Clinical Linguistics & Phonetics, June–July 2013; 27(6–7): 472–483

© 2013 Informa UK Ltd

ISSN: 0269-9206 print / ISSN 1464-5076 online
DOI: 10.3109/02699206.2013.771214

Cortical auditory evoked potentials in unsuccessful cochlear

implant users

BOŠKA MUNIVRANA1 & VESNA MILDNER2

1
SUVAG Polyclinic, Zagreb, Croatia, and 2Department of Phonetics, Faculty of Humanities and Social
Sciences University of Zagreb, Croatia

(Received 15 September 2012; revised 23 January 2013; accepted 25 January 2013)

Abstract
In some cochlear implant users, success is not achieved in spite of optimal clinical factors (including age at
implantation, duration of rehabilitation and post-implant hearing level), which may be attributed to disorders
at higher levels of the auditory pathway. We used cortical auditory evoked potentials to investigate the
ability to perceive and discriminate auditory stimuli in 10 unsuccessful implant users aged 8–10 years (CI)
and 10 healthy age-matched controls with normal hearing (NH). Pure tones (1 and 2 kHz) and double conso-
nant-vowel syllables were applied. The stimuli were presented in an oddball paradigm that required the subjects
to react consciously. The latencies and amplitudes of the P1, N1, P2, N2 and P3 waves were analyzed, in
addition to reaction times and number of responses. Significant differences in the average response times
and number of responses were observed between the CI and NH groups. The latencies also indicate that the
CI group took longer to perceive and discriminate between tonal and speech auditory stimuli than the NH
group.

Keywords: child, speech perception, hearing, hearing disorders, assessment, pitch perception

Introduction
For the successful use of cochlear implants, three crucial factors are age at implantation, duration of
speech and hearing rehabilitation and hearing level after implantation. Age at implantation is the
basic criterion for predicting implant usage success. The optimal age for implantation is between
the first and second year of life (Archbold et al., 2008; Sharma, Dorman, & Spahr, 2002a,
2002b). Relatively good success can be expected if implantation occurs after that period, but the
child must participate in speech and hearing rehabilitation therapy (Teoh, Pisoni, & Miyamoto,
2004). Implantation after the age of seven in prelingually deaf children has not proven successful
in terms of speech and hearing development (Sharma et al., 2002b; Sharma, Dorman, & Kral,
2005; Sharma, Gilley, Dorman, & Baldwin, 2007).
The second most important criterion for predicting the success of cochlear implant usage is the
duration of speech and hearing rehabilitation (Kirk et al., 2002; Profant, Kabátová, & Šimková,
2008). Extensive research conducted at the SUVAG Polyclinic in Zagreb, Croatia has shown that

Correspondence: Vesna Mildner, Department of Phonetics, Faculty of Humanities and Social Sciences, University of Zagreb, Ivana Lučića,
3, 10000 Zagreb, Croatia. Tel: +385 1 6120097. Cell: +385 98 322793. E-mails: vmildner@ffzg.hr; vesna.mildner@ffzg.hr
 Cortical auditory evoked potentials 473

