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. 

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 1)

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Amid all of the excitement of a newborn child, there are several tests that are run shortly after birth while your baby is in the newborn nursery that are mandated by the state.  One of those tests is a hearing screen which checks to see if the most basic parts of the hearing mechanism are intact.  We are going to discuss the newborn hearing screening, how it works, what the results mean, and what should be done in follow-up of an abnormal test in a 3-part posting.  Please be sure to check back for the second and third parts to follow shortly.

To understand the hearing screening test, we should first talk about how sound gets from the outside world into the brain.  There are many important pieces which are needed in order to hear sound.  Sound is actually a pressure wave.  That wave gets funneled into the ear canal by the ear which you see on the side of the head, or pinna/auricle.  Once in the ear canal that wave is transmitted down to the ear drum, which it vibrates.  The eardrum is connected to 3 of the tiniest bones in the body: the malleus, incus and stapes (or hammer, anvil and stirrup bones).  When the sound wave hits the eardrum, the eardrum vibrates, and, as a result, the 3 hearing bones vibrate as well.  The 3^rd hearing bone (stapes) is connected to the inner ear and transmits that wave into the inner ear. 

Here is where all of the magic happens.  The sound wave that is transmitted into the inner ear, or cochlea, vibrates delicate membranes that are within the body of the cochlea.  There are cells along those membranes which respond to different frequencies of vibration.  When that frequency of sound is present, those cells, called hair cells, activate and change that mechanical wave into an electrical signal.  This electrical signal is then collected by the cochlear, or auditory, nerve which then takes that information into the brainstem and relays it all the way to the temporal lobe of the brain where that signal is perceived as sound.

For a basic animation to understand this process, please visit: http://www.youtube.com/watch?v=tkPj4IGbmQQ

In the next part of this series, we will discuss the types of newborn hearing screening tests and what type of information these tests gives us as ear, nose, and throat doctors.

Thank you very much for reading our blog!  Please check back again for parts 2 and 3 of this series.

Earache after swimming? We can help!

Vacationing this weekend, I spent many hours in the water, both in the pool and at the beach.  After my first day I noticed that my ear was hurting a bit, which has prompted this blog entry on swimmer’s ear, or otitis externa.

Swimmer’s ear is an infection of the outer ear, primarily within the external auditory canal or ear canal.  This is a bony and cartilaginous structure which extends from the pinna, or ear you can see on the side of the head, down to the eardrum.  It is separated from the middle ear space by the eardrum. 

Infections in the ear canal are common.  They frequently come after a period of time at the beach, lake or in the pool.  The first presenting signs include pain, fullness in the ear, hearing loss, and drainage.  These infections can be very painful.  Frequently though, these infections do not get attention until they are severe.  Occasionally, over-the-counter ear remedies are tried.  These include medicated pain drops, alcohol, peroxide, and anti-inflammatory pain relievers.  These remedies can exacerbate the pain, particularly if the products contain alcohol. 

With these infections, the ear canal swells and, as a result, debris accumulates.  This makes the environment darker and moister and the infection continues to worsen.  The treatment of choice for otitis externa is ototopical antibiotic drops.  I prefer a drop with a steroid in it to help with the inflammation.  Occasionally, the drops are unable to make it into the ear canal.  This is a problem in that the drops actually have to make it into the ear canal to work.

This is where your otolaryngologist, or ENT, can help your child!  When the ear canal is too swollen to apply the antibiotic drops, sometimes this requires a debridement, or cleaning of the ear canal.  If the ear canal is still too swollen, a wick may be placed to help transfer the drops down the swollen ear canal.  This usually stays in for 3 days and is then removed for the remainder of the duration of antibiotic drop treatment.  If the infection is severe enough, with extension onto the face or into the bone of the ear, oral or possibly intravenous antibiotics may be required.  This is very uncommon. 

Remember swimmer’s ear when your child has ear pain after swimming.  This is common and is usually well treated with ear drops.  Avoid putting cotton swabs in the ears and do not wait too long to seek treatment.   Your ENT can help if routine treatment does not solve the problem.  For more information about this and other ear pathology visit the Children's Ear, Nose and Throat Associates webpage.