& Internstional Journal of Pediatric Otorhinolaryngology ELSEVIER 58 (2001) 208-210 swww.eleevercom/locate ior! Hearing loss in speech-language delayed children loannis M, Psarommatis *, Bleni Goritsa, Dimitrios Douniadakis, Michael Tsakanikos, Alexandra D. Kontrogianni, Nikolaos Apostolopoulos Departnent of Otorhnolaryngology, Children’s Hoapital of Athens, ‘P. & A. Kyrlokow’, Thloon & Lisadas Steet, 11527 Goudi, Alen, Greece Received 13 July 2000; received in revised form 10 January 2001; accepted 13 January 2001 Abstract An infant begins to communicate with his/her environment from the first months of life. However, true words do rot appear until the age of 12-15 months, following a rather predictable sequence. Delay or failure of normal language development is not a rare situation in childhood and may be due to a variety of reasons. Among these, hearing undoubtedly plays a leading part in the language acquisition process. The purpose of this study was to assess the percentage of heating-impaired children in a group of phenotypically healthy children presenting with speech-lan- ‘guage delay. Between March 1993 and March 1999, 726 speech-language delayed children were examined in our department, In 72 of them, vasious diseases or syndromes had already been diagnosed and so they were excluded from the study. The remaining 654 apparently healthy children entered the study and underwent a thorough audiological assessment for determination of their hearing thresholds. Eighty-seven children (13.3%) showed various degrees of hearing loss. Most of them (35 children, 8.4%) suffered from sensorineural hearing impairment, while in 232 children (4.9%) a conductive heating loss was discovered. The increased prevalence of hearing impairment found in our population mandates a thorough hearing evaluation for every case of speech-language delay, even for those children who show no evidence of other handicaps, This will help in the early diagnosis of hearing loss, allowing proper management to be instituted as easly as possible, © 2001 Flsevier Science Ireland Ltd. All rights reserved. Keywords: Speech-language delay; Hearing loss; Children Ae eaca containing socially acceptable meanings for com- municating between people [1-3]. Mankind pre- dominantly uses words or written symbols to receive and send messages; gestures (sign lan- guage), facial expressions or body movements may also be used. On the other hand, speech is : cay, the physical process of production of oral sym- coLimeenaing autor, Pret adds 1626. Vesinde js, including their articulation (1,3), The nor rene nee Tanti 0h ae mally developing child begins to communicate E-mail address: ipsar@imternet.ge (LM, Psarommatis). with his/her environment using spoken symbols Language is one of the most elaborate skills possessed by human beings. The term language, in its broad sense, refers to a system of symbols (0165-5876)01/5 - sce front mater © 2001 Elsevier Science Ireland Lid, All rights reserved PU: $0165-5876(01)00430-X206 IM, Paarommatis eta. (Int, J. Pediat, Otoriinolarynol, $8 (2001) 205-210 from the first months of life, following a rather predictable sequence, An infant babbles (repeats a series of unintelligible sounds) by the age of 6 months, expresses the first true words at about his/her first birthday, and is able to construct sentences of three to five words by the age of 3 years (Table 1) [1,3-8]. In spite of the lack of a world-wide agreement concerning the definition of Fanguage delay, as a rough guide, one can say that failure to express words by 24 months ot phrases by 3 years of age may be characterised as lan- ‘guage delay and should cause concern [1,4]. Hearing is considered to be a sine qua non for the development of language skills. This simply ‘means that hearing evaluation is of utmost impor- tance when we deal with a speech-language de- layed child [5.6.9]. However, we do not accurately now the percentage of hearing-impaired children among those with speech-language delay. Further- ‘more, we are almost completely unaware of the percentage of hearing-impaired children among those who present language delay without associ- ated anomalies or developmental deficits The aim of this study was to investigate the incidence of hearing impairment among @ group of phenotypically healthy children presenting with language delay. Table 1 ‘The main stages of expressive language development Age Language 0-8 weeks 6 months Reflexive cries and vegetative sounds Cooing {mascal open vowel sounds), ‘monosyllables: ‘ba. “ga” Polssllabic babbling: ls’ "mamama" Uses jargon hisyber own language), oubied syllables: ‘mama’, “dada" 6-8 mouths 8-12 montis 12-18 months Fist