Low-frequency pitch coding: relationships with speech-in-noise and music perception by pediatric populations with typical hearing and cochlear implants.

PURPOSE: This study aimed to investigate the effects of low frequency (LF) pitch perception on speech-in-noise and music perception performance by children with cochlear implants (CIC) and typical hearing (THC). Moreover, the relationships between speech-in-noise and music perception as well as the effects of demographic and audiological factors on present research outcomes were studied. METHODS: The sample consisted of 22 CIC and 20 THC (7-10 years). Harmonic intonation (HI) and disharmonic intonation (DI) tests were used to assess LF pitch perception. Speech perception in quiet (WRSq)/noise (WRSn + 10) were tested with the Italian bisyllabic words for pediatric populations. The Gordon test was used to evaluate music perception (rhythm, melody, harmony, and overall). RESULTS: CIC/THC performance comparisons for LF pitch, speech-in-noise, and all music measures except harmony revealed statistically significant differences with large effect sizes. For the CI group, HI showed statistically significant correlations with melody discrimination. Melody/total Gordon scores were significantly correlated with WRSn + 10. For the overall group, HI/DI showed significant correlations with all music perception measures and WRSn + 10. Hearing thresholds showed significant effects on HI/DI scores. Hearing thresholds and WRSn + 10 scores were significantly correlated; both revealed significant effects on all music perception scores. CI age had significant effects on WRSn + 10, harmony, and total Gordon scores (p < 0.05). CONCLUSION: Such findings confirmed the significant effects of LF pitch perception on complex listening performance. Significant speech-in-noise and music perception correlations were as promising as results from recent studies indicating significant positive effects of music training on speech-in-noise recognition in CIC.

Emotional abilities in preadolescents and adolescents with long-term cochlear implant use.

OBJECTIVES: Emotional abilities (EAs) are particularly important during preadolescence/adolescence, two challenging periods characterized by significant biological, physical, and cognitive changes. The present study attempted to a holistic EA approach in preadolescents/adolescents with cochlear implants (CI) and typical hearing (TH), considering various aspects such as perception, cognitive facilitation, comprehension, and management of emotions. A secondary aim was to identify significant demographic and audiological factors of EA development. METHODS: CI/TH groups were matched for chronological age, nonverbal IQ, gender, economic income, and maternal level of education. Each group consisted of 43 participants (age range 10-18 years). EAs were evaluated by using the multi-trait/method IE-ACCME test. Auditory-linguistic assessments included participants' lexical skills and Matrix performance as well. RESULTS: EA performance for perception and cognitive facilitation did not show any statistically significant CI/TH group differences (p > 0.05). Significant CI/TH differences emerged for emotion comprehension and management: CI group performed significantly worse in understanding emotional blends (t = 2.56, p = 0.014) but better in personal emotion management (t = -2.01, p = 0.048). For the CI group, gender showed statistically significant effects on cognitive facilitation in sensations, with males performing better than females (U = 129, p = 0.018). TH preadolescents showed significantly lower scores in understanding emotional changes in comparison to TH adolescents (U = 125.5, p = 0.01). Emotional blends understanding showed a weak negative correlation with Matrix performance (r = - 0.38, p = 0.013) and a moderate positive correlation with lexical skills (r = 0.40, p = 0.008). Relationships management showed various significant correlations: weak negative correlations with age at CI (r = - 0.38, p = 0.011) and Matrix performance (r = - 0.36, p = 0.016) as well as weak positive correlations with nonverbal-IQ (r = 0.38, p = 0.013) and positive moderate correlations with lexical skills (r = 0.49, p < 0.001). CONCLUSION: Cochlear implantation seems to show significant positive effects on emotional development in children, allowing them to achieve age appropriate EAs as they grow up and become preadolescents/adolescents. EA assessment in CI users may not only support monitorization of EA trajectory, but also early identification of any EA disorders, so that subjects with low EA profiles could be timely and properly intervened.

Executive functions in preschool and school-age cochlear implant users: do they differ from their hearing peers? A systematic review and meta-analysis.