the duration of speech and hearing rehabilitation must be three to five years (Paškvalin et al., 2005).
The third most important criterion is hearing level after implantation. According to some authors
(Vlahović & Šindija, 2004), in children with cochlear implants, a post-operative hearing threshold
below 40 dB does not have a negative impact on successful hearing (and consequently, speech)
development.
In addition to these three criteria, other important factors must be considered, such as the assess-
ments of psychologists, speech and hearing therapists, neurologists and paediatricians. Good func-
tion of the vestibular system has also been associated with speech and hearing development (Asp,
2006; Mijić-Munivrana, 1994). However, even when these factors are optimal, some children do not
achieve the expected outcomes. During monitoring and evaluation of hearing and speech progress,
regular follow-ups consisting of pure tone audiometry (PTA) and speech audiometry (SA) can reveal
that, for no apparent reason, success has not been achieved. Hearing disorders at higher levels of the
auditory pathway may be the culprit.
Due to their good temporal resolution, the use of cortical auditory evoked potentials (CAEPs) permits
a functional evaluation of the auditory cortex and other structures that are responsible for the cognitive
processing of auditory stimuli. CAEP is non-invasive and financially acceptable and, most importantly,
can be used in children with cochlear implants. CAEPs are useful for investigating the brain processes
that underlie auditory perception, such as loudness, pitch and source of sound detection.
Exogenous components (P1, N1 and P2) provide information on the primary auditory cortex,
whereas endogenous components (N2 and P3) provide information on higher cognitive processes
(Martin, Tremblay, & Korczak, 2008; Picton et al., 1999). Both exogenous and endogenous com-
ponents provide a window into the earliest stages of processing in the auditory cortex. P1 typically
occurs 50 ms after stimulus onset in adults with normal hearing and is a biomarker of the central
auditory pathway (Dorman, Sharma, Gilley, Martin, & Roland, 2007; Sharma et al., 2004) as its
latency becomes shorter with age (Cunningham, Nicol, Zecker, & Kraus, 2000; Ponton, Eggermont,
Kwong, & Don, 2000). The age-dependent shorter latencies of P1 indicate more efficient synaptic
transfer and a more efficient auditory pathway (Sharma et al., 2007). Maturation of the central audi-
tory system is related to speech and language development in children with cochlear implants
(Ponton et al., 2000; Wunderlich, Cone-Wesson, & Shepherd, 2006). P1 is an important indicator
of central auditory pathway maturation in children with hearing impairment (fitted with hearing
aids or cochlear implants). In addition to other factors, such as age at intervention, the duration
of hearing experience affects the latency of P1. If implantation is performed within the optimal
age range, the latency of P1 is comparable to that of hearing age-matched peers after six months
(Sharma et al., 2002a). Children whose hearing deprivation exceeds seven years never reach
normal age-matched P1 latencies (Dorman et al., 2007).
N1 represents the encoding of the beginning of a stimulus at the level of the auditory cortex
(Čeponiené, Torki, Alku, Koyama, & Townsend, 2008; Steinschneider & Dunn, 2002). N2, which re-
flects automatic processing, appears even when recognition of the differences between stimuli is not
requested (Näätänen & Gaillard, 1983; Näätänen & Picton, 1986). If N1 and P2 are obtained as
responses using an oddball paradigm, it indicates that the participant perceived both stimuli.
P3 is a cortical evoked potential that reflects the cognitive processes involved in the discrimi-
nation of dissimilar sensory stimuli. P3 is an event-related potential (ERP) that occurs approximately
300 ms following stimulus onset. Almost all CAEP studies of cochlear implant users whose hearing
did not develop as expected revealed extended P3 latencies and diminished amplitudes (Beynon &
Snik, 2004; Kileny, 1991; Micco et al., 1995; Obert & Cranford, 1990). This is evidence that P3 is a
good indicator of sensory cortical processing and can provide reliable information regarding acous-
tical-phonological processing. The number of responses and reaction time (RT) to a target stimulus
reveals conscious integration of perceived auditory information (Henkin, Kileny, Hildesheimer, &
Kishon-Rabin, 2008; Henkin, Tetin-Schneider, Hildesheimer, & Kishon-Rabin, 2009).
474 B. Munivrana and V. Mildner

The aim of this study was to investigate auditory function at the level of the representation of
elementary speech sounds in order to determine the ability of unsuccessful cochlear implant
users to perceive and discriminate sound stimuli in comparison with age-matched normal hearing
children using CAEPs. Because CAEPs provide information regarding the biological processes
that underlie speech processing, we used speech stimuli in addition to tone burst (TB) stimuli.

