Hearing And Speech Rehabilitation Of Children With Hearing Loss After HA/CI And Influencing Factors

Objective:This study intends to make a comprehensive and longitudinal summary of the overall development law of cochlear implant（CI）children and children wearing hearing aids（HA）from early pre-speech listening to late advanced speech perception and understanding,and on this basis,establish a good longitudinal prediction model for clinical use,and introduce longitudinal data research methods to explore the long-term factors affecting early pre-speech listening,and further explore the specific advantages of binaural dual mode（unilateral CI+contralateral HA）in listening.The sub-chapters are stated as follows:Chapter 1:1)To study the early prelingual auditory development（EPLAD）and the changes of hearing threshold in children after cochlear implantation in two years;2)Establish the score curve model of infant meaningful auditory integration scale（ITMAIS）which changes with time;3)To explore the correlation between preoperative hearing threshold and the development of EPLAD.Chapter 2:1)to explore the influencing factors of EPLAD at different time points after cochlear implantation in children with severe binaural presbyopia;2)Establish a suitable mixed linear and growth model to study the longitudinal data and explore the long-term influencing factors of children’s EPLAD development after CI implantation.Chapter 3:1)To study the longitudinal development of EPLAD in children with different hearing loss after wearing HAs;2)According to the results of long-term multi-point follow-up,compare the differences of EPLAD development track of children with hearing AIDS,and establish a curve model to predict their scores changing with time;3)For hearing impaired children with bilateral severe or profound hearing loss,compare whether there are differences in the development of EPLAD under different intervention measures（wearing HAs or implanting CI）.Chapter 4:1)Explore the development of CI children’s early speech perception and understanding of Putonghua as a whole;2)To study the development of speech comprehension ability of children of different hearing ages under different signal-to-noise ratios;3)To explore the development differences between normal children and CI children in early Mandarin speech perception and understanding;4)Discuss the influence of binaural dual mode on early speech perception and comprehension of Putonghua.Material and method:Chapter 1 and Chapter 2:Children who received unilateral CI implantation in Otorhinolaryngology Head and Neck Surgery of west china hospital from January2016 to January 2018 were selected,and their listening level and early hearing ability were followed up for two years.Children’s hearing threshold was evaluated by behavioral audiometry or pure tone audiometry,and EPLAD was evaluated by ITMAIS.They were evaluated before operation and 1,3,6,12,18 and 24 months after cochlear implant activation.The EPLAD trajectory of all children with hearing impairment is described by Spline function,which makes it a smooth curve.linear regression is generally used to predict the change of Pure Tone Average（PTA）with time,while Cubic function curve fitting is used to predict the change of ITMAIS score with time.Pearson correlation is used to analyze the correlation between PTA and ITMAIS before operation.Multiple linear regression model was used to explore the influencing factors of EPLAD in children with hearing impairment before operation,6 months,12 months and 24 months after activation.For repeated measurement of ITMAIS data,linear mixed model and growth mixed model are constructed in R language to study the factors affecting vertical development.Furthermore,the children were divided into groups with or without influencing factors,and the development differences of EPLAD among different groups of children with weak hearing were compared.Chapter 3:From January 2016 to January 2018,the hearing level and EPLAD of hearing impaired children who received bilateral hearing AIDS fitting in Otorhinolaryngology Head and Neck Surgery of west china hospital were followed up for 18 months.According to the degree and type of hearing loss,children with weak hearing loss are divided into seven groups,among which children with symmetrical hearing loss are divided into mild group,moderate group,severe group and profound group.Children with slightly asymmetric hearing loss were divided into mild-moderate group,moderate-severe group and severe-extreme group.Children’s hearing threshold was evaluated by behavioral audiometry or pure tone audiometry,and EPLAD was evaluated by ITMAIS.They were evaluated at the fitting time of hearing AIDS and at the 3rd,6th,12th and 18th months after hearing AIDS were worn.Use Spline function to describe the EPLAD trajectory of all children;Cubic function curve fitting is used to predict the change value of ITMAIS score with time;According to the nature of data,the differences between groups or within groups were compared by paired t test,chi-square test or Student T test.Chapter 4:From January 2016 to January 2018,the hearing-impaired children aged 1-7 years after receiving unilateral CI implantation in Otorhinolaryngology Head and Neck Surgery of west china hospital were selected to test their Mandarin speech ability.Mandarin Early Speech Perception Test（MESP）was used to evaluate the perception ability of speech rhythm,homophonic words,finals recognition,initials recognition and tone recognition of children with weak hearing.The mandarin pediatric speech intelligibility test（mpsi）was used to evaluate the speech comprehension ability of children with weak hearing under different signal-to-noise ratios.According to the different hearing ages,children are divided into three groups:1-3 years old group,3-5 years old group and 5-7 years old group.For the difference comparison of categorical variables among the three groups,multiple contingency table chi-square test is used.For the difference comparison of continuous variables between the two groups,according to whether they meet the normal distribution,independent sample T test or nonparametric test is used;For the classified variables between the two groups,Chi-square test or Fisher exact probability test is selected according to whether the theoretical frequency is greater than 5.Results:Chapter 1:86 children with hearing impairment were included in this study.Compared with pre-operation,the hearing threshold of children with weak hearing improved greatly after CI was turned on,and PTA after CI was turned on reached36.86±4.29 