Gereç ve Yöntem: Bu çalışmaya 3-15 yaşları arasında, tek taraflı koklear implantasyon yapılmış ve cihazı en az 1 yıldır düzenli olarak kullanan, ileri derecede sensörinöral işitme kaybı olan toplam 40 çocuk dahil edilmiştir. Koklear implant operasyonu öncesi ve operasyondan 1 yıl sonra çocukların ebeveynleri tarafından sosyodemografik veri formu, Çocuklar için Yaşam Kalitesi Ölçeği (ÇİYKÖ) ve Vineland Uyum Davranış Ölçeği (VUDÖ) doldurularak sonuçlar karşılaştırılmıştır.

Bulgular: Katılımcıların 18'i (%45) kız, 22'si (%55) erkekti ve yaş ortalaması 6,18±3,40 idi. Katılımcıların tamamının ameliyat sonrası düzenli rehabilitasyonlarına devam ettikleri görülmüştür. Operasyon öncesi ve sonrası puanlar karşılaştırıldığında ÇİYKÖ alt ölçek puanları ve VUDÖ alt ölçek puanlarının (İletişim, günlük yaşam becerileri, sosyalleşme ve motor beceriler) ameliyattan bir yıl sonra anlamlı olarak yüksek olduğu saptanmıştır.

Sonuç: Bu çalışma, koklear implant uygulamasının çocuklarda yaşam kalitesi, dil becerilerinin gelişimi, motor beceriler ve sosyalleşme üzerinde olumlu etkisi olduğunu göstermektedir. İşitme kaybı olan çocuklarda koklear implant uygulaması gelişimin desteklenmesi açısından önemlidir ve çocuğun yaşam kalitesini artırır.

Cochlear implants are electronic devices applied to provide hearing in individuals with severe or very severe sensorineural hearing loss (SNHL), who do not benefit from the devices used in hearing loss. Although the most important indication of this operation is the hearing loss detected in the pre-lingualistic period, it is beneficial to apply it in all age groups where an implant is required.

Although the age of cochlear implantation varies regionally, in some countries it is determined as the individuals over one year of age⁴. The most important benefit of this operation is hearing gain that supports speech language development⁵. Developmental areas (language, cognitive, social and physical) regularly progress in interaction with each other. Changes in one area of development affect others positively or negatively.

It has previously been shown that hearing impaired children also exhibit atypical performance in a range of motor skills such as balance, eye-hand coordination, running and throwing compared to control children of the same age⁶. Conversely, improvement in hearing may lead to improvement in other development stages.

This in turn, supports motor development and may result in an improvement in the person's quality of life. The number of publications investigating quality of life associated with cochlear implant surgery has increased recently^7,8. The common result of these studies is that devices or cochlear implantation can prevent problems and contribute positively to quality of life.

However, when we look at the literature, there are few studies examining the effects of cochlear implantation on general development and adaptive behaviors in children. In this study, it was aimed to evaluate the pre- and post-operative general development and compare the quality of life of children with severe sensorineural hearing loss who were planned for cochlear implant operation.

Participants: When the difference between the preoperative and postoperative scale score averages of the participants was predicted as 1±1.8, when alpha two-sided = 0.05, 1-beta (power) = 0.90, it was calculated that at least 37 participants should be included in the study. This study included 40 children who were brought to the otorhinolaryngology clinic of a university hospital between May 2014 and September 2015 with the complaint of hearing loss who were diagnosed with bilateral very severe SNHL in the audiological evaluation and planned for cochlear implantation. Anomalies in the central auditory pathways and cochlear anomalies of the patients were investigated using radiological imaging methods (axial, coronal thin-section temporal Computed Tomography and Ear Magnetic Resonance Imaging) and their psychiatric examinations were performed. Patients who did not develop inner ear, whose presence of cochlear nerve could not be detected, and who were determined not to be suitable candidates for implant in psychiatric examination were excluded the study. Written informed consent was obtained from the families of all cases, and the VABS, PedsQL and SDD form were applied to the parents in the preoperative period. Unilateral cochlear implant operation was performed on these patients, and fitting adjustments were made by inserting a speech processor four weeks later in the post-operative period and afterwards, these patients were followed up regularly.

All patients used the cochlear implant device and continued their education in this process. VABS and PedsQL were re-administered to the patients one year after the operation and the results were compared.

Measures
Socio-demographic Data Form (SDF): It is a form prepared by researchers who question information such as age, gender, number of siblings, age of parents, education level of the child, education level of parents, family structure, place of residence, income level.

