MINIMAL, PROGRESSIVE, AND FLUCTUATING HEARING LOSSES IN CHILDREN: Characteristics, Identification, and Management

doi:10.1016/S0031-3955(05)70081-X

Pediatric Clinics of North America

Volume 46, Issue 1, 1 February 1999, Pages 65-78

https://doi.org/10.1016/S0031-3955(05)70081-X Get rights and content

It has long been recognized that children with persistent moderate to profound hearing impairment of early onset experience a variety of communicative, academic, psychosocial, and emotional difficulties.7, 21, 25 Even some children with significant unilateral sensorineural hearing loss (SNHL) (> 40 dB) exhibit problems in learning and difficulties with speech understanding in noisy situations.⁹ Also, significant costs are associated with early childhood hearing impairments. The estimated lifetime cost of childhood hearing loss exceeds $1 million for each affected child. Other less obvious costs include family tension, breakdowns in family communication, and social isolation.8, 20, 47

In contrast to the moderate to profound hearing losses, limited information exists on children with minimal, progressive, and fluctuating types of hearing impairments. In recent years, however, we have witnessed an increasing amount of published research on these rather unique populations of children. Because pediatricians are often the first to encounter children with hearing loss, it is important for them to develop some familiarity with the clinical characteristics of minimal, progressive, and fluctuating hearing losses in children. To this end, current clinical data on children with these types of hearing impairment are presented. For the purpose of this report, minimal hearing loss includes both conductive and sensorineural hearing losses; emphasis is placed on clinical characteristics, appropriate identification in pediatric practice settings, and recommended management.

Section snippets

MINIMAL CONDUCTIVE HEARING LOSS

Conductive hearing loss typically is characterized by air conduction thresholds through the mid-frequency range (0.5, 1.0, 2.0 kHz) of 25 to 30 dB hearing level (HL). Bone conduction values are relatively normal through this same frequency region producing an air-bone gap of approximately 25 dB HL. The degree of hearing loss varies and ranges from normal sensitivity to levels as great as 55 dB HL. Although many causes of conductive hearing loss in children exist, including middle ear anomalies

MINIMAL SENSORINEURAL HEARING LOSS

Since 1985, numerous clinical reports and essays have addressed the potential educational and psychosocial problems associated with minimal SNHL. Minimal SNHL typically refers to three different types of hearing impairment: unilateral SNHL, bilateral SNHL, and high-frequency SNHL. Unilateral SNHL is defined as an average air conduction threshold (0.5, 1.0, 2.0 kHz) of 20 dB HL or greater in the impaired ear, with an air-bone gap no greater than 10 dB at 1, 2, and 4 kHz. Average air conduction

FLUCTUATING AND PROGRESSIVE SENSORINEURAL HEARING LOSS

Hearing loss that fluctuates or progresses poses a unique challenge to a child's medical, audiologic, and educational management. One concern, particularly with younger children, is that professionals may assume that changes in audiometric results reflect attentional or behavioral factors as opposed to true changes in hearing sensitivity. By the authors' definition, a change in hearing sensitivity as reflected by an audiogram is an improvement or decrement in auditory threshold greater than 10

IDENTIFICATION AND MANAGEMENT

There is a dearth of information regarding the impact of progressive and fluctuating SNHL on children. It is certainly reasonable to assume that a change in hearing can be at most a frightening experience and at least a confusing one for a child. One could expect that family members can also be confused or misled by changes in a child's hearing. That is, during childhood, when behavioral boundaries are being explored, a parent may confuse a decline in hearing sensitivity with seemingly

SUMMARY

Referring to specific types of hearing loss as “minimal” or “mild” seems to imply that their effects are equally mild or negligible. A growing body of literature, however, supports the notion that such losses can have a significant impact on the communicative and educational development of young children. Although OME is considered a common childhood ailment, mounting evidence suggests that it is not always benign and may contribute to significant educational and communicative difficulties in

