Professional Documents
Culture Documents
Systematic Review
Patricia L. Purcell, MD, MPH; Justin R. Shinn, MD; Greg E. Davis, MD, MPH; Kathleen C. Y. Sie, MD
10.5/high
13/high
10/high
12/high
and performance
and performance
Full-scale, verbal,
Full-scale, verbal,
Type of IQ Score
Full-scale, verbal
Full-scale only
Reported
neurological injury
Matched from clinic
cohort at-risk for
clinic population
Source of Control
Matched siblings
Identified within
Matched from
Group
population
pediatric
Fig. 1. Flow diagram of study selection
IQ 5 intelligence quotient; NH 5 normal hearing; SD 5 standard deviation; UHL 5 unilateral hearing loss.
Therefore, it was deemed appropriate to report results
TABLE I.
Scale of Intelligence
Stanford-Binet IQ test
Weschler Abbreviated
Weschler Intelligence
Weschler Intelligence
Nashville,
St. Louis,
Mexico
TN
200916
198617
that of normal hearing children, 95% CI (27.5, 20.4) A number of significant differences between chil-
(see Figure 4). dren with UHL and bilateral normal hearing were noted
in study by Martinez-Cruz et al.16 The authors reported
the following differences: neonatal intensive care unit
Performance IQ (NICU) stays were longer for children with UHL at 26
Because only two studies reported performance IQ days as compared with 8 days for children with NH, P
results, meta-analysis of performance IQ scores was car- value < 0.001. Hospital stays were longer for children
ried out using fixed-effects model. It detected a signifi- with UHL at 47 days as compared with 25 days for chil-
cant pooled mean difference in IQ scores, P value 0.037. dren with NH, P value 0.004. The 1-minute and 5-
Children with UHL were estimated to have a mean minute APGAR scores were lower for children with
performance IQ that was 3.8 points lower than that UHL, P value 0.01. Indirect bilirubin levels were higher
of normal hearing children, 95% CI (27.3, 20.2) (see for children with UHL, P value 0.004. Children with
Figure 5). UHL were more likely to have suffered from hypoglyce-
mia, P value 0.04, and bronchopulmonary dysplasia, P
Potential Confounding Conditions value 0.002.
Observational studies are subject to the limitations
of confounding to a greater extent than randomized tri- DISCUSSION
als. All of the studies included in the meta-analysis Accurately measuring educational achievement can
made some effort to document characteristics of children be challenging. Intelligence quotient scores are reported
with UHL and controls with NH (see Table II). Despite in a standardized method, making it easier to compare
efforts to match characteristics between the groups, results across studies. This meta-analysis suggests that
some important differences were noted. In the study by children with UHL have significantly lower full-scale
Lieu et al.,15 15.6% of children with UHL had a history and performance IQ scores than normal-hearing peers.
of head trauma as compared to 3.2% in the sibling Results for verbal IQ were not quite as conclusive; how-
matched controls, P value 0.008. Parents also reported a ever, after removal of the outlying study, we calculated a
history of meningitis in 3% of children with UHL, significant difference. Such results are important
although this was not assessed in sibling controls. because, in many cases, the individual studies had failed
to detect a significant difference. For example, both functional magnetic resonance imaging to better under-
studies that reported performance IQ15,17 did not find a stand the impact of UHL on neural connectivity in audi-
significant difference in score between children with tory processing and executive function, finding
UHL and children with NH; however, when pooled, a differences in brain network interconnections between
significant difference was noted. Overall, we found that children with UHL and normal hearing controls.19 There
children with UHL have a mean full-scale IQ that is have also been attempts to investigate whether these
more than 6 points lower than children with normal abnormal networks differ based on if a child has a right-
hearing. In terms of clinical relevance, this difference in or a left-sided hearing loss.20 Investigations have eval-
IQ points is not quite half a standard deviation lower on uated the functional impact of UHL on sound localiza-
the IQ scale. tion and speech discrimination and have determined
There was not significant heterogeneity in reporting that unilateral impairment is a significant handicap.21
of full-scale and performance IQ results. However, we For example, children with UHL require significantly
found substantial heterogeneity when evaluating verbal higher signal-to-noise ratios than normal hearing chil-
IQ scores. With exclusion of the source of the heteroge- dren under all listening conditions, including when a
neity—the Martinez-Cruz study,16 which relied upon a signal is delivered directly to their unimpaired ear.22
high-risk medical cohort—we found a significant differ- To evaluate quality of life among children with
ence in verbal IQ score between children with UHL and UHL, Borton et al. conducted focus groups of children
children with NH. with UHL and their parents.23 Group discussions
Previous studies have used a diverse array of tests revealed that children with UHL perceived barriers in
to characterize the impact of UHL among children and educational and social settings; however, many children
adolescents. For example, Ead et al. used a battery of displayed resilience in adapting to their impairment.
