Keywords
hearing - cleft lip - cleft palate - otitis media
Palavras-chave
audição - fenda labial - fissura palatina - otite média
Introduction
With the objective to obtain an adequate evaluation of all vestibulocochlear system,
the use of tests which evaluate the auditory processing has been shown a challenger
instrument of clinical audiology[14].
Hearing losses and history of otitis can be risk indicators for auditory processing
development, as well as for language development, speech and learning, as the literature
has been established that children with history of recurrent otitis during the childhood
tend to have significant differences on the performance of hearing perception, auditive
memory, acquisition of oral language and scholar progress[4]
[16].
According to American Speech Hearing Association
[2] (ASHA), auditory processing disorder (DPA) is a change in one or more mechanisms
or processes of auditory system responsible for the conduct of sound localization
and lateralization; auditory discrimination; auditory pattern recognition; temporal
aspects of hearing, including resolution, masking, integration and temporal ordination;
auditory performance in the presence of competitive signs and auditory performance
with acoustic signs degraded.
By studying the relation among the recurrent otitis media, language and auditory processing,
it was checked that the language and auditory processing in children with Otitis Media
with Effusion (OME) presented results significantly worse than children that did not
presented history[8]. Many authors affirmed that children with recurrent otitis during the childhood
tend to present significant differences on the auditory perception performance, auditory
memory, oral language acquisition and scholar progress[4]
[3]
[20]
[29]).
Other authors[23] who affirmed that, individuals with peripheral hearing loss probably will have impaired
performance on test of auditory processing. However, it could be persons that, even
presenting peripheral hearing loss (from light to moderate level), present normal
auditory processing.
Cleft Palate (CP) is a result of malformation due to failures on development or in
the maturation processes embryonic[1].
Several studies[10]
[11]
[21]
[27] have emphasized peripheral hearing in the population with CP, being largely known
to its high incidence of alterations in the middle ear, due to a faulty velotubal
aeration mechanism. Thus, the media otitis and hearing losses of conductive type,
usually bilateral, have figured as the most important pathologies in this population.
These changes have as consequence a sensory deprivation, leading it to a risk indicator
to changes in the auditory process development, language, speech, learning and cognitive
potential of a child with CP.
However, studies show emerging[5]
[7]
[9]
[17]
[18] over the hearing processing in children with CP.
The identification of difficulties of auditory verbal processing and non-verbal in
preschool and school children has importance affirmed in academic foundations, maturational,
psychological and economics. The premature identifications in children with limitations
in the hearing processing skills reduce the time and other costs for intervention[15].
Considering that hearing losses and otologic complications can interfere in the maturation
processe of central nervous system, this study had as objective to verify the performance
of children with CP and with or without media otitis history in the evaluation of
auditory processing.
Method
This study was approved by the Ethics and Research Committee from institution where
it was held, with protocol number 15/2001.
20 children of both genders regularly enrolled in a referral hospital for rehabilitation
of craniofacial anomalies in the state of São Paulo participated in this study
The criteria of inclusion of the participants in this study were: have CP operated,
being in the age group between 7 to 11 years old, do not present complaint and/ or
superior airway infection in exam situation, do not present neurological disorder
history, parents permit and the Term of Free and Clarified Consent signed.
The children formed two groups, divided according to the presence of not of otitis
history:
It was performed comparing between the findings of the groups sampled (GI e o GII).
The auditory processing tests were selected considering the age group and hearing
development.
The applied tests are divided in: diotic, monotic and dichotic.
The diotics tests[22] are tests where the same stimuli are presented simultaneously to both ears. They
are: Sound Locate Test in 05 directions (right, left, behind, above and front)[22], Memory Tests for Verbal Sounds and Non-Verbal Sounds in sequence[22] and the Auditory Fusion Test - Revised - AFT-R[24] which is a procedure to measure the temporal processing skill, determining the length
(in ms) in which the listener can detect a short break of silence between two tones,
and report if he heard or not one or two tones.
The monotics tests[28] are tests in which different stimuli or not are presented simultaneously to the
same ear, i.e., ipsilaterally. They are: Words and Phrases cith Ipsilateral Competitive
Message Test - Pediatric Speech Intelligibility (PSI) in which verbal stimuli used
are 10 phrases that are presented randomly, along with a competitive message, which
must be identified by child indicating the figure that it represents, being the competitive
message an infant story; the Speech in Noise Test with figures e with words (PSI with
words) composed of 10 words which must be indentified through the figure that corresponds
to the word listened can be performed with two competitive different messages ipsilaterally
(white noise or an infant story); the Phrases Test with Ipsilateral Competitive Message
(SSI) in which are used verbal stimuli composed of 10 synthetic third-order phrases
and the competitive message is a Brazil history text.
The dichotic tests are composed of different stimuli simultaneously to both ears.
The Dichotic Test with Competitive Non-Verbal Sounds[22] is performed with 03 environmental sounds (noise of thunder, church bell noise and
a noise of door slamming) and three onomatopoeic sound (sound of cat meowing, barking
dog and rooster crowing), that must be identified by indicating the figures that it
represents. These sounds were combined among them and synchronized in time in order
to form twelve pairs. In the Test Staggered Spondaic Word (SSW)[6] are used as verbal stimuli 160 words composed of two-syllable from Brazilian Portuguese
and the Digits Dichotic Test[26] are constituted of 20 pairs of digits which represent two-syllables in Portuguese.