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Cited by (49)

Impact of unilateral congenital aural atresia on academic Performance: A systematic review
2018, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
This systematic review emphasizes the need for future studies regarding this subject. According to the literature a significantly higher proportion of children demonstrate academic problems in case of (profound) unilateral SNHL compared with their normal-hearing peers [10–16]. In the 1980s and 1990s, 22–33% repeated at least one grade and 8–10% repeated two grades.
Little is known about the academic performance of children with unilateral congenital aural atresia (CAA).
of review: Our objective was to summarize what is known about the academic performance of children with hearing loss by unilateral congenital aural atresia, in order to provide pragmatic recommendations to clinicians who see children with this entity.
Systematic review.
We conducted a systematic search in PubMed Medline, EMBASE, and Cochrane Library combining the terms “atresia” and synonyms with “unilateral hearing loss” and synonyms. Date of the most recent search was 16 May 2018.
Two independent authors identified studies, extracted data, and assessed risk of bias. This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Observational studies on the academic achievements of patients of any age with unilateral conductive hearing loss of any level due to congenital aural atresia were included. We considered grade retention, special education, individualized education plans, and parental report of school performance as outcome measures for academic achievement.Results: Two studies reporting on academic performance of patients with unilateral CAA, which both had a significant risk of bias. One study (n = 140) showed a grade retention rate of 3.6% (n = 5) in total. 15.7% (n = 22) needed special education, and 36.4% (n = 51) used an individualized education program. The second study, reporting on 67 patients with unilateral CAA, showed that 29.9% (n = 20) of the patients received school intervention, and 25.4% (n = 17) had learning problems.
Current evidence regarding the effect of unilateral congenital aural atresia on academic performance is sparse, inconclusive and has a significant risk of bias. High quality observational studies assessing the effects of aural atresia on academic performance in these patients should be initiated.
Epidemiology of cerumen impaction among municipal kindergartens children in Wuhan, China
2017, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
In contrast, studies from developing countries report prevalence rates in children from 7.4% to 63% [5–11]. Impacted cerumen is associated mainly with conductive hearing loss which is often insidious in nature and can be fluctuating, mild, unilateral or bilateral with deleterious effects on social, cognitive and academic development [12,13]. Epidemiological data of cerumen impaction in Chinese children are rare.
To investigate the epidemiology of cerumen impaction among children of municipal kindergartens in Wuhan.
The ear canal of children of municipal kindergartens in Wuhan was examined using an electric otoscope by the same otologist in 2005, 2006 and 2012, with age, gender, ears and the nature of cerumen (dry cerumen or wet cerumen) recorded. A chi-square test was performed to investigate for significant differences between cerumen impaction rates and the recorded variables.
A total of 1,214, 1863 and 5205 children were examined in 2005, 2006 and 2012, and cerumen impaction prevalence rates for each year were 17.2%, 15.4% and 10%, respectively. Prevalence of cerumen impaction was significantly lower in 2012 than in 2005 or 2006. In 2005, dry cerumen impaction accounted for 22.2% of the total dry cerumen, while wet cerumen impaction only accounted for 5% of the total wet cerumen, showing a statistically significant difference.
The prevalence of cerumen impaction among children of kindergartens in Wuhan is higher than 10%, and children with dry cerumen are more prone to cerumen impaction. Annual otological examination of kindergarten children is recommended. And improved community ear health promotion activities should reduce the avoidable prevalence of cerumen impaction in pediatric population.
The validity of family history as a risk factor in pediatric hearing loss
2015, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
In postnatal cases, indeed, the proportion of conductive hearing loss was greatly higher than sensorineural hearing loss (only 13% SNHL/mixed). Such was expected and could be attributed to known OME peaks in childhood [30]. Although 87% of the children diagnosed with postnatal hearing loss were conductive cases, this could still be considered a worthy use of targeted surveillance resources.
