www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Quality
of
life
and
cochlear
implant:
results
in
adults
with
postlingual
hearing
loss
夽
Aline
Faria
de
Sousa
∗,
Maria
Inês
Vieira
Couto,
Ana
Claudia
Martinho-Carvalho
UniversidadedeSãoPaulo(USP),FaculdadedeMedicina,SãoPaulo,SP,BrazilReceived9May2017;accepted10June2017 Availableonline5July2017
KEYWORDS Cochlear implantation; Qualityoflife; Hearingloss; Adult; Deafness Abstract
Introduction:Considering the variability of results found in the clinical populationusing a cochlearimplant,researchersintheareahavebeeninterestedintheinclusionofqualityof lifemeasurestosubjectivelyassessthebenefitsoftheimplantation.
Objective:Toassessthequalityoflifeofadultusersofcochlearimplant.
Methods:A cross-sectional andclinicalstudy inagroup of26adultsofboth genders,with meandurationofcochlearimplantuseof6.6years.TheNijmegenCochlearImplantation Ques-tionnaireandthegenericWorldHealthOrganizationQualityofLifequestionnaireweresent electronically.
Results:Thebestassesseddomaininthequalityoflifeassessmentforthecochlear implanta-tionquestionnairewasthesocialdomain,whereasforthequalityoflifequestionnaireitwas thepsychologicaldomain.The variables,gender, timeofcochlearimplantuseandauditory modalitydidnotinfluencetheresultsofbothquestionnaires.Onlythevariablelevelof edu-cationwascorrelatedwiththeenvironmentdomainofthequalityoflifequestionnaire.The variabletelephonespeechcomprehensionwasassociatedwithabetterperceptionofquality oflifeforallthedomainsofthespecificquestionnaireandfortheself-assessmentofquality oflifeingeneral.
Conclusion:Fromthe users’perspective,bothquestionnairesshowed thatcochlearimplant broughtbenefitstodifferentaspectsrelatedtoqualityoflife.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:SousaAF,CoutoMI,Martinho-CarvalhoAC.Qualityoflifeandcochlearimplant:resultsinadultswithpostlingual
hearingloss.BrazJOtorhinolaryngol.2018;84:494---9.
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
∗Correspondingauthor.
E-mail:falineso@hotmail.com(A.F.Sousa).
https://doi.org/10.1016/j.bjorl.2017.06.005
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Implantecoclear; Qualidadedevida; Perdaauditiva; Adulto; Surdez
Qualidadedevidaeimplantecoclear:resultadosemadultoscomdeficiênciaauditiva pós-lingual
Resumo
Introduc¸ão: Dianteda variabilidadede resultados clínicos encontrada napopulac¸ãousuária deimplantecoclear,pesquisadores daáreatêmseinteressado pelainclusãodemedidasde qualidadedevidaparaavaliardemaneirasubjetivaosbenefíciosdoimplantecoclear.
Objetivo: Avaliaraqualidadedevidadeadultosusuáriosdeimplantecoclear.
Método: Estudotransversal eclínicoemum grupode26adultos,deambososgêneros,com tempodeusomédiodoimplantecoclearde6,6anos.Foramutilizadosoquestionárioespecífico
NijmegendeImplantesCocleareseoquestionáriogenéricoWorldHealthOrganizationQuality ofLife,enviadosviamídiaeletrônica.
Resultados: Odomíniomelhorpontuadonaavaliac¸ãodaqualidadedevidaparaoquestionário
Nijmegen foiosocialepara oquestionárioWorldHealth OrganizationQualityofLifefoi o psicológico.Asvariáveis,gênero,tempodeusodoimplantecoclearemodalidadeauditivanão influenciaramosresultados deambososquestionários. Apenasavariávelnível deinstruc¸ão correlacionou-se como domíniomeio ambientedoquestionáriosobre qualidadedevida. A variávelcompreensãodefalaaotelefoneassociou-seaumamelhorpercepc¸ãodaqualidadede vidaparatodososdomíniosdoquestionárioespecíficoeparaaautoavaliac¸ãodaqualidadede vidaemgeral.