PURPOSE: Executive functions (EF) play a fundamental role in planning and executing goal-driven behaviours. The purpose of this systematic review and meta-analysis was to investigate EF skills mastered by preschool/school-age cochlear implanted children (CIC) without morpho-functional abnormalities and to compare their outcomes with typically hearing children (THC). METHODS: Bibliographic search for observational studies of any language/date up to 16 December 2022 was performed with the following electronic databases: PubMed, Scopus, and Web of Science. After removal of duplicates, 2442 records were subjected to a three-stage screening process and 83 potentially eligible articles were identified. A total of 15 studies was included in the final analysis: 9 articles directly meeting the eligibility criteria plus 6 more studies thanks to the authors sharing their data set, specifically for participants who met present inclusion criteria. RESULTS: Meta-analysis showed a statistically significant difference only for verbal short-term memory, whereas group differences for visuospatial short-term memory and verbal/visuospatial working memory were not significant. For fluency skills, meta-analysis revealed statistical significance for the semantic fluency task but not for the rapid naming test. Qualitative analysis reflected group similarities in flexibility but CIC's difficulties in auditory attention/planning skills. Controversial findings for inhibitory control skills were observed. CONCLUSIONS: EF performance comparisons between CIC and THC show inter-skill and inter-test variances. Due to the paucity of existing studies, present findings should be interpreted with caution. Future research in this domain is strongly recommended.

Vocal singing skills by cochlear implanted children without formal musical training: Familiar versus unfamiliar songs.

OBJECTIVES: Vocal singing skills in pediatric CI users are not much known due to the limited number of studies. The principal aim of the present study was to evaluate vocal singing skills in Italian pediatric CI users. A further aim was to investigate factors that may significantly influence their performance. METHODS: The participants were twenty-two implanted children and twenty-two hearing peers. Their vocal singing skills for familiar ("Happy Birthday to You") and unfamiliar songs ("Baton Twirler" from Pam Pam 2- Tribute to Gordon) were evaluated in relation to their music perception (the Gordon test). Acoustic analysis was performed using Praat and MATLAB software. Nonparametric statistical tests and principal component analysis (PCA) were used to analyze the data. RESULTS: Hearing children outperformed implanted peers in both music perception and vocal singing tasks (all measures regarding intonation, vocal range, melody, and memory for the familiar song versus measures regarding intonation and overall melody production for the unfamiliar song). Music perception and vocal singing performances revealed strong correlations. For the familiar and unfamiliar songs, age-appropriate vocal singing was observed in 27.3% versus 45.4% of children, all implanted within 24 months of age. Age at implantation and duration of CI experience were moderately correlated with the total score obtained from the Gordon test. CONCLUSION: Implanted children show limited vocal singing skills in comparison to their hearing peers. However, some children implanted within 24 months of age seem to achieve vocal singing skills as good as their hearing peers. Future research could be useful to better understand the role of brain plasticity to implement specific training programs for both music perception and vocal singing.

Long-term speech perception and morphosyntactic outcomes in adolescents and young adults implanted in childhood.

BACKGROUND: Long-term assessments of children with cochlear implants (CI) are important inputs to help guide families and professionals in therapeutic and counselling processes. Based on these premises, the primary aim of the present study was to assess the long-term speech and language outcomes in a sample of prelingually deaf or hard of hearing (DHH) adolescents and young adults with unilateral or bilateral implantation in childhood. The secondary aim was to investigate the correlations of age at implantation with long-term speech and language outcomes. MATERIALS AND METHODS: Retrospective observational study on 54 long-term CI users, 33 unilateral and 21 bilateral (mean age at CI surgery 38.1 ± 24.6 months; mean age at last follow-up assessment 19.1 ± 4.3 years of age and mean follow-up time 16 ± 3.7 years). Means and standards were used to describe speech perception (in quiet, in fixed noise and in adaptive noise using It-Matrix) and morphosyntactic comprehension (TROG-2) outcomes. A univariate analysis was used to evaluate outcome differences between unilateral and bilateral patients. Bivariate analysis was performed to investigate the relationships between age at CI, audiological variables, and language outcomes. Finally, multivariate analysis was performed to quantify the relationship between It-Matrix, sentence recognition in quiet and at SNR+10 and TROG-2. RESULTS: The participants showed good speech recognition performance in quiet (94% for words and 89% for sentences) whilst their speech-in-noise scores decreased significantly. For the It-Matrix, only 9.2% of the participants showed scores within the normative range. This value was 60% for TROG-2 performance. For both auditory and language skills, group differences for unilateral versus bilateral CI users were not statistically significant (p > 0.05). Bivariate analysis showed that age at CI correlated significantly with overall results at TROG-2 (r = -0.6; p < 0.001) and with It-Matrix (r = 0.5; p < 0.001). TROG-2 was negatively correlated with results for It-Matrix (r = -0.5; p < 0.001). In the multivariate analysis with It-Matrix as a dependent variable, the model explained 63% of the variance, of which 60% was related to sentence recognition and 3% to morphosyntax. CONCLUSIONS: These data contribute to the definition of average long-term outcomes expected in subjects implanted during childhood whilst increasing our knowledge of the effects of variables such as age at CI and morphosyntactic comprehension on speech perception. Although the majority of this prelingually DHH cohort did not achieve scores within a normative range, remarkably better It-Matrix scores were observed when compared to those from postlingually deafened adult CI users.