A family history of permanent childhood hearing loss is considered a risk factor for pediatric hearing loss, although its validity has been sparsely examined. This study aimed to: (1) investigate the prevalence and yield of this risk factor for congenital and postnatal hearing losses, (2) define the audiometric characteristics of hearing loss in children with positive family histories, and (3) assess the nature of the familial relationships.
A retrospective cohort study including all children born in Queensland, Australia between September 2004 and December 2011 who had completed Healthy Hearing's newborn hearing screen (n = 380,895).
(1) Prevalence of the risk factor was 1.09% (4138/380,895). Prevalence of the risk factor in congenital cases was 7.29% and in postnatal cases was 36.84%. A low yield was identified for both congenital and postnatal groups (1.43% and 1.7%, respectively). (2) The degree of loss in congenital cases was highly varied, whereas the predominant degree in postnatal cases was mild. The most frequent type of loss for congenital cases was sensorineural, whereas for postnatal cases it was conductive. (3) Maternal or sibling relationships were most commonly reported for congenital losses, and maternal or paternal relationships for postnatal losses.
Children with a family history of pediatric hearing loss should have their hearing screened at birth and be monitored throughout early childhood. However, more efficient surveillance methods should be considered in view of the high prevalence with low yield.
A test protocol for assessing the hearing status of students with special needs
2014, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Pure tone audiometry results showed that about 25% of students responded at levels higher than 40 dB HL in at least one test frequency. The prevalence of hearing loss for students enrolled in mainstream schools in Taiwan was 5.6%, 2.9%, 2.0%, and 1.6% for 1, 4, 7, and 10 graders, respectively [47], when hearing loss is defined as having pure tone averages at 500, 1000, and 2000 Hz greater than 25 dB HL. The much higher failure rates obtained in this study are consistent with previous studies that individuals with special needs are more prone to have hearing disorders/loss than their normally developing peers [1–4,6,65–68].
Individuals with disabilities are often reported to have a high prevalence of undetected hearing disorders/loss, but there is no standardized hearing test protocol for this population. The purposes of this study were (1) to examine the hearing status of students with special needs in Taiwan, and (2) to investigate the use of an on-site hearing test protocol that would adequately detect hearing problems in this population and reduce unnecessary referrals for off-site follow-up services.
A total of 238 students enrolled in two schools for special education and one habilitation center participated in the study. Most students had intellectual disabilities and some also had additional syndromes or disorders. A hearing screening protocol including otoscopy, tympanometry, and distortion product otoacoustic emissions was administered to examine students’ outer, middle, and inner ear functions, respectively. Pure tone tests were then administered as an on-site follow-up for those who failed or could not be tested using the screening protocol.
Only 32.4% of students passed. When administered alone, the referral rate of otoscopy, tympanometry, and otoacoustic emissions were 38.7%, 46.0%, and 48.5%, respectively. The integration of these subtests revealed 52.1% of students needed follow-up services, 11.8% could not be tested, 2.5% had documented hearing loss, and 1.3% needed to be monitored because of negative middle ear pressure. The inclusion of pure tone audiometry increased the passing rate by 9.9% and provided information on hearing sensitivity for an additional 8.6% of students.
Hearing assessments and regular hearing screening should be provided as an integral part of health care services for individuals with special needs because of high occurrences of excessive cerumen, middle ear dysfunction, and sensorineural hearing loss. The training of care-givers and teachers of students with special needs is encouraged so that they can help identify hearing problems and reduce the negative impact of hearing disorders and hearing loss. The screening protocol needs to include subtests that examine the status of different parts of their auditory system. The addition of pure tone audiometry as an on-site follow-up tool reduced the rate of off-site referrals and provided more information on hearing sensitivity.
The Hearing Scale Test for hearing screening of school-age children
2010, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
