Age and Outcome of Cochlear Implantation for
Patients with Bilateral Congenital Deafness in a
Cantonese-Speaking Population
Michael C. F. Tong, Eric K. S. Leung, Albert Au, William Lee, Virgil Yue, Kathy Y. S. Lee,
Vanessa S. W. Chan, Terence K. C. Wong, Dilys M. C. Cheung, and C. Andrew van Hasselt
Objective: To evaluate the effect of age at implanta-
tion by assessment of speech perception in cochlear
implant users with bilateral congenital deafness.
Design: A retrospective cohort analysis of 60 co-
chlear implant users (age at implantation, 1.01 to
22.0 yr) who have at least 2 yr of experience. Their
outcome performance was defined by the change in
i) speech perception category (SPC) score based on
postoperative assessment results and ii) the type of
education attended after implantation. The associ-
ation of age at implantation with SPC scores was
analyzed at different ages at implantation (2, 3, 4, 5,
and 6 yr old). The SPC scores for a particular age at
implantation were compared at 6, 12, and 24 mo
after implantation. The impact of age at implanta-
tion on choice of education was evaluated by ana-
lyzing the transition from a school for the deaf to
mainstream education for the 45 children who were
operated on before the age of 10, because older
children are less likely to make such a change.
Results: Children implanted at the ages of 2, 3, 4, 5,
and 6 yr all obtained significant improvements in
SPC scores 24 mo after implantation. The greatest
improvement was noted at 24 mo after implantation
among those operated on before age 3. For all age
groups, improvement at 24 mo after implantation is
greater than at 12 mo, whereas the latter is greater
than the improvement noted at 6 mo after implan-
tation. Comparison of children implanted before
the age of 3 and between ages 3 and 10 showed a
significant difference in the choice of education
after implantation. Children who were implanted
before the age of 3 were more likely to attend
mainstream education after implantation.
Conclusion: Results from the present study are con-
sistent with the current belief that implantation at
a younger age provides greater benefit. The propor-
tion of children attending mainstream education
was significantly higher for those implanted before
age 3, which may be a potential benefit to early
implantation for relieving the burden of govern-
ments in providing special education.
(Ear & Hearing 2007;28;56S–58S)
The current trend in pediatric cochlear implanta-
tion is, undeniably, decreasing age of implantation.
The Chinese University of Hong Kong, Hong Kong, China.
0196/0202/07/282 Supplement-0056S/0 • Ear & Hearing • Copyright © 2007 by Lippincott Williams & Wilkins • Printed in the U.S.A.
56S
Implementation of universal newborn hearing screening
makes early detection of hearing impairment possi-
ble; advancing surgical techniques allow infants
under the age of 12 mo to be implanted safely
(James & Papsin, 2004), and improvement in neural
response telemetry facilitates initial programming
of speech processors, providing auditory stimulation
for infants (Gordon, Gilden, Ebinger, et al., 2002).
Evidence in favor of early implantation is numerous,
the most important evidence is that early implanta-
tion entails better performance outcome. Speech
perception ability (Manrique, Cervera-Paz, Huarte, et
al., 2004a; 2004b; Svirsky, Teoh, & Neuburger, 2004;
Zwolan, Ashbaugh, Alarfaj, et al., 2004), onset of
babbling (Schauwers, Gillis, Daemers, et al., 2004),
and plasticity of the central auditory system (Sharma,
Dorman, & Spahr, 2002) have been proven to be
correlated with age at implantation. Such advantages
have been reported in Western studies, but substan-
tiation in a Cantonese-speaking population is lim-
ited. This paper aims to evaluate the effect of age at
implantation on speech perception performance in a
Cantonese-speaking population.
MATERIALS AND METHODS
Subjects
This is a retrospective cohort study. Sixty patients
(32 males and 28 females; age at implantation, 1.01 to
33.0 yr) who received cochlear implants at Prince of
Wales Hospital for at least 2 yr were selected. All
subjects had bilateral congenital deafness and were
implanted unilaterally with Nucleus 24 or 22 devices
with full electrode insertion. Residual hearing, taken
as average preoperative hearing thresholds at 0.5, 1,
and 2 KHz on the side to be implanted, ranged from 97
to 125 dB HL, with a mean of 113 dB HL.
Outcome Measure
Outcome was defined by change in speech percep-
tion category (SPC) scores and change in the type of
education opted for (mainstream school versus
school for the deaf) after implantation. SPC scores
were based on adult and pediatric versions of the
EAR & HEARING, VOL. 28 NO. 2 SUPPLEMENT
Hong Kong Speech Perception Test Manual (Co-
chlear Implant Working Group, 2000), which were
used for all pre- and postoperative assessments. A
longitudinal set of data containing preoperative as-
sessments and postoperative assessments at 6, 12,
and 24 mo was collected. Scores of the Hong Kong
Speech Perception Test Manual tests, including seven-
sound detection, syllable identification, vowel and
consonant identification, open-set sentence, and
word recognition, were used to determine the SPC
scores, which ranked from 0 to 7. Patients are
granted a score of 0 for no sound detection; 1 for
sound detection; 2 for suprasegmental perception; 3
for vowel identification; 4 for consonant identifica-
tion; 5 for minimal open-set word recognition; 6 for
⬎20% score in open-set word recognition; and 7 for
⬎50% score in open-set word recognition. Similar
classification systems have been used in other West-
ern studies (Mondain, Sillon, Vieu, et al., 1997).