Conclusão:Naperspectivadosusuários,oimplantecocleartrouxebenefíciosparaosdiversos aspectosrelacionadosàqualidadedevidaemambososquestionários.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Severalstudieshaveshowntheeffectivenessofthecochlear implant (CI) through the assessment of hearing and lan-guage skills; however, these tests arelimited in terms of the impact of such treatment on social relations, well-being,andtheindividual’sabilityforeasycommunication, allaspectsrelatedtothequalityoflife.
Researchersintheareahavebeeninterestedinthe inclu-sionofmeasuresthatcanmorefullyevaluatetheimpactof hearingimpairmentandtheavailablepossibilitiesof habili-tationandrehabilitation,using,forthispurpose,qualityof lifemeasures.
TheWorldHealthOrganization(WHO)definesqualityof lifeas‘‘theindividuals’perceptionoftheirpositioninlifein thecontextofthecultureandvaluesystemsinwhichthey liveandinrelationtotheirgoals,expectations,standards, andconcerns.’’
The emphasis given in recent years to the subjective and multidimensional aspects related to quality of life was, therefore, derived fromthe need to understand the impactofaparticularcomplaintanditstreatmentfromthe patient’s point of view. This allowsthe analysisof health through different domains, such as physical, functional, socialandemotional.1
Some tools are available to evaluate the population’s quality of life and, among them, the generic question-naires, usedinthegeneral population, withoutspecifying thepathologies, andthespecific questionnaires,designed toevaluatethe qualityof lifein a populationthat hasor hadacertaindisability.2
Itisnecessarytobetterunderstandthedifferentaspects relatedtoqualityoflifeoftheadultpopulationthatusesCI, aimingtoobtainmoredetailedinformation,whichwillallow professionalstoassistintheCIprocess,inthevalidationof theresultsofthistechnology,aswellasinthemanagement ofthetherapeuticprocess.
Therefore,theaimofthisstudywastoassessthe qual-ityof life in adult CI users andto verifythe associations betweenage,gender,levelofeducation,hearingstatusand telephoneuseforthedifferentaspectsrelatedtoqualityof life.
Methods
Thiswasacross-sectional andclinicalstudy thatassessed thequalityoflifein26adultusersofCI,14femalesand12 males,agedbetween18and62yearswithmeandurationof 80monthsofCIuse.
The study was approved by the Research Ethics Com-mittee of the institution under opinion n. 442/15. All participantsreceivedaninvitationletterthroughelectronic mail. After agreeing to participate in the research, they signedtheFreeandInformedConsentform.
Quality of life assessment was performed using the NijmegenCochlearImplantquestionnaire(NCIQ-P)andthe genericWorldHealthOrganizationQualityofLife (WHOQOL-bref)questionnaire,accessedandansweredonline.Allthe documents(letterofresearchpresentation,informed con-sent form and NCIQ-P and WHOQOL-bref questionnaires) weremadeavailableattheGoogleDocsplatformofonline questionnaires.
Thefollowinginclusioncriteriawereusedtoselectthe research subjects: age between 18 and 60 years of age; havingfinishedhighschoolastheminimumlevelof school-ing;hearing impairment acquired after the oral language development(post-lingual)andtimeofCIuse≥12months. The NCIQ questionnaire is characterized as a specific questionnairethatassessesqualityoflifeinadultCIusers, whichwasdevelopedbyHinderinketal.(2000)3andadapted toBrazilianPortuguesebySantosetal.(2017,inpress).4It consistsof60questionsdividedintothreeoveralldomains, withtheirrespectivesubdomains:physical(basicperception ofsound,advancedperceptionofsoundandspeech produc-tion),psychological(self-esteem)andsocial(limitationsin socialactivitiesandfunctions).
The WHOQOL-bref is the abbreviated version of the WHOQOL-100 generic quality of life questionnaire devel-opedbytheWHOandvalidatedinBrazil.5,6Itconsistsof26 questions,twoofthemaboutoverallqualityoflife,called ‘‘qualityoflifeself-assessment’’.Theotherquestionswere takenfromtheWHOQOL-100andrepresenteachofthe24 toolfeatures,coveringfourdomains: physical, psychologi-cal,socialrelationsandenvironment.Eachdomainisscored independently,withnooverallscoreforthetool.
Theoverallqualityoflifequestions,calledqualityoflife self-assessment,representedinthisstudythemeanofthe scoresobtainedinQuestions1and2.