Vineland Adaptive Behavioral Scales (VABS): This scale, which was developed by Sparrow et al. (1984), is used to evaluate the adaptation behaviors of children with or without developmental delay consisting of 297 items. In the scale four fields about; Communication (Receptive and Expressive Language), Daily Life Skills (Personal, Domestic, Social Skills), socialization (Interpersonal relations, play, leisure and coping Skills) and motor skills (Fine and Gross Motor) are available. Items for each sub domain of Vineland start at birth, which is the lowest developmental level, and increase to 18 years and 11 months. Scoring at three levels; It is scored as 2 (always able), 1 (occasionally able) and 0 (don't know). The 7 items that the individual can always do (get 2 points out of 7 consecutive items) are determined as the "Base Score", which is the lowest level of development, and the 7 items that the individual cannot do (get 0 points from 7 consecutive items) are determined as the "Ceiling Score", which is the highest level of development. Therefore, while scoring the items, they progress from the lowest developmental level (baseline score) to the highest developmental level (ceiling score). Then, raw scores for each domain and its sub-areas and Total Scores are converted into standard scores, and the level of age-related and adaptive behavior is determined accordingly. In this study, the statistical evaluation of VABS results was made by calculating the difference between the expected development level and the current development level according to the patient's calendar age, both before and after the operation.

The Pediatric Quality of Life Inventory (PedsQL): The scale, which was developed by Varni et al. in 1999, aims to measure the general quality of life in the 2-18 age group (9). This scale has been prepared for four different age groups. The scale prepared for the 2-4 age group has only a parent form. The school subsection of this form, unlike other forms, consists of three items instead of five. The scale, which was developed for the 5-7 age group, has a parent and child form. The child form is filled by the researcher with the help of a diagram representing happy, neutral and sad facial expressions with the child. There is a parent and child form of the scale prepared for the 12-year-old group. The parent form is completed separately and simultaneously by the caregiver and the child form by the child included in the study. The scale, which was developed for the 13-18 age group, has a parent and adolescent form. The total score is obtained by adding the scores and dividing by the number of items filled. The psychosocial health total score, which consists of the scale total score, the physical health total score and the item scores evaluating emotional, social and school functionality is calculated. The higher the total PedsQL score, the better the health-related quality of life is perceived⁹. In this study, PedsQL parent forms were used for all age groups.

Statistical Analysis: The data of the study were evaluated with the SPSS “Statistical Package for Social Sciences (SPSS17.0)” program. Data related to qualitative variables are given as number and percentage. Normal distribution of data related to quantitative variables was investigated with the Kolmogorov Smirnov normality test. Data related to quantitative variables (age, number of siblings, maternal and paternal age) that do not show normal distribution are given as median and min-max. PedsQL and VABS scores show normal distribution, and the preoperative and postoperative scores of these two scales were compared with the paired sample t-test. In the evaluations, p<0.05 was accepted as the level of significance.

Demographic Data of Families: It was determined that 33 (82.5%) of the participants had a nuclear family and 7 (17.5%) had an extended family structure. Maternal age was 31.55±4.47 (min- max:23-41) and father's age was 34.45±3.94 (min-max: 28-43). Considering the monthly income of the families: 21 of them (52.5) were found to be low, 15 of them were moderate (37.5), and 4 of them were high. (low: less than 2000 TL, moderate: 2000-5000 TL, high: more than 5000 TL).

Bilingualism was found in 19 (47.5%) of the families of the participants. When asked about kinship in the parents of the participants, it was seen that the parents of 21 children (52.5%) were related.

Data on the demographic characteristics of the participants and their families are given in Table 1.

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Table 1: Clinical characteristics

Findings Related to Scale Scores: When the PedsQL Physical Functioning, Emotional Functioning, Social Functioning, and School Functioning scores were compared, post-operative scores were found to be significantly higher in all subscales (p<0.05).

Looking at the VABS scores, communication (receptive and expressive language), daily life skills (personal, domestic, social), socialization skills (interpersonal relations, play and leisure time and coping) and motor skills (Fine and Gross Motor) both total scores and subscale scores were found to be significantly higher after the operation (p<0.05). Information on PedsQL and VABS scale scores is given in Table 2.

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Table 2: Scales scores

Although several demographic factors, including age at implantation and modality of communication, have been found to affect coclear implant operation outcomes in deaf children, a large portion of the variance remains unexplained⁶.