The influence of auditory selective attention on linguistic outcomes in deaf and hard of hearing children with cochlear implants.

PURPOSE: Auditory selective attention (ASA) is crucial to focus on significant auditory stimuli without being distracted by irrelevant auditory signals and plays an important role in language development. The present study aimed to investigate the unique contribution of ASA to the linguistic levels achieved by a group of cochlear implanted (CI) children. METHODS: Thirty-four CI children with a median age of 10.05 years were tested using both the "Batteria per la Valutazione dell'Attenzione Uditiva e della Memoria di Lavoro Fonologica nell'età evolutiva-VAUM-ELF" to assess their ASA skills, and two Italian standardized tests to measure lexical and morphosyntactic skills. A regression analysis, including demographic and audiological variables, was conducted to assess the unique contribution of ASA to language skills. RESULTS: The percentages of CI children with adequate ASA performances ranged from 50 to 29.4%. Bilateral CI children performed better than their monolateral peers. ASA skills contributed significantly to linguistic skills, accounting alone for the 25% of the observed variance. CONCLUSIONS: The present findings are clinically relevant as they highlight the importance to assess ASA skills as early as possible, reflecting their important role in language development. Using simple clinical tools, ASA skills could be studied at early developmental stages. This may provide additional information to outcomes from traditional auditory tests and may allow us to implement specific training programs that could positively contribute to the development of neural mechanisms of ASA and, consequently, induce improvements in language skills.

Music perception and speech intelligibility in noise performance by Italian-speaking cochlear implant users.

OBJECTIVE: The goal of this study was to investigate the performance correlations between music perception and speech intelligibility in noise by Italian-speaking cochlear implant (CI) users. MATERIALS AND METHODS: Twenty postlingually deafened adults with unilateral CIs (mean age 65 years, range 46-92 years) were tested with a music quality questionnaire using three passages of music from Classical Music, Jazz, and Soul. Speech recognition in noise was assessed using two newly developed adaptive tests in Italian: The Sentence Test with Adaptive Randomized Roving levels (STARR) and Matrix tests. RESULTS: Median quality ratings for Classical, Jazz and Soul music were 63%, 58% and 58%, respectively. Median SRTs for the STARR and Matrix tests were 14.3 dB and 7.6 dB, respectively. STARR performance was significantly correlated with Classical music ratings (rs = - 0.49, p = 0.029), whereas Matrix performance was significantly correlated with both Classical (rs = - 0.48, p = 0.031) and Jazz music ratings (rs = - 0.56, p = 0.011). CONCLUSION: Speech with competitive noise and music are naturally present in everyday listening environments. Recent speech perception tests based on an adaptive paradigm and sentence materials in relation with music quality measures might be representative of everyday performance in CI users. The present data contribute to cross-language studies and suggest that improving music perception in CI users may yield everyday benefit in speech perception in noise and may hence enhance the quality of listening for CI users.

Temporal coding and music perception in bimodal listeners.