These tests were performed in acoustic cabinet through an two channels audiometer
engaged to a CD player.
The results were analyzed and compared with normal standard proposed by each test,
being classified as bad performance those which presented lower score than the normal
and good performance the others.
It was performed descriptive statistical analysis of the groups according to the performance
in each test, comparing the results of group I and group II.
Results
Some children that participated in this study could not perform all of the proposed
and described tests in the methodology of this study, for not understanding the instruction
to perform the test or presented articulatory problems. Thus, the Dichotic test was
not performed in a child (GI), the test SSW was not performed in four children (1
GI e 3 GII) and the test SSI/PSI was not performed in two children (GII).
On [Table 1] are described the tests results evaluated according to the children performance
in the groups sampled.
Table 1.
Description of the evaluated tests results.
|
Poor Performance
|
Good Performance
|
Total
|
|
GI
|
GII
|
GI
|
GII
|
GI
|
GII
|
|
Diotics Tests
|
% (N)
|
% (N)
|
% (N)
|
% (N)
|
% (N)
|
% (N)
|
|
Localization
|
30% (3)
|
10% (1)
|
70% (7)
|
90% (9)
|
100% (10)
|
100% (10)
|
|
Memory
|
30% (3)
|
40% (4)
|
70% (7)
|
60% (6)
|
100% (10)
|
100% (10)
|
|
AFT-R
|
60% (6)
|
40% (4)
|
40% (4)
|
60% (6)
|
100% (10)
|
100% (10)
|
|
Monotics Tests
|
|
|
|
|
|
|
|
PSI/SSI
|
60% (6)
|
75% (6)
|
40% (4)
|
25% (2)
|
100% (10)
|
100% (8)
|
|
Dichotics Tests
|
|
|
|
|
|
|
|
Non-verbal sounds
|
100% (10)
|
100% (10)
|
0% (0)
|
0% (0)
|
100% (10)
|
100% (10)
|
|
SSW
|
89% (8)
|
85% (6)
|
11% (1)
|
15% (1)
|
100% (9)
|
100% (7)
|
|
Digits
|
44% (4)
|
50% (5)
|
66% (5)
|
50% (5)
|
100% (9)
|
100%(10)
|
Discussion
Both groups (GI e GII) presented bad performance in most of the tests. However, the
population with otitis history (GI) presented worse results in auditory processing
evaluation, if compared to the population without otitis history (GII).
It was observed that, regardless of the presence of otitis history in the first years,
the population with lip and palate cleft presented considerable difficulties in the
applied tests, indicating percentage change in both groups, being the otitis an aggravation
of the situation.
Children without otitis history (GII) presented normal performance in dichotics tests,
whereas, in other test, it was predominantly poor performance. The children with otitis
history (GI) presented lower rates in normal performance, compared to GII, being more
frequent poor performance in dichotics tests.
These data are consistent with literature found, given that in almost of the studies
involve auditory processing and CP the evaluation results presente high rate of changes.[7]
[5].
Comparing the performance good and bad among evaluated children belonging to the same
group, it was possible to conclude that the tests with more poor results were SSW
and Non-Verbal Dichotic for GI. For GII, the tests PSI and SSI also presented high
rate of poor performance, beyond of SSW and Dichotic Non-Verbal.
In children without CP and with suspect of hearing change there was a greater change
on the dichotics tests results, specially the Dichotic of Digits and SSW, being these
tests of high linguistic level made them to be more sensitive to identify changes
in the auditory processing[12].
In relation to the test AFT-R, the performance changed rate of otitis history group
(GI - 60%) was higher. It is known that a higher threshold of auditory fusion leads
to a greater probability of temporal processing deficit and interference in speech
perception[19].
The literature reports that children with FLP presents threshold of auditory fusion
significantly greater than the children without this malformation[9]. This fact can be justified by the high occurrence of otitis in population with
CP.
Presence of otitis history during childhood can interfere in auditory skills development
and in the perception of the distinctive features of speech, which may lead to phonological
changes.
The presence of otitis history can cause greater prejudices in auditory skills of
figure-ground and auditory closure, auditory memory and language[25].
The exact determination of the relation between media otitis and Auditory Processing
Disorder has not been widely elucidated. It is necessary caution in the results interpretation
and determination of other variables can be interfering as na etiology to Auditory
Processing Disorder, like malnutrition, sociocultural environment with few stimuli,
reducing motivation and the health state in general[30].
Conclusion
It was observed that, regardless of the presence of otitis history in the first years,
the population with CP presented important difficulties on the applied tests, indicating
poor performance percentage in both of groups, being otitis an aggravation of the
situation.
Thereby, it is suggested the auditory processing evaluation in the whole population
with CP and not only in those who otitis are the risk indicators, so that to establish
a large and complete study of rehabilitation, as the auditory processing difficulties
can interfere on the language development and school performance.
