West Visayas State University – College of Medicine – Batch 2020

Block XX
Module 1
Lecture 4
04/ 10/ 19
Dr.Jenelyn J. Magno, MD, DBPBOHNS

TOPIC OUTLINE Usually, if there’s a congenital hearing loss and theirs

I. Rationale for Hearing Screening is/are presence of risk factors, hearing onset is
II. Review of Anatomy and Physiology delayed
III. Hearing Loss
IV. Hearing Milestones Table 1. Sound/Noise and its corresponding decibels
V. Early Diagnosis Source: Doc Magno ppt
VI. Deafness
VII. Types of Hearing Impairment Sound Decibel (dB)
VIII. Methods of Hearing Screening Tests Soft whisper 20
IX. Basic Audiometric Tests Quiet room 30
X. RA 9709
XI. Management Ordinary speaking voice 50
XII. Treatment Ave. street traffic 60
Review Questions Heavy traffic 70-80
References
Appendices Pneumatic hammer 80-90
LECTURER BOOK REFERENCE OLD TRANS Discomfort for pure tones 90-100
Thunder 120
Aircraft engine 130
I. RATIONALE FOR HEARING SCREENING Air raid siren 140
• Normal hearing critical for speech and oral language
development in first 6 months When you’re in the heavy traffic (≥80 dB) for 8 hours
• Late detection is a critical time for stimulating Auditory per day, it could already cause a noise-induced
pathways to brain hearing centers is lost. hearing loss e.g. traffic aids
• Late detection of Hearing Loss (HL) results in delayed An earmuff could only protect you for only 50 dB
speech & language development, affecting social and II. EARS
emotional and academic achievement and A. ANATOMY OF THE EAR
occupational opportunities
• Early identification and treatment is the only means of
minimizing the consequences of neonatal hearing loss

JOINT COMMITTEE ON INFANT HEARING (JCIH)

2000 POSITION STATEMENT:
• If HL is confirmed, they should receive intervention
before 6 months of age
RA 9709: Universal Newborn Hearing
Screening and Intervention Act of 2009
All patients born in the Philippines are required Figure 1. Anatomy of the External Ear. Doc Magno ppt
to undergo hearing screening before discharge
or as early as 72 hours after birth
• If risk indicators for delayed onset or progressive
hearing loss are present, they should undergo
audiologic and medical monitoring for 3 years
What are the risk factors?
─ Prematurity
─ Enrolment in neonatal ICU
─ Intubation
─ Hyperbilirubinemia
Hearing screening test results are either pass or
refer. You do not put fail because it is just a
screening
Even if it’s a pass but there is/are presence of risk Figure 2. Coronal section of the ear. Doc Magno ppt
factors, you still have to test the patient every year for
3 years

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MD 3 Perez, Perualila, Pontica

Figure 3. Anatomy of Inner Ear. Doc Magno ppt
B. PHYSIOLOGY
• The ear is an organ of hearing and balance
Due to presence of semicircular canal connected
to cochlea
• Hearing is essential to understanding
• Speech cannot develop without hearing
III. HEARING LOSS
• Perhaps the most affected age group with hearing loss
is the pediatric group. Hearing loss in these groups
have several very important effects on their
development.
• Hearing Impairment is the single most common
condition affecting newborns
1-3 per 1000 in well-baby
2-4 per 100 in the NICU
Why single most? Because most of diseases
involved in newborn screening (hypothyroidism &
galactosemia) have prevalence less than 1%
compared to hearing loss which is 12%.
TWO IMPORTANT ASPECTS OF A CHILD’S LIFE
ARE AFFECTED
Speech
• Severity depends on the period during which the insult
occurred
• Prelingual:
Before the age of 2 when the child cannot make
complete sentences yet
Usually patients with congenital hearing problem
• Postlingual:
After being able to talk
Patients with complete vocabulary and then
hearing loss sets in
E.g. Presbycusis (secondary sensorineural hearing
loss due to old age)
Mental Ability
• 51% of deaf children have lower average IQ scores
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IV. HEARING MILESTONES
A. BIRTH – 3 MONTHS
• Reacts to loud sounds with startle reflex
• Is soothed and quieted by soft sounds
• Turns head to you when you speak
• Is awakened by loud voices and sounds
• Smiles in response to voices when spoken to
• Seems to know your voice and quiets down if crying
B. 3 – 6 MONTHS
• looks or turns toward a new sound
• Responds to "no" and changes in tone of voice
• Imitates his/her own voice
• Enjoys rattles and other toys that make sounds
• Begins to repeat sounds (such as ooh, aah, and ba-ba)
• Becomes scared by a loud voice or noise
C. 6 – 10 MONTHS
• Responds to his/her own name, telephone ringing,
someone's voice, even when not loud
• Knows words for common things (cup, shoe) and
sayings (bye-bye)
• Makes babbling sounds, even when alone
• Starts to respond to requests such as "come here"
• Looks at things or pictures when someone talks about
them
D. 10 – 15 MONTHS
• Plays with own voice, enjoying the sound and feel of it
• Points to or looks at familiar objects or people when
asked to do so
• Imitates simple words and sounds; may use a few
single words meaningfully
• Enjoys games like peek-a-boo and pat-a-cake
• Follows one step commands when shown by a gesture
E. 15 – 18 MONTHS
• Follows simple directions, such as "give me the ball"
without being shown
• Uses words he/she has learned often
• Uses 2 to 3 word sentences to talk about and ask for
things
• Knows 10 to 20 words
• Points to some body parts when asked
F. 18 – 24 MONTHS
• Understands simple "yes-no" questions (Are you
hungry?)
• Understands simple phrases (in the cup; on the table)
• Enjoys being read to
• Points to pictures when asked
G. 24 – 36 MONTHS
• Understands "not now" and "no more"
• Chooses things by size (big, little)
• Follows two step commands, such as "get your shoes
and come here"
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• Understands many action words (run, jump)
Remember: There’s no such thing as delay in hearing
because at 4 months intrauterine, the cochlea is
already adult size. So there’s no excuse that they
could not hear at birth. That’s why pregnant women
are encouraged to talk to their baby because they
could already react to sounds.
V. EARLY DIAGNOSIS: AT RISK BABIES
PRENATAL
• Family history of deafness
• Rubella and other viral infections in early pregnancy
First trimester is when your cochlea is developing
Rubella is the most common culprit
• Hyperemesis
• Threatened abortion
• Severe illness necessitating chemotheraphy or major
surgery (particularly under GA) occuring in early
months of pregnancy
• Toxemia later in pregnancy
• Presence of other congenital anomalies
• Low APGAR score
• Severe jaundice at birth
• Maternal illness during pregnancy, e.g., Rubella
• Hydrocephalus
Hydrocephalus causes ear damage due to the
toxicity of the water, increased ICP and eventually
the increased pressure in cochlea. The first to
rupture inside the cochlea is the innermost spiral
which is responsible for low frequency (vowel)
sounds.
***End of Supplementary Notes***
TAKE NOTE
• A child who has not uttered a recognizable word by the
age of 16 months should receive prompt
investigation.
VI. DEAFNESS
• Deafness means any patient with a detectable
impairment of hearing

PERINATAL CAUSES OF DEAFNESS

• Prolonged or difficult labor CONGENITAL
• Premature birth • Genetic
• Anoxia • Intrauterine
• Neonatal jaundice • Perinatal
• Convulsions
• Cerebral palsy ACQUIRED
• Noise-induced
POSTNATAL • Disease: infections/tumors
• Meningitis or encephalitis • Drug-induced
• URTI Medications for TB and malaria are ototoxic
Due to antibiotics medications • Trauma
• Acute infections such as mumps, measles and otitis • Age (presbycusis)
media
Table 2. Ototoxic Drugs and Toxins. Source: Adeos notes
SYMPTOMATIC BABIES
• Mother’s suspicion that the child is deaf
• Inattention to sound
• Delayed development of speech

***Supplementary Notes***
RISK FACTORS FOR HEARING LOSS IN CHILDREN
• Speech delay
• Frequent or recurrent ear infections
• Family history of hearing loss
• Syndromes known to be associated with hearing loss
• Infectious diseases that cause hearing loss
• Medical treatments that may have hearing loss as a
side effect
• Poor school performance

INDICATIONS FOR HEARING ASSESSMENT IN

INFANTS
• Low birth weight (<2 lbs) and/or prematurity
• Assisted ventilation for more than 10 days after birth
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 Most common cause is congenital, and in
congenital deafness, the outer hair cells are
commonly affected
• Using signal averaging techniques, the AudioPath
separates the third tone from all other sounds within
the ear canal and displays the data on graphical
display
This is very soft and very small
Any sizes of ear canal can fit the tips
Made up of rubber
VII. TYPES OF HEARING IMPAIRMENT Eliminates sounds that goes into the cochlea
CONDUCTIVE They will put a probe which will emit sounds
• Results from an abnormality of the outer or middle which will go to your cochlea
ear/usually temporary and treatable with medications For a healthy cochlea, it will emit sound back
or surgery to the machine and this results to a “pass”
Otitis externa/media hearing test
Tympanic Membrane Perforation If there are problems in cochlea, sounds are
Cholesteatoma not bounced back, therefore there is no
Otosclerosis reaction and would result to a “refer”
Impacted cerumen
Collapsed ear canal

B. SENSORINUEURAL
• Nerve damage generally no medication or surgical help
available/ amplification needed
Presbycusis
Congenital problems (syndromes)
Birth related diseases
Noise-induced
Drug-induced
• Abnormal bone and air conduction with a difference of
<10 dB
C. MIXED HEARING LOSS (MHL)
• Involves the external, middle, and inner ear
• E.g. Complicated otitis media (with perforated ear
drum) in which there are discharges that block the
external ear. It is a chronic condition that involves
already the bones and nerves of the middle ear. A
perforated ear drum decreases hearing by 15 dB.
There is erosion of bone so eventually damage nerve.
• Abnormal bone and air conduction with a difference of
>10 dB
VIII. METHODS OF HEARING SCREENING TESTS
• Neonatal Hearing Screening
• Behavioral audiometry
• Checking the hearing milestones of the child
A. NEONATAL HEARING SCREENING
1. OTOACOUSTIC EMISSION (OAE)
• Sounds generated by the cochlea that can be
measured in the external auditory canal
• Produced by the motile activity of the outer hair cells
Figure 4. OtoAcoustic Emission. Doc Magno ppt
Evoked OAEs (EOAEs) is in Pediatric Audiology.
Among the potential pediatric applications are:
Screening for hearing impairment in neonates and
infants
Separating peripheral hearing loss and central
auditory dysfunction in infants and young children,
particularly those with multiple disabilities, and
Monitoring cochlear status in infants and young
children receiving ototoxic drugs such as
aminoglycosides, loop diuretics, or antineoplastic
drugs.
Baseline OAE prior to enrolment to TB-DOTS clinic.
Monthly monitoring of patients taking anti-TB
medications which is due to the drugs rifampicin and
ethambutol.
OAE tests elicit no response if hearing is worse than
30-40 dB, no matter what the cause; children who fail
OAE tests undergo an ABR for a more definitive
evaluation.
Results: pass/refer
2-second procedure; no need to sedate baby

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Device Options for OAE Screening
• Types:
Handheld
Portable Screening Devices
PC-based hybrids
PC-based clinical systems
Figure 5. OAE wave form
OAE wave form (figure 5) is usually what you see
during the screening
There is a sound and reaction, so this is normal
Left: noise level offered by the machine
Right - response; should be higher than your
stimulus
Before doing the OAE, do OTOSCOPY first
Figure 6. Failed OAE
Failed OAE has sound but no reaction
2. AUDITORY BRAINSTEM RESPONSE OR
BRAINSTEM EVOKED AUDITORY RESPONSE
(BERA/BAER)
• A computerized hearing test used to measure the
brain waves the ear produces when it hears sound
Measures integrity of auditory nerve
what is cause of deafness
You test CN VIII
If you have an inner ear tumor, it is usually along
the auditory nerve so there is a flat line in the result
Painless because this is just like the ECG. May
ginatapik ka lg sa forehead and sa mastoid (refer
to figure 7)
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Then you insert a probe in the ear canal for
stimulus
• Indicated when complete results cannot be obtained by
routine audiometry like the OAE
• Can detect any nerve defect or neural dysfunction.
Tracing results are shown for each specific site in the
auditory pathway. A flat tracing in wave III, for
example, indicates a problem in the cochlear nucleus.
It will just give a result of pass or refer
It is not failed but REFER because it is only for
screening
Used when referred from OAE
When the result is failed again in this test, use the
Auditory Steady State Response Audiometry (ASSR)
or hearing test for babies ; while for adult it's
audiometry
Figure 7. BERA. Source: Doc Magno ppt
• Neural generators:
I: Distal part of CN VIII
II: Proximal part
III: Cochlear nucleus
IV: Cochlear nucleus, superior
V: Olivary complex, lateral lemniscus
• These waves correspond to the part of the different
parts of your brain where your CN VIII pass through
Wave 1: distal end of CN VIII
Wave 3: lower brain stem
Wave 5: upper brain stem
• When there's no ASSR in the locality, use ABR to
quantify the hearing of the baby (but only on the high
frequency from 2000 to 4000 Hz), it can't cover low
frequency
• Tip: low frequencies (vowels A, E, I)
• Base: high frequencies (th, c, s)
• ABR is recorded as 5-7 waves. Wave I, III and V can
be consistently obtained in all age groups; waves II
and IV appear less consistently
• Confirm hearing loss in young children, obtain ear-
specific information and test children who cannot
cooperate with behavioral test methods
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• Stimulus with very rapid onset such as clicks or tone
bursts must be used
• Click stimuli correlate best with higher frequencies
(1000-4000 Hz); low frequencies require different
stimuli (tone bursts or filtered clicks)
• Not affected by sedation or general anesthesia
• 4 months to 4 years of age are routinely sedated to
minimize clinical interference caused by muscle activity
• This is also useful in adults in the localization of brain
tumors. In schwannoma, a slow growing (1 mm/year),
miniscule tumor, hearing loss is also gradual. There is
flattening of the tracing in wave III which indicates that
the lesion is near the cochlear nucleus. MRI is the
adjunct test; CT scan will not help.
Figure 8. Evoked response audiometry. The response evoked by a
sound stimulus can be recorded at a specific site along the auditory
pathway e.g., eighth nerve, brain stem or the cortex.
ABR Advantages
• A useful diagnostic tool for measuring high frequency
hearing when more conventional hearing tests cannot
be used
• Unaffected by the use of anesthesia (one exception is
enflurane which increase IPLs) or sedation, or whether
the patient is asleep or attentive
• Indirectly estimates the level of hearing in the
peripheral auditory system
• Does not rely on any form of subjective response from
the individual being tested
Normal
• All latencies within normal limits (WNL)
• Good morphology
Conductive Hearing Loss
• Wave I latency markedly delayed
• Interwave latencies WNL
• Good morphology
Sensory Hearing Loss
• Wave I latency slightly delayed
• Wave I small or absent
• Interwave latencies WNL
• Poor morphology
Neural Hearing Loss
• Wave I normal
• Wave I-III latency delayed
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• Interwave latencies delayed
Poor morphology
• If prolonged meaning there's conductive hearing loss,
you do otoscopy for it might have an impacted
cerumen or serous otitis media
• Flattened wave 1 and 3:
Sensory hearing loss with poor morphology
• With neural hearing loss, consider tumor and do MRI
B. BEHAVIORAL OBSERVATION AUDIOMETRY
This is done in children 2-5 years old, who can hold
their head and neck
• Some expected behavioral responses
Startle reflex
Auropalpebral reflex/Eye-blink reflex
Eye movements
Head movements
Requires 2 clinicians; one distracts and observes,
the other presents the stimulus
Makes use of toys, noisemakers, or phonemes
representative of different frequencies maybe used
The child is placed in a sound-proof audio booth.
Patient wears an earphone, stimulus is introduced
and behavior, limited to unconditioned reflexive
responses to complex (not frequency-specific) test
sounds, is observed. For example, 1 clinician plays
with a rattle (distraction) and another introduces a
beeping sound (stimulus). Behaviors like blinking or
crying are noted.
VISUAL RESPONSE ORIENTATION AUDIOMETRY
(VROA)/VISUAL REINFORCEMENT OBSERVATION
AUDIOMETRY
Some observable responses
• Head turns towards the sound
• Head turn toward visual reinforcer
• Change in facial expression
• Cry
• Vocalizes response
This is a form of conditioning in which if you put a
stimulus on the right ear, there's a corresponding
puppet that will light. If the child hears the sound on
the right once again, he will turn his head expecting
the puppet to light even though it is not there
anymore, this means he can hear the sound
• In the first stage, the audiologist positions the infant so
that it is looking straight forward. Next, a sound will be
made on one side of the child and the audiologist
checks to see if the child turns to the direction of the
noise. This indicates that the child has heard the
sound.
• This is repeated as the sound gets softer. To ensure
that the child makes an effort for the quieter sounds,
the child is rewarded with a puppet show for each
successful head turn.
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• The child is placed in a sound-proof audio booth with a
box in front of him or her with earphones worn over the
ears. When a stimulus is elicited in the left ear, a bright
light illuminates a moving toy in a box in the left. The
same is true when there is stimulus in the right ear.
This is a form of conditioning in the patient such that
whenever sound is heard in the left or right ear, the
child turns towards the corresponding side. The child
must be capable of moving the head, thus, this is not
done in newborns.
PLAY AUDIOMETRY
• Used in testing children 2-5 years old
• Child is conditioned to respond by accomplishing a task
which is usually a form of play.
• This is also conditioning but at times this is not reliable
so you have to condition the baby, make sure he is full
and attentive and use loud sounds that child will
identify
• The child is placed in a sound-proof audio booth with a
ball in front of him or her and earphones worn over the
ears. When a stimulus is elicited in the left ear, the
child is asked to shoot the ball (or perform other
C. CHECKING THE HEARING MILESTONES OF THE
CHILD
IX. BASIC AUDIOMETRIC TESTS
TUNING FORK
• 512 Hz steel tuning fork
Best all-purpose TF
• ↓ frequency: felt rather than heard
• ↑ frequency: attenuates readily
Figure 9. Parts of a tuning fork
• The higher the frequency, the higher the pitch.
• Should not be struck too hard; overtones give false
information. Strike the palm of the hands when
performing tuning fork tests.
• Should not touch the ear. Broad side of the prongs
must face the ear.
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AIR CONDUCTION USING THE TF:
• Measures the ability of airborne sound waves to be
transmitted to the inner ear along the external canal,
eardrum and ossicular chain
TESTS USING THE TUNING FORK:
• Weber Test
• Rinne Test
• Schwabach Test
• Bing Test
Weber Test
• Test of lateralization
• Extends the familiar experience of hearing one’s own
voice louder when an ear is blocked. The stem of the
vibrating fork is held to the midline of the forehead, and
the patient is asked to report whether the sound is
heard in the left, right, or both ears.
• The patient perceives the sound of the fork in the ear
with better bone conductance or greater conductive
component.
• Normal hearing: midline
• Unilateral conductive hearing loss: poorer ear
• Unilateral sensorineural hearing loss: better ear
If the tone is heard in the reportedly poorer ear, a
conductive hearing loss should be suspected in
that ear.
If patient hears better in the better ear, a
sensorineural loss is suspected for the poorer
ear.
• The Weber test is most useful in instances of unilateral
impairment, but ambiguity may develop when one ear
has both conductive and sensorineural (combined)
involvement, or when a tuning fork of only one
frequency is available.
• Use the Weber test only in conjunction with other tests
and should not be interpreted the test by itself.
Figure 10. Algorithm after performing Weber test.
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Rinne Test

Figure 11. Rinne’s test procedure

• Compares air and bone conduction hearing

• Compares the patient’s hearing by bone conduction
against that by air conduction. The hilt of the vibrating
fork is held against the patient’s mastoid (bone
conduction) until sound is no longer heard; the tines
are then placed close to the same ear (air conduction).
• Results are explained by an impedance mismatch.
• Normal: louder by air (positive Rinne Test)
• Unilateral conductive hearing loss: louder by bone
(negative Rinne Test)
• Unilateral sensorineural hearing loss: louder by air
(positive Rinne test)
Positive Rinne (AC>BC): The normal ear will
resume hearing the fork by air conduction.
Negative Rinne (AC<BC): The patient cannot
resume hearing by air conduction after the fork is
no longer audible by bone conduction.
Figure 13. Classification of sensorineural and conductive hearing loss
with the tuning fork tests. A normal result (symmetrical Weber and
positive Rinne) is not substantially different from the result in patients
with bilateral sensorineural hearing loss.
Schwabach Test
• Mastoid to mastoid
• Compares the patient’s bone conduction to that of the
examiner’s.
• While the stem of the vibrating fork is held against the
mastoid, the patient reports when the sound becomes
inaudible. At that moment, the examiner applies the
fork stem to his own mastoid and measures the time
(in seconds) the examiner can still perceive the sound.
• Normal Schwabach: patient = examiner
• Prolonged Schwabach: patient > examiner; conductive
hearing impairment
• Diminished Schwabach: patient < examiner;
sensorineural hearing impairment

Table 4. Interpreting the Schwabach test

SCHWABACH HEARING
LOCUS
TEST RESULT STATUS
Normal Normal None
Prolonged Conductive loss External and/or
(prolonged for middle ear
patient; shorter
Figure 12. Principle in Rinne test.
for examiner)
Diminished Sensorineural Cochlear and/or
Table 3. Interpreting the Rinne test results
(shorter for loss retrocochlear
RINNE TEST HEARING
LOCUS patient;
RESULT STATUS
prolonged for
Positive AC≥BC Normal or None or
examiner)
sensorineural cochlear-
impairment retrocochlear
Bing Test
Negative Conductive External or
• An application of the so-called occlusion effect, in
AC<BC impairment middle ears
which the fork is heard louder as the normal ear is
occluded.

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• If the auditory meatus is alternately occluded and left Table 5. PTA Test Results
open, as the vibrating fork is held to the mastoid, an AIR BONE
RESULT
increase and decrease in loudness will be perceived by CONDUCTION CONDUCTION
the normal ear. Normal hearing <25 dB <25 dB
• A similar result will occur with sensorineural hearing Conductive >25 dB <25 dB
impairment, but the patient in whom the conductive Hearing Loss
mechanism is already modified, as in OM or Sensorineural >25 dB >25 dB
otosclerosis, should not notice any loudness changes. Hearing Loss
• Positive Bing: (+) changes in loudness Mixed Hearing >25 dB >25 dB
• Negative Bing: (-) changes in loudness Loss

LIMITATIONS OF THE TUNING FORK TESTS: Examples of PTA results

• Rough approximation of hearing
• Sound may be transmitted to the opposite ear (cross-
over)

PURE TONE AUDIOMETRY (PTA)

• Audiometry provides the fundamental description of
hearing sensitivity.
• Air-conducted signals are presented through
earphones (or loudspeakers)
• Same test sounds can be delivered to the ear through
an oscillator that is placed on the head, usually the
mastoid.
Figure 14. The “speech banana” that contains within it the
Such signals are considered bone conducted frequencies associated with speech. From 250-500 Hz are the low
because the bones of the skull transmit vibrations frequency vowel sounds while >2000 Hz are the high frequency
sounds: th, ch, p, s, t
as sound energy directly to the inner ear,
essentially bypassing the outer and middle ears.
• Beyond the speech level, you can hear the word but
• In a normal ear, and also in children with SNHL, the air
cannot understand
and bone-conduction thresholds are the same.
• In those with CHL, the air- and bone-conduction
thresholds differ and this is called the air–bone gap.
• Pure Tone average – average of air conduction
thresholds at 500, 1000, and 2000 Hz.
• X-axis – stimulus frequency (Hz). Frequency tested
area at octave intervals between 250 and 8000 Hz.
250-500 Hz low frequency vowel sounds
>2000 Hz high frequency, th, ch, p, s, t
• Y-axis – threshold of sound intensity that can be heard
by the patient 50% of the time (dB).
From 0 -120 dB
• The pure tone audiometer is an electronic device which Figure 15. In mild HL, the audiometry shows a line that intersects the
produces sounds that are relatively free of noise or speech banana which indicates that there is difficulty hearing sounds
with ranges of frequency above the line.
sound energy in overtones, hence “pure” tones.

3 ESSENTIAL PARTS:
• Variable frequency oscillator:
To produce sounds
• Attenuator
To permit variations of intensity
• Transducer (earphones or speaker)
To convert electrical to acoustic energy

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 Figure 16. In severe HL, frequencies above the line are not easily
heard thus, only unintelligible sounds are registered. Hearing is below
the speech level. At <60 dB no speech sounds are heard.
Figure 19. Conductive HL: Bone conduction remains normal while
there is a downward shift of air conduction. Example: impacted
cerumen

• Medical treatment for mild conductive HL secondary to

impacted cerumen or effusion is by decongestion.

Figure 17. Audiogram exhibiting profound hearing loss.

Figure 20. Sensorineural HL: both bone conduction and air conduction
show a downward shift but the difference is <10dB. Example:
Presbycusis: slowly sloping in the high frequency range; Noise-
induced HL: If there is an upward shift at 4096 Hz.

• If after cleaning of the ear, HL persists, consider

prescribing a hearing aid which is indicated for a mild
sensorineural HL.

Figure 18. Both air conduction and bone conduction are adjacent to
each other and found at the level of 0-20 dB.

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Figure 21. Mixed HL: Both bone conduction and air conduction show a
downward shift but the difference is >10 dB. Example: Presbycusis
with middle ear pathology: stiff eardrum and ossicles brings about
conductive HL while damage in the base of the cochlea responsible for
high frequency sounds brings about sensorineural HL; Perilymphatic
fistula

Figure 24. Classification of hearing impairment in relation to handicap

for speech recognition. Normal 0-20 dB or 0-25 dB depending on the
parameter

• Get the average of the following frequencies: 500,

1000 and 2000 Hz because these frequencies are
involved in speech.

X. CLINICAL CLASSIFICATIONS OF HEARING

NORMAL (0-20 DB)
• Can hear spoken voice at distance of 18 feet
Figure 22. Meniere’s disease: there is downward shift in the low • No loss of hearing exceeding 20 dB
frequency. “High blood pressure in the ear” affecting the cochlea, a
cone-shaped structure where the base is responsible for the high
MILD HEARING LOSS
frequency sounds while the apex is for low frequency sounds. With
increasing pressure, the tip of the cochlea is first filled with fluid, owing • Cannot hear beyond a distance of 12 feet
to its small surface area. Thus, the apex or tip of the cochlea is the first • A loss between 20-40 dB
to rupture and low frequency sounds are first to be affected. It may
show a waxing and waning pattern.

Figure 25. PTA of mild hearing loss

MODERATE HEARING LOSS

• Cannot hear beyond 3 feet
• Loss of up to 60 dB

Figure 23. Serial audiograms of the left ear, illustrating the effect of
long term noise damage. Notice that the earliest frequency affected is
4 kHz. The low tones are reasonable well maintained but eventually all
frequencies are affected. The patient was a boiler worker.

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Figure 26. PTA of moderate hearing loss
SEVERE HEARING LOSS
• Cannot hear conversational voice but is able to
understand spoken voice if amplified
• A loss of 60-80 dB
Figure 27. PTA of severe hearing loss
PROFOUND HEARING LOSS
• Unable to hear spoken/loud sounds but maybe
improved by amplification (cochlear implant)
• Loss of >80 dB
Figure 28. PTA of profound hearing loss
TOTAL HEARING LOSS
• Unable to hear spoken voice despite maximum
amplification
XI. RA 9709
• An act establishing a universal newborn hearing
screening program for the prevention, early diagnosis
and intervention of hearing loss
• All infants born in hospitals in the Philippines shall be
made to undergo newborn hearing loss screening
before discharge, unless the parents or legal guardians
of the newborn object to the screening subject to
Section 7 of this Act.
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Block XX: Hearing Loss in Infants and Children
MD 3
• Infants who are not born in hospitals should be
screened within the first three (3) months after
birth.
• Within 2 days or before hospital discharge
• In the event of a positive newborn hearing loss
screening result, the newborn shall undergo audiologic
diagnostic evaluation in a timely manner to allow
appropriate follow-up, recall and referral for
intervention before the age of six (6) months:
provided, that audiologic diagnostic evaluation shall be
performed by Newborn Hearing Screening Centers
duly certified by the DOH.
• Approved: August 12, 2009
XII. MANAGEMENT
• Take note: a child who has not uttered a recognizable
word by the age of 16 months should receive prompt
investigation.
• Treat ear infection
• Total communication: Sign Language
• Hearing aids
Provides 30 dB
For example if you have a hearing loss of 80 dB,
subtract 30 dB from the hearing aid, you now have
50 dB hearing or average, you can already hear
words if you are an adult
If you have 100 dB hearing loss with hearing aid,
you now have 70 dB hearing which is still below
the speech level; doc doesn't advise to have a
hearing aid especially with the elderly
Not all hearing loss can benefit from hearing aids
For pre-lingula pediatric patients, doc advises
hearing aid starting from mild hearing loss
They give hearing aid as early as 1 month if with
profound hearing loss
Hearing aid will stimulate the nerve to work as
early as 6 months, hearing will then improve
• Cochlear implants:
Mechanism:
─ Sounds picked up by microphone
─ Speech Processor codes it into a signal of
electrical impulses
─ Signal sent to headpiece
─ Signal transmitted across skin to implant
─ Implant sends signal to electrodes in the
cochlea
─ Auditory nerve picks up signal and sends it to
the brain
─ Brain recognizes this signal as sound
If you have a profound hearing loss and by using a
cochlear implant you'll improve to mild hearing loss
• Therapy: you have to teach the child to speak
especially after you put the hearing aid at 2 years old
• The child can already hear intrauterine and the cochlea
is already adult size at 4 months
12 of 15
 These implants bypass injury to the organ of Corti
and provide neural stimulation by way of an external
microphone and a signal processor that digitizes
auditory stimuli into digital radiofrequency impulses.
Serious complication is an excessively high incidence
of pneumococcal meningitis, hence, PCV is
recommended.
Brainstem implant is used if no nerve is functional.

XIII. TREATMENT
• Parental Guidance:
Deaf children are not handicapped
Deaf children can live normal lives
Maximum stimulation and parental cooperation is
needed
• Other types of communication aids especially in
Figure 29. A selection of hearing aids. The patient’s hearing loss, severely deaf prelingual types:
manual dexterity and vanity will determine the precise aid that is Sign language
recommended.
Hand writing
Lip reading
Texting

REVIEW QUESTIONS
1. Lani decided to bring her Lolo Stephen in the
mall. As they are about to leave the house, she
noticed that Stephen has no shoes and asked him
where are his “sapatos”. Due to old age, Lolo
stephen heard “sapatos” as “tawo” so he ignored
his granddaughter’s question. Lolo Stephen is
suffering from what kind hearing loss?
a. Ossicular Discontinuity
b. Presbycusis
c. Otitis Media
d. Head trauma
Figure 30. Osseointegrated aid or bone-anchored hearing aid. This
avoids many of the problems of traditional aids.
2. At 10-15 months, a child is expected to achieve
this hearing milestone.
a. Knows words for common things (cup, shoe)
and sayings (bye-bye)
b. Understands "not now" and "no more"
c. Enjoys games like peek-a-boo and pat-a-cake
d. Begins to repeat sounds (such as ooh, aah, and
ba-ba)

3. True or False. A child who has not uttered a

recognizable word by the age of 10 months should
receive prompt investigation.

Figure 31. Cochlear implantation. The device is employed to stimulate

any residual cochlear nerve fibers via the electrode implanted in the
scala tympani of the cochlea. It converts electrical signals to chemical
signals.

CCetC
Block XX: Hearing Loss in Infants and Children 13 of 15
MD 3
4. Best describes Weber test: • Management pearls: surgery is usually done after
a. If the tone is heard in the reportedly poorer ear, adolescence when external ear is already fully
a conductive hearing loss should be suspected developed. If still developing, defer the surgery
in that ear. because it will halt the normal growth of the external
b. If the tone is heard better in the better ear, a ear.
conductive is suspected for the poorer ear. • Do CT scan before surgery to make sure that there is
c. If the tone is heard in the reportedly poorer ear, no inner ear involvement. Note that congenital
a sensoneural hearing loss should be suspected
anomalies of the outer ear may be accompanied by
in that ear.
other problems in the middle and inner ear.
d. Normal position of the TF may be at the lateral
of the midline
Congenital stapes fixation
5. Loss of hearing up to 60 dB: • hardening and fixation causing the so-called “frozen
a. Mild eardrum”
b. Moderate • Congenital malleus fixation
c. Severe • Primary cholesteatoma
d. Profound abnormal skin growth in the middle ear behind the
eardrum
B, C, False, A, B ACQUIRED CONDUCTIVE HEARING LOSS
Obstruction of external ear canal
REFERENCES • The most common cause is cerumen
• Upclass notes
• Doctor’s lecture Ear drum perforation
• causes 15 dB HL.
SUPPLEMENTARY NOTES • ear drum repair is possible and it can spontaneously
heal by keeping the ear dry post-treatment even with
AUDIOLOGY central perforation
• Audiology, which is the science of hearing, involves the
• for instance, appraise the patient to avoid swimming for
evaluation of hearing and the rehabilitation of
2 months and place ear plugs or cotton moistened with
individuals with communication problems related to
baby oil on the ear during bathing
hearing impairment.
Otitis media
GOALS OF AUDIOLOGIC EXAMINATION • In recurrent or chronic otitis media, there is a tendency
• Detect a hearing disorder for the edges of the perforation to be hardened and
• Classify a hearing disorder remain unfused. This is an indication for
• Quantify a hearing disorder tympanoplasty.
Tympanoplasty is a microsurgical reconstructive
TYPES OF HEARING EVALUATION
procedure that seals the tympanic cavity from the
• Tuning Fork tests
external ear canal and restores a largely physiologic
• Pure Tone Audiometry
mechanism of sound transmission. It consists of
• Speech Audiometry
reconstructuring the tympanic membranes
• Special tests
(myringoplasty) and the ossicular chain
• Pediatric Audiometry
(ossiculoplasty). The most commonly used graft
CAUSES OF HEARING LOSS materials for myringoplasty are temporalis fascia,
CONGENITAL CONDUCTIVE HEARING LOSS perichondrium from the auricle (tragus or concha) or
Atresia of external canal thin cartilage slices. It has 80% success rate of graft
• The outer ear is 2/3 cartilage and 1/3 bone. The healing. Meanwhile, the ossicular chain can be
cartilaginous portion is the one that commonly fuses. It reconstructed with endogenous material, allograft
causes conductive hearing loss. material or synthetic implants from metals (gold,
• Recall that the inner ear develops in the first trimester titanium), plastic or ceramic.
while the outer ear develops in the second or third
trimester. In other words, the inner ear is fully Ossicular discontinuity
• Trauma
developed in the first trimester and adult size at birth.
• Infection
The cochlea serves as the organ of hearing. Appraise
The ossicles, the smallest bone in the body, are
the patient that the patient has an intact hearing organ;
easily damaged by infection causing a HL of >20-
only that that there is narrowing of the ear canals.
25 dB.
CCetC
Block XX: Hearing Loss in Infants and Children 14 of 15
MD 3
• Cholesteatoma
Head trauma
Dead skin erodes, occupies and blocks the middle
• Longitudinal or transverse fracture, damaging the
ear, thus, there is conductive HL.
nerves
HEREDITARY DEAFNESS Drug toxicity
• Defect of cochlear development secondary to a genetic • sensorineural HL
defect.
Sudden sensorineural hearing loss
NONHEREDITARY CONGENITAL DEAFNESS • 25 to 40-year-old young professionals who complain
• Caused by: sudden HL that involves both ears. It may be caused
Viral infection: by rupture of vessels, viral infection like German
─ German measles measles, autoimmune disease or idiopathic
Most common cause of congenital deafness • Management: steroids
Birth trauma
Kernicterus Perilymphatic leak
─ Kernicterus is a bilirubin-induced brain • secondary to trauma; accompanied by dizziness,
dysfunction. Recall that the anatomy (Fig. 18 in vertigo and hearing loss
appendix) of the inner ear consists of the organ
Table 6. Stages of hearing development
of Corti inside the cochlea which has inner and
Age Characteristics
outer hair cells containing cilia. These cilia are
0-4 mos Awakens to loud noise
adjacent to the tectorial membrane so that
Exhibit startle reflex to loud sound
sound is conducted from the tectorial
Cries with loud noise
membrane to the cilia to the outer hair cells
5-7 mos Turns to sound
where the auditory nerve connects. With
Follows sound or voices
hyperbilirubinemia, the tips of these cilia are
damaged, losing the connections that transmit 8-10 mos Makes noise in response to noise/voices
sound. 11-14 mos Mimics sound
Drug toxicity – quinine, antibiotics Makes variety of sounds
─ The same pathophysiological mechanisms Responds to voices
occur but usually both ears are affected 15-24 mos Vocabulary starts to develop
Congenital syphilis Voice has inflection
─ This is classified as delayed hearing loss which
means, hearing loss does not occur at birth but
later in life usually from 30 to 35 years of age

NONHEREDITARY ACQUIRED SENSORINEURAL

HEARING LOSS
Presbycusis
• hearing loss due to ageing
• usually involves high frequency sounds. The high
frequencies are found outside (in the base), making it
prone to damage, while low frequencies is found inside
(in the tip), giving it some sort of protection.
• Low frequency: vowel sounds like a,e,i,o,u
• High frequency: th, ch, p, t, s
• For instance, if you say to an elderly with presbycusis
the word “sapatos,” it will be interpreted as “bao,”
“tawo” or “awo.” That is why, we tend to increase the
intensity of our voice but it is actually the quality of
words that is affected.

Occupational or Noise-induced hearing loss

• Damage is more than 80 dB for >8 hours exposure.
The sound level meter of a boiler is about 100-120 dB.
Temporary at first but with prolonged exposure, it may
become permanent hearing loss.
CCetC
Block XX: Hearing Loss in Infants and Children 15 of 15
MD 3