Hearing Impairment Treatment & Management

Updated: Jul 14, 2017
  • Author: Rahul K Shah, MD, FACS, FAAP; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
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Treatment

Medical Care

Conductive hearing loss

Manage conductive hearling loss (CHL) due to otitis media or its sequelae with a course of appropriate antibiotics. Patients with serous otitis media for longer than 3 months benefit from myringotomy and removal of the fluid in the middle ear. Ventilation tubes may ultimately be necessary. If the hearing loss continues, amplification with a hearing aid may be needed. Speech therapy is rarely necessary unless the loss is prolonged and cannot be corrected with amplification.

CHL that results from obstruction of the auditory canal because of cerumen or a foreign body should be treated by removing the obstruction.

Sensorineural hearing loss

Sensorineural hearing loss (SNHL) cannot be treated medically. [35] In mild-to-moderate hearing loss, amplification with hearing aids is used to give the child as much auditory input as possible. Speech therapy may be beneficial. If the child requires special schooling, the school should determine how much speech training is routinely part of the school day. Preferential seating and use of FM systems should be discussed with the patient's family and teachers.

In older children and in adults with moderate-to-profound hearing loss, hearing aids may correct up to 40-60 dB. Beyond that, the limiting factor is the physical sound pressure exerted on the tympanic membrane, which becomes painful after a certain threshold. Young children with small ear canals may perceive pain at amplification volumes as low as 10-15 dB. Modern hearing aids can selectively amplify a specified range of frequencies more than others rather than all frequencies equally.

There are two main goals of amplification. The first is to provide language. After the hearing aid is fitted by using proper molds, the hearing aid is tested to see how well it matches the goals for loudness at various frequencies. With older children, speech recognition should be part of this testing. For young children, the goal is to optimize auditory input without causing pain. If the hearing aids are painful to use, children will avoid using them. If amplification is successful in providing improved spoken language comprehension without pain, its use in and out of school should be encouraged.

The second goal of amplification is to provide environmental cues. The use of hearing aids aids in connecting young children to their environment, helps maximize auditory language development if it allows them to hear any speech sounds, and uses auditory pathways to the brain, which may prevent the brain from “ignoring” them (as it does in cortically blinded laboratory animals). The ability to hear environmental sounds is important for safety and some general functioning. Important safety cues include car or truck horns, alarms, or even someone yelling “stop.” Functional cues might include class bells, oven timers, doorbells, or someone calling their name loudly.

Older children may choose not to use their hearing aids because they “don’t look cool.” Rather than making this a significant ongoing argument, parents should be reasonable. For example, if their child is succeeding in school, the hearing aids may not offer a substantial language benefit to their child’s functioning. Additionally, the child is likely safe in the classroom, so benefit might be gained by letting the child “win.” If the child prefers not to wear the hearing aids after school, parents should respect this decision if the child is participating in safe activities that do not pose an increased risk of harm because of missed environmental cues.

There is no medical disadvantage for children choosing to not use hearing aids. In fact, many deaf adults use their hearing aids selectively or not at all because they find that the extraneous noises and distortions they hear are more bothersome than helpful. They may decide to use their hearing aids only when they anticipate a particular benefit.

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Surgical Care

Conductive hearing loss

Some causes of CHL may be managed or aided surgically. Children with persistent chronic or recurrent otitis media with resultant effusions may benefit from the placement of myringotomy tubes to ventilate the middle-ear space to prevent negative pressure in this area. If otitis results in the destruction or fixation of the ossicles, surgery may improve ossicular function. Cholesteatoma is a surgical disease.

Bone-anchored hearing aids (BAHAs) may be useful in some patients. Examples are patients with microtia, those with anotia who are awaiting auricular reconstruction, and patients with persistent otorrhea who cannot use a hearing aid.

Carter et al reported that an endoscopic transcanal approach to middle-ear exploration offered good visualization in pediatric patients with CHL and was especially helpful with apparently unexplained CHL in which ossicular deformity or fixation or discontinuity was suspected. [36] When the cause oif the CHL is definitively found, it can often be repaired in the same sitting.

