IP Indian Journal of Anatomy and Surgery of Head, Neck and Brain

Print ISSN: 2581-5210

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Vishwa and Fefar: Effect of age on outcome of auditory verbal therapy in cochlear implantation


Cochlear implantation brings hope for patients having profound hearing loss. Auditory nerve excitation by electrical stimulation results in poor resolution of information of verbal stimulation. Only implantation will not suffice but adequate and timely post implantation Auditory Verbal Therapy can help patients make greatest use of their cochlear implantation. The rehabilitation programme includes structured set of exercises designed to help the patient understand and recognize the sound signal. It begins with simply detecting the sound then distinguishing different sounds and thence to recognize spoken words.

The first 3 years in a child’s life are critical for acquiring information about the world, communicating with the family and developing a cognitive and linguistic foundation. Children deprived of language input in early life are at risk of poor academic performance later in childhood resulting in socio-emotional and behavioral problems. Thus speech is the most efficient means of communication within families and local community.1 The existence of a critical period for language development during first five years of life is well established. Providing auditory stimulation during this period is critical.2 Speech intelligibility refers to the amount by which a speaker’s message is recognized by the listener. When impaired it impacts communication. Adequate development of speech intelligibility is important for –integration into society, quality of life, access to mainstream education, psychosocial and professional development. A cochlear implant is a prosthetic device which replaces the transducer function of damaged hair cells and provides electrical stimulation enabling meaningful activation of auditory cortex.2 Children implanted early who do not have other significant developmental disabilities and when coupled with intensive post implantation speech language therapy, may acquire age appropriate speech, language, developmental and social skills. A team approach coordinated by ENT consultant, cochlear implant coordinator, speech language pathologist, audiologist and counselor is essential for language development. There are many therapies available to address learning and communication for children with hearing impairment- Auditory verbal therapy, sign language, cued speech, total communication, simultaneous communication, verbo-tonal or guberina method and natural auditory oral approach. Auditory verbal therapy is a parent centered approach that encourages the use of naturalistic conversation and use of spoken language to communicate.3 Auditory verbal therapists are trained to provide therapy sessions, train parents and manage educational services. The ultimate goal is to develop hearing as an active sense so that listening becomes an integral part of the child’s development. Total language development consists of comprehension, verbal reasoning, narrative ability and spontaneous language production.4

Materials and Methods

This is a prospective study carried out in 40 bilaterally deaf children of age group 2-7 years of both genders with no benefit with hearing aid who underwent cochlear implantation surgery and receiving auditory verbal therapy at regular intervals at the department of otorhinolaryngology, P.D.U. medical college and hospital, Rajkot.

Inclusion criteria

All bilaterally deaf children of age group 2-7 years with no benefit with hearing aid no other known conditions that interfere with speech/language development, no known problems with the cochlear implant lasting over 30 days and completed 6 months of AVT.

Exclusion criteria

  1. Children with neurological defects

  2. Children with anatomic defects of the middle ear, inner ear, eighth nerve.

  3. Children with less than 6 months of AVT

The children were assessed by revised Categories of Auditory Performance (CAP) score described by The Shepherd centre based on Nottingham CI program, 1995. 5 Speech intelligibility and quality was assessed by Speech Intelligibility Rating (SIR) of O’Donoghue et al. 6 The aim of the study is to examine the effects of age, duration and type of early auditory experience on spoken language competence. Patients are assessed by number of levels of development of speech and listening skills:

Table 1

revised Categories of Auditory Performance (CAP) score: The Shepherd centre based on Nottingham CI program, 19955



Level 0

Unaware of environmental sounds

Level 1

Detects some environmental sounds

Level 2

Responds to some speech sounds

Level 3

Can identify some environmental sounds

Level 4

Understands some spoken words with additional performatives e.g. ‘ where is the duck that says quack quack’, ‘give me the car brmm’

Level 5

Understands common phrases e.g. pick it up; it’s bath time

Level 6

Understands some spoken words without performatives e.g. give me the duck’/ ‘go get the car’

Level 7

Responds appropriately to simple questions e.g. what is it?

Level 8

Understands conversations with familiar speakers

Level 9

Understands conversations with unfamiliar speakers

Level 10

Follows recorded stories

Level 11

Uses the telephone with familiar speakers

Level 12

Uses the telephone with unfamiliar speakers

Table 2

Speech Intelligibility Rating (SIR): O’Donoghue et al 6




Connected speech is intelligible to all listeners. Child is understood easily in everyday contexts


Connected speech is intelligible to a listener who has little experience of a deaf person’s speech.


Connected speech is intelligible to a listener who concentrates and lip reads.


Connected speech is unintelligible. Intelligible speech is developing in single words when context and lip reading clues are available.


Connected speech is unintelligible. Pre-recognizable words in spoken language; primary mode of communication may be manual.

Result and Discussion

Table 3

Age and sex distribution


<4 years

4-7 years















40 children who underwent cochlear implantation were divided in two groups based on age at implantation- <4 years and 4-7 years. 18(45%) children belonged to less than 4 years group and 22(55%) children belonged to 4-7 years age group. Out of 40 children, 12(30%) were female and 28(70%) were male.

