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New notes

Notes for Hearing Loss cases

HearingLossCases.png

Case 1

  • There are equal reductions in both air and bone conduction
  • So this man has a sensorineural hearing loss

Case 2

  • Sarah has bilateral otitis media as a result of acute URTI
  • She has mild to moderate conductive hearing loss in both ears, shown on the audiogram as reduced air conduction but normal bone conduction

Case 3

  • Mixed hearing loss (left ear shown)
  • This can occur when a person has a permanent sensorineural hearing loss and then also develops a temporary conductive hearing loss (e.g. with URTI)unable able to known the direction of sound

Case 4

  • The case audiogram shows a severe bilateral sensorineural hearing loss
  • Bone conduction is not shown here but would show a similar amount of hearing loss
  • May only hear very loud speech or loud environmental sounds, such as a fire truck siren or a door slamming
  • He/she might communicate through sign language

Explanation of masking

Grow strong video

What are some key elements of approaches that have proven successful at improving the health of Indigenous children, with respect to the following areas?

Indigenous community participation and/or control

  • To have some people from the community approve of the development of programs, so that the programs are more likely to be accepted by the wider population
  • Self-­‐determination
  • Improve the follow up of children with health issues (liaison officer between health care and communities)
  • Get local community involved in the intervention
  • Key thing to do: involve the indigenous people in the approach

Coordinated approach between different government and community services/agencies

  • Look at the problem holistically
  • Improving communication between services/agencies

Address barrier preventing indigenous people accessing health care

  • Physical/Geographic – isolation from health centres (poor access to GP, healthcare, hospitals, pharmacies)
  • Cultural – language, cultural practices in regard to health issues (e.g. herbs), trust (Western medicine; intimidated; feel unwelcome in health centre; few Indigenous in workforce)
  • Education – lack of education (regarding health, risks)
  • Socio-­‐economic – Travel to GP, medication, price of ambulance

Focus on preventive health care

  • Primary prevention – prevent the onset of ill health and disease conditions, e.g. immunization programs and healthy eating programs in schools
  • Secondary prevention – early detection of disease, to improve chance of preventing progression of the disease and development of symptoms, e.g. screening programs

What can health professionals do to contribute to improvements in health of Indigenous children?

  • More doctors in rural/remote areas even if temporary
  • Financial incentives to work in rural/remote areas
  • Incorporate the social context in the prevention, treatment and management conditions
  • Be informed about the current treatment and management guidelines, e.g. Indigenous clnical treatment guidelines for OM
  • Be diligent about identifying and following up children at risk
  • Use social networks – professional colleagues and community contracts
  • Consider the social needs of the mother when trying to improve the health of their child
  • Encourage and enable Indigenous community input into program and services
  • Be informed about social and health policy, and consider how this impacts upon the ability of Indigenous Australians to comply with treatment
  • Be realistic about what can be achieved not fatalistic

Programs targeting otitis media in indigenous children

Group 2 Group 1 Group 3
Objectives of the program To determine health impact of salt water swimming pools with aim of improving quality of life and reducing high rates of pyoderma and OM Nose blowing, coughing, deep breathing and exercise-->lung and otitis media To see the effect of nutrition on otitis media
Specific population groups targeted
  • 2 Aboriginal communities in WA
  • <17 years old
Indigenous primary school children in central Australia
  • Indigenous communities
  • Primary school aged children
  • Also extended to families of Aboriginal communities
    • With children that had skin and ear infections
Risk factors targeted
  • Poor hygiene
  • Can also be risk factors for cardiac and renal disease
Low SE status, signs of upper and lower respiratory tract disease and pulmonary function
  • Poor nutrition
    • Vitamin C
    • Iron
  • Economic (families pay $5/week to receive $40/week of fruit and vegetables)
Strategies used to target risk factors Salt water in pool cleans out the ears
  • Blowing nose
  • Coughing
  • Deep breathing
  • Exercise
People, groups and organisations involved in the program
  • WA state government
  • Parents implemented no school no pool policy
  • Royal lifesaving association
  • Department of Health and Community Services, Alice Springs
  • Medical Service in Darwin
  • Community councils and community schools
  • Aboriginal communities and families
  • Schools
  • Aboriginal medical service
  • General Practitioners
Measures implemented to assess the effectiveness of the program in improving health outcomes
  • Measured type, severity and prevalence of skin infection and otitis media
  • School attendance
  • Social impact of pool
  • Otoscopy
  • Audiometry - portable AD 17 audiometer
  • Respiratory function tests - nose blow test, cough test
  • Pulmonary function tests - FEV1, FVC, peak expiratory flow rate
  • 3 intervention and post-­‐ intervention blood samples obtained
  • Otoscopy to check ears before and after
  • Physical screening of skin infections based on clinical presentation
  • Negatives: small number of children in the study, no controls, no blinding
Effectiveness of the program
  • Reduced incidence of pyoderma 6218% (community A), 70-->20% (community B)
  • Tympanic membrane perforation 32-­‐13% (community A), 32-->18% (community B)
  • Statistically significant improvements in respiratory tract disease and function
  • No change in hearing
  • Otoscopy
    • Initially: 38% active ear infections, 25% normal ear drums
    • After 7 months: 80% normal ear drums Skin
    • Initially: 75% skin infections
    • After 7 months: 20% skin infections
Likely sustainability of the program Depends on adequate funding. Pool will be used for recreational purposes to keep it going. Need to employ staff to keep it going Very cheap
  • Aboriginal Medical Service grant will expire
  • Nature of the grant is important
  • Age of the children
  • Need more research to continue the program

Alternate case 2

  • Grommets used to treat otitis media with effusion despite evidence of effectiveness

A grommet is a tiny tube inserted into the eardrum to allow air to enter the middle ear. The grommet does the work that the poorly functioning Eustachian tube should be doing, giving the middle ear a chance to recover. Grommets cause no discomfort while in place. The healing ability of the eardrum is so great that it usually pushes the tube out in 6 to 12 months, leaving the drum intact.

  • Cochrane review: The insertion of grommets into the ear drum is a surgical treatment option commonly used to improve hearing in children with bilateral glue ear as this condition results in minimal, if any, hearing disability

In children with bilateral glue that had not resolves after a period of 12 weeks and was associated with a documented hearing loss, the beneficial effect of grommets on hearing ead present at 6 months but diminished thereafeter. Most grommets come out over this time and by then the condition ill have resolves in most children

  • No evidence that grommets help speech and language development but no study has been performed in children with established speech, language, learning or develomental problems Active observation would be an appropriate management strategy for the majority of children with bilateral glue ear as middle ear fluid will resolve spontaneously in most children.

Alex and William

  • Alex and William: Several episodes of infection-->chronic effusion bilaterally William seems to have hearing issues leading to behavioural problems

Alex’s ear problems likely to improve over time. Education regarding nose-­‐blowing, etc. (to help drain middle ear). Should be OK in the long-­‐term. Should be followed up.

  • William has more complicated problem (speech and behaviour). Should be consideredbetter hearing.

41⁄2 Aboriginal girl

  • Severe hearing problem due to bilateral non-­‐suppurative effusions and damaged inner ear bilaterally. Missing out on family life, learning and play.

Key outcomes for surgical intervention.

  • Maximise hearing, minimise further damage to the ear.

Grommets likely to only maintain short-­term improvement. If hard to maintain hygiene in the child’s home environments this might result in re-­‐infection via the grommets. Grommets may not be the best option and does not impact on the existing damage.

Wiki stuff

William and Shana become playmates and while they are playing Williams mother notices that William does not respond to noises and to calling his name like the other children. His mother takes William to audiologist who does a hearing test. The following is William’s hearing test results for one ear (the other is similar):

  • 1a Does William have a problem with his hearing? If so what is the problem?

Yes, He has conductive hearing loss. This audiogram shows a conductive hearing loss in the ear as William can hear at a lower dB with bone conduction compared to air conduction. Conductive hearing losses occur when the outer or middle portions of the ear fail to work properly. Sound is blocked from being transferred to the inner ear at normal intensity. The bone conduction is normal because noise vibrations skip the outer conduction pathway and act directly on the oval window into the inner ear. Common causes of conductive hearing loss are fluid build up in the middle ear (e.g. otitis media), wax blockage in the ear canal, outer ear injury, perforation of the tympanic membrane and congenital disorders such as down syndrome. Children are more likely to have a conductive hearing loss than a sensorineural hearing loss.


  • 1b Should William be referred for surgery for his ear problems?

Students should research the evidence-base for effectiveness of grommets and other forms of treatment for otitis media with effusion. Evidence:

Children treated with grommets spent 32% less time (95% confidence interval [CI] 17% to 48%) with effusion during the first year of follow-up. Treatment with grommets improved hearing levels, especially during the first 6 months. In the randomized controlled trials that studied the effect of grommet insertion alone, the mean hearing levels improved by around 9 dB (95% CI 4 dB to 14 dB) after the first 6 months, and 6 dB (95% CI 3 dB to 9 dB) after 12 months. In the randomized controlled trials that studied the combined effect of grommets and adenoidectomy, the additional effect of the grommets on hearing levels was improvement by 3 to 4 dB (95% CI 2 dB to 5 dB) at 6 months and about 1 to 2 dB (95% CI 0 dB to 3 dB) at 12 months. Ears treated with grommets had an additional risk for tympanosclerosis of 0.33 (95% CI 0.21 to 0.45) 1 to 5 years later. Different trials of early insertion of tympanostomy tubes have shown variable outcomes in terms of language development. One randomized controlled trial in children with OME more than 9 months, hearing loss and disruptions to speech, language, learning, or behavior showed a very marginal effect of grommets on comprehensive language (Burton & Rosenfeld, 2006). Maw et al. (1999) found that surgical intervention for recurrent otitis media had a marginal effect on language development. Rovers et al. (2000) however, found no significant improvement compared to more conservative treatment, but do not rule out the possibility of benefits for individual patients. The Cochrane review found that in children with bilateral glue ear that had not resolved after a period of 12 weeks and was associated with a documented hearing loss, the beneficial effect of grommets on hearing was present at six months but diminished thereafter.


Conclusions:

Insertion of tympanostomy tubes must be decided on a case by case basis. Even where otitis media is the underlying cause of conductive hearing loss, surgical intervention may not be necessary. Otitis media may respond well to antibiotics, or may clear up spontaneously, so surgery should not be the first choice of therapy (Rovers et al., 2000). In a study of the attitudes to surgery of otolaryngologists in Canada, McIsaac et al. (2000) found broad agreement on the below indicators, but a wider variance with other factors such as parental concerns. Commonly agreed indications for tympanostomy tube insertion (McIsaac et al., 2000):

  • Frequent attacks of acute otitis media (>7 episodes in 6 months)
  • Persistent effusion (>3 months per episode)
  • Lack of response to antibiotic therapy after three months
  • Bilateral conductive hearing loss (20 dB or more)


While William’s bilateral hearing loss would make him a potential candidate for surgery (provided the underlying cause of his hearing loss is otitis media) other interventions such as antibiotic therapy, hearing aids, or simply taking a ‘watch and wait’ approach, should be considered. The benefits of grommets in children appear small. The effect of grommets on hearing diminished during the first year. Potentially adverse effects on the tympanic membrane are common after grommet insertion. Therefore, an initial period of watchful waiting seems to be an appropriate management strategy for most children with OME. As no evidence is yet available for the subgroups of children with speech or language delays, behavioral and learning problems, or children with defined clinical syndromes (generally excluded from the primary studies included in this review), the clinician will need to make decisions with respect to treatment for such children based on other evidence and indications of disability related to hearing impairment (Burton & Rosenfeld, 2006).

Old notes

DVD: Rural health – growing strong

  • ATSI have some of the worst levels of health problems in the world
    • Bad health in childhood often leads to health problems later in life
  • Many children have chronic ear diseases
    • Can’t interact, learn, social skills can be affected
  • Anaemia
    • Currently just treat
    • Need progress to prevention
  • Scabies and other skin sores and infections
  • Prevention, increase of living conditions:
    • Household,housing–environment
    • Clean running water
    • Refrigeration
    • Population density
    • Well being individual, family, community
  • Immunisation
    • Pretty good rates
    • Trust exists between health care workers and the local community
  • Growth assessment action team
    • Community capacity allows:
      • Safety nets for not growing kids
      • Proper training
      • Formal assessment of kids biannually
    • Assessment is used to implement programs to specifically target problems
  • Hygiene, children and parents
    • Healthy families = health children = health families (continuing cycle)
      • Need to target both
  • Difficulties in remote communities:
    • Followup, nutrition at home
    • Need to work with community to keep track of children
  • Staff need to be informed of social context and factors
    • Need open-mindedness and respect for social/cultural context
  • Nutrition in communities
    • Extended families–large homes
    • Environmental situation/health
    • Housing, refrigeration
      • limited money
  • Communities have own organisation:
    • Deals with food companies
    • Refrigeration services
  • Ginani childcare centre
    • Offer after and before care school
    • Family and nutrition program
      • In case kids don’t have good food at home
    • Ear program
    • Educational programs and prevention
  • Successful programs like this set up teams and work with the community

Key elements of successful programs

• Framework for tracking and follow up • Training of medical staff in indigenous issues • Immunisations and prevention methods • Working with families – educational programs (also education for indigenous staff) • Provision of food, availability of food • Involved cooperation of several groups and involving the community Health professionals – what can they do • Education about: o Healthyeating o Hygiene • Ensure follow up • Home environment • Sensitivity to issues in the context of indigenous communities Programs targeting otitis media in indigenous children Group 1: Intervention with hygiene • Every day, blow nose, cough a few times and exercise • Objectives was to decrease incidence of OM with hygienic methods in primary school children • People involved: Aboriginal healthcare workers, teachers, assistants, translators – multidisciplinary • Measures to assess effectiveness: audiometry, physiotherapy • Effectiveness – improved respiratory, but no significant improvement in hearing • Sustainability – yes, low cost Group 2: Swimming pools • Objective was to reduce the rates of pyoderma and otitis media by implementing salt water swimming pools in remote indigenous communities. Also, to increase social and community well being • Study targeted children under 17 in 2 remote Aboriginal communities in WA • People involved: government of WA, aboriginal communities, families, paediatricians, ENT specialists, royal life saving association • Study looked at the rates of OM and pyoderma in children before and after pool was opened (4x 6 month intervals) o Pyoderma–severitybasedonnumberoflesionsandseverity o OM–otoscopicexam:colour,positionoftympanicmembrane,wax,perforations,otorrhea • Effectiveness: marked reduction in pyoderma and tympanic membrane perforation • Sustainable, yes: swimming pools are quite cost effective Group 3: Nutrition • 1st journal o ObjectivewastoincreasehealthofAboriginalchildrenbyincreasingtheirintakeoffreshfruitandvitamins o Peopleinvolved:schools,doctors,Aboriginalmedicalservices,teachers o Outcomes–good,40%showedimprovement,allergiesdecreased o Fruitwassubsidised,educationneededathometoensurecontinuationofgoodpractices • 2nd journal o EarnursesinNZ o InvolvedinthetreatmentandidentificationofOMinkids 􏰀 Effective, improve ear health of children o Sustainable,aftertraining,continueworkingforquitealongtime Overall, these studies show that a program in a small community can have a large impact if it is implemented effectively involving the right people, community and providing education, prevention as well as treatment