The reported prevalence rate of hearing impairment among children regardless of frequency or severity has varied from 1.5% to 14.9% [2,3]. The causes of unidentified hearing impairment in children include minimal sensorineural and fluctuating conductive hearing loss problems, with the most frequently found in school-age children being cerumen impaction, otitis media effusion, noise-induced hearing loss, unilateral hearing loss, and late-onset sensorineural hearing loss [4–7]. Early detection and identification of these hearing impairments is difficult, with routine hearing screening currently being the best choice [8,9].
This study aimed to demonstrate a new modified hearing screening method that can rapidly screen hearing and provide stratified test values for each screened ear of children.
The proposed Hearing Scale Test (HST) and pure-tone screening (PTS) were applied to 384 school-age children. PTS involved applying four test tones to each tested ear: 500 Hz at 25 dB, and 1000, 2000, 4000 Hz at 20 dB; and classifying the results as “pass” (normal hearing in the ear) or “fail” (possible hearing impairment). The HST employs ten stratified hearing scales from S₁ to S₁₀, with each hearing scale containing four test tones and where adjacent scales differ from each other by 5 dB, ranging from 0 dB (S₁) to 45 dB (S₁₀). The four test tones of hearing scale S₅ are the same hearing criteria and the median reference standard of the stimulus level in the HST. Scales S₁–S₅ on the HST are equivalent to a PTS “pass” result, while S₆–S₁₀ and no response (NR) are equivalent to a PTS “fail” result.
The two screening methods produced comparable “pass” and “fail” results. In the HST, the “pass” results were further stratified as S₁ in 4 ears, S₂ in 52 ears, S₃ in 226 ears, S₄ in 272 ears, and S₅ in 169 ears, while the “fail” results were stratified as S₆ in 23 ears, S₇ in 12 ears, S₈ in 1 ear, S₉ in 2 ears, S₁₀ in 5 ears, and no response (NR) in 2 ears. The hearing screening results of the HST are interpreted as follows: scales S₁–S₅ indicate normal hearing, scales S₆ and S₇ indicate possible hearing impairment, and scales S₈–S₁₀ and NR indicate confirmed hearing impairment.
Conventional PTS only gives a pass/fail result for each screened ear, lacks hearing status assessment, and lacks stratified test values to be recorded for follow-up. In contrast, the HST has stratified hearing scales for each screened ear, which reflects the current hearing status and provides test values that can be recorded for follow-up.
Air-conduction estimated from tympanometry (ACET): 2. The use of hearing level-ACET discrepancy (HAD) to determine appropriate use of bone-conduction tests in identifying permanent and mixed impairments
2009, International Journal of Pediatric Otorhinolaryngology
The caseload at secondary care in paediatric otology is largely otitis media with effusion (OME) and highly recurrent acute otitis media (RAOM). Few of these cases merit suspicion for hearing loss beyond the middle ear. The companion paper showed that the air conduction estimated from tympanometry (ACET) formula, derived on a very large clinical sample referred for ear or hearing problems and pre-assessed for a clinical trial, gives usable although only approximate estimates for hearing level (HL) on such a caseload. Tympanometry corresponds to a conductive loss (i.e. air–bone gap) so the HL–ACET discrepancy (HAD) should approximate the bone-conduction (BC) threshold. Clinical criteria might enable HAD to substitute for BC tests where those are infeasible, or to identify those most needing BC tests.
ACET had been derived for the 4-frequency binaural average on 3085 cases with tympanometry and air-conduction HL available. On the 2701 of those with BC data at 1 kHz, we re-calculated ACET for 1 kHz only, and then explored the sensitivity/specificity trade of the discrepancy (HAD) in detecting clinically significant BC levels and the correlation between these measures. We further illustrated the generalization of the formula and cut-off on a small separate retrospective clinical sample.
Correlations were moderate in the clinically relevant region. There were five cases of BC ≥ 30 dB in the database. At a HAD cut-off of +5 dB, the sift would identify all (nominal 100% sensitivity). For marginal cases, two definitions were adopted (BC ≥ 25 dB and ≥20 dB; 9 and 23 cases, respectively). Sift sensitivity remained high (89% and 83%, respectively), and specificity was acceptable (75% for both definitions).
Given tympanometry and air-conduction HL, comparison of HAD with a recommended cut-off gives acceptable sensitivity and specificity for non-OME hearing problems. BC testing can be reserved for probable positive cases, provisionally only 25% of caseload. HAD could temporarily substitute for BC measurement in children too young to accept bone-conduction transducers in awake testing. Where a high proportion of the caseload is expected to have middle ear fluid, ACET and HAD together offer efficient possibilities for best use of available information.