Table 4

Revised CAP score and SIR score before and after implant.

<4 years

4-7 years

Before implant

1 month

6 months

Before implant

1 month

6 months

Average CAP score







Average SIR score







Before cochlear implantation, CAP score was category 0 and SIR score was category 1 in all patients.

CAP score and SIR score was evaluated in all patients after 1 month. Average CAP score was 1.3 in <4years age group and 1.27 in 4-7 years age group. SIR score was 1 in all children.

There was an improvement in all patients at 6 months after implantation. Average CAP score in children implanted below 4 years was 4.7 whereas in case of age group 4-7 age group, average CAP score was 3.72. So on an average child implanted before 4 years is able to understand common phrases while child implanted after 4 years is able to understand some spoken words.

On calculating t value, t(calculated)-3.33>t(critical)2.02. This states that the results are statistically significant.

Table 5

RevisedCAP score and SIR score at 6 months according to sex distribution.



Average CAP score



Average SIR score



On comparing the scores based on gender groups, average CAP scores in males was 4.17 and females was 4.16; the average SIR score was 2.92 in males and 3 in female. The difference was found to be of no significance.

In our study, average CAP score in children implanted below 4 years was 4.7 whereas in case of age group 4-7 age group, average CAP score was 3.72 at 6months after implantation. The average SIR score was 3.78 in <4 years age group and 2.54 in 4-7 years age group.

In the study done by V. Saravanan7 he compared CAP and SIR scores between age group <3 years and 3-6 years at 1 year after implantation. The mean CAP score was 5.17 in age group <3 years and 3.62 in age group 3-6 years. The mean SIR score was 4.04 in age group <3 years and 2.23 in age group 3-6 years at 1 year after implantation.

In the study done by Yang et al8 CAP and SIR scores among 3 age groups were compared; 1.3-2.9 years, 3-4.9 years and 5-7.9 years. The study showed that the scores were significantly higher in age group 1.3- 2.9 years as compared to other two groups.

Nikolopoulos et al9 studied 133 children and showed acceptable results in children implanted before 8 years of age. Better results were seen in patients implanted before the age of 4 years as compared to those after the age of 4 years.

Govaerts et al.10 analyzed a retrospective cross sectional study of 70 cochlear implant children and demonstrated that children implanted after the age of 4 years CAP scores rarely reached normal while children implanted at 2-4 years normal CAP scores were achieved.

Similar studies were carried out by Tajudeen et al and Fang et al; both the studies showed that before 3 years of age had significantly better CAP and SIR scores as compared to children >3 years.

Thus it can be concluded by the study that irreversible changes occurring in auditory system with prolonged auditory deprivation becomes a hindrance for normal language development. Therefore cochlear implantation should be performed as early as possible.


Cochlear implantation along with Auditory Verbal Therapy provides satisfactory hearing and speech abilities to congenitally deaf children. Auditory verbal therapy teaches young children to listen and communicate without depending on lip reading and sign language. Earlier cochlear implantation dramatically affects the amount of spoken language development.3 Children should be screened for hearing impairment to diagnose severe to profound hearing loss as early as possible and intervention provided at the earliest for best outcome. Regular follow up and active participation by parents is necessary to maximize the benefits.


  1. Comparatively small sample size

  2. Lack of long term follow up

Conflicts of Interest

All contributing authors declare no conflicts of interest.

Source of Funding




J Nicholas AE Geers Effects of Early Auditory Experience on the Spoken Language of Deaf Children at 3 Years of AgeEar and Hearing20062732869810.1097/01.aud.0000215973.76912.c6


M Gleeson JG Toner Scott-Brown’s Otorhinolaryngology, Head and Neck surgery17th Edn.18608


W Estabrooks Auditory verbal therapy for Parents and Professionals2004


AE Geers JG Nicholas AL Sedey Language Skills of Children with Early Cochlear ImplantationEar Hear20032414658




G M O'Donoghue D Dyar T P Nikolopoulos C Allen Reliability of a rating scale for measuring speech intelligibility after pediatric cochlear implantationOto Neurotol2001222631410.1097/00129492-200109000-00012


V Saaravanan M Nallasivam M Sivakumar Agewise Outcome of Speech And Hearing In Prelingually Deaf Children After Cochlear ImplantationIOSR-JMDS2017746974


HM Yang The auditory performance of children using cochlear implants: effects of mental functionInt J Pediatr Otorhinolaryngol200468911858


TP Nikolopoulos The development of auditory perception in children following cochlear implantationInt J Pediatr Otorhinolaryngol999118991


PJ Govaerts CD Beukelaer K Daemers GD Ceulaer M Yperman T Somers Outcome of Cochlear Implantation at Different Ages from 0 to 6 YearsOtol Neurotol20022368859010.1097/00129492-200211000-00013


© This is an open access article distributed under the terms of the Creative Commons Attribution License - Attribution 4.0 International (CC BY 4.0). which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Authors Details

Choksi Vishwa, Alpesh D Fefar

Article History

Received : 31-12-2020

Accepted : 30-01-2021

Available online : 21-04-2021

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