The patient's age, operation age, implant model, time spent with hearing loss before using a hearing aid, patient's gender, and the child's psychiatric and behavioral status are the most common factors affecting the results of the operation.^5,12,13. In this study, the mean age of the patient was 6, and it was observed that implantation performed in the relatively early period and regular continuation of rehabilitation significantly reduced the difference between the calendar age and the current development level in both receptive and expressive language.

Previous studies suggest that the close connections between language and motor systems may be the result of shared neural processing in the pre-motor cortex⁶.

Again, due to the close connection between the hearing organ and the vestibular system, damage to one of the organs may affect the other, negatively affecting muscle control and motor functions. Although all these factors are well known, studies examining the effect of the cochlear implant on motor and other developmental areas are limited in the literature.

In the study of Horn et al.⁶; While the gross motor skills of hearing- impaired children who had cochlear implantation before the age of 5 without intellectual disability or developmental delay were found close to their chronological age, these children's fine motor skills were found to be delayed. In our study, it was shown that the cochlear implant provides significant improvement in both gross and fine motor skills. However, there are studies in the literature showing that the effects of early auditory deprivation may be far-reaching and that some cognitive, motor, and social functions may continue to be impaired in children using cochlear implants^14,15.

The difficulties they experience in communication skills also negatively affect the social and emotional development of children with hearing loss in their daily lives. These children lag behind their normally hearing peers in their emotional development, which includes recognizing and understanding words that express emotions¹⁶. It has also been shown in previous studies that the social and emotional development of children after cochlear implants increases^17,18.

Huttunen et al., in their study with 36 families, reported that in children whose average age of implantation was two and when reached to average age of 5, the subjects that families were most satisfied with increased: Social relations, increased communication, spoken language and general function¹⁹. In our study, the post-operative socialization subscales (interpersonal relations, play and leisure time activities, and coping skills) and total scores were found to be significantly closer to their peers, supporting the literature in this aspect.

In this study, both subcategories and total scores of VABS Daily living skills were found to be significantly higher after the operation. This section consists of questions on personal skills such as “How does the child eat, dress and take care of himself?” household skills such as "What are the child's household duties?", and social skills such as “How is the child's use of time, money, telephone, computer?”. Based on this, it is possible to deduce that developments in cognitive, social and motor areas also have a positive effect on daily life skills.

The World Health Organization (WHO) defined the quality of life in 1997 as how individuals perceive their positions in life in line with their goals, expectations, interests and living standards within the culture and value system in which they live. The general view about cochlear implantation operation and quality of life is that such devices and a successful rehabilitation process will prevent many problems and contribute positively to the quality of life. By applying a life questionnaire consisting of 22 questions prepared by Edward et al.²⁰ to 89 parents, they stated that the cochlear implant had a positive effect on the quality of life of the patients, and that the children's communication skills and freedoms increased. Tavares et al.²¹ Also reported that cochlear implant had a positive effect on quality of life in a 40- question survey conducted with mothers of 10 implanted children. Vidas et al.^22, in their study with the families and therapists of 4 children, emphasized that children are good at hearing and perceiving sounds, but the effect on the quality of life is not one-to-one, so tests for quality of life are necessary. In a study, they stated that there were differences in the quality of life between children with normal hearing and hearing loss, and these differences were especially prominent in school or social environments²³. In this study, a significant increase was found in all subscales of the quality of life (Physical Functioning, Emotional Functioning, Social Functioning, and School Functioning) of children who underwent surgery, and the results are consistent with previous findings in the literature.

Our study has some strengths and limitations. First of all, this study is one of the few prospective studies evaluating general development and adaptation behaviors from a parent perspective in cochlear implantation. The relatively large number of samples in the study, the fact that all the patients were followed up for one year continue to the regular rehabilitation program, and the fact that patients with psychopathology were not included are the other strengths of this study. However, the lack of a causal relationship between the results, the fact that information was only taken from parents, results were evaluated with scales and that it consisted of only patients with unilateral cochlear implants are the limitations of the study. The fact that evaluation of motor development does not include a physical examination is another limitation of the study. Another important limitation is that data reached after one year cannot be generalized to all stages of life. Taking this issue into account in the future, longer- term follow-up studies will provide clearer information on this issue.

In conclusion, this study shows that cochlear implantation has a positive effect on an increase in the quality of life, the development of language skills, motor skills and socialization in children. Considering that developmental areas affect each other, this operation should be performed in the early period to support the development of the child in all of the mentioned areas.

Source of funding: None.