trne words appear, Tmitates sounds ‘The child uses up 1020 single words by age 18 months, 1}4 ineligible speech 18-24 months A few two-word phrases: me down, “my shoe’ 12 ineligible speech, Vocabulary containing approximately 200 words months “Real” sentences combining 3-5 words. ‘Uses plurals, question forms and negaive forms, 34 intelligible speech 36-48 months Count (0 10, Clear syntax. Vocabulary of 1000 words. Completely intligible spech 2. Patients and methods We studied retrospectively the medical records of all language-delayed children (n= 726) who were examined consecutively in our department between March 1993 and March 1999. Seventy- two children suffered from known diseases and syndromes (Down syndrome, Alport syndrome, anatomic deformities, ete.) and were excluded from the study. The remaining 654 children showed no other pathological signs and symptoms apart from their language delay. These otherwise healthy children had a negative personal history and their attending paediatricians had recom- mended a consultation by a specialist, exclusively due to language delay. Finally, children were re- ferred for hearing evaluation to our department, by specialised doctors (speech-language patholo- gists and logopedists) who had previously assessed the children’s mental, psychomotor and verbal capabilities, For a small number of children, re- ferral was made either by the attending paediatti cians or by their parents The population under investigation comprised 374 males (57.2%) and 280 females (42.8%), and their age ranged from 19 to 52 months (mean age, 35 months). Audiologic examination included careful his tory taking, clinical evaluation, otoscopy, immi- tance measurements and hearing tests. The latter included free field and play-tone audiometry for those children who could cooperate, otoacoustic emission recordings and auditory brainstem re- sponse (ABR) audiometry. Although the findings of all aforementioned tests were taken into ac- count in the diagnostic process, the definitive esti- mation of hearing was mainly based on ABR measurements that were performed in all children of the study. Auditory. brainstem response recordings were carried out in a quiet but non-soundproof room. under sedation induced by chloral hydrate (40-60 mg/kg), using a Biologic Traveller Express unit. A detailed description of the method used for ABR recordings can be found elsewhere [10]. Briefly square wave pulses (100 ys) of alternating polarity were passed monaurally through a shielded TDH- 39 earphone to produce clicks presented at a rateLM, Paarommari eta. (Tar J Pedite. Otorhinolarmngol. 58 (2001) 205-210 207 of 31/s, Two-channel recordings were obtained using four silver dise electrodes at the vertex (active), the mastoid processes (reference) and the Forehead (ground). The electroencephalogram sig- nal was amplified ( x 150000), filtered (100-3000 Hz) and, the first 10.2 ms after the stimulus (2048 samples), were averaged and replicated, Wave- forms were digitally stored and plotted on hardeopy. Based on ABR findings, children were classified as having: (a) normal ABR threshold, when a clear and reproducible wave V was recorded bilat- «rally at 40 decibel normal hearing level (GBnHL) within normal latencies; (b) mildly to moderately elevated ABR threshold, when a clear wave V was elicited by a stimulus at 45~65 dBnFIL; (c) signifi cantly elevated ABR threshold, if the wave V was produced by a 70-95 dBnH1L acoustic stimulus; and, finally, (A) absence of ABR response, when no observable wave V was recorded even at the ‘maximum stimulus level (95 dBnHL), In a few cases with otoscopic and tympanometric findings suggestive of middle car effusion, a clear but delayed wave V at 40 dBnHIL was recorded. This finding was attributed to otitis media with effu- sion and children were characterised as having a ‘near normal’ hearing threshold The presence of middle ear effusion was a frequent reason for postponing the audiologic evaluation until the resolution of middle ear fluid (Geveral days or weeks). Rarely, when middle ear effusion showed a persistent character, hearing assessment took place despite the presence of secretory otitis media, taking into consideration the effects of middle ear fluid on ABR recordings (good waveform morphology, delayed wave I, interwave latencies within normal limits). These children were invariably re-evaluated after the resolution of middle ear pathology. 