Tips for a successful school year for children with hearing loss

This post is courtesy of Dr. Amy Arthur, Director of Audiology for Children's Ear, Nose, Throat and Allergy.  These are recommendations for establishing a good base for a successful school year for your child with hearing loss.

 Annual Audiogram and ENT check up:  August is the perfect time to schedule an annual audiogram with your child’s audiologist.  Many families find it helpful to schedule in August while they are planning for back to school.  It serves as a reminder and they make it a part of their back to school routine, along with school supplies, clothes and shoes.   Annual audiograms are important to rule out that there have been no significant changes to your child’s hearing loss over the last 12 months.  In addition, your child should be seen by their Otolaryngologist at least once a year to monitor for any medical changes that can be common with hearing loss.

Annual Hearing aid/Cochlear Implant Check:   Following the annual hearing test, your child’s audiologist should ensure that your child’s hearing aids are working optimally.  With Behind-the-ear hearing aids, the most common type of hearing aids worn by children, earmolds need to fit well to prevent a reduction in amplification and annoying feedback.  It is typical that when a child’s shoe size has changed, there will be a need for new earmolds, once again coinciding with the back to school routine.  The hearing aids can be cleaned and checked, the proper amplification can be verified electroacoustically in the office.  If there is a problem with the electronics, then the devices can be sent to the manufacturer to be repaired in time for school to start.  If your child uses a Cochlear Implant (CI) this is a good time to schedule a re-mapping session with the audiologist.  You should schedule this appointment a few weeks before the start of school to allow your child to acclimate to the changes to the CI map. 

 Meet the Teacher:  Discuss your child’s hearing loss with the new teacher.  Many children with hearing loss attend schools that have an emphasis on working with children who are deaf and hard of hearing.  If this is your child’s situation, the teachers in your child’s classrooms will likely have a lot of experience teaching children with hearing loss.  However, if your child is mainstreamed, the teacher may not have this experience.  Talk to your child’s teacher and find out what their experiences are.  If they have not had a child with hearing loss and amplification, you may have to advocate for your child and set a time to meet with the teacher to give them the tools they need to help your child if the hearing aid fails.  This is a great way to have some private time to educate the teacher on your child’s strengths and weaknesses in the classroom.  If you are uncomfortable or unable to do this, most school systems have educational audiologists whose job it is to be a liaison for the child and the classroom teacher. 

 Collaborate:  Early in the school year a team should gather to discuss your child’s academic year.  This is typically carried out at the Individual Educational Plan (IEP) meeting for the school year.   At this meeting, the teacher, audiologists, speech language pathologists, administrators and parents gather to assess the needs of the child and to plan goals.  This meeting is a great opportunity to discuss any concerns you have for your child or request further assistance if needed.  It is possible that your child may need further accommodations, such as an interpreter or an FM system in the classroom.  The team will discuss your child’s needs and plan accordingly.

Back to school is a great time to accomplish all of these goals for your child, but they can be completed anytime throughout the year.  To make an appointment for your child with our Doctors or Audiologists, please call 407-253-1000.  We look forward to meeting you. 

Tonsillectomy and adenoidectomy

     In followup to our last post, today we are going to talk about tonsillectomy and adenoidectomy.  As we discussed, the indications for this procedure have changed greatly over the last 20+ years.  Formerly, it was a procedure done for infections and now it is much more frequently done for obstructive sleep apnea.  Whatever the indication for surgery, the procedure really is the same. 

     For children, the day before surgery your doctor will generally want them to have nothing to eat or drink after midnight.  This can be variable from center to center so be sure to discuss this with your doctor at your appointment.  It truly depends on the time of day your child will be going to surgery.  Once at the surgery site, your child will be checked in and routinely will go to a preoperative holding area ("PREOP").  There, your child will get a gown, get their vitals taken, meet the operating room team, see your doctor as well as meet and talk with the anesthesiologist.  This is a great time for any last minute questions that have come up since your last appointment.