The nonparametric Wilcoxon test (variables with two categories) and the nonparametric Kruskal---Wallis test (variables with three categories) were used to associate gender,levelofschooling,hearingstatus(unilateralor bilat-eralCI)andtheuseofthetelephonewiththeNCIQ-Pand WHOQOL-brefdomainscores.Similarly,Spearman’s correla-tiontestwasusedtoassociatethevariablesage,andtimeof CIusewiththedomainscoresofbothquestionnaires,aswell astheanalysisoftheNCIQ-PandtheWHOQOL-brefdomains inrelationtothequalityoflifeself-assessmentandinthe analysisofthecorrespondingdomainsofthequestionnaires. The variabletelephoneusewasdefinedbasedonNCIQ Question60scores:patientswithascore<50wereclassified as‘‘no’’andtheotherswereclassifiedas‘‘yes’’.The non-parametricWilcoxontest wasusedtoassociate telephone usewiththedomainscoresofbothquestionnaires.
Results
The quality of life assessment based on the specific tool NCIQ-Pdemonstratedthatthesocialdomain,comprisingthe subdomainslimitations insocialactivitiesandinteractions wasthebestscoredfeatureinadultswithpost-lingual hear-inglossandCIusersparticipatinginthestudy,followedby thepsychologicalandphysicaldomains. Forthe WHOQOL-brefgeneric tool,the psychological andphysical domains werethebestevaluatedaspects(Table1).
Thecomparisonbetweensimilardomainsineach ques-tionnaire showed that the physical and psychological domainsoftheWHOQOL-brefquestionnairecorrelatedwith the corresponding NCIQ-P domains, with p=0.04 for the physicaldomainandp=0.01forthepsychologicaldomain. Additionally,the qualityoflife self-assessmentcorrelated withtheoverallNCIQ-Pscore(p=0.02).
Regardingtheanalyzedvariables,gender,durationofCI useandhearingmodalitydidnotinfluencethequalityoflife resultsofbothquestionnaires.
Regardingthestimulationcondition,althoughnot statis-tically significant, theuse of bilateral CIseemed tohave influencedthequalityofliferesultsfortheNCIQ-Pspecific questionnaire,sinceahigherscorewasobservedinusersof bilateralCIforalldomainsofthetool(Table2).
The variable level of education correlated with the environment domain of the WHOQOL-bref questionnaire (p=0.02).
The complex ability of understanding speech on the telephone was associated with the NCIQ-P, WHOQOL-bref domains and with the WHOQOL-bref quality of life self-assessment. Patients who reported good use of the telephone showed, on average, higher scores in the psy-chological, social, and global domains of the NCIQ-P, respectively,p=0.015;p=0.02andp=0.001(Table3).For theWHOQOL-brefgenericquestionnaire,acorrelationwas foundonlybetweentelephoneuseandqualityoflife self-assessment(p=0.042)(Table3).
Discussion
Although all the analyzed studies demonstrated that the population of adultCI userswithpost-lingualhearing loss showedsignificantqualityoflifeimprovementafterCIuse, agreatvariabilitycanbeobservedregardingthescores.3,7---9 Thisisbecausethetermqualityoflifeaggregatesdifferent lifeconditionsandcircumstances,inordertomakeit diffi-culttoestablishareferentialinrelationtothescoretobe obtainedinagivenpopulation.
In the present study, the domains with the highest scores in the NCIQ-Pspecific questionnaire were, respec-tivelysocial,psychological,andphysicaldomains,withvery similar scores for the psychological and physical domains (Table1).Theseresultscorroboratethedatashownin litera-ture,inwhichthesocialdomainrepresentsthebestassessed aspectrelatedtoqualityoflifebytheadultpopulationusing CI.3,4,9---12Thestudythattranslatedandadaptedthistoolinto Brazilian Portuguese found similarscores for all domains, with thesocial domain alsobeing the bestscored aspect amongthestudyparticipants.4
Thehigherscoreobtainedforthesocialdomainis possi-blyassociatedwiththequestionsthatcomprisethisaspect: limitations of the CI user in several environments and theuser’ssocial interactionwithdifferentindividuals and groups, since these aspects are directly related to the communication and insertion in different daily life situa-tions.Thehearingstatusimprovementand,therefore,the improvementincommunicationsituations,certainly repre-sentsapositiveimpactontheusers’socialization.