Conflicts of interest: The authors have no conflicts of interest to declare

1) Korver AM, Smith RJ, Van Camp G. et al. Congenital hearing loss. Nat Rev Dis Primers 2017; 3(1): 1-17.

2) Lieu JE, Kenna M, Anne S. et al. Hearing Loss in Children: A Review. JAMA 2020; 324(21): 2195-2205.

3) Peters JP, Ramakers GG, Smit AL. et al. Cochlear implantation in children with unilateral hearing loss: A systematic review. Laryngoscope 2016; 126(3): 713-721.

4) İncesulu ŞA. Koklear implant endikasyonları: Günümüzden geleceğe. Turkiye Klinikleri J ENT Special Topics 2021; 5: 52-58.

5) Schow RL, Nerbonne MA. Introduction to audiologic rehabilitation: Pearson, 2017.

6) Horn DL, Pisoni DB, Miyamoto RT. Divergence of fine and gross motor skills in prelingually deaf children: Implications for cochlear implantation. Laryngoscope 2006; 116(8): 1500-1506.

7) Hendriksma M, Bruijnzeel H, Bezdjian A. et al. Quality of life (QoL) evaluation of children using cochlear implants: Agreement between pediatric and parent proxy-QoL reports. Cochlear Implants Int 2020; 21(6): 338-343.

8) Yorgun M, Sürmelioğlu Ö, Tuncer Ü. et al. Quality of life in pediatric cochlear implantations. J Int Adv Otol 2015; 11(3): 218-221.

9) Varni JW, Seid M, Kurtin PS. PedsQL™ 4.0: Reliability and validity of the pediatric quality of life ınventory™ version 4.0 generic core scales in healthy and patient populations. Med Care 2001; 800-812.

10) Miyamoto RT, Robbins AM, Svirsky M.et al. Speech intelligibility of children with multichannel cochlear implants. Ann Otol Rhinol Laryngol Suppl 1997; 106(5): 35.

11) Svirsky MA, Robbins AM, Kirk KI. et al. Language development in profoundly deaf children with cochlear implants. Psychol Sci 2000; 11(2): 153-158.

12) Clark G. Cochlear Implants: Fundamentals and Applications Springer. New York, 2003.

13) Nadol Jr JB. Patterns of neural degeneration in the human cochlea and auditory nerve: Implications for cochlear implantation. Otolaryngol Head Neck Surg 1997; 117(3): 220-228.

14) Cupples L, Ching TY, Button L. et al. Spoken language and everyday functioning in 5-year-old children using hearing aids or cochlear implants. Int J Audiol 2018; 57(sup2): S55-S69.

15) Lund E, Dinsmoor J. Taxonomic knowledge of children with and without cochlear implants. Lang Speech Hear Serv Sch 2015; 47(3): 236-245. 16. Dyck M, Farrugia C, Shochet I, Holmes-Brown M. Emotion recognition/understanding ability in hearing or vision-‐ımpaired children: Do sounds, sights, or words make the difference. J Child Psychol Psychiatry 2004; 45(4): 789-800.

17) Chen M, Wang Z, Zhang Z. et al. Intelligence development of pre-lingual deaf children with unilateral cochlear implantation. Int j Pediatr Otorhinolaryngol 2016; 90: 264-269.

18) Martin D, Bat-Chava Y, Lalwani A. et al. Peer relationships of deaf children with cochlear implants: Predictors of peer entry and peer interaction success. J Deaf Stud Deaf Educ 2011; 16(1): 108-120.

19) Huttunen K, Rimmanen S, Vikman S. et al. Parents’ views on the quality of life of their children 2–3 years after cochlear implantation. IntJournal Pediatr Otorhinolaryngol 2009; 73(12): 1786-1794.

20) Edwards L, Hill T, Mahon M. Quality of life in children and adolescents with cochlear implants and additional needs. Int J Pediatr Otorhinolaryngol 2012; 76(6): 851-857.

21) Fortunato-Tavares T, Befi-Lopes D, Bento RF. et al. Children with cochlear implants: Communication skills and quality of life. Braz J Otorhinolaryngol 2012; 78(1): 15-25.

22) Vidas S, Hassan R, Parnes L. Real-life performance considerations of four pediatric multi-channel cochlear implant recipients. J Otolaryngol 1992; 21(6): 387-393.

23) Spahn C, Richter B, Burger T. et al. A comparison between parents of children with cochlear implants and parents of children with hearing aids regarding parental distress and treatment expectations. Int J Pediatric Otorhinolaryngol 2003; 67(9): 947-955.