3. Results Eighty-seven (13.3%) out of 654 children who participated in the study showed elevated ABR thresholds. Their mean age was found to be 32 months. Fifty-five children (8.4%) had ABR find- ings consistent with sensorineural hearing impair- Children examined 358 >———,, lovated ABR threshold Norma ABR threshold 87 (133%), 567 (68.7%) L a Sensorineural hearing loss Conductive hearing loss 55 (0.45) 22 (4.9%) HM —,— Ansonce of Significantly Mldimoderately.Uniaeral ‘ABR response slevated ABR elevated ABR 5 (09%) 34(62%) hvoshold threshold 421%) 203%) Fig. 1. Diagrammatic representation ofthe results in the study population, ‘ment, whereas the remaining 32 (4.9%) gave evidence of having conductive hearing loss (Fig. D. In most children suffering from sensorineural hearing loss, ABR waveforms were completely absent (34 children, 5.2% of the total). Fourteen children (2.1% of the total) showed significantly elevated ABR thresholds bilaterally, while in only two children (0.3%) a bilateral mild to moderate clevation of ABR thresholds was revealed. Fic nally, we found five children (0.8%) with unilat- eral sensorineural hearing impairment. The average age of this group of children was found to be 28 months. All children suffering from conductive hearing Joss (n=32 or 4.9% mean age, 38 months) showed otoscopic, tympanometric and ABR find- ings consistent with otitis media with effusion. In these cases, ABR findings varied from ‘near nor- mal’ thresholds (a clear but delayed wave V at 40 ABnEIL) to mild/moderate hearing losses. 4 iscussion Language acquisition is the end product of a series of complicated processes. Receptive abili ties, central processing mechanisms and expressive skills are all involved in speech and language development {I}. Although there are large nor- mal variations concerning language expressive208 IM, Psarommaris eto. [Tos J. Pediatr. Otoninolwrmgol. $8 (2001) 205-210 skills, recent studies suggest that children of 24 months of age who produce fewer than 50 words ‘can be considered as performing at a level below the normal expressive language range and may be at_risk for chronic communication handicaps [12,13]. Even earlier, however, from the first months of life, infants’ prelinguistie behaviour may provide clues about a potentially impending speech-language disorder [3]. Failure or delay of normal language acquisition can be ascribed to a variety of reasons. The most frequent causes of speech and language delay are presented in Table 2 (1.3.5.5). To monitor language development effectively, hearing acuity, mental capacities and psychomo- tor development must be tested. If a language-de- layed child shows no other concomitant factors, such as mental retardation, hearing loss, emo- tional or neurological problems, then hejshe could bbe characterised as suffering from specific lan- ‘guage impairment, a language pathology that is always diagnosed by exclusion [5,14] Hearing impairment and, by extension, speech and language retardation can be encountered in syndromic or developmentally handicapped chil- ddren at an inereased rate [15-17]. However, a larger number of speech-language delayed chil- dren do not present any other associated anomaly, The present study showed that in such a group of phenotypically healthy children the per- centage of hearing-impaired children was as high as 13.3%. ‘The results of the present study were mainly based on ABR findings. Despite its limitations, ABR audiometry can effectively evaluate hearing status and has been found to be a particularly useful clinical test, especially when behavioural Table 2 ‘The most frequent causes of ypcet guage delay Menta retardation Hearing loss (sensorineural or conductive) ‘ais Dysarthcis Stuttering Poor verbal cxvironment Psychological disorders (including eletive mutism) Specific language disorder procedures are not suitable or when the results of such testing are inconclusive [18]. Besides, it has been proved that there is a good agreement be- tween ABR findings and behavioural pure tone thresholds at 2-4 kHz [19,20], It is reasonable, therefore, to conclude that, by using ABR au- diometry, a considerable portion of the speech. range frequencies can be reliably tested. Most of the hearing-impaired children of the present study (48 cases or 7.3%; Fig. 1) showed strong ABR abnormalities: ranging from signifi- cantly elevated ABR thresholds to totally absent ABR response, bilaterally. These findings are sug- gestive of severe to profound bilateral hearing Joss, which is the obvious reason for their lan- uage delay. It is well accepted that severe hearing losses are firmly linked with severe speech prob- Jems (5,21,22} Children with less than severe hearing impair- ment lear to speak adequately, although a delay in language expression can be anticipated 21} ‘The percentage of mildly to moderately hearing impaired children in our population was found to be 5.2% (34 