The other outcome indicator is the choice of main-
stream school versus school for the deaf after im-
plantation. The stream of school attended after
implantation was analyzed for subjects implanted
under the age of 10. The cutting point at age 10 is
arbitrary, although older children, even after im-
plantation, are less likely to be transferred from a
school for the deaf to a mainstream school.
Statistical Analysis
The data was first tested for normality by the
Shapiro-Wilk test. For the nonnormally distributed
data, the association of age at implantation with
outcome was analyzed by the Mann-Whitney U test
at different ages (i.e., ages 2, 3, 4, 5, and 6 yr). Under
a particular age at implantation, the benefit was
compared by the mean rank difference at 6, 12, and
24 mo after implantation. Other possible parame-
ters such as gender, residual hearing, magnetic
resonance imaging/computed tomography status of
the implanted ear, and side of implantation were
analyzed by chi-square test. The relationship be-
tween age at operation and likelihood of entering
mainstream education was evaluated by chi-square
and Fisher exact test.
RESULTS
Outcome Performance
Subjects were divided into five groups by their
age at implantation: 2, 3, 4, 5, or 6 yr. All groups
achieved a positive change in SPC score at 24 mo
after implantation (Fig. 1). The Mann-Whitney U
tests yielded significant differences (p ⬍ 0.05) in
mean rank between groups of implantation at ages
3, 4, 5, and 6 yr. Improvement at 24 mo was greater
57S
Fig. 1. Six-, 12-, and 24-mo postoperation mean rank differ-
ences at different ages of implantation.
than at 12 mo (Fig. 1), whereas improvement at 12
mo was greater than at 6 mo after implantation (Fig.
1). At 24 mo after implantation, the greatest rank
difference of 19.28 was between age at implantation
before versus after age 3, which also had a high
significance of p ⬍ 0.001, as shown in Fig. 1.
No significant differences were demonstrated by
the chi-square tests between different groups on sex,
side of implantation, or computed tomography/mag-
netic resonance imaging findings on cochlear and
residual hearing. These parameters were not statis-
tically different between groups tested.
Type of Postoperative Education
Forty-five subjects implanted before age 10 were
analyzed for the stream of school attended after
implantation. Comparison for subjects implanted
before age 3 and between ages 3 and 10 by chi-
square and Fisher exact test showed that the two
groups had a significantly different score for the
different types of postoperative education attended
(Fisher exact test significant ⫽ 0.034). Five of 13
subjects (38.5%) implanted before age 3 made the
transition to normal education after implantation,
whereas 3 of 32 subjects (9.4%) of those operated on
between ages 3 and 10 made the transition.
DISCUSSION
Children with bilateral congenital deafness can bene-
fit significantly from cochlear implantation. Existing ev-
idence suggests that implantation at younger age pro-
vides greater benefit (McConkey Robbins, Burton Koch,
& Osberger, 2004; Manrique, Cervera-Paz, Huarte, et
al., 2004; Nikolopoulos, Dyar, Archbold, et al., 2004;
Pulsifer, Salorio, & Niparko, 2003). Early implanta-
tion maximizes auditory stimulation to the child
during the critical period for language acquisition
(Colletti, Carner, Miorelli, et al., 2005). Results of
this study are consistent with current findings,
demonstrating greater improvement in younger age
58S
groups compared with the older age groups at 24 mo
after implantation. A possible limitation of this
present study is the small sample size of the younger
group when the cut point was at the extremity of
age. With only six children implanted before age 2, a
nonsignificant difference (p ⫽ 0.08) was demon-
strated against subjects implanted after age 2. With
more subjects in that age group and long-term
follow-up studies, those who are implanted before
the age of 2 are more likely to demonstrate higher
SPC scores. Although no definite conclusion could be
drawn about the critical age at which implantation
provides the greatest benefit, the trend we found
coincides with current understanding that implan-
tation at a younger age can provide greater benefit.
The proportion of children entering mainstream
education after implantation was significantly higher
in those implanted before age 3 (38.5%) than in those
implanted between ages 3 and 10 (9.4%), with p ⫽
0.034 by the Fisher exact test. One potential benefit of
earlier implantation is that it might relieve the burden
on governments to provide special schooling.
CONCLUSION
Our study confirms the benefits in terms of
speech perception outcome in performing cochlear
implantation in a younger age group in a Chinese
population. We have further shown that a younger
age of implantation is a favorable factor for main-
streaming in school age children.
Address for correspondence: Michael C. F. Tong, Division of Otorhi-
nolaryngology, Department of Surgery, CUHK, 6/F, Clinical Sci-
ences Building, Prince of Wales Hospital, New Territories, Hong
Kong SAR, China. E-mail: mtong@surgery.cuhk.edu.hk
Received December 15, 2005; accepted May 17, 2006.
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