d B HL.Follow-up showed that there was no significant difference in hearing threshold at the 3rd,6th,12th,18th and 24th months after CI was turned on（p=0.08）,and the change of hearing threshold described by general linear model was Y_（PTA）=-0.177*X+38.92（R=0.93,0≤X≤24）.However,the ITMAIS scores were significantly different at the 1st,3rd,6th,12th,18th and 24th months after CI activation（p<0.01）.The ITMAIS scores increased with time,and each follow-up was significantly improved compared with the previous follow-up.In the first year after CI was started,the score of ITMAIS increased by 67.53%,and the second year continued to increase by 15.23%based on the first year.The model of predicting ITMAIS score with time by Cubic function is Y_（EPLAD）=0.01*X³-0.54*X²+10.85X+16.17（R=0.99,0≤X≤24）.Preoperative PTA was negatively correlated with ITMAIS score（R=0.05,p=0.05）Chapter 2:The factors affecting EPLAD of CI children before operation include preoperative hearing threshold,preoperative speech imitation ability and preoperative hearing aid wearing.The influencing factors of half a year and one year after operation are preoperative speech imitation ability and postoperative opposite hearing aid wearing;Two years after operation,the influencing factors were wearing hearing AIDS to the side ear after operation,and the training time of hearing and speech rehabilitation after operation.The factors affecting the longitudinal development of EPLAD for children with hearing impairment include:wearing hearing aids to the ear and whether they have the ability of speech imitation before operation.Children are divided into two groups according to whether they wear hearing aids after CI implantation.There are differences in the development track of EPLAD between CI+HA group and CI group（p<0.01）.EPLAD in CI+HA group develops more rapidly,and the EPLAD scores of the two groups are not close until the 24th month after CI is turned on.At the same time,compared with CI group,CI+HA group has more obvious improvement in sound perception and recognition ability within two years（p=0.007;p<0.001）.Compared with the children with speech imitation and the children without speech imitation,the development track of EPLAD between the two groups is also different（p<0.05）.The improvement of EPLAD,voice detection and recognition ability of children with speech imitation ability is more obvious in two years（p=0.023;p=0.037;p=0.019）.Chapter 3:This part of the study finally included 97 children with different hearing loss.After wearing hearing aids,the hearing level of seven groups of children with weak hearing improved significantly（p<0.001）.There is no significant difference between two adjacent time points in ITMAIS scores of children with mild hearing impairment after wearing hearing aids（p>0.05）.For children with mild-moderate,moderate,moderate-severe,severe-profound,and profound hearing impairment,the ITMAIS scores after wearing hearing aids were significantly higher at each follow-up time than the previous one（p<0.01）.Children with mild,mild-moderate,and moderate hearing loss have an ITMAIS score of over 90%one year after wearing hearing aids.However,for children with severe,severe-profound,and profound hearing loss,the scores are relatively backward.Especially for the profound children,although the early hearing was improved,the score was only 58.5%at the last follow-up in the 18th month.In the severe to profound group,the scores of ITMAIS in CI children at the 3rd,6th,12th,and 18th months were significantly better than those in hearing aids（p<0.01）.According to the data of seven groups of children with hearing impairment at different time points,the scores of ITMAIS of hearing-aid and non-hearing-aid children were fitted by curves,and Cubic（Y=B₀+B₁*X+B₂*X²+B₃*X³）model was the best one,with all fitting R>0.99.ConclusionChapter 1:The hearing threshold of CI children has been greatly improved after operation,and remains stable after activation;However,EPLAD showed a continuous and uneven upward trend,with the fastest growth rate within 12 months after activation,and the score was close to full marks in the 24th month.For children with severe or profound hearing loss,the more serious the hearing loss,the more backward the development of EPLAD.Chapter 2:The influencing factors of EPLAD in children after CI operation are not fixed but change dynamically with time.The long-term influencing factors of EPLAD in children after CI operation are wearing hearing aids on the opposite side and speech imitation ability.Chapter 3:The development of EPLAD is similar to CI after hearing aids are worn by children with different hearing loss,which is fast at first and then slow,and gradually enters the plateau.Hearing aids have the best compensation ability for children with mild,mild-moderate,moderate and moderate-severe hearing loss.For children with severe and profound hearing loss,CI is the best hearing compensation effect,but hearing aids can still partially compensate for hearing when cochlear implants are not available.Chapter 4:（1）For hearing children aged 1-7 years with CI implanted unilaterally,the recognition ability of speech rhythm and spondee words develops the fastest,followed by initial recognition,while the development of final and tone recognition is the slowest;Among all tones,the development of two or three tones recognition is the slowest,and the other tones develop similarly.（2）On the whole,the development of normal children’s speech perception ability in early Putonghua is better than that of CI children,among which the recognition ability of speech rhythm and spondee words is still the fastest,while the development of finals and initials is almost simultaneous,without obvious backwardness.Compared with other recognition abilities,the development of tone recognition ability is slow.（3）The speech rhythm,vowel,initial consonant,tone and short sentence recognition ability of hearing-impaired children with binaural dual-mode listening are obviously superior to those of children who only wear CI.Therefore,in clinical work,doctors should encourage children with CI implanted unilaterally to wear hearing aids continuously and regularly in opposite ears.（4）For CI children aged 2-5 years,the higher the signal-to-noise ratio and the longer the hearing age,the better the speech comprehension.When environmental noise is stronger than signal sound,normal children have obvious advantages over unilateral CI children in speech comprehension,so it is of great significance to further improve the speech recognition of cochlear implants in noisy environment.