Pediatric Primary Care (47 page)

7.  Refer to otolaryngologist if:

a.  Object is an alkaline battery.

b.  Object cannot be easily removed.

c.  Ear canal is swollen or bleeding.

d.  Object is tightly wedged in canal.

e.  Child is unable to cooperate.

H.  Follow up.

1.  Generally none, well-child care.

I.  Complications.

1.  Perforation of tympanic membrane (TM).

J.  Education.

1.  Advise parents not to attempt to remove foreign body.

2.  Tell parents some bleeding may occur after removal.

3.  Cleaning ear canal is not necessary.

II. HEARING LOSS: CONDUCTIVE, SENSORINEURAL

A.  Etiology.

1.  Genetic or hereditary factors, environmental or acquired diseases, malformations.

2.  Trauma.

3.  Congenital perinatal infections.

4.  About 33% of cases of hearing impairment: cause unknown.

B.  Occurrence.

1.  About 15% of school-age children have significant conductive hearing losses.

2.  OM and its sequelae most common cause of conductive hearing losses during childhood.

3.  Acquired conductive hearing losses most common types of hearing loss in childhood.

C.  Clinical manifestations.

1.
Conductive hearing loss
(middle ear hearing loss).

a.  Decreased hearing.

b.  May have history of middle ear effusions.

c.  OM and its sequelae.

d.  Foreign body and/or impacted cerumen.

e.  May report delayed language and speech development or parental concern about child's ability to hear.

f.  Allergies.

g.  Head or ear trauma.

h.  Middle ear anomalies.

i.  Cholesteatoma can cause hearing loss.

2.
Sensorineural hearing loss
(perceptive or nerve deafness) may report distortion of sound and problems in discrimination of sounds. Hearing loss often involves high-range frequencies, speech difficulties.

D.  Physical findings.

1.  Conductive hearing loss (middle ear hearing loss).

a.  Possible:

•  Otitis externa.

•  OM.

•  Foreign body.

•  Impacted cerumen.

•  Growths or tumors, cholesteatomas.

•  TM perforation.

b.  Rinne test on affected side; bone conduction (BC), air conduction (AC).

c.  Weber test sounds lateralized to involved side.

d.  Average hearing loss 27-31 dB (mild), may be intermittent, may occur in one or both ears.

2.  Sensorineural hearing loss (perceptive or nerve deafness).

a.  Possible dysmorphic facial features suggesting presence of syndrome.

b.  Head and/or neck anomalies.

c.  Anomalies of pinnae and external ear canals.

d.  Weber test sounds louder in unaffected ear.

e.  Rinne test: in normal ear or ear with sensorineural hearing loss, AC, BC.

3.  Audiometric testing: soft sounds not well perceived, loud sounds perceived almost normally. In older children, if normal in high and low frequencies but poor in middle frequencies, suspect congenital hearing loss.

4.  Acquisition of language skills affected.

E.  Diagnostic tests.

1.  Evoked otoacoustic emissions (EOAE) testing (can be performed on children of all ages): newer type of newborn screening, 10 minutes.

2.  Automated auditory brainstem response (AABR): for newborn screening, 10 minutes.

3.  Brainstem auditory evoked response (BAER): newborn screening, 90 minutes; often used in children of all ages who are unable to cooperate for audiometry testing.

4.  Behavioral observation audiometry.

5.  Pure tone audiometry for children 5 years of age.

6.  Tympanometry identifies a middle ear effusion.

7.  Impedance audiometry.

8.  Language screening: Early Language Milestone Scale.

F.  Differential diagnosis.

1.  Careful history and thorough physical examination, including screening and laboratory data, essential in identifying those at risk and in early detection of hearing losses.

2.  Hearing disorders classified into three categories:

a.  Conductive hearing loss.

b.  Sensorineural hearing loss.

c.  Mixed conductive sensorineural loss.

G.  Treatment.

1.  Refer for audiologic testing.

2.  Surgery for conductive hearing loss (usually bilateral myringotomy with tubes).

3.  Refer to multidisciplinary team, hearing center, or ENT specialist if hearing impairment detected.

4.  For sensorineural loss:

a.  Amplification (hearing aids; bilateral is best) benefits most children.

b.  Cochlear implants with sensorineural loss, if done within 4 years of hearing loss.

c.  Clarion CII Bionic Ear System for deafness.

H.  Follow up.

1.  Determined by type and cause of hearing loss.

2.  Well-child care.

I.  Complications.

1.  Speech and language disorders.

J.  Education.

1.  Early detection imperative to minimize negative consequences for language, other development.

2.  Disease process, type of loss, causes. Conductive loss usually reversible, sensorineural loss often irreversible.

3.  To decrease incidence of communication disorder in child with middle ear disease:

a.  When speaking to child, turn off sources of background noise (e.g., dishwasher, television, radio, stereo, computer games, etc.).

b.  Make sure child is looking directly at speaker and that speaker has child's attention.

c.  Speak louder than normal.

d.  Child should sit in front of classroom (may need referral for full evaluation of hearing needs).

4.  Effects on child.

a.  Speech and language development.

b.  Social development.

c.  Learning process.

5.  Needs of child.

a.  Emotional.

b.  Social.