medical screening -hearing - haad · • such treatment may result in restoration of hearing ......

Medical screening - HearingMedical screening - Hearing

Objectives• Review anatomy of the ear and pediatric problems that

lead to hearing loss

• Recognise the effects of hearing loss

• Outline the importance of hearing screening.

• Outline protocols for hearing screening• Outline protocols for hearing screening

• Describe techniques to ensure accurate testing.

• Understand the technique for performing hearing

screening using a pure-tone audiometer.

• suggest strategies for students with hearing loss.

Importance

• Children need to be screened for hearing loss beyond

the New Born period.

• Newborns can be lost to follow-up and not all

hearing loss can be identified at birth

• Progressive and late-onset hearing loss may occur

throughout the early childhood years.

Importance

• Because of the importance of hearing for learning,

routine screening occurs on an annual basis for every

child until the age of 7 years.

• It is estimated that 35% of preschoolers will have

repeated ear infections that cause a temporary

hearing loss that can significantly disrupt language

acquisition and other education progress (ASHA,

2004)

• Results of hearing screening program have shown

that five to ten percent of the school age population

do not pass audiometric tests. The majority of these

children are in need of medical treatment.

Importance

• Such treatment may result in restoration of hearing

and prevention of permanent hearing impairment.

• Approximately two percent will show permanent

hearing impairment and will require special

educational services.

• Hearing loss is referred to as the silent, overlooked

epidemic of developing countries because of its invisible

nature which prevents detection through routine clinical

procedures (Swanepoel, Hugo & Louw, 2005a, in Early

hearing detection and Intervention programmes in hearing detection and Intervention programmes in

South Africa Position statement,

2007 ).

Continuation…

• The hearing loss affects language and cognitive

development and psychosocial behaviour.

• society is burdened by hearing loss due to the extensive

economic costs associated with it.

• Hearing loss without adequate intervention affects an

individual’s ability to obtain, perform in and keep a job, individual’s ability to obtain, perform in and keep a job,

and it causes people to be isolated and stigmatised

during the entire course of their lives

• In a child, some of the consequences may be:

(a) Interference with normal speech and language

development.

(b) Development of abnormal social growth and

behavior.

(c) Interference with education and human (c) Interference with education and human

potential.

(d) Development of adjustment problems in the

child and his/her family.

(e) Isolation

Signs

• A child’s behavior in the classroom may indicate the

possibility of hearing loss.

• Warning signs:

– Inattentive– Inattentive

– asks for frequent repetitions

– his/her achievement may be low

Hearing

• We hear by funneling sound from the environment

into the outer ear and causing the tympanic

membrane to vibrate.

• Those sound waves vibrations are transferred into

mechanical vibrations of the ossicles.

• Those mechanical vibrations cause the oval window

to move back and forth causing the perilymph of the

inner ear to begin wave-like motions.

Hearing

• The perilymph fluid motion is transferred to the

endolymph and the wave motion is transformed into

electrical impulses picked up by the hairy cells of

Corti and sent to the brain via the cochlear nerve.

• The round window is responsible for absorbing the

fluid wave vibrations and releasing any increased

pressure in the inner ear caused by the wave motion.

Hearing Loss

• Sensorineural (permanent) loss can result from:

– viral (especially measles and mumps)

– bacterial infections

– prolonged exposure to loud noises such as rock – prolonged exposure to loud noises such as rock

bands, gunfire, motorcycles, and power motors

– ototoxicity

– congenital abnormality

– head trauma.

Treatment of Sensori-Neural

(Permanent Hearing Loss)

• Auditory training with amplification devices (hearing

aids)

• Cochlea implants• Cochlea implants

• Aural rehabilitation (including speech reading)

• Speech and language therapy

Conductive (Temporary)

Hearing Loss

• Conductive (temporary) hearing loss can result from:

– impacted earwax

– foreign objects (beans, erasers, cotton, etc.) in – foreign objects (beans, erasers, cotton, etc.) in

the ear canal

– middle ear infections (otitis media)

– congenital abnormalities

– ruptured or scarred eardrums secondary to

trauma or infection.

Treatment for Conductive

(Temporary)Hearing Loss

• Many cases of conductive loss respond well to

medical or surgical treatment.

– losses may fluctuate over time so that a pupil

who is referred to a physician for follow-up may who is referred to a physician for follow-up may

not be experiencing the loss at the time of

medical evaluation.

– This is a strong argument for the necessity of

rescreening before referring a pupil.

Hearing Loss

• It is possible to have a conductive and sensorineural

hearing loss at the same time.

– An individual with a document history of

fluctuating hearing loss may need immediate

intervention to detect the need for medical

treatment and to prevent permanent damage.