     Depending on the child and the medical condition, your child may receive some relaxing medicine in the preop area.  Then, it is off to the operating room.  The anesthesia team will put your child to sleep and then the surgery begins.  The surgery time, from the time the patient leaves your side to the time the doctor comes to talk to you is about 30-45 minutes.  Afterwards, the anesthesiologists begin the wake-up process and the children come to the recovery room.  Once safe and awake, you will be called back to be with your child.  Some children will be required to stay overnight in the hospital for observation.  This will be at the discretion of your surgeon.  Usually, most children are able to be discharged the morning after surgery if required to stay. 

     The first 5-7 days are usually the most difficult in the recovery.  Then the children are starting to feel a bit better.  They should maintain a soft diet for 2 weeks after surgery.  This means nothing crunchy to eat.  No chips, crackers, cookies, crusty breads, or pizza crust.  Popsicles, ice cream, macaroni and cheese, mashed potatoes, and things like these are good things with which to start.  We also ask that you keep the child's activity under control for the first 2 weeks after surgery.  This can be difficult, which we understand, particularly during that second week.  We generally recommend a week home from daycare or school and then they may return with the understanding that they will have a reduced activity for the next week.

     There are many different techniques to remove the tonsils and the adenoids.  You may hear about cold dissection, coblation, electrocautery, microdebriding, laser, and others.  Just remember that these are all tools that your doctor can use to accomplish the goal of removing the tissue that needs to be removed.  This will vary from surgeon to surgeon. 

     Even though this procedure is one of the most common procedures done across the United States, there are still risks involved.  In general, we go through the mouth to remove the tonsils and adenoids.  This places the lips, teeth and gums at risk because they are in the path of getting equipment into and out of the mouth during the procedure.  The risk of a severe injury is rare.  Things to consider include dislodging of a loose tooth and a burn to the lips as potential problems. 

     Bleeding is the risk we tend to worry about the most.  The risk of bleeding from the nose or mouth after removing the tonsils and adenoids is around 1-3%.  That risk has been stable in the literature throughout the years.  Fortunately the chance of severe bleeding is rare, and the chance of needing a blood transfusion or something worse happening is very uncommon.  If there is any bleeding from the nose or mouth after surgery, be sure to contact your doctor.

     Removing the tonsils and adenoids is a painful procedure.  This is likely related to the fact that the tonsils sit in a bed of muscle, and, in addition to that, we are creating a large open wound like a big ulcer in the back of the throat.  Your doctors will give you an appropriate pain regimen for after surgery but you have to encourage your kids to take it.  It is also important that the throat stay well hydrated during this time.  A dry throat after surgery is very painful and can lead to not wanting to drink and more pain until one ends up back at the hospital with dehydration. 

     When the tonsils and adenoids are removed, we are increasing the space in the back of the throat.  Sometimes, it is too much space and the body is not able to compensate for that.  Particularly, the palate can have a difficult time closing the gap between the throat and the nose.  This may result in a change in the voice to a hypernasal quality.  You might think that your child already has a nasal voice from this tissue, but in general, that is a hyponasal voice: an obstructed voice from too much tissue in the back of the throat and nose.  If this happens, it frequently will resolve on its own.  If not, about 1:1,000 children will require speech therapy or potentially even surgery to correct this.

     There are small risks of the adenoids regrowing or scarring in the back of the nose.  These happening to any significant degree is rare, but may mean an additional surgery or medication down the line. 

     For these reasons, we as surgeons try to make sure you as parents are well informed prior to making a decision to go to surgery.  Be sure to ask any questions that you have so that you are able to make the best decision.  After surgery, be sure to contact your doctor after for a fever over 101.5, pain uncontrolled by medication, bleeding, poor oral intake, decreased urination, or any other concerns. Please check out Dr. EJ on Twitter @DrEJ76 and @childrenentdocs and like us on Facebook:www.facebook.com/ChildrensENT.

Tonsils and adenoids: not just there to take out!

After a long hiatus, I have returned with anticipation to the blogging arena.  I wish I had a great excuse for being absent for so long.  As time has gone by, however, I realized just how quickly that time has faded into a memory.   

In reflecting on the last 8 months...yes...it has been 8 months since I last wrote... I was trying to think about a topic that I have really needed to address during that time.  Something that I have seen frequently.  Something where trends have changed and new guidelines have been published.  Ah, yes, I know it...we will discuss tonsils and adenoids.