Method
Participants
The study group (CI) consisted of 10 children with hearing loss, aged 8–10 years, who were fitted
with cochlear implants. The children were elementary school pupils at the Suvag Polyclinic (Zagreb,
Croatia), and the inclusion criterion was poor success on standard SA. The capacity of intelligibility
field (calculated as the ratio of the area spanned by the SA curve to the typical SA) of the CI children
was 80% at 50 dB. The aided hearing levels of all CI participants were between 15 and 30 dB (PTA).
Other possible neurological, psychological, audiological and motor disorders were excluded
(Table 1).
The control group (NH) consisted of 10 age-matched children with normal hearing, selected from
among friends and family of CI participants, who displayed typical speech and language develop-
ment. All NH participants were without irregularities, with normal neurological status. The study
was approved by the Polyclinic’s Ethics Committee, and parental consent was obtained for all chil-
dren included in the study. The participants included 8 boys and 12 girls. We set the lower age limit
at eight years because of the nature of the testing, which required the subject to be still and awake.

Table 1. Demographic details of the unsuccessful cochlear implant users.

Onset of Prior Age at Age at Duration of Type of

Child/ deafness/ hearing aid implantation test implant use implant Implant
gender aetiology experience (years) (years) (years) (nucleus) ear SRT a %/dB

1/M Prelingual/ Yes/ 3 8;5 5;5 22 R 60% 45 dB

unknown traditional
2/F Prelingual/ Yes/ 3 10 7 22 R 65% 40 dB
unknown traditional
3/M Prelingual/ Yes/ 3;3 8;2 4;7 22 R 55% 50 dB
unknown traditional
4/M Prelingual/ Yes/ 3;8 9;6 5;8 22 R 65% 40 dB
unknown traditional
5/F Prelingual/ Yes/ 3;2 8;7 5;4 22 R 73% 55 dB
unknown traditional
6/M Prelingual/ Yes/ 3;6 9;5 5;9 22 R 45% 60 dB
unknown traditional
7/M Pre-lingual/ Yes/ 3;5 8;6 5;1 22 L 43% 60 dB
unknown traditional
8/F Prelingual/ Yes/ 3;5 10 6;6 22 R 43% 55 dB
unknown traditional
9/M Prelingual/ Yes/ 4 9;5 4;1 22 R 45% 60 dB
unknown traditional
10/F Genetic Yes/ 3;1 8;2 5;1 22 L 45% 60 dB
traditional
a
Speech reception (recognition) threshold: minimum intensity in decibel at which the greatest number of words (%) are
repeated correctly.
 Cortical auditory evoked potentials 475

Gender was not considered a relevant variable as it does not influence responses to auditory stimuli.
A comparison of unsuccessful cochlear implant users with successful users is discussed in detail
elsewhere (Munivrana, submitted). Participants were interested in the research, were in a good
mood and were willing to cooperate.

Equipment and procedures

We measured the responses, latencies and amplitudes of P1, N1, P2, N2 and P3 waves in response to
two types of stimuli, as well as RTs, which are an acceptable measure of the cognitive processing of
auditory stimuli. The recording was performed with a 32-channel NeuroScan system (Compumedics
NeuroScan, El Paso, TX, USA) using an electrode cap with a set of electrodes arranged according to
the International 10–20 electrode positioning system. The reference electrodes were linked together
and were placed over the left and right mastoid processes. All electrode impedances were less than
5 kΩ. During the recording, a child fitted with a headset lay comfortably on a bed with their eyes
closed in a dark, quiet room. ERP recording was performed according to the auditory oddball para-
digm and consisted of two types of stimuli: target (rare) and non-target (frequent). The subjects were
instructed to ignore the non-target stimuli and to press a keyboard button with the index finger of
their dominant hand as soon as the target stimulus was recognized. Recording was performed
twice for each different types of stimulus: first for TB stimulation and then for speech stimulation.
The stimuli were presented by means of a loudspeaker (Trust 460P soundforce) placed 20 cm from
the head of the CI participant on the implant side or 30 cm in front of NH participants. The stimulus
intensity was 70 dB SPL for input to the cochlear implant microphone or 70 dB SPL for output from
a loudspeaker. Stimulus intensity was measured with a SPL meter (“Digital-Display Sound-Level
Meter”, Model: 33-2055). Testing lasted 1 h per participant, including preparation and recording.