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: Address reprint requests to, Anne Marie Tharpe, PhD, Vanderbilt Bill Wilkerson Center, 1114 19th Avenue South, Nashville, TN 37212

^*: Department of Hearing and Speech Sciences, Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Vanderbilt University Medical Center, Nashville, Tennessee

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MINIMAL, PROGRESSIVE, AND FLUCTUATING HEARING LOSSES IN CHILDREN: Characteristics, Identification, and Management

Section snippets

MINIMAL CONDUCTIVE HEARING LOSS

MINIMAL SENSORINEURAL HEARING LOSS

FLUCTUATING AND PROGRESSIVE SENSORINEURAL HEARING LOSS

IDENTIFICATION AND MANAGEMENT

SUMMARY

Am J Otolaryngol

Int J Pediatr Otorhinolaryngol

Brain Res Dev

Infect Dis Clin North Am

Guidelines for Audiologic Screening

SIFTER Screening Instrument for Targeting Educational Risk in Children Identified by Hearing Screening or Who Have Minimal Hearing Loss

Hearing loss in school children

Scand Audiol

Early noise-induced hearing loss in teenage boys

Scand Audiol

Perceptive hearing loss in children with respect to genesis and the use of hearing aid

Acta Otolaryngol Rhinol

Infectious agents that deafen

Universal screening for infant hearing impairment: Not simple, not risk-free, not necessarily beneficial, and not presently justified

Pediatrics

Unilateral hearing impairment in children

Pediatrics

The effects of mild sensorineural hearing loss on academic performance of young school-age children

The Volta Review

The pattern and stability of postmeningitic hearing loss in children

Laryngoscope

Unilateral hearing loss in children

Laryngoscope

The Early Language Milestone Scale and the Sequenced Inventory of Communication Development: Comparison of Language Performance with Two Year Old Children

Genetics, syndromology, and craniofacial anomalies

Validation of an early language milestone scale in a high-risk population

Pediatrics

Ménière's disease: Study based on examinations made before and after intracranial division of vestibular nerve

Medicine

Progressive hearing impairment in children with congenital cytomegalovirus infection

J Speech Hear Dis

Management of the school age child: A psychosocial perspective

Characteristics of hearing-impaired children in the public schools: Part II. Psychoeducational data

J Speech Hear Dis

Congenital syphilis: A reminder about the return of an old scourge

Missouri Med

Otoneurologic diseases and associated audiologic profiles

Educational implications of deafness: Language and literacy

The stapes gusher

Arch Otolaryngol

Audiological management of otitis media

Early otitis media, auditory abilities, and educational risk

Am J Speech Language Pathol

Sudden or fluctuating hearing loss and vertigo in children due to perilymph fistula

Ann Otol

Reversible hearing loss after meningitis: Prospective assessment using auditory evoked responses

Ann Otol Rhinol Laryngol

Inner ear autoantibodies in patients with rapidly progressive sensorineural hearing loss

Laryngoscope

Hearing loss in infants with persistent fetal circulation

Pediatrics

Effects of chronic otitis media on language and speech development

Pediatrics

Clinical diagnosis of immune inner-ear disease

Laryngoscope

Practical versus theoretical management of autoimmune inner ear disease

Laryngoscope

High frequency hearing loss associated with otitis media

Ear Hear