First, let's discuss a little anatomy (click link for picture).  The tonsils and adenoids are part of a surveillance system for the upper airway.  The tonsils sit on either side of the throat at the level of the soft palate and the adenoids sit above the palate at the back of the nose.  Things (antigens) that are recognized as foreign coming into the nose or mouth are identified in these tissues and antibodies (defenses) are made to fight them.  The greatest contributions of tonsils and adenoids to immunity are made in the early years before age 10.  After that, their function decreases, perhaps secondary to the fact that these tissues have seen most of these antigens and do not have to work hard to produce antibodies against them.  This is why the tonsils and adenoids decrease in size, when kids get older, to nearly nothing in most adults.

So one might ask...if the tonsils and adenoids go away eventually, why do they have to be taken out?  That is an excellent question.  By the numbers, tonsillectomy and adenoidectomy procedures have actually decreased over the years due to changes in the criteria for candidacy for the procedure.  Back in the old days, tonsils were frequently taken out because they looked big or for just a few infections.  The current recommendations from the American Academy of Otolaryngology are for tonsils to be removed for infectious reasons for 7 infections in 1 year; 5 infections per year for 2 consecutive years; or 3 infections per year for 3 consecutive years.  These are strict criteria, but they do not indicate that each of these infections has to be strep throat.  Other infectious reasons for surgery could include recurrent peritonsillar abscess.

Nearly 80% of tonsillectomies done today are done for sleep disordered breathing or obstructive sleep apnea.  This is a disease of too much tissue in the back of the throat.  When the tonsils are enlarged, they occupy space in the throat, sometimes creating a blockage when the muscles of the throat relax during sleep.  This can present as snoring, restless sleep, frequent awakenings, and even pauses, choking and gasping during sleep.  This does not mean that all sleep apnea in children is caused by enlarged tonsils, but they are frequently contributing. 

Frequently parents will come into the office with a presumption that the tonsils need to be removed purely because they are big, or for 1 or 2 infections.  Your ENT physician will work with you to get a history of exactly how those big tonsils are affecting your child and what other options are available for treatment.  During your evaluation, some additional workup may be required including a sleep study, a neck x-ray, or potentially laboratory studies.  In our next installment, we will discuss the  procedure including potential risks, surgical considerations, and post-operative expectations.  Please check out Dr. EJ on Twitter @DrEJ76 and like us on Facebook: www.facebook.com/ChildrensENT.  

And don't forget the bacon!

One remedy that has gotten significant attention recently is the use of bacon for stopping nosebleeds.  This comes from a recent article published in the Annals of Otology, Rhinology, and Laryngology in November of 2011.  In a patient with a rare bleeding disorder who had uncontrollable nosebleeds, strips of cured pork, i.e. bacon, were used for control of bleeding in this patient.  A wise man once told me about using salt pork for difficult-to-control nosebleeds.  Guess the idea wasn't so far fetched.

Digging for gold

One of the more common reasons to visit a pediatric ENT is for nosebleeds, also known as epistaxis.  Nosebleeds are extremely common.  These can range in severity from a small amount of blood in the nasal mucus to bleeding like from a faucet.  In any case, particularly when it happens in your child, it can be very scary.

Nosebleeds can happen at any time.  One of the most common times is during sleep, where a child will wake up either in the morning, with blood on their pillow, or from sleep in the middle of the night with active bleeding from the nose.

The nose can bleed for many reasons.  The anatomy of the nose explains the ease with which the nose seems to bleed.  There is an extensive blood supply to the nose coming from all different directions.  The middle part of the nose, or nasal septum, which divides the left and right side of the nose, has blood supply coming from the back of the nose, bottom of the nose and top of the nose.  These all meet on the front part of the nasal septum in an area called Kisselbach’s plexus or Little’s area.  This network of vessels is under a very thin lining of mucosa.  A small disruption of that mucosa, from a sneeze, nose picking, or a simple bump of the nose, can result in an injury to those vessels and a nosebleed.

While children are notorious for picking their noses, there are many other reasons for this problem.  A simple cold, nasal trauma, allergies, or anything that causes congestion can result in engorgement of the vessels increasing their prominence and making them higher risk for injury.  While most nosebleeds come from the front part of the septum, there are other more serious causes of nosebleeds which need to be evaluated by your pediatric ear, nose and throat doctor.  Anytime a nosebleed is associated with headaches, changes in vision, double vision, weight loss, loss of smell, or pain, it raises a concern of something more significant occurring.  These symptoms should be brought to the attention of your doctor right away.

In general, nosebleeds from the front of the nose are controllable.  If the nose is actively bleeding, it is important to encourage your child, and for you, to remain calm.  This will help keep blood pressure low and help facilitate the bleeding vessel to clot.  Firmly apply pressure to the soft part of the nose with your thumb and index finger and hold that pressure for 1 minute, watching the clock, without letting go.  You should not apply pressure to the hard part of the nose or bridge of the nose as this wont give pressure to the area most likely bleeding.  Be sure to have your child’s head tilted slightly forward so that blood is not running down the back of the throat.

After 1 minute, you should let go, again, trying not to have your child get upset and see if the bleeding has stopped.  If it has, success, but if you have not, then it is safe to use oxymetazoline (brand name Afrin) 1-2 sprays on each side, then hold pressure for 2 minutes without letting go.  These maneuvers should stop the great majority of nosebleeds.  If this is unsuccessful, you should go to the emergency room or call your pediatric ear, nose and throat doctor.

Now that we have stopped the nosebleed, we should focus on prevention.  Encourage your child not to aggressively rub or pick their nose.  Sometimes this is not enough.  I like to have my children use a small amount of bacitracin ointment in each nostril each night before bed.  After applying a small amount to each nostril, gently squeeze the soft part of the nose together and wipe away the excess.  Body heat will melt the ointment, then, the natural function of the nose will transport that ointment back through the nose.  This provides both a low grade antibiotic effect as well as a moisturizing barrier effect to the mucosa of the nose.  This should be done only if your child does not have an allergy to bacitracin.  You should stop this after 2 weeks and be reevaluated. 

Further workup should be done if this does not solve your problems.  Your child may require cauterization of the bleeding area in the nose, which can be done in the office.  Also, an in office endoscopy to look at the inside of the nose can provide additional information.  Sometimes, blood tests and imaging may need to be ordered.  Visit our website at www.childrenentdocs.com, like us on Facebook (www.facebook.com/ChildrensENT), and follow us on Twitter @DrEJ76 and @childrenentdocs.  

My child failed his/her newborn hearing screening (part 3)

We have now talked about the anatomy of the ear and the tests.  Now let’s discuss what a failed hearing screening means and what will usually follow.  In general, there are 2 types of hearing loss: sensorineural and conductive.  If you refer back to part 1 of the series, conductive hearing loss occurs when there is a break in the conduction of sound between the outside world and the end of the stapes or 3^rd hearing bone.  The second type of hearing loss is sensorineural, or nerve related.  This can occur within the cochlea or anywhere along the path of the cochlear/auditory nerve and remainder of the pathways from the cochlea to the brain. 

Conductive hearing loss is easy to understand.   Something is blocking the sound from getting into the inner ear.  There things that cause a conductive hearing loss which result in a failed newborn hearing screening.  The most common of these is fluid in the ear canal or middle ear.  The middle ear space is filled with fluid in general up until delivery.  As the baby is delivered, the movement through the birth canal helps push the fluid out of the middle ear space.  When this does not happen effectively, fluid can remain in the middle ear space and cause a conductive hearing loss and a failed newborn screening.  This usually goes away after a short time, but it can persist for 4-6 months and may necessitate a procedure to drain the fluid from the ears. 

A second cause of conductive hearing loss is a malformation of the ear canal called congenital aural atresia.  This differs from a malformation of the pinna or external ear called microtia.  Both can cause difficulties with hearing but an isolated microtia does not usually cause enough hearing loss to result in a failed hearing screening.  When the ear canal has not developed, sound is unable to be conducted down it, thereby causing a conductive hearing loss and a failed newborn screening.  It may occur with or without a microtia.  This should be evident on physical examination.  Other causes of conductive hearing loss resulting in a failed newborn screening include fixation of the hearing bones, poor development of the hearing bones, and a disconnection between 1 or more of the hearing bones.

Sensorineural hearing loss can also cause a failed newborn screening.  The conductive apparatus may be fully developed and normal but if the sound pressure wave is not converted into electrical signal, sensorineural hearing loss will result.  The number of causes of sensorineural hearing loss is vast.  There can be infectious reasons like cytomegalovirus (CMV), herpes simplex virus (HSV), meningitis or congenital syphilis.  There can be congenital malformations of the cochlea or balance system.  There can be an error in the development of the cochlear/auditory nerve called auditory neuropathy.  There can be impaired blood flow to the nerve or cochlea which causes the structure to have impaired function.  Prematurity and jaundice are also risk factors for sensorineural hearing loss. 

After a failed hearing screening, your child will require follow-up with an audiologist, and, if another failed screening occurs, then with a pediatric otolaryngologist (ENT doctor).  The second test is usually more thorough than the first and usually is done when the baby is napping.  Sometimes this limits the amount of testing that can be done, especially if the baby is waking up during the examination.  Follow-up is very important as the earlier we are able to intervene, the less impact there will be on speech and language development should that be your desired mode of communication for your child.  For more information about hearing loss and the services we offer, visit our website: www.childrenentdocs.com

My child failed his/her hearing screening (part 2)

Now that we have reviewed how sound makes its way from the outside world into the brain, today we are going to discuss the different types of tests which make up a newborn hearing screen.  The newborn hearing screening program was setup as an early intervention program in an attempt to identify children with early onset hearing loss and facilitate early treatment.  Children with even mild hearing loss can have significant delays in their speech and language development. 

There are 2 main tests which are currently used to perform a newborn hearing screening.  The first test is called otoacoustic emissions, or OAEs.  This test checks the hearing pathway from the outside world to the cochlea.  It does not test cochlear/auditory nerve integrity or any of the pathways from the nerve to the brain.    In order to have a normal OAE test, the hair cells of the cochlea must be present and healthy.  They actually produce a very slight sound, which we cannot routinely hear, in response to a sound administered to the ear through a very small probe.  Therefore the sound administered by the probe must be funneled to the eardrum, vibrate the eardrum, vibrate the hearing bones, and vibrate the membranes of the cochlea to vibrate these hair cells, which, in turn, produce a sound.  The probe that produces the initial stimulus sound is able to detect the sound produced by the hair cells, or the otoacoustic emission. 

OAEs are a good screening test, but have several important limitations.  First, if there is a blockage of the ear canal, whether from ear wax, fluid or vernix, or a developmental malformation of the ear canal, the OAEs will be absent.  Similarly, and abnormality in the ear or eardrum that blocks the conduction of sound will impair OAEs.  That is because the sound cannot be conducted to the inner ear effectively to vibrate the hair cells.  Secondly, one may have a perfectly intact cochlea with normal hair cells and have a profound hearing loss due to a break in the pathway from the cochlea to the brain, an example of which is auditory neuropathy where there is abnormal development of the cochlear/auditory nerve.

The second test is called automated auditory brainstem response testing, or AABR.  This is a newer test which actually checks the integrity of the entire pathway of hearing, including the area beyond the cochlea up to the brain.  During this test, there is a probe which is placed into the ear which administers a broad-band click stimulus at a consistent level.  This device then measures, with probes that are placed on the head, the passing of that sound from the probe, through the ear, into the cochlear/auditory nerve and into the pathway from the brainstem to the brain.  This test is very good at ruling out children who do not have hearing loss and ruling in children who do.  Each ear is measured independently as in the other test.

While this test evaluates the more of the hearing pathway, it, too, has some limitations.  First, this test is a pass/fail test.  There is no interpretation possible.  Therefore a failed test must be followed up with a formal auditory brainstem response (ABR) test.  Second, the click stimulus is not frequency specific.  It generally tests from 1000 to 4000 Hz which are the frequencies thought to be most important for speech and language, but there is much more to our hearing range than is tested with a click stimulus.  Finally, as with the OAE test, the AABR depends on the conduction of the administered sound into the inner ear and hearing pathway.  Therefore any abnormality in the outer or middle ear could compromise the result of this test.

Given the relative strengths and weaknesses of these tests, many institutions are using a combination of tests for newborn hearing screening.  Now that we have discussed these tests and what they measure, in part 3 of our series we will discuss how we deal with a failed newborn hearing screening and what follow-up is involved.