Review Article|Articles in Press

Voice Parameters in Children With Cochlear Implants: A Systematic Review and Meta-Analysis



      An intact auditory system is essential for the development and maintenance of voice quality and speech prosody. On the contrary hearing loss affects the adjustments and appropriate use of organs involved in speech and voice production. Spectro-acoustic voice parameters have been evaluated in Cochlear Implant (CI) users, and the authors of previous systematic reviews on the topic concluded that fundamental frequency (F0) seemed preliminarily the most reliable parameter to evaluate voice alterations in adult CI users. The main aim of this systematic review and meta-analysis was to clarify the vocal parameters and prosodic alterations of speech in pediatric CI users.

      Materials and methods

      The protocol of the systematic review was registered on the PROSPERO database, International prospective register of systematic reviews. We conducted a search of the English literature published in the period between January 1, 2005 and April 1, 2022 on the Pubmed and Scopus databases. A meta-analysis was conducted to compare the values of voice acoustic parameters in CI users and non-hearing-impaired controls. The analysis was conducted using the standardized mean difference as the outcome measure. A random-effects model was fitted to the data.


      A total of 1334 articles were initially evaluated using title and abstract screening. After applying inclusion/exclusion criteria, 20 articles were considered suitable for this review. The age of the cases ranged between 25 and 132 months at examination. The most studied parameters were F0, Jitter, Shimmer and Harmonics-to-Noise Ratio (HNR); other parameters were seldom reported. A total of 11 studies were included in the meta-analysis of F0, with the majority of estimates being positive (75%); the estimated average standardized mean difference based on the random-effects model was 0.3033 (95% CI: 0.0605 to 0.5462; P = 0.0144). For Jitter (0.2229; 95% CI: -0.1862 to 0.7986; P = 0.2229) and shimmer (0.2540; 95% CI: -0.1404 to 0.6485; P = 0.2068) there was a trend toward positive values without reaching statistical significance.

      Discussion and conclusions

      This meta-analysis confirmed that higher F0 values have been observed in the pediatric population of CI users compared to age-matched normal hearing volunteers, whereas the parameters of voice noise were not significantly different between cases and controls. Prosodic aspects of language need further investigations. In longitudinal contexts, prolonged auditory experience with CI has brought voice parameters closer to the norm. Following the available evidence, we stress the utility of inclusion of vocal acoustic analysis in the clinical evaluation and follow-up of CI patients to optimize the rehabilitation process of pediatric patients with hearing loss.

      Key Words


      ACE (Advanced Combination Encode), CAG (Case Group), CI (Cochlear Implant), COG (Control Group), EI (Early Implanted), FSP (Fine Structure Processing), F0 (fundamental frequency), F1-F2 (Formant's 1 and 2), HL (Hearing Loss), HNR (Harmonics-to-Noise Ratio), LI (Late Implanted), MDVP (Multi-Dimensional Voice Program), MPT (Mean Phonation Time), mts (Months), NA (Not Applicable), NOS (Newcastle Ottawa Scale), NR (Not Reported), PRAAT (Praat's Voice Program), PTA (Pure Tone Average), SDF0 (Standard Deviation of fundamental frequency)
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