At some point in your practice, most of you have faced an anxious mother worried about her child's hearing. I am Dr. David Mitchell, an otolaryngologist at the hospital for sick Children and in this video tape I hope to demonstrate how significant hearing loss can be determined in the physician's office we will look at three cases that might present to the general practitioner or the pediatrician. Each child is suspected of having a hearing loss. We hope the clues provided will allow you to determine whether or not such a problem exists and if not what the problem might be. At the end of each case presentation, we will provide you with the exact diagnosis. The general practitioner involved takes an appropriate case history from the mother and interprets the clues that she provides about his development. This discussion in history taking is most important because it is the mother who knows her child's best and is aware of the failure of normal development. Part of hearing Children may be slow in attaining normal milestones such as walking and toilet training, but most important they are slow in the area of speech development. We believe that early diagnosis can significantly help these Children for the longer it takes to make a diagnosis the longer it takes to establish some training in regard to the child's critical speech and language development which takes place at a nerdy phase and after all speech and language is what allows the individual to communicate with the world around him. In this videotape, we hope to demonstrate to you how the practitioner in his office using good history taking and simple tools may diagnose significant hearing problems. Once he has made the diagnosis, he may choose to send the child to a hearing clinic for further evaluation and therapy. If indicated will be performed we will show you some of these more elaborate tests. Now let us look at our first case. Hello? Mrs huff, how are you? I'm very well thank you doctor but I am a little worried about erin my youngest here, he's nearly six months now and he seems pretty healthy. But lately my husband and I have been a bit worried about his hearing. I see what makes you think he's got a hearing loss. Well um he when I go into his room or say something to him he really doesn't seem to notice me until I'm right on top of him. And um well just generally he doesn't seem to respond in the same way that the other kids did at his age. Is he startled by loud noises or does he for instance, cry when he hears the telephone ring? No he doesn't. As a matter of fact he could be lying right next to the phone and it doesn't seem to bother him. Oh he responds but I think that's because he sees us running for it. Another thing the other day he was in the living room with my son tim he's a teenager and you know how they are with music. Well he turned the stereo on and put on his favorite rock band and turned it up full blast. It gave me a real start. But Aaron didn't seem to mind. In fact he looked like he was enjoying it. Let me ask you a few questions about his medical history. Mrs huff. Um When he was born was it a normal labor and delivery? Yes If you'd call 27 I asked for 1/4 baby normal. That is a long time. How much did he weigh then? Uh £7. 14 ounces. Oh wait a minute I think metric 3.7 kg. They said was there any difficulty with his breathing after he was born? And was there any jaundice or were there any blood problems at all? No no my husband and I both had blood tests before we were married and there was no problem. So he didn't have to go into the nursery for special therapy or anything like that. Did he go home with you? Oh yes we went home a day early. I see. And has he been sick since then? Um Well he had a cold or two in Montreal before he came to Toronto. And then when I took him in for a three month checkup the doctor there said that he had a slight ear infection but that's all is there any history in the family of hearing loss? um well my grandmother was hard of hearing for 10 years or so before she died and I think it was, my husband's uncle had something wrong with one of his ears. He had surgery on it and then he was much better after that. Did anybody in the family have kidney disease as a child? Um Are you and your husband mrs half at all related to each other? I mean are you blood relations apart from being married to each other? No, I don't think so. Though. We were brought up in the same small town in the north of England and our families have been there for generations. Perhaps it's possible. Well it does sound likely that erin has a small hearing problem but we'll know more about that when I've examined him. Let's have a look into his ears. Can you turn him around? Yes. Oops. Mhm. Well his ear drums look normal. Let's see how he responds to. Okay, well he seems to be responding quite well. Mrs huff. I don't know why he doesn't seem to be responding at home to make sure he's all right. I think I'd like some special tests done that I can't do here in the office will send him to have these tests done. Because there are a few things that we should think about this. I'm relieved that you think he's all right. But what are these special tests you want to do? What are they going to do to him? The ideologist tests the child's hearing in a special soundproof room uses VR A or visual reinforcement audiology with Aaron? The child responds to a Saudi here is by looking up to see a flashing light. The light is his reward for looking at the appropriate time. This machine, an audio meter can make high and low pitch and loud and soft sounds. The audiologist adjust these dials, which control the sound levels in the soundproof room. By observing the responses to these sounds, it is usually possible to find out which sound Aaron hears best in which he has the most difficulty with. If the response is poor, the audiologist may try other types of tests, evoked response. Audiology looks at the brain's electrical responses to sound, electrical choreography measures the cochlear as electrical response to sound. Aaron, at his age should startle to measure its speech stimuli at 65 To 70 decibels and should be aware of it at 20 decibels. Fortunately Aaron's hearing tests, showed responses that were all within the normal range frequently infants, Aaron's age with significant loss are not detected until they are much older. Although the parents may be aware of the early signs of hearing loss, they feel the child is going through a stage which he will get over often. It is not until the child is 2.5 to 3 years of age and has failed to develop real speech that the parents become alarmed and seek medical help? Let us take a look at one such case. What makes you think that Jason has a hearing problem? Well doctor he's 2.5 years old and he's not talking very well yet. His sister at that age never stopped talking. She was always babbling away. Even if we couldn't understand everything she was saying and Jason doesn't always pay attention to me. He maybe he's just not listening but he seems like he's off in another world sometimes. What if he wants something? Can he communicate with you? Supposing he wants a cookie. What does he do about it? He has no problem getting what he wants. He just takes my hand and points to the cookie jar. Tell me Mrs Proctor. How aware is he of you? Does he hear you when you go into his room? And how soundly does he sleep? I'm not sure if he hears me or not. He's such a sound sleeper. I have to shake him to wake him up. At first I thought it was a blessing. But now I'm not so sure. What does he do with your phone rings? Well he looks mildly interested him he watches us and we answered but he doesn't seem to want to play with it or to talk into the mouthpiece as his sister did. What about the doorbell does he head for the door when it rings? He does particularly at night when my husband comes home from work. Jason seems to recognize the sound of his car in the driveway and his key in the lock. He gets all excited and he runs to the door to meet him when he gets excited. Does he babble or talk at all? As a matter of fact he does last week we took him to the zoo and he ran about babbling for hours. Sometimes I understood several words that he said. I couldn't understand everything he said. Does he understand you? How does he respond when you talk to him? Well it takes a while. He doesn't always respond right away. He has my husband's stubborn streak, but if I repeat myself several times to him, he usually does it, but he gets confused. He doesn't always understand what I say. Sometimes he brings me the wrong thing as if you misunderstood me. For example, just this morning before breakfast he was standing beside the table and he grabbed the serial, started to spill it all over the floor. Well I said pick that up please. But he thought I said pick up the cup. So he dropped the cereal and picked up his cup of orange juice, confusing similar words and phrases is common at Jason's age, particularly if a child has a hearing impairment. Now let's get some of his medical history. When did he first walk? About a year but he didn't walk for long. He ran can he feed himself? Yes, fairly well. He's pretty well coordinated. And is he still in diapers? Only at night during the day. He's pretty well dry. So you feel apart from a possible hearing and speech defect, he's developing normally. Oh yes, definitely. At first I thought maybe he wasn't as bright and as quick as a sister and maybe that's why he wasn't talking so soon. But he's pretty well normal in other respects. I see from his chart that he's had some recurring ear problems. How has he responded to the antibiotics we gave him? Well, initially there's always a great improvement, but after a couple of months he's as bad as ever and it bothers him, you know, he pulls at it. He's always touching it. Like some kids sucking your thumb and he's turned into a mouth breather. I've told him to close his mouth, but he just doesn't listen. Yes. You mentioned that the last time you were here, I checked his sinuses then they seemed fine. All right, Jason. I think it's time we had to look at you. Let's just look in your ears now. Yes, there seems to be a little fluid in the left. Is that the one that's been bothering him? Mm hmm. That's the one he's been pulling. Yes. Well, perhaps I'd better have another look at that one. Let's have a look in here again, Jason. Yeah. Yes. He seems to have a mild acute infection in there, which should clear on medication if it doesn't, we'll have him seen by the specialist? I'll leave your prescription before you leave. Now Jason. Look at your mother. Well he seemed to hear that. All right didn't he? Yes. Look at mother Jason. That's good. Where's he knows? That's good. Alright. How many noses have you got? No. Well now I bet you'd like one of these now wouldn't you? Would you? Thank you. Thank you. Well mrs Proffitt Jason seems to be hearing well out of his right here. But the problem is really on the left. I think it would be worthwhile referring him to a specialist to have his left ear drained. It would probably help to have his adenoids out at the same time as I said the hearing problems in his left. Um So I'm going to send him to the hearing clinic for a few more hearing tests and we should know what's wrong with them as a result of those about his speech. If it doesn't improve in about three months time, I think you should probably see a speech therapist will go to the speech clinic and and what we should do about his ear infection. In addition to the visual reinforcement audie ometraco. Child Jason's age responds very well to what is known as play audio mama tree here. Jason puts the peg in the hole when he hears the test sound in the ear phones again. The audiologist varies the loudness and pitch of the sound to determine the degree of any hearing problem that may exist. The fact that it is a game, increases the child's attention span and willingness to concentrate. Middle ear function is assessed using a process known as impedance idea, mama tree, middle ear pressure estimates and compliance measurements are commonly taken from with this test, in Jason's case, he showed a significant negative pressure in his left ear. By the time a child reaches school age, a significant hearing handicap is usually readily apparent. The child's language and speech development may be limited and distorted in comparison to his classmates. Frequently, there is a history of difficulty with socializing with his peers and siblings. A child with a significant hearing loss tends to be demanding and strong willed. His inability to communicate is frustrating, leading to belligerent and aggressive behavior. Teachers frequently report difficulty at school and often note an inability on the part of the child to pay attention for long periods of time. At this stage, the child himself plays a major role in the history taking and in the diagnosis as he can be tested in much the same way as the adult. Once the diagnosis is established, the school system must be notified immediately in order that they may institute appropriate educational planning. Now let's take a look at Jamie, a five year old about to start school, Dr. Jamie started talking late. That didn't worry me at first because all of our Children are quiet. However, he just isn't progressing. He doesn't talk much better now than he did a year ago lately. I began to wonder if it's because he doesn't hear properly. Well that's certainly a possibility. Can you explain to me what's different about his speech? Yes. He doesn't say his words properly. Even simple words that he's known for a long time. For example he doesn't pronounce his younger brother's name correctly. He calls him divan instead of Stephen. I've also noticed that he leaves off the last part of words. He just doesn't say the last syllable does he hear when you talk to him? Well it's difficult to attract his attention even in a quiet room and when the tv is on forget it, he blares the set and I have to shake him to get his attention. Even that doesn't work. If Sesame street is on you could light a bomb under that child. What happens when you call him from another room? Nothing much. Even if I asked him if he'd like some candy or an ice cream cone, he doesn't seem to respond. Not unless I go into the room with him. And the other day he was sitting beside me on the sofa, I was reading him a story pointing to the pictures and asking him questions. He wasn't very quick with his answers and suddenly he grabbed my face with his hands and pulled it over to his so I was looking right at him then he said let me see you when you talked mommy. It was then that I decided to come to you? Has he had any problems with the ear, nose and throat in the past? No, he's always been a very healthy child. He's never been sick a day in his life. It's the hearing problem that's been bothering me. He starts to kindergarten in several months and I'd like to know how much of a hearing problem he has before he goes to school. Perhaps a hearing aid would help him. I just don't know. Well I can certainly see why you're worried Mrs Boyd in. If he does have a problem though, it can be corrected and he'll be able to understand teacher better and learn at the same rate as the other kids at school. How are you Jamie? Do you want to come and stand over here? How old are you now? Five? Did you go to school? You are a big fella, aren't you? Can you say something's after me? Can you say The boy saw six cats? The boy saw six cats. Oh boys are thick. I see you see this that's a tuning fork. Can you hear that? What about that? I see now I'm going to cover up your ears. All right. I'm gonna cover my face and I'm gonna say some words and I want you to repeat them after me. All right. Hey baseball, baseball, hot dog, hot dog ice cream, sidewalk french fries. Okay Jamie, can you hear this watch now? Can you hear that? Can you hear that? Tell me if you hear that? All right, well mrs Boyd in. I'm sure Jaime does have some hearing impairment. You must have noticed when I gave him the words and the tuning fork tests. He missed out parts of the words and he couldn't hear words and the tuning fork when they were quite audible to us. How serious is it Doctor? Will he ever be able to hear properly? And what about his education? Well, it's hard to say now I'd like him to go to the hearing clinic for some further testing. Um I guess he has a mild hearing impairment and it may be that the audiologist will suggest a suitable hearing aid and perhaps with some special help at school he can lead a normal life. Let's make an appointment for the hearing clinic. Jamie's hearing can be tested in much the same way as an adult. Rather than putting a peg in the hole, he is old enough to raise his hand when he hears a sound. And in addition the audiologist asked Jamie to repeat words which he presents a child like Jamie has a relatively good chance of leading a normal life, providing his hearing loss can be determined early enough appropriate history taking and simple office testing and provide the clues which lead the general practitioner to the diagnosis. Subsequent, more extensive testing by the audiologist and the autologous can determine the depth and the cause of the hearing loss. Treatment can be instituted. An appropriate hearing aid and suitable educational program can be selected to help minimize the effect of the hearing handicap on the child's general development and educational future. In conclusion, we have presented some typical case histories of Children who might present in a general practitioners office. There is no way I can overemphasize the importance of early diagnosis and assisting Children who have hearing handicaps. In a study conducted at the hospital for sick Children of Children with significant hearing loss, there was a delay of an average of 12 to 14 months between the time the parents first sought help and the diagnosis was finally established. We hope this video tape will help you to help us to reduce this gap.