TB stimulation
TB stimuli at frequencies of 1000 Hz for non-target (frequent) and 2000 Hz for target (rare) stimuli
were used. These frequencies were selected because both tones are within the frequency range of
speech. The fact that the TBs were an octave apart ensured auditory distinction between the
sounds. Both stimuli were shaped with a linear envelope with a 10 ms rise time, 30 ms of constant
amplitude and a fall time of 10 ms.

Speech stimulation
For speech stimulation, double syllable (DS) stimuli were used. For the frequent (non-target) stimu-
lus, the syllable ka-ka was used, while for the rare (target) stimulus, the DS te-te was used. Both
stimuli consisted of two consonants and two vowels typical of Croatian language. These syllables
were chosen on the basis of the optimal frequency range of the sounds of which they are composed
(Guberina & Asp, 1981). The optimal frequency ranges are 800–1600 Hz for k and a, and 1600–
3200 Hz for t and e. The first octave (the frequency range for k and a) contains the 1000 Hz fre-
quency, while the other octave (1600–3200 Hz range) contains the 2000 Hz frequency. Thus,
both frequency ranges are comparable to TB frequencies. The duration of each DS was 370 ms,
and the interval between the two syllables was 30 ms. We used the DS consonant–vowel (CV) stimu-
lus as the speech stimulus due to its complexity. These stimuli were tested in comparison with single-
syllable CV, and there were no double/overlapping CAEP responses.
The intensity of every stimulus was equal and was set to 70 dB for each ERP recording. The non-
target stimulus was frequently repeated, whereas the target stimulus appeared rarely and randomly.
The ratio of frequent to rare stimuli was 4:1. During recording, the inter-stimulus interval was set to
2.5 s, with 10% variability. The actual number of target stimuli presented was slightly above 50
476 B. Munivrana and V. Mildner

because the averaging procedure stops after 50 artifact-free responses have been collected. The arti-
fact rejection level was ±100 µV. Therefore, the non-target stimuli were presented more than 200
times. The analysis time was set to 1100 ms, including 100 ms of pre-stimulus interval for baseline
correction. The amplifier gain was set to 40 000, the sampling rate was set at 1 kHz, and the EEG
was processed using band-pass filters ranging from 0.1 to 30 Hz. EEG sequences distorted by ocular
movements and blinking were automatically rejected if their amplitudes exceeded ±100 μV of the
artifact rejection level. Averaging was performed on-line and off-line if excessive ocular artifacts
were detected. In such cases, the NeuroScan ocular rejection artifact algorithm was applied.
Additionally, an ocular algorithm was applied to both groups of participants during off-line aver-
aging. The responses to target and non-target stimuli were averaged. The evoked potential latencies
and amplitudes were measured. Peak amplitudes at the Cz electrode were measured relative to the
pre-stimulus baseline.

Statistics
Saved EEG data were averaged using NeuroScan software, and the obtained values were analyzed
using descriptive statistics and Mann–Whitney tests. All the measured variables are presented as
mean values with standard deviations (latencies and amplitudes obtained by averaging individual
responses), and Mann–Whitney tests for between-group comparisons were applied. Non-parametric
tests were applied because the data did not meet the requirements for parametric testing. To analyze
the target stimuli RT, the number of non-responses was counted, and a Mann–Whitney test was used
to evaluate possible differences between the unsuccessful cochlear implant users and normal hearing
controls in average RT to TB and DS stimuli. The data were analyzed using the Statistical Package for
the Social Sciences, ver. 15.0 (SPSS 15.0 for Windows).

Results
Statistical analysis (descriptive statistics and Mann–Whitney test) of the data revealed significant
differences between the NH and CI groups in the latencies of all studied waves (P1, N1, P2, N2
and P3) after non-target and target TB stimuli. These results are given in Table 2.

Table 2. Descriptive statistics for latencies of studied waves in TB stimuli.