RegardingtheWHOQOL-brefquestionnaire,ahighscore wasobserved among the present study participants in all domains,withahigherscoreforthepsychologicaland phys-icaldomains,respectively(Table1).
Thevaluesfoundforeachdomainwerehigherthanthose describedforqualityoflifeintheoverallpopulationbyCruz etal.(2011).1Ontheotherhand,approximatescoreswere describedinaBrazilianstudyevaluatingqualityoflifeinCI usersusingthissametool.13
Table1 DescriptivemeasuresfortheNCIQ-PandWHOQOL-brefdomains.
Subdomain/domain Mean Standarddeviation Minimum Median Maximum
NCIQ-P Physical 67.8 16.2 35.8 65.0 97.5 Psychological 69.9 20.1 12.5 77.5 90.0 Social 72.9 19.4 6.3 78.1 97.5 Overall 70.2 16.1 20.1 73.6 90.8 WHOQOL-bref Physical 72.5 14.0 42.9 75.0 96.4 Psychological 73.6 9.9 58.3 72.9 95.8 SocialRelations 69.9 15.3 33.3 70.8 100.0 Environment 61.1 12.6 34.4 60.9 87.5 QoLself-assessment 77.4 11.2 50.0 75.0 100.0
Table2 DescriptivemeasuresforNCIQ-Pdomainsandsubdomainsaccordingtothehearingstatus(unilateralorbilateralHF).
Subdomain/domain HS M DP Min. Med. Max. p
PhysicalNCIQ Bilateral 74.9 16.7 49.2 80.0 94.2 0.29
Unilateral 65.6 15.9 35.8 64.2 97.5
Self-esteem Bilateral 71.7 19.0 35.0 76.3 90.0 1.00
Unilateral 69.4 20.9 12.5 77.5 90.0
SocialNCIQ Bilateral 78.0 15.0 53.8 76.7 97.5 0.71
Unilateral 71.3 20.6 6.3 78.8 90.0
OverallNCIQ Bilateral 74.8 13.5 55.7 74.0 90.8 0.69
Unilateral 68.8 16.8 20.1 73.6 90.8
HS,hearingstatus;M,mean;SD,standarddeviation;Min.,minimum;Med.,median;Max.,maximum;p,p-value.
Table3 AssociationoftelephoneusewiththedomainsofthequestionnairesNCIQ-PandWHOQOL-bref.
Domains TU n M SD Min. Med. Max. p
PsychologicalNCIQ No 9 57.22 25.72 12.50 60.00 87.50 0.01a Yes 17 76.62 12.75 35.00 77.50 90.00 SocialNCIQ No 9 58.99 25.09 6.25 65.00 82.50 0.02a Yes 17 80.20 10.27 53.75 80.31 97.50 OverallNCIQ No 9 56.05 17.63 20.14 60.79 74.03 0.00a Yes 17 77.65 8.71 55.69 78.89 90.83 PhysicalWHOQOL No 9 70.63 12.60 53.57 75.00 92.86 0.43 Yes 17 73.53 15.00 42.86 78.57 96.43 PsychologicalWHOQOL No 9 71.30 11.87 58.33 66.67 95.83 0.25 Yes 17 74.75 8.90 58.33 75.00 95.83
SocialRelationsWHOQOL No 9 62.96 16.20 33.33 66.67 91.67 0.10
Yes 17 73.53 13.89 50.00 75.00 100.00
EnvironmentWHOQOL No 9 56.94 9.21 40.63 59.38 71.88 0.24
Yes 17 63.24 13.87 34.38 68.75 87.50
QoLself-assessmentWHOQOL No 9 72.22 5.51 62.50 75.00 75.00 0.04a
Yes 17 80.15 12.55 50.00 75.00 100.00
QoL,qualityoflife;TU,telephoneuse;n,subjects;M,mean;SD,standarddeviation;Min.,minimum;Med.,median;Max.,maximum;
p,p-value.
a Statisticaldifferencep≤0.05.
The highest score obtained in the CI user popula-tion compared to that found in the overall population may suggest a better quality of life perception in CI users,especiallyregarding theaspectsthatconstitute the physical and psychological domains of the WHOQOL-bref
questionnaire.AlbrechtandDevlieger(1999)14 hadalready described the ‘‘disability paradox’’, in which individuals with disabilities can report good or excellent quality of life, so as to reflect how some individuals manage to live with their limitations and value certain aspects of
life that go unnoticed by biologically healthy individu-als.
