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 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.

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.