OBJECTIVE: Limited low frequency (LF) pitch and temporal fine structure (TFS) sensitivity have been thought to contribute significantly to poor music perception in cochlear implant (CI) listeners. Thus, this study aimed to evaluate music perception in relation to LF pitch perception and temporal coding, specifically in people with bimodal stimulation as a promising approach to improve spectro-temporal sensitivity in CI listeners. METHODS: Eleven postlingually deafened bimodal listeners participated in the study (mean age=55.5 years, range 36-75 years, SD=11.7). LF pitch/TFS sensitivity was evaluated by using two recently developed tests: Harmonic Intonation (HI) and Disharmonic Intonation (DI). The music perception protocol was based on three audio files in the genres of Classical, Jazz and Soul music and a music quality questionnaire regarding four subjective aspects: Clarity, Pleasantness, Naturalness and General Quality of Sounds. RESULTS: CI alone and bimodal findings showed statistically significant differences for both temporal coding and music perception. DI findings showed statistically significant correlations with music quality ratings (p<0.05). CONCLUSION: Bimodal music quality ratings were significantly better, indicating a significant improvement in the quality of music towards being significantly more clear, more natural, more pleasant, and better quality. Similarly, bimodal HI/DI findings improved significantly, although the amount of benefit was greater for the DI task with spectral information only below 300 Hz. Significant DI correlations with music quality ratings supported the test to be more indicative of better temporal coding of LF residual hearing and its effects on music perception.

Bimodal cochlear implantation in elderly patients.

OBJECTIVE: Bimodal stimulation is a standard option for asymmetric hearing loss in adults. Questions have been raised whether receiving two stimulations may conflict in elderly listeners where the central integration of an acoustic/electrical signal may be very important to obtain benefit in terms of speech perception. DESIGN: Clinical retrospective study. STUDY SAMPLE: The outcomes from 17 bimodal cochlear implant (CI) users were analysed. The test material consisted of speech audiometry in quiet and in noise (STARR and Matrix). RESULTS: Bimodal PTA and speech perception both in quiet and in noise were significantly better than CI or HA alone. Age showed a significant effect on bimodal STARR outcomes. Similarly, bimodal STARR scores improved significantly in comparison to Better Ear. CONCLUSION: Both Matrix and STARR tests were very difficult for many elderly CI listeners from the present study group, especially in unilateral listening condition. The performance improved significantly, emphasising a good integration of acoustic and electric hearing in this group of elderly bimodal listeners. Overall results highlighted how a specific study, based on speech perception in noise in the elderly listeners, might shed light on the effect of speech test modality on bimodal outcomes.

Intonational cues for speech perception in noise by cochlear implant listeners.

PURPOSE: The objectives of this study are to evaluate cochlear implant (CI) listeners' ability to infer low frequency (LF) pitch information from temporal fine structure (TFS) cues and to gain insight into its effects on speech perception, especially in the presence of a fluctuating background noise. Pitch perception assessment using linguistic stimuli is believed to better reflect the role of pitch in communicatively realistic situations. METHODS: The low-pass-filtered sentence intonation (SI-LPF) test based on linguistic stimuli marked by intonation changes is used to estimate a difference limen for discrimination of LF pitch changes in adult CI listeners (N = 17 ears). Speech perception in the presence of noise is assessed using the sentence test with adaptive randomized roving level (STARR), where everyday sentences are presented at low, medium, and high levels in a fluctuating background noise. SI-LPF correlations with STARR are compared to those with sentence recognition tests presented in quiet (SRQ) and in noise, using fixed signal-to-noise ratio (SNRs at +10 and +5 dB). RESULTS: SI-LPF findings show significant positive correlations with STARR performance (rs = 0.63, p = 0.007), whilst the associations with SRQ (rs = - 0.37, p = 0.149), SNR + 10 (rs = - 0.24, p = 0.345), and SNR + 5 (rs = - 0.14, p = 0.587) are not statistically significant. CONCLUSIONS: Present findings reflecting considerably stronger correlations than previous studies using non-linguistic stimuli, in particular for speech perception with roving-level adaptive test method (STARR) highlight the effects of LF pitch perception and TFS sensitivity on challenging everyday situations, where CI users listen to speakers with varying levels in a fluctuating background.

Perception of lexical stress cued by low-frequency pitch and insights into speech perception in noise for cochlear implant users and normal hearing adults.

