Maintaining the Balance: Vestibular Help for Children With Hearing Loss Vestibular physical therapy can help children with hearing loss and cochlear implants. All Ears on Audiology
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All Ears on Audiology  |   August 01, 2018
Maintaining the Balance: Vestibular Help for Children With Hearing Loss
Author Notes
  • Jaynee A. Handelsman, PhD, CCC-A, is director of pediatric audiology and a clinical assistant professor in the Department of Otolaryngology Head and Neck Surgery at Michigan Medicine. Handelsman, the 2016 ASHA president, is an affiliate of ASHA Special Interest Groups 8, Audiology and Public Health; 9, Hearing and Hearing Disorders in Childhood; 11, Administration and Supervision; and 17, Global Issues in Communication Sciences and Related Disorders. jaynee@med.umich.edu
    Jaynee A. Handelsman, PhD, CCC-A, is director of pediatric audiology and a clinical assistant professor in the Department of Otolaryngology Head and Neck Surgery at Michigan Medicine. Handelsman, the 2016 ASHA president, is an affiliate of ASHA Special Interest Groups 8, Audiology and Public Health; 9, Hearing and Hearing Disorders in Childhood; 11, Administration and Supervision; and 17, Global Issues in Communication Sciences and Related Disorders. jaynee@med.umich.edu×
Article Information
Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / Balance & Balance Disorders / All Ears on Audiology
All Ears on Audiology   |   August 01, 2018
Maintaining the Balance: Vestibular Help for Children With Hearing Loss
The ASHA Leader, August 2018, Vol. 23, 18-19. doi:10.1044/leader.AEA.23082018.18
The ASHA Leader, August 2018, Vol. 23, 18-19. doi:10.1044/leader.AEA.23082018.18
The vestibular system helps us maintain clear vision during head movement and gives us the ability to stand and walk, especially on uneven or soft surfaces. When this system is impaired, other sensory systems—including vision and proprioception—can help us navigate.
Without a fully operational vestibular system, our functional abilities take a hit. For example, someone with a bilateral vestibular loss may be unable to sense gravity, so an activity like swimming in murky water might not be safe. In addition, walking on soft or uneven surfaces in the dark might result in an increased chance of falls.
While we’re clearer about vestibular effects in adult patients, we know less from research about these effects in children. As more research in the area emerges, we’re finding that sensorineural hearing loss (SNHL) and cochlear implants (CIs) in young children are both associated with increased vestibular problems.
There’s also good news: Vestibular physical therapy can result in improved balance in children with vestibular loss. Also, vestibular physical therapy can improve children’s dynamic visual acuity (DVA), which may also improve reading acuity. So, as audiologists, we should screen for vestibular loss in all our kids with SNHL.

Vestibular physical therapy can result in improved static and dynamic balance in children with vestibular loss.

Pediatric vestibular disorders
The advent of such relatively new technologies as vestibular evoked myogenic potentials (VEMP) and video head impulse testing (vHIT) has bolstered our understanding of younger children’s vestibular systems. Happily, vHIT can be a reliable indicator of semicircular canal function and is easy to use with young children (see sources).
Those measures, along with rotational testing and tests of balance—including the Peabody Developmental Motor Scales-2 (PDMS), the Bruininks-Overetsky Test of Motor Profiency (BOT2) and other measures of gross motor performance—help to determine how children with SNHL, and those with CIs, perform relative to their peers with normal hearing.
In addition, recent evidence indicates how children with hearing loss without CIs perform compared on these measures with those with CIs on tests of balance (see sources).
It is not surprising that, given the anatomical relationship between the auditory and vestibular systems, the literature suggests that about 50 percent of children with SNHL also have vestibular loss (see sources). These abnormalities are found in caloric responses, rotary chair results, VEMP responses and performance on the BOT2.
In addition, the literature suggests that children with CIs have a 10-percent increase in the prevalence of vestibular loss following implantation (see sources). Given these data, it is important to consider the impact of vestibular loss on performance of daily activities, and the potential benefit of vestibular rehabilitation, for children with SNHL with and without CIs.

Even those children with unilateral deafness may have balance impairments similar to children with bilateral vestibular loss.

Cochlear implants and balance
Children with bilateral vestibular loss have reduced vision when moving their heads, difficulty reading, and increased difficulty with balance, especially in the dark or when they do not have access to normal cues from their feet and legs (uneven surface or standing on one foot). Recent evidence suggests that even those children with unilateral deafness may have balance impairments similar to children with bilateral vestibular loss (see sources).
The same authors examined the potential impact of cochlear implantation on gross motor development of children with hearing loss, which revealed a delay in gross motor development in implanted children from 6 to 18 months, about when the children received the implant (see sources). Some children recovered by the age of 2, although it was not clear that the children caught up with their normally hearing peers. This suggests that all children undergoing CI implantation could benefit from vestibular physical therapy to reduce the negative impacts of CI on motor development.
Children with SNHL, with and without CIs, are at an increased risk of vestibular system impairment. This impairment can negatively affect visual acuity with head movement, reading acuity, standing and dynamic balance (especially when the support surface is uneven or in darkness), gravitational sense, and participation in activities that minimize other sensory modalities.
As reported earlier, children have an estimated 10-percent increase loss following CI implantation (see sources). These children demonstrate delayed motor milestones in early childhood and impairments in dynamic visual acuity and static and dynamic balance later in life. Audiologists need to screen for vestibular loss in all children with SNHL.
Consider screening your patients with SNHL using the single-leg stance, a test that times a patient’s ability to maintain the stance unassisted. Data suggests this is the most sensitive measure for children age 5 and up (see sources). Children in this age range should be able to stand on one foot with eyes closed for four seconds. If audiologists incorporate this screening with pediatric patients, we can quickly refer children who fail the screen for vestibular evaluation by an audiologist with expertise in this area and vestibular physical therapy with a pediatric vestibular physical therapist. Getting our at-risk patients into the follow-up they need may then see improved outcomes, not only in terms of balance, but also in terms of reading ability.
Sources
Cushing, S. L., Papsin, B. C., Rutka, J. A., James, A. L., amp; Gordon, K. A. (2008). Evidence of vestibular and balance dysfunction in children with profound sensorineural hearing loss using cochlear implants. Laryngoscope, 118(10), 1814#x2013;1823. [Article] [PubMed]
Cushing, S. L., Papsin, B. C., Rutka, J. A., James, A. L., amp; Gordon, K. A. (2008). Evidence of vestibular and balance dysfunction in children with profound sensorineural hearing loss using cochlear implants. Laryngoscope, 118(10), 1814#x2013;1823. [Article] [PubMed]×
De Kegel, A., Maes, L., Van Waelvelde, H., amp; Dhooge, I. (2015). Examining the impact of cochlear implantation on the early gross motor development of children with a hearing loss. Ear and Hearing, 36(3), e113#x2013;e121. [Article] [PubMed]
De Kegel, A., Maes, L., Van Waelvelde, H., amp; Dhooge, I. (2015). Examining the impact of cochlear implantation on the early gross motor development of children with a hearing loss. Ear and Hearing, 36(3), e113#x2013;e121. [Article] [PubMed]×
Janky, K., & Givens, D. (2015). Vestibular, visual acuity and balance outcomes in children with cochlear implants: A preliminary report. Ear and Hearing, 36(6), e364#x2013;e372. [Article] [PubMed]
Janky, K., & Givens, D. (2015). Vestibular, visual acuity and balance outcomes in children with cochlear implants: A preliminary report. Ear and Hearing, 36(6), e364#x2013;e372. [Article] [PubMed]×
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August 2018
Volume 23, Issue 8