Latency – stimulus Groups M C Sd Min Max Mann–Whitney test

P1 – TB non-target NH 71.30 75.00 11.76 50 83 Z = − 3.78; p < 0.01

CI 106.60 96.00 23.53 84 157
N1 – TB non-target NH 115.00 104.00 25.07 97 176 Z = − 3.06; p < 0.01
CI 158.70 151.50 34.32 118 219
P2 – TB non-target NH 170.90 160.50 33.21 146 260 Z = − 3.18; p < 0.01
CI 227.30 219.50 41.43 180 277
P1 – TB target NH 71.20 74.50 10.22 53 83 Z = − 3.78; p < 0.01
CI 113.20 111.50 23.34 87 143
N1 – TB target NH 116.90 110.50 24.92 97 175 Z = − 3.21; p < 0.01
CI 169.60 181.50 29.43 120 201
P2 – TB target NH 173.50 167.00 39.48 135 280 Z = − 3.10; p < 0.01
CI 224.80 235.50 38.02 177 289
N2 – TB target NH 241.20 237.50 36.67 199 315 Z = − 3.11; p < 0.01
CI 310.20 301.00 32.34 272 371
P3 – TB target NH 350.30 343.00 31.57 300 390 Z = − 3.10; p < 0.01
CI 493.40 518.50 74.88 309 560
 Cortical auditory evoked potentials 477

Table 3. Descriptive statistics for amplitudes of studied waves in TB stimuli.

Amplitude – stimulus Groups M C Sd Min Max Mann–Whitney test

P1 – TB non-target NH 1.55 2.31 3.25 −6.81 4.53 ns

CI 1.87 1.20 2.18 0.12 7.37
N1 – TB non-target NH −4.68 −3.33 3.68 −13.86 −1.07 ns
CI −3.89 −4.45 3.08 −9.26 0.49
P2 – TB non-target NH 9.75 5.26 10.64 0.07 33.47 ns
CI 3.51 3.01 3.05 0.09 8.79
P1 – TB target NH 2.65 3.10 1.96 −2.07 5.29 ns
CI 2.97 2.44 2.23 0.74 7.87
N1 – TB target NH −4.38 −3.90 3.71 −12.02 0.48 ns
CI −4.48 −5.37 2.83 −8.25 1.30
P2 – TB target NH 9.79 7.26 9.55 1.84 29.5 ns
CI 4.49 5.17 3.17 0.48 9.76
N2 – TB target NH −1.99 −3.34 6.16 −11.08 11.6 ns
CI −1.24 −1.29 3.06 −6.14 3.66
P3 – TB target NH 19.33 19.09 9.21 3.01 36.89 Z = − 2.57; p < 0.01
CI 8.93 10.60 6.62 −5.34 15.60

The CI group displayed significantly longer latencies for all studied waves after non-target and
target TB stimuli than the NH group. However, there were no significant differences between
these two groups in wave amplitudes after non-target TB stimuli. After target TB stimuli, there
were significant differences in the P3 amplitudes. CI children had significantly lower P3 wave am-
plitudes after target TB stimuli than NH children (Table 3).
After a non-target DS stimulus, all studied variables exhibited significant differences in latencies
for P1, P2, N2 and P3. Unsuccessful cochlear implant users had significantly longer latencies for all

Table 4. Descriptive statistics for latencies of studied waves in DS stimuli.

Latency – stimulus Groups M C Sd Min Max Mann–Whitney test

P1 – DS non-target NH 87.10 80.00 15.89 67 109 Z = − 2.58; p < 0.01

CI 119.00 104.50 33.69 91 187
N1 – DS non-target NH 148.40 121.00 52.38 98 227
CI 195.50 180.50 81.07 108 393
P2 – DS non-target NH 198.40 158.00 65.95 135 306 Z = − 2.69; p < 0.01
CI 291.20 292.50 67.78 185 431
N2 – DS non-target NH 257.80 245.00 55.27 188 335 Z = − 3.55; p < 0.01
CI 396.60 382.00 49.70 312 467
P3 – DS non-target NH 340.40 341.50 38.56 269 390 Z = − 3.78; p < 0.01
CI 520.90 523.50 76.37 404 641
P1 – DS target NH 97.20 94.00 20.51 70 129
CI 122.30 117.50 24.09 87 163
N1 – DS target NH 163.40 153.50 46.05 109 228
CI 171.10 165.50 36.14 114 224
P2 – DS target NH 224.90 250.50 59.41 134 295
CI 232.50 238.50 42.09 163 303
N2 – DS target NH 274.20 287.50 46.53 182 320
CI 356.20 366.00 90.31 269 569
P3 – DS target NH 346.50 346.00 31.72 289 402 Z = − 3.78; p < 0.01
CI 472.90 437.50 72.46 414 640
478 B. Munivrana and V. Mildner