PURPOSE: Cochlear implant (CI) users show great difficulty for understanding speech in noise and this fact may partly stem from their poor low-frequency (LF) pitch perception and temporal fine structure (TFS) processing. Clinical assessment of pitch perception is usually based on non-speech tasks. However, linguistically relevant contexts such as lexical stress may better reflect the role of pitch in speech perception, especially for everyday speech where background noise is inevitable. Hence, the study aimed to assess perception of lexical stress cued by LF pitch and TFS cues for CI and normal hearing (NH) listeners, and to investigate relationships with speech perception in noise. METHODS: The low-pass-filtered Word Stress Pattern (WSP-LPF) test was used to evaluate perception of lexical stress cued by LF pitch. Speech perception was assessed with the sentence test with adaptive randomized roving level (STARR) test which presented everyday sentences at low, medium, and high levels in a fluctuating noise to estimate a Speech Reception Threshold. This new test intended to give a realistic estimate for real-world listening. RESULTS: Median WSP-LPF scores in NH (N = 18) and CI listeners (N = 18) were 12.0 Hz and 67.0 Hz, respectively. The corresponding STARR scores were - 9.1 dB and 17.3 dB. Group differences were statistically significant (p < 0.001). Analysis showed significant positive correlations for NH (rs = 0.50) and CI listeners (rs = 0.60). CONCLUSIONS: Present findings reveal stronger correlations than previous studies using non-speech materials, supporting that CI listeners' poor speech perception in noise might be strongly associated with their inability for LF pitch perception and TFS processing.

The role of speech rate for Italian-speaking cochlear implant users: insights for everyday speech perception.

This study investigated the effect of speech rate for Italian-speaking cochlear implant (CI) users with the aim of gaining insight into everyday listening situations where speaker's rate may vary considerably together with speech level in fluctuating background noise. The test material was prepared by processing the Italian STARR test with temporal compression of sentence material. Twelve adult CI users were divided into two subgroups based on their STARR performance: good and poor performers. The effect of varying speech rate was remarkable for both subgroups. Good performers showed significant performance deterioration for the faster speech rate, whereas outcomes for poor performers improved significantly for the slower speech rate. Background noise is inevitable during daily life and CI users face a variety of speakers, so must cope with changes in both speech level and rate. Traditional tests with a single talker speaking very clearly while using a moderate to low speech rate may overestimate everyday speech perception for CI users. The use of tests that mimic everyday perception is of great importance and should become a routine part of audiometric measures for hearing impaired people.

Temporal Fine Structure Processing, Pitch, and Speech Perception in Adult Cochlear Implant Recipients.

OBJECTIVES: The aim of the study was to investigate the link between temporal fine structure (TFS) processing, pitch, and speech perception performance in adult cochlear implant (CI) recipients, including bimodal listeners who may benefit better low-frequency (LF) temporal coding in the contralateral ear. DESIGN: The study participants were 43 adult CI recipients (23 unilateral, 6 bilateral, and 14 bimodal listeners). Two new LF pitch perception tests-harmonic intonation (HI) and disharmonic intonation (DI)-were used to evaluate TFS sensitivity. HI and DI were designed to estimate a difference limen for discrimination of tone changes based on harmonic or inharmonic pitch glides. Speech perception was assessed using the newly developed Italian Sentence Test with Adaptive Randomized Roving level (STARR) test where sentences relevant to everyday contexts were presented at low, medium, and high levels in a fluctuating background noise to estimate a speech reception threshold (SRT). RESULTS: Although TFS and STARR performances in the majority of CI recipients were much poorer than those of hearing people reported in the literature, a considerable intersubject variability was observed. For CI listeners, median just noticeable differences were 27.0 and 147.0 Hz for HI and DI, respectively. HI outcomes were significantly better than those for DI. Median STARR score was 14.8 dB. Better performers with speech reception thresholds less than 20 dB had a median score of 8.6 dB. A significant effect of age was observed for both HI/DI tests, suggesting that TFS sensitivity tended to worsen with increasing age. CI pure-tone thresholds and duration of profound deafness were significantly correlated with STARR performance. Bimodal users showed significantly better TFS and STARR performance for bimodal listening than for their CI-only condition. Median bimodal gains were 33.0 Hz for the HI test and 95.0 Hz for the DI test. DI outcomes in bimodal users revealed a significant correlation with unaided hearing thresholds for octave frequencies lower than 1000 Hz. Median STARR scores were 17.3 versus 8.1 dB for CI only and bimodal listening, respectively. STARR performance was significantly correlated with HI findings for CI listeners and with those of DI for bimodal listeners. CONCLUSIONS: LF pitch perception was found to be abnormal in the majority of adult CI recipients, confirming poor TFS processing of CIs. Similarly, the STARR findings reflected a common performance deterioration with the HI/DI tests, suggesting the cause probably being a lack of access to TFS information. Contralateral hearing aid users obtained a remarkable bimodal benefit for all tests. Such results highlighted the importance of TFS cues for challenging speech perception and the relevance to everyday listening conditions. HI/DI and STARR tests show promise for gaining insights into how TFS and speech perception are being limited and may guide the customization of CI program parameters and support the fine tuning of bimodal listening.