Thevariablesgender,timeofCIuse,andagedidnot influ-encethequalityofliferesultsofbothquestionnaires.Other studiesinthescientificliteraturehadpreviouslydescribed thelittlesignificantinfluenceofgender,age,andtimeofCI useonthequalityoflifeofadultCIusers.13,15---17
Regardingtheassessmentoftheeducationallevel influ-enceontheresearchsubjects’qualityoflife,acorrelation was found between this variable and the environment domainoftheWHOQOL-brefquestionnaire(p=0.02).These resultsresemblethosedescribedbyCruzetal.(2011)1and Angeloetal.(2016),13whichshowedthatthevariableslevel ofschoolingandsocioeconomiclevelcanhaveanimpacton thequalityof lifeof the overallpopulation and,possibly, evenmoreonthequalityoflifeofindividualswithhearing impairment,considering the difficultyof having accessto rehabilitation,schooling,andwork.18
DuetoitsspecificityfortheCIuserpopulation,the NCIQ-Pseemedtobemoresignificanttoevaluatetheinfluenceof bilateralCIonthedifferentaspectsrelatedtothequalityof lifeoftheassessedpopulation,sinceevenwithoutstatistical significance,abetterscorewasfoundinbilateral CIusers inalldomainsofthequestionnaire(Table2).Thistrendwas notobserved inthe qualityof lifeassessment when using thegenericWHOQOL-brefquestionnaire.
ThehigherscoreobtainedbyusersofbilateralCIis asso-ciatedwiththebenefitsofbinauralhearing,resultingfrom thedeviceuseinbothears,inordertoprovidemoresecurity andbetterauditoryperformanceinthedifferentdailylife situations.Theresultsofthepresentstudyareinagreement withthoseby Olzeetal. (2012),19 whoalsofound better qualityoflifeinbilateral CIusers,withahigherscorefor alldomainsoftheNCIQquestionnaireafterthesecondCI.
In the present study, the existing association between theabilitytounderstandspeechonthetelephoneand qual-ityoflifewasassessedthroughtheanalysisoftheanswers obtainedfromQuestion60oftheNCIQ-Pspecific question-naire.Correlations were found between the possibilityof maintainingasatisfactorytelephoneconversationforboth thepsychological(p=0.015)andsocial(p=0.020)domains; aswellasfortheoverallqualityoflifeassessment(p=0.001) oftheNCIQ-Pquestionnaire(Table3).
The ability tounderstand speechonthetelephonedid notcorrelatewiththedomainsoftheWHOQOL-brefgeneric questionnaire. However, in spite of a poor correlation (p=0.042), subjects who were able to maintain a simple telephoneconversationshowedamorepositiveassessment oftheiroverallqualityoflifeintheWHOQOL-bref question-naire.
Thestrongestassociationsbetweentheabilityto under-standspeech on the telephone andthe differentaspects relatedtoqualityoflifewerefoundforthedomainsofthe NCIQ-Pspecific questionnaire,thus reinforcing the impor-tance of the use of a specific tool to assess the CI user population, created with the objective of reflecting the achievementsanddifficultiesexperiencedbythesepatients intheiractivitiesofdailyliving.
Theseresultssuggestthat,consideringitsspecificity,the NCIQ-Pseemedtobemoresensitiveinevaluatingthe influ-enceofthemorecomplexhearingabilitiesinthedifferent aspects related to quality of life. The data found in the
present study corroboratethe onecarriedout byRumeau etal.(2015),12inwhichtheauthorsobservedthatthe abil-itytounderstandspeechonthetelephonecanimpactthe overall qualityof lifeestimatein CIuserswhen usingthe NCIQ-Pspecificquestionnaire.
Conclusion
From the users’ perspective, CI brought benefits to the different aspects related to quality of life in both ques-tionnaires.TheNCIQ-Pquestionnairewasmorefavorableto assessqualityoflifequestionsrelatedtothecommunication andinteractionofCIusers.Thecombineduseofqualityof lifemeasuresrepresentedaclinicaldifferentialcapableof complementing theobjective evaluationdata andguiding themanagementofthetherapeuticprocess.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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