Effects of Hearing Loss

The Health Authority of Abu Dhabi

• HAAD School Screening Standards

– Hearing will be tested in grades 5 & 9

When to Screen

• It is important to conduct hearing tests on the young,

school age pupil to ensure early identification of

those with hearing loss and for hearing conservation

purposes

• hearing tests on the older adolescent, because of the

potential for noise induced hearing loss among

teenagers.

Minimum Recommendations

Internationally

• Hearing should be tested before November of the school year.

– Before entering kindergarten

– Yearly from kindergarten through grade 3– Yearly from kindergarten through grade 3

– In grade 7 and grade 11

– Prior to entering special education or repeating a grade

– When entering a new school system, if passing results from a previous exam cannot be obtained

When to Screen

• The older student is less likely to complain of ear or

hearing problems than a younger child; the impact

on their ability to perform can be as detrimental as

on a young child.

• Because Hearing Loss is so insidious, it should always

be monitored regardless of age.

Difficult-to-Test Children

• Who are they?

• Children with:

– Motor difficulties

– Cognitive challenges– Cognitive challenges

– Sensory deficits (e.g. vision)

– Behavioural difficulties

What to do with difficult to test

students?• Ear examination, using an otoscope, by a physician.

• Teacher input regarding child’s performance in classroom.

• Gross testing procedures such as alerting (eye movement, head turn, facial expression) to noise movement, head turn, facial expression) to noise maker, finger-snap, hand-clap, crinkling paper, voice, etc., when presented at varying loudness and distance from the ear and outside the child’s visual field and awareness.

• Parent input regarding child’s auditory awareness and responsiveness to voice, music, and sound in the home environment.

Audiometer Testing

• Maintenance:

– The audiometer and headphones should be

checked for proper functioning before conducting

each series of tests.

– The audiometer should be checked by measuring

the tester’s hearing in the room where testing will

be done.

Audiometer Testing

• Calibration:

– The audiometer is a delicate instrument and

should be handled with utmost care.

– Calibration of the instrument should be done – Calibration of the instrument should be done

annually.

– If the audiometer has been dropped, earlier

calibration is necessary.

• Arrangements for repair and calibration services should

be made with the dealer at the time of purchase.

• After each calibration, the dealer/lab should provide

the school with a Certificate of Calibration.

– This is an extremely important matter. In order to – This is an extremely important matter. In order to

ensure proper testing and reliable test results for

each pupil

– school authorities must provide for reliable

calibration and repair services on a regular basis.

Helpful Hints for Testing

• The procedure for testing should be described and

demonstrated briefly to the entire class or entire group.

– present exaggerated tones from the audiometer and

ask the children to respond by raising their hands

when they hear the tone. when they hear the tone.

– Practice with a group will simplify the testing on

individual children.

– Should a child be confused, it would be wise to

demonstrate with one or two tones before starting

to test.

The following instructions should be

provided to each class to be tested:• “You are going to have your hearing tested. You will hear

sounds from the earphones. Some will be high-sounding

and some will be low-sounding. Some will sound like

whistles and some will sound like hums. When you hear whistles and some will sound like hums. When you hear

the sound, no matter how soft or little it is, you are to

raise your hand. Keep your hand up as long as you hear

the sound, and put it down as soon as the sound goes

away. When you hear a sound again, raise your hand

again. Remember, no matter how soft the sound is, if you

think you hear it, raise your hand.”

Ensure ambient noise is eliminated

• Ask teachers to instruct students to be quiet this day.

• Reschedule noisy activities, music, songs, PA

announcements.

• Plan testing around bells and not at break times.

Screening Recommendations

• Children 3 ½ years and older

• Traditional Audiometry (raises hand when hears a

tone).

• Screen at the following frequencies/decibel levels in • Screen at the following frequencies/decibel levels in

the following order:

– 1000, 2000 and 4000 Hz @ 20dB.

– Finish at 500 Hz @25dB.

Hearing Screening Tips and

Techniques:

• Make sure that the testing area is quiet

• The audiometer should be calibrated yearly

• Ensure the audiometer is on for at least 10mins

before testing.before testing.

• Have the child practice once or twice to make sure

the child understands the instructions

• The tester should not show facial expressions that

may give sound clues to the child while testing

Hearing Screening

• Ask about recent cold or ear ache

• seat child at proper angle

• check for hearing aid, cotton or drainage

• instruct BEFORE putting on phones• instruct BEFORE putting on phones

• raise hand when sound heard; down when sound

stops

• An otoscopic examination is traditionally completed

BEFORE testing. Those who fail the otoscopic

examination require medical management and are

scheduled to be re-screened.

Hearing Screening

• remove glasses, head bands, etc.

• hair behind ears

• red coded earphone - right ear

• earphone diaphragm in line with ear canal• earphone diaphragm in line with ear canal

• check form if NO response

Pure Tone Threshold Screening

• Equipment: Pure tone audiometer.

• Facilities: Quiet room, free from visual distraction


• Seat the children so they cannot see the front of the audiometer.

• Instruct the child to raise either hand when a tone is heard.

• Set selector switch to Right.• Set selector switch to Right.

• Set HL dial to 40 dB.

• Set frequency dial to 1000 Hz.

• Place the earphones on child's head with the red phone on the right ear and the headband flush to the head.


• Screen right or better ear.

• Present the 1000 Hz tone at 40, 20, 0 dB until there

is no response.is no response.

• At the level there is no response, increase in 5 dB

increments until there is response.


• Drop 10 dB.

• Increase in 5 dB increments until there is a response.

• Repeat until there are 2 responses at the same level.• Repeat until there are 2 responses at the same level.

• Record threshold level.

• Repeat the process for 2000, 4000 recheck 1000 Hz

and 500 Hz in the right or better ear. (Note

frequencies!)

• Repeat for the other ear.


• WNL: Child's threshold is above the bold line on the

audiogram (20dB at 500 Hz, 15dB at 1000, 2000,

4000 Hz).

• For screening acceptable thresholds are 25dB at • For screening acceptable thresholds are 25dB at

500Hz and 20dB at remaining frequencies (because

of ambient noise).

• Referral: Any threshold level on or below the bold

line on the audiogram (25dB at 500 Hz, 20dB at

1000, 2000, 4000 Hz).


• Exceptions: When a child has a known hearing loss

that has been diagnosed as non-treatable, referral to

an audiologist should be made if there is a change of

10dB poorer at any frequency.10dB poorer at any frequency.

• NOTE: For children who are difficult to screen, use

play audiometry procedures

• This is NOT advisable for nurses as it is requires

special equipment and training.

Otoscope

• SCHOOL NURSES TRAINED IN THE USE OF AN

OTOSCOPE ARE TO EXAMINE THE EARS OF ALL

PUPILS FAILING THE PURE TONE HEARING TEST.

– Examination of the ear canal for presence of

excessive cerumen, discharge, odor, foreign bodies

(including insects), and inspection of the tympanic

membrane for perforation and mobility.

Screening protocol

Pure tone audiometry

• Grades K,1,2,3: annual PT screen at 25dB HL/500Hz,

20dB HL/ 1000,2000 and 4000Hz.

• Grades 6-12: administer pt audiometric screen one • Grades 6-12: administer pt audiometric screen one

time in middle school (grades 6-8) and one time in

high school (grades 9-12) at 20dBHL/1000, 2000 and

4000 Hz; 25dbHL/6000Hz

FK2

FK2 this is just a suggestion. Ref Katz (2002)Farhana Khan, 3/5/2011

Screening Protocol

Immittance:

• Grades K,1,2: administer in conjunction with PT

screening

• Grades 3 or higher: administer for children with • Grades 3 or higher: administer for children with

known hearing loss, children with a history of otitis

media

Referral consideration

Pure tone audiometry

• Rescreen if any signal presentations are not passed

at frequency and intensity levels indicated; refer if

condition is present at rescreen

Acoustic immitance

• If child has tympanostomy tubes, refer if ear canal

vol is less than 1.0cm

• Rescreen asymptomatic abnormal middle ear

function within 4-6 weeks; refer at rescreen if

condition persists.

Screening for special populations

or difficult to screen

• OAE screening for children with whom you

cannot perform audiometrycannot perform audiometry

• This is currently not possible via school

screening

Considerations

• Children with hearing difficulties may be prone to

accident.

• Teachers may need support with educational

adaptations for students with hearing deficits.

• Psychosocial support is important

• Education of other students regarding aids, sign

language, lip reading, is helpful.

References

• Guidelines for the School Hearing Screening

Program for Pennsylvania’s School Age Population.

Department of Health. Retrieved January 25th, 2011

from www.portal.state.pa.us

• Health Authority of Abu Dhabi: Standards for School

Health Screening. Retrieved January 25th, 2011 from

http://haad.aspgulf.net/?lang=en-US

Continuation…

• Minnesota Department of Health: Vision Screening

Online Training Program. Found at

http://www.health.state.mn.us/divs/fh/mch/webcou

rse/vision/mod6c.cfm

• Ohio Government Department of Health: Hearing

and Vision Screening for Children. Retrieved January

25th, 2011 from

www.odh.ohio.gov/odhprograms/cfhs/hvscr/hvscr1.

aspx

medical screening -hearing - haad · • such treatment may result in restoration of hearing ......

Documents