Adaptation of the STARR test for adult Italian population: A speech test for a realistic estimate in real-life listening conditions.

OBJECTIVES: To introduce the Italian adaptation of the STARR test based on a roving-level adaptive method to mimic challenging real-life listening conditions for use in people with auditory prostheses. DESIGN: Normative data were collected and interlist-variability, as well as learning effects, were investigated using a within-subject design with repeated measures. STUDY SAMPLE: A group of 32 normal-hearing (NH) adults participated in the study. RESULTS: The average speech reception threshold (SRT) for NH subjects was -8.4 dB SNR. The variability of mean SRTs across test lists was relatively small (≤1 dB for all test lists). The statistically significant differences between lists were eliminated after applying correction factors. On the basis of variability for the corrected SRTs within each subject, a difference of 2.8 dB in SRT was meaningful for outcome comparisons using one test list per condition and 2 dB using two lists per condition. Statistical analysis did not show any significant learning effects. CONCLUSIONS: Findings in NH listeners suggested that the Italian STARR test could be a promising supplement to existing speech assessment tools. Further studies in populations with hearing impairment could contribute to cross-language studies.

Adequate formal language performance in unilateral cochlear implanted children: is it indicative of complete recovery in all linguistic domains? Insights from referential communication.

OBJECTIVES: Referential communication (RC) is a key element in achieving a successful communication. This case series aimed to evaluate RC in children with unilateral cochlear implants (CIs) with formal language skills within the normal range. METHODS AND MATERIALS: A total of 31 children with CIs, with language development within the normal range, were assessed using the Pragmatic Language Skills test (MEDEA). RESULTS: Of the children with CIs, 83.9% reached performance levels appropriate for their chronological ages. The results confirmed a positive effect of cochlear implantation on RC development, although difficulties remained in some CI users. CONCLUSIONS: The outcomes emphasize the need to pay greater attention to the pragmatic aspects of language, assessing them with adequate testing in the early phase after cochlear implantation. Clear knowledge of children's communicative competence is the key in optimizing their communicative environments in order to create the basis for future successful interpersonal exchanges and social integration.

Low-frequency pitch perception in children with cochlear implants in comparison to normal hearing peers.

The aim of the present study was to investigate the application of two new pitch perception tests in children with cochlear implants (CI) and to compare CI outcomes to normal hearing (NH) children, as well as investigating the effect of chronological age on performance. The tests were believed to be linked to the availability of Temporal Fine Structure (TFS) cues. 20 profoundly deaf children with CI (5-17 years) and 31 NH peers participated in the study. Harmonic Intonation (HI) and Disharmonic Intonation (DI) tests were used to measure low-frequency pitch perception. HI/DI outcomes were found poorer in children with CI. CI and NH groups showed a statistically significant difference (p < 0.001). HI scores were better than those of DI test (p < 0.001). Chronological age had a significant effect on DI performance in NH group (p < 0.05); children under the age of 8.5 years showed larger inter-subject-variability; however, the majority of NH children showed outcomes that were considered normal at adult-level. For the DI test, bimodal listeners had better performance than when listening with CI alone. HI/DI tests were applicable as clinical tools in the pediatric population. The majority of CI users showed abnormal outcomes on both tests confirming poor TFS processing in the hearing-impaired population. Findings indicated that the DI test provided more differential low-frequency pitch perception outcomes in that it reflected phase locking and TFS processing capacities of the ear, whereas HI test provided information of its place coding capacity as well.