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Relationship between proximity to a cochlear implant center and early presentation in children with congenital hearing loss.

Normal hearing is an important sensory function that enables children to develop communication skills. (1) Congenital sensorineural hearing loss (SNHL) is a common disability in pediatric health, which can impede normal language development and educational achievement of deaf children. However, cochlear implant (CI) intervention has provided a remarkable solution. (2) with results that vary widely among recipients. (3) Early diagnosis of severe to profound SNHL is an important step in providing CI intervention at the recommended age to avoid language delay. (1) Deaf children who received CI intervention before the age of (6) months performed better in expressive language and social skills later in school. (4) Notably, post-CI results and language performance can be affected by many external factors that are related to the recipient's family. (3) Although there is a higher number of CI candidates in rural populations than in urban populations, untreated SNHL is more prevalent in rural populations. (5) Furthermore, rural populations have limited access to health care services, which can result in delayed diagnosis of SNHL, thereby negatively affecting outcomes of CI. Importantly, rural families must undertake extensive travel to tertiary medical centers to undergo hearing tests. (1) Rehabilitation therapy after CI is a fundamental process for successful outcomes. (2) However, rural families again experience difficulty because of the travel distance required to attain the full benefit of speech therapy sessions after CI. (3) Thus, parents report dissatisfaction because of the shortage of speech and language therapy services provided in remote areas. (6) Finally, the prevalence of CI mechanical complications or device malfunctions is reportedly higher among recipients in rural areas. (2)

The aim of this study is to determine whether among children with congenital SNHL, place of living and distance from a CI center influence the ages of presentation, diagnosis, hearing aid fitting, and discussion with CI committees. Secondary objectives include identification of the mean ages of suspicion of hearing loss, presentation to the hospital for audiological evaluation, hearing aid fitting, diagnosis, and discussion with CI committee, among the population in Saudi Arabia; moreover, this study aimed to study the delay before being fitted with hearing aids after establishing the diagnosis.

Methods. This cross-sectional retrospective study was performed in a tertiary hospital (King Abdullah Ear Specialist Center at King Abdulaziz University Hospital) in Riyadh, Saudi Arabia. The sample size in this study comprised 221 patients who presented to the CI committee at King Abdullah Ear Specialist Center for the first time during the period from March 2016 to March 2018 and fulfilled the following criteria. We included all pediatric patients with bilaterally severe to profound hearing loss who were prelingually deaf; we excluded any patient who was adult, who presented for the second ear, who had unilateral SNHL, who developed language pre-implant, or who had any psychological or neurological difficulties.

Using a custom-designed data collection sheet, we retrieved the following information through phone interviews with parents (or direct caregivers if parents were deceased) and patients' files: age at suspicion, age at audiology testing, age at diagnosis, age at hearing aid fitting, and age at CI discussion, as well as demographic information, place of residence, and distance from the nearest CI center. The data were stored as a hard copy, then entered in Excel sheet as a soft copy, then analyzed using IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA). Patients were grouped as follows: Group 1 (those residing within 200 km of the CI center), Group 2 (those residing 200-500 km from the CI center), and Group 3 (those residing >500 km from the CI center). We selected 200 km as a threshold because patients' families residing within 200 km could reasonably drive to the CI center in one day.

All demographic data were analyzed using frequency with percentages. Groups were compared using mean, and groups' different means were compared using one-way analysis of variance (ANOVA) and post-hoc test.

Formal review and approval were received by institutional review board of King Saud University. Confidentiality was maintained. The research was fully explained to each patient's family, and verbal informed consent was obtained from them during the phone interview for all patients included in this analysis.