Table 5. Descriptive statistics for amplitudes of studied waves in DS stimuli.

Amplitude – stimulus Groups M C Sd Min Max Mann–Whitney test

P1 – DS non-target NH 0.65 1.07 3.27 −4.52 5.50 p > 0.01

CI 1.57 1.44 2.60 −3.29 5.31
N1 – DS non-target NH −4.74 −5.94 4.13 −9.32 0.984 p > 0.01
CI −3.70 −3.85 3.58 −9.13 1.01
P2 – DS non-target NH 0.52 0.95 2.22 −3.31 4.02 Z = − 0.61; p > 0.01
CI 1.67 1.74 4.08 −3.67 8.27
N2 – DS non-target NH −7.97 −7.31 4.47 −16.69 −1.13 Z = − 2.12; p < 0.05
CI −4.41 −5.15 2.90 −7.24 0.08
P3 – DS non-target NH 3.77 2.20 3.66 0.31 10.40 p > 0.01
CI 3.00 3.45 1.41 0.24 5.02
P1 – DS target NH 2.65 2.85 3.05 −1.48 8.27 p > 0.01
CI 1.21 1.67 2.92 −3.42 6.27
N1 – DS target NH −8.35 −6.87 5.45 −18.39 0.64 p > 0.01
CI −5.84 −4.77 4.27 −14.92 0.60
P2 – DS target NH −1.04 −0.99 2.98 −4.88 5.05 p > 0.01
CI 2.94 4.01 6.06 −9.46 12.12
N2 – DS target NH −8.84 −9.17 5.18 −18.61 −0.24 p > 0.01
CI −7.48 −6.74 6.87 −18.33 4.48
P3 – DS target NH 6.76 4.89 5.98 0.02 15.28 p > 0.01
CI 4.51 4.14 7.03 −4.54 18.94

studied waves, with the exception of N1. For the N1 wave, there were no significant differences in
latency between the two groups after the non-target DS stimuli (Table 4).
The CI children displayed significantly lower amplitudes after the non-target DS stimuli for the
P2 and N2 waves than did the NH children. For target DS stimuli, there were no significant differ-
ences in the amplitudes of any of the studied waves (Table 5).
The number of (non)responses to target stimuli was expressed as a percentage. Thus, the NH chil-
dren had response rates of 99.2% (no response to 4 out of 500 stimuli) to the TB and 100% to the DS
stimuli. CI children had 86.8% response rates (no response to 57 out of 500 stimuli) to the TB and
97.6% (no response to 12 out of 500 stimuli) to the DS stimuli (Table 6).
Statistically significant differences in the RTs to both types of stimuli were observed between the
groups (Table 7).

Table 6. Number of (non)responses to TB and DS stimuli.

TB DS

NH 4/500 = 99.2% 0/500 = 100%

CI 57/500 = 86.8% 12/500 = 97.6%

Table 7. RTs to TB and DS stimuli.

RT Groups M C Sd Min Max Mann–Whitney test

TB NH 0.48 0.48 0.09 0.35 0.67 Z = 7.00; p < 0.01

CI 0.72 0.72 0.16 0.51 0.93
DS NH 0.55 0.53 0.10 0.39 0.69 Z = 12.00; p < 0.01
CI 0.76 0.81 0.12 0.57 0.89
 Cortical auditory evoked potentials 479

The CI children exhibited slower RTs than the NH children for both types of stimuli.

