Hearing: Cases and Questions

Contents

By Valerie Niketakis

Learning Objectives:

  1. Recognize the different types of hearing loss.
  2. Be familiar with the available audiologic testing procedures, both the behavioral procedures that target different developmental age groups and the electrophysiologic procedures that can be used universally.  Be aware of the advantages and limitations of each for diagnosing different types of hearing loss.
  3. Know the principles and guidelines of Universal Newborn Hearing Screening and Intervention as they relate to Pediatricians as the Medical Home Providers.
  4. Know the Pediatricians responsibility for ongoing surveillance of communicative development and screening for risk factors of hearing loss during well child visits.  Know the appropriate referrals and treatment options available to patients and their families.

 

Required Reading:

  1. Pediatrics in Review Vol 25 No7 July 2004 “Pediatric Audiology:  A Review”  p 224-234.
  2. Pediatrics  “Year 2007 Position Statement:  Principles and Guidelines for Early Hearing Detection and Intervention Programs—Joint Committee on Infant Hearing”  Online version http://www.pediatrics.org/cgi/content/full/120/4/898   

 

Case 1:  Tommy Toddler is an 18 month old who presents to your clinic for his Well Child visit.  His mother expresses concern regarding his “behavior”.  Tommy has been having an increasing number of tantrums over the past 3months and does not follow her simple commands, although “he used to”.  His mother tells you that he does not consistently respond to her unless she “yells” or “the T.V. is off”.  You look back through his chart, and Tommy passed all developmental milestones on his Denver at his 12 m.o. visit.  He then had 2 walk-in visits for otitis medias with effusions, but missed his 15 month old well child visit.  You perform a Denver on Tommy, in which you note that he has a vocabulary of 5 words, points to body parts only when his mother gestures, and

does not follow your simple commands.  Tommy does very well on the gross motor, fine motor and personal/social parts of the Denver, and by additional history you do not note any other characteristics suggestive of Autism or PDD although you can not definitively rule out mild mental retardation.  Tommy’s physical examination is entirely normal, including no microcephaly, no dysmorphic features, no abnormal pinna, no atresia or stenosis of his ear canal, no ear tags, no bony growth in his ear and no dimples or pits by his ear.  Tommy’s tympanic membranes appear normal, although the insufflator is missing in your exam room.

 

Question 1.   What is the pediatrician’s responsibility for assessing language delay?  When language delay is suspected, what is the Pediatrician’s responsibility for evaluation/management?

Question 2:  How is hearing loss classified?

Question 3:  What behavioral audiologic test would be helpful to evaluate Tommy’s hearing? 

Question 4:  What electrophysiologic test would be helpful to further asses the etiology of Tommy’s hearing loss?

Question 5:  Tommy Toddler comes back to you for follow up after the audiologic tests were performed.  His mother hands you the raw results of the audiologists report, but she does not have the interpretation, and you did not receive a consult report from either audiology or otolaryngology.  The mother has a follow up apt with otolaryngology, but she is understandably concerned and asks you “what does it mean?”  Please interpret Tommy’s audiology report with respect to type and severity of his hearing loss.  See attatched

Question 6:  What are the treatment options available to Tommy and his family?

Case 2:  Nelly Newborn, a 5 day old former 39 week gestational age female who was discharged from the well baby nursery 3 days ago, comes to see you for her first well child care visit.  Nelly’s mother is very concerned because she was informed by the hospital staff that Nelly failed her newborn hearing screen in her right ear.  Nelly has a follow up out-patient screen scheduled in 2 weeks, but not an appointment for a full audiological evaluation and Nelly’s mother is not sure if this is “all right”.

 

Question 1:  What advice do you give Nelly’s mother?

Question 2:  What are the accepted audiologic tests for newborn hearing screening in the well baby nursery?

Question 3:  When Nelly comes back for her 1 month well child visit, Nelly’s mother tells you that although Nelly failed her first newborn screen in her right ear, she had both ears retested and passed her second outpatient screen, much to her mother’s relief.  Her mother then informs you that the reason that she was so worried initially was that she did not want Nelly to have to go for a full audiologic evaluation, since she knows how long they take since she has a family member who developed permanent hearing loss as a child.  What discussion do you now have with Nelly’s mother?

Additional Resources:

  1. “Universal Newborn Hearing Screening, Diagnosis and Intervention. Guidelines for Pediatric Medical Home Providers” http://www.medicalhomeinfo.org/screening/Screen%20Materials/Algorithm.pdf
  2. Pediatrics Vol. 111 No 2 February 2003, “Hearing Assessment in Infants and Children:  Recommendations Beyond Neonatal Screening” pp 436-440.
  3. JAMA, October 24/31, 2001—Vol 286, No 16, “Universal Newborn Hearing Screening Summary of Evidence” pp 2000-2010.
  4. Early Hearing Detection and Intervention—The Role of the Primary Care Physician, AAP CME Teleconference October 15,2003(Power point presentation)  http://www.infanthearing.org/medicalhome/aapteleconference/AAPTeleconference20031015.ppt
  5. Newborn Hearing Screening, AAP Teleconference, November 12, 2003(power point presentation)

http://www.infanthearing.org/medicalhome/aapteleconference/AAPTeleconference20031112.ppt

  1. Pediatrics in Review Vol 15 No. 3 March 1994 Consultation with the Specialist “Hearing Loss in the Absence of Otitis Media” by John F. Kveton, MD pp 115-116.
  2. Pediatr.Rev.2002;23;155 “Hearing Screening” pp 155-162.
  3. Pediatr.Rev.1998;19;155 “Early Identification and Intervention for Children Who are Hearing Impaired” pp 155-165.
  4. National Institute on Deafness and Other Communication Disorders Fact Sheet “When a Newborn Doesn’t Pass the Hearing Screening:  How Medical and Other Health Professionals Can Help Increase the Number of Infants Who Return for a Follow-up Evaluation”