Results. A total of 221 patients met the inclusion criteria for this study: 99 currently resided within 200 km of the CI center, 33 resided 200-500 km from the nearest CI center, and 89 resided >500 km from the nearest CI center. Notably, 188 (85.1%) of the patients' fathers were working and served as the main provider for the family, and 160 (72.4%) of the patients' mothers were housewives without a job. Furthermore, 119 (54.8%) of the patients' fathers and 109 (49.5%) of the patients' mothers had a Bachelor's degree or higher for their level of education. A total of 64 (29%) patients were the first child in their families, 51 (23.1%) were the second, 33 (14.9%) were the third, 28 (12.7%) were the fourth, 16 (7.2%) were the fifth, and 29 (13.1%) were the sixth or higher. Additionally, 14 (6.5%) of patients had no siblings, 48 (22.1%) had only 1 sibling, 52 (24%) had 2 siblings, 32 (14.7%) had 3 siblings, 25 (11.5%) had 4 siblings, 15 (6.9%) had 5 siblings, and 31 (14.3%) had >6 siblings.

The mean ages at suspicion of hearing loss, presentation to the hospital for audiological evaluation, hearing aid fitting, diagnosis, and discussion with CI committee are shown in Figure 1. The mean ages for the different groups, based on their distance from the CI center, are shown in Table 1.

A comparison of the mean ages at each stage among the 3 groups, using one-way analysis of variance (ANOVA), showed no significant differences (p-values of age at suspicion, age at audiology testing, age at diagnosis, age at hearing aid fitting, and age at CI discussion are 0.792, 0.204, 0.214, 0.156, and 0.247 respectively). A subsequent post-hoc test also did not show any significant differences.

Discussion. Age at CI has been identified as an important predictor of language development outcomes in children with hearing loss. The location where the family's resides is a primary reason for delayed CI. (7) There is a proportional relationship between age at CI and distance to the CI center, as access to care is more limited for patients who live in rural areas than for those who live in urban areas. (8)

As demonstrated in Table 1, the mean ages at each stage are comparable among the 3 groups (p>0.05). This may be because of the availability of advanced hearing assessment tools in peripheral hospitals, rapid access for patients living in the periphery to the closest CI center, and full governmental support to patients who are following up with tertiary hospitals outside their cities (namely, through airfare for patients and caregivers).

Regarding the mean ages at each stage of the CI process, we found that our patients do not meet the 2007 recommendations of the Joint Committee on Infant Hearing (JCIH). (9) Notably, JCIH 2007 recommended that all infants are identified before the age of 3 months, and that early intervention (namely, hearing aids) should be initiated no later than 6 months of age. Therefore, initiatives are needed to increase general awareness of congenital hearing loss and the actions to take when it is suspected. Additionally, there is an unnecessary delay of approximately 5 months between confirmation of the diagnosis and fitting for hearing aids. The availability of hearing aids and facilities for fitting and servicing them is crucial to ensure early intervention for all children in both urban and rural areas.

Other factors that might have played a role in these findings are: the availability and abundance of flights from and to large cities in Saudi Arabia, the fact that familial awareness about hearing loss and its management is not affected by proximity to referral care centers (which might be secondary to the widespread of social networks), and the availability of appointments coordinators who help to make the visits of those coming from another city more convenient and productive by optimizing their schedule.

Study limitations. Mode of transportation was not taken into consideration; whether patients are coming to the CI center by car, train, or airplane. Although all patients with hearing loss have access to CI centers; other limitations are number of visits before being presented to the CI committee and how long did it take to be accepted after presentation, which were not taken into consideration as well.

In conclusion, in Saudi Arabia, the distance from residence to the nearest CI centers does not significantly impact the age of presentation to the hospital for hearing assessment. We encourage increased governmental logistic support for patients traveling to CI centers, as this may enable them to achieve comparable ages to their peers who reside near CI centers.

Acknowledgment. We would like to thank Editage for their efforts in English language editing.

Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.


(1.) Elpers J, Lester C, Shinn JB, Bush ML. Rural family perspectives and experiences with early infant hearing detection and intervention: A qualitative study. J Community Health 2016; 41: 226-233.

(2.) Noblitt B, Alfonso KP, Adkins M, Bush ML. Barriers to rehabilitation care in pediatric cochlear implant recipients. Otol Neurotol 2018; 39: e307-e313.

(3.) Sharma S, Bhatia K, Singh S, Lahiri AK, Aggarwal A. Impact of socioeconomic factors on paediatric cochlear implant outcomes. Int JPediatr Otorhinolaryngol 2017; 102: 90-97.

(4.) Bush ML, Bianchi K, Lester C, Shinn JB, Gal TJ, Fardo DW, Schoenberg N. Delays in diagnosis of congenital hearing loss in rural children. J Pediatr 2014; 164: 393-397.

(5.) Chan S, Hixon B, Adkins M, Shinn JB, Bush ML. Rurality and determinants of hearing healthcare in adult hearing aid recipients. Laryngoscope 2017; 127: 2362-2367.

(6.) Zaidman-Zait A, Curle D, Jamieson JR, Chia R, Kozak FK. Cochlear implantation among deaf children with additional disabilities: Parental perceptions of benefits, challenges, and service provision. J Deaf Stud Deaf Educ 2015; 20: 41-50.

(7.) Fitzpatrick EM, Ham J, Whittingham J. Pediatric cochlear implantation: why do children receive implants late? Ear Hear 2015; 36: 688-694.

(8.) Bush ML, Burton M, Loan A, Shinn JB. Timing discrepancies of early intervention hearing services in urban and rural cochlear implant recipients. Otol Neurotol 2013; 34: 1630-1635.

(9.) Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 2007; 120: 898-921.

[Please note: Some non-Latin characters were omitted from this article.]

doi: 10.15537/smj.2020.3.24918

Yazeed A. Al-Shawi, MD, Fahad K. Alrawaf, MD, Najd S. Al-Gazlan, MD, Munahi M. Al-Qahtani, MD, Fida A. Almuhawas, MD, SB-ORL.

Received 20th August 2019. Accepted 6th January 2020.

From the Department of Otolaryngology and Head and Neck Surgery, King Abdullah Ear Specialist Center, King Saud University, Riyadh, Kingdom of Saudi Arabia.

Address correspondence and reprints request to: Dr. Fida A. Almuhawas, Consultant, Department of Otolaryngology and Head and Neck Surgery, King Abdullah Ear Specialist Center, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail: ORCID ID:

Caption: Figure 1--Mean ages at presentation of patients for each stage of the cochlear implant process. HA-hearing aid
Table 1--Mean ages of presentation for different location groups
(based on distance from cochlear implant center).

                                                  Std.       Std.
Mean ages of presentation       N      Mean    Deviation    Error

Age at suspicion by months
  Residing within 200 km        99    13.19      11.014     1.107
  Residing 200-500 km away      33    15.06      12.796     2.228
  Residing >500 km away         89    13.93      16.848     1.786
  Total                        221    13.77      13.849     0.932

  Residing within 200 km
  Residing 200-500 km away      99    16.82      12.718     1.278
  Residing >500 km away         33    22.61      19.190     3.341
  Total                         89    19.49      19.710     2.089
  Total                        221    18.76      16.886     1.136

Age at diagnosis by months
  Residing within 200 km        99    18.29      13.692     1.376
  Residing 200-500 km away      33    24.18      20.229     3.521
  Residing >500 km away         89    21.12      20.137     2.135
  Total                        221    20.31      17.595     1.184

Age at HA fitting by months
  Residing within 200 km        99    23.24      14.481     1.455
  Residing 200-500 km away      33    29.52      21.902     3.813
  Residing >500 km away         89    27.34      21.422     2.271
  Total                        221    25.83      18.781     1.263

Age at cochlear implant
committee by months
  Residing within 200 km        97    32.10      25.042     2.543
  Residing 200-500 km away      31    40.16      26.431     4.747
  Residing >500 km away         87    37.08      28.398     3.045
  Total                        215    35.28      26.696     1.821

HA--hearing aid
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Article Details
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Title Annotation:Brief Communication
Author:Al-Shawi, Yazeed A.; Alrawaf, Fahad K.; Al-Gazlan, Najd S.; Al-Qahtani, Munahi M.; Almuhawas, Fida A
Publication:Saudi Medical Journal
Geographic Code:7SAUD
Date:Mar 1, 2020
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