Discussion
When a TB was the stimulus, the CI group displayed significantly longer latencies for all studied waves
after non-target and target TB stimuli (Figures 1 and 2). This indicates that the maturation processes and
the perception of auditory stimulus occur later, as do the discrimination and encoding of auditory stimuli.
There were no significant differences in wave amplitudes for any of the studied waves with the
exception of the P3 amplitudes after target TB stimuli. The CI group exhibited significantly
lower amplitudes compared with the NH children. Longer latencies and diminished P3 wave ampli-
tudes after target TB stimuli indicate that cognitive processing of auditory stimuli is impaired in
unsuccessful implant users.
Statistical analysis of the wave latencies after non-target DS stimuli revealed a significant differ-
ence between NH and CI children (Figure 3). The latter group exhibited significantly longer
latencies for all studied waves, with the exception of the N1 wave. This may indicate that the matu-
ration of neuronal structures and discrimination of speech stimuli occur later in unsuccessful implant
users. Because N1 represents encoding of the beginning of a stimulus at the level of the auditory
cortex (Čeponiené et al., 2008; Steinschneider & Dunn, 2002), the lack of a statistical difference
between the two groups in this parameter may indicate that the unsuccessful implant users are suc-
cessful at encoding speech stimuli. This may be attributed to adequate speech and hearing
rehabilitation.
After a target DS stimulus, there were no significant differences in the wave latencies between the
two groups, with the exception of the P3 latencies (Figure 4). The P3 latencies were significantly
longer in the CI group. This indicates that the cognitive processing of auditory speech stimuli is
impaired in unsuccessful implant users.

Figure 1. CAEP for non-target TB stimuli – Cz electrode.

480 B. Munivrana and V. Mildner

Figure 2. CAEP for target TB stimuli – Cz electrode.

Figure 3. CAEP for non-target DS stimuli – Cz electrode.

Significant differences in wave amplitudes after DS target stimuli were observed only for the N1
and P2 waves. The CI children exhibited lower amplitudes than the NH children. These findings
indicate that neuronal function is impaired in unsuccessful implant users, meaning that unsuccessful
implant users had problems with the automatic processing and discrimination of speech stimuli.
 Cortical auditory evoked potentials 481

Figure 4. CAEP for target DS stimuli – Cz electrode.

Discrimination between the fine acoustic features in speech sounds is fundamental to speech percep-
tion. Clinical assessment of speech discrimination is concerned with a patient’s ability to discrimi-
nate among such acoustic differences (Sharma et al., 1997).
These results suggest that unsuccessful CI users have difficulty with the cognitive processing of
auditory and speech stimuli and that they are impaired in discriminating between the fine acoustic
features of speech sounds.

Conclusions
The study demonstrated that unsuccessful cochlear implant users take longer to perceive and dis-
criminate tonal and speech auditory stimuli than do NH children. Furthermore, unsuccessful
implant users have deficits in the maturation of neuronal structures (Gordon, Tanaka, Wong, &
Papsin, 2008) and in the discrimination and cognitive processing of tonal and speech stimuli, par-
ticularly for speech stimuli (Bishop & McArthur, 2005). In this respect, these results may be similar
to those reported for children with SLI. Children with normal hearing and SLI have difficulties in the
perception and discrimination of short sounds that follow each other in short time intervals (Bishop
& McArthur, 2004). In addition, it is well known that some children with SLI have difficulties in
discriminating sound frequency characteristics because their temporal processing of acoustic
stimuli is impaired (Bishop, Hardiman, Uwer, & von Suchodoletz, 2007). It would be interesting
to pursue this line of research in further studies.
The results of this research will be useful in speech and language therapy as well as in the diag-
nosis of these difficulties because they provide objective patterns and directions for more effective
therapy. The results indicate that therapy should contain more hearing exercises that include speech
discrimination tasks and measures of cognitive progress.
482 B. Munivrana and V. Mildner

Acknowledgements
The authors thank two anonymous reviewers for their helpful comments on an earlier version of the
manuscript.

Declaration of Interest: This work was supported by grant 130-0000000-3096. The authors report
no conflict of interest. The authors alone are responsible for the content and writing of the paper.

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