tests to find that children with UHL have reduced accu- Studies have also used the Screening Instrument for
racy and efficiency of phonological processing, along Targeting Education Risk (SIFTER) to determine how
with difficulty maintaining verbal information in the well teachers rate performance of children with UHL
face of auditory distractions.18 Tibbetts et al. utilized when compared to normal-hearing peers. Not only did
Schmithorst, Age 7–12 Mixed or conductive hearing loss Gender None No significant differences
201414 reported in characteris-
UHL for 2 years or greater* History of head trauma Age
tics that were
751
Purcell et al.: Unilateral Hearing Loss
these studies find that children with UHL receive signif- vided children with UHL individualized education plans
icantly lower SIFTER scores than their peers,24 but over a 3-year period.34 Preferential seating at the front
somewhat surprisingly, there was a negative association of the class is another option for educational support. It
between degree of hearing impairment and teachers’ rat- has been found that individuals with UHL must sit
ings of student performance.25 Children with more approximately half the distance away from a speaker as
severe bilateral hearing loss were rated as scoring better an individual with NH to have similar speech
academically, participating more fully in class, communi- discrimination.35
cating more effectively, and demonstrating better behav- Although this meta-analysis suggests that children
ior than children with minimal or UHL. The authors with UHL have lower IQ scores, it is important to con-
posited that this positive correlation between hearing sider the limitations of the study. First, only four obser-
threshold and SIFTER score could be due to the fact vational studies were identified for inclusion in the
that children who are more severely affected have meta-analysis. It is possible that publication bias could
greater access to support services. Somewhat similarly, a play a role by limiting the publication of studies that did
large case series from Omaha, Nebraska, of 324 children not find a significant difference in results.
and adolescents with UHL found 31% of the children to Heterogeneity among studies was detected when
have scholastic or behavioral problems in school.26 Evi- investigating verbal IQ. The Martinez-Cruz et al.
dence suggests that educational disparities continue into study16 differed from the others in terms of its results,
adolescence.27 In summary, it appears that children with detecting a greater degree of difference between IQ
UHL face a range of difficulties in educational environ- scores of children with UHL and children with normal
ments, and these challenges may be underappreciated. hearing. The study was conducted in Mexico, whereas
Unfortunately, management of UHL remains a the other three studies were performed in the United
challenge. Variability in management is perhaps based States. It is possible that differences in available resour-
on the lack of definitive evidence that children with ces to support children with hearing loss might be con-
UHL differ from children with NH. Based on the find- tributing to some of the variation that was identified.
ings of this meta-analysis, IQ scores may be a relevant With the Martinez-Cruz et al. study16 excluded, the
outcome to follow in the future. There is also a need for meta-analysis calculated a significant difference in
future studies to investigate how well various methods verbal IQ score.
of hearing amplification, such as conventional hearing In addition, this meta-analysis did not include stud-
aids or contralateral routing of signal devices, improve ies that primarily evaluated educational outcomes in
detection and localization of signal. Determining benefit children with craniofacial disorders, such as aural atre-
can be difficult because studies have found subjective sia. Two studies were identified that investigated chil-
reports of benefit with conventional hearing aids despite dren with atresia. The results of the studies were mixed:
no change in speech perception scores.28 Questions one found that children with atresia seemed to perform
regarding optimal management of UHL continue to gain better academically than children with unilateral
importance as interest grows in surgical options such as SNHL,12 whereas the other found similar risks of speech
bone conduction hearing devices and even cochlear and learning difficulties as children with unilateral
implants.29,30 SNHL.13 Additional research is needed to evaluate edu-
The age at which an intervention is applied may cational impact of UHL associated with craniofacial
also affect outcome. For example, Johnstone et al. found disorders.
that children who received hearing amplification earlier It is possible that duration of UHL may also affect
in life were more likely to show bilateral benefit with educational achievement. Only the 2013 Lieu et al.
sound localization; however, children who were fit with study15 reported on the method of UHL detection and
hearing aids later in childhood or adolescence were more average age at diagnosis. Interestingly, only 8% of chil-
likely to experience bilateral interference with localiza- dren with UHL in that study were detected by newborn
tion with hearing aids in place.31 Such results reinforce hearing screening, so it is possible that some of the chil-
the notion that critical brain development occurs early dren could have developed progressive hearing loss in a
in life; therefore, if a child with UHL does not receive more delayed fashion. All of the studies included in the
early intervention during the appropriate time window, meta-analysis attempted to limit enrollment to long-
the child may be less successful with future attempts at standing UHL. Schmithorst et al.14 were unable to
management. Studies suggest that universal newborn determine time of diagnosis for four of the children
hearing screening has reduced the average age at diag- included in their study, although all of the children with
nosis of UHL,32 which may improve efforts to provide UHL were confirmed to have SNHL.
early intervention.33 Although in the 2013 study by Lieu In addition, IQ testing is only one method for meas-
et al.,15 only 8% of the 107 children with UHL had been uring educational development. There are a number of
diagnosed through newborn hearing screening, perhaps other methods for assessing speech and language skills
indicating a need to further optimize newborn screening and cognitive growth. Some other possibilities include
for children with UHL. age at first word or two-word sentence, presence or
Apart from amplification, there is evidence that absence of special education requirements, and specific
educational support services benefit school-aged children speech and language standardized testing. We attempted
with UHL. In a separate longitudinal study, Lieu et al. to analyze these other markers of educational develop-
found improvement in language scores when schools pro- ment but did not find enough consistency between