children). The great majority of them 32 children or 4.9%) were diagnosed as having conductive hearing loss, Most authors agree that carly chronic conductive hearing loss due to otitis media with effusion can lead to later learning disabilities (2,23,24]. This can be explained by the fact that, during infaney, much progress in lan- guage acquisition is made; consequently, any problem in receiving or interpreting acoustic sig- nals might have a deleterious effect on speech and language development [25]. Since all children with conductive hearing losses included in our study exhibited no other handicaps, the expressive lan- guage delay they showed might be ascribed to their conductive hearing impairment. Unilateral hearing loss usually cannot be re- sponsible for speech and language delay (21 However, there are reports showing that children ‘with unilateral hearing impairment score less well ‘on auditory, linguistic and behavioural tests than children with normal hearing [26]. One can argue that unilateral hearing deficits might affect in- fants’ linguistic performance by blurring speech signals if this pathology occurs during critical periods of language acquisition, i. during theEM, Psurommatis eta, Tnt J. Petr first months of life 25]. In the present study, we found five children (0.8%) suffering from various degrees of unilateral hearing loss. Taking into account its possible effect on language develop- ment, we consider this finding very important, since it suggests the need for a thorough clinical and laboratory work up for associated anomalies, ‘on one hand, and the need for increased care of the healthy car, on the other. That is, unilateral hearing impairment should represent an alarm signal for both clinicians and parents. Only language-delayed children without associ- ated anomalies participated in our study: syn- dromic ot developmentally retarded children were excluded. Consequently, we can argue that the prevalence of hearing loss in a mixed population, including all language-delayed children would be higher than that found in the present study (13.3%). Unfortunately, the mean age of diagnosis of hearing handicapped children was found to be 32 months in our population, Earlier diagnosis and management is highly desirable. Paediatricians should raise their index of suspicion when they deal with language-delayed children, even if chile dren do not show associated anomalies or handi- caps, whereas parents should be better informed concerning their child’s hearing. Perhaps the vague and ill-defined terms that are commonly found in the relevant literature, such as ‘speech and language delay’, linguistically ‘delayed’ child, truly ‘disordered’, ‘immature’ or ‘deviant’ lan- ‘euage, prevent some physicians from diagnosing the problem in its early stage. However, a full discussion of the topic is beyond the scope of thi paper ‘The unexpectedly high percentage of undiag- nosed hearing loss found in the present study mandates a formal audiologic assessment to be performed as soon as possible, while normal ap- pearance and negative personal and family history in a speech-language-delayed child must not be misleading. Therefore, we recommend not relying on informal hearing sereening tests; otherwise, in normal appearing children, an erroneous diagno- sis of specific developmental language disorder may be made and precious time will be surely lost. Otorhinolaryngol. $8 (2001) 208-210 209) Finally, although most studies of delayed lan guage development have focused on 3-year-old children [27,28], it is our opinion that one should not wait until this age to confirm the diagnosis by applying standardised tests. The late appearance of the first true word, beyond the age 15 months, should raise suspicions of a probable speech-lan- guage handicap, and a thorough hearing evalua tion should be recommended. References U) J. Herskowitz, N:P. Rosman, Potitrcs, Neurology and Poychiatry — Common Ground, MacMillan Publishing, “Toronto, 1982, 2) PE, Brookhouser, D.E, Goldgar, Medical profile of the language delayed hil ofitis-prone versas ois free, In 4. Pediatr. Otorhinolaryngol. 12 (1987) 237-211, [8] CJ. Crosley, Speech and language disorders, in: F. Klein (Ga), Pesiatric Neurology Principles and Practice, CV ‘Mosby, Baltimore, MD, 1989, pp. 141-148 [MI R, Paul, L, Baker, D. Cantwell, Development of comme nication, in: M. Lewis (Ed), Child and Adolescent Psy- chiatry: A Comprehensive Textbook, 2nd ed, Williams & Wilkins, Baltimore, MD, 1996, pp. 191-202, [5] J. Coplan, Normal speech and language development: an fovervie, Pediat, Rev, 16 (3) (1995) 91-100, [6] D. Cantwell, L. 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