Sensorineural hearing loss

SNHL cannot be treated with surgical means other than cochlear implantation. Cochlear implantation may be an option in some children, but it should not be mistaken for a cure.

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Consultations

Otolaryngologist

Consulting an otolaryngologist is imperative if the child has CHL. An otolaryngologist can provide advice pertaining to medical and potential surgical interventions. Consultation is also recommended if the child has profound SNHL and is a potential candidate for cochlear implants. The otolaryngologist is a crucial member of the multidisciplinary team needed to help patients with profound SNHL.

Specialists in early intervention

Early intervention programs are essential to help parents understand how to raise a deaf child or one hard of hearing. Such programs are also needed to begin discussing and implementing language and/or educational programs.

Audiologist

Consulting an audiologist is essential for evaluating patients for hearing aids and for fitting them.

Geneticist

Consultation with a geneticist is recommended if the cause of deafness may be syndromic or if the family history suggests a hereditary pattern.

Ophthalmologist, nephrologist, cardiologist, or other subspecialty consultants

Consulting these subspecialists is recommended if an identifiable syndrome implicates involvement of the visual, renal, cardiac, or any other organ system (eg, a deaf child with hematuria should see a nephrologist to check for Alport syndrome).

Similarly, if involvement of an organ system is anticipated because a child is diagnosed with a particular syndrome, a specialist may need to be involved (eg, a deaf child may benefit from aggressive ophthalmologic screening for the development of retinitis pigmentosa, as in Usher syndrome, or simply because vision is so important to communication that mild losses in visual acuity should be managed promptly).

Occasionally, a specialist may be able to identify abnormalities that may lead to the diagnosis of a specific syndrome that would not be seen without specialized equipment (eg, an ophthalmologist for a funduscopic examination or a cardiologist for electrocardiography [ECG] or echocardiography).

Because almost any organ system is potentially related to hearing loss, there is no need to consult every subspecialist for each child with hearing loss. As noted earlier, even routine ECG testing for a prolonged QT interval or laboratory testing for the development of nephritis or changes in blood urea nitrogen and creatinine are not recommended universally.

Experts in managing hearing loss

Consult physicians with expertise in caring for patients with hearing loss, if any are available in the community. Some physicians have developed expertise in the field of deafness and may be available for consultation. They can offer information about any associated medical conditions that may be present, as well as perspective about language and education, use of hearing aids and cochlear implants, and other equipment.

The literature is filled with debates about the most appropriate educational venues for children who are deaf or hard of hearing. Many people involved in early intervention are affiliated with a particular program because it matches their personal biases. Physicians with expertise in deafness may be more neutral. However, there is a clear bias in the literature towards spoken language as the outcome measure defining success, and relatively good literature about the success of an all-sign-language education (even the literature on reading ability can be questioned).

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Long-Term Monitoring

Follow-up of the interventions is as important in hearing impairment as in any other disability or medical condition. [37] Physicians too frequently relegate the care of children who are deaf to audiologists and educators. Children who are deaf need ongoing referrals to an audiologist to monitor the progression of their hearing loss and to refit hearing aids so as to match changing losses, ear growth, or both.

Pediatricians should monitor the child's linguistic and social development. They should ask about language and school performance. The child's placement in school may not be optimal for his or her abilities. For instance, a child who is not successfully learning lip-reading cannot learn math or science. Pediatricians should ask how the child is doing in school and in the family, how family members interact with the child, and how the parents discipline or instruct the child.

Children who cannot communicate with those around them may be frustrated and, therefore, act out or display withdrawal behaviors. These behaviors may be misinterpreted as being a behavioral or psychological problem rather than being reactions to the child's environment or situation.

Children who are deaf or hard of hearing are at particular risk for abuse. Physical abuse may be inflicted by parents who are frustrated because their child is not acting as they expect. Also, children who perpetrators perceive as being unable to report misconduct are at high risk for sexual abuse. Furthermore, most children with hearing impairment have no physical disabilities and may be attractive to a potential perpetrator. Deaf children are sometimes socially isolated because of the communication barrier, and they may be susceptible to individuals who give them special attention. Watch for physical signs of abuse or for behavioral manifestations of child abuse.

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