – but with a better hearing outcomes within the last group. However, only a few studies compared the results among younger implanted children.

Liu et al.[21] retrospectively evaluated the auditory and speech abilities in children with the auditory neuropathy spectrum disorder after cochlear implantation before or after 2 years of age. They found that children implanted before 2 years of age tended to show better results in auditory and speech tests than those implanted after that age. In another study, children between 1 and 3 years of age who underwent to a cochlear implantation were compared based on their auditory skills. The younger group showed acquired auditory skills closer to those children with normal hearing at a younger age.[22] Harrison et al.[23] investigated 82 children implanted between 2 and 13 years of age; children implanted at age 5 or younger were found to outperform their older peers in all speech tasks with children implanted at 2 years of age exceeding all other groups. Furthermore, Montag et al.[24] investigated long-term speech intelligibility outcomes in 63 deaf children, adolescents, and young adults who received their CI before age seven and used for at least 7 years. Their results were compared with normal hearing listeners. They found that the majority of CI users scored within the range of the control sample.

Our study found interesting results since we observed that a premature cochlear implantation with activation of the device before the age of 3 years resulted in better speech language development when compared to children implanted after that age. Similar results were obtained by Ramos-Macías et al.[8] that found statistical differences between groups of sequentially bilaterally implanted children, ranging from 10 months to 5 years. Children under 2 years of age reached better results than the ones implanted after this age (P < 0.05). Another study showed better auditory skills, speech perception, and language production in children implanted under the age of 5 years.[25] Thus, excellent or good results may be reached in most of the children when a CI is implanted before the age of 3 years, as demonstrated in this study.

  Conclusion Top

We observed a correlation on younger age of implantation and better outcomes in audiological tests. Early diagnostic and rehabilitation are, indeed, recommended for children so they may be able to reach proper auditory skills.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Duarte I, Santos CC, Rego G, Nunes R. Health-related quality of life in children and adolescents with cochlear implants: Self and proxy reports. Acta Otolaryngol 2014;134:881-9.  Back to cited text no. 1
Huttunen K, Rimmanen S, Vikman S, Virokannas N, Sorri M, Archbold S, et al. Parents' views on the quality of life of their children 2-3 years after cochlear implantation. Int J Pediatr Otorhinolaryngol 2009;73:1786-94.  Back to cited text no. 2
Heman-Ackah SE, Roland JT Jr., Waltzman SB. Cochlear implantation in the late childhood and adolescence: Is there such a thing as 'too late'? Expert Rev Med Devices 2012;9:201-4.  Back to cited text no. 3
Bond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: A systematic review and economic model. Health Technol Assess 2009;13:1-330.  Back to cited text no. 4
Colletti L, Mandalà M, Zoccante L, Shannon RV, Colletti V. Infants versus older children fitted with cochlear implants: Performance over 10 years. Int J Pediatr Otorhinolaryngol 2011;75:504-9.  Back to cited text no. 5
May-Mederake B. Early intervention and assessment of speech and language development in young children with cochlear implants. Int J Pediatr Otorhinolaryngol 2012;76:939-46.  Back to cited text no. 6
Geers AE. Speech, language, and reading skills after early cochlear implantation. Arch Otolaryngol Head Neck Surg 2004;130:634-8.  Back to cited text no. 7
Ramos-Macías Á, Borkoski-Barreiro S, Falcón-González JC, Plasencia DP. Results in cochlear implanted children before 5 years of age. a long term follow up. Int J Pediatr Otorhinolaryngol 2014;78:2183-9.  Back to cited text no. 8
Frota S, Butler J, Correia S, Severino C, Vicente S, Vigário M. Infant communicative development assessed with the European Portuguese MacArthur–Bates Communicative Development Inventories short forms. First Lang 2016;36:525-45. [DOI: 10.1177/0142723716648867].  Back to cited text no. 9
van Wieringen A, Wouters J. What can we expect of normally-developing children implanted at a young age with respect to their auditory, linguistic and cognitive skills? Hear Res 2015;322:171-9.  Back to cited text no. 10
Kos MI, Deriaz M, Guyot JP, Pelizzone M. What can be expected from a late cochlear implantation? Int J Pediatr Otorhinolaryngol 2009;73:189-93.  Back to cited text no. 11
Kral A, Tillein J, Heid S, Klinke R, Hartmann R. Cochlear implants: Cortical plasticity in congenital deprivation. Prog Brain Res 2006;157:283-313.  Back to cited text no. 12
Clopton BM, Silverman MS. Plasticity of binaural interaction. II. Critical period and changes in midline response. J Neurophysiol 1977;40:1275-80.  Back to cited text no. 13
Guiraud J, Besle J, Arnold L, Boyle P, Giard MH, Bertrand O, et al. Evidence of a tonotopic organization of the auditory cortex in cochlear implant users. J Neurosci 2007;27:7838-46.  Back to cited text no. 14
Sharma A, Gilley PM, Dorman MF, Baldwin R. Deprivation-induced cortical reorganization in children with cochlear implants. Int J Audiol 2007;46:494-9.  Back to cited text no. 15
Lazard DS, Giraud AL, Gnansia D, Meyer B, Sterkers O. Understanding the deafened brain: Implications for cochlear implant rehabilitation. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:98-103.  Back to cited text no. 16
Watson SD, Balko KA, Comer LK, Bishop RD, Reilley D, Backous DD, et al. Benefits of cochlear implantation in pre-lingual adult users: Oral and manual communicators. Cochlear Implants Int 2003;4 Suppl 1:75-6.  Back to cited text no. 17
Angelo TC, Bevilacqua MC, Moret AL. Speech perception in pre-lingual deaf users of cochlear implant. Pro Fono 2010;22:275-9.  Back to cited text no. 18
Souza IP, Brito R, Bento RF, Gomez MV, Tsuji RK, Hausen-Pinna M. Speech perception in adolescents with pre-lingual hearing impairment with cochlear implants. Braz J Otorhinolaryngol 2011;77:153-7.  Back to cited text no. 19
Bosco E, Nicastri M, Ballantyne D, Viccaro M, Ruoppolo G, Ionescu Maddalena A, et al. Long term results in late implanted adolescent and adult CI recipients. Eur Arch Otorhinolaryngol 2013;270:2611-20.  Back to cited text no. 20
Liu Y, Dong R, Li Y, Xu T, Li Y, Chen X, et al. Effect of age at cochlear implantation on auditory and speech development of children with auditory neuropathy spectrum disorder. Auris Nasus Laryn×2014;41:502-6.  Back to cited text no. 21
McConkey Robbins A, Koch DB, Osberger MJ, Zimmerman-Phillips S, Kishon-Rabin L. Effect of age at cochlear implantation on auditory skill development in infants and toddlers. Arch Otolaryngol Head Neck Surg 2004;130:570-4.  Back to cited text no. 22
Harrison RV, Gordon KA, Mount RJ. Is there a critical period for cochlear implantation in congenitally deaf children? Analyses of hearing and speech perception performance after implantation. Dev Psychobiol 2005;46:252-61.  Back to cited text no. 23
Montag JL, AuBuchon AM, Pisoni DB, Kronenberger WG. Speech intelligibility in deaf children after long-term cochlear implant use. J Speech Lang Hear Res 2014;57:2332-43.  Back to cited text no. 24
AlSanosi A, Hassan SM. The effect of age at cochlear implantation outcomes in Saudi children. Int J Pediatr Otorhinolaryngol 2014;78:272-6.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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