**4. Auditory rehabilitation**

It is known that hearing loss due to OM during childhood development may result in long-term changes in neural function, structure, and connectivity. The changes are associated with a series of sensory, cognitive, and social difficulties suggestive of impaired brain function [41, 42] which may culminate in central auditory processing disorder (CAPD) [11].

Intervention for CAPD should be initiated as soon as the diagnosis, made through a series of behavioral and electrophysiological procedures, demonstrates the involvement of the CANS. Early identification, followed by intensive intervention, makes best use of the brain's inherent plasticity. Successful treatment outcomes depend on stimulation and repeated practice that induce cortical reorganization (and possibly reorganization of the brainstem), which is reflected in behavioral change [43–45].

Neuroplasticity is the key to the effectiveness of repeated auditory stimulation. Through experience and stimulation it induces reorganization of the cortex and brainstem, improving synaptic efficiency and neural density, giving rise to associated cognitive and behavioral changes [46–48]. The ability of the CANS to adapt to internal and external changes has important implications for learning [49].

Auditory training (AT) is defined as a set of (acoustic) conditions and/or tasks designed to activate the auditory system and related structures in such a way that their underlying neural processes and associated auditory behavior is altered in a positive way [8]. Both formal and informal AT procedures are conducted by audiologists in clinics; the difference between them is that formal training is acoustically controlled, meaning control over stimulus generation and presentation. Combined formal and informal AT offers an approach that provides more intensive practice and leads to better treatment efficacy [8]. AT performed in an individual with CAPD should include activities that aim to improve auditory skills such as sound localization and lateralization tasks, auditory discrimination, auditory pattern recognition, temporal aspects of audition, and auditory discrimination among competing acoustic signals [4].

Donadon and colleagues [50] have studied the efficacy of AT through behavioral CAP tests in children with a history of OM who had undergone bilateral tympanotomy for insertion of ventilation tubes. The sample consisted of 34 subjects who were divided into two groups: an auditory training group (ATG) formed by 20 children and adolescents, aged 8–13 years, diagnosed with CAPD, who were given an auditory training program; and a visual training group (VTG) formed of 14 children and adolescents, aged 9–13 years, diagnosed with CAPD who were given a visual training program. All subjects underwent peripheral auditory evaluation

**75**

*Otitis Media, Behavioral and Electrophysiological Tests, and Auditory Rehabilitation*

i.binaural integration-through dichotic listening exercises;

iv.figure-background exercises with competing noise.

iii.perception and discrimination of sizes and formats; and

ii.temporal resolution-by means of minimum time interval perception exercises;

iii.temporal ordering-using nonverbal tasks related to frequency, intensity, and

The visual stimulation protocol was elaborated using varied stimuli and tasks from the website via a 15″ notebook positioned in front of the subject on a table arranged in a sound booth. The stimulation protocol was designed with the purpose

All subjects were reevaluated after 8 weeks with the same battery of behavioral tests as performed at the initial evaluation. In the ATG the results showed a statistically significant difference in the abilities of binaural integration (*p* = 0.001), temporal ordering (*p* < 0.0001), temporal resolution (*p* < 0.0001), and bottom figure (<0.0001) in a comparison of before and after AT. These results suggest that the auditory stimulation performed during AT induced changes in the central auditory nervous system, as demonstrated by the better values recorded in the behavioral tests after intervention. Behavioral changes observed after AT in this population with a history of OM point to evidence of neuroplasticity, since auditory stimulation brought about improvements to the

For the visual training group, however, there was no significant difference in performance for any CAP behavioral tests when comparing pre and post interventions. Thus, auditory training appears to be effective as an intervention strategy for re-adjusting the auditory skills in subjects with a history of OM. Auditory stimulation brought about improvements in impaired hearing skills. AT was able to reorganize the neural substrate, providing appropriate experiences, shaping existing circuits in the CANS, and increasing neural density, reflected by an improvement in

Modifications to a child's environment are also important aspects for teachers and parents to address in order to help individuals with CAPD improve access to

and behavioral evaluation of their CAP (using the dichotic digit test, sentence identification test with ipsilateral competing message, gaps-in-noise test, frequency pattern test, and dichotic vowel test). Auditory training was given through repeated verbal and non-verbal stimuli and associated tasks (available at the website www. afinandoocerebro.com.br) via headphones in an acoustic booth (the intensity was set at 50 dB HL). Each session lasted between 40 and 45 minutes and was performed once a week. The stimulation protocol was developed with the purpose of

*DOI: http://dx.doi.org/10.5772/intechopen.88800*

developing the auditory abilities of:

duration; and

of stimulating the visual abilities of:

identified impaired hearing abilities.

the behavioral evaluation **Figure 7**.

i.visual background;

ii.visual closure;

iv.visual memory.

### *Otitis Media, Behavioral and Electrophysiological Tests, and Auditory Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.88800*

and behavioral evaluation of their CAP (using the dichotic digit test, sentence identification test with ipsilateral competing message, gaps-in-noise test, frequency pattern test, and dichotic vowel test). Auditory training was given through repeated verbal and non-verbal stimuli and associated tasks (available at the website www. afinandoocerebro.com.br) via headphones in an acoustic booth (the intensity was set at 50 dB HL). Each session lasted between 40 and 45 minutes and was performed once a week. The stimulation protocol was developed with the purpose of developing the auditory abilities of:


iv.figure-background exercises with competing noise.

The visual stimulation protocol was elaborated using varied stimuli and tasks from the website via a 15″ notebook positioned in front of the subject on a table arranged in a sound booth. The stimulation protocol was designed with the purpose of stimulating the visual abilities of:

i.visual background;

ii.visual closure;

*The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy*

latencies for N1, P2, N2 (female), and P300, in comparison with responses of children without auditory changes. Children with unilateral OME had prolonged latencies for P2 and P300 in comparison to the responses from healthy children. The evaluation of the LLAEP using both nonverbal and verbal stimuli seems to be able to identify neurophysiological changes resulting from OM. However, it is important to note that, in unilateral OM episodes, only verbal sound stimuli (speech LLAEP) seem to be able to differentiate groups on the basis of latency. OM impairs speech perception as a result of a failure to recognize sound signals (discrimination, storage, memory). Therefore, the more accurate identification of LLAEP changes with verbal and non-verbal stimuli may relate to underlying OM.

**4. Auditory rehabilitation**

processing disorder (CAPD) [11].

behavioral change [43–45].

competing acoustic signals [4].

In the studies of Sanfins [33], children with bilateral OME presented prolonged

It is known that hearing loss due to OM during childhood development may result in long-term changes in neural function, structure, and connectivity. The changes are associated with a series of sensory, cognitive, and social difficulties suggestive of impaired brain function [41, 42] which may culminate in central auditory

Intervention for CAPD should be initiated as soon as the diagnosis, made through a series of behavioral and electrophysiological procedures, demonstrates the involvement of the CANS. Early identification, followed by intensive intervention, makes best use of the brain's inherent plasticity. Successful treatment outcomes depend on stimulation and repeated practice that induce cortical reorganization (and possibly reorganization of the brainstem), which is reflected in

Neuroplasticity is the key to the effectiveness of repeated auditory stimulation. Through experience and stimulation it induces reorganization of the cortex and brainstem, improving synaptic efficiency and neural density, giving rise to associated cognitive and behavioral changes [46–48]. The ability of the CANS to adapt to

Auditory training (AT) is defined as a set of (acoustic) conditions and/or tasks designed to activate the auditory system and related structures in such a way that their underlying neural processes and associated auditory behavior is altered in a positive way [8]. Both formal and informal AT procedures are conducted by audiologists in clinics; the difference between them is that formal training is acoustically controlled, meaning control over stimulus generation and presentation. Combined formal and informal AT offers an approach that provides more intensive practice and leads to better treatment efficacy [8]. AT performed in an individual with CAPD should include activities that aim to improve auditory skills such as sound localization and lateralization tasks, auditory discrimination, auditory pattern recognition, temporal aspects of audition, and auditory discrimination among

Donadon and colleagues [50] have studied the efficacy of AT through behavioral

CAP tests in children with a history of OM who had undergone bilateral tympanotomy for insertion of ventilation tubes. The sample consisted of 34 subjects who were divided into two groups: an auditory training group (ATG) formed by 20 children and adolescents, aged 8–13 years, diagnosed with CAPD, who were given an auditory training program; and a visual training group (VTG) formed of 14 children and adolescents, aged 9–13 years, diagnosed with CAPD who were given a visual training program. All subjects underwent peripheral auditory evaluation

internal and external changes has important implications for learning [49].

**74**

iii.perception and discrimination of sizes and formats; and

iv.visual memory.

All subjects were reevaluated after 8 weeks with the same battery of behavioral tests as performed at the initial evaluation. In the ATG the results showed a statistically significant difference in the abilities of binaural integration (*p* = 0.001), temporal ordering (*p* < 0.0001), temporal resolution (*p* < 0.0001), and bottom figure (<0.0001) in a comparison of before and after AT. These results suggest that the auditory stimulation performed during AT induced changes in the central auditory nervous system, as demonstrated by the better values recorded in the behavioral tests after intervention. Behavioral changes observed after AT in this population with a history of OM point to evidence of neuroplasticity, since auditory stimulation brought about improvements to the identified impaired hearing abilities.

For the visual training group, however, there was no significant difference in performance for any CAP behavioral tests when comparing pre and post interventions. Thus, auditory training appears to be effective as an intervention strategy for re-adjusting the auditory skills in subjects with a history of OM. Auditory stimulation brought about improvements in impaired hearing skills. AT was able to reorganize the neural substrate, providing appropriate experiences, shaping existing circuits in the CANS, and increasing neural density, reflected by an improvement in the behavioral evaluation **Figure 7**.

Modifications to a child's environment are also important aspects for teachers and parents to address in order to help individuals with CAPD improve access to

#### **Figure 7.**

*Comparison of performance in behavioral evaluation pre and post intervention by groups. ATG Pre = auditory training pre intervention; ATG Post = auditory training post intervention; VTG Pre = visual training pre intervention; VTG Post = visual training post intervention; DD = dichotic digits; FPT V = frequency pattern test verbalizing; FPT H = frequency pattern test humming; SSI = synthetic sentence identification.*

auditory information outside the therapy room. Some simple changes may bring many benefits to learning. Common recommendations for individuals with auditory disorders include the following:

**77**

*Otitis Media, Behavioral and Electrophysiological Tests, and Auditory Rehabilitation*

• The negative effects of otitis media on the development of auditory abilities in children and the maturation of their central auditory pathways is undeniable;

• Early medical intervention in OM and family counseling is extremely

• The aim should be to avoid prolonged auditory fluctuation caused by OM, thereby minimizing the effects generated by fluid in the middle ear in the

• The overall recommendation is that audiological diagnosis should include both behavioral evaluations and electrophysiological testing of auditory processing;

• In cases of auditory processing disorder, research shows that auditory training

\*, Piotr Henryk Skarzynski2,3,4

1 CENA – Centro de Eletrofisiologia e Neuroaudiologia Avançada, São Paulo, Brazil

2 Department of Teleaudiology and Hearing Screening, World Hearing Center,

3 Department of Heart Failure and Cardiac Rehabilitation, Medical University of

5 Faculty of Medical Science, State University of Campinas, Campinas, Brazil

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Institute of Physiology and Pathology of Hearing, Warsaw, Poland

is the most effective procedure to re-adjust auditory skills.

*DOI: http://dx.doi.org/10.5772/intechopen.88800*

development of auditory abilities;

**5. Summarize**

important;

**Author details**

Warsaw, Poland

Milaine Dominici Sanfins1

and Maria Francisca Colella-Santos<sup>5</sup>

4 Institute of Sensory Organs, Poland

provided the original work is properly cited.

\*Address all correspondence to: msanfins@uol.com.br


*Otitis Media, Behavioral and Electrophysiological